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Fang C, Kibriya N, Heaton ND, Prachalias A, Srinivasan P, Menon K, Peddu P. Safety and efficacy of irreversible electroporation treatment in hepatobiliary and pancreatic tumours: a single-centre experience. Clin Radiol 2021; 76:599-606. [PMID: 33934875 DOI: 10.1016/j.crad.2021.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 03/29/2021] [Indexed: 01/05/2023]
Abstract
AIM To report initial experience with irreversible electroporation (IRE) in a single tertiary oncology centre and to describe its role in the management of liver and pancreatic tumours. MATERIALS AND METHODS The present study was a retrospective review of the technical success rate, complications, and treatment efficacy of patients who had undergone IRE treatment for hepatobiliary and pancreatic tumours between February 2014 to January 2020. The patients were divided into two cohorts: first 30 patients (cohort A) and subsequent 70 patients (cohort B) after a change in protocol. RESULTS One hundred IRE procedures (n=69 liver lesions; n=28 pancreatic lesions, n=3 nodal disease) were reviewed. The overall technical success rate was 99%. Early and immediate complications were 4% and 3%, respectively. In cohort A, the complete tumour ablation rate was 65% (13/20) for hepatic tumours, 20% (1/5) for locally advanced pancreatic adenocarcinoma, 50% (2/4) for pancreatic neuroendocrine tumours, and 0% (0/1) for nodal metastasis. For cohort B, the rate improved to 87.76% (43/49) for hepatic tumours, 28.57% (4/14) for locally advanced pancreatic adenocarcinoma, 80% (4/5) for pancreatic neuroendocrine, and 50% (1/2) for nodal metastasis. After the initial cohort A, cohort B showed a significant increase in the initial complete ablation rate in hepatic tumours (p=0.028). CONCLUSION IRE is a complex technique with a steep learning curve. It is safe, effective, and is valuable in the treatment of liver tumours that are unsuitable or considered high risk for conventional thermal ablation. Its role in the management of pancreatic tumours is less clear and requires larger studies.
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Affiliation(s)
- C Fang
- Department of Radiology, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - N Kibriya
- Department of Radiology, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - N D Heaton
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - A Prachalias
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - P Srinivasan
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - K Menon
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - P Peddu
- Department of Radiology, King's College Hospital, Denmark Hill, London SE5 9RS, UK.
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Mondragon R, Mieli-Vergani G, Heaton ND, Mowat AP, Vougas V, Williams R, Tan KC. Liver transplantation for fulminant liver failure in children. Transpl Int 2018. [DOI: 10.1111/tri.1992.5.s1.206] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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3
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Nicholls G, Heaton ND, Lewis AM. Use of Bacteriology in Anorectal Sepsis as an Indicator of Anal Fistula: Experience in a District General Hospital. J R Soc Med 2018; 83:625-6. [PMID: 2286960 PMCID: PMC1292854 DOI: 10.1177/014107689008301010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The bacteriology of anorectal sepsis in a district general hospital has been reviewed to see whether the information gained helped patient management. Forty-six patients with anorectal sepsis were reviewed, underlying fistulas were identified in nine patients (19.5%). Bacteroides species were not routinely subtyped in the department. It was found that isolation of unspecified Bacteroides species was not helpful in identifying those patients with underlying fistulas. Unless subtyping of Bacteroides species is specifically requested, pus from anorectal sepsis should not routinely be sent for bacteriology.
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Affiliation(s)
- G Nicholls
- Department of Surgery, Royal Sussex County Hospital, Brighton, East Sussex
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Affiliation(s)
- N D Heaton
- Department of Surgery King's College Hospital, Denmark Hill, London SE5 8RX
| | - E R Howard
- Department of Surgery King's College Hospital, Denmark Hill, London SE5 8RX
| | - J R Garrett
- Department of Oral Pathology, King's College Hospital, Denmark Hill, London SE5 8RX
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Affiliation(s)
- N D Heaton
- Department of Surgery, King's College Hospital, Denmark Hill, London
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Kohli R, Cortes M, Heaton ND, Dhawan A. Liver transplantation in children: state of the art and future perspectives. Arch Dis Child 2018; 103:192-198. [PMID: 28918383 DOI: 10.1136/archdischild-2015-310023] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 07/03/2017] [Accepted: 07/06/2017] [Indexed: 12/13/2022]
Abstract
In this review, we provide a state of the art of liver transplantation in children, as the procedure is now carried out for more than 30 years and most of our paediatric colleagues are managing these patients jointly with liver transplant centres. Our goal for this article is to enhance the understanding of the liver transplant process that a child and his family goes through while explaining the surgical advances and the associated complications that could happen in the immediate or long-term follow-up. We have deliberately introduced the theme that 'liver transplant is a disease' and 'not a cure', to emphasise the need for adherence with immunosuppression, a healthy lifestyle and lifelong medical follow-up.
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Affiliation(s)
- Rohit Kohli
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Miriam Cortes
- Department of Adult and Pediatric Liver Transplant Surgery, Institute of Liver Studies, King's College Hospital, London, UK
| | - N D Heaton
- Department of Adult and Pediatric Liver Transplant Surgery, Institute of Liver Studies, King's College Hospital, London, UK
| | - Anil Dhawan
- Pediatrics Liver GI and Nutrition Centre and MowatLabs, King's College Hospital, London, UK
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7
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Al-Freah MAB, McPhail MJW, Dionigi E, Foxton MR, Auzinger G, Rela M, Wendon JA, O'Grady JG, Heneghan MA, Heaton ND, Bernal W. Improving the Diagnostic Criteria for Primary Liver Graft Nonfunction in Adults Utilizing Standard and Transportable Laboratory Parameters: An Outcome-Based Analysis. Am J Transplant 2017; 17:1255-1266. [PMID: 28199762 DOI: 10.1111/ajt.14230] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 01/11/2017] [Accepted: 02/04/2017] [Indexed: 01/25/2023]
Abstract
Current diagnostic criteria for primary nonfunction (PNF) of liver grafts are based on clinical experience rather than statistical methods. A retrospective, single-center study was conducted of all adults (n = 1286) who underwent primary liver transplant (LT) 2000-2008 in our center. Laboratory variables during the first post LT week were analyzed. Forty-two patients (3.7%) had 2-week graft failure. Transplant albumin, day-1 aspartate aminotransferase (AST), day-1 lactate, day-3 bilirubin, day-3 international normalized ratio (INR), and day-7 AST were independently associated with PNF on multivariate logistic regression. PNF score =(0.000280*D1AST)+ (0.361*D1 Lactate)+(0.00884*D3 Bilirubin)+(0.940*D3 INR)+(0.00153*D7 AST)-(0.0972*TxAlbumin)-4.5503. Receiver operating curve analysis showed the model area under receiver operating curve (AUROC) of 0.912 (0.889-0.932) was superior to the current United Kingdom (UK) PNF criteria of 0.669 (0.634-0.704, p < 0.0001). When applied to a validation cohort (n = 386, 34.4% patients), the model had AUROC of 0.831 (0.789-0.867) compared to the UK early graft dysfunction criteria of 0.674 (0.624-0.721). The new model performed well after exclusion of patients with marginal grafts and when modified to include variables from the first three post-LT days only (AUROC of 0.818, 0.776-0.856, p = 0.001). This model is superior to the current UK PNF criteria and is based on statistical methods. The model is also applicable to recipients of all types of grafts (marginal and nonmarginal).
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Affiliation(s)
- M A B Al-Freah
- Institute of Liver Studies, King's College Hospital, London, UK
| | - M J W McPhail
- Institute of Liver Studies, King's College Hospital, London, UK
| | - E Dionigi
- Institute of Liver Studies, King's College Hospital, London, UK
| | - M R Foxton
- Institute of Liver Studies, King's College Hospital, London, UK
| | - G Auzinger
- Institute of Liver Studies, King's College Hospital, London, UK
| | - M Rela
- Institute of Liver Studies, King's College Hospital, London, UK
| | - J A Wendon
- Institute of Liver Studies, King's College Hospital, London, UK
| | - J G O'Grady
- Institute of Liver Studies, King's College Hospital, London, UK
| | - M A Heneghan
- Institute of Liver Studies, King's College Hospital, London, UK
| | - N D Heaton
- Institute of Liver Studies, King's College Hospital, London, UK
| | - W Bernal
- Institute of Liver Studies, King's College Hospital, London, UK
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8
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Abstract
Purpose: To compare lesion detection and characterisation predicted by MnDPDP-enhanced MR imaging with surgical excision and pathological examination. Material and Methods: Ninety patients were intravenously infused at a rate of 2 to 3 ml/min with 5 μmol/kg mangafodipir trisodium (MnDPDP, Teslascan). The patients were examined with spin-echo and gradient-echo T1-weighted MR imaging at 1 h and 24 h after the end of infusion. The results were compared with identical pre-contrast sequences. In 20 of these patients, the pre-operative MR findings were compared with intra-operative ultrasonography and histology of the resected liver specimens. Results: In those with liver metastases, there was a good correlation between MR and the hepatic disease in 11 out of 14 cases. In the group with primary liver tumours, MR findings correlated with hepatic disease in 5 out of 6 cases. Conclusion: Liver lesion characterisation is possible with MnDPDP, and MR contrast enhancement with this agent is considered to be an important adjunct to the radiological assessment of patients with neoplastic liver disease where accurate decisions for surgical planning are imperative.
