Living-donor vs deceased-donor liver transplantation for patients with hepatocellular carcinoma

With the increasing prevalence of living-donor liver transplantation(LDLT) for patients with hepatocellular carcinoma(HCC),some authors have reported a potential increase in the HCC recurrence rates among LDLT recipients compared to deceased-donor liver transplantation(DDLT) recipients.The aim of this review is to encompass current opinions and clinical reports regarding differences in the outcome,especially the recurrence of HCC,between LDLT and DDLT.While some studies report impaired recurrence- free survival and increased recurrence rates among LDLT recipients,others,including large database studies,report comparable recurrence- free survival and recurrence rates between LDLT and DDLT.Studies supporting the increased recurrence in LDLT have linked graft regeneration to tumor progression,but we found no association between graft regeneration/initial graft volume and tumor recurrence among our 125 consecutive LDLTs for HCC cases.In the absence of a prospective study regarding the use of LDLT vs DDLT for HCC patients,there is no evidence to support the higher HCC recurrence after LDLT than DDLT,and LDLT remains a reasonable treatment option for HCC patients with cirrhosis.

Living donor liver transplantation does not increase tumor recurrence of hepatocellular carcinoma compared to deceased donor transplantation

AIM: To compare the recurrence-free survival(RFS) and overall survival(OS) of hepatitis B virus(HBV)-positive hepatocellular carcinoma(HCC) after living donor liver transplantation(lDlT) and deceased donor liver transplantation(DDlT).METHODS: We retrospectively collected clinical data from 408 liver cancer patients from February 1999 to September 2012. We used the chi-squared test or Fisher's exact test to analyze the characteristics of lDlT and DDlT. Kaplan-Meier analysis was used to compare the RFS and OS in HCC.RESULTS: Three hundred sixty HBV-positive patients(276 DDlT and 84 lDlT) were included in this study.The mean follow-up time was 27.1 mo(range 1.1-130.8 mo). One hundred eighty-five(51.2%) patients died during follow-up. The 1-, 3-, and 5-year RFS rates for lDlT were 85.2%, 55.7%, and 52.9%, respectively; for DDlT, the RFS rates were 73.2%, 49.1%, and 45.3%(P = 0.115). The OS rates were similar between the lDlT and DDlT recipients, with 1-, 3-, and 5-year survival rates of 81.8%, 49.5%, and 43.0% vs 69.5%, 43.0%, and 38.3%, respectively(P = 0.30). The outcomes of HCC according to the Milan criteria after lDlT and DDlT were not significantly different(for lDlT: 1-, 3-, and 5-year RFS: 94.7%, 78.7%, and 78.7% vs 89.2%, 77.5%, and 74.5%, P = 0.50; for DDlT: 86.1%, 68.8%, and 68.8% vs 80.5%, 62.2%, and 59.8% P = 0.53).CONCLUSION: The outcomes of lDlT for HCC are not worse compared to the outcomes of DDlT. lDlT does not increase tumor recurrence of HCC compared to DDlT.

Outcome of hepatocellular carcinoma treated by liver transplantation:comparison of living donor and deceased donor transplantation

BACKGROUND: Liver transplantation (LT) has been widely accepted as the treatment of choice for end-stage liver diseases. Due to the scarcity of cadaveric donors, adult-to-adult living donor liver transplantation (LDLT) is advocated as a practical alternative to deceased donor liver transplantation (DDLT). However, some reports suggest that the long-term and recurrence-free survival rates of LDLT are poorer than those of DDLT for hepatocellular carcinoma (HCC). This study aimed to compare the long-term and recurrence-free survival rates of HCC between LDLT and DDLT. METHODS: We retrospectively analyzed the clinical data of 150 patients with HCC from January 2005 to March 2009. Eleven patients who died of complications during the perioperative period were excluded. The remaining 139 eligible patients (101 DDLT and 38 LDLT) were regularly followed up to October 2009. The Chi-square test or Fisher's exact test were used to compare the characteristics of LDLT and DDLT. The long-term and recurrence-free survival curves of both groups were determined using the Kaplan-Meier method with comparisons performed using the log-rank test. One-way analysis of variance was performed to compare the waiting time of the two groups. RESULTS: Survival rates at 1, 2, 3, and 4 years for LDLT were 81%, 62%, 53%, and 45% and for DDLT were 86%, 60%, 50%, and 38%, respectively. The overall 1-, 2-, 3-, and 4-year recurrence-free rates for LDLT were 71%, 49%, 42%, and 38%, and for DDLT were 76%, 52%, 41%, and 37%, respectively. No significant differences were found by the log-rank test on both long-term and recurrence-free survival rates. CONCLUSIONS: The role of LDLT is reinforced by our study. It may expand the donor pool and achieve the same long-term and recurrence-free survival rates of DDLT.

