Liver Re-transplantation in Adults: Indications and Outcomes Analysis of a 23-year Experience in a Single Center in Argentina

Background

Liver re-transplantation (re-LT) represents the only treatment for patients with irreversible graft failure.

Objective

The aim of the current study was to describe the outcomes of both, patient and graft, after re- LT, at a high-volume referral center.

Methods

Our population consisted of patients, with liver disease, who underwent re-LT in our institution between January 1996 and December 2019.

Results

49 patients met the inclusion criteria. The patient's overall survival (OS) for the first year was 85% (Confidence Intervals (CI) 71-92) and 70% at five years (CI 53-82). In our population, three (6.12%) patients presented loss of graft and were included again in the transplant list; of these, one agreed to a new transplant while the remaining two died. This gave us graft survival results similar to those obtained for the re-LT patient; 85% at one year (CI 71-92) and 70% at 5 years (CI 53-82).

Conclusion

Our study shows that re-LT is a valid and safe treatment for both early graft dysfunction and for transplanted patients who again present end-stage liver disease, showing a satisfactory long-term evolution, with parameters comparable to primary transplantation.

Catastrophic antiphospholipid syndrome complicating orthotopic liver transplantation

Catastrophic antiphospholipid syndrome (CAPS) is an acutely devastating situation characterized by widespread thrombotic microangiopathy in the presence of elevated titers of antiphospholipid antibodies. We describe a 57-year old woman who underwent liver transplantation for primary sclerosing cholangitis and developed this malignant variant of the antiphospholipid syndrome.

[Multimodal treatment of hepatocellular carcinoma]

BACKGROUND

Several options now available create the need for a multidisciplinary approach to the treatment of patients with hepatocellular carcinoma (HCC).

OBJECTIVE

To describe the experience with a group of patients with HCC diagnosed and treated with the current modalities for control of this entity.

POPULATION AND METHOD

A total of 169 consecutive patients with HCC treated between January 1990 and February 1998; 41 liver resections, 14 liver transplants, 87 chemoembolizations and 8 alcoholizations were performed. The median follow-up time was 23.6 months (range: 0.2-94). In the other 29 patients, only support treatment was administered.

RESULTS

Resected patients had a lower median hospitalization rate, blood transfusions, and hospitalization mortality. Recurrence was 42.1% in the resected group but 0% in transplanted patients. The overall survival at 36 months was better for transplanted than for resected patients (100% vs. 62.3%; p < 0.02). The median survival time was 13 months (IC: 95%: 11-15 months) in chemoembolizated patients.

CONCLUSIONS

1. The outcome of patients with HCC is influenced by several factors, therefore calling for multimodal approach. 2. Surgical procedures should be indicated with low morbimortality rates. 3. The overall survival and disease free survival time is better in transplanted patients than in the resected group. 4. The survival time of patients with unresectable HCC without extra-liver disease could be improved with chemoembolization.

Liver transplantation for the sequelae of intra-operative bile duct injury

BACKGROUND

Intra-operative bile duct injuries (IBDI) are potentially severe complications of the treatment of benign conditions, with unpredictable long-term results. Multiple procedures are frequently needed to correct these complications. In spite of the application of these procedures, patients with severe injuries can develop irreversible liver disease. Liver transplantation (LT) is currently the only treatment available for such patients, but little information has been published concerning the results of LT.

METHODS

Eight patients with LT for end-stage liver disease for IBDI were studied retrospectively. They had failure of multiple previous treatments and experienced recurrent episodes of cholangitis, oesophageal variceal bleeding, severe pruritus, refractory ascites and spontaneous peritonitis.

RESULTS

Mean recipient hepatectomy time was of 243 minutes (range 140-295 min), the complete procedure averages 545 minutes (260-720) and intraoperative red-blood-cells consumption was 6.5 units (1-7). One patient required reoperation due to perforation of a Roux-en-Y loop, and three developed minor complications (2 wound infections, I inguinal lymphocele). One patient died due to nosocomial pneumonia (mortality rate 12.5%). One patient required retransplantation due to delayed hepatic artery thrombosis. At follow-up 75% of patients are alive with normal graft function and an excellent quality of life.

