Some articles on live-doner liver transplant

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Right Lobe Graft in Living Donor Liver

Transplantation

Inomata Y, Uemoto S, Asonuma K, et al.

Transplantation. 2000;69:258-264

Background: For the sake of donor safety in living

donor liver transplantation (LDLT), the left lobe is

currently being used most often for the graft.

However, size mismatch has been a major obstacle for

an expansion of the indication for LDLT to larger-size

recipients, because a left lobe graft is not safe

enough for them.

Methods: In 1998, LDLT using a right lobe graft was

introduced and performed on 26 recipients to overcome

the small-for-size problem. The right lobe, which does

not include the middle hepatic vein of the donor, was

used. Initially, indication for right lobe LDLT was

basically defined as an estimated left lobe graft

volume/recipient body weight ratio (GRWR) of <0.8%,

which was later raised to <1.0%.

Results: All the donors recovered from the operation

without persistent complications. Two donors with

transient bile leakage were successfully treated with

a conservative approach. A right lobectomy resulted in

more blood loss (337+/-175 ml), and a longer operative

time (6.67+/-0.85 hr) than a lateral segmentectomy,

but not a left lobectomy. Grafts with a GRWR >0.8%

were implanted in all recipients, except for two, who

received relatively smaller right lobes (GRWR of 0.68%

and 0.66%). In one of these two, the right lobe from

the donor was used as the orthotopic auxiliary graft.

Postoperative transitory increases in total bilirubin

and aspartate transaminoferase for right lobe donors

were higher than those for the left lateral

segmentectomy. Nineteen recipients (73.1%) were

successfully treated with this procedure. The causes

of death were not specific for right lobe LDLT, except

for one patient with a graft that had multiple hepatic

venous orifices. These multiple and separate

anastomoses of the hepatic veins caused an outflow

block as a result of a positional shift of the graft,

which finally led to graft loss.

Conclusion: Our experience suggests that right lobe

grafting is a safe and effective procedure, resulting

in the expansion of the indication for LDLT to

large-size recipients. How to deal with the possible

variation in the anatomy of the right lobe graft

should be given attention throughout the procedure.

Living Related Liver Transplantation: Histopathologic

Analysis of Graft Dysfunction in 304 Patients

Minamiguchi S, Sakurai T, Fujita S, et al.

Hum Pathol. 1999;30:1479-1487

Between June 1990 and August 1997, 304 mainly

pediatric patients underwent a total of 311 orthotopic

living related liver transplantations (LRLTs) under

tacrolimus immunosuppression at Kyoto University

Hospital. Congenital biliary atresia was the most

common underlying disease. The donor was a parent, and

the left lateral segments were used as grafts in most

cases. The average number of loci of HLA-A, -B, and

-DR mismatches between the donor and the recipient

were 2.1. Forty-three transplants were

ABO-incompatible. Liver histology at the time of

abnormal liver function after transplantation was

analyzed. Preservation injury was rare and mild. Acute

cellular rejection (ACR) occurred in 36% of

transplants during the first 6 months. Average

rejection activity index (the Banff schema) was 4.2

and severe rejection was rarely seen. The number of

mismatching HLA loci and immunosuppression regimens

affected the incidence of ACR. Chronic rejection (CR)

occurred in 2% of transplants. Concerning humoral

rejection, no hyperacute rejection was seen. However,

hepatic artery thrombosis (delayed hyperacute

rejection) was seen in an ABO-incompatible transplant.

Acute hepatitis, including those related to

cytomegalovirus and Epstein-Barr virus, occurred in

17% of transplants. Chronic hepatitis, including

hepatitis B and C, developed in 3%. Acute or chronic

cholangitis occurred in 16%, and a significantly

higher incidence of cholangitis was found in

ABO-incompatible transplants. Posttransplantation

lymphoproliferative disease developed in 2%. In LRLT,

milder preservation injury and less frequent ACR and

CR were suggested, probably because of the short

cold-ischemia time and the advantages of HLA

histocompatibility, respectively.

Experience With Living Related Liver Transplantation

in 63 Children

Otte JB, Reding R, de Ville de Goyet J, et al. .

