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Bajpai M, Kakkar B, Gupta S, Rastogi A, Pamecha V. Cascade plasmapheresis as a desensitization strategy for patients undergoing ABO incompatible living donor liver transplantation (ABOi LDLT): A single center experience. Transfus Apher Sci 2019; 58:442-446. [PMID: 31311754 DOI: 10.1016/j.transci.2019.04.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/06/2019] [Accepted: 04/28/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM The reduction of antibody titres (AT's) to a safe level is essential pre-requisite for patients awaiting ABO-incompatible liver transplantation (ABOi LT). We report our experience of performing cascade plasmapheresis (CP) on 2 different apheresis platforms (COBE Spectra and Spectra Optia) as a desensitization strategy for patients undergoing ABOi LT in our centre. METHODS This retrospective observational study was conducted on patients who underwent CP included in the desensitization protocol for ABOi LDLT. CP/conventional TPE was performed (daily/alternate day with daily estimation of AT) until a target titre of ≤ 8 was achieved. RESULTS During the study period, 4 patients (mean age 46.7 years; 100% males) underwent desensitization for ABOi LDLT with baseline AT (combined IgM and IgG) ranging from 64 to 512. A total of 15 CP sessions (range 2 - 6) were performed with a median of 3.5 sessions/patient. Desensitization rate was 100%. Only 1 patient underwent conventional TPE in the post-transplant due to rise in AT level to 64 (post-operative day 8). Average post-operative length of stay was 49 days (range 30 - 105). None of the patients experienced any episode of rejection (repeat liver biopsy). On follow up (1 year), 2 patients were alive and doing well, while other 2 patients succumbed during their hospital stay due to sepsis. CONCLUSION In our limited experience, the use of CP was safe and effective desensitization strategy for patients undergoing ABOi LDLT.
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Affiliation(s)
- Meenu Bajpai
- Department of Transfusion Medicine, Institute of Liver and Biliary Sciences, New Delhi, 110 070, India.
| | - Brinda Kakkar
- Department of Transfusion Medicine, Institute of Liver and Biliary Sciences, New Delhi, 110 070, India.
| | - Shruti Gupta
- Department of Transfusion Medicine, Institute of Liver and Biliary Sciences, New Delhi, 110 070, India.
| | - Archana Rastogi
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, 110 070, India.
| | - Viniyendra Pamecha
- Department of Liver Transplant Surgery, Institute of Liver and Biliary Sciences, New Delhi 110 070, India.
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Lattanzi B, Ott P, Rasmussen A, Kudsk KR, Merli M, Villadsen GE. Ischemic Damage Represents the Main Risk Factor for Biliary Stricture After Liver Transplantation: A Follow-Up Study in a Danish Population. In Vivo 2019; 32:1623-1628. [PMID: 30348725 DOI: 10.21873/invivo.11423] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 08/03/2018] [Accepted: 08/06/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Biliary complications (BC) are frequently observed following liver transplantation. The aim of the present retrospective study, conducted at an outpatients' tertiary care hospital, was to determine the incidence of biliary complications and risk factors associated with their development in liver transplantation (lT) patients. MATERIALS AND METHODS The medical records were reviewed for all patients who underwent liver transplantation at the Rigshospitalet, Copenhagen, Denmark, from 2000 to 2011 and were referred to the Aarhus University Hospital for follow-up. Patients who died within 3 months of surgery or had incomplete clinical information were excluded. All data for demographic characteristics and possible risk factors for development of biliary stricture were collected. Fifty-one patients were included. RESULTS The median age at transplantation was 40 (range=7-64) years, and 53% of patients were males. Biliary complications occurred in 18 patients (35%), the majority of whom developed strictures (12 patients, 24%). Univariate and multivariate analyses revealed that cytomegalovirus infection (p=0.008), hepatic artery obstruction (p=0.03) and hepatic artery graft abnormalities (p=0.03) were independent risk factors for the development of biliary strictures. CONCLUSION One-third of patients presented biliary complications after liver transplantation, among which biliary strictures were the most common. Cytomegalovirus infection, hepatic artery stenosis and anatomical abnormality of the graft's hepatic artery are independent risk factors for the development of biliary stricture.
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Affiliation(s)
- Barbara Lattanzi
- Department of Clinical Medicine, Umberto 1 Hospital, Rome, Italy
| | - Peter Ott
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Allan Rasmussen
- Department of Surgical Gastroenterology and Liver Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Karen Raben Kudsk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Manuela Merli
- Department of Clinical Medicine, Umberto 1 Hospital, Rome, Italy
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Ramisch D, Rumbo C, Echevarria C, Moulin L, Niveyro S, Orce G, Crivelli A, Martinez MI, Chavez L, Paez MA, Trentadue J, Klein F, Fernández A, Solar H, Gondolesi GE. Long-Term Outcomes of Intestinal and Multivisceral Transplantation at a Single Center in Argentina. Transplant Proc 2017; 48:457-62. [PMID: 27109978 DOI: 10.1016/j.transproceed.2015.12.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/29/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intestinal failure (IF) patients received parenteral nutrition (PN) as the only available therapy until intestinal transplantation (ITx) evolved as an accepted treatment. The aim of this article is to report the long-term outcomes of a series of ITx performed in pediatric and adult patients at a single center 9 years after its creation. PATIENTS AND METHODS This is a retrospective analysis of the ITx performed between May 2006 and January 2015. Diagnoses, pre-ITx mean time on PN, indications for ITx, time on the waiting list for types of ITx, mean total ischemia time, and warm ischemia time, time until PN discontinuation, incidence of acute and chronic rejection, and 5-year actuarial patient survival are reported. RESULTS A total of 42 patients received ITx; 80% had short gut syndrome (SG); the mean time on PN was 1620 days. The main indication for ITx was lack of central venous access followed by intestinal failure-associated liver disease (IFALD) and catheter-related infectious complications. The mean time on the waiting list was 188 days (standard deviation, ±183 days). ITx were performed in 26 children and 14 adults. In all, 32 procedures were isolated ITx (IITX); 10 were multiorgan Tx (MOT; 3 combined, 7 multivisceral Tx (MVTx), 1 modified MVTx and 2 with kidney); 2 (4.7 %) were retransplantations: 1 IITx, 1 MVTx, and 5 including the right colon. Thirteen patients (31%) received abdominal rectus fascia. All procedures were performed by the same surgical team. Total ischemia time was 7:53 ± 2:04 hours, and warm ischemia time was 40.2 ± 10.5 minutes. The mean length of implanted intestine was 325 ± 63 cm. Bishop-Koop ileostomy was performed in 67% of cases. In all, 16 of 42 Tx required early reoperations. The overall mean follow-up time was 41 ± 35.6 months. The mean time to PN discontinuation after Tx was 68 days (P = .001). The total number of acute cellular rejection (ACR) episodes until the last follow-up was 83; the total number of grafts lost due to ACR was 4; and the total graft lost due to chronic rejection was 3. At the time of writing, the overall 5-year patient survival is 55% (65% for IITx vs 22% for MOT; P = .0001); 60% for pediatric recipients vs 47% for adults (P = NS); 64% when the indication for ITx was SG vs 25% for non-SG (P = .002). CONCLUSIONS At this center, candidates with SG, in the absence of IFALD requiring IITx, showed the best long-term outcomes, independent of recipient age. A multidisciplinary approach is mandatory for the care of intestinal failure patients, to sustain a rehabilitation and transplantation program over time.
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Affiliation(s)
- D Ramisch
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - C Rumbo
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - C Echevarria
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - L Moulin
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - S Niveyro
- Anesthesia Department, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - G Orce
- Anesthesia Department, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - A Crivelli
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - M I Martinez
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - L Chavez
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - M A Paez
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - J Trentadue
- Pediatric Intensive Care Unit, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - F Klein
- Adult Intensive Care Unit, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - A Fernández
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - H Solar
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina
| | - G E Gondolesi
- Instituto de Trasplante Multiorgánico, Unidad de Insuficiencia Intestinal, Rehabilitación y Trasplante de Intestino, Hospital Universitario, Fundación Favaloro, CABA, Argentina.
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O’Shea D, Law J, Egli A, Douglas D, Lund G, Forester S, Lambert J, Law M, Burton D, Tyrrell D, Houghton M, Humar A, Kneteman N. Prevention of hepatitis C virus infection using a broad cross-neutralizing monoclonal antibody (AR4A) and epigallocatechin gallate. Liver Transpl 2016; 22:324-32. [PMID: 26389583 PMCID: PMC4769112 DOI: 10.1002/lt.24344] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 09/01/2015] [Indexed: 01/13/2023]
Abstract
The anti-hepatitis C virus (HCV) activity of a novel monoclonal antibody (mAb; AR4A) and epigallocatechin gallate (EGCG) were studied in vitro using a HCV cell culture system and in vivo using a humanized liver mouse model capable of supporting HCV replication. Alone, both exhibit reliable cross-genotype HCV inhibition in vitro, and combination therapy completely prevented HCV infection. In vitro AR4A mAb (alone and combined with EGCG) robustly protects against the establishment of HCV genotype 1a infection. EGCG alone fails to reliably protect against an HCV challenge. In conclusion, AR4A mAb represents a safe and efficacious broadly neutralizing antibody against HCV applicable to strategies to safely prevent HCV reinfection following liver transplantation, and it lends further support to the concept of HCV vaccine development. The poor bioavailability of EGCG limits HCV antiviral activity in vitro.
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Affiliation(s)
- D. O’Shea
- Transplant Infectious Diseases, Alberta Transplant Institute, Department of Medicine, University of Alberta,Li Ka Shing Institute of Virology, University of Alberta, Edmonton, Alberta, Canada,To whom correspondence should be addressed: Daire O’Shea, Consultant in Infectious Diseases, Regional Infectious Diseases Unit, Crewe Road, Edinburgh EH4 2XU, Scotland, UK, Tel: +441315372862, Fax: +441315372878,
| | - J Law
- Li Ka Shing Institute of Virology, University of Alberta, Edmonton, Alberta, Canada
| | - A Egli
- Li Ka Shing Institute of Virology, University of Alberta, Edmonton, Alberta, Canada
| | - D Douglas
- Li Ka Shing Institute of Virology, University of Alberta, Edmonton, Alberta, Canada
| | - G Lund
- KMT Hepatech, University of Alberta, Edmonton, Alberta, Canada
| | - S Forester
- Dept. of Food Science, Pennsylvania State University, PA
| | - J Lambert
- Dept. of Food Science, Pennsylvania State University, PA
| | - M Law
- Department of Immunology and Microbial Science, The Scripps Research Institute, La Jolla CA 92037, USA
| | - D.R. Burton
- Department of Immunology and Microbial Science, The Scripps Research Institute, La Jolla CA 92037, USA,Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
| | - D.L.J. Tyrrell
- Li Ka Shing Institute of Virology, University of Alberta, Edmonton, Alberta, Canada
| | - M. Houghton
- Li Ka Shing Institute of Virology, University of Alberta, Edmonton, Alberta, Canada
| | - A. Humar
- Toronto General Hospital, University Health Network, Multi-Organ Transplant Program Toronto, Ontario, Canada
| | - N Kneteman
- Li Ka Shing Institute of Virology, University of Alberta, Edmonton, Alberta, Canada,Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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Golabi P, Otgonsuren M, Suen W, Koenig AB, Noor B, Younossi ZM. Predictors of Inpatient Mortality and Resource Utilization for the Elderly Patients With Chronic Hepatitis C (CH-C) in the United States. Medicine (Baltimore) 2016; 95:e2482. [PMID: 26817883 PMCID: PMC4998257 DOI: 10.1097/md.0000000000002482] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
New incidents of chronic hepatitis C (CH-C) have stabilized yet the full impact of CH-C is not realized.Assess inpatient mortality and resource utilization for CH-C patients hospitalized in the United States.Adult CH-C patients were identified from The National Inpatient Sample (NIS) 2005 to 2009 database using the International Classification of Disease, Ninth Revision (ICD-9) diagnosis codes (070.51, 070.54, 070.70, 070.71, 070.41, and 070.44) also used to identify comorbidities.324,823 hospitalized CH-C patients were identified. Of these, 13.63% (N = 44,288) were older than 65. The rate of hospitalization for the elderly cohort steadily increased over the study period with Medicare as the payer for the majority (86%). This cohort had higher inpatient charges, approximately a half day longer hospital stay (P < 0.001) and more moderate or severe illness. During the index hospitalization, older CH-C patients were twice more likely to die than the younger age-group (5% versus 2%, P < 0.001). In the adjusted model, older age (OR: 1.02 [95% CI, 1.02-1.03]), severity of illness (OR: 12.06 [95% CI, 10.68-13.62]), and number of diagnoses (OR: 1.10 [95% CI, 1.09-1.11]) were associated with higher in-hospital mortality; severity of illness and having private insurance were significantly associated with charge per hospital stay (P < 0.001).The number of CH-C patients 65 and older increased due to the aging of the baby boomer population. Early treatment of CH-C patients with highly effective, well-tolerated, new anti-HCV regimens may prevent this significant societal burden.