Standard liver weight model in adult deceased donors with fatty liver: A prospective cohort study

BACKGROUND Standard liver weight(SLW)is frequently used in deceased donor liver transplantation to avoid size mismatches with the recipient.However,some deceased donors(DDs)have fatty liver(FL).A few studies have reported that FL could impact liver size.To the best of our knowledge,there are no relevant SLW models for predicting liver size.AIM To demonstrate the relationship between FL and total liver weight(TLW)in detail and present a related SLW formula.METHODS We prospectively enrolled 212 adult DDs from West China Hospital of Sichuan University from June 2019 to February 2021,recorded their basic information,such as sex,age,body height(BH)and body weight(BW),and performed abdominal ultrasound(US)and pathological biopsy(PB).The chi-square test and kappa consistency score were used to assess the consistency in terms of FL diagnosed by US relative to PB.Simple linear regression analysis was used to explore the variables related to TLW.Multiple linear regression analysis was used to formulate SLW models,and the root mean standard error and interclass correlation coefficient were used to test the fitting efficiency and accuracy of the model,respectively.Furthermore,the optimal formula was compared with previous formulas.RESULTS Approximately 28.8%of DDs had FL.US had a high diagnostic ability(sensitivity and specificity were 86.2%and 92.9%,respectively;kappa value was 0.70,P<0.001)for livers with more than a 5%fatty change.Simple linear regression analysis showed that sex(R2,0.226;P<0.001),BH(R2,0.241;P<0.001),BW(R2,0.441;P<0.001),BMI(R2,0.224;P<0.001),BSA(R2,0.454;P<0.001)and FL(R2,0.130;P<0.001)significantly impacted TLW.In addition,multiple linear regression analysis showed that there was no significant difference in liver weight between the DDs with no steatosis and those with steatosis within 5%.Furthermore,in the context of hepatic steatosis,TLW increased positively(nonlinear);compared with the TLW of the non-FL group,the TLW of the groups with hepatic steatosis within 5%,between 5%and 20%and more than 20%increased by 0 g,90 g,and 340 g,respectively.A novel formula,namely,-348.6+(110.7 x Sex[0=Female,1=Male])+958.0 x BSA+(179.8 x FLUS[0=No,1=Yes]),where FL was diagnosed by US,was more convenient and accurate than any other formula for predicting SLW.CONCLUSION FL is positively correlated with TLW.The novel formula deduced using sex,BSA and FLUS is the optimal formula for predicting SLW in adult DDs.

Comparison of demographic features and laboratory parameters between COVID-19 deceased patients and surviving severe and critically ill cases

BACKGROUND Coronavirus disease 2019(COVID-19) has been far more devastating than expected, showing no signs of slowing down at present. Heilongjiang Province is the most northeastern province of China, and has cold weather for nearly half a year and an annual temperature difference of more than 60℃, which increases the underlying morbidity associated with pulmonary diseases, and thus leads to lung dysfunction. The demographic features and laboratory parameters of COVID-19 deceased patients in Heilongjiang Province, China with such climatic characteristics are still not clearly illustrated.AIM To illustrate the demographic features and laboratory parameters of COVID-19 deceased patients in Heilongjiang Province by comparing with those of surviving severe and critically ill cases.METHODS COVID-19 deceased patients from different hospitals in Heilongjiang Province were included in this retrospective study and compared their characteristics with those of surviving severe and critically ill cases in the COVID-19 treatment center of the First Affiliated Hospital of Harbin Medical University. The surviving patients were divided into severe group and critically ill group according to the Diagnosis and Treatment of New Coronavirus Pneumonia(the seventh edition).Demographic data were collected and recorded upon admission. Laboratory parameters were obtained from the medical records, and then compared among the groups.RESULTS Twelve COVID-19 deceased patients, 27 severe cases and 26 critically ill cases were enrolled in this retrospective study. No differences in age, gender, and number of comorbidities between groups were found. Neutrophil percentage(NEUT%), platelet(PLT), C-reactive protein(CRP), creatine kinase isoenzyme(CK-MB), serum troponin I(TNI) and brain natriuretic peptides(BNP) showed significant differences among the groups(P = 0.020, P = 0.001, P < 0.001, P = 0.001, P < 0.001, P <0.001, respectively). The increase of CRP, D-dimer and NEUT% levels, as well as the decrease of lymphocyte count(LYMPH) and PLT counts, showed significant correlation with death of COVID-19 patients(P = 0.023, P = 0.008, P = 0.045, P = 0.020, P = 0.015, respectively).CONCLUSION Compared with surviving severe and critically ill cases, no special demographic features of COVID-19 deceased patients were observed, while some laboratory parameters including NEUT%, PLT, CRP, CK-MB, TNI and BNP showed significant differences. COVID-19 deceased patients had higher CRP, D-dimer and NEUT% levels and lower LYMPH and PLT counts.

