Protocol liver biopsy is the only examination that can detect mid-term graft fibrosis after pediatric liver transplantation

AIM:To assessed the clinical significance of protocol liver biopsy(PLB)in pediatric liver transplantation(LT).METHODS:Between July 2008 and August 2012,89and 55 PLBs were performed in pediatric patients at two and five years after LT,respectively.We assessed the histopathological findings using the Metavir scoring system,including activity(A)and fibrosis(F),and we identified factors associated with scores of≥A1 and≥F1.Our results clarified the timing and effectiveness of PLB.RESULTS:The incidences of scores of≥A1 and≥F1 were 24.7%and 24.7%,respectively,at two years after LT and 42.3%and 34.5%,respectively,at five years.Independent risk factors in a multivariate analysis of a score of≥A1 at two years included≥2 h ofcold ischemic time,no acute cellular rejection and an alanine amino transaminase(ALT)level of≥20 IU/L(P=0.028,P=0.033 and P=0.012,respectively);however,no risk factors were identified for a score of≥F1.Furthermore,no independent risk factors associated with scores of≥A1 and≥F1 at five years were identified using multivariate analysis.A ROC curve analysis of ALT at two years for a score of≥A1 demonstrated the recommended cutoff value for diagnosing≥A1 histology to be 20 IU/L.The incidence of scores of≥A2 or≥F2 at two years after LT was 3.4%(three cases),and all patients had an absolute score of≥A2.In contrast to that observed for PLBs at five years after LT,the incidence of scores of≥A2 or≥F2 was 20.0%(11 cases),and all patients had an absolute score of≥F2.In all cases,the dose of immunosuppressants was increased after the PLB,and all ten patients who underwent a follow-up liver biopsy improved to scores of≤A1 or F1.CONCLUSION:PLB at two years after LT is an unnecessary examination,because the serum ALT level reflects portal inflammation.In addition,immunosuppressive therapy should be modulated to maintain the ALT concentration at a level less than 20 IU/L.PLB at five years is an excellent examination for the detection of early reversible graft fibrosis because no serum markers reflect this finding.

Pediatric living donor liver transplantation for congenital hepatic fibrosis using a mother's graft with von Meyenburg complex: A case report

This is the first report of living donor liver transplantation(LDLT) for congenital hepatic fibrosis(CHF) using a mother's graft with von Meyenburg complex. A 6-year-old girl with CHF, who suffered from recurrent gastrointestinal bleeding, was referred to our hospital for liver transplantation. Her 38-year-old mother was investigated as a living donor and multiple biliary hamartoma were seen on her computed tomography and magnetic resonance imaging scan. The mother's liver function tests were normal and she did not have any organ abnormality, including polycystic kidney disease. LDLT using the left lateral segment(LLS) graft from the donor was performed. The donor LLS graft weighed 250 g; the graft recipient weight ratio was 1.19%. The operation and post-operative course of the donor were uneventful and she was discharged on post-operative day(POD) 8. The graft liver function was good, and the recipient was discharged on POD 31. LDLT using a graft with von Meyenburg complex is safe and useful. Long-term follow-up is needed with respect to graft liver function and screening malignant tumors.

Rescue case of low birth weight infant with acute hepatic failure

We report a case involving a rescued low birth weight infant(LBWI) with acute liver failure. Case: The patient was 1594 g and 32^(3/7) gestational wk at birth. At the age of 11 d, she developed acute liver failure due to gestational alloimmune liver disease. Exchange transfusion and high-dose gamma globulin therapy were initiated, and body weight increased with enteral nutrition. Exchange transfusion was performed a total of 33 times prior to living donor liver transplantation(LDLT). Her liver dysfunction could not be treated by medications alone. At 55 d old and a body weight of 2946 g, she underwent LDLT using an S2 monosegment graft from her mother. Three years have passed with no reports of intellectual disability or liver dysfunction. LBWIs with acute liver failure may be rescued by LDLT after body weight has increased to over 2500 g.

Immunohistochemical evaluation for outflow reconstruction using opened round ligament in living donor right posterior sector graft liver transplantation: A case report

Utilizing the opened round ligament as venous grafts during liver transplantation is useful but controversial,and there are no pathological analyses of this procedure. Herein,we describe the first reported case of a pathological analysis of an opened round ligament used as a venous patch graft in a living donor liver transplantation(LDLT). A 13-year-old female patient with biliary atresia underwent LDLT using a posterior segment graft from her mother. The graft had two hepatic veins(HVs),which included the right HV(RHV; 15 mm) and the inferior RHV(IRHV; 20 mm). The graft RHV and IRHV were formed into a single orifice using the donor's opened round ligament(60 mm × 20 mm) as a patch graft during bench surgery; it was then anastomosed end-to-side with the recipient inferior vena cava. The recipient had no post-transplant complications involving the HVs,but she died of septic shock with persistent cholangitis and jaundice 86 d after LDLT. The HV anastomotic site had no stenosis or thrombus on autopsy. On pathology,there was adequate patency and continuity between the recipient's HV and the donor's opened round ligament. In addition,the stains for CD31 and CD34 on the inner membrane of the opened round ligament were positive. Hepatic venous reconstruction using the opened round ligament as a venous patch graft is effective in LDLT,as observed on pathology.