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Affiliation(s)
- Pegah Golabi
- From the Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA (PG, MO, WS, ABK, BN, ZMY); and Center for Liver Diseases, Department of Medicine, Inova Fair Falls Church, VA (WS, ZMY)
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de la Peña-Moral JM, Pons JA, Tome S, Gude F, Miras M, Bermejo J, Ramirez P, Berenguer M, Varo E, Forteza J, Parrilla P. Acute cellular rejection versus recurrent hepatitis C after liver transplantation: Clinical and pathological features driving a rational diagnostic approach. Hepatol Res 2015; 45:423-31. [PMID: 24906075 DOI: 10.1111/hepr.12369] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Revised: 05/20/2014] [Accepted: 06/02/2014] [Indexed: 02/08/2023]
Abstract
AIM The aim of our study was develop and validate an algorithm system based on morphological features for finding the differences between recurrent hepatitis C virus (HCV) and acute cellular rejection (ACR) in liver biopsies of HCV-transplanted patients. METHODS Two hundred and eighty-eight liver biopsies were analyzed from 121 patients transplanted for HCV. A diagnostic consensus was reached between clinicians and pathologists in 214 biopsies for the diagnosis of recurrent HCV or ACR. A random sample of 114 liver biopsies (derivation cohort) was taken to generate the diagnostic tree and was subsequently evaluated using the validation cohort in 100 liver biopsies by recursive partitioning analysis of morphological variables and time since transplantation. RESULTS The presence of endotheliitis together with a time of less than 6 weeks since LT definitely excluded recurrent HCV. After obtaining the regression tree, diagnostic accuracy was 96% and 93% in the derivation and validation cohort, respectively. Both cases surpassed the pathologist's original diagnosis, which had a diagnostic accuracy of 91% (P < 0.05, for both comparisons). CONCLUSION A recursive partitioning analysis of the morphological features in liver biopsies from HCV-transplanted patients may be useful for easily distinguishing between recurrent HCV and ACR.
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Masson S, Marrow B, Kendrick S, Elsharkawy AM, Latimer S, Hudson M. An ‘alcohol contract’ has no significant effect on return to drinking after liver transplantation for alcoholic liver disease. Transpl Int 2014; 27:475-81. [DOI: 10.1111/tri.12283] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 11/22/2013] [Accepted: 02/11/2014] [Indexed: 12/18/2022]
Affiliation(s)
- Steven Masson
- Liver Transplant Unit; Freeman Hospital; Newcastle Upon Tyne UK
- Institute of Cellular Medicine; Newcastle University Medical School; Newcastle upon Tyne UK
| | - Benjamin Marrow
- Liver Transplant Unit; Freeman Hospital; Newcastle Upon Tyne UK
| | - Stuart Kendrick
- Liver Transplant Unit; Freeman Hospital; Newcastle Upon Tyne UK
- Institute of Cellular Medicine; Newcastle University Medical School; Newcastle upon Tyne UK
| | | | - Sandra Latimer
- Liver Transplant Unit; Freeman Hospital; Newcastle Upon Tyne UK
| | - Mark Hudson
- Liver Transplant Unit; Freeman Hospital; Newcastle Upon Tyne UK
- Institute of Cellular Medicine; Newcastle University Medical School; Newcastle upon Tyne UK
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Gurusamy KS, Nagendran M, Davidson BR. Methods of preventing bacterial sepsis and wound complications after liver transplantation. Cochrane Database Syst Rev 2014; 2014:CD006660. [PMID: 24599680 PMCID: PMC10882578 DOI: 10.1002/14651858.cd006660.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Bacterial sepsis and wound complications after liver transplantation increase mortality, morbidity, or hospital stay and are likely to increase overall transplant costs. All liver transplantation patients receive antibiotic prophylaxis. This is an update of our 2008 Cochrane systematic review on the same topic in which we identified seven randomised clinical trials. OBJECTIVES To assess the benefits and harms of different methods aimed at preventing bacterial sepsis and wound complications in people undergoing liver transplantation. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded to February 2013. SELECTION CRITERIA We included only randomised clinical trials irrespective of language or publication status. We excluded quasi-randomised and other observational studies for assessment of benefits, but not for harms. DATA COLLECTION AND ANALYSIS Two review authors collected the data independently. We calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) using fixed-effect and the random-effects models based on available-case analysis. MAIN RESULTS We identified only seven trials for inclusion, including 614 participants. Only one trial was of low risk of bias risk. Overall, the quality of evidence was very low. There were five comparisons in the seven trials: selective bowel decontamination versus inactive control; selective bowel decontamination versus prebiotics with probiotics; selective bowel decontamination versus prebiotics; prebiotics with probiotics versus prebiotics; and granulocyte-colony stimulating factor (G-CSF) versus control. Four trials compared selective bowel decontamination versus placebo or no treatment. In one trial, participants were randomised to selective bowel decontamination, active lactobacillus with fibres (probiotic with prebiotic), or to inactivated lactobacillus with fibres (prebiotic). In one trial, active lactobacillus with fibres (probiotic with prebiotic) was compared with inactive lactobacillus with fibres (prebiotic). In the remaining trial, different doses of G-CSF and placebo were compared. There was no trial comparing different antibiotic prophylactic regimens in people undergoing liver transplantation. Most trials included adults undergoing elective liver transplantation. There was no significant difference in proportion of people who died or required retransplantation between the intervention and control groups in any of the five comparison groups. MORTALITY There were no differences between 190 participants (three trials); 5/87 (adjusted proportion: 6.2%) in selective bowel decontamination group versus 7/103 (6.8%) in inactive control group; RR 0.91 (95% CI 0.31 to 2.72); 63 participants (one trial); 0/32 (0%) in selective bowel decontamination group versus 0/31 (0%) in prebiotics with probiotics group; RR - not estimable; 64 participants (one trial); 0/32 (0%) in selective bowel decontamination group versus 0/32 (0%) in prebiotics group; RR - not estimable; 129 participants (two trials); 0/64 (0%) in prebiotics with probiotics group versus 0/65 (0%) in prebiotics group; RR - not estimable; and 194 participants (one trial); 22/124 (17.7%) in G-CSF group versus 10/70 (14.3%) in placebo group; RR 1.24 (95% 0.62 to 2.47). RETRANSPLANTATION There were no differences between 132 participants (two trials); 4/58 (adjusted proportion: 6.9%) in selective bowel decontamination group versus 6/74 (8.1%) in inactive control group; RR 0.85 (95% CI 0.26 to 2.85); 63 participants (one trial); 1/32 (3.1%) in selective bowel decontamination group versus 0/31 (0%) in prebiotics with probiotics group; RR 2.91 (0.12 to 68.81); 64 participants (one trial); 1/32 (3.1%) in selective bowel decontamination group versus 0/32 (0%) in prebiotics group; RR 3.00 (95% CI 0.13 to 71.00); 129 participants (two trials); 0/64 (0%) in prebiotics with probiotics group versus 1/65 (1.5%) in prebiotics group; RR 0.33 (95% CI 0.01 to 7.9); and 194 participants (one trial); 10/124 (7.1%) in G-CSF group versus 5/70 (7.1%) in placebo group; RR 1.13 (95% CI 0.4 to 3.17).There was no significant difference in the graft rejections, intensive therapy unit stay, or hospital stay between the intervention and control groups in any of the comparisons. Overall, 193/611 participants (31.6%) developed infective complications. The proportion of people who developed infective complications and the number of infective complication episodes were significantly higher in the selective bowel decontamination group than in the prebiotics with probiotics group (1 study; 63 participants; 15/32 (46.9%) in selective bowel decontamination group versus 4/31 (12.9%) in prebiotics with probiotics group; RR 3.63; 95% CI 1.36 to 9.74 and 23/32 participants (0.72 infective complications per participant) in selective bowel decontamination group versus 4/31 participants (0.13 infective complications per participant) in prebiotics with probiotics group; rate ratio 5.58; 95% CI 1.94 to 16.09). There was no significant difference between the proportion of participants who developed infection and the number of infection episodes between the intervention group and control group in any of the other comparisons.No trials reported quality of life and overall serious adverse events. AUTHORS' CONCLUSIONS Currently, there is no clear evidence for any intervention offering significant benefits in the reduction of bacterial infections and wound complications in liver transplantation. Selective bowel decontamination may even increase the rate of infections compared with prebiotics with probiotics. The confidence intervals were wide and further randomised clinical trials of low risk of bias are necessary.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Department of Surgery, Royal Free Campus, UCL Medical School, Royal Free Hospital, Rowland Hill Street, London, UK, NW3 2PF
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Gurusamy KS, Tsochatzis E, Toon CD, Davidson BR, Burroughs AK. Antiviral prophylaxis for the prevention of chronic hepatitis C virus in patients undergoing liver transplantation. Cochrane Database Syst Rev 2013; 2013:CD006573. [PMID: 24297303 PMCID: PMC6599865 DOI: 10.1002/14651858.cd006573.pub3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND It is not clear whether prophylactic antiviral therapy is indicated to improve patient and graft survival in patients undergoing liver transplantation for chronic decompensated hepatitis C virus (HCV) infection. OBJECTIVES To compare the benefits and harms of different prophylactic antiviral therapies for patients undergoing liver transplantation for chronic HCV infection. