Liver transplantation in Turkey: The importance of experience

Approach to Liver Transplantation: Is There a Difference between East and West?

Liver transplantation (LT) remains the only curative treatment for end-stage liver disease as well as acute liver failure. With the exponential increase in organ demand due to the increasing incidence and prevalence of liver diseases, the need to overcome the supply and demand mismatch has arisen. In this review, we discuss the current universal status of LT, emphasizing various LT practices worldwide.

Contribution of Turkey in Liver Transplant Research: A Scopus Database Search

OBJECTIVES

Liver transplantation is considered the most effective treatment modality for end-stage liver failure. The first deceased donor liver transplant in Turkey was performed by Haberal and colleagues in 1988; in 2019, a total of 1776 livertransplant procedures were performed in Turkey. While these are well-known and documented facts, the scientific output of publications on liver transplantation from Turkey is unknown.This study aimed to analyze the contribution of Turkey in liver transplant global research.

MATERIALS AND METHODS

Publications from Turkey on liver transplantation were analyzed using the bibliometric study method. The following research parameters were analyzed: year of publication, institutions and authors, funding, themes, sample population, and methods. We used the Scopus database to research key words containing "liver" or "hepatic"and"transplantation" in the titles, abstracts, and key words. Among duplications or multiple results, only 1 publication was included in the study. Data were analyzed by quantitative and qualitative methods.

RESULTS

We identified 45 763 publications on liver transplant. Most of the publications were in the field of medicine (93.48%). Turkey ranked fourteenth with 843 publications. The top productive affiliation was Başkent University, and the most productive author was Prof. Haberal.

CONCLUSIONS

Among countries, Turkey had the most living donor liver transplants in 2019 and could serve as a modelto European countries for donor shortages. Although the United States performs 5 times more liver transplants than Turkey, their publications rate was almost 22 times more. Combining a workload of performing research and publishing along with transplant surgery is together hard to master. Although Turkey has valuable experiences and has opened frontiers in transplantation, publications need to keep up with their hard work and innovations.

A brief history of liver transplantation and transplant anesthesia

In this review, we describe the major milestones in the development of organ transplantation with a specific focus on hepatic transplantation. For many years, the barriers preventing successful organ transplantation in humans seemed insurmountable. Although advances in surgical technique provided the technical ability to perform organ transplantation, limited understanding of immunology prevented successful organ transplantation. The breakthrough to success was the result of several significant discoveries between 1950 and 1980 involving improved surgical techniques, the development of effective preservative solutions, and the suppression of cellular immunity to prevent graft rejection. After that, technical innovations and laboratory and clinical research developed rapidly. However, these advances alone could not have led to improved transplant outcomes without parallel advances in anesthesia and critical care. With increasing organ demand, it proved necessary to expand the donor pool, which has been achieved with the use of living donors, split grafts, extended criteria organs, and organs obtained through donation after cardiac death. Given this increased access to organs and organ resources, the number of transplantations performed every year has increased dramatically. New regulatory organizations and transplant societies provide critical oversight to ensure equitable organ distribution and a high standard of care and also perform outcome analyses. Establishing dedicated transplant anesthesia teams results in improved organ transplantation outcomes and provides a foundation for developing new standards for other subspecialties in anesthesiology, critical care, and medicine overall. Through a century of discovery, the success we enjoy at the present time is the result of the work of well-organized multidisciplinary teams following standardized protocols and thereby saving thousands of lives worldwide each year. With continuing innovation, the future is bright.

Regional and National Trends of Adult Living Donor Liver Transplantation in the United States Over the Last Two Decades

BACKGROUND AND AIMS

Liver organ shortage remains a major health burden in the US, with more patients being waitlisted than the number of liver transplants (LTs) performed. This study investigated US national and regional trends in living donor LT (LDLT) and identified factors associated with recipient survival.

METHODS

We retrospectively analyzed LDLT recipients and donors from the United Network Organ Sharing/Organ Procurement Transplant Network database from 1998 until 2019 for clinical characteristics, demographic differences, and survival rate. National and regional trends in LDLT, recipient outcomes, and predictors of survival were analyzed.

RESULTS

Of the 223,571 candidates listed for an LT, 57.5% received an organ, of which only 4.2% were LDLTs. Annual adult LDLTs first peaked at 412 in 2001 but experienced a significant decline to 168 by 2009. LDLTs then gradually increased to 445 in 2019. Region 2 had the highest LDLT numbers (n=919), while region 1 had the highest proportion (11.1%). Overall, post-LT mortality was 21.4% among LDLT recipients. Post-LDLT survival rates after 1-, 5-, and 10-years were 92%, 87%, and 70%, respectively. Interval analysis (2004-2019) showed that patients undergoing LDLT in recent years had lower mortality than in earlier years (hazard ratio=0.81, 95% confidence interval=0.75-0.88).

CONCLUSIONS

Following a substantial decline after a peak in 2001, the number of adult LDLTs steadily increased from 2011 to 2019. However, LDLTs still constitute the minority of the transplant pool in the US. Life-saving policies to increase the use of LDLTs, particularly in regions of high organ demand, should be implemented.