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Affiliation(s)
- P A Kane
- Department of Radiology, Kings College Hospital, London, UK
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9
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Menon KV, Hakeem AR, Heaton ND. Review article: liver transplantation for hepatocellular carcinoma - a critical appraisal of the current worldwide listing criteria. Aliment Pharmacol Ther 2014; 40:893-902. [PMID: 25155143 DOI: 10.1111/apt.12922] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 01/16/2014] [Accepted: 07/27/2014] [Indexed: 12/08/2022]
Abstract
BACKGROUND Liver transplantation (LT) plays an important role in the management of patients with hepatocellular carcinoma (HCC). Although early results following LT for HCC were poor, since the introduction of the Milan criteria in 1996 morphological criteria have since been well established. Thereafter, various expansions of the Milan criteria were introduced worldwide. Listing criteria for LT for HCC in the United Kingdom (UK) initially conformed to the Milan criteria but were re-defined in 2009 by expansion of the Milan criteria. AIMS To look at the evidence in literature on listing criteria and management of HCC worldwide in comparison with the UK. Secondly, we aim to review worldwide vs. UK literature on prioritisation models, loco-regional therapy protocols and role of alpha-fetoprotein (AFP) in LT for HCC. METHODS An electronic literature search with Medline was carried out to identify articles related to LT for HCC. RESULTS Although various expansions of the Milan criteria have been described, they remain the gold standard against which other criteria are measured. The UK criteria are an expansion of the Milan criteria that go beyond Milan and University of California, San Francisco (UCSF) criteria. The current UK listing criteria for LT for HCC when compared to the worldwide criteria have a worse survival benefit (projected 5-year survival between 35-50%) when plotted on the metroticket calculator. CONCLUSIONS In keeping with most transplant centres worldwide, the UK have adopted expansions to Milan to allow more patients to benefit from LT. However, currently, as it stands the UK criteria when plotted in the modification of the Metroticket model project worse survival that would seem unjustified.
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Affiliation(s)
- K V Menon
- Institute of Liver Studies, Kings College Hospital, London, UK
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10
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Thomas BR, Barnabas A, Agarwal K, Aluvihare V, Suddle AR, Higgins EM, O'Grady JG, Heaton ND, Heneghan MA. Patient perception of skin-cancer prevention and risk after liver transplantation. Clin Exp Dermatol 2013; 38:851-6. [DOI: 10.1111/ced.12159] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2013] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | | | | | - E. M. Higgins
- Department of Dermatology; King's College Hospital; London UK
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11
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Menon KV, Hakeem AR, Heaton ND. Meta-analysis: recurrence and survival following the use of sirolimus in liver transplantation for hepatocellular carcinoma. Aliment Pharmacol Ther 2013; 37:411-9. [PMID: 23278125 DOI: 10.1111/apt.12185] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 09/13/2012] [Accepted: 11/26/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND The use of sirolimus (SRL)-based immunosuppression protocols have been reported to reduce recurrence rates following liver transplantation (LT) for hepatocellular carcinoma (HCC), although this is still a matter for debate. AIM To undertake a systematic review and meta-analysis of available literature on the usage of SRL as an immunosuppressive agent following LT for HCC, with a view to comparing cancer outcomes with the commonly used calcineurin inhibitors (CNIs). METHODS Systematic review and meta-analysis carried out in line with the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. Primary outcomes of interest were tumour recurrence rate and recurrence-free survival (RFS). Secondary outcomes were recurrence-related mortality and overall survival (OS). RESULTS In all, 5 studies met the inclusion criteria (n = 474). The recurrence rate was lower in SRL group (4.9-12.9%) in comparison with CNIs (17.3-38.7%). The 1-, 3- and 5-year RFS was 93-96%, 82-86% and 79-80% for SRL group, which was much better in comparison with the CNIs 70-78%, 64-65% and 54-60% respectively. Similarly, 1-, 3- and 5-year OS was much better for SRL group (94-95%, 85% and 80%) in comparison with CNIs (79-83%, 66% and 59-62%) respectively. Meta-analysis demonstrated lower recurrence (OR = 0.30, 95% CI = 0.16-0.55, P < 0.001), lower recurrence-related mortality (OR = 0.29, 95% CI = 0.12-0.70, P = 0.005) and lower overall mortality (OR = 0.35, 95% CI = 0.20-0.61, P < 0.001) for SRL group. CONCLUSION The review showed lower recurrence rate, longer recurrence-free survival and overall survival and lower recurrence-related mortality in sirolimus-treated patients in comparison with the calcineurin inhibitor-treated patients following liver transplantation for hepatocellular carcinoma.
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Affiliation(s)
- K V Menon
- Institute of Liver Studies, King's College Hospital, London, UK
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12
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Sutcliffe RP, Lewis D, Kane PA, Portmann BC, O'Grady JG, Karani JB, Rela M, Heaton ND. Manganese-enhanced MRI predicts the histological grade of hepatocellular carcinoma in potential surgical candidates. Clin Radiol 2010; 66:237-43. [PMID: 21295202 DOI: 10.1016/j.crad.2010.08.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 08/03/2010] [Accepted: 08/13/2010] [Indexed: 02/07/2023]
Abstract
AIM To evaluate the role of manganese-enhanced magnetic resonance (Mn-MRI) in predicting tumour differentiation prior to liver transplant or resection for hepatocellular carcinoma (HCC). MATERIALS AND METHODS The inclusion criteria were patients with HCC who underwent Mn-MRI prior to transplantation or resection from 2001-2008. T1-weighted MRI images were acquired at 0 and 24h after manganese dipyridoxal diphosphate (MnDPDP) intravenous contrast medium and reviewed prospectively. Manganese retention at 24h was correlated with tumour differentiation and disease-free survival. RESULTS Eighty-six patients underwent Mn-MRI (transplantation 60, resection 26); 114/125 lesions (91%) that were arterialised as evidenced at computed tomography (CT) and had manganese uptake on MRI were HCC. There were 11 false positives (9%) that were regenerative nodules. Ten of fourteen non-manganese-retaining HCC (71%) were poorly differentiated, compared with only 13/114 manganese-retaining HCC (11%) (p<0.0001). Sensitivity, specificity, positive and negative predictive values of non-retention of MnDPDP in predicting poorly differentiated tumours were 0.43, 0.96, 0.71 and 0.88. Median disease-free survival of patients with non-manganese-retaining HCC was less than for patients with manganese-retaining HCC (14±5 months versus 39±3 months, log rank p=0.025). CONCLUSION Non-manganese-retaining HCCs are likely to be poorly differentiated and have a poor prognosis. Manganese-enhanced MRI appears to have a role in preoperative assessment of HCC and warrants further evaluation.
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Affiliation(s)
- R P Sutcliffe
- Institute of Liver Studies, King's College Hospital, London, UK
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13
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Westbrook RH, Yeoman AD, Joshi D, Heaton ND, Quaglia A, O'Grady JG, Auzinger G, Bernal W, Heneghan MA, Wendon JA. Outcomes of severe pregnancy-related liver disease: refining the role of transplantation. Am J Transplant 2010; 10:2520-6. [PMID: 20977643 DOI: 10.1111/j.1600-6143.2010.03301.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Severe liver disease in pregnancy is generally considered to have a favorable prognosis. The limited data available have not yielded disease-specific prognostic criteria or guidance on who should undergo liver transplantation (LT). We retrospectively evaluated 54 admissions with pregnancy-related liver disease to (1) evaluate if any admission parameters were associated with death and/or transplantation and (2) identify maternal complications. Eighteen had acute fatty liver of pregnancy and 32 had hypertension/eclampsia related disease. Seven patients (13%) died and four (7%) underwent LT. Survival rates were 43/48 if not listed for LT and 4/6 if listed. Of the four transplanted, three survived. Patients who died and/or underwent LT were more likely to have encephalopathy (p = 0.04) and hyperlactaemia (p = 0.03). Serum lactate was the best discriminant (ROC AUC 0.84). An admission lactate greater than 2.8mg/dL had 73% sensitivity and 75% specificity for predicting death or LT. The addition of encephalopathy to this parameter increased sensitivity and specificity to 90% and 86%, respectively. The King's College criteria were not effective in predicting outcome. This study confirms the overall favorable prognosis in pregnancy-related liver failure but indicates that elevated lactate levels in the presence of encephalopathy best identify patients at greatest risk of death or LT.