Acta Gastroenterol Belg. 1999;62:355-362

The incentive to develop intrafamilial living related

liver transplantation (LRLT) originated from the

shortage of cadaveric organ supply. We report our

experience with LRLT in 63 children during 1993-1998

in the frame of a protocol approved by the Ethics

Committee of our Institution. During this period, 152

potential intrafamilial (mostly parental) donors were

evaluated; 44 (28.5%) were excluded because of

surgical (n = 4), medical (n = 39) or psychosocial

reason (n = 1). Out of 108 who matched all medical,

surgical and psychological criteria of selection, 45

did not underwent living donation because their child

received a cadaveric graft (n = 22; LRLT was their

second option) or because one of the parents who had

both been selected was chosen [by the surgical team

because of more favourable anatomy (n = 8) or by

mutual agreement between the two parents (n = 5)].

Sixty-three living donors (36 mothers, 24 fathers, one

grand mother, one aunt and one uncle) underwent

procurement of the left lobe (n = 52), the left lobe

extended to part of segment IV (n = 8) or a left

hepatectomy (n = 3) without mortality or any serious

morbidity. Their median hospital stay was 7 days

(range: 6-12); full physical rehabilitation and

normalization of liver tests were usually obtained

within three weeks. Their psychological follow-up did

not disclose any longstanding serious sequellae. The

median age of the recipients was 13 months (range

5-189); 30 were younger than one year at the time of

transplant. Their median weight was 8.1 kg (range: 4.3

to 60); 36 had an actual weight under 10 kg. Fifty-two

received an ABO identical and 11 received an ABO

compatible transplant. The native liver diseases were

similar to common data in children, with biliary

atresia being the most frequent indication (74.6%).

The median weight of the graft was 260 gr (range:

138-680) with a median ratio between the graft weight

and the recipient body weight of 3.17% (range:

0.75-8.08). All grafts were implanted orthotopically

with semi-microvascular reconstruction of the hepatic

vein, portal vein and hepatic artery [end to end

anastomosis in 58 (2 arteries were reconstructed in 7

patients) and interposition of an iliac arterial

allograft from the infrarenal aorta in 5]. Base line

immunosuppression consisted of a triple drug regimen

including steroids, Azathioprine and either

Cyclosporine-Sandimmun (n = 9), Cyclosporine

Microemulsion formulation-Neoral (n = 13) or

Tacrolimus-Prograft (n = 41). Biopsy-proved acute

rejection was treated with intravenous bolus of

steroids; steroid-resistant acute rejection was

treated by a switch from Cyclosporine to Tacrolimus or

addition of Mycophenolate-Mofetil (Cellcept) in

Tacrolimus treated patients. Actuarial patient

survival was 91.8% and 89.6% after LRLT at one and

five years post-transplant, respectively, and 87.5%

and 82.8% at one and five years, respectively, in 90

patients who received a cadaveric graft during the

same interval. Actuarial graft survival was 91.8% and

84.1% after LRLT at one and five years, respectively,

and 76.4% and 73.3% at one and five years,

respectively, after cadaveric transplants. Vascular

thrombosis was observed in 9.5% of the patients

(arterial thrombosis: 1.6%; portal thrombosis: 7.9%)

without graft loss. Biliary complications were

observed in 26.9% (bile leak from cut surface in 3.1%,

anastomotic stricture in 22.2% and intrahepatic

stricture in 1.5%); two patients died from septic

shock possibly related to uncompletely relieved

anastomotic stricture; all other biliary complications

were successfully treated either conservatively or

surgically. The incidence of acute rejection was 90.9%

in 22 patients with Cyclosporine-based

immunosuppression; acute rejection was

corticoresistant in 50%. It was 46.3% in 41 patients

with Tacrolimus-based immunosuppression (64% with

Prograft in capsules and 18.7% with Prograft in

granules); no acute rejection was corticoresistant.

Living-Related Liver Transplantation in Children: the

'Parisian' Strategy to Safely Increase Organ

Availability

Revillon Y, Michel JL, Lacaille F, et al.