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 1, 2013), MEDLINE, EMBASE, and Science Citation Index Expanded to February 2013. SELECTION CRITERIA Only randomised clinical trials irrespective of language, blinding, or publication status and comparing various prophylactic antiviral therapies (alone or in combination) in the prophylactic treatment of patients undergoing liver transplantation for chronic HCV infection. DATA COLLECTION AND ANALYSIS Two authors collected the data independently. We calculated the risk ratio (RR) or mean difference (MD) or hazard ratio (HR) with 95% confidence intervals (CI) using the fixed-effect and the random-effects models based on available case analysis. MAIN RESULTS A total of 501 liver transplant recipients undergoing liver transplantation for chronic HCV infection were randomised in 12 trials to various experimental interventions and control interventions. The proportion of genotype I varied between 49% and 100% in the seven trials that reported the genotype. Only one or two trials were included under each comparison. All the trials were of high risk of bias. Ten trials including 441 liver transplant recipients provided data for this review.There were no significant differences in the 90-day mortality (1 trial; 81 participants; 5/35 (adjusted proportion: 14.2%) in interferon group versus 5/46 (10.9%) in control group; RR 1.31; 95% CI 0.41 to 4.19); mortality at maximal follow-up (2 trials; 105 participants; 7/47 (adjusted proportion: 14.8%) in interferon group versus 10/58 (17.2%) in control group; RR 0.86; 95% CI 0.36 to 2.08); long-term mortality (1 trial; 81 participants; HR 0.45; 95% CI 0.13 to 1.56); mortality at maximal follow-up (1 trial; 54 participants; 1/26 (3.9%) in pegylated interferon group versus 2/28 (7.1%) in control group; RR 0.54; 95% CI 0.05 to 5.59); 90-day mortality (1 trial; 115 participants; 5/55 (9.1%) in pegylated interferon plus ribavirin group versus 3/60 (5.0%) in control group; RR 1.82; 95% 0.46 to 7.25); 90-day mortality (3 trials; 53 participants; 3/37 (adjusted proportion: 4.3%) in HCV antibody group versus 1/16 (6.3%) in placebo group; RR 0.69; 95% CI 0.15 to 3.11); or 90-day mortality (2 trials; 31 participants; 2/14 (adjusted proportion: 16.2%) in HCV antibody high-dose group versus 1/17 (5.9%) in HCV antibody low-dose group; RR 2.75; 95% CI; 0.30 to 25.35). There were no significant differences in the retransplantation at maximal follow-up (2 trials; 105 participants; 2/47 (adjusted proportion: 4.0%) in interferon group versus 2/58 (3.4%) in control group; RR 1.17; 95% CI 0.22 to 6.2); 90-day retransplantation (1 trial; 18 participants; 1/12 (8.3%) in HCV antibody group versus 0/6 (0%) in control group; RR 1.71; 95% CI 0.09 to 32.93); or 90-day retransplantation (1 trial; 12 participants; 1/6 (17.7%) in HCV antibody high-dose group versus 0/6 (0%) in HCV antibody low-dose group; RR 3.00; 95% CI 0.15 to 61.74). There were no significant differences in serious adverse events, graft rejection, worsening of fibrosis, or HCV recurrence between intervention and control groups in any of the comparisons that reported these outcomes. None of the trials reported quality of life, liver decompensation, intensive therapy unit stay, or hospital stay. Life-threatening adverse events were not reported in either group in any of the comparisons. AUTHORS' CONCLUSIONS There is currently no evidence to recommend prophylactic antiviral treatment to prevent recurrence of HCV infection either in primary liver transplantation or retransplantation. Further randomised clinical trials with adequate trial methodology and adequate duration of follow-up are necessary.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
| | - Emmanuel Tsochatzis
- Royal Free Hampstead NHS Foundation Trust and UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentrePond StreetHampsteadLondonUKNW3 2QG
| | - Clare D Toon
- West Sussex County CouncilPublic Health1st Floor, The GrangeTower StreetChichesterWest SussexUKPO19 1QT
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
| | - Andrew K Burroughs
- Royal Free Hampstead NHS Foundation TrustSheila Sherlock Liver CentrePond StreetHampsteadLondonUKNW3 2QG
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A current update on the rule of alternative and complementary medicine in the treatment of liver diseases. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2013; 2013:321234. [PMID: 24109491 PMCID: PMC3784269 DOI: 10.1155/2013/321234] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Accepted: 08/02/2013] [Indexed: 02/05/2023]
Abstract
There is a vast body of knowledge which is ever-increasing about the treatment of liver disease with alternative and complementary medicine for which hundreds of thousands of literatures have been documented. Liver disease is a general term. This term covers all the potential problems that cause the liver to fail to perform its specified operations. Liver disease has a variety of presentations and causes a great public health problem worldwide which threatens the wellness of billions of people. Incidences of many types of liver disease are currently rising. Although there is still a debate about the entity of alternative and complementary medicine, it is now widely used and it is improving. And it covers the shortages and compensates for the weaknesses of conventional methods in the treatment of liver diseases. Alternative and complementary medicine for liver diseases provides benefits by regulating immunity, controlling disease progression, improving quality of life, and prolonging survival. This paper reviews the increasing interest and growing research into alternative and complementary medicine for liver diseases, with a look at the rough classification, principle of management, evidence-based applications, and issues for prescription and perspectives.
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Vera-Llonch M, Martin M, Aggarwal J, Donepudi M, Bayliss M, Goss T, Younossi Z. Health-related quality of life in genotype 1 treatment-naïve chronic hepatitis C patients receiving telaprevir combination treatment in the ADVANCE study. Aliment Pharmacol Ther 2013; 38:124-33. [PMID: 23725204 DOI: 10.1111/apt.12354] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 04/03/2013] [Accepted: 05/09/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Chronic hepatitis C virus (HCV) infection and its treatment impact patients' health-related quality of life (HRQL). AIM To report on treatment impact and predictors of HRQL among treatment-naïve patients with genotype 1 chronic HCV infection who received 12-week telaprevir (T) with 24 (T12PR24) or 48 weeks (T12PR48) peginterferon alpha-2a/ribavirin (PR), or 48 weeks of PR in the ADVANCE study. METHODS The EQ-5D-3L (EQ-5D) questionnaire (index range: 0-1) was completed at baseline and weeks 4, 12, 24, 36, 48 and 72. Patients indicated their health state on five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Descriptive statistics for the EQ-5D index and descriptive system and area under the curve from baseline to week 12 were calculated. Predictors of EQ-5D index were identified using multivariate analyses. RESULTS Data from 722 patients were included. The mean EQ-5D index decreased during the first 12 weeks and returned to baseline by week 72 (T12PR24 by week 36) across treatments. In multivariate analysis, sustained virological response (SVR) at week 72 was associated (P < 0.0001) with improved EQ-5D index [mean; SVR+ (0.90), SVR- (0.86)], a 4% difference, within the published range of minimal clinically important difference. CONCLUSIONS Post hoc analyses of data from ADVANCE suggested that HRQL worsened during the first 12 weeks of therapy and returned to baseline by week 72 across treatments. Improvements were observed early following completion of a 24-week treatment (T12PR24). Telaprevir combination therapy was associated with slightly higher reductions in HRQL during the first 12 weeks (vs. PR). SVR was a statistically significant and meaningful predictor of HRQL at week 72.
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Affiliation(s)
- M Vera-Llonch
- Vertex Pharmaceuticals Incorporated, Cambridge, MA 02139, USA.
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12
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Abstract
Acute liver failure (ALF) is a condition wherein the previously healthy liver rapidly deteriorates, resulting in jaundice, encephalopathy, and coagulopathy. There are approximately 2000 cases per year of ALF in the United States. Viral causes (fulminant viral hepatitis [FVH]) are the predominant cause of ALF in developing countries. Given the ease of spread of viral hepatitis and the high morbidity and mortality associated with ALF, a systematic approach to the diagnosis and treatment of FVH is required. In this review, the authors describe the viral causes of ALF and review the intensive care unit management of patients with FVH.
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MESH Headings
- Acetylcysteine/therapeutic use
- Adult
- Brain Edema/etiology
- Brain Edema/virology
- Developing Countries
- Female
- Hepatectomy
- Hepatitis, Viral, Human/complications
- Hepatitis, Viral, Human/drug therapy
- Hepatitis, Viral, Human/prevention & control
- Herpesviridae/pathogenicity
- Humans
- Hypothermia, Induced/adverse effects
- Hypothermia, Induced/standards
- Immunocompromised Host
- Intensive Care Units
- Intubation, Intratracheal
- Liver Failure, Acute/etiology
- Liver Failure, Acute/therapy
- Liver Failure, Acute/virology
- Liver Transplantation
- Pregnancy
- Pregnancy Complications, Infectious/virology
- Prognosis
- Viral Hepatitis Vaccines/administration & dosage
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Affiliation(s)
- Saumya Jayakumar
- Faculty of Medicine and Dentistry, Division of Gastroenterology, University of Calgary, TRW Building, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
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Orman ES, Barritt AS, Wheeler SB, Hayashi PH. Declining liver utilization for transplantation in the United States and the impact of donation after cardiac death. Liver Transpl 2013; 19:59-68. [PMID: 22965893 PMCID: PMC3535500 DOI: 10.1002/lt.23547] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 08/29/2012] [Indexed: 12/21/2022]
Abstract
Worsening donor liver quality resulting in decreased organ utilization may be contributing to the recent decline in liver transplants nationally. We sought to examine trends in donor liver utilization and the relationship between donor characteristics and nonuse. We used the United Network for Organ Sharing database to review all deceased adult organ donors in the United States from whom at least 1 solid organ was transplanted into a recipient. Trends in donor characteristics were examined. Multivariate logistic regression was used to evaluate the association between donor characteristics and liver nonuse between 2004 and 2010. Population attributable risk proportions were determined for donor factors associated with nonuse. We analyzed 107,259 organ donors. The number of unused livers decreased steadily from 1958 (66% of donors) in 1988 to 841 (15%) in 2004 but then gradually increased to 1345 (21%) in 2010. The donor age, the body mass index (BMI), and the prevalence of diabetes and donation after cardiac death (DCD) all increased over time, and all 4 factors were independently associated with liver nonuse. DCD had the highest adjusted odds ratio (OR) for nonuse, and the odds increased nearly 4-fold between 2004 [OR = 5.53, 95% confidence interval (CI) = 4.57-6.70] and 2010 (OR = 21.31, 95% CI = 18.30-24.81). The proportion of nonuse attributable to DCD increased from 9% in 2004 to 28% in 2010. In conclusion, the proportion of donor livers not used has increased since 2004. Older donor age, greater BMI, diabetes, and DCD are all independently associated with nonuse and are on the rise nationally. Current trends may lead to significant declines in liver transplant availability.