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Affiliation(s)
- R H Westbrook
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom
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14
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Orr DW, Patel RK, Lea NC, Westbrook RH, O'Grady JG, Heaton ND, Pagliuca A, Mufti GJ, Heneghan MA. The prevalence of the activating JAK2 tyrosine kinase mutation in chronic porto-splenomesenteric venous thrombosis. Aliment Pharmacol Ther 2010; 31:1330-6. [PMID: 20331577 DOI: 10.1111/j.1365-2036.2010.04299.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Occult myeloproliferative disorders (MPD) are present in 25% of patients with chronic portal, splenic and mesenteric venous thrombosis (PSMVT). A somatic mutation of JAK2 (JAK2V617F) can be used to identify patients with latent MPD. AIM We evaluated the prevalence and clinical significance of JAK2V617F in patients with chronic PSMVT. METHODS Allele-specific polymerase chain reaction was performed to screen for JAK2V617F. RESULTS Thirty-five patients were tested for JAK2V617F. The underlying pro-coagulant condition was MPD in seven of 35 (20.0%) patients; other aetiologies included hereditary thrombophilia (n = 5), chronic pancreatitis (n = 2), liver abscess (n = 1) and umbilical vein sepsis (n = 3). The remainder were labelled idiopathic, i.e. 17/35 (48.6%) patients. JAK2V617F was detected in 16/35 (45.7%) patients: seven of seven (100%) with MPD, two of 11 (18.1%) with non-MPD acquired conditions and seven of 17 (41.2%) with 'idiopathic' chronic PSMVT. Mean haemoglobin concentration (P = 0.04), haematocrit (P = 0.04), white cell count (P = 0.002) and platelet count (P = 0.05) were significantly higher in patients with JAK2V617F. None of the seven patients with latent MPD have progressed to overt MPD over median follow-up of 85 months. CONCLUSION JAK2V617F occurs in 41% of patients with idiopathic chronic portal, splenic and mesenteric venous thrombosis, confirming the presence of latent myeloproliferative disorders, and should form part of the routine pro-coagulant screen.
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Affiliation(s)
- D W Orr
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
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15
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Abstract
Bile leak in split and living donor liver transplantation is not an uncommon postoperative complication with significant morbidity to both donor and recipients. Nonanastomotic bile leaks in these transplants are less well characterized and generally described as cut-surface leaks. A proportion of these leaks may derive from biliary radicles draining the caudate lobe. Based on the caudate lobe biliary anatomy the authors describe measures that may help to reduce such complications after segmental liver transplantation.
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Affiliation(s)
- W Jassem
- Liver Transplant Unit, Institute of Liver Studies, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
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16
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Abstract
People with type 1 diabetes have normal exocrine pancreatic function, making islet cell rather than whole organ transplantation an attractive option. Achieving insulin independence in type 1 diabetes was the perceived goal of islet cell transplantation. The success of the Edmonton group in achieving this in a selected group of type 1 patients has led to renewed optimism that this treatment could eventually replace whole organ pancreas transplantation. However the long-term results of this treatment indicate that insulin independence is lost with time in a significant proportion of patients, although they may retain glycaemic stability. In this context, the indications for islet cell transplantation, which have evolved over the last 5 years, indicate that the patients who benefit most are those who experience severe hypoglycaemic reactions despite optimal insulin therapy. This review will summarise the history of islet cell transplantation, islet isolation techniques, the transplant procedure, immunosuppressive therapy, indications for islet cell transplantation, current clinical trials, the early UK islet cell transplant experience using the Edmonton protocol, and some of the challenges that lie ahead.
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Affiliation(s)
- P Srinivasan
- King's College London School of Medicine at King's College Hospital, Institute of Liver Studies and Diabetes Research Group, King's College Hospital, London, UK
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17
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Cucchetti A, Vivarelli M, Heaton ND, Phillips S, Piscaglia F, Bolondi L, La Barba G, Foxton MR, Rela M, O'Grady J, Pinna AD. Artificial neural network is superior to MELD in predicting mortality of patients with end-stage liver disease. Gut 2007; 56:253-8. [PMID: 16809421 PMCID: PMC1856758 DOI: 10.1136/gut.2005.084434] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite its accuracy, the model for end-stage liver disease (MELD), currently adopted to determine the prognosis of patients with liver cirrhosis, guide referral to transplant programmes and prioritise the allocation of donor organs, fails to predict mortality in a considerable proportion of patients. AIMS To evaluate the possibility to better predict 3-month liver disease-related mortality of patients awaiting liver transplantation using an artificial neural network (ANN). PATIENTS AND METHODS The ANN was constructed using data from 251 consecutive people with cirrhosis listed for liver transplantation at the Liver Transplant Unit, Bologna, Italy. The ANN was trained to predict 3-month survival on 188 patients, tested on the remaining 63 (internal validation group) unknown by the system and finally on 137 patients listed for liver transplantation at the King's College Hospital, London, UK (external cohort). Predictions of survival obtained with ANN and MELD on the same datasets were compared using areas under receiver-operating characteristic (ROC) curves (AUC). RESULTS The ANN performed significantly better than MELD both in the internal validation group (AUC = 0.95 v 0.85; p = 0.032) and in the external cohort (AUC = 0.96 v 0.86; p = 0.044). CONCLUSIONS The ANN measured the mortality risk of patients with cirrhosis more accurately than MELD and could better prioritise liver transplant candidates, thus reducing mortality in the waiting list.
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Affiliation(s)
- A Cucchetti
- Dipartimento di Discipline Chirurgiche, Rianimatorie e dei Trapianti, University of Bologna, S Orsola-Malpighi Hospital, 9 40138 Bologna, Italy
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18
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Gillmore JD, Stangou AJ, Lachmann HJ, Goodman HJ, Wechalekar AD, Acheson J, Tennent GA, Bybee A, Gilbertson J, Rowczenio D, O'Grady J, Heaton ND, Pepys MB, Hawkins PN. Organ transplantation in hereditary apolipoprotein AI amyloidosis. Am J Transplant 2006; 6:2342-7. [PMID: 16925563 DOI: 10.1111/j.1600-6143.2006.01507.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Patients with hereditary apolipoprotein AI (apoAI) amyloidosis often have extensive visceral amyloid deposits, and many develop end-stage renal failure as young adults. Solid organ transplantation to replace failing organ function in systemic amyloidosis is controversial due to the multisystem and progressive nature of the disease and the risk of recurrence of amyloid in the graft. We report the outcome of solid organ transplantation, including dual transplants in 4 cases, among 10 patients with apoAI amyloidosis who were followed for a median (range) of 16 (4-28) and 9 (0.2-27) years from diagnosis of amyloidosis and transplantation, respectively. Eight of 10 patients were alive, seven with a functioning graft at censor. Two patients died, one of disseminated cytomegalovirus infection 2 months after renal transplantation and the other of multisystem failure following severe trauma more than 13 years after renal transplantation. The renal transplant of one patient failed due to recurrence of amyloid after 25 years. Amyloid disease progression was very slow and the natural history of the condition was favorably altered in both cases in which the liver was transplanted. Failing organs in hereditary apoAI amyloidosis should be replaced since graft survival is excellent and confers substantial survival benefit.
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Affiliation(s)
- J D Gillmore
- National Amyloidosis Centre, Centre for Amyloidosis and Acute Phase Proteins, Department of Medicine, Hampstead Campus, Royal Free and University College Medical School, London, UK.