Lobar lung transplantation from deceased donors: A systematic review

AIM To systematically review reports on deceased-donor-lobar lung transplantation(dd LLTx) and uniformly describe sizematching using the donor-to-recipient predicted-total lung-capacity(pT LC) ratio. METHODS We set out to systematically review reports on ddL LTx and uniformly describe size matching using the donorto-recipient pT LC ratio and to summarize reported oneyear survival data of ddL LTx and conventional-LTx. We searched in Pub Med, CINAHL via EBSCO, Cochrane Database of Systematic Reviews via Wiley(CDSR),Database of Abstracts of Reviews of Effects via Wiley(DARE), Cochrane Central Register of Controlled Trials via Wiley(CENTRAL), Scopus(which includes EMBASE abstracts), and Web of Science for original reports on ddL LTx. RESULTS Nine observational cohort studies reporting on 301 ddL LTx met our inclusion criteria for systematic review of size matching, and eight for describing one-year-survival. The dd LLTx-group was often characterized by high acuity;however there was heterogeneity in transplant indications and pre-operative characteristics between studies. Data to calculate the pT LC ratio was available for 242 ddL LTx(80%). The mean pT LCratio before lobar resection was1.25 ± 0.3 and the transplanted pT LCratio after lobar resection was 0.76 ± 0.2. One-year survival in the ddL LTxgroup ranged from 50%-100%, compared to 72%-88%in the conventional-LTx group. In the largest study ddL LTx(n = 138) was associated with a lower one-year-survival compared to conventional-LTx(n = 539)(65.1% vs84.1%, P < 0.001). CONCLUSION Further investigations of optimal donor-to-recipient size matching parameters for ddL LTx could improve outcomes of this important surgical option.

C-Reactive protein role in assessing COVID-19 deceased geriatrics and survivors of severe and critical illness

Numerous risk variables,including age,medical co-morbidities,and deranged inflammatory response,lead to higher mortality in a senior population with coronavirus disease 2019.C-reactive protein(CRP),an acute phase inflammatory protein secreted by the liver,was tested in the elderly,showing a diagnostic and prognostic role.However,recent research has shed light on new applications for CRP in geriatrics.It was used as a follow-up marker and as a therapeutic target.Early and accurate identification of patients’ risks may mitigate the devastation of the invading virus in older cases and permit the implementation of a quick treatment plan for those most likely to deteriorate.

State of deceased donor transplantation in India:A model for developing countries around the world

Renal replacement therapy(RRT) resources are scarce in India, with wide urban-rural and interstate disparities. The burden of end-stage renal disease is expected to increase further due to increasing prevalence of risk factors like diabetes mellitus. Renal transplantation, the best RRT modality, is increasing in popularity, due to improvements made in public education, the deceased donor transplantation(DDT) programme and the availability of free and affordable transplant services in government hospitals and certain non-governmental philanthropic organizations. There are about 120000 haemodialysis patients and 10000 chronic peritoneal dialysis patients in India, the majority of them waiting for a donor kidney. Shortage of organs, lack of transplant facilities and high cost of transplant in private facilities are major barriers for renal transplantation in India. The DDT rate in India is now 0.34 per million population, among the lowest in the world. Infrastructural development in its infancy and road traffic rules not being strictly implemented by the authorities, have led to road traffic accidents being very common in urban and rural India. Many patients are declared brain dead on arrival and can serve as potential organ donors. The DDT programme in the state of Tamil Nadu has met with considerable success and has brought down the incidence of organ trade. Government hospitals in Tamil Nadu, with a population of 72 million, provide free transplantation facilities for the underprivileged. Public private partnership has played an important role in improving organ procurement rates, with the help of trained transplant coordinators in government hospitals. The DDT programmes in the southern states of India(Tamil Nadu, Kerala, Pondicherry) are advancing rapidly with mutual sharing due to public private partnership providing vital organs to needy patients. Various health insurance programmes rolled out by the governments in the southern states are effective in alleviating financial burden for the transplantation. Post-transplant immunological and pathological surveillance of recipientsremains a challenge due to the scarcity of infrastructure and other facilities.