J Pediatr Surg. 1999;34:851-853

Purpose: The aim of the authors was to report their

experience with living related liver transplantation

(LRLT) in children, particularly focusing on the

safety of the two-center " Parisian " strategy.

Methods: The records of donors and recipients of 26

pediatric living-related donor liver transplantations

performed between November 1994 and March 1998 were

reviewed retrospectively. Donors were assessed 1 year

after transplantation for medical and overall status.

Results: Indications for LRLT included biliary atresia

(n = 18), Byler's disease (n = 5), alpha-1-antitrypsin

deficiency (n = 1), Alagille syndrome (n = 1), and

undefined cirrhosis (n = 1). Liver harvesting

consisted of either a complete left hepatectomy (n =

14) or left lateral hepatectomy (n = 12) without

vascular clamping. The recipient procedure essentially

was the same as in split liver transplantation. Mean

overall cold ischemia time averaged 140 minutes

(range, 90 to 230 minutes). Twenty-four of 26 patients

had end-to-end vascular anastomoses without

interposition. Biliary reconstruction consisted of a

Roux-en-Y choledochojejunostomy in all patients. All

recipients except one received cyclosporine A (CSA).

Mean donor hospitalization was 8 days (range, 6 to 13)

with normalization of all liver function assays by the

time of discharge. There were no donor deaths and two

postoperative complications (perihepatic fluid

collection and bleeding from the wound). One year

after donation, the initial 19 donors had resumed

their pretransplant status. Two of the children who

underwent transplant died. Thirteen of the recipients

required reoperation for hepatic artery thrombosis (n

= 2), portal vein thrombosis (n = 2), biliary

complications (n = 6), fluid collection (n = 3), small

bowel perforation (n = 1), and plication for

diaphragmatic eventration (n = 1). With mean follow-up

of 2 years, 24 of 26 patients are alive and well

(patient and graft survival rate, 92%).

Conclusions: LRLT is still controversial, even with

minimal and decreasing donor risk. The " Parisian "

strategy consists of harvesting the liver in an adult

unit by an adult hepatic surgery team. The

transplantation is then performed in a pediatric

hospital by the pediatric liver transplantation team.

The two steps of the procedure allow units specialized

in adult surgery, on one hand, and pediatric liver

transplantation, on the other hand, to dedicate

themselves completely to their respective procedures,

improving the safety of the harvest, and alleviating

stress for both the medical staff and the families.

Assessment of Potential Donors for Living Related

Liver Transplantation

Baker A, Dhawan A, Devlin J, et al.

Br J Surg. 1999;86:200-205

Background: Living related liver transplantation has

been developed as an important potential source of

organs for treatment of children with acute and

chronic liver disease. A single UK centre performing

living related liver transplantation was established

in 1993.

Methods: Parents who were potential donors for their

children for living related liver transplantation were

assessed for suitability according to a protocol based

on one developed and published by the University of

Chicago Transplant Group. Records kept by the

transplant coordinators were retrieved and data were

extracted.

Results: Of 64 potential donors for 32 potential

recipients ten were excluded at a preliminary stage.

Fourteen ultimately became donors. Of 54 parents who

began evaluation 23 were finally considered to be

suitable. There were 19 non-disease-related reasons

for unsuitability: blood group mismatch (eight cases),

size discrepancy (six), pregnancy (two), oral

contraceptive medication (one), vascular anatomy

variant (one) and age (one). Sixteen were unsuitable

because disease was found, namely fatty liver (four),

thyroid disease (two), hepatitis B positivity (two),

cardiac murmur (one), anaemia (one),

glucose-6-phosphate dehydrogenase deficiency (one),

diabetes mellitus (one) and psychological problems

(one), and three parents were affected by the same

disorder as the child (Alagille syndrome, one;

mitochondrial disorder, one; recurrent cholestasis,

one). Three parents were rejected for more than one

reason. Both parents were unsuitable for donation in

21 per cent of cases.

Conclusion: Parents approach living related liver

transplantation with enthusiasm. They should be

advised of the high chance of unsuitability, including

the finding of significant pathology. The limitation

of living related liver transplantation as the major

source of organs for children is recognized.