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Foxton MR, Quaglia A, Muiesan P, Heneghan MA, Portmann B, Norris S, Heaton ND, O'Grady JG. The impact of diabetes mellitus on fibrosis progression in patients transplanted for hepatitis C. Am J Transplant 2006; 6:1922-9. [PMID: 16780550 DOI: 10.1111/j.1600-6143.2006.01408.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Despite the recognition of numerous factors for aggressive hepatitis C virus (HCV) recurrence after liver transplantation (LT) our understanding of this phenomenon is incomplete. We tested the hypothesis that diabetes mellitus (DM) was implicated. One hundred sixty-three patients undergoing primary LT for HCV from 1990 to 2004 were evaluated and biopsies were scored according to the modified Ishak score. Severe recurrence of HCV was defined as a fibrosis score > or = 4 within 6 years of LT. Risk factors assessed included recipient, donor and transplant variables. Fifty-four patients (33.1%) had a fibrosis score > or = 4 at the end of the study period. Factors associated with progression to severe fibrosis was donor age (p = 0.008) especially donor age >55 (p = 0.038, HR 2.43), pre-LT DM (p = 0.039, HR 2.68) and DM post-LT (p = 0.004, HR 3.28). The combination of receiving a liver from a donor older than 55 years and having DM post-LT was associated with an 8.38-fold risk of progression to severe fibrosis (p = 0.000124) when compared to patients not diabetic post-LT who received livers from donors aged <55 years. These data indicate that diabetic status is one of the more important variables determining the severity of HCV recurrence and is synergistic with donor age. This observation may provide an additional management opportunity to modify the impact of HCV recurrence.
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Affiliation(s)
- M R Foxton
- Institute of Liver Studies, King's College Hospital, London, UK
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20
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Abstract
BACKGROUND First described in 1988, attenuated familial adenomatous polyposis (AFAP) is a rare autosomal dominant precancerous condition of the gastrointestinal tract. Few reports have described adenocarcinomatous change in the gastroduodenal region thus far. CASE OUTLINE We report a case of AFAP presenting with extensive gastric polyposis and ampullary adenocarcinoma in absence of a positive family history of gastrointestinal cancer and a novel mutation.
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Affiliation(s)
- P. Bhatnagar
- Institute of Liver Studies, King's College HospitalLondonUK
| | - H. Tetzlaff
- Institute of Liver Studies, King's College HospitalLondonUK
| | - L. Izatt
- Department of Clinical Genetics, Guy's HospitalLondonUK
| | - J. Devlin
- Institute of Liver Studies, King's College HospitalLondonUK
| | - N. D. Heaton
- Institute of Liver Studies, King's College HospitalLondonUK
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21
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Orr DW, Portmann BC, Knisely AS, Stoll S, Rela M, Muiesan P, Bowles MJ, Heaton ND, O'Grady JG, Heneghan MA. Anti-interleukin 2 receptor antibodies and mycophenolate mofetil for treatment of steroid-resistant rejection in adult liver transplantation. Transplant Proc 2006; 37:4373-9. [PMID: 16387124 DOI: 10.1016/j.transproceed.2005.10.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2005] [Indexed: 01/04/2023]
Abstract
BACKGROUND Steroid-resistant rejection (SRR) results in significant morbidity and mortality from the adverse effects of rescue therapy and in graft loss from chronic rejection. In our knowledge, the efficacy and safety of anti-interleukin (IL) 2r antibodies (daclizumab and basiliximab) for the treatment of SRR in adult liver transplantation has not previously been evaluated. METHODS Twenty-five patients received either daclizumab or basiliximab as rescue therapy for SRR. Outcome and biochemical parameters were recorded before and after treatment with an anti-IL-2r antibody. RESULTS The median time from transplantation to SRR was 25 days. Secondary immunosuppression included mycophenolate mofetil in 18 patients. Twelve patients (48%) had complete resolution of SRR. Aspartate transaminase levels normalized at a median of 37 days (range, 1-168 days). In 13 patients (52%) progressive hepatic dysfunction developed. Four of these patients received another transplant, and 6 patients had chronic rejection. Three patients died with graft failure. Of 16 patients with acute cellular rejection, 12 (75%) had resolution, 2 had chronic rejection, 1 required a repeat transplantation, and 1 died with graft failure. In contrast, all 9 patients with established chronic rejection in their pretreatment biopsy continued to have significant graft dysfunction, with 4 having persistent chronic graft dysfunction, 3 requiring repeat transplantation, and 2 dying with graft failure. CONCLUSION Twelve (48%) of 25 patients who received an anti-IL-2r antibody because of SRR were successfully treated. All successfully treated patients had ongoing acute cellular rejection at liver biopsy (75%), whereas patients with histologic evidence of chronic rejection responded poorly.
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Affiliation(s)
- D W Orr
- King's College Hospital, Institute of Liver Studies, London, England.
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22
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Abstract
A case of a 15-year-old girl with a malignant extraadrenal pheochromocytoma situated between the inferior vena cava and the portal triad is described. Using ex vivo technique, the tumour was successfully resected on the bench, as a previous attempt to remove the tumour in situ had been abandoned. The surgical aspects and implications of ex vivo surgery are discussed, highlighting the increased operative risk, perioperative mortality, and poor long-term results in patients with malignant tumours.
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Affiliation(s)
- G Fusai
- Institute of Liver Studies and Liver Transplant Surgical Service, King's College Hospital, Denmark Hill, SE5 9RS London, UK
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23
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Abstract
Eighteen liver transplant recipients were followed up for 10 years after a trial of immunosuppression withdrawal. Three groups were identified according to the early outcome of complete (group A, n = 5), partial (group B, n = 9), and unsuccessful (group C, n = 4) withdrawal of immunosuppression. The indications for liver transplantation (LT) (August 1983-December 1988) were as follows: primary biliary cirrhosis (n = 3), primary sclerosing cholangitis (n = 3), Budd-Chiari syndrome (n = 3), acute liver failure (n = 3), hepatitis C virus (HCV) cirrhosis (n = 1), HCV and autoimmune hepatitis (n = 1), HCV and alcohol-related cirrhosis (n = 1), HCV and hepatocellular carcinoma (HCC) (n = 1), cystic fibrosis (n = 1), and liver metastases from testicular teratoma (n = 1). Immunosuppression was based on cyclosporine. All patients experienced 1 or more complications of prolonged immunosuppression (median, 7 years; range, 5-11). Thirteen patients (72%) are alive at a median interval of 17 years (range, 16-21) after LT. Of the 5 patients in group A, 2 currently have normal graft function with no rejection episodes, and 3 have restarted immunosuppression following late low-grade acute rejection (n = 1), retransplantation for chronic rejection (n = 1), and kidney transplantation (n = 1). Of the 9 patients in group B, 5 died. The deaths were due to ruptured arterial pseudoaneurysm following retransplantation, HCC recurrence, cardiac failure, renal failure, and posttransplant lymphoma at 5, 7, 7, 14, and 17 years after LT, respectively. All 4 patients in group C are alive on a full immunosuppressive regimen. Long-term follow-up of 18 LT recipients withdrawn from immunosuppression has shown that at a median of 17 years 10% of patients remain off all immunosuppression.
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Affiliation(s)
- R Girlanda
- Liver Transplant Surgical Service, King's College Hospital, London, United Kingdom
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24
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Girlanda R, Vilca-Melendez H, Srinivasan P, Muiesan P, O'Grady JG, Rela M, Heaton ND. Immunosuppression Withdrawal After Auxiliary Liver Transplantation for Acute Liver Failure. Transplant Proc 2005; 37:1720-1. [PMID: 15919444 DOI: 10.1016/j.transproceed.2005.03.141] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND The potential for immunosuppression withdrawal is the rationale for auxiliary liver transplantation (AUX) in patients with acute liver failure (ALF). PATIENTS AND METHODS Forty-four AUX were performed in 28 adults and 16 children with ALF secondary to seronegative hepatitis (n = 20; 45%), paracetamol hepatotoxicity (n = 14; 32%), acute viral hepatitis (hepatitis B virus [HBV] n = 3, Epstein-Barr virus n = 1; 9%), drug-induced hepatitis (n = 3; 7%), autoimmune hepatitis (n = 2; 5%), and mushroom poisoning (n = 1; 2%). All patients fulfilled the King's College Hospital transplant criteria for ALF. After partial hepatectomy, 38 patients received a segmental auxiliary graft and six, a whole auxiliary graft. Immunosuppression was based on calcineurin inhibitors and steroids. RESULTS Thirty-four patients (77%) are alive after a median follow-up of 30 months (range 4 to 124). Eight adults and two children died of sepsis (n = 6; 14%) at a median interval of 30 days (range 2 to 66), intraoperative cardiac failure (n = 1), brain edema on postoperative day 8 (n = 1), sudden death on day 35 (n = 1), and multiple organ failure associated with HBV recurrence 4 years after transplantation (n = 1). Three patients underwent retransplantation for small-for-size graft syndrome with sepsis on postoperative day 15 (n = 1) and for ductopenic rejection 4 and 15 months after AUX (n = 2). In 10/31 (32%) survivors (6/18 adults and 4/13 children) immunosuppression was completely withdrawn after a median of 19 months. CONCLUSION Complete immunosuppression withdrawal can be achieved in a significant proportion of patients after AUX for ALF.