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Affiliation(s)
- Eric S. Orman
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill
| | - A. Sidney Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill
| | - Stephanie B. Wheeler
- Department of Health Policy and Management, University of North Carolina, Chapel Hill
| | - Paul H. Hayashi
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill
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Wang GS, Yang Y, Li H, Jiang N, Fu BS, Jin H, Yang JX, Chen GH. Health-related quality of life after liver transplantation: the experience from a single Chinese center. Hepatobiliary Pancreat Dis Int 2012; 11:262-6. [PMID: 22672819 DOI: 10.1016/s1499-3872(12)60158-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Few studies have been performed to assess health-related quality of life (HRQOL) in liver transplantation (LT) patients in the mainland of China. This study aimed to investigate the HRQOL of post-LT patients in a single center. METHODS HRQOL was evaluated by the SF-36 (Chinese version) questionnaire in 60 patients (LT group) who had received LT for benign end-stage liver disease (BELD). Fifty-five patients with BELD (BELD group) and 50 healthy volunteers from the general population (GP group) were also evaluated, and the results were compared among the three groups. RESULTS There was a significant difference among the three groups in terms of the scores of eight domains in the SF-36 (P<0.01). Patients in the BELD group had lower scores in each domain of the SF-36 in comparison with those in the GP group (P<0.025). The LT group had mental health scores equivalent to those of the BELD group (P>0.025), but higher scores for the remaining seven domains (P<0.025). Compared with the GP group, the LT group scored equivalently for role physical, body pain, vitality, social function and role emotion (P>0.025), but had lower scores for the remaining three domains (P<0.025). Lower family income was found to be associated with reduced physical function and mental health scores (P<0.05). Better education was associated with increased mental health scores (P<0.05). CONCLUSIONS LT patients generally have a good HRQOL although some respects of their HRQOL remains to be improved. Lower family income and poor education are important factors relating to the poor HRQOL of LT patients.
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Affiliation(s)
- Gen-Shu Wang
- Department of Hepatic Surgery and Liver Transplant Center, Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
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Gurusamy KS, Naik P, Abu-Amara M, Fuller B, Davidson BR. Techniques of flushing and reperfusion for liver transplantation. Cochrane Database Syst Rev 2012:CD007512. [PMID: 22419324 DOI: 10.1002/14651858.cd007512.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Various techniques of flushing and reperfusion have been advocated to improve outcomes after liver transplantation. There is considerable uncertainty as to which method is superior. OBJECTIVES To compare the benefits and harms of different methods of flushing and reperfusion during liver implantation in the transplant recipients. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until March 2011. SELECTION CRITERIA We included all randomised clinical trials that were performed to compare different techniques of flushing and reperfusion during liver transplantation. DATA COLLECTION AND ANALYSIS Two authors independently identified the trials and extracted the data. We analysed the data with both the fixed-effect model and the random-effects model using RevMan analysis. For each outcome we calculated the hazard ratio (HR), risk ratio (RR), rate ratio, mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on available case analysis. MAIN RESULTS We included six trials involving 418 patients for this review. The sample size in the trials varied from 30 to 131 patients. Only one trial involving 131 patients was of low risk of bias for mortality. This trial was at high risk of bias for other outcomes. Four trials excluded patients who underwent liver transplantation for acute liver failure. All the trials included livers obtained from cadaveric donors. The remaining five trials were of high risk of bias for all outcomes. Liver transplantation was performed by the conventional method (caval replacement) in two trials and piggy-back method (caval preservation) in one trial. The method of liver transplantation was not available in the remaining three trials. The comparisons performed included an initial hepatic artery flush versus initial portal vein flush; blood venting via inferior vena cava in addition to venting of storage fluid versus no blood venting; initial hepatic artery reperfusion versus initial portal vein reperfusion; simultaneous hepatic artery and portal vein reperfusion versus initial portal vein reperfusion; and retrograde inferior vena cava reperfusion versus simultaneous hepatic artery and portal vein reperfusion. Only one or two trials could be included under each comparison. There was no significant difference in mortality, graft survival, or severe morbidity rates in any of the comparisons. Quality of life was not reported in any of the trials. AUTHORS' CONCLUSIONS There is currently no evidence to support or refute the use of any specific technique of flushing or reperfusion during liver transplantation. Due to the paucity of data, absence of evidence should not be confused with evidence of absence of any differences. Further well designed trials with low risk of systematic error and low risk of random errors are necessary.
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16
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Gurusamy KS, Davidson BR. Perfusion techniques for liver retrieval in liver donors. Hippokratia 2012. [DOI: 10.1002/14651858.cd009754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical School; Department of Surgery; Royal Free Hospital, Pond Street London UK NW3 2QG
| | - Brian R Davidson
- Royal Free Campus, UCL Medical School; Department of Surgery; Royal Free Hospital, Pond Street London UK NW3 2QG
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17
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Gurusamy KS, Pissanou T, Pikhart H, Vaughan J, Burroughs AK, Davidson BR. Methods to decrease blood loss and transfusion requirements for liver transplantation. Cochrane Database Syst Rev 2011; 2011:CD009052. [PMID: 22161443 PMCID: PMC8939250 DOI: 10.1002/14651858.cd009052.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Excessive blood loss and increased blood transfusion requirements may have significant impact on the short-term and long-term outcomes after liver transplantation. OBJECTIVES To compare the potential benefits and harms of different methods of decreasing blood loss and blood transfusion requirements during liver transplantation. SEARCH METHODS We searched The Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and metaRegister of Controlled Trials until September 2011. SELECTION CRITERIA We included all randomised clinical trials that were performed to compare various methods of decreasing blood loss and blood transfusion requirements during liver transplantation. DATA COLLECTION AND ANALYSIS Two authors independently identified the trials and extracted the data. We analysed the data with both the fixed-effect and the random-effects model using RevMan Analysis. For each outcome we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on available data analysis. We also conducted network meta-analysis. MAIN RESULTS We included 33 trials involving 1913 patients. The sample size in the trials varied from 8 to 209 participants. The interventions included pharmacological interventions (aprotinin, tranexamic acid, epsilon amino caproic acid, antithrombin 3, recombinant factor (rFvIIa), oestrogen, prostaglandin, epinephrine), blood substitutes (blood components rather than whole blood, hydroxy-ethyl starch, thromboelastography), and cardiovascular interventions (low central venous pressure). All the trials were of high risk of bias. Primary outcomes were reported in at least two trials for the following comparisons: aprotinin versus control, tranexamic acid versus control, recombinant factor VIIa (rFVIIa) versus control, and tranexamic acid versus aprotinin. There were no significant differences in the 60-day mortality (3 trials; 6/161 (3.7%) in the aprotinin group versus 8/119 (6.7%) in the control group; RR 0.52; 95% CI 0.18 to 1.45), primary graft non-function (2 trials; 0/128 (0.0%) in the aprotinin group versus 4/89 (4.5%) in the control group; RR 0.15; 95% CI 0.02 to 1.25), retransplantation (3 trials; 2/256 (0.8%) in the aprotinin group versus 12/178 (6.7%) in the control group; RR 0.21; 95% CI 0.02 to 1.79), or thromboembolic episodes (3 trials; 4/161 (2.5%) in the aprotinin group versus 5/119 (4.2%) in the control group; RR 0.59; 95% CI 0.19 to 1.84) between the aprotinin and control groups. There were no significant differences in the 60-day mortality (3 trials; 4/83 (4.8%) in the tranexamic acid group versus 5/56 (8.9%) in the control group; RR 0.55; 95% CI 0.17 to 1.76), retransplantation (2 trials; 3/41 (7.3%) in the tranexamic acid group versus 3/36 (8.3%) in the control group; RR 0.79; 95% CI 0.18 to 3.48), or thromboembolic episodes (5 trials; 5/103 (4.9%) in the tranexamic acid group versus 1/76 (1.3%) in the control group; RR 2.20; 95% CI 0.38 to 12.64) between the tranexamic acid and control groups. There were no significant differences in the 60-day mortality (3 trials; 8/195 (4.1%) in the recombinant factor VIIa (rFVIIa) group versus 2/91 (2.2%) in the control group; RR 1.51; 95% CI 0.33 to 6.95), thromboembolic episodes (2 trials; 24/185 (13.0%) in the rFVIIa group versus 8/81 (9.9%) in the control group; RR 1.38; 95% CI 0.65 to 2.91), or serious adverse events (2 trials; 90/185 (48.6%) in the rFVIIa group versus 30/81 (37.0%) in the control group; RR 1.30; 95% CI 0.94 to 1.78) between the rFVIIa and control groups. There were no significant differences in the 60-day mortality (2 trials; 6/91 (6.6%) in the tranexamic acid group versus 1/87 (1.1%) in the aprotinin group; RR 4.12; 95% CI 0.71 to 23.76) or thromboembolic episodes (2 trials; 4/91 (4.4%) in the tranexamic acid group versus 2/87 (2.3%) in the aprotinin group; RR 1.97; 95% CI 0.37 to 10.37) between the tranexamic acid and aprotinin groups. The remaining outcomes in the above comparisons and the remaining comparisons included only only trial under the primary outcome or the outcome was not reported at all in the trials. There were no significant differences in the mortality, primary graft non-function, graft failure, retransplantation, thromboembolic episodes, or serious adverse events in any of these comparisons. However, the confidence intervals were wide, and it is not possible to reach any conclusion on the safety of the interventions. None of the trials reported the quality of life in patients.Secondary outcomes were reported in at least two trials for the following comparisons - aprotinin versus control, tranexamic acid versus control, rFVIIa versus control, thromboelastography versus control, and tranexamic acid versus aprotinin. There was significantly lower allogeneic blood transfusion requirements in the aprotinin group than the control group (8 trials; 185 patients in aprotinin group and 190 patients in control group; SMD -0.61; 95% CI -0.82 to -0.40). There were no significant differences in the allogeneic blood transfusion requirements between the tranexamic acid and control groups (4 trials; 93 patients in tranexamic acid group and 66 patients in control group; SMD -0.27; 95% CI -0.59 to 0.06); rFVIIa and control groups (2 trials; 141 patients in rFVIIa group and 80 patients in control group; SMD -0.05; 95% CI -0.32 to 0.23); thromboelastography and control groups (2 trials; 31 patients in thromboelastography group and 31 patients in control group; SMD -0.73; 95% CI -1.69 to 0.24); or between the tranexamic acid and aprotinin groups (3 trials; 101 patients in tranexamic acid group and 97 patients in aprotinin group; SMD -0.09; 95% CI -0.36 to 0.19). The remaining outcomes in the above comparisons and the remaining comparisons included only only trial under the primary outcome or the outcome was not reported at all in the trials. There were no significant differences in the blood loss, transfusion requirements, hospital stay, or intensive care unit stay in most of the comparisons. AUTHORS' CONCLUSIONS Aprotinin, recombinant factor VIIa, and thromboelastography groups may potentially reduce blood loss and transfusion requirements. However, risks of systematic errors (bias) and risks of random errors (play of chance) hamper the confidence in this conclusion. We need further well-designed randomised trials with low risk of systematic error and low risk of random errors before these interventions can be supported or refuted.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Pond StreetLondonUKNW3 2QG
| | - Theodora Pissanou
- Royal Free Hampstead NHS Foundation Trust8th Floor South, Hepatology OfficePond StreetLondonUKNW3 2QG
| | - Hynek Pikhart
- University College LondonEpidemiology & Public Health, Division of Population Health1‐19 Torrington PlaceLondonUKWC1E 7HB
| | - Jessica Vaughan
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Pond StreetLondonUKNW3 2QG
| | - Andrew K Burroughs
- Royal Free Hampstead NHS Foundation TrustSheila Sherlock Liver CentrePond StreetHampsteadLondonUKNW3 2QG
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Pond StreetLondonUKNW3 2QG
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Liver Transplantation for Hepatocellular Carcinoma: Defining the Impact of Using Extended Criteria Liver Allografts. Transplantation 2011; 92:446-52. [DOI: 10.1097/tp.0b013e3182252733] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Bikhchandani J, Metcalfe M, Illouz S, Puls F, Dennison A. Extracorporeal liver perfusion system for artificial liver support across a membrane. J Surg Res 2011; 171:e139-47. [PMID: 21920550 DOI: 10.1016/j.jss.2011.07.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2011] [Revised: 06/30/2011] [Accepted: 07/08/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND An extracorporeal porcine liver perfusion (ECPLP) system circumvents the limitations of hepatocyte based bio-artificial liver, but its clinical application has been limited so far due to the potential risk of transmission of porcine endogenous retroviruses. The aim of this study was to develop an ECPLP model that can provide artificial hepatic support across a semi-permeable membrane, which has the potential to block porcine viruses due to its pore size. MATERIALS AND METHODS Livers from white landrace pigs were perfused with normothermic oxygenated blood using Medtronic BP560 centrifugal pump (Medtronic, Inc., Minneapolis. MN). This ECPLP system was used to support a "surrogate" patient across the filter Evaclio-EC4A. Function of liver was measured by indocyanine green retention at 15 min (ICGR15). Clearance of galactose, ammonia, and para-aminobenzoic acid infused into the "surrogate" patient circulation was calculated to assess liver support across the membrane. The study was designed as test (n = 15) versus control (n = 5), with control experiments having no liver in the circuit. RESULTS For the test experiments, we perfused 15 livers with mean hepatic artery pressure of 87 mm Hg and flows of 1.2 L/min. ICGR15 in test experiments was 11%. Ammonia clearance was 945 mg/min/kg, galactose metabolic rate was 111.7 mg/min/Kg, and the hippurate ratio was 91% in the test. In contrast, the control experiments did not show any significant change in the concentration of any of these compounds. CONCLUSION Our ECPLP model was able to provide hepatic support in an experimental setting across a hollow fiber filter. Further work on an anhepatic animal is needed prior to application in human trials.
