Liver Transplantation最新文献

In living donor liver transplant, graft hyperperfusion can lead to early allograft dysfunction, graft loss, and even mortality. Portal inflow modulation is advocated to prevent hyperperfusion injury. We implemented intraoperative distal splenic artery ligation (SAL) since January 2021 in recipients with one or more of the indications: graft to recipient weight ratio <0.8, graft to spleen volume ratio ≤1, high post-reperfusion portal venous flow (≥250 mL/min/100 g of graft weight), low hepatic artery peak systolic velocity (≤20 cm/s), and/or high post-reperfusion portal venous pressure (≥15 mm Hg). This group was compared with a retrospective splenic artery ligation-not done (non-SAL) group, during July 2019-December 2020, who met any one or more of the above criteria, but had not undergone SAL. Out of 426 patients who underwent living donor liver transplant during the study period, 90 and 42 right lobe adult recipients were included in the SAL and non-SAL groups, respectively. The SAL group had a significant reduction in post-reperfusion portal flow and pressure and also improved hepatic arterial peak systolic velocity compared to the non-SAL group ( p <0.01). Significant reduction in serum total bilirubin and ascitic fluid was observed on post-operative days 1, 3, 5, 7, and 14 in the SAL group ( p <0.01). There was a significant reduction in the incidence of early allograft dysfunction in the SAL group compared to the non-SAL group (8.8% vs. 26.2%, p <0.01). There was a decreased incidence of small for size syndrome (SFSS) ( p <0.05) with no incidence of grade-C SFSS and lower 90-day mortality in the SAL group ( p <0.01). Intraoperative distal SAL significantly reduces portal hyperperfusion, thereby reducing early allograft dysfunction, small for size syndrome, morbidity, and improving 1-year survival.

The prevalence of comorbid metabolic dysfunction-associated steatotic liver disease (MASLD) and obesity has increased exponentially over the last several years, with current estimates demonstrating that up to 40% of adults in the United States have MASLD. Metabolic dysfunction-associated steatohepatitis is now a leading indication for liver transplantation, and rates of obesity and MASLD pre-transplant and post-transplant are on the rise. Our understanding of the physiology of obesity and metabolic disease and the availability of effective obesity treatments have evolved over the same time frame. With the availability of new anti-obesity medications, there has been a debate over the role of pharmacotherapy versus interventional approaches in the treatment of obesity and MASLD in the liver transplantation population. In October 2024, the American Society of Transplantation (AST) Liver and Intestinal Community of Practice held a virtual Controversies Conference on obesity and liver transplantation. Experts in the field presented the available data, and smaller working groups had interactive breakout sessions that identified knowledge gaps and developed recommendations. This perspective prepared on behalf of the participants of the AST Controversies Conference on obesity and liver transplant aims to summarize the available evidence for surgical and pharmaceutical treatment in the liver transplantation population.

Social determinants of health are known to lead to adverse health outcomes, including high acute care utilization. The mechanisms underlying health care disparities among children who have undergone liver transplantation (LT) are poorly understood. To elucidate the relationship between social determinants of health and health care utilization among children (<18 y old at the time of LT) who have undergone LT, we performed a retrospective study merging data from the Organ Procurement and Transplantation Network (OPTN) and the Pediatric Health Information System (PHIS) database. Children with lower Child Opportunity Index (COI) scores, a composite measure of social determinants of health, were admitted for 28% more days in the first year and 29% more days over the first 2 years after LT, as compared to children with higher COI. We also observed that in the second year after LT, children with a lower COI were more often admitted with a complication of LT (23%) than those with a higher COI (18%). COI may be a useful composite screening instrument for clinical teams to target resources and limit acute care use after LT.