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Affiliation(s)
- R Girlanda
- Liver Transplant Surgical Service, King's College Hospital, London, UK
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25
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Affiliation(s)
- R Girlanda
- Liver Transplant Surgical Service, King's College Hospital, Denmark Hill, London SE5 9RS, UK
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26
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Abstract
Liver transplantation is the accepted treatment for a wide variety of liver diseases in children. Over the past 10 years a number of innovative surgical techniques have been developed to overcome the shortage of size matched donors particularly in children less than 5 years of age. Graft and patient survival at one year after liver transplantation has continued to improve, and is now over 85% and higher for good risk cases. Complications are relatively common, but provided graft function is satisfactory, long term survival for these children is to be expected. The need for retransplantation has fallen significantly. Causes of early mortality include graft dysfunction and sepsis. Late mortality is due to sepsis, post-transplant lymphoproliferative disease, and non-compliance. Long term survival with good graft function and excellent quality of life is possible for the majority of children undergoing liver transplantation.
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Affiliation(s)
- H Vilca-Melendez
- Liver Transplant Surgery, Institute of Liver Studies, King's College Hospital, Denmark Hill, London SE5 9RS, UK
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27
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Abstract
The mortality rate of fulminant hepatic failure (FHF) in childhood has remained between 70% and 95% despite recent improvements in medical therapy. Liver transplantation has become an important therapeutic option in adults with this entity, but has been infrequently performed in children. Many children do not receive transplants because of the rapid progression of the illness and the lack of suitable donor livers. We present our experience in liver transplantation in children with FHF. Between March 1988 and December 1989, seven children aged between 15 months and 12 years received eight liver transplants. The aetiology of FHF was viral hepatitis in five and drug hepatotoxicity (carbamazepine) in two. Five of our patients were in grade III-IV coma. Reduced-sized livers were used in six of the eight transplants. The post-operative morbidity included viral and fungal infections, and abdominal bleeding. Two patients died from graft-versus-host disease and one from brain aspergillosis. Four patients (57%) survived a median follow-up of 15 months. Liver transplantation should be the therapeutic option in children with FHF where the chances of medical recovery are poor.
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Affiliation(s)
- R Mondragon
- Department of Surgery, King's College Hospital and King's College School of Medicine and Dentistry, London, UK
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28
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Andreani P, Srinivasan P, Ball CS, Heaton ND, Rela M. Congenital absence of the portal vein in liver transplantation for biliary atresia. Int J Surg Investig 2003; 2:81-4. [PMID: 12774342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Extrahepatic biliary atresia is the most common indication for liver transplantation in children. Coexistent congenital anomalies are common (25%), but the combination of polysplenia syndrome (10%) and absence of portal vein is rare. AIMS We report a case of successful reduced size liver transplantation on a 13-month-old girl with extrahepatic biliary atresia, polysplenia syndrome and congenital absence of the portal vein. METHODS Technical and post-operative problems related to absence of the portal vein and polysplenia are described and the literature reviewed. RESULTS The donor portal vein was successfully anastomosed to the confluence of the superior mesenteric vein and splenic vein. The child is well with good graft function at a follow-up of 20 months. CONCLUSION Absence of the portal vein and polysplenia syndrome is not a contraindication for liver transplantation although an increased post-operative morbidity may be expected.
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Affiliation(s)
- P Andreani
- Liver Transplant Surgical Service, King's College Hospital, Denmark Hill, London SE5 9RS, UK
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29
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Aw MM, Taylor RM, Verma A, Parke A, Baker AJ, Hadzic D, Muiesan P, Rela M, Heaton ND, Mieli-Vergani G, Dhawan A. Basiliximab (Simulect) for the treatment of steroid-resistant rejection in pediatric liver transpland recipients: a preliminary experience. Transplantation 2003; 75:796-9. [PMID: 12660504 DOI: 10.1097/01.tp.0000054682.53834.ea] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The role of interleukin-2 receptor antibodies as rescue therapy in steroid-resistant rejection (SRR) has not been studied. We evaluated the safety and efficacy of an interleukin-2 receptor antibody, basiliximab (Simulect, Novartis, East Hanover, NJ), in treating SRR in pediatric liver transplant recipients. METHODS This was a prospective study of seven pediatric liver transplant recipients with biopsy-proven SRR who would have otherwise received OKT3 or antithymocyte globulin. The primary immunosuppression consisted of cyclosporine (Neoral, Novartis), azathioprine, and prednisolone in four patients and tacrolimus and prednisolone in three patients who had undergone retransplantation for chronic rejection (n=2) and hyperacute rejection (n=1). Four patients had received two cycles of high-dose steroids, and three patients had received a single cycle; all had been converted to tacrolimus, followed by the addition of mycophenolate mofetil. RESULTS The median time from transplant to SRR was 30 days (range, 8 days-23 months). Five children received two doses of basiliximab (10 mg, 3-7 days apart), and two children received a single dose. Aspartate aminotransferase levels normalized in three children 12, 21, and 30 days after basiliximab treatment. Aspartate aminotransferase levels decreased without normalizing in two children, but there was no further evidence of cellular rejection on repeat biopsies. All five children are rejection-free with a median follow-up of 22 months (range, 5-32 months). Biochemical abnormalities persisted in the remaining two children, and both developed chronic rejection. There were no immediate side effects associated with basiliximab. Two patients were treated empirically for possible cytomegalovirus infection 21 and 57 days after basiliximab treatment, with no evidence of cytomegalovirus disease. CONCLUSION Five of seven pediatric liver transplant recipients with SRR experienced successful outcomes with basiliximab treatment without major side effects, indicating that it is a safe alternative to OKT3 and other antilymphocyte antibodies.
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Affiliation(s)
- M M Aw
- Department of Pediatrics, National University of Singapore, Children's Medical Institute, National University Hospital, Singapore
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30
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Heaton ND, Maguire D. Adult living donations: lessons learned. Transplant Proc 2002; 34:2450-3. [PMID: 12270476 DOI: 10.1016/s0041-1345(02)03174-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- N D Heaton
- Liver Transplant Surgery, Institute of Liver Studies, Kings College Hospital, London, UK.
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31
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Affiliation(s)
- N D Heaton
- Institute of Liver Studies, Kings College Hospital, London, UK.
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32
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Abstract
BACKGROUND The emergence of split and living donor liver transplantation has necessitated re-evaluation of liver anatomy in greater depth and from a different perspective than before. Early attempts at split liver transplantation were met with significant numbers of vascular and biliary complications. Technical innovations in this field have evolved largely by recognizing anatomical anomalies and variations at operation, and devising novel ways of dealing with them. This has led to increasing acceptance of these procedures and decreased morbidity and mortality rates, similar to those observed with whole liver transplantation. METHODS AND RESULTS The following review is based on clinical experience of more than 180 split and living related liver transplantations in adults and children, performed over a 7-year period from 1994 to 2001. CONCLUSION A comprehensive understanding and application of surgical anatomy of the liver is essential to improve and maintain the excellent results of segmental liver transplantation.
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Affiliation(s)
- R R Deshpande
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London SE5 9RS, UK
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33
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Prachalias AA, Pozniak A, Taylor C, Srinivasan P, Muiesan P, Wendon J, Cramp M, Williams R, O'Grady J, Rela M, Heaton ND. Liver transplantation in adults coinfected with HIV. Transplantation 2001; 72:1684-8. [PMID: 11726833 DOI: 10.1097/00007890-200111270-00020] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To report our experience of prospectively identifying and transplanting livers into HIV-positive patients. DESIGN Liver transplantation in HIV-positive patients remains controversial. The finding of HIV is usually considered a contraindication to any form of transplantation. Previously reported cases are few and refer to patients who tested HIV positive after they had their liver transplantations or who seroconverted in the posttransplantation period. This is, to our knowledge, the only report of patients who were known to be HIV positive at the time of decision for listing for transplantation. METHODS The medical records of five HIV-positive patients who received liver transplants in King's College Hospital, London, during a 5-year period (January 1995-December 1999) were reviewed. All five were known to be HIV positive at the time of listing for liver replacement. Three of them had end-stage liver disease due to hepatitis C (two of them had underlying Hemophilia A) while the other two had acute liver failure, one due to hepatitis B infection and one due to nonA-nonB-nonC hepatitis. In all but one patient the HIV infection had been asymptomatic. RESULTS All patients survived the immediate posttransplantation period, but the three patients with hepatitis C died of complications of recurrent hepatitis C between 6 and 25 months posttransplantation. The other two patients are currently alive 4 and 34 months posttransplantation with good graft function and without complications from their HIV infection. CONCLUSION The early outcome of liver transplantation in HIV seropositive patients can be good, and patients should not be excluded from transplantation if their liver disease determines their prognosis. More effective antiviral therapy for hepatitis C given posttransplantation, and for hepatitis B reinfection, should improve the longer-term outcome of HIV patients with end-stage liver disease due to hepatitis.
