Liver transplantation in the UK

Long-term outcomes of liver transplant recipients followed up in non-transplant centres: Care closer to home

INTRODUCTION

Increasing rates of liver transplantation and improved outcomes have led to greater numbers of transplant recipients followed up in non-transplant centres. Our aim was to document long-term clinical outcomes of liver transplant recipients managed in this 'hub-and-spoke' healthcare model.

METHODS

A retrospective analysis of all adult patients who underwent liver transplantation between 1987 and 2016, with post-transplant follow-up in two non-transplant centres in the UK (Nottingham) and Canada (Ottawa), was performed.

RESULTS

The 1-, 5-, 10- and 20-year patient survival rates were 98%, 95%, 87% and 62%, and 100%, 96%, 88% and 62% in the Nottingham and Ottawa groups, respectively (p=0.87). There were no significant differences between the two centres in 1-, 5-, 10- and 20-year cumulative incidence of death-censored graft-survival (p=0.10), end-stage renal disease (p=0.29) or de novo cancer (p=0.22). Nottingham had a lower incidence of major cardiovascular events (p=0.008).

CONCLUSION

Adopting a new model of healthcare provides a means of delivering post-transplant patient care close to home without compromising patient survival and long-term clinical outcomes.

A Multicenter Japanese Survey Assessing the Long-term Outcomes of Liver Retransplantation Using Living Donor Grafts

BACKGROUND

Liver transplantation is the most suitable treatment option available for end-stage liver disease. However, some patients require retransplantation, despite medical advances that have led to improved survival. We aimed to compile a definitive, nationwide resource of liver retransplantation data in Japan, seeking to identify the predictors of patient survival posttransplantation.

METHODS

Questionnaires were sent to 32 institutions that had conducted 281 retransplantations before 2015.

RESULTS

Among the 265 patients included in this study (142 pediatric cases), the average age at primary transplantation was 23 years, and retransplantation was performed after an average of 1468 days. The main indication for retransplantation was graft rejection (95 patients). Living-donor liver transplantation accounted for 94.7% of primary transplantations and 73.2% of retransplantations. Patient survival at 1, 3, or 5 years did not differ by type of transplantation but was better for pediatric (70.8%, 68.3%, and 60.1%, respectively) than for adult (57.2%, 50.4%, and 45.2%, respectively) recipients (P = 0.0003). Small-for-size syndrome, retransplantation within 365 days, and inpatient status at retransplantation were significant predictors of poor survival in pediatric cases. Retransplantation within 365 days and conditions warranting retransplantation were significant predictors of poor survival in adult patients.

CONCLUSIONS

In Japan, where >70% of retransplantations are performed using living donors, the indications and timing are different from those in previous reports from other countries, while maintaining comparable survival rates. Considering technical challenges, graft failure within 365 days should be thoroughly restricted to justify the use of living donor.

Transplanting Patients with Alcohol-related Liver Disease in the National Health System: New Rules and Decisions

Aims

The UK has a socialized healthcare system that provides treatment that is free at the point of care for acute and chronic health disorders (the National Health Service-NHS), which is currently experiencing a period of unprecedented challenge.

Methods

A narrative review that discusses present and future arrangements for transplantation of alcohol-related liver disease (ArLD) in the UK.

Results

Liver disease in the UK is reaching epidemic proportions due to obesity and metabolic disease compounding alcohol-mediated liver damage. Unfortunately, hepatology services in the UK are geographically disparate and subject to significant variations in liver morbidity and mortality, prompting concerns that this may negatively impair access to transplantation. In an attempt to improve referrals to tertiary liver services, the UK listing criteria for alcohol-associated liver disease were revised in 2016 by a working party under the aegis of the UK-Liver Advisory Group with the ambition of increasing opportunities for disease evaluation and improving the condition of candidates referred for assessment.

Conclusion

Liver transplantation for ArLD is well established in the UK. Recent organizational changes seek to reduce inequities in access to transplant services.

Short Summary

Liver disease in the UK is reaching epidemic proportions. Concerns over equity of access to liver transplantation prompted revision of the UK listing criteria for alcohol-associated liver disease in 2016, to improve to the availability of tertiary hepatology services. Transplanting patients with alcohol-related liver disease in the National Health System: New Rules and Decisions '…The second property of your excellent sherris is, the warming of the blood; which, before cold and settled, hath left the liver white and pale…'Falstaff; Henry IV Part 2: Act 4, Scene 3.