Clinical Outcomes of Liver Transplantation for Patients Over 60 Years Old: A Single-Center Experience

OBJECTIVES

Although advanced age is no longer considered an absolute contraindication for liver transplant, transplant in elderly patients with comorbid diseases remains debatable because of high risks with surgery. Here, we report patient outcomes in this population.

MATERIALS AND METHODS

We retrospectively reviewed medical records of 276 liver transplant recipients, grouped by age. Group 1 (≤59 years old) consisted of 247 recipients, and group 2 (≥60 years old) consisted of 29 recipients. Reviewed data included age, sex, cause of liver disease, presence of hepatocellular carcinoma, Child-Pugh and Model for End-Stage Liver Disease scores, survival, and posttransplant complications.

RESULTS

In both groups, most patients (n = 108) required liver transplant for hepatitis B virus. Mean age was 40 ± 12.3 and 63 ± 2.3 years in groups 1 and 2, respectively, with more men than women in both group 1 (71.7% vs 28.3%) and group 2 (75.9% vs 24.1%). No significant differences were shown between groups for patient characteristics, except group 1 had significantly higher Model for End-Stage Liver Disease score. Group 1 mean survival time was 10.2 ± 0.6 years, with patient survival rates at 1, 5, 10, and 15 years of 65.5%, 53%, 46.3%, and 40%, respectively. In group 2, respective results were 10.6 ± 1.3 years and 75.9%, 68.6%, 61%, and 48.8% (no significant difference vs group 1).

CONCLUSIONS

Liver transplant recipients >60 years of age had survival rates, acute rejection rates, and complications similar to younger recipients. Liver transplant should not be withheld from older recipients on the basis of age alone. However, comprehensive screening for comorbidities should be performed.

Changes in the clinical characteristics of chronic hepatitis B patients at the initiation of treatment over a 15-year period

Background and Aim

This study aimed to evaluate the changes in the clinical characteristics of chronic Hepatitis B (CHB) patients at the initiation of treatment over a 15-years period.

Materials and Methods

The study included 659 treatment-naive CHB patients who started receiving nucleos(t)ide analogs between January 2006 and December 2020. The patients included in the study were divided into three groups of five years each, according to the start date of treatment.

Results

The mean age was 46.2±14.5 years and 445 (67.5%) were male. Two hundred and five (31.1%) patients had cirrhosis. Hepatocellular carcinoma (HCC) developed in forty-one patients (6.2%). Compared to patients in Group 1, Group 2 were younger and had lower decompensated cirrhosis, HCC and ascites, had higher Child A cirrhosis (all p<0.05). Cirrhosis and esophageal varices were higher in patients in Group 3 compared to patients in Group 2 (all p<0.05). Entecavir or tenofovir use increased from 66.5% in Group 1 to 99.2% in Group 3 (p<0.05).

Conclusion

The mean age at initiation of treatment for CHB patients increased. The patients had less cirrhosis. In the last 5 years, almost all patients were treated with entecavir or tenofovir.

The position of transarterial chemoembolization with drug-eluting beads and yttrium-90 transarterial radioembolization in patients with hepatocellular carcinoma: Consensus statements from a Delphi-method expert panel in Turkey

PURPOSE

Clinical studies conducted in different geographic regions using different methods to compare transarterial chemoembolization (TACE) and transarterial radioembolization (TARE) have demonstrated discordant results. Meta-analyses in this field indicate comparable overall survival (OS) with TACE and TARE, while reporting a longer time to progression and a higher downstaging effect with TARE treatment. In terms of isolated procedure costs, treatment with TARE is 2 to 3 times more, and in some countries even more, expensive than TACE. However, relevant literature indicates that TARE is more advantageous compared to TACE regarding the need for repeat procedures, costs of complication management, total hospital stay and quality of life. Heterogeneity of hepatocellular carcinoma (HCC) patients as well as the shortcomings of clinical classifications, randomized clinical trials and cost-effectiveness studies make it difficult to choose between treatment alternatives in this field. As in other countries, these challenges lead to differences in treatment choice across different centers in Turkey.

METHODS

The present expert panel used two round modified Delphi method to investigate the resources and clinical parameters referenced while selecting patients for drug-eluting beads (DEB)-TACE and TARE treatment modalities in Turkish clinical practice. The cost-effectiveness parameters and comparisons of these treatments have also been evaluated at a prediction level.

RESULTS

The panelists stated that they most commonly use the BCLC staging system for the management of HCC patients in Turkey. However, they did not find any of the staging systems or treatment guidelines sufficient enough for their clinical practice in terms of covering the down-staging intent of treatments. Since living donor transplant preference is higher in Turkey than the rest of the Western countries, down-staging treatments are thought to be more prioritized in Turkey than that in other Western countries. The panelists reached a consensus that TARE may provide improved OS and reduce the number of repeat procedures compared to DEB-TACE in intermediate-stage patients with a single tumor spanning a diameter above 5 cm who experience recurrence after previous treatment with TACE and most TACE-naïve patient groups in intermediate stage.

CONCLUSION

Based on the consensus on OS and the number of procedures, the panelists assumed that TARE would be more cost-effective than DEB-TACE in most groups of TACE-naïve patients in intermediate stage and in those with a single tumor spanning a diameter above 5 cm. It was also stated that the predicted cost-effectiveness advantage of TARE could be more pronounced in patients with a tumor diameter greater than 7 cm.