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Affiliation(s)
- A A Prachalias
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
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34
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Murphy ND, Kodakat SK, Wendon JA, Jooste CA, Muiesan P, Rela M, Heaton ND. Liver and intestinal lactate metabolism in patients with acute hepatic failure undergoing liver transplantation. Crit Care Med 2001; 29:2111-8. [PMID: 11700405 DOI: 10.1097/00003246-200111000-00011] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To determine the relative contribution of the gastrointestinal tract and the liver in lactate metabolism in patients with acute liver failure (ALF) and the effect of liver transplantation on this. We hypothesized that the liver and gut are net producers of lactate in ALF and that this is reversed after liver transplantation. SETTING A university-affiliated specialist liver transplant operating theater. SUBJECTS Eleven patients with ALF undergoing liver transplantation. MEASUREMENTS AND INTERVENTIONS After ethical approval, 11 patients with ALF listed for orthotopic hepatic transplantation were studied. Whole blood was analyzed for lactate concentration from radial artery (RA) catheter, portal vein (PV), and hepatic vein (HV) during the dissection phase and was repeated postreperfusion of the liver graft. Gradients across the gut and the liver were calculated to see if there was net production or consumption. RESULTS HV lactate was significantly higher than arterial (p =.028) in patients with ALF before liver transplantation, suggesting splanchnic production of lactate. Total splanchnic lactate gradient (HV-RA) is positive in ALF. Both the gut (PV-RA) and the liver (HV-PV) were net producers of lactate. After liver transplantation, hepatic venous lactate falls below arterial levels but not significantly. The gradient across the gut (PV-RA) remained positive, but the transhepatic gradient (HV-PV) became significantly negative, showing consumption by the graft (p =.021). The magnitude of lactate consumption after transplantation correlated positively with portal venous lactate concentration (p =.029) and inversely with graft cold ischemic time (p =.007). CONCLUSION The liver is a net producer of lactate in patients with ALF and an elevated whole blood lactate. After liver transplantation, the graft becomes a consumer of lactate as shown by the negative lactate gradient. The degree of consumption is dependent on portal venous lactate concentration and cold ischemic time.
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Affiliation(s)
- N D Murphy
- Institute of Liver Studies, Kings College Hospital, London, UK
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35
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Heneghan MA, Portmann BC, Norris SM, Williams R, Muiesan P, Rela M, Heaton ND, O'Grady JG. Graft dysfunction mimicking autoimmune hepatitis following liver transplantation in adults. Hepatology 2001; 34:464-70. [PMID: 11526530 DOI: 10.1053/jhep.2001.26756] [Citation(s) in RCA: 138] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In children, a type of graft dysfunction associated with autoimmune features has been described. We have identified 7 adult liver-transplant (LT) recipients from a series of over 1,000 consecutive transplant recipients who presented between 0.3 years and 7.2 years following transplantation with characteristic symptoms, autoantibody profiles, and histologic findings of autoimmune disease. The indications for transplantation were Ecstasy overdose, alcohol-related cirrhosis, primary sclerosing cholangitis (PSC) (2), primary biliary cirrhosis (PBC), hepatitis C cirrhosis, and cryptogenic cirrhosis. Two patterns of de novo autoantibody development were noted; anti-liver-kidney-microsome (LKM) antibody development at high titer in association with an aspartate transaminase (AST) > 500 and antinuclear (ANA) and antismooth muscle (AMA) antibody development at titers >1/80 with lower AST levels. All cases had elevated IgG. Liver biopsies showed changes of an autoimmune-type hepatitis with portal and periportal hepatitis in association with a marked infiltrate of plasma cells, lymphocytes, and bridging collapse. Two patients lost their grafts because of the disease. Patients were treated with reintroduction of steroids and azathioprine in cases in which it had been withdrawn. Major histocompatibility class I and II mismatching did not incur risk. Eight of 12 liver allografts were acquired from either DRB*0301- or DRB*0401-positive donors, and 4 recipients were DRB*0301-positive. This series illustrates that both symptoms and histologic findings of graft dysfunction compatible with autoimmune hepatitis (AIH) exist in adult LT recipients. Graft loss may be a consequence. This entity may represent a specific type of rejection that should currently be classified as "graft dysfunction mimicking autoimmune hepatitis."
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Affiliation(s)
- M A Heneghan
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London, England
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36
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Aw MM, Samaroo B, Baker AJ, Verma A, Rela M, Heaton ND, Mieli-Vergani G, Dhawan A. Calcineurin-inhibitor related nephrotoxicity- reversibility in paediatric liver transplant recipients. Transplantation 2001; 72:746-9. [PMID: 11544444 DOI: 10.1097/00007890-200108270-00034] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIM To study the efficacy of mycophenolate mofetil (MMF) as renal rescue in paediatric liver transplant recipients with calcineurin-inhibitor- (CI) related nephrotoxicity. METHODS Pediatric liver transplant recipients with stable graft function and a glomerular filtration rate (GFR) <80 ml/min/1.73 m2 were enrolled. MMF was introduced at 20 mg/kg/day and increased to 40 mg/kg/day after 1 week. CI dose was then reduced 6 weeks to achieve blood levels 25% of baseline. GFR was reassessed after 6 and 12 months. RESULTS Fourteen children with a median (range) interval from transplant of 57 (4-111) months were studied. Their median (range) GFR in ml/min/1.73 m2 increased from a baseline of 52 (31-71), to 69 (38-111) and 73 (35-98) at 6 and 12 months, respectively (P=0.00014). Side effects of MMF include leucopaenia in two and backache in one, two of whom discontinued MMF. Acute allograft rejection occurred in three children. All 14 are well with a median (range) follow-up of 24 (14-38) months from MMF introduction. CONCLUSION MMF allows the recovery of renal function from CI related nephrotoxicity in more than 70% of paediatric liver transplant recipients with renal impairment.
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Affiliation(s)
- M M Aw
- Paediatric Liver Service, King's College Hospital, London, United Kingdom
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37
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Abstract
BACKGROUND The etiology of abdominal cocoon (a rare cause of intestinal obstruction) is unknown. It has occurred in adolescent girls, cirrhotic patients after peritoneal-venous shunting, and patients undergoing peritoneal dialysis. We report our experience with patients after orthotopic liver transplantation (OLT). METHODS Five patients (4 male, 1 female, aged 16 to 57 years) underwent OLT (3 whole liver, 2 right lobe grafts) and subsequently developed abdominal cocoon. RESULTS All developed pyrexia by 66 +/- 21 hours posttransplant. Additional symptoms (epigastric discomfort and intermittent vomiting) occurred 12 +/- 10 days later. Bacterial peritonitis was confirmed by microbiology in 2 cases and diagnosed by exclusion in the others. C-reactive protein levels were persistently elevated in all patients (35 to 82 mg/L). While abdominal CT consistently demonstrated marked ascites with the small intestine confined to a particular area of the abdomen, intestinal contrast studies and ultrasound were not diagnostic. All patients underwent surgical removal of the cocoon membrane by 58 +/- 22 days after transplant. CONCLUSIONS Sclerosing peritonitis may complicate liver transplantation and occurs because of low-grade intra-abdominal sepsis.
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Affiliation(s)
- D Maguire
- Liver Transplant Unit, Kings College Hospital, SE5 9RS, London, England, UK
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38
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Marshall MM, Muiesan P, Srinivasan P, Kane PA, Rela M, Heaton ND, Karani JB, Sidhu PS. Hepatic artery pseudoaneurysms following liver transplantation: incidence, presenting features and management. Clin Radiol 2001; 56:579-87. [PMID: 11446757 DOI: 10.1053/crad.2001.0650] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIM Hepatic artery pseudoaneurysm (PA) is an uncommon complication of liver transplantation. We report a series of 13 patients, the largest published review including outcome. The presenting features, risk factors and role of radiology in the diagnosis and management of this frequently fatal complication are discussed.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aneurysm, False/diagnostic imaging
- Aneurysm, False/etiology
- Aneurysm, False/therapy
- Angiography, Digital Subtraction/methods
- Child
- Child, Preschool
- Embolization, Therapeutic/methods
- Female
- Hepatic Artery
- Humans
- Infant
- Infant, Newborn
- Liver Transplantation/adverse effects
- Male
- Middle Aged
- Radiography, Interventional/adverse effects
- Retrospective Studies
- Risk Factors
- Sepsis/complications
- Tomography, X-Ray Computed/methods
- Treatment Outcome
- Ultrasonography, Doppler/methods
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Affiliation(s)
- M M Marshall
- Department of Radiology, King's College Hospital, London, UK.
