[Left-Lateral Living Related Liver Donation - The Essen Experience]

Background: The international organ shortage for liver transplantation exists particularly in paediatric transplantation. Therefore left-lateral living related liver donation (LLRLD) plays a major role in this field. The aim of the present study was to analyse all procedures of LLRLD in terms of donor safety from December 2008 to October 2012 at the University Hospital of Essen, Germany. Methods: All procedures of LLRLD from December 2008 to October 2012 at the University Hospital of Essen were included in the present study. All operations were carried out via an open narrowed median longitudinal laparotomy. General donor data were analysed. Complications were recorded and classified in accordance to their relevance. Results: 35 LLRLD were performed between December 2008 and October 2012 at the University Hospital of Essen, Germany. Mean age of the donors was 31.9 (23.4-61.7) years and 60 % were female. Past medical histories of the donors showed no relevant diagnoses. Mean length of the surgical procedure was 180 (± 89) minutes. Survival rate was 100 %. Minor complications were seen in 1 of 35 patients. Laboratory data showed a peak of the transaminases on the first postoperative day which resolved during the further course. Median postoperative hospital stay was 7 (5-11) days. Conclusion: LLRLD can be performed safely for the donors after adequate donor selection. The organ pool for paediatric recipients can be expanded by this procedure at suitable transplant centres.

[Orthotopic liver transplantation for polycystic liver disease with massive hepatomegaly]

HISTORY

A 51-year-old man (126 kg, 192 cm) with massive hepatomegaly causing cardiopulmonary symptoms was referred to our transplant center 14 years after initial diagnosis of polycystic liver disease.

TREATMENT AND COURSE

Uneventful hepatectomy was followed by orthotopic liver transplantation using caval replacement. Donor liver came from a 73-year-old woman (extended criteria donor organ offer). A portocaval shunting was not established during transplantation although the explanted liver weighed 22 kg. 18 months after transplantation liver function is stable and the patient enjoys normal quality of life.

CONCLUSION

This case report demonstrates the value and success of transplantation for patients suffering from enormous hepatomegaly due to polycystic liver disease.

[Relevance of Ablation Therapies for HCC: "A Real Bridging" for Liver Transplantation?]

BACKGROUND

The utilisation of interventional ablation procedures in the context of bridging and downstaging plans for hepatocellular carcinomas before liver transplantation is increasing. The aim of the present study was to summarise current data for the application of bridging and downstaging procedures before liver transplantation.

METHODS

The present study is based on an extensive investigation of the literature in PubMed. RESULTS of controlled trials, cohort studies, meta-analyses and reviews were included.

RESULTS

Recommendations for the usage of bridging procedures for hepatocellular carcinomas within the Milan criteria and an expected waiting time of more than 6 months until transplantation depend on the size of the lesions and have a low level of evidence. After successful downstaging of hepatocellular carcinomas beyond the Milan criteria into the range of the Milan criteria liver transplantation is recommended with a low level of evidence, as well.

CONCLUSION

Randomised controlled trials, clearly proving the success of bridging and downstaging procedures, are not available at the time and are not awaited for ethical reasons. Due to the uncomplicated application and low risk for therapy-associated complications, interventional procedures for bridging and downstaging are accepted and recommended.

Liver transplantation for hepatocellular carcinoma using extended criteria donor grafts

BACKGROUND

Liver transplantation (OLT) represents the treatment of choice for small hepatocellular carcinomas (HCC) in patients with end-stage liver disease. However, because of organ scarcity, alternative options must be explored, such as the use of extended criteria donor (ECD) grafts.

PATIENTS AND METHODS

We reviewed data of transplanted HCC patients using ECD grafts. Statistical analysis included uni- and multivariate Cox proportional hazards regression and survival analysis using the Kaplan-Meier method with the log-rank test.