Stabilization of estimated glomerular filtration rate in kidney transplantation from deceased donors with acute kidney injuries

AIM To evaluate and compare the outcomes of kidney transplant(KT) from deceased donors among standard criteria, acute kidney injury(AKI) and expanded criteria donors(ECDs). METHODS This retrospective study included 111 deceased donor kidney transplant recipients(DDKT). Deceased donors were classified as standard criteria donor(SCD), AKI donor and ECD. AKI was diagnosed and classified based on change of serum Cr by acute kidney injury network(AKIN) criteria. Primary outcome was one-year estimated glomerular filtration rate(eG FR) calculated from Cr by CKD-EPI. Multivariate regression analysis was done by adjusting factors such as type of DDKT, %Panel-reactive antibodies, cold ischemic time, the presence of delayed graft function and the use of induction therapy. Significantfactors that can affect the primary outcomes were then identified. RESULTS ECD group had a significantly lower eG FR at one year(33.9 ± 17.3 mL /min) when compared with AKI group(56.6 ± 23.9) and SCD group(63.6 ± 19.9)(P < 0.001). For AKI group, one-year eG FR was also indifferent among AKIN stage 1, 2 or 3. Patients with AKIN stage 3 had progressive increase of eG FR from 49.6 ± 27.2 at discharge to 61.9 ± 29.0 mL /min at one year. From Kaplan-Meier analysis, AKI donor showed better two-year graft survival than ECD(100% vs 88.5%, P = 0.006). Interestingly, AKI group had a stable eG FR at one and two year. The two-year eG FR of AKI group was not significantly different from SCD group(56.6 ± 24.5 mL /min vs 58.6 ± 23.2 mL /min, P = 0.65). CONCLUSION Kidney transplantations from deceased donors with variable stage of acute kidney injuries were associated with favorable two-year allograft function. The outcomes were comparable with KT from SCD. This information supports the option that deceased donors with AKI are an important source of organ for kidney transplantation even in the presence of stage 3 AKI.

Deceased donor organ procurement injuries in the United States

AIM: To determine the incidence of surgical injury during deceased donor organ procurements. METHODS: Organ damage was classified into three tiers, from 1-3, with the latter rendering the organ nontransplantable. For 12 consecutive months starting in January of 2014, 36 of 58 organ procurement organization's(OPO)'s prospectively submitted quality data regarding organ damage(as reported by the transplanting surgeon and confirmed by the OPO medical director) seen on the procured organ.RESULTS: These 36 OPOs recovered 5401 of the nations' s 8504 deceased donors for calendar year 2014.A total of 19043 organs procured were prospectively analyzed. Of this total, 59 organs sustained damage making them non-transplantable(0 intestines; 4 pancreata; 5 lungs; 6 livers; 43 kidneys). The class 3 damage was spread over 22(of 36) reporting OPO's.CONCLUSION: While damage to the procured organ is rare with organ loss being approximately 0.3% of procured organs, loss of potential transplantable organs does occur during procurement.