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Stringer MD, Marshall MM, Muiesan P, Karani JB, Kane PA, Mieli-Vergani G, Rela M, Heaton ND. Survival and outcome after hepatic artery thrombosis complicating pediatric liver transplantation. J Pediatr Surg 2001; 36:888-91. [PMID: 11381419 DOI: 10.1053/jpsu.2001.23963] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/PURPOSE Hepatic artery thrombosis (HAT) represents a significant cause of graft loss and mortality after pediatric orthotopic liver transplantation (OLT). The incidence and etiology of this complication have been investigated in detail but relatively little is known about outcome. METHODS A review was conducted of all children with confirmed HAT complicating OLT during a 10-year period (1990 through 1999) in a single center. HAT was established by angiography or at operation in all cases. RESULTS From a consecutive series of 400 pediatric OLTs, there were 31 (7.8%) instances of HAT in 29 children of median age 3.8 years (range, 8 days to 16 years). Twenty-four (83%) are alive after a median follow-up of 3.6 years. Fourteen cases occurred after transplantation of whole grafts and 17 after reduced or split livers. Of the 18 episodes resulting in retransplantation, there were 5 deaths and 2 second episodes of HAT; surviving children are alive with good graft function. Of the 13 episodes managed without retransplantation, 4 patients underwent attempted early revascularisation of the graft, which was successful in 2, and the remainder initially were treated conservatively. All 13 children are alive after a median follow-up of 4.1 years (range, 0.6 to 5.8), but 5 required radiologic or surgical intervention for biliary or septic complications; biochemical liver function is normal in 8, mildly abnormal in 3, and poor in 2. Retransplantation was less likely in those who had received reduced or split grafts (7 of 17) compared with those who had received whole grafts (11 of 14), but this difference just failed to reach statistical significance (chi(2) = 3.01, 0.1 > P > .05). CONCLUSIONS Using a selective policy of retransplantation, revascularisation, and conservative treatment, 83% of children survived HAT complicating OLT. Approximately 40% of children with HAT survived without retransplantation. J Pediatr Surg 36:888-891.
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Affiliation(s)
- M D Stringer
- Liver Transplantation Surgical Service, Paediatric Liver Service, and Department of Radiology, King's College Hospital, London, England
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40
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Corbally MT, Rela M, Heaton ND, Ball C, Portmann B, Mieli-Vergani G, Mowat AP, Williams R, Tan KC. Orthotopic liver transplantation for acute hepatic failure in children. Transpl Int 2001; 7 Suppl 1:S104-7. [PMID: 11271176 DOI: 10.1111/j.1432-2277.1994.tb01322.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Thirty children received 35 liver transplants for fulminant or late-onset liver failure between March 1988 and May 1993. Aetiology included non-A non-B hepatitis in 12, Wilson's disease in 8, drug-induced hepatic failure in 6, hepatitis B in 1, hepatitis A in 1, tyrosinaemia in 1 and congenital haemochromatosis in 1. Three patients were retransplanted, one each for hepatic artery thrombosis, non-A non-B graft reinfection, and chronic rejection. Two of these three patients received a third transplant for chronic rejection and hepatic artery thrombosis. One patient in the retransplant group survived. Overall, graft and patient survival at a mean follow-up of 17 months were 49% and 57%, respectively. Mortality was related to vascular complications in three patients (hepatic venous obstruction, portal vein thrombosis and hepatic artery thrombosis). Two patients died of primary sepsis (cerebral aspergillosis and cytomegalovirus (CMV) pneumonitis in association with graft-versus-host disease). Systemic sepsis and multiorgan failure was documented as a cause of death in four children and sepsis in association with chronic rejection in a further three patients. One child died of respiratory failure 4 weeks after transplantation. Mortality in eight children less than 2 years was 75% and this was significantly greater than for older children (P < 0.003, Mantel Cox). Earlier referral, even in the absence of a definitive diagnosis and particularly in children under 2 years is advisable and may improve survival.
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Affiliation(s)
- M T Corbally
- Liver Transplant Surgical Service, Kings College Hospital, London, UK
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41
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Abstract
The success of the triangulation technique for hepatic venous anastomosis in left lateral segment liver transplantation has led to standardization of this procedure. We report a case of syndromic biliary atresia with absent inferior vena cava in which we constructed a neo cava to implant a living related left lateral segment graft by using the triangulation technique.
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Affiliation(s)
- P Srinivasan
- Liver Transplant Surgical Service, King's College Hospital, London, UK
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42
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Gillmore JD, Stangou AJ, Tennent GA, Booth DR, O'Grady J, Rela M, Heaton ND, Wall CA, Keogh JA, Hawkins PN. CLINICAL AND BIOCHEMICAL OUTCOME OF HEPATORENAL TRANSPLANTATION FOR HEREDITARY SYSTEMIC AMYLOIDOSIS ASSOCIATED WITH APOLIPOPROTEIN AI Gly26Arg1. Transplantation 2001; 71:986-92. [PMID: 11349736 DOI: 10.1097/00007890-200104150-00026] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Treatment of systemic amyloidosis comprises measures to support failing organ function coupled with attempts to reduce the supply of the respective amyloid fibril precursor protein. Orthotopic hepatic transplantation is effective in familial amyloid polyneuropathy associated with variant transthyretin, because this protein is produced almost exclusively in the liver. Hepatic transplantation has not been performed in hereditary apolipoprotein AI (apoAI) amyloidosis, and the liver's contribution to plasma apoAI levels has not been determined in vivo. METHODS A 57-year-old Irish man with hereditary systemic amyloidosis associated with apoAI Gly26Arg, which had led to end-stage renal failure and progressive liver dysfunction, underwent hepatorenal transplantation. His outcome was followed clinically and his amyloid deposits were monitored with serum amyloid P component scintigraphy. The proportion of variant apoAI in the plasma was estimated by quantitative isoelectric focusing before and after liver transplantation. RESULTS Plasma levels of variant apoAI decreased by 50% after liver transplantation, and the patient was asymptomatic 2 years after surgery. Subclinical amyloid deposits that were present in his spleen and heart preoperatively have regressed and stabilized respectively. CONCLUSIONS Orthotopic liver transplantation substantially reduces the supply of the amyloid fibril precursor protein in hereditary apoAI amyloidosis, and the excellent outcome in this patient probably reflects the balance between deposition and turnover of amyloid having been altered in favor of the latter. These findings support the use of liver transplantation in patients with hereditary apoAI amyloidosis who develop hepatic dysfunction.
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Affiliation(s)
- J D Gillmore
- Centre for Amyloidosis and Acute Phase Proteins, Department of Medicine, Royal Free and University College Medical School, London.
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Srinivasan P, Heaton ND, Rela M. Liver transplantation in Polysplenia syndrome. Transplantation 2001; 71:818-9. [PMID: 11330550 DOI: 10.1097/00007890-200103270-00024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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44
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Prachalias AA, Kalife M, Francavilla R, Muiesan P, Dhawan A, Baker A, Hadzic D, Mieli-Vergani G, Rela M, Heaton ND. Liver transplantation for alpha-1-antitrypsin deficiency in children. Transpl Int 2001; 13:207-10. [PMID: 10935704 DOI: 10.1007/s001470050688] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Alpha-1-antitrypsin (a1-AT) deficiency is an inborn error of metabolism, which can cause liver disease. The condition is one of the most common genetic disorders in the Caucasian population. Here we review our experience with 21 children suffering from end-stage liver disease due to a1-AT deficiency. All children are PIZZ homozygotes. Nineteen of them initially presented with neonatal jaundice and two with hepatosplenomegaly in childhood. Twenty-five liver transplantations were performed. All children are currently alive at a median followup of 40 months. Liver replacement provides the only definite treatment for children with end-stage liver disease associated with a1-AT deficiency. Excellent results can be achieved by reducing waiting time for transplantation and by early referral to a liver transplant centre.