Robotic donor hepatectomy (RDH) has been reported with lower morbidity than its open counterpart. Donor safety remains the primary concern, precluding its wide adoption. We aimed to evaluate donor complications following RDH and identify their predictive factors. Out of 348 live donor liver transplants performed between 2018 and 2021, the prospective data of 202 RDH were analyzed for complications by the modified Clavien-Dindo grading system. Multivariate analysis of donor and operative parameters was done to identify factors predicting complications, and CUSUM (cumulative sum) analysis was done to evaluate the effect of a learning curve. Out of 202 RDH (mean age: 37.5 [±10.4]; f [female]:m [male]-133:69; mean body mass index: 25.2±3.84), 196 (97%) were modified right lobe grafts. Conversion to open occurred in 7 (3.4%) (5-bleeding, 1-hepatic duct injury, and 1-portal vein kink). Postoperative complications occurred in 33 (16.3%), the most common being bile leak (5.9%) and bleeding (3.9%). Grades IIIa, IIIb, and IVa complications were seen in 3.4%, 3.4%, and 0.9% of patients, respectively. Reoperation was required in 3 cases for PVT, narrowing of IVC, and biliary peritonitis, respectively. At follow ups of 4 years, these patients are doing well. Although in univariate analysis, higher blood loss and body mass index appeared to be significant, multivariate analysis did not reveal any donor factor that could predict complications (biliary anatomy, portal anatomy, blood loss, body mass index, duration of surgery, or future liver remnant volume). The number of overall complications (21.7% vs. 9.9%; p =0.020; OR, 2.53) came down significantly in the second half. On RA-CUSUM (risk-adjusted CUSUM) analysis, we identified that it took around 130 cases for our unit to collectively overcome the learning curve. Although RDH appears to be safe, critical complications can occur in a minority of cases. Safety lies in flattening the learning curve.

In liver transplantation (LT), determining the optimal recipients is crucial, and the MELD score has been used for this purpose. However, the MELD score does not reflect functional status, leading to the evaluation of sarcopenia. While the L3 skeletal muscle index (SMI L3 ) is commonly used for assessment, the upper thigh skeletal muscle index (SMI UT ) may better represent functional capacity. This retrospective study included 246 male LT recipients aged 40-60 from 2013 to 2015. Preoperative and postoperative muscle and fat areas at the L3 and upper thigh levels were quantified using artificial intelligence software. Clinical outcomes, including ventilator, intensive care unit, and hospital days, were analyzed using logistic regression, while survival was evaluated using Cox regression and Kaplan-Meier curves. Longitudinal body composition changes were assessed over 5 years post-LT. SMI UT demonstrated stronger associations with hospital days ( R2 =0.378) than SMI L3 ( R2 =0.302). High SMI UT correlated with improved survival ( p =0.02), unlike SMI L3 . Longitudinal analysis revealed a significant divergence in SMI UT between survivors and non-survivors, whereas SMI L3 showed no significant changes. The visceral fat index at L3 (VFI L3 ) increased continuously, highlighting potential metabolic risks. SMI UT showed a similar or even stronger association with LT outcomes than SMI L3 , effectively reflecting patient prognosis. SMI UT in the postoperative period also better reflected clinical status. Therefore, preoperative and postoperative SMI UT is helpful for patient assessment and ongoing management in LT patients.

Decompensated cirrhosis secondary to metabolic dysfunction-associated steatohepatitis (MASH) is not only a common indication for liver transplant (LT) but is becoming the leading cause of LT in postmenopausal women in the United States. Given the different complex mechanisms involved in the occurrence of MASH, it is being recognized as the hepatic manifestation of the metabolic syndrome. There are multiple metabolic issues associated with MASH, including obesity, DMT2, cardiovascular disease, and chronic kidney disease, which need to be addressed in the pretransplant and posttransplant setting for better patient outcomes. Recurrence of MASH following LT can occur due to many reasons including reversal of the catabolic state seen in cirrhosis, improvement in appetite, and the effect of certain post-LT medications on the graft; however, managing recurrence can be challenging and thus urges addressing these issues before transplant, in addition to recognizing, and treating them in the posttransplant setting. In this review, we discuss the various metabolic issues that face patients with MASH and the medical and surgical management options available to improve outcomes and reduce chances of recurrence.

Total hepatectomy and liver transplantation have emerged as a game-changing strategy in the treatment of several liver-confined primary or metastatic tumors, opening a new era of transplant oncology. However, the expansion of indications is going to worsen the chronic scarcity of organs, and new strategies are needed to enlarge the donor pool. A possible source of organs could be developing split liver transplantation programs. We propose to refer donors aged 18-50 years unsuitable for pediatric patients and donors aged 50-60 years for split evaluation. This will generate new small left lateral grafts that can be used for resection and partial liver segment II-III transplantation with delayed total hepatectomy procedures, based on a national waiting list specifically for non-HCC oncologic patients. Centralized imaging review will streamline the donor-recipient matching process and address organizational challenges. Additionally, adopting an ex situ splitting technique during hypothermic oxygenated machine perfusion could further enhance logistical efficiency and improve graft viability. The proposed protocol (ALERT 50) will therefore promote the development of oncologic indications without affecting the standard waiting list and without competing with urgent or pediatric patients.