Journal of Liver Transplantation最新文献

Despite pre-transplant screening, patients with chronic liver disease may present with previously undiagnosed pulmonary hypertension (PH) at the time of liver transplantation. While severe portopulmonary hypertension (PoPH) at the time of surgery is considered a contraindication to transplantation, the current evidence guiding perioperative management of newly diagnosed PH is limited.

We present a case of a 65-year-old male with previously undiagnosed severe PH secondary to cirrhosis-related hyperdynamic circulation, successfully managed with intra- and postoperative inhaled nitric oxide (iNO) therapy during orthotopic liver transplantation. Rapid stabilization of elevated mean pulmonary pressures (mPAP) allowed an uncomplicated perioperative transplant course.

This case highlights the importance of recognizing and addressing newly diagnosed PH at the time of liver transplantation. Whereas severe PoPH presents significant perioperative risk, PH in cirrhosis is more commonly due to alternative etiologies of venous congestion or hyperdynamic circulation. Our case suggests that elevated mPAP of alternative etiologies may not immediately compromise postoperative transplant outcomes. Intraoperative vasodilator therapy, including iNO, may be a useful therapeutic and diagnostic tool in these cases. Further investigation into perioperative management of new PH in liver transplantation is warranted to refine surgical decision-making and improve patient outcomes.

Background

Vascular thromboses (VT) are life-threatening events after pediatric liver transplantation (LT). Single-center studies have identified risk factors for intra-abdominal VT, but large-scale pediatric studies are lacking.

Methods

This multicenter retrospective cohort study of isolated pediatric LT recipients assessed pre- and perioperative variables to determine VT risk factors and anticoagulation-associated bleeding complications.

Results

Within seven postoperative days, 31/331 (9.37%) patients developed intra-abdominal VT. Open fascia occurred more commonly in patients with VT (51.61 vs 23.33%) and remained the only independent risk factor in multivariable analysis (OR = 2.84, p = 0.012). Patients with VT received more blood products (83.87 vs 50.00%), had significantly higher rates of graft loss (22.58 vs 1.33%), infection (50.00 vs 20.60%), and unplanned return to the operating room (70.97 vs 16.44%) compared to those without VT. The risk of bleeding was similar (p = 0.2) between patients on and off anticoagulation.

Conclusions

Prophylactic anticoagulation did not increase bleeding complications in this cohort. The only independent factor associated with VT was open fascia, likely a graft/recipient size mismatch surrogate, supporting the need to improve surgical techniques to prevent VT that may not be modifiable with anticoagulation.

Background and aim

The burden of Liver disease has significant implications on the healthcare infrastructure in Pakistan, with viral hepatitis being the leading etiology of end-stage liver disease. Liver transplant remains the only curative treatment option for end-stage liver disease. A decade ago, the liver transplant facility was almost non-existent for the Pakistani population, and the patients with end-stage liver disease had to travel overseas to receive liver transplantation. Gradually, during the last decade the country has progressed steeply and achieved various milestones in living donor liver transplantation. Various public and private sector hospitals are providing liver transplant services nationwide. The study aimed to describe the evolution and success of living donor liver transplant programs in Pakistan. We will also discuss the current practices involved in donor and recipient selection, factors related to non-existent deceased donor organ programs, and the introduction of innovative strategies to overcome the shortage of donor organ pools.

Methods

We retrospectively analyzed the data of the first 416 living donor liver transplants (LDLTs) performed at PKLI&RC from March 2019 to April 2023. The stepwise approach for the donor and recipient selection process is described in detail, along with the survival outcomes of LDLT at our center.

Results

Among the 416 living donor liver transplants performed between March 2019 and April 2023. The Hepatitis C virus was the most common etiology (50.5 %) for chronic liver disease. Hepatocellular carcinoma (HCC) was present in 27.9 % of cases. Most donors were offspring of the recipients, with sons accounting for 23 % and daughters for 17.5 % of cases. Only a single (0.24 %) patient had a deceased donor transplant. The annual donor rejection rate was up to 68 % at our center. Nine SWAP transplants were performed to overcome the donor shortage. The Clavien Dindo classification system was used to grade the severity of complications after donor hepatectomy. No donor mortality (grade-5 complication) was observed in our cohort, whereas 1- and 3-year recipient survival rates were 89 % and 88 %, respectively.

Conclusion

Hepatitis C virus remains the most common etiology of chronic liver disease requiring liver transplantation. The major pool of living donations was from first-degree relatives. There was no donor mortality with acceptable 1- and 3-year recipient's survival rates. Living donor liver transplantation is a feasible and safe strategy in regions where cadaveric liver transplant program is limited.

Background and aim

The number of studies reporting in detail the complications that occur after liver transplantation in patients with primary sclerosing cholangitis (PSC), especially after living donor liver transplantation (LDLT), is limited. In this study we present the complications and outcomes of PSC patients after liver transplantation in a predominantly LDLT center.

