Evaluation of the updated definition of early allograft dysfunction in donation after brain death and donation after cardiac death liver allografts

BACKGROUND:An updated definition of early allograft dysfunction(EAD) was recently validated in a multicenter study of 300 deceased donor liver transplant recipients.This analysis did not differentiate between donation after brain death(DBD) and donation after cardiac death(DCD) allograft recipients.METHODS:We reviewed our prospectively entered database for all DBD(n=377) and DCD(n=38) liver transplantations between January 1,2006 and October 30,2011.The incidence of EAD as well as its ability to predict graft failure and survival was compared between DBD and DCD groups.RESULTS:EAD was a valid predictor of both graft and patient survival at six months in DBD allograft recipients,but in DCD allograft recipients there was no significant difference in the rate of graft failure in those with EAD(11.5%) compared with those without EAD(16.7%)(P=0.664) or in the rate of death in recipients with EAD(3.8%) compared with those without EAD(8.3%)(P=0.565).The graft failure rate in the first 6 months in those with international normalized ratio ≥1.6 on day 7 who received a DCD allograft was 37.5% compared with 6.7% for those with international normalized ratio <1.6 on day 7(P=0.022).CONCLUSIONS:The recently validated definition of EAD is a valid predictor of patient and graft survival in recipients of DBD allografts.On initial assessment,it does not appear to be a useful predictor of patient and graft survival in recipients of DCD allografts,however a study with a larger sample size of DCD allografts is needed to confirm these findings.The high ALT/AST levels in most recipients of DCD livers as well as the predisposition to biliary complications and early cholestasis make these parameters as poor predictors of graft failure.An alternative definition of EAD that gives greater weight to the INR on day 7 may be more relevant in this population.

A comparison of survival and pathologic features of non-alcoholic steatohepatitis and hepatitis C virus patients with hepatocellular carcinoma

AIM:To compare the clinical outcome and pathologic features of non-alcoholic steatohepatitis(NASH) patients with hepatocellular carcinoma(HCC) and hepatitic C virus(HCV) patients with HCC(another group in which HCC is commonly seen) undergoing liver transplantation.METHODS:Patients transplanted for HCV and NASH at our institution from January 2000 to April 2011 were analyzed.All explanted liver histology and pre-transplant liver biopsies were examined by two specialist liver histopathologists.Patient demographics,disease free survival,explant liver characteristics and HCC features(tumour number,cumulative tumour size,vascular invasion and differentiation) were compared between HCV and NASH liver transplant recipients.RESULTS:A total of 102 patients with NASH and 283 patients with HCV were transplanted.The incidence of HCC in NASH transplant recipients was 16.7%(17/102).The incidence of HCC in HCV transplant recipients was 22.6%(64/283).Patients with NASH-HCC were statistically older than HCV-HCC patients(P < 0.001).A significantly higher proportion of HCV-HCC patients had vascular invasion(23.4% vs 6.4%,P = 0.002) and poorly differentiated HCC(4.7% vs 0%,P < 0.001) compared to the NASH-HCC group.A trend of poorer recurrence free survival at 5 years was seen in HCV-HCC patients compared to NASH-HCC who underwent a Liver transplantation(P = 0.11).CONCLUSION:Patients transplanted for NASH-HCC appear to have less aggressive tumour features compared to those with HCV-HCC,which likely in part accounts for their improved recurrence free survival.

Reuse of liver grafts following the brain death of the initial recipient

AIM: To determine if there is a reasonable prospect of success of a re-use liver transplantation.METHODS: We systematically searched for reports of liver graft re-use using electronic searches of PubMed and Web of Knowledge. We performed hand searches of references lists of articles reporting re-use of grafts.RESULTS: A systematic review of the literature reveals 28 liver transplantations using previously transplanted grafts. First and second recipients ranged in age from 4 to 72 years and 29 to 62 years respectively. Liver disease in the first recipient was varied including 5(18%) patients with fulminant liver failure who died subsequently of cerebral edema. The second transplanta-tion was performed after a median interval of 5 d(one day-13 years). Viral hepatitis was present in 3(11%) of the initial recipients and in 8(29%) of final recipients. Hepatocellular carcinoma was present in 6(21%) of the final recipients. Early survival after the final transplantation was 93%, whereas long-term survival was 78% with a mean follow-up of 23.3(3-120) mo.CONCLUSION: Outcomes of transplantation using previously transplanted grafts in this select population are similar to those seen with conventional grafts.

Intraoperative management of liver transplant in a patient with an undiagnosed ventricular septal defect:A case report

BACKGROUND The intraoperative management of patients undergoing orthotopic liver transplantation(OLT)frequently encounters hemodynamic instability after reperfusion of the new liver graft.The resulting post-reperfusion syndrome is characterized by an increase in pulmonary vascular resistance and decrease in systemic vascular resistance.In the presence of a left to right intracardiac shunt,this hemodynamic perturbance can lead to shunt reversal followed by hypoxemia and embolization of air and debris into the systemic circulatory system.CASE SUMMARY A 43 years-old male with end-stage liver disease due to primary sclerosing cholangitis complicated by portal hypertension and hepatocellular carcinoma presented for an OLT.A bedside transthoracic echocardiography(TTE)was performed immediately before the procedure and unexpectedly identified a ventricular septal defect(VSD).The patient and the surgical team agreed to proceed with the surgery as it was a time critical donation after circulatory organ death.We developed an intraoperative plan to optimize pulmonary and systemic pressures using vasoactive support,optimized mechanical ventilation,and used transesophageal echocardiography(TEE)for intraoperative monitoring.During reperfusion,considerable turbulent flows with air were noted in the right ventricle,but no air was visualized in the left ventricle.Color flow Doppler showed no reversal flow in the VSD.At the end of the procedure,the patient was extubated in the operating room without complication and was transferred to the transplant unit for recovery.CONCLUSION Our case highlights the importance of echocardiography in the perioperative assessment of patients undergoing liver transplantation.The TTE findings obtained immediately before the procedure and the real-time use of intraoperative TEE to modify our management during the critical phases of the transplant resulted in continuity of care and a good surgical outcome for this patient.