Trends in liver transplantation 2011

This review will highlight some of the important recent trends in liver transplantation. When possible, we will compare and contrast these trends across various regions of the world, in an effort to improve global consensus and better recognition of emerging data.

Clinical usefulness of measuring red blood cell distribution width in patients with hepatitis B

Background

Red blood cell distribution width (RDW), an automated measure of red blood cell size heterogeneity (e.g., anisocytosis) that is largely overlooked, is a newly recognized risk marker in patients with cardiovascular diseases, but its role in persistent viral infection has not been well-defined. The present study was designed to investigate the association between RDW values and different disease states in hepatitis B virus (HBV)-infected patients. In addition, we analyzed whether RDW is associated with mortality in the HBV-infected patients.

Methodology/Principal Findings

One hundred and twenty-three patients, including 16 with acute hepatitis B (AHB), 61 with chronic hepatitis B (CHB), and 46 with chronic severe hepatitis B (CSHB), and 48 healthy controls were enrolled. In all subjects, a blood sample was collected at admission to examine liver function, renal function, international normalized ratio and routine hematological testing. All patients were followed up for at least 4 months. A total of 10 clinical chemistry, hematology, and biochemical variables were analyzed for possible association with outcomes by using Cox proportional hazards and multiple regression models. RDW values at admission in patients with CSHB (18.30±3.11%, P<0.001), CHB (16.37±2.43%, P<0.001) and AHB (14.38±1.72%, P<0.05) were significantly higher than those in healthy controls (13.03±1.33%). Increased RDW values were clinically associated with severe liver disease and increased 3-month mortality rate. Multivariate analysis demonstrated that RDW values and the model for end-stage liver disease score were independent predictors for mortality (both P<0.001).

Conclusion

RDW values are significantly increased in patients with hepatitis B and associated with its severity. Moreover, RDW values are an independent predicting factor for the 3-month mortality rate in patients with hepatitis B.

Emerging roles for biomaterials in the treatment of liver disease

This review explores potential roles for biomaterials in the field of liver surgery and hepatology. The studies reviewed are presented in three sections. The first section discusses liver regeneration and strategies to modulate it. The second section outlines the pathophysiology of liver inflammation and fibrosis and highlights novel therapeutic targets. The final section summarises the current challenges in liver surgery and discusses how biomaterials may be used to address these challenges and focuses on early translational applications for biomaterials for drug delivery and liver surgery.

A novel model for evaluating the risk of hepatitis B recurrence after liver transplantation

BACKGROUND

Hepatitis B virus (HBV) recurrence is a major risk factor affecting the long-term survival of recipients for liver transplantation (LTx). Therefore, a model that can assess this risk before transplantation is highly desirable.

METHODS

One hundred and eighty-five consecutive liver transplant recipients because of HBV-related end-stage liver diseases were selected. Their perioperative laboratory examination results, treatment protocol and the status of HBV recurrence were the primary parameters used to assess their risk of post-transplant HBV recurrence. A model that may be generally used to evaluate the risk of post-transplant HBV recurrence was thus established. A cohort for further validation and a cross-validation were designed.

RESULTS

After a follow-up time of 26.0 ± 10.8 months, the overall HBV recurrence rate was 8.6%. The 1-, 2- and 3-year cumulative survival rates were 98.5, 89.2 and 83.4% respectively. By correlation with the pretransplant presence of hepatocelluar carcinoma (HCC), serum HBV DNA level and status of antiviral treatment (AVT), the risk assessment model can be summarized using the following equation: RISK=-4.378 + 1.493 × HCC + 1.286 × DNA - 2.426 × AVT. The HBV recurrence rate and survival were found to be significantly different between the recipients with risk scores ≤-2.8 and >-2.8. The model was well validated in this work.

CONCLUSIONS

Pretransplant HBV DNA level, presence of HCC, AVT status and post-transplant viral mutation were identified as the major risk factors associated with HBV recurrence after LTx. A novel model incorporating these factors could effectively evaluate the risk of post-transplant HBV recurrence before transplantation.