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Affiliation(s)
- Jai Bikhchandani
- Department of Hepatobiliary Pancreatic Surgery, University Hospitals of Leicester, Leicester, United Kingdom.
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Abstract
BACKGROUND Routine use of abdominal drainage in patients undergoing liver transplantation is controversial. OBJECTIVES To assess the benefits and harms of routine abdominal drainage after orthotopic liver transplantation versus no drainage and to address different drain types. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and the MetaRegister of Controlled Trials until March 2011 to identify the randomised trials. SELECTION CRITERIA We planned to include only randomised clinical trials (irrespective of language, blinding, or publication status) addressing this issue. DATA COLLECTION AND ANALYSIS Two authors identified the trials for inclusion independently. Two authors planned to collect the data independently. We planned to analyse the data with both the fixed-effect and the random-effects model using RevMan Analysis. For each outcome we planned to calculate the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat analysis whenever possible. MAIN RESULTS We did not identify any randomised clinical trials addressing this issue. AUTHORS' CONCLUSIONS There is currently no evidence to conclude whether routine abdominal drainage is useful or harmful in patients undergoing orthotopic liver transplantation. Evidence from non-randomised studies of high risk of bias showed conflicting results on the impact of routine drainage in orthotopic liver transplantation on serious adverse events, showing that this question is an important clinical research question. Well-designed randomised clinical trials with adequate sample size to decrease systematic errors and to decrease random errors are necessary.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Department of Surgery, Royal Free Campus, UCL Medical School, 8th Floor South (Hepatology office), Royal Free Hospital, Pond Street, London, UK, NW3 2QG
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Abstract
BACKGROUND Veno-venous bypass is used to overcome the effects of clamping of the inferior vena cava and portal vein during liver transplanation. The routine use of veno-venous bypass is, however, controversial. OBJECTIVES To compare the benefits and harms of veno-venous bypass (irrespective of open or percutaneous technique; heparin-coated or no heparin-coating) versus no veno-venous bypass during liver transplantation. To compare the benefits and harms of the different techniques of veno-venous bypass during liver transplantation. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until December 2010. SELECTION CRITERIA We included randomised clinical trials comparing veno-venous bypass during liver transplantation (irrespective of language or publication status). DATA COLLECTION AND ANALYSIS Two authors independently assessed trials for inclusion and independently extracted data. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis. For continuous outcomes, we calculated the mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat or available case analysis. For binary outcomes, we used the Fisher's exact test since none of the comparisons of binary outcomes included more than one trial. MAIN RESULTS We identified three trials with high risk of bias which compared veno-venous bypass (n = 65) versus no veno-venous bypass (n = 66). None of the trials reported patient or graft survival. There were no significant differences regarding renal failure or blood transfusion requirements between the two groups. None of the trials reported on the morbidity related to veno-venous bypass or the requirement of veno-venous bypass in the control group.We identified one trial with high risk of bias which compared percutaneous (n = 20) versus open technique (n =19) of veno-venous bypass. The patient or graft survival was not reported. There was no difference in veno-venous bypass related morbidity between the two groups. The operating time was significantly shorter in the percutaneous technique group (MD -59 minutes; 95% CI -102 to -16). AUTHORS' CONCLUSIONS There is no evidence to support or refute the use of veno-venous bypass in liver transplantation. There is no evidence to prefer any particular technique of veno-venous bypass in liver transplantation.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Department of Surgery, Royal Free Campus, UCL Medical School, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG
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Gurusamy KS, Davidson BR. Methods to decrease blood loss and transfusion requirements for liver transplantation. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2011. [DOI: 10.1002/14651858.cd009052] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Chang TI, Ho MC, Wu YM, Lee PH, Hu RH. Biliary Complications After Liver Transplantation: An 18-Year Single-center Experience. J Formos Med Assoc 2011; 110:183-9. [DOI: 10.1016/s0929-6646(11)60029-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Revised: 06/02/2010] [Accepted: 08/02/2010] [Indexed: 12/13/2022] Open
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Abstract
BACKGROUND Piggy-back method of transplantation, which involves preservation of the recipient retrohepatic inferior vena cava, has been suggested as an alternative to the conventional method of liver transplantation, where the recipient retrohepatic inferior vena cava is resected. OBJECTIVES To compare the benefits and harms of piggy-back technique versus conventional liver transplantation as well as of the different modifications of piggy-back technique during liver transplantation. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until June 2010 for identifying randomised trials using search strategies. SELECTION CRITERIA Only randomised clinical trials, irrespective of language, blinding, or publication status were considered for the review. DATA COLLECTION AND ANALYSIS Two authors (KSG and VP) independently identified trials and independently extracted data. We calculated the mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI) using both the fixed-effect and the random-effects models with RevMan 5 based on intention-to-treat analysis for continuous outcomes. For binary outcomes, we used the Fisher's exact test since none of the comparisons of binary outcomes included more than one trial. MAIN RESULTS Two trials randomised in total 106 patients to piggy-back method (n = 53) versus conventional method with veno-venous bypass (n = 53). Both trials were at high risk of bias. There was no significant difference in post-operative mortality, primary graft non-function, vascular complications, renal failure, transfusion requirements, intensive therapy unit (ITU) stay, or hospital stay between the two groups. The warm ischaemic time was significantly shorter in the piggy-back method than the conventional method (MD -11.50 minutes; 95% CI -19.35 to -3.65; P < 0.01). The proportion of patients who developed chest complications were significantly higher in the the piggy-back method than the conventional method (75.8% versus 44.1%; P = 0.01).One trial randomised 80 patients to piggy-back with porto-caval bypass (n = 40) versus piggy-back without porto-caval bypass (n = 40). This trial was at high risk of bias. There was no significant difference in post-operative mortality, re-transplantation due to primary graft non-function, vascular complications, renal failure, or hospital stay between the two groups. Fewer patients required blood transfusion in the piggy-back with porto-caval bypass group (55%) than the piggy-back without porto-caval bypass group (75%) (P = 0.02). There was no significant difference in the mean amount of blood transfused between the groups (MD -1.00 unit; 95% CI -2.19 to 0.19; P = 0.10). The ITU stay was significantly shorter in the piggy-back with porto-caval bypass group (2.9 days) than the piggy-back without porto-caval bypass group (4.9 days; MD -2.00 days; 95% CI -3.82 to -0.18; P = 0.03).There were no trials comparing piggy-back method with conventional method without veno-venous bypass or different techniques of piggy-back method. AUTHORS' CONCLUSIONS There is currently no evidence to recommend or refute the use of piggy-back method of liver transplantation.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Department of Surgery, Royal Free Campus, UCL Medical School, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG
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Poordad F, Theodore D, Sullivan J, Grotzinger K. Medical resource utilisation and healthcare costs in patients with chronic hepatitis C viral infection and thrombocytopenia. J Med Econ 2011; 14:194-206. [PMID: 21348807 DOI: 10.3111/13696998.2011.562266] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Thrombocytopenia is a significant risk for patients with chronic HCV infection and a common side-effect of treatment with pegylated (PEG) interferon (IFN). Thrombocytopenia predisposes patients to bleeding and requirements for platelet transfusions, and may thus place an increased burden on patients and on medical resource utilisation. SCOPE In a retrospective analysis of an integrated, longitudinal database of medical and pharmacy claims and laboratory results in a US commercial health (insurance) plan, patients with chronic hepatitis C viral (HCV) infection were identified by reviewing ICD-9-CM HCV-, chronic liver disease-, and cirrhosis-related diagnoses. Medical resource utilisation and laboratory results were evaluated during the year following the HCV diagnosis index date as well as during the baseline year prior to that index date. Medical resource utilisation was determined by comparing outpatient visits, emergency department (ER) visits, and inpatient hospital stays for HCV patients with or without thrombocytopenia. FINDINGS HCV patients diagnosed with thrombocytopenia had a greater incidence of bleeding events (27.3 vs. 9.9%), platelet transfusions (8.5 vs. <1%), liver disease-related ambulatory visits (10.4 vs. 4.4; odds ratio [OR] = 2.3; p < 0.001), ER visits (OR = 8.6; p < 0.01), and inpatient hospital stays (OR = 17.7; p < 0.01) during the study period compared with HCV patients without a thrombocytopenia diagnosis. HCV patients with thrombocytopenia had significantly higher overall healthcare costs ($37,924 vs. $12,174; p < 0.001) and liver disease-related costs ($14,569 vs. $4107; p < 0.001) than patients without thrombocytopenia. LIMITATIONS Administrative claims data are subject to coding errors; additionally, the patient population may not be completely representative of the general chronic HCV population. CONCLUSIONS Diagnosis of thrombocytopenia in patients with HCV is associated with increased incidence of certain comorbidities, complications, and medical interventions, and significantly increased medical resource utilisation.