CONCLUSIONS

LT represents a safe curative treatment for end-stage liver disease after IBDI, albeit a major undertaking in the context of a surgical complication in the treatment of benign disease. The complications of the surgical procedure and the long-standing immunosuppression impart a high cost for resolutions of these sequelae but LT represents the only long-term effective treatment for these selected patients.

Nitric oxide synthase activity in the splanchnic vasculature of patients with cirrhosis: relationship with hemodynamic disturbances

BACKGROUND/AIMS

It has been demonstrated that an overproduction of nitric oxide plays an important role in the pathogenesis of the hyperdynamic circulation exhibited by cirrhotic patients. Nevertheless, evidence is supported by studies performed in experimental models or by indirect measurements in humans. The purpose of this study has been to evaluate nitric oxide production in splanchnic vasculature of patients with cirrhosis and to investigate its possible relationship with systemic and splanchnic hemodynamics.

METHODS

Nitric oxide synthase (NOS) activity was measured in hepatic artery and portal vein tissues of nine cirrhotic patients. Samples were obtained during liver transplantation. Control samples were obtained simultaneously from the corresponding tissues of the liver donors. Hemodynamic parameters were determined with Doppler ultrasonography.

RESULTS

NOS activity was significantly higher in hepatic artery of cirrhotic patients than in controls (8.17 +/- 1.30 vs 4.57 +/- 0.61 pmoles/g of tissue/min, P < 0.05). Patients with ascites showed a higher hepatic artery NOS activity than patients without ascites. Highly significant correlation was observed between cardiac output and hepatic artery NOS activity as well as between portal blood flow and hepatic artery NOS activity.

CONCLUSIONS

The present study demonstrates an enhanced production of nitric oxide in the splanchnic vasculature of patients with cirrhosis.

Partial left lateral segment transplant from a living donor

A shortage of liver donors for low-weight transplant recipients has prompted the development of procedures for liver-reduction, split-liver, and living related donor transplantations. For pediatric recipients weighing less than 10 kg, the left lateral segment is often still too large. We describe the procedure of monosegmental transplantation using segment II after segment III was resected in situ from a living related donor. Successful monosegmental transplantation is technically feasible and is a valid alternative to be considered for cases of size discrepancy between the recipient's volume and the donor's left lateral segment.

Splanchnic hyperemia after liver transplantation in patients with end-stage liver disease

Systemic and splanchnic hemodynamic parameters were evaluated in 12 patients with cirrhosis before and 3 and 6 months after liver transplantation. Results were compared with those obtained in 8 healthy subjects. Three months after liver transplantation recipients had an increase in mean arterial pressure (98 +/- 7 v 78 +/- 9 mmHg; P < .05), an insignificant decrease in cardiac index (3. 4 +/- 0.6 v 4.0 +/- 1.0 L . min-1 . m-2), and a marked increase in peripheral vascular resistance (1,563 +/- 308 v 800 +/- 205 dyne . s . cm-5; P < .05) compared with pretransplantation values. Portal blood flow was also significantly increased (1,494 +/- 200 v 829 +/- 130 mL/min; P < .05). These hemodynamic changes were more pronounced 6 months after transplantation (mean arterial pressure, 100 +/- 8 mmHg; cardiac index, 3.0 +/- 1.0 L . min-1 . m-2; P < .01; peripheral vascular resistance, 1,680 +/- 405 dyne . s . cm-5; portal blood flow, 1,520 +/- 180 mL/min). Systemic hemodynamics 6 months after liver transplantation were similar to those observed in the healthy control group (mean arterial pressure, 95 +/- 6 mmHg; cardiac index, 2.9 +/- 0.9 L . min-1 . m-2; peripheral vascular resistance, 1,480 +/- 380 dyne . s . cm-5). However, portal blood flow was still significantly higher than in healthy controls at 6 months (1,520 +/- 180 v 910 +/- 140 mL/min; P < .05). This study shows that systemic hemodynamics are normalized after liver transplantation. However, an increase in portal blood flow occurs and persists for at least 6 months after liver transplantation. Further studies are needed to clarify the cause of the abnormally high portal flows.