Liver retransplantation in adults: a single-centre, 25-year experience

BACKGROUND

Retransplantation is the only form of treatment for patients with irreversible graft failure. The aim of this study was to analyse a single centre's experience of the indications for and outcomes of retransplantation.

METHODS

A total of 196 patients who underwent liver retransplantation using 225 grafts, between January 1982 and July 2007, were included in the study. The following parameters were analysed: patient demographics; primary diagnosis; distribution of retransplantation over different time periods; indications for retransplantation; time interval to retransplantation, and overall patient and graft survival.

RESULTS

Of the 2437 primary orthotopic liver transplantations, 196 patients (8%) required a first regraft, 23 patients (1%) a second regraft and six patients (0.25%) a third regraft. Autoimmune hepatitis was the most common primary diagnosis for which retransplantation was required (12.7% of primary transplantations). The retransplantation rate declined from 12% at the beginning of our programme to 7.6% at the end of the study period. The most common indication for retransplantation was hepatic artery thrombosis (31.6%). Nearly two-thirds of the retransplantations were performed within 6 months of the primary transplantation. The 1-, 3-, 5- and 10-year patient survival rates following first retransplantation were 66%, 61%, 57% and 47%, respectively. Five-year survival after second retransplantation was 40%. None of the patients have yet survived 3 years after a third regraft. Donor age of < or =55 years and a MELD (Model for End-stage Liver Disease) score of < or =23 were associated with better outcome following retransplantation.

CONCLUSIONS

First retransplantation was associated with good longterm survival. There was no survival benefit following second and third retransplantations. A MELD score of < or =23 and donor age of < or =55 years correlated with better outcome following retransplantation.

Formation of microchimerism in rat small bowel transplantation by splenocyte infusion

AIM: To investigate the effect of donor splenocyte infusion combined with cyclosporine A (CsA) on rejection of rat small bowel transplantation (SBT).

METHODS: Male Sprague-Dawley (SD) rats and female Wistar rats weighing 230-270 g were used as donors and recipients respectively in the study. Heterotopic small bowel transplantation was performed. The rats were divided into three groups: group one receiving allotransplantation (SD→Wistar), group two receiving allotransplantation (SD→Wistar) + donor splenocyte infusion, group three receiving allotransplantation (SD→Wistar) + donor splenocyte infusion + CsA followed by CsA 10 mg/kg per day after transplantation, in which recipient Wistar rats were injected with 2 ×10⁸ SD splenocytes 28 d before transplantation, and treated with CsA after transplantation. Finally, the specific DNA fragment of donor Y chromosome was detected in recipient peripheral blood and skin by PCR. The survival time after small bowel transplantation was observed. Gross and histopathological examinations were performed.

RESULTS: The survival time after small bowel trans-plantation was 7.1 ± 1.2 d in group 1, 18.4 ± 3.6 d in group 2 and 31.5 ± 3.1 d in group 3. The survival time was significant longer (P < 0.01) in group 3 than in groups 1 and 2. The gross and histopathological examination showed that the rejection degree in group 3 was lower than that in groups 1 and 2.

CONCLUSION: Donor splenocyte infusion combined with CsA decreases remarkably the rejection and prolongs the survival time after rat small bowel transplantation.

Mil trasplantes hepáticos en el Hospital Clínic i Provincial de Barcelona

The aim of this study was to evaluate a consecutive series of 1000 liver transplants performed in our institution and to evaluate changes over time in donors and recipients, as well as results.

MATERIAL AND METHOD

To clearly evaluate the differences between the initial transplantation period and the present period, the first 100 consecutive liver transplantations performed (June 1988-June 1990) and the last 200 consecutive liver transplantations performed (January 2001-June 2003) were compared.

RESULTS

Donor age increased (23+/-10 vs. 45+/-19), the etiology of brain death changed (severe head injury: 78% vs. 23.5%; stroke: 17% vs. 52.5%) and the percentage of donors from alternative methods to cadaveric donors increased (living donors: 12.5%) in the second period. Regarding recipients, the piggy-back technique and biliary anastomosis without T-tube were introduced in the second period. Actuarial 1-year survival was higher in the second period than in the first (84% vs. 91.3%). The need for retrasplantation in the entire series was 9.5%, with actuarial survival at 1, 5 and 10 years of 67.7%, 51.3% and 39.4%, respectively.