Materials and methods

Adult and pediatric patients who underwent liver transplantation for PSC between February 2008 and October 2020 were included in the study. The demographic characteristics, presence of co-existing diseases, indications for transplantation, type of transplantation, and immunosuppressive treatments used were recorded. Patient survival, survival times, cause of death, recurrences, rejection, and biliary complications were recorded.

Results

Thirty patients who underwent liver transplantation for PSC were included in the study. Twenty-seven patients (90 %) were living donor transplants. The 1-, 3-, and 5-year survival rates after transplantation were 75.9 %, 74.9 %, and 74.9 %, respectively. Biliary complications occurred in 15 patients (50 %). All patients with biliary complications were successfully treated with endoscopic and percutaneous interventional treatments. Chronic rejection occurred in three patients (10 %) and acute rejection occurred in five patients (13.3 %). PSC recurrence developed in five patients (18.5 %).

Conclusion

Biliary complications are the most common complication after liver transplantation in patients with PSC in our center, where LDLT is used extensively and PSC patients are followed closely with respect to biliary complications after transplantation.

Liver transplantation (LT) is life-saving for patients with alcohol-associated liver disease (ALD) and severe alcohol-associated hepatitis (SAH). In this retrospective analysis of deceased donor LT from 10/2018 to 4/2022, patients were subdivided into those with ALD with <6 months (M) or >6 M sobriety vs. non-ALD etiologies of liver disease. Patients with <6 M sobriety were further stratified into those meeting the NIAAA criteria for SAH. Of the 367 LT, ALD comprised 171(47 %) of all LT; 85(50 %) had <6 M sobriety. Comparing those with ALD with <6 M to >6 M sobriety and other non-ALD etiologies, those with <6 M were younger (mean age 46 vs. 54 and 56 years; p < .001), had higher MELD (36 vs. 26 and 23; p < .001), and on the list fewer days (14 vs. 83 and 168; p < .001) while there were no differences in gender or length of stay following LT. Of those with <6 M sobriety, 41 met the NIAAA definition of SAH: mean age 43, 42 % female, 0 % AA, mean MELD of 37, mean days of abstinence 58d prior to LT with 29 % prior ALD rehabilitation, 58 % failed steroids, and were listed for 7 days prior to LT. The 1-year survival was similar in all groups with 90 % in SAH, 93 % in <6 M, 93 % in >6 M, and 94 % in those receiving LT for all other causes. While 24 % with SAH had an alcohol slip following LT, only 4 % had a return to harmful drinking. Our single center experience shows LT for those with AUD and <6 M of sobriety and specifically SAH have excellent 1-yr survival similar to those with AUD >6 M sobriety and other etiologies with a low rate of return to harmful drinking.

Background

There is a growing interest in qualitative methodologies for understanding complexities in the lived experience of liver transplantation. Frequently, such studies explore quality of life and offer insights for integrating patient-oriented outcomes into conventional research strategies. The scope of qualitative research in liver transplantation tends to be limited, however, with respect to engagement with critical theories, leaving certain aspects of lived experience unexamined.

Methods

The authors describe the process of layering multiple modes of critical qualitative research in liver transplantation, exploring how experiences in liver transplantation are structured discursively and what aspects of recipients’ stories are not easily spoken or shared. This study pairs a critical discourse analysis of patient manuals from a Canadian liver transplant program with digital storytelling with liver transplant recipients.

Results

A homogenous narrative emerges from patient manuals that does not adequately capture the complexity of lived experience of liver transplant survivors. Digital storytelling opens new narrative possibilities by layering sensory aspects of the transplant experience, which are often difficult to articulate through words. This complicates common ideas of survivorship, who is considered a “good” patient, and the cultural scripts that transplant stories frequently engage.

Conclusion

Critical qualitative research offers opportunities for understanding structures of power embedded within biomedical transplant narratives. Layering qualitative and arts-based methodologies within a framework of co-creation can shift knowledge/power relations while also intervening through material-discursive practices to offer novel insights and opportunities for critical reflection on transplant experiences for recipients, families, and healthcare providers.

Liver donation is an altruistic act wherein donor safety takes paramount importance. Donor selection is done after a meticulous evaluation to rule out any perioperative health risk. It is not unusual to find uncorrected congenital heart disease (CHD) in adults as a part of this detailed examination. This case reports a 34-year-old male liver transplant donor, with no known comorbidities, who was incidentally detected with a large atrial septal defect (ASD). We report the successful management of this case after ASD closure with the various therapeutic options available to us. The need for ASD closure for donor hepatectomy, and the unique preoperative and intraoperative challenges are elaborated in this report as limited literature is available to guide the course of action in this context. A multidisciplinary approach can facilitate safe perioperative management and prevent the exclusion of such donors from the scanty liver donor pool.