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Affiliation(s)
- Fred Poordad
- Cedars-Sinai Medical Center, Los Angeles, CA; David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Gurusamy KS, Tsochatzis E, Davidson BR, Burroughs AK. Antiviral prophylactic intervention for chronic hepatitis C virus in patients undergoing liver transplantation. Cochrane Database Syst Rev 2010:CD006573. [PMID: 21154370 DOI: 10.1002/14651858.cd006573.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND It is not clear whether prophylactic antiviral therapy is indicated in patients undergoing liver transplantation for chronic decompensated hepatitis C virus (HCV) infection. OBJECTIVES To compare the benefits and harms of different prophylactic anti-viral therapies for patients undergoing liver transplantation for chronic HCV infection. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until August 2010. SELECTION CRITERIA Only randomised clinical trials irrespective of language, blinding, or publication status and comparing various prophylactic antiviral therapies (alone or in combination) in the prophylactic treatment of patients undergoing liver transplantation for chronic HCV infection. DATA COLLECTION AND ANALYSIS Two authors collected the data independently. We calculated the risk ratio (RR) or mean difference (MD) or hazard ratio (HR) with 95% confidence intervals (CI) using the fixed-effect and the random-effects models based on available case analysis. MAIN RESULTS A total of 477 liver transplant recipients undergoing liver transplantation for chronic HCV infection were randomised in eleven trials to various interventions and controls. The proportion of genotype I varied between 49% to 88% in the five trials that reported the genotype. Only one or two trials were included under each comparison. All the trials were of high risk of bias. There was no significant differences in the patient survival, graft rejection, re-transplantation, or HCV recurrence between intervention and control groups in any of the comparisons that reported these outcomes. None of the trials reported liver decompensation, primary graft non-function, intensive therapy unit stay, hospital stay, or quality of life. Life-threatening adverse events were not reported in either group in any of the comparisons. Up to 91% of patients required reduction in dose and up to 36% of patients required cessation of treatment in the various comparisons because of adverse events or because of patient's choice to stop treatment. AUTHORS' CONCLUSIONS There is currently no evidence to recommend prophylactic antiviral treatment to prevent recurrence of HCV infection either in primary liver transplantation or re-transplantation. Further randomised clinical trials with adequate trial methodology and adequate duration of follow-up are necessary.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Department of Surgery, Royal Free Campus, UCL Medical School, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG
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High prevalence of hepatitis C associated with familial history of hepatitis in a small town of south Brazil. Efficiency of the rapid test for epidemiological survey. Braz J Infect Dis 2010. [DOI: 10.1016/s1413-8670(10)70097-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Abu-Amara M, Gurusamy KS, Fuller B, Davidson BR. Pharmacological interventions to decrease ischaemia reperfusion injury in liver transplantation. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd008374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Mahmoud Abu-Amara
- Royal Free Hospital and University College School of Medicine; University Department of Surgery; London UK
| | - Kurinchi Selvan Gurusamy
- Royal Free Hospital and University College School of Medicine; University Department of Surgery; London UK
| | - Barry Fuller
- Royal Free Hospital and University College School of Medicine; University Department of Surgery; London UK
| | - Brian R Davidson
- Royal Free Hospital and University College School of Medicine; University Department of Surgery; London UK
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Goralczyk AD, Obed A, Schnitzbauer A, Doenecke A, Tsui TY, Scherer MN, Ramadori G, Lorf T. Adult Living Donor Liver Transplantation with ABO-Incompatible Grafts: A German Single Center Experience. J Transplant 2010; 2009:759581. [PMID: 20148072 PMCID: PMC2817542 DOI: 10.1155/2009/759581] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Accepted: 10/18/2009] [Indexed: 01/11/2023] Open
Abstract
Adult living donor liver transplantations (ALDLTs) across the ABO blood group barrier have been reported in Asia, North Americas, and Europe, but not yet in Germany. Several strategies have been established to overcome the detrimental effects that are attached with such a disparity between donor and host, but no gold standard has yet emerged. Here, we present the first experiences with three ABO-incompatible adult living donor liver transplantations in Germany applying different immunosuppressive strategies. Four patient-donor couples were considered for ABO-incompatible ALDLT. In these patients, resident ABO blood group antibodies (isoagglutinins) were depleted by plasmapheresis or immunoadsorption and replenishment was inhibited by splenectomy and/or B-cell-targeted immunosuppression. Despite different treatments ALDLT could safely be performed in three patients and all patients had good initial graft function without signs for antibody-mediated rejection (AMR). Two patients had long-term graft survival with stable graft function. We thus propose the feasibility of ABO-incompatible ALDLT with these protocols and advocate further expansion of ABO incompatible ALDLT in multicenter trials to improve efficacy and safety.
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Affiliation(s)
- Armin D. Goralczyk
- Department of General and Visceral Surgery, University Medical Center Göttingen, 37099 Göttingen, Germany
| | - Aiman Obed
- Department of General and Visceral Surgery, University Medical Center Göttingen, 37099 Göttingen, Germany
| | - Andreas Schnitzbauer
- Department of Surgery, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
| | - Axel Doenecke
- Department of Surgery, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
| | - Tung Yu Tsui
- Department of Surgery, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
- Department of Hepatobiliary and Transplant Surgery, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Marcus N. Scherer
- Department of Surgery, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany
| | - Giuliano Ramadori
- Department of Gastroenterology, University Medical Center Göttingen, 37099 Göttingen, Germany
| | - Thomas Lorf
- Department of General and Visceral Surgery, University Medical Center Göttingen, 37099 Göttingen, Germany
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Gurusamy KS, Pamecha V, Davidson BR. Piggy-back graft for liver transplantation. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd008258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Liver transplantation is currently the definitive treatment of end-stage liver disease. This article reviews the complex multidisciplinary care of the liver transplant recipient beginning immediately after transplantation but extending into the long term. The presentation, evaluation and treatment of common post-transplant complications are outlined. Importantly, immunosuppression strategies along with the issues of acute and chronic rejection are discussed in detail with an emphasis on how practice has evolved over time. The spectrum of infectious problems is systematically presented, based on the time since transplantation and the institution of immunosuppression. Finally, the substantial challenges of recurrent disease and long-term medical comorbidities are addressed as these are clearly the primary issues that threaten the longevity and wellbeing of the liver transplant recipient.
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Affiliation(s)
- Bruce Gelb
- Division of Transplantation, Department of Surgery, UCSF Medical Center, San Francisco, CA, USA
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Delis SG, Bakoyiannis A, Tassopoulos N, Athanassiou K, Kechagias A, Kelekis D, Madariaga J, Dervenis C. Hepatic resection for large hepatocellular carcinoma in the era of UCSF criteria. HPB (Oxford) 2009; 11:551-8. [PMID: 20495706 PMCID: PMC2785949 DOI: 10.1111/j.1477-2574.2009.00084.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2008] [Accepted: 05/07/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Treating patients with hepatocellular carcinoma (HCC) remains a challenge, especially when the disease presents at an advanced stage. The aim of this retrospective study was to determine the efficacy of liver resection in patients who fulfil or exceed University of California San Francisco (UCSF) criteria by assessing longterm outcome. METHODS Between 2002 and 2008, 59 patients with large HCC (>5 cm) underwent hepatectomy. Thirty-two of these patients fulfilled UCSF criteria for transplantation (group A) and 27 did not (group B). Disease-free survival and overall survival rates were compared between the two groups after resection and were critically evaluated with regard to patient eligibility for transplant. RESULTS In all patients major or extended hepatectomies were performed. There was no perioperative mortality. Morbidity consisted of biliary fistula, abscess, pleural effusion and pneumonia and was significantly higher in patient group B. Disease-free survival rates at 1, 3 and 5 years were 66%, 37% and 34% in group A and 56%, 29% and 26% in group B, respectively (P < 0.01). Survival rates at 1, 3 and 5 years were 73%, 39% and 35% in group A and 64%, 35% and 29% in group B, respectively (P= 0.04). The recurrence rate was higher in group B (P= 0.002). CONCLUSIONS Surgical resection, if feasible, is suggested in patients with large HCC and can be performed with acceptable overall and disease-free survival and morbidity rates. In patients eligible for transplantation, resection may also have a place in the management strategy when waiting list time is prolonged for reasons of organ shortage or when the candidate has low priority as a result of a low MELD (model for end-stage liver disease) score.
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Affiliation(s)
- Spiros G Delis
- Liver Surgical Unit, First Surgical Department, Kostantopouleio-Agia Olga HospitalAthens, Greece,Division of Liver and Gastrointestinal Transplantation, University of Miami Miller School of MedicineMiami, FL, USA
| | - Andreas Bakoyiannis
- Liver Surgical Unit, First Surgical Department, Kostantopouleio-Agia Olga HospitalAthens, Greece
| | - Nikos Tassopoulos
- First Department of Medicine, Western Attica General HospitalAthens, Greece
| | - Kostas Athanassiou
- Liver Surgical Unit, First Surgical Department, Kostantopouleio-Agia Olga HospitalAthens, Greece
| | - Aristotelis Kechagias
- Liver Surgical Unit, First Surgical Department, Kostantopouleio-Agia Olga HospitalAthens, Greece
| | - Dimitrios Kelekis
- Second Department of Radiology, Athens University Medical SchoolAthens, Greece
| | - Juan Madariaga
- Division of Liver and Gastrointestinal Transplantation, University of Miami Miller School of MedicineMiami, FL, USA
| | - Christos Dervenis
- Liver Surgical Unit, First Surgical Department, Kostantopouleio-Agia Olga HospitalAthens, Greece
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Abstract
Liver transplantation has become a lifesaving procedure for patients who have chronic end-stage liver disease and acute liver failure. The satisfactory outcome of liver transplantation has led to insufficient supplies of deceased donor organs, particularly in East Asia. Hence, East Asian surgeons are concentrating on developing and performing living-donor liver transplantation (LDLT). This review article describes an update on the present status of liver transplantation, mainly in adults, and highlights some recent developments on indications for transplantation, patient selection, donor and recipient operation between LDLT and deceased-donor liver transplantation (DDLT), immunosuppression, and long-term management of liver transplant recipients. Currently, the same indication criteria that exist for DDLT are applied to LDLT, with technical refinements for LDLT. In highly experienced centers, LDLT for high-scoring (>30 points) Model of End-Stage Liver Disease (MELD) patients and acute-on-chronic liver-failure patients yields comparably good outcomes to DDLT, because timely liver transplantation with good-quality grafting is possible. With increasing numbers of liver transplantations and long-term survivors, specialized attention should be paid to complications that develop in the long term, such as chronic renal failure, hypertension, diabetes mellitus, dyslipidemia, obesity, bone or neurological complications, and development of de novo tumors, which are highly related to the immunosuppressive treatment.
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Affiliation(s)
- Deok-Bog Moon
- Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Rapid reversal of parenteral-nutrition-associated cirrhosis following isolated intestinal transplantation. J Gastrointest Surg 2009; 13:1717-23. [PMID: 19418102 DOI: 10.1007/s11605-009-0914-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2009] [Accepted: 04/15/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Liver disease and the development of hepatic fibrosis are complications associated with total parenteral nutrition (TPN). Patients developing cirrhosis and portal hypertension in the setting of intestinal failure have a high mortality and may require combined liver and intestinal transplantation which carries much higher morbidity and mortality than isolated intestinal transplantation. DISCUSSION Recently, regression of hepatic fibrosis in patients with TPN liver disease has been described following intestinal transplantation. To date, there has been no demonstration of the reversal of established cirrhosis due to long-term TPN injury. Herein, we describe a patient with intestinal failure who developed cirrhosis from long-standing TPN injury and underwent isolated intestinal transplantation. He had no overt clinical stigmata of portal hypertension and had preserved liver function. Serial liver biopsies were reviewed and assessed with standard histology and quantitation of fibrosis using image analysis. Dramatic regression of fibrosis and reversal of cirrhosis were observed 17 months posttransplantation. Image analysis demonstrated a 14% total decrease in the percentage area of fibrosis. CONCLUSIONS Cirrhosis related to TPN may be rapidly reversible after isolated intestinal transplantation. Such patients may be able to undergo isolated intestinal transplantation if they do not have hepatic synthetic compromise or clinical stigmata of portal hypertension.