Pediatric Liver Transplantation With Cadaveric or

Living Related Donors: Comparative Results in 90

Elective Recipients of Primary Grafts

Reding R, de Goyet J de V, Delbeke I, et al.

J Pediatr. 1999;134:280-286

Study Design: Between July 1993 and March 1997, 110

children were listed for primary elective liver

transplantation with cadaveric (Cad: n = 68) or

living-related (LR: n = 42) donors. Pregraft

mortality, post-transplant survival, and surgical and

immunologic complications were retrospectively

compared in both groups.

Results: The pregraft mortality rate was 10 (15%) of

68 versus 1 (2%) of 42 in the Cad and LR groups,

respectively (P = .049). Postliver transplantation

1-year patient and graft survival rates were 87% and

75% in the Cad group (n = 49) versus 92% and 90% in

the LR group (n = 41), respectively (NS). The

incidence of post-transplant complications was as

follows: hepatic artery thrombosis (Cad: 16%; LR: 0%,

P =.020), portal vein thrombosis (Cad: 8%; LR: 2%,

NS), and biliary complications (Cad: 14%; LR: 34%, P

=.044). The overall incidence of acute rejection was

similar in both groups; however, a lower incidence of

acute rejection occurred in LR graft recipients

treated with tacrolimus.

Conclusions: The introduction of an LR donor liver

transplantation program allowed a significant decrease

in the pretransplant mortality rate, with a consequent

overall improvement in patient survival compared with

the Cad series. The incidence of biliary complications

was higher in the LR series, whereas better human

leukocyte antigen matching in this subgroup did not

result in a lower rejection incidence.

Living Related Liver Transplantation for Acute Liver

Failure in Children

Emre S, Schwartz ME, Shneider B, et al.

Liver Transpl Surg. 1999;5:161-165

The mortality rate among children with acute liver

failure (ALF) on the waiting list for liver

transplantation is high. We present our experience

with living related donor liver transplantation

(LRD-LT) in children who required urgent

transplantation for ALF. Between December 1995 and

July 1997, 6 children underwent LRD-LT for ALF. Cause

of liver failure, recipient and donor demographics,

clinical and laboratory data, surgical details,

complications, and 6-month and 2-year graft and

patient survival were recorded. Five boys and 1 girl

received left lateral segment grafts from their

parents. The mean age was 4 +/- 2.8 years (range, 1 to

9 years). ALF was caused by 's disease in 1

patient and sickle cell intrahepatic cholestasis

syndrome in 1 patient; in 4 patients, the cause was

unknown. All patients had mental status changes; 2

were on life support. Mean pretransplantation liver

function test values were: alanine aminotransferase,

972 +/- 565 U/L (normal, 1 to 53 U/L), total

bilirubin, 31.3 +/- 12.4 mg/dL (normal, 0.1 to 1.2

mg/dL), prothrombin time, 34.3 +/- 12.4 seconds

(normal, 10.8 to 13.3 seconds), international

normalized ratio, 8.46 +/- 5.4 (normal < 2), and

fibrinogen, 109 +/- 23.9 mg/dL (normal, 175 to 400

mg/dL). The donors were 5 mothers and 1 father. The

mean donor age was 32.5 +/- 7.6 years (range, 19 to 40

years). No donor required blood transfusion, and no

donor had any early or late postoperative

complications. The donors' mean hospital length of

stay was 5 days. In five cases, grafts were blood

group-compatible; 1 child received a blood

group-incompatible graft. All grafts functioned

immediately. No patient had hepatic artery or portal

vein thrombosis or biliary complications. The child

who received a mismatched graft died of infection of

the brain caused by Aspergillus spp at 22 days

posttransplantation with a functioning graft. The

child with ALF caused by sickle cell intrahepatic

cholestasis syndrome developed outflow obstruction 3

months posttransplantation and required

retransplantation; he eventually died of vascular

complications related to his primary disease. Four

children are alive at a mean follow-up of 27 months

(range, 14 to 36 months). LRD-LT for children with ALF

facilitates timely transplantation without drawing on

cadaveric donor resources. The established safety

record of LRD-LT made this option appealing to both

physicians and parental donors.

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