ABO-nonidentical liver transplantation from a deceased donor and clinical outcomes following antibody rebound:A case report

BACKGROUND Although ABO-nonidentical and ABO-incompatible liver transplantation(LT)are other options for end-stage liver disease treatment,the development of antibodies against blood group antigens(anti-A/B antibodies)is still a challenge in managing and follow-up of the recipients.CASE SUMMARY A 56-year-old male with end-stage liver disease with rapid deterioration and poor prognosis was considered to receive a deceased ABO-nonidentical liver graft.All required tests were performed according to our pre-LT diagnostic protocol.The orthotopic LT procedure involving O+donor and A1B+recipient was performed.Our treatment strategy to overcome the antibodymediated rejection included a systemic triple immunosuppressive regimen:methylprednisolone,mycophenolate mofetil,and tacrolimus.The immunological desensitization consisted of the chimeric anti-CD20 monoclonal antibody rituximab and intravenous immunoglobulins.The patient was also on antibiotic treatment with amoxicillin/clavulanate,cefotaxime,and metronidazole.On the 10th postoperative day,high titers of IgG anti-A and anti-B antibodies were found in the patient’s plasma.We performed a liver biopsy,which revealed histological evidence of antibody-mediated rejection,but the rejection was excluded according to the Banff classification.The therapy was continued until the titer decreased significantly on the 18th postoperative day.Despite the antibiotic,antifungal,and antiviral treatment,the patient deteriorated and developed septic shock with anuria and pancytopenia.The conservative treatment was unsuccessful,which lead to the patient’s fatal outcome on the 42nd postoperative day.CONCLUSION We present a patient who underwent ABO-nonidentical LT from a deceased donor.Even though we implemented the latest technological advancements and therapeutic approaches in the management of the patient and the initial results were promising,due to severe infectious complications,the outcome was fatal.

The Effect of Non-Invasive Goal Directed Fluid Administration on Graft Function in Deceased Donor Renal Transplantation: A Pilot Study

Background: Non-invasive goal directed fluid therapy during deceased donor renal transplant (CRT) may reduce the incidence of delayed graft function. Plethysmograph Variability Index (PVI) has been shown to predict fluid responsiveness during surgery. This pilot study evaluated the feasibility of goal directed fluid administration protocol based upon PVI studying the incidence of delayed graft function (DGF) in renal transplant recipients. Methods: Twenty patients underwent primary CRT. The Control group received intravenous fluid (IVF) at a calculated constant rate. The Treatment group received a baseline IVF infusion throughout the surgery. PVI values greater than 13% were treated with 250 ml boluses of IVF. Primary end point was DGF;total IVF administration and urinary biomarker NGAL levels were secondary endpoints. Results: Treatment group at every time point received significantly less IVF. There was no significant difference in incidence of DGF between the groups. 2 patients in the Control group and 6 in the Treatment group developed DGF. NGAL was not associated with the group assignment or total IVF given (p < 0.2). Conclusions: The effectiveness of goal directed fluid therapy with non-invasive dynamic parameters has not been validated in renal transplant surgery and larger prospective studies are needed to determine its utility in renal transplantation.

CAS MEMBERS DECEASED IN 1995

Bao Wenkui(1916-1995), geneticist and cultivar breeder.Born in Ningbo City,Zhejiang Province, he was a research fellow at the Institute of Crop Breeding & Cultivation under the Chinese Academy of Agriculture.In 1939,he graduated from the School of Agronomics under the Zhongyang(National) University in Nanjing and obtained his Ph.D. from the California Institute of Technology of the US in 1950.In the next year,he started probing man-made polyploids of various crops as a way of cultivation of new strains.After a 40-year-long study, he discovered that a biological species’ evolution consists of two stages.The appearance of the new species comes first,which is catastrophic and eruptive, the evolution follows, which is progres-

Hepatocellular carcinoma recurrence in living and deceased donor liver transplantation:a systematic review and meta-analysis

Background:Although a number of technical problems and donor safety issues associated with living donor liver transplantation(LDLT)have been resolved,some initial clinical studies showed an increased risk of hepatocellular car cinoma(HCC)recurrence in LDLT.This meta-analysis was conducted to assess differences in tumor recurrence between LDLT and deceased donor liver transplantation(DDLT).Methods:After systematic retrievals of studies about LDLT and DDLT for HCC,articles were selected with a rationale of emphasizing inter-group comparability.Results from multivariate analyses were combined and discussed together with univariate analyses.In subgroup analysis,the impact of organ allocation policy was taken into consideration.Results:Seven articles were included in the meta-analysis.Overall,a salient result that emerged from the seven studies was a significant increased risk of HCC recurrence in the LDLT group than in the DDLT group(P=0.01).The most significant increase in hazard ratio was found in studies where organs tended to be allocated to non-tumor patients.Conclusions:An increased risk for HCC recurrence in LDLT as compared with DDLT patients was found.The relatively shorter preoperative observation windows in LDLT may lead to fewer cases of HCC with invasive features being screened out,which may provide a possible explanation for the high rates of HCC recurrence.