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Kramer ES, Hofmann C, Smith PG, Shiffman ML, Sterling RK. Response to hepatitis A and B vaccine alone or in combination in patients with chronic hepatitis C virus and advanced fibrosis. Dig Dis Sci 2009; 54:2016-25. [PMID: 19517231 DOI: 10.1007/s10620-009-0867-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2009] [Accepted: 05/19/2009] [Indexed: 12/31/2022]
Abstract
Patients with advanced fibrosis are at increased risk of severe outcomes if they develop acute infection with hepatitis A (HAV) or hepatitis B (HBV) viruses. There are no data on the efficacy of combined HAV/HBV vaccination in patients with advanced fibrosis. Our aim was to evaluate the response to the HAV and HBV vaccine alone or in combination for patients with chronic hepatitis C (HCV) and advanced fibrosis and to evaluate the impact of administering the vaccine while patients were receiving peginterferon for treatment of chronic HCV. In this prospective study of patients with advanced fibrosis (Ishak 3-6), those without serologic evidence of prior exposure were vaccinated with either Havrix HAV, Engerix( HBV, or the TWINRIX HAV/HBV combination vaccine as appropriate, and response was defined as the development of anti-HAV or anti-HBV surface antibodies. Of the 162 eligible patients, the prevalence of prior exposure to HAV and HBV was 30 and 18%, respectively. Of the 84 patients vaccinated, 38% received Havrix, 14% Engerix, and 48% TWINRIX. The response to the HAV vaccine was 75% in those receiving Havrix compared to 78% receiving TWINRIX. In contrast, the response to HBV vaccination was 42% in patients receiving Engerix compared to 60% in those vaccinated with TWINRIX (difference 18.3%; OR 0.29; 95% CI: 0.57-7.79). The presence of diabetes was the only risk factor identified for reduced HBV response (P = 0.01). Responses to both HAV and HBV vaccines when administered alone or in combination were lower than expected in patients with HCV and advanced fibrosis, especially in those with diabetes. The observation that the decline in HBV vaccine response was somewhat lower when this was administered alone as opposed to the combination A/B vaccine suggests that the administration of a combination vaccine may enhance the vaccination response to HBV.
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Affiliation(s)
- Erik Seth Kramer
- Department of Epidemiology and Community Health, Virginia Commonwealth University, Richmond, VA 23298-0341, USA
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Gurusamy KS, Sharma D, Davidson BR. Veno-venous bypass versus none for liver transplantation. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2009. [DOI: 10.1002/14651858.cd007712] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Smith JO, Shiffman ML, Behnke M, Stravitz RT, Luketic VA, Sanyal AJ, Heuman DM, Fisher RA, Cotterell AH, Maluf DG, Posner MP, Sterling RK. Incidence of prolonged length of stay after orthotopic liver transplantation and its influence on outcomes. Liver Transpl 2009; 15:273-9. [PMID: 19243008 DOI: 10.1002/lt.21731] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Orthotopic liver transplantation (OLT) is the only effective treatment for end-stage liver disease. Although most patients do well and are discharged promptly, some require prolonged length of stay (PLOS). The prevalence of PLOS, associated factors, and their impact on survival are not well defined. We reviewed our adult OLT database for patients who survived > 30 days. PLOS was defined as hospitalization > 30 days following OLT. Of 521 OLT recipients, 68 (13%) had PLOS with a median duration of 50 days versus only 10 days for patients discharged within 30 days. Significant differences in pre-OLT variables between patients with and without PLOS included the mean wait list time (P = 0.001), hospitalization at the time of OLT (P = 0.001), and prior OLT (P = 0.041). Factors independently associated with PLOS included intensive care unit status at the time of OLT [odds ratio (OR), 4; 95% confidence interval (CI), 1.6-10.4], OLT prior to Model for End-Stage Liver Disease implementation (OR, 2.27; 95% CI, 1.04-5.26), in-hospital post-OLT bacterial infection (OR, 9.34; 95% CI, 4.65-18.86), gastrointestinal bleeding (OR, 4.34; 95% CI, 1.4-14.08), renal failure (OR, 10.86; 95% CI, 5.07-23.25), and allograft rejection (OR, 3.7; 95% CI, 1.23-11.11). One-year graft survival and patient survival were significantly less in those with PLOS (for both, P < 0.0001). Among PLOS patients, factors independently associated with increased 1-year mortality were donor age (OR, 1.07; 95% CI, 1.009-1.13), primary diagnosis of hepatitis C virus (OR, 6.89; 95% CI, 1.40-34.48), in-hospital post-OLT bacterial infection (OR, 13.3; 95% CI, 2.11-83.33), and cardiac complications (OR, 20.4; 95% CI, 1.51-250; c-statistic for the model, 0.85). In conclusion, PLOS following OLT is associated with a significant decrease in survival despite a marked increase in cost and resource utilization. Efforts to modify those factors that contribute to PLOS may reduce this event, improve survival, and reduce OLT-associated costs.
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Affiliation(s)
- Jenny O Smith
- Hepatology Section and Liver Transplant Program, Virginia Commonwealth University Medical Center, Richmond, VA, USA
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Yilmaz N, Shiffman ML. Impact of the donor liver with steatosis in patients with hepatitis C virus: not so FAst. Liver Transpl 2009; 15:4-6. [PMID: 19109836 DOI: 10.1002/lt.21661] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Gurusamy KS, Kumar Y, Davidson BR. Methods of preventing bacterial sepsis and wound complications for liver transplantation. Cochrane Database Syst Rev 2008:CD006660. [PMID: 18843724 DOI: 10.1002/14651858.cd006660.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Bacterial sepsis and wound complications after liver transplantation increase mortality, morbidity, hospital stay, and overall transplant costs. OBJECTIVES To assess the benefits and harms of different methods aimed at preventing bacterial sepsis and wound complications in patients undergoing liver transplantation. SEARCH STRATEGY We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until June 2007. SELECTION CRITERIA We included only randomised clinical trials irrespective of language or publication status. DATA COLLECTION AND ANALYSIS We collected the data on infections, adverse effects of intervention, ITU (intensive therapy unit) stay, and hospital stay. We analysed the data with both the fixed-effect and the random-effects models using RevMan Analysis and risk ratio (RR) or weighted mean difference (WMD) with 95% confidence intervals (CI) based on intention-to-treat analysis. MAIN RESULTS We identified seven trials for inclusion including 614 patients. Four trials compared selective bowel decontamination versus placebo or no treatment. In one trial, patients were randomised to selective bowel decontamination, active lactobacillus with fibres (probiotic with prebiotic), or to inactivated lactobacillus with fibres (prebiotic). In another trial, different doses of granulocyte-colony stimulating factor and placebo were compared. The remaining two trials compared lactobacillus with fibres versus fibres alone and early enteral feeding versus no intervention. Only one trial was of low bias-risk. There was no statistically significant difference in any outcome between the selective bowel decontamination and the control groups. Selective bowel decontamination increased incidence of cholangitis (RR 4.84, 95% CI 1.15 to 20.35), incidence of bacterial infection (RR 3.63, 95% CI 1.36 to 9.74), and hospital stay (WMD 4.00, 95% CI 3.14 to 4.86) than the participants in the combined pre- and probiotic group. Hospital stay was prolonged in the selective bowel decontamination group compared to the prebiotic group. There was a statistically significant lower occurrence of urinary infection in the pre- and probiotic group than in the prebiotic group. The number of people experiencing gram-negative bacterial infection was not significantly lower in the probiotic group (RR 0.18, 95% CI 0.03 to 1.17). The ITU stay was lower in the probiotic group (WMD -1.41 days, 95% CI -2.09 to -0.73). There were no differences in any outcomes in the other comparisons. AUTHORS' CONCLUSIONS Currently, there is no clear evidence for any intervention offering significant benefits in the reduction of bacterial infections and wound complications in liver transplantation. Selective bowel decontamination increases the risk of infection and hospital stay compared to prebiotics and probiotics. The use of prebiotics and probiotics offers promise. Further randomised clinical trials are necessary.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, UK, NW3 2QG.
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Desai R, Jamieson NV, Gimson AE, Watson CJ, Gibbs P, Bradley JA, Praseedom RK. Quality of life up to 30 years following liver transplantation. Liver Transpl 2008; 14:1473-9. [PMID: 18825684 DOI: 10.1002/lt.21561] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Liver transplantation provides a return to a satisfactory quality of life (QOL) for the majority of patients in the short to medium term (first 5 years), but there is very little information on the QOL in the longer term and the factors influencing it. We therefore undertook a single-center cross-sectional analysis to determine QOL in patients 10 or more years after liver transplantation. All liver transplant recipients who were followed up at the Cambridge Transplant Unit for 10 or more years (transplanted between 1968 and 1994) and resident in the United Kingdom were asked to complete by post the Short Form 36 version 2 and the Ferrans and Powers questionnaires to evaluate their QOL. Univariate and multivariate analysis were performed to assess the relationship between a range of clinical parameters and QOL. One hundred two patients were invited to participate, and 61 (59.8%) responded. Overall, the patients reported a satisfactory QOL. On the Ferrans and Powers questionnaire, the patients had a mean Quality of Life Index score of 24.5. Factors associated with reduced physical functioning were age > 50 years at transplantation, female gender, and recurrence of the primary liver disease. On the Short Form 36 version 2 questionnaire, recipients had reduced physical functioning but normal mental health parameters in comparison with the normal population. Age > 60 years at the time of survey, female gender, and posttransplant complications were associated with reduced physical functioning. In conclusion, patients 10 or more years after liver transplantation generally have a good QOL, although physical functioning is reduced. Addressing issues such as recurrent disease and posttransplant problems such as osteoporosis may help to improve long-term QOL.
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Affiliation(s)
- Rajendra Desai
- National Institute for Health Research Comprehensive Biomedical Research Centre, Cambridge University Hospitals National Health Service Foundation Trust, Addenbrooke's Hospital, Cambridge, England.
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Saab S, Ibrahim AB, Surti B, Durazo F, Han S, Yersiz H, Farmer DG, Ghobrial RM, Goldstein LI, Tong MJ, Busuttil RW. Pretransplant variables associated with quality of life in liver transplant recipients. Liver Int 2008; 28:1087-94. [PMID: 18662279 DOI: 10.1111/j.1478-3231.2008.01831.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
OBJECTIVE With an increasing number of liver transplant recipients living, understanding quality-of-life issues is essential. Our goal is to identify pretransplant variables associated with post-transplant quality of life in liver transplant recipients. METHODS Three hundred and eight liver transplant recipients were administered the Short Form 36 and a basic demographical questionnaire. Variables associated with post-transplant quality of life were studied in a multivariate regression analysis. Interaction terms were used to examine effect modification. RESULTS Male gender, longer pretransplant work hours and interaction term between work hours and male gender were independently associated with Physical Functioning. Work hours positively correlated with Role-Physical, while viral hepatitis and ascites were negatively associated with Role-Physical. Ascites and viral hepatitis were independently negatively associated with Bodily Pain. Encephalopathy, hepatocellular carcinoma and viral hepatitis were independently associated with General Health. Ascites was also negatively associated with Social Functioning, Role-Emotional, Bodily Pain, General Health and Vitality. Viral hepatitis was negatively correlated with Vitality and Mental Functioning. CONCLUSIONS Pretransplant variables such as ascites, encephalopathy, hepatocellular carcinoma, viral hepatitis, work hours, time unable to work and gender were significantly associated with post-transplant quality of life in liver transplant recipients. Interventions addressing these issues may be initiated to improve the post-transplant quality of life.