Liver transplantation as treatment for arterioportal fistulae

The authors present the case of a 14-year-old boy with secondary portal hypertension caused by arterio-portal fistulae. Ascites, edema, severe abdominal pain, and steatorrhea developed in the patient. In an attempt to decrease arterioportal flow the authors carried out vascular embolization that was partially successful. A liver transplant was performed as a last therapeutic resource in view of the fact that it constitutes an accepted therapy for patients with severe liver disease. Orthotopic liver transplantation may be considered as another possible treatment of arterio-portal fistulae.

[Renal failure in patients with liver transplant: incidence and predisposing factors]

Renal failure is a common finding in patients undergoing orthotopic liver transplantation. The aim of the present study was to evaluate the incidence, prognostic value of pre, intra and postoperative factors and severity of renal dysfunction in patients who undergo liver transplantation. Therefore, the records of 38 consecutive adult patients were reviewed. Renal failure was defined arbitrarily as an increase in creatinine (> 1.5 mg/dl) and/or blood urea (> 80 mg/dl). Three patients were excluded of the final analysis (1 acute liver failure and 2 with a survival lower than 72 hs.) Twenty one of the 35 patients has renal failure after orthotopic liver transplantation. Six of these episodes developed early, having occurred within the first 6 days. Late renal impairment occurred in 15 patients within the hospitalization (40 +/- 10 days) (Mean +/- SD). In he overall series, liver function, evaluated by Child-Pugh classification, a higher blood-related requirements and cyclosporine levels were observed more in those who experienced renal failure than those who did not (p < 0.05). Early renal failure was related with preoperative (liver function) and intraoperative (blood requirements) factors and several causes (nephrotoxic drugs and graft failure) other than cyclosporine were present in patients who developed late renal impairment. No mortality. No mortality was associated with renal failure. We conclude that renal failure a) is a common finding after liver transplantation, b) the pathogenesis of this complication is multifactorial and, c) in not related with a poor outcome.

Conversion and pharmacokinetic studies of a microemulsion formulation of cyclosporine in pediatric liver transplant patients

A study of conversion from the standard cyclosporine treatment to a microemulsion formulation was performed in 29 stable pediatric liver transplant patients. The study was divided into conversion and in follow-up phases. While on therapy with the standard formulation at a mean daily dose+/-SD of 231+/-101.8 mg patients had a mean cyclosporine trough level of 188.7+/-51.4 ng/ml. Following a 1:1 conversion from the standard to the microemulsion formulation an increase in the cyclosporine trough level was observed in 75% of the patients. The mean cyclosporine trough level at this point was 221.5+/-69.7 ng/ml. On follow-up, the dose had to be reduced an average of 21.7% in 49% of the patients, whereas the rest remained stable. The incidence of adverse events was not significant and no differences were observed between the two formulations. The pharmacokinetic study of the microemulsion in 11 patients showed a monophasic curve, with an early absorption at 30 min and maximum concentration+/-SD of 880.8+/-72.8 ng/ml and time to maximum concentration of 1.5+/-0.12 hr. Basal time showed the least correlation with the area under the curve and T4 the most statistically significant. The microemulsion showed better bioavailability and pharmacokinetic characteristics than the standard formulation.

Bronchobiliary fistulas in adults

Reported herein are 16 cases of nontraumatic bronchobiliary fistula in adults observed over 32 years. The fistulas were due to either biliary obstruction or infectious diseases involving the liver. All patients had biloptysis and other respiratory symptoms, and most had cholangitis, jaundice, and/or sepsis. The diagnosis was established by fistulography or cholangiography. All patients except one were treated surgically by relief of biliary obstruction and drainage of intra-abdominal abscesses. All 15 surgically treated patients had a successful outcome. Rapid diagnosis and early treatment of septic complications are necessary, but careful assessment and surgical relief of the biliary obstruction are essential in successfully treating this condition.