CONCLUSION

Because of the lack of donors and the greater number of patients on the waiting list, poorer quality donors and more critical recipients have been accepted and alternative and innovative programs have been started. Nevertheless, due to improvement in patient management before, during and after transplantation, the previous good results have been maintained.

Establishment of a new pig model for auxiliary partial orthotopic liver transplantation

AIM: To establish a new pig model for auxiliary partial orthotopic liver transplantation (APOLT).

METHODS: The liver of the donor was removed from its body. The left lobe of the liver was resected in vivo and the right lobe was used as a graft. After the left lateral lobe of the recipient was resected, end-to-side anastomoses of suprahepatic inferior vena cava and portal vein were performed between the donor and recipient livers, respectively. End-to-end anastomoses were made between hepatic artery of graft and splenic artery of the host. Outside drainage was placed in donor common bile duct.

RESULTS: Models of APOLT were established in 5 pigs with a success rate of 80%. Color ultrasound examination showed an increase of blood flow of graft on 5^th d compared to the first day after operation. When animals were killed on the 5^th d after operation, thrombosis of hepatic vein (HV) and portal vein (PV) were not found. Histopathological examination of liver samples revealed evidence of damage with mild steatosis and sporadic necrotic hepatocytes and focal hepatic lobules structure disorganized in graft. Infiltration of inflammatory cells was mild in portal or central vein area. Hematologic laboratory values and blood chemical findings revealed that compared with group A (before transplantation), mean arterial pressure (MAP), central venous pressure (CVP), buffer base (BB), standard bicarbonate (SB) and K⁺ in group B (after portal vein was clamped) decreased (P<0.01). After reperfusion of the graft, MAP, CVP and K+ restored gradually.

CONCLUSION: Significant decrease of congestion in portal vein and shortened blocking time were obtained because of the application of in vitro veno-venous bypass during complete vascular clamping. This new procedure, with such advantages as simple vessel processing, quality anastomosis, less postoperative hemorrhage and higher success rate, effectively prevents ischemia reperfusion injury of the host liver and deserves to be spread.

Incidence and treatment of hepatic artery complications after orthotopic liver transplantation

AIM: To investigate the incidence and treatment of hepatic artery complications after orthotopic liver transplantation.

METHODS: From February 1999 to May 2002, orthotopic liver transplantations (OLT) were performed in 72 patients with end-stage liver diseases with an average age of 40.2 ± 13.6 years (ranged from 11 to 68 years), 56 were males and 16 females. The preoperative evaluation for the 72 patients was performed using duplexsonography, abdominal CT scan, and angiography of the hepatic artery. All donor grafts were perfused and preserved in University of Wisconsin solution at 4 °C. OLT was performed with standard techniques with or without a veno-venous bypass. Reconstructions of hepatic artery were performed between the branch patches of gastroduodenal/hepatic or splenic/common hepatic artery confluence of the donors and recipients, and an end-to-end anastomosis between other arterial vessels of the donors and recipients was done. Arterial anastomosis was performed with interrupted 7-0/8-0 monofilament polypropylene suture under 3.5 x loupe magnification. Diagnosis of the complications of hepatic artery after OLT was based on the clinical presentations, ultrasound findings and arterial angiography. All patients were followed up regularly for duplex ultrasound scan after discharge.

RESULTS: The overall incidence of arterial complications in 72 patients after OLTs was 1.4% (1/72). One 3 cm pseudoaneurysm at the side of anastomotic site of hepatic artery was found by urgent arteriogram due to hemoperitoneum secondary to bile leakage after OLT. Subsequently the pseudoaneurysm was successfully embolized and the blood flow toward the donor liver in hepatic artery remained. The overall postoperative 30-day mortality rate was 8.33%. The one-year survival rate was 83.72% in 50 patients with benign diseases and was 71.43% in 22 patients with malignant diseases following OLT. No death associated with complications of hepatic artery occurred.

CONCLUSION: Careful preoperative evaluations and intraoperative microsurgical technique for hepatic artery reconstructions are the keys in prevention of hepatic artery complications after OLT.

Influence of liver nonparenchymal cell infusion combined with cyclosporin A on rejection of rat small bowel transplantation

AIM: To investigate the effect of liver nonparenchymal cell infusion combined with cyclosporin A (CsA) on rejection of heterostrain rat small bowel transplantation.