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Affiliation(s)
- A A Prachalias
- Liver Transplant Surgical Service, King's College Hospital, Denmark Hill, London, UK
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45
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Abstract
BACKGROUND Hepatic artery thrombosis remains the most common technical complication that causes graft failure following orthotopic liver transplantation. The development of split liver and living related liver transplantation has led to the use of shorter and smaller arteries for arterial reconstruction to the graft. The present aim was to assess the effectiveness of the superior mesenteric artery as an interpositional graft in arterial reconstruction during liver transplantation. METHODS Cadaveric superior mesenteric artery was used to reconstruct small and short or multiple hepatic arteries in 35 liver transplants including 29 split, three living related, two whole liver transplants and one emergency revascularization post-transplantation. RESULTS AND CONCLUSION A low incidence of hepatic artery thrombosis (one of 35 patients) was achieved utilizing cadaveric superior mesenteric artery as an interpositional vascular graft in liver transplantation.
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Affiliation(s)
- P Muiesan
- Liver Transplant Surgical Service, King's College Hospital, Denmark Hill, London SE5 9RS, UK.
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Auzinger G, Devlin J, O'Callaghan PG, Heaton ND, Mufti GJ, Wendon JA. Reactive haemophagocytic lymphohistiocytosis: a frequent finding in immunosuppressed patients with multiple organ failure. Crit Care 2001. [PMCID: PMC3333261 DOI: 10.1186/cc1141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Abstract
BACKGROUND Aplastic anemia is a rare but well-recognized complication of acute hepatitis and acute liver failure. The cause is unknown, and the condition is fatal without bone marrow recovery. Treatment includes immunosuppression regimens or bone marrow transplantation. The purpose of this study was to investigate the incidence, cause, treatment, and outcomes of this disorder in children. METHODS Retrospective chart review of 75 patients with acute liver failure in a major pediatric liver center. RESULTS Eight patients had evidence of bone marrow failure. Of those, six had aplastic anemia, and two had transient bone marrow suppression. There were five boys, median age 57 months (range, 36-132 months). Two had parvovirus B19, six had non-A, non-B, non-C hepatitis. Five underwent liver transplantation: auxiliary in one, orthotopic in four. The interval between initial symptoms and development of aplastic anemia and/or bone marrow suppression was 21 to 99 days (median, 39 days). Four patients with aplastic anemia received intravenous antithymocyte globulin (ATG) or antilymphocyte globulin (ALG). Median recovery period of granulopoiesis was 62 days (range, 27-115 days). Two made a full recovery, one had myelodysplasia, and one with unresponsive disease died of septic complications. Four did not receive ATG/ALG, two had aplastic anemia, and two had bone marrow suppression. Three underwent liver transplantation, and all four resumed granulopoiesis. One child who underwent liver transplantation died of sepsis with chronic rejection. Median recovery of granulopoiesis was 99 days (range, 20-153 days). CONCLUSIONS Bone marrow failure occurs in 10.7% of children with acute liver failure. It sometimes occurs in association with non-A, non-B, non-C hepatitis and parvovirus B19 infection. Treatment with ATG/ALG is successful and is well tolerated in most cases.
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Affiliation(s)
- J Tung
- Department of Child Health, King's College Hospital, United Kingdom
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48
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Hadzic N, Pritchard J, Webb D, Portmann B, Heaton ND, Rela M, Dhawan A, Baker AJ, Mieli-Vergani G. Recurrence of Langerhans cell histiocytosis in the graft after pediatric liver transplantation. Transplantation 2000; 70:815-9. [PMID: 11003364 DOI: 10.1097/00007890-200009150-00019] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Two girls were diagnosed with Langerhans cell histiocytosis (LCH) at the age of 16 and 7 months and developed end stage chronic liver disease related to LCH-induced sclerosing cholangitis at 28 and 8 months, respectively. They received liver transplants at 34 and 14 months of age. Five months post-orthotopic liver transplantation (OLT) one of the patients developed posttransplant lymphoproliferative disease, successfully treated with a combination of surgery and reduction of immunosuppression. Fourteen months post-OLT she developed diabetes insipidus, bilateral ear discharge, and new osteolytic lesions. After transplantation both girls had mild skin reactivations of LCH, requiring minimal steroid increments. At 60 and 5 months post-OLT intrahepatic LCH recurrence was diagnosed on the basis of abnormal biliary enzymes and presence of Langerhans cells in the grafts. Initial cholangiography in both patients was unremarkable. LCH activity was controlled by maintenance chemotherapy with vinblastine, etoposide, and prednisolone. Ten months after reappearance of LCH in the liver graft a follow-up cholangiography in one of the girls demonstrated a low grade cholangiopathy. Residual elevation of liver enzymes probably represents an ongoing pathogenic process.
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Affiliation(s)
- N Hadzic
- Department of Child Health, Institute of Liver Studies, King's College Hospital, Denmark Hill, London, UK
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49
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Verma A, Dhawan A, Wade JJ, Lim WH, Ruiz G, Price JF, Hadzic N, Baker AJ, Rela M, Heaton ND, Mieli-Vergani G. Mycobacterium tuberculosis infection in pediatric liver transplant recipients. Pediatr Infect Dis J 2000; 19:625-30. [PMID: 10917220 DOI: 10.1097/00006454-200007000-00008] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To study the incidence, clinical presentation, management, complications and outcome of tuberculosis in pediatric liver transplant recipients. METHODS A retrospective review of the medical records of children who underwent liver transplantation between 1991 and 1998. RESULTS Mycobacterium tuberculosis infection occurred in 6 of 254 (2.4%) children undergoing liver transplantation between 1991 and 1998. Cough, pyrexia and poor appetite were common presentations; one-half had normal chest radiographs. The median time to confirmation of diagnosis was 8 months (range, 1 to 17 months). Tests contributing to diagnosis included: Ziehl-Neelsen (ZN) stain (2 patients), M. tuberculosis polymerase chain reaction (1 patient), Mantoux test (1 patient) and histopathology (4 patients). Family health screening was productive for 4 patients. Duration of treatment varied from 9 to 18 months. Isoniazid-induced hepatitis was observed in 2 patients but resolved with dose reduction. Two patients died while receiving treatment, one of Klebsiella spp. septicemia and the other of pulmonary hemorrhage. CONCLUSIONS Tuberculosis after liver transplantation has a significant morbidity and mortality. Pretransplantation a personal and family history of tuberculosis must be sought, and screening of patients and their families should be considered. Standard regimens incorporating isoniazid and rifampin are effective, but regular monitoring of liver function is essential to detect drug-induced hepatotoxicity.
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Affiliation(s)
- A Verma
- Dulwich Public Health Laboratory and Medical Microbiology, King's College Hospital, London, UK.
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50
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Muiesan P, Dhawan A, Novelli M, Mieli-Vergani G, Rela M, Heaton ND. Isolated liver transplant and sequential small bowel transplantation for intestinal failure and related liver disease in children. Transplantation 2000; 69:2323-6. [PMID: 10868633 DOI: 10.1097/00007890-200006150-00017] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Liver dysfunction is a well-recognized complication of intestinal failure in children. Advances in total parenteral nutrition (TPN) have allowed these children to survive while their intestinal tract gradually adapts. Unfortunately TPN may lead to cholestatic liver disease particularly in the young children. Progression of liver disease is associated with a poor prognosis and is an indication for small bowel transplantation. We report our experience of orthotopic liver transplantation in four children with short gut and sequential liver and small bowel transplantation in one child. All children had TPN-related liver failure. Causes of intestinal failure included necrotising enterocolitis (n=2), gastroschisis (n=1), intestinal atresia (n=1), and megacystic, microcolon syndrome (n=1). At the time of liver transplantation the children's mean age was 10.9 months (2.5-24) and weight 6.7 kg (4.8-10.1). The mean serum bilirubin was 522 micromol/liter (299-823), aspartate transaminase 423 IU/liter (49-1024) and international normalized ratio 2.8 (2-3.9). There were two deaths both from respiratory failure secondary to adenovirus pneumonia including the child who received a sequential small bowel transplant. Three children with isolated liver grafts are alive and off TPN at 20 months (mean) follow up (range 6-35). Isolated orthotopic liver transplantation has a role in selected children with intestinal failure, particularly those with short but normally functioning gut and progressing with satisfactory intestinal adaptation but developing liver disease. Those children with TPN-related liver disease and unadapted gut or irreversible intestinal disease need combined liver and small bowel transplantation. Sequential small bowel transplantation is feasible after orthotopic liver transplantation and may provide an option for the child with terminal liver and small bowel failure.
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Affiliation(s)
- P Muiesan
- Department of Child Health, King's College Hospital, London, United Kingdom
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