Categories: Anesthesiology, Transplantation

Background

Portal Vein Thrombosis (PVT) is a common concern in cirrhotic patients awaiting liver transplantation (LT), with high morbidity and mortality rates. While preexisting PVT was traditionally considered a contraindication for the LT procedure, recent advances in surgical techniques have provided new possibilities for operating on these patients. This retrospective cohort study compared the surgical outcomes of adult living donor liver transplantation (LDLT) patients with and without preexisting PVT.

Methods

The study analyzed data from 416 liver transplant recipients and included 270 patients without PVT and 69 patients with PVT who underwent LDLT between March 2019 and March 2023. Preoperative imaging methods and intraoperative assessments were used to diagnose PVT and classify the extent of the thrombus using the Yerdel classification. Various surgical techniques were employed to remove the thrombus and establish a portal flow to the graft. Postoperatively, patients were monitored for complications and followed up regularly.

Results

There were no significant differences between the non-PVT and PVT groups regarding recipient age, gender, body mass index, primary disease leading to transplantation, Child-Pugh class, or Model for End-Stage Liver Disease (MELD) score. The operative variables, including graft type, duration of surgery, and cold and warm ischemia times, were also similar between the groups. The surgical procedures varied based on the Yerdel classification grade of PVT, with most patients undergoing partial or complete thrombectomy. The mean hospital stays, intensive care unit (ICU) stay duration, and reexploration rates were comparable between the non-PVT and PVT groups. However, the incidence of portal vein thrombosis was significantly higher in the PVT group (p < 0.001). Other complications, such as portal vein stenosis and hepatic artery thrombosis, occurred in a small number of patients.

Conclusion

This retrospective cohort analysis demonstrates the feasibility of performing LDLT in patients with preexisting PVT using various surgical techniques. While the overall surgical outcomes and postoperative complications were comparable between patients with and without PVT, the incidence of portal vein thrombosis was higher in the PVT group. Further studies are needed to explore optimal management strategies for PVT in LDLT patients and improve outcomes in this population.

Background

Patients with advanced liver disease (ALD) have unique hemodynamics including high resting cardiac output and low systemic vascular resistance which may reduce the sensitivity of pharmacological myocardial perfusion imaging (MPI). MPI is frequently ordered for patients with ALD if liver transplantation is being considered. Because of the limited data on effectiveness of MPI in the ALD population, we conducted this cohort study focused on cardiac outcomes after pharmacological MPI.

Methods

We conducted a cohort study comparing normal versus abnormal MPI among 454 patients with ALD between 1/1/2011 and 06/01/2021 at a single tertiarycare academic medical center. Abnormal MPI was defined as summed stress score > 2 on LVEF < 40 %. The primary outcome was to compare the frequency of major adverse cardiovascular events (MACEs) among ALD patients with and without abnormal MPI. Secondary outcome included individual components of MACE analyzed by chi square. Kaplan-Meier survival curves and a logistic-regression model of associations with MACE were also performed.

Results

In this cohort, 58 patients were observed to have an abnormal MPI. Baseline characteristics between the groups were similar, except prior coronary disease, which was more common among the abnormal MPI group (risk ratio 2.07, 95 % confidence interval 1.30–3.30, P = 0.003). MACE was more common in the group with abnormal MPI (n = 24, 41.4 % versus normal MPI n = 104, 26.3 %, P < .001). No difference in MACE was observed when stratified by liver disease type. In the logistic regression model, diabetes mellitus, stage 3 chronic kidney disease, and summed stress score >2 were retained as being associated with MACE.

Conclusions

Our data suggest that MPI remains an effective test for identifying ALD patients at higher risk of mortality and cardiac events. Further study is needed to understand whether a strategy of routine MPI for liver transplant candidates effectively improves long term survival.

Enhanced recovery after surgery (ERAS) is a fascinating new approach to the perioperative care of liver transplantation (LT). Being an already established pathway in other surgical fields, ERAS in LT (ERALT) is moving its first steps into a complex scenario.

Material and Methods

In this study, using an Italian multicentre database dedicated to LT (Petalo Trapianto Fegato), we compared a group of patients who had a relatively short length of hospital stay (LHoS) after LT (12 days, 569 patients) vs a group that exceeded this LHoS (1017 patients). The main aim was to find a clinical rule to select patients who could afford safely and successfully an ERAS pathway. We used several machine learning techniques to find the best model to predict a short LHoS. We used logistic regression and Boruta random forest to select the most important features to be included in a prognostic score.

Results

According to our results, early after LT, an ERAS pathway might be confidently considered early after LT when the MELDNa is less than 10 or when the MELDNa is between 10 and 17 and the patient received ≤ 5 units of Packed Red Blood Cells intraoperatively (accuracy 72%, sensitivity 78%, specificity 66%, positive predictive value 78%).

Conclusion

This simple clinical rule is intended to be used as a screening tool in patient selection for centres approaching ERAS in LT focusing clinical safety and efficacy, physician confidence and patients’ satisfaction.