METHODS: The liver nonparenchymal cell suspension was prepared by density gradient centrifugation method with Percoll centrifugal solution. Heterotopic small bowel transplantation was performed. Then the rats were divided into four groups. Group one: homogenic transplantation (F344/N→F344/N), group two: allotransplantation (F344/N →Wistar), group three: allotransplantation (F344/N→Wistar) + CsA, with CsA 10 mg·kg^-1·d^-1 after transplantation, group four: allotransplantation + CsA (F344/N→Wistar) + liver nonparenchymal cell infusion + CsA (F344/N→Wistar), in which recipient Wistar rats had been injected with 2 × 10⁸ F344/N liver nonparenchymal cells 20 days before transplantation, and treated with CsA after transplantation. Finally, the survival time after small bowel transplantation, gross and histopathological examination, and IL-2 levels in serum were observed.

RESULTS: The survival time after small bowel transplantation was 7.14 ± 0.33 d, 16.32 ± 0.41 d and 31.41 ± 0.74 d in group 2, 3, and 4, respectively. The survival time was significant longer (P < 0.01) in group 4. The gross and histopathological examination showed that the rejection degree in group 4 was lower than those in groups 2 and 3. Serum IL-2 level in group 4 was also lower than those in groups 2 and 3 (P < 0.01).

CONCLUSION: Liver nonparenchymal cell infusion combined with CsA can prolong the survival time of rat small bowel transplantation, and the anti-rejection effect is good.

Cognitive dysfunction and health-related quality of life in long-term liver transplant survivors

Although several studies have investigated short-term effects of liver transplantation on cognitive function and health-related quality of life, there have been no studies looking at long-term effects. Patients who received a single liver transplant at St James's University Hospital (Leeds, UK) before October 1, 1991, were invited to participate in this cross-sectional study. Cognitive function was assessed using the Mini-Mental State Examination, the Rey Auditory Verbal Learning Test, trail-making tests, the Stroop test, and the Benton Visual Retention Test. Anxiety and depression were documented using the Hospital Anxiety and Depression Scale. Health-related quality of life was assessed using the EuroQol. Twenty-five healthy volunteers acted as controls. Thirty-six patients had undergone transplantation before October 1, 1991. Thirteen patients (36%) had died, 6 patients had received more than one transplant, 2 patients did not speak English, and 3 patients did not want to participate, leaving 12 patients included in the study. Patients scored significantly lower on measures of health-related quality of life than healthy controls, but there were no differences in levels of anxiety or depression. Patients scored significantly lower than controls across a wide range of cognitive functions, suggesting global cognitive impairment. We show that patients who survive for more than 10 years after liver transplantation have significant cognitive dysfunction and poor health-related quality of life. Whether these patients never return to normal after transplantation or whether they experience an increased rate of decline in cognitive function and health-related quality of life is uncertain and requires further study.

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Modifications in combined liver-small bowel transplantation in pigs

AIM: To introduce combined liver-small bowel transplantation in pigs.

METHODS: Eighteen transplantations in 36 large white pigs were performed. Three modifications in combined liver-small bowel transplantation model were applied: Veno-venous bypass was not used. Preservation of the donor duodenum and head of pancreas in continuity with the combined graft to avoid biliary reconstruction. The splenic vein of donor was anastomosed end-to-end with the portal vein of recipients by the formation of a “cuff”.

RESULTS: Without immunosuppressive therapy, 72-hour survival rate of the transplanted animals was 72% (13/18). Five of 18 pigs operated died of respiratory failure (3 cases) and bleeding during hepatectomy (2 cases). The longest survival time of animals was 6 days.

CONCLUSION: Our surgical modifications are feasible and reliable, which have made the transplantation in pigs simpler and less aggressive, and thus these can be used for preclinical study.

Influence of intrauterine injection of rat fetal hepatocytes on rejection of rat liver transplantation

AIM: To investigate the influence of immune tolerance induced by intrauterine exposure to fetal hepatocytes on liver transplantation in the adult rat.

METHODS: LOU/CN rat fetal hepatocytes were injected into the fetuses of pregnant CHN rats (14-16 days of gestation). At 7-9 weeks of age, the surviving male rats received orthotopic liver transplantation (OLT) from male LOU/CN donors and the survival period was observed and monitered by mixed lymphocyte reaction assay and cytotoxicity test.