Outcomes of Liver Transplantation Using Pediatric Deceased Donor Livers： A Single-Center Analysis of 102 Donors

Background： The outcome of pediatric deceased donor liver transplantation （LT） has not been well studied, especially pediatric deceased donor livers used in adult transplantation. This study aimed to evaluate the efficacy of LT using pediatric deceased donor livers and compare the outcomes between pediatric-to-pediatric LT and pediatric-to-adult LT. Methods： A retrospective review of LT using pediatric deceased donor livers from June 2013 to August 2016 was performed. The patients were divided into the pediatric-to-pediatric LT group and pediatric-to-adult LT group based on the ages of the recipients. The survival and incidence of early vascular complications （VCs） were observed between the two groups. We also analyzed the risk factors of early VCs in pediatric LT and the effect of donor hypernatremia on the prognosis of recipients. Results： There were 102 cases of LT using pediatric deceased donor livers in our hospital from June 2013 to August 2016. 83 pediatric-to-pediatric LT （recipients＇ age ≤13 years） and 19 pediatric-to-adult LT （recipients＇ age≥19 years）. The ratio of early VC was similar in the two groups （19.3% vs. 10.6%, P = 0.514）. Low body weight of recipient was an independent risk factor of early VC in pediatric LT （odds ratio： 0.856, 95% confidence interval： 0.752-0.975, P = 0.019）. The 1-year cumulative survival rates of grafts and patients were 89.16% and 91.57% in pediatric-to-pediatric LT and 89.47% and 94.74% in pediatric-to-adult LT, respectively （all P 〉 0.05）. In all cases. patients using donors with hypernatremia （serum sodium levels ≥ 150mmol/L） had worse graft survival （χ2=4.330, P = 0.037）. Conclusions： Pediatric-to-pediatric LT group has similar graft and patient survival rates with those of pediatric-to-adult LT group. Low body weight of recipients is an independent risk factor of early VC in pediatric LT. Patients using donors with hypernatremia have worse graft survival.

Comparison of “Normal” Craniocerebral Computed Tomography of Deceased and Living Individuals

To compare“normal”craniocerebral computed tomography(CT)of deceased and living individuals.Nineteen parameters of craniocerebral CT scans of 50 deceased and 50 living individuals that met specific filtering criteria were measured separately:The intensity(CT value)ratio of gray matter to white matter(GM/WM),maximum and minimum length of frontal horn of ventricle,transverse diameter of cerebral parenchyma,length of choroid plexus,maximum external diameter of body of lateral ventricle,maximum internal transverse diameter of cranium,length of cerebral longitudinal fissure,length between two calvarium,transverse and longitudinal diameter of the third and fourth ventricle,length of the cerebral longitudinal fissure,Hackman value,ventricular index(D/A),index of the somatic part of lateral ventricle(F/E),lateral ventricular body index(G/E),frontal horn index(G/A),and ventriculocranial ratio(VCR).The values of these 19 parameters for the deceased and living individuals were performed using statistical methods.There were significant statistic differences between deceased and living individuals in terms of eight craniocerebral CT parameters,including GM/WM,D/A,transverse diameter of the fourth ventricle,and length of the cerebral longitudinal fissure.The craniocerebral CT findings differ between deceased and living individuals.Knowledge of the normal postmortem craniocerebral CT parameters is key to correct postmortem craniocerebral radiopathological diagnosis.

Outcome of split liver transplantation vs living donor liver transplantation:A systematic review and meta-analysis