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Affiliation(s)
- Sammy Saab
- Department of Medicine, University of California, Los Angeles, CA 90095, USA.
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Declining outcomes in simultaneous liver-kidney transplantation in the MELD era: ineffective usage of renal allografts. Transplantation 2008; 85:935-42. [PMID: 18408571 DOI: 10.1097/tp.0b013e318168476d] [Citation(s) in RCA: 138] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND When the United Network for Organ Sharing changed its algorithm for liver allocation to the model for end-stage liver disease (MELD) system in 2002, highest priority shifted to patients with renal insufficiency as a major component of their end-stage liver disease. An unintended consequence of the new system was a rapid increase in the number of simultaneous liver-kidney transplants (SLK) being performed yearly. METHODS Adult recipients of deceased donor liver transplants (LT, n=19,137), kidney transplants (n=33,712), and SLK transplants (n=1,032) between 1987 and 2006 were evaluated based on United Network for Organ Sharing data. Recipients were stratified by donor subgroup, MELD score, pre- versus post-MELD era, and length of time on dialysis. Matched-control analyses were performed, and graft and patient survival were analyzed by Kaplan-Meier and Cox proportional hazards analyses. RESULTS MELD era outcomes demonstrate a decline in patient survival after SLK. Using matched-control analysis, we are unable to demonstrate a benefit in the SLK cohort compared with LT, despite the fact that higher quality allografts are being used for SLK. Subgroup analysis of the SLK cohort did demonstrate an increase in overall 1-year patient and liver graft survival only in those patients on long-term dialysis (> or =3 months) compared with LT (84.5% vs. 70.8%, P=0.008; hazards ratio 0.57 [95% CI 0.34, 0.95], P=0.03). CONCLUSION These findings suggest that SLK may be overused in the MELD era and that current prioritization of kidney grafts to those liver failure patients results in wasting of limited resources.
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Shiffman ML, Rockey DC. Role and support for hepatologists at liver transplant programs in the United States. Liver Transpl 2008; 14:1092-9. [PMID: 18668665 DOI: 10.1002/lt.21523] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Liver transplantation has evolved into a successful option for patients with end-stage liver disease. Transplant hepatologists are involved in the management of patients with end-stage liver disease both before and after liver transplantation. The goals of this study were to evaluate the roles that transplant hepatologists play at liver transplantation programs in the United States and the demand for and institutional support provided for these physicians. A web-based questionnaire was sent via e-mail to the medical directors of all 108 United Network for Organ Sharing-recognized liver transplant programs during the fall of 2006. Follow-up e-mails were sent and phone calls were made to those not completing the survey within 4 weeks. The survey was completed by 72 (67%) medical directors. The average number of liver transplants performed per center was 62, and a broad range of program sizes were represented. The number of transplant hepatologists increased in proportion to the number of transplants performed on an annual basis but lagged behind the number of surgeons and transplant coordinators. On average, 33 liver transplants were performed per year per transplant hepatologist. Transplant hepatologists were involved in all aspects of pretransplant and posttransplant care at all but 10% of these institutions; they provided virtually all pretransplant care at all of these programs and all long-term posttransplant care at 45% of these programs. Overall, 94% of liver transplant programs provided direct salary support and/or ancillary personnel for their transplant hepatologists. Despite this, over half of transplant hepatologists and 75% of those that received no direct salary support performed endoscopic procedures on a regular basis. Eighty-one percent of programs were recruiting additional transplant hepatologists. In conclusion, although the vast majority of transplant hepatologists receive institutional support, this support appears to be inadequate. The current shortage of transplant hepatologists is likely to increase if appropriate support mechanisms are not implemented.
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Affiliation(s)
- Mitchell L Shiffman
- Hepatology Section and Liver Transplant Program, Virginia Commonwealth University Medical Center, Richmond, VA 23298, USA.
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Abstract
BACKGROUND The negative effects of increased donor age on liver transplantation became evident in deceased donor liver transplantation. In living donor liver transplantation (LDLT), the details remain unclear. METHODS Initially, 137 adult LDLT recipients from August 1996 to May 2005 were divided into two groups (donors <50 years of age: n=99, donors >or= 50 years of age: n=38) for the retrospective study. Then, 24 recipients who received LDLT from June 2005 to July 2006 were divided into two groups: group 1 (donors <50 years of age, n=14) and group 2 (donors >or= 50 years of age, n=10) and enrolled in the prospective study to analyze their clinical course and prognostic factors in the aged graft. RESULTS In the retrospective study, the younger donor group had significantly better survival than that of the aged donor group (P=0.015, Log rank test). In the prospective study, the postoperative graft functions showed that the serum total bilirubin levels were significantly lower in group 1 (P<0.02, by ANOVA analysis). The phosphorylated-Signal Transducer and Activator of Transcription3 expression at 4 hr after reperfusion (RT2) in group 2 was significantly lower than that in group 1. At RT2, the expressions were up-regulated in group 1, but were down-regulated in group 2. The serum 8-hydroxydeoxyguanosine value became significantly higher in group 1 two weeks after LDLT. CONCLUSIONS In the near term, Signal Transducer and Activator of Transcription3 gene induction during cold preservation may be of great use in improving the outcome of aged grafts in LDLT.
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Hot topics in liver transplantation: organ allocation--extended criteria donor--living donor liver transplantation. J Hepatol 2008; 48 Suppl 1:S58-67. [PMID: 18308415 DOI: 10.1016/j.jhep.2008.01.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Liver transplantation has become the mainstay for the treatment of end-stage liver disease, hepatocellular cancer and some metabolic disorders. Its main drawback, though, is the disparity between the number of donors and the patients needing a liver graft. In this review we will discuss the recent changes regarding organ allocation, extended donor criteria, living donor liver transplantation and potential room for improvement. The gap between the number of donors and patients needing a liver graft forced the transplant community to introduce an objective model such as the modified model for end-stage liver disease (MELD) in order to obtain a transparent and fair organ allocation system. The use of extended criteria donor livers such as organs from older donors or steatotic grafts is one possibility to reduce the gap between patients on the waiting list and available donors. Finally, living donor liver transplantation has become a standard procedure in specialized centers as another possibility to reduce the donor shortage. Recent data clearly indicate that center experience is of major importance in achieving good results. Great progress has been made in recent years. However, further research is needed to improve results in the future.
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Volk M, Marrero JA. Liver transplantation for hepatocellular carcinoma: who benefits and who is harmed? Gastroenterology 2008; 134:1612-4. [PMID: 18471530 DOI: 10.1053/j.gastro.2008.03.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Gurusamy KS, Mehta N, Davidson BR. Techniques of biliary reconstruction for liver transplantation. Hippokratia 2008. [DOI: 10.1002/14651858.cd007055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Hospital and University College School of Medicine; University Department of Surgery; 9th Floor, Royal Free Hospital Pond Street London UK NW3 2QG
| | - Naimish Mehta
- Royal Free Hospital and University College School of Medicine; University Department of Surgery; 9th Floor, Royal Free Hospital Pond Street London UK NW3 2QG
| | - Brian R Davidson
- Royal Free Hospital and University College School of Medicine; University Department of Surgery; 9th Floor, Royal Free Hospital Pond Street London UK NW3 2QG
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Facciuto ME, Koneru B, Rocca JP, Wolf DC, Kim-Schluger L, Visintainer P, Klein KM, Chun H, Marvin M, Rozenblit G, Rodriguez-Davalos M, Sheiner PA. Surgical treatment of hepatocellular carcinoma beyond Milan criteria. Results of liver resection, salvage transplantation, and primary liver transplantation. Ann Surg Oncol 2008; 15:1383-91. [PMID: 18320284 DOI: 10.1245/s10434-008-9851-z] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2008] [Revised: 02/04/2008] [Accepted: 02/04/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is no clear consensus regarding the best treatment strategy for patients with advanced hepatocellular carcinoma (HCC). METHODS Patients with cirrhosis and HCC beyond Milan who had undergone liver resection (LR) or primary orthotopic liver transplantation (OLT) between November 1995 and December 2005 were included in this study. Pathological tumor staging was based on the American Liver Tumor Study Group modified Tumor-Node-Metastasis classification. RESULTS A total of 23 HCC patients were primarily treated by means of LR, 5 of whom eventually underwent salvage OLT. An additional 32 patients underwent primary OLT. The overall actuarial survival rates at 3 and 5 years were 35% after LR, and 69% and 60%, respectively, after primary OLT. Recurrence-free survival at 5 years was significantly higher after OLT (65%) than after LR (26%). Of the patients who underwent LR, 11 (48%) experienced HCC recurrence only in the liver; 6 of these 11 presented with advanced HCC recurrence, poor medical status, or short disease-free intervals and were not considered for transplantation. Salvage OLT was performed in 5 patients with early stage recurrence (45% of patients with hepatic recurrence after LR and 22% of all patients who underwent LR). At a median of 18 months after salvage OLT, all 5 patients are alive, 4 are free of disease, and 1 developed HCC recurrence 16 months after salvage OLT. CONCLUSION For patients with HCC beyond Milan criteria, multimodality treatment-including LR, salvage OLT, and primary OLT-results in long-term survival in half of the patients. When indicated, LR can optimize the use of scarce donor organs by leaving OLT as a reserve option for early stage HCC recurrence.
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Affiliation(s)
- Marcelo E Facciuto
- Liver Transplant & Hepatobiliary Service, Westchester Medical Center, New York Medical College, 95 Grasslands Road, Valhalla, New York 10595, USA.
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Schaubel DE, Sima CS, Goodrich NP, Feng S, Merion RM. The survival benefit of deceased donor liver transplantation as a function of candidate disease severity and donor quality. Am J Transplant 2008; 8:419-25. [PMID: 18190658 DOI: 10.1111/j.1600-6143.2007.02086.x] [Citation(s) in RCA: 244] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The survival benefit of liver transplantation depends on candidate disease severity, as measured by MELD score. However, donor liver quality may also affect survival benefit. Using US data from the SRTR on 28 165 adult liver transplant candidates wait-listed between 2001 and 2005, we estimated survival benefit according to cross-classifications of candidate MELD score and deceased donor risk index (DRI) using sequential stratification. Covariate-adjusted hazard ratios (HR) were calculated for each liver transplant recipient at a given MELD with an organ of a given DRI, comparing posttransplant mortality to continued wait-listing with possible later transplantation using a lower-DRI organ. High-DRI organs were more often transplanted into lower-MELD recipients and vice versa. Compared to waiting for a lower-DRI organ, the lowest-MELD category recipients (MELD 6-8) who received high-DRI organs experienced significantly higher mortality (HR = 3.70; p < 0.0005). All recipients with MELD > or =20 had a significant survival benefit from transplantation, regardless of DRI. Transplantation of high-DRI organs is effective for high but not low-MELD candidates. Pairing of high-DRI livers with lower-MELD candidates fails to maximize survival benefit and may deny lifesaving organs to high-MELD candidates who are at high risk of death without transplantation.
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Affiliation(s)
- D E Schaubel
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA.
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