RESULTS: (1) A total of 31 pregnant CHN rats with 172 fetuses received fetal hepatocytes from LOU/CN rats via intrauterine injection. Among them, thirteen pregnant rats showed normal parturition, with 74 neonatal rats growing up normally. (2) The mean survival period after OLT in rats with fetal exposure to fetal hepatocytes was 32.1 ± 3.7 days, which was significantly different from the control (11.8 ± 2.3 days, P < 0.01) in rats without fetal induction of immune tolerance. (3) Mixed lymphocyte proliferation assays yielded remarkable discrepancies between the groups of rats with- or without fetal exposure to fetal hepatocytes, with values of 8411 ± 1361 and 22473 ± 1856 (CPM ± SD, P < 0.01) respectively. (4) Cytotoxicity assays showed values of 21.2 ± 6.5% and 64.5 ± 7.2% (P < 0.01) in adult rats with or without fetal induction of immune tolerance.

CONCLUSION: Intrauterine injection of fetal hepatocytes into rat fetuses can prolong the survival period of liver transplant adult male rats recipients, inducting immune tolerance in OLT.

Combined small bowel and reduced auxiliary liver transplantation: Case report

AIM: To present a case of combined small bowel and reduced auxiliary liver transplantation.

METHODS: A 55-year-old patient with short bowel syndrome and TPN-related liver dysfunction received small bowel transplantation combined with a reduced auxiliary liver graft. A liver was added to restore the patient's liver function and to protect the intestinal allograft from rejection. His own liver was not removed.

RESULTS: Without donor pretreatment and by conventional immunosuppresive therapy following transplantation, the patient experienced had only one episode of mild intestinal rejection, which was easily reversed by treatment with Methylprednisolone. No liver rejection occurred. Unfortunately, the patient died of heart and lung failure 30 d after transplantation, despite successful graft replacement. Histopathologic examination of specimens after death demonstrated normal structure in both intestinal and liver grafts.

CONCLUSION: The auxiliary liver graft might play a role in preventing intestinal allograft rejection. However, the observation period in this case is short. Further study is needed to determine the risks, effect on the protecting the small-bowel from rejection, and feasibility of general application of this procedure.

DNA-PKcs subunits in radiosensitization by hyperthermia on hepatocellular carcinoma hepG2 cell line

AIM: To investigate the role of DNA-PKcs subunits in radiosensitization by hyperthermia on hepatocellular carcinoma HepG₂ cell lines.

METHODS: HepG₂ cells were exposed to hyperthermia and irradiation. Hyperthermia was given at 45.5 °C. Cell survival was determined by an in vitro clonogenic assay for the cells treated with or without hyperthermia at various time points. DNA DSB rejoining was measured using asymmetric field inversion gel electrophoresis (AFIGE). The DNA-PKcs activities were measured using DNA-PKcs enzyme assay system.

RESULTS: Hyperthermia can significantly enhance irradiation-killing cells. Thermal enhancement ratio as calculated at 10% survival was 2.02. The difference in radiosensitivity between two treatment modes manifested as a difference in the α components and the almost same β components, which α value was considerably higher in the cells of combined radiation and hyperthermia as compared with irradiating cells (1.07 Gy^-1vs 0.44 Gy^-1). Survival fraction showed 1 logarithm increase after an 8-hour interval between heat and irradiation, whereas DNA-PKcs activity did not show any recovery. The cells were exposed to heat 5 min only, DNA-PKcs activity was inhibited at the nadir, even though the exposure time was lengthened. Whereas the ability of DNA DSB rejoining was inhibited with the increase of the length of hyperthermic time. The repair kinetics of DNA DSB rejoining after treatment with Wortmannin is different from the hyperthermic group due to the striking high slow rejoining component.

CONCLUSION: Determination with the cell extracts and the peptide phosphorylation assay, DNA-PKcs activity was inactivated by heat treatment at 45.5 °C, and could not restore. Cell survival is not associated with the DNA-PKcs inactivity after heat. DNA-PKcs is not a unique factor affecting the DNA DSB repair. This suggests that DNA-PKcs do not play a crucial role in the enhancement of cellular radiosensitivity by hyperthermia.