BACKGROUND The outcomes of liver transplantation(LT)from different grafts have been studied individually and in combination,but the reports were conflicting with some researchers finding no difference in both short-term and long-term outcomes between the deceased donor split LT(DD-SLT)and living donor LT(LDLT).AIM To compare the outcomes of DD-SLT and LDLT we performed this systematic review and meta-analysis.METHODS This systematic review was performed in compliance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines.The following databases were searched for articles comparing outcomes of DD-SLT and LDLT:PubMed;Google Scholar;Embase;Cochrane Central Register of Controlled Trials;the Cochrane Database of Systematic Reviews;and Reference Citation Analysis(https://www.referencecitationanalysis.com/).The search terms used were:“liver transplantation;”“liver transplant;”“split liver transplant;”“living donor liver transplant;”“partial liver transplant;”“partial liver graft;”“ex vivo splitting;”and“in vivo splitting.”RESULTS Ten studies were included for the data synthesis and meta-analysis.There were a total of 4836 patients.The overall survival rate at 1 year,3 years and 5 years was superior in patients that received LDLT compared to DD-SLT.At 1 year,the hazard ratios was 1.44(95%confidence interval:1.16-1.78;P=0.001).The graft survival rate at 3 years and 5 years was superior in the LDLT group(3 year hazard ratio:1.28;95%confidence interval:1.01-1.63;P=0.04).CONCLUSION This meta-analysis showed that LDLT has better graft survival and overall survival when compared to DD-SLT.

Transplant benefit for patients with hepatocellular carcinoma

Although liver transplantation is theoretically the best treatment for hepatocellular carcinoma(HCC),it is limited by the realities of perioperative complications,and the shortage of donor organs.Furthermore,in many cases there are available alternative treatments such as resection or locoregional therapy.Deciding upon the best option for a patient with HCC is complicated,involving numerous ethical principles including:urgency,utility,intention-to-treat survival,transplant benefit,harm to candidates on waiting list,and harm to living donors.The potential contrast between different principles is particularly relevant for patients with HCC for several reasons:(1)HCC candidates to liver transplantation are increasing;(2)the great prognostic heterogeneity within the HCC population;(3)in HCC patients tumor progression before liver transplantation may significantly impair post transplant outcome;and(4)effective alternative therapies are often available for HCC candidates to liver transplantation.In this paper we suggest that allocating organs by transplant benefit could help balance these competing principles,and also introduce equity between patients with HCC and nonmalignant liver disease.We also propose a triangular equipoise model to help decide between deceased donor liver transplantation,living donor liver transplantation,or alternative therapies.

Risk factors and outcomes of delayed graft function in renal transplant recipients receiving a steroid sparing immunosuppression protocol

AIM To analyse the risk factors and outcomes of delayed graft function(DGF) in patients receiving a steroid sparing protocol. METHODS Four hundred and twenty-seven recipients of deceased donor kidney transplants were studied of which 135(31.6%) experienced DGF. All patients received monoclonal antibody induction with a tacrolimus based, steroid sparing immunosuppression protocol.RESULTS Five year patient survival was 87.2% and 94.9% in the DGF and primary graft function(PGF) group respectively, P = 0.047. Allograft survival was 77.9% and 90.2% in the DGF and PGF group respectively, P < 0.001. Overall rejection free survival was no different between the DGF and PGF groups with a 1 and 5 year rejection free survival in the DGF group of 77.7% and 67.8% compared with 81.3% and 75.3% in the PGF group, P = 0.19. Patients with DGF who received IL2 receptor antibody induction were at significantly higher risk of rejection in the early post-transplant period than the group with DGF who received alemtuzumab induction. On multivariate analysis, risk factors for DGF were male recipients, recipients of black ethnicity, circulatory death donation, preformed DSA, increasing cold ischaemic time, older donor age and dialysis vintage.CONCLUSION Alemtuzumab induction may be of benefit in preventing early rejection episodes associated with DGF. Prospective trials are required to determine optimal immunotherapy protocols for patients at high risk of DGF.

Kidney transplantation from donors with hepatitis C infection

The increasing demand for organ donors to supply the increasing number of patients on kidney waiting lists has led to most transplant centers developing protocols that allow safe utilization from donors with special clini cal situations which previously were regarded as contra indications.Deceased donors with previous hepatitis C infection may represent a safe resource to expand the donor pool.When allocated to serology-matched recipi ents,kidney transplantation from donors with hepatitis C may result in an excellent short-term outcome and a significant reduction of time on the waiting list.Specia care must be dedicated to the pre-transplant evaluation of potential candidates,particularly with regard to live functionality and evidence of liver histological damage such as cirrhosis,that could be a contraindication to transplantation.Pre-transplant antiviral therapy could be useful to reduce the viral load and to improve the long-term results,which may be affected by the progression of liver disease in the recipients.An accurate selection of both donor and recipient is mandatory to achieve a satisfactory long-term outcome.