RESULTS

Over a 6-year period, we transplanted 53 HCC patients with ECD grafts. The 38 men and 15 women showed a mean age of 56.3 ± 8.26 years. Thirty-four patients underwent a bridging treatment before OLT. Thirty-eight patients (72%) were outside the Milan criteria. The median value for alpha fetoprotein (AFP) level was 30.7 ng/dL. Pathologic tumor grade was G1 (n = 4), G2 (n = 32), G3 (n = 6), or Gx (n = 11). Median follow-up time was 23 months (range, 9-75). Overall 3- and 5- year patient survivals were 79% and 74%, respectively. The 5-year survivals for patients within or outside the Milan criteria were 87% versus 69%, respectively (P = .3728). Donor transaminases and post-OLT hemodialysis were prognostic factors for patient survival upon mutivariate regression analysis (P = .0043 and P = .0003, respectively).

CONCLUSION

OLT with ECD grafts constitutes an additional option for patients with HCC and cirrhosis, particularly subjects outside the Milan criteria. The risk- benefit ratio in these instances should be evaluated on a case-by-case basis.

Long-term outcomes of liver transplant patients with human immunodeficiency virus infection and end-stage-liver-disease: single center experience

Objective

Orthotopic-liver-transplantation (OLT) in patients with Human-Immunodeficiency-Virus infection (HIV) and end-stage-liver-disease (ESDL) is rarely reported. The purpose of this study is to describe our institutional experience on OLT for HIV positive patients.

Material and methods

This is a retrospective study of all HIV-infected patients who underwent OLT at the University Hospital of Essen, from January 1996 to December 2009. Age, sex, HIV transmission-way, CDC-stage, etiology of ESDL, concomitant liver disease, last CD4cell count and HIV-viral load prior to OLT were collected and analysed. Standard calcineurin-inhibitors-based immunosuppression was applied. All patients received anti-fungal and anti-pneumocystis carinii pneumonia prophylaxis post-OLT.

Results

Eight transplanted HIV-infected patients with a median age of 46 years (range 35-61 years) were included. OLT indications were HCV (n = 5), HBV (n = 2), HCV/HBV/HDV-related cirrhosis (n = 1) and acute liver-failure (n = 1). At OLT, CD4 cell-counts ranged from 113-621 cells/μl, and HIV viral-loads from < 50-175,000 copies/ml. Seven of eight patients were exposed to HAART before OLT. Patients were followed-up between 1-145 months. Five died 1, 3, 10, 31 and 34 months after OLT due to sepsis and graftfailure respectively. Graft-failure causes were recurrent hepatic-artery thrombosis, HCV-associated hepatitis, and chemotherapy-induced liver damage due to Hodgkin-disease. One survivor is relisted for OLT due to recurrent chronic HCV-disease but non-progredient HIV-infection 145 months post-OLT. Two other survivors show stable liver function and non-progredient HIV-disease under HAART 21 and 58 months post-OLT.

Conclusions

OLT in HIV-infected patients and ESLD is an acceptable therapeutic option in selected patients. Long-term survival can be achieved without HIV disease-progression under antiretroviral therapy and management of the viral hepatitis co-infection.

Use of marginal organs in kidney transplantation for marginal recipients: too close to the margins of safety?

Objective

Due to organ shortage, average waiting time for a kidney in Germany is about 4 years after start of dialysis. Number of kidney grafts recovered can only be maintained by accepting older and expanded criteria donors. The aim of this study was to analyse the impact of donor and recipient risk on kidney long-term function.

Methods

All deceased kidney transplantations were considered. We retrospectively studied 332 patients between 2002 and 2006; divided in 4 groups reflecting donor and recipient risk.

Results

Non-marginal recipients were less likely to receive a marginal organ (69 of 207, 33%) as compared to marginal recipients, of whom two-thirds received a marginal organ (p < 0.0001). Graft function significantly differed between the groups, but detrimental effect of marginal recipient status on eGFR after 12 months (-6 ml/min/1.73 qm, 95% CI -2 to -9) was clearly smaller than the effect of marginal donor status (-10 ml/min/1.73 qm, 95% CI -7 to -14).

Conclusions

As we were able to show expanded criteria donor has a far bigger effect on long-term graft function than the "extra risk" recipient. Although there have been attempts to define groups of recipients who should be offered ECD kidneys primarily the discussion is still ongoing.