Liver retransplantation: indications and outcomes

BACKGROUND: Liver transplantation is a life-saving the- rapeutic modality for patients with end-stage liver diseases. After liver transplantation, however, more than 10% pa- tients may lose the grafts caused by a variety of reasons. This review covers the most frequent indications for liver retransplantation as well as the results and specific problems with each indication. DATA RESOURCES: Searching MEDLINE (1997-2003) for articles on liver retransplantation. RESULTS: The most frequent indications of liver retrans- plantation are primary non-function, hepatic artery throm- bosis, graft rejection and recurrent diseases. The results af- ter liver retransplantation remain inferior to those after first transplantation. CONCLUSION: Liver retransplantation, which is the only means of prolonging survival in those patients whose initial graft has failed, makes an important contribution to overall survival.

Complex liver retransplantation to treat graft loss due to long-term biliary tract complication after liver transplantation: A case report

BACKGROUND Loss of graft function after liver transplantation(LT) inevitably requires liver retransplant. Retransplantation of the liver(Re LT) remains controversial because of inferior outcomes compared with the primary orthotopic LT(OLT).Meanwhile, if accompanied by vascular complications such as arterial and portal vein(PV) stenosis or thrombosis, it will increase difficulties of surgery. We hereby introduce our center’s experience in Re LT through a complicated case of ReLT.CASE SUMMARY We report a patient who suffered from hepatitis B-associated cirrhosis and underwent LT in December 2012. Early postoperative recovery was uneventful.Four months after LT, the patient’s bilirubin increased significantly and he was diagnosed with an ischemic-type biliary lesion caused by hepatic artery occlusion. The patient underwent percutaneous transhepatic cholangial drainage and repeatedly replaced intrahepatic biliary drainage tube regularly for 5 years.The patient developed progressive deterioration of liver function and underwent liver re-transplant in January 2019. The operation was performed in a classic OLT manner without venous bypass. Both the hepatic artery and PV were occluded and could not be used for anastomosis. The donor PV was anastomosed with the recipient’s left renal vein. The donor hepatic artery was connected to the recipient’s abdominal aorta. The bile duct reconstruction was performed in an end-to-end manner. The postoperative process was very uneventful and the patient was discharged 1 mo after retransplantation.CONCLUSION With the development of surgical techniques, portal thrombosis and arterial occlusion are no longer contraindications for ReLT.

Report of 8 cases of liver retransplantation

BACKGROUND: Retransplantation of the liver is required for several complications of primary grafting, such as primary allograft non-function, hepatic artery thrombosis, biliary problems, or chronic ductopenic rejection. Surgeons usually take regrafting as the only pathway to treat those patients who are considered to have a poor outcome after the first operation. Whether the retransplantation is early or late, further attempts at rescue with a second or more grafts are associated with higher mortality and morbidity. However, retransplantation plays a role in improving survival of the patients. Therefore, it is necessary to summarize the experiences in liver retransplantation, as well as the factors influencing operative effects. METHOD: The clinical data of 8 patients who received liver retransplantation in our center were analyzed retrospectively. RESULTS: Complications of the biliary tract occurred in 5 of the 8 patients, chronic rejection in 2, and embolism in the hepatic artery in 1. Infections occurred in 7 patients before engraftment. Patient I had developed renal failure before the surgery, and he died of severe infection and multi-organ failure after transplantation. Patient 4 had a massive hemorrhage during the operation and also died of multi-organ failure after transplantation. Patient 7 developed intracranial hemorrhage and abdominal infection and died soon after transplantation. The other 5 patients recovered and discharged from the hospital. CONCLUSIONS: Liver retransplantation is the only measure that can be taken to save the lives of patients whose liver allograft fails to function. It is very important that the indications and time of retransplantation are carefully selected. Factors leading to harmful effects on retransplantation include the preoperative condition of the recipient, a difficult and prolonged operation, massive hemorrhage during the operation, and severe complications after the surgery.

Liver retransplantation： a single-centre experience

Background The curative effect of liver transplantation for patients with end-stage liver disease was encouraging in recent years and the 5-year patient survival rate can reach up to 70%. However, some patients might lose grafts due to a variety of reasons, including bile duct complications, vascular complications, primary non-function, graft rejection and disease recurrence etc. Liver retransplantation （re-LT） was the only available means for those patients whose initial grafts had failed, but the inferior outcomes of re-LT compared to primary liver transplantation （PLT） continue to be a major concern. This study aimed to analyze the indications for re-LT, optimal timing of re-LT, and strategies to improve the survival rate after re-LT.Methods From January 2001 to December 2006, we performed 738 liver transplants and 39 re-LT （5.3%） at our center. A retrospective analysis was performed to identify factors （indication for re-LT, preoperative score of model for end-stage liver disease （MELD）, interval to re-LT from primary liver transplantation, methods of vascular and biliary reconstruction and common causes of death） associated with survival.Results Mean follow-up period was 1.8 years （1 to 5 years）. Patients with MELD score less than 20 were better than those whose MELD score was 〉20 and MELD score〉30 （1-year survival, 80.0% versus 50.0% and 3/5）. The perioperative survival rate of patients who received re-LT at an interval of more than 30 days and less than 8 days after the initial transplantation was higher than those who received retransplantation between 8 to 30 days following the first operation （88.5% and 74.3% versus 50.0%）. The main causes of death were infection （60.0%）, multiple organ failure （20.0%）, vascular complications （10.0%） and biliary fistula （10.0%） in perioperative period. The overall patient survival rate of 1-month, 6-month and 1-year was 80.0%, 76.7% and 66.7%, respectively.Conclusions Our study suggested the favorable results after re-LT. The analysis also showed optimal timing of operation, refined surgical techniques, individualized immunosuppressive regimen and effective prophylaxis and treatment of perioperative infection play an important role in achieving a higher survival after re-LT.

A single center analysis of long-term outcomes and survival related risk factors in liver retransplantation

Background:Liver retransplant is the only option to save a patient with liver graft failure.However,it is controversial due to its poor survival outcome compared to primary transplantation.Insufficient deceased organ donation in Taiwan leads to high waitlist mortality.Hence,living-donor grafts offer a valuable alternative for retransplantation.This study aims to analyze the single center’s outcome in living donor liver retransplantation(re-LDLT)and deceased donor liver retransplantation(re-DDLT)as well as the survival related confounding risk factors.Methods:This is a single center retrospective study including 32 adults who underwent liver retransplantation(re-LT)from June 2002 to April 2020.The cohort was divided into a re-LDLT and a re-DDLT group and survival outcomes were analyzed.Patient outcomes over different periods,the effect of timing on survival,and multivariate analysis for risk factors were also demonstrated Results:Of the 32 retransplantations,the re-LDLT group(n=11)received grafts from younger donors(31.3 vs.43.75 years,P=0.016),with lower graft weights(688 vs.1,457.2 g,P<0.001)and shorter cold ischemia time(CIT)(45 vs.313 min,P<0.001).The 5-year survival was significantly better in the re-LDLT group than in the re-DDLT group(100%vs.70.8%,P=0.02).This difference was adjusted when only retransplantation after 2010 was analyzed.Further analysis showed that the timing of retransplantation(early vs.late)did not affect patient survival.Multivariate analysis revealed that prolonged warm ischemia time(WIT)and intraoperative blood transfusion were related to poor long-term survival.Conclusions:Retransplantation with living donor graft demonstrated good long-term outcomes with acceptable complications to both recipient and donor.It may serve as a choice in areas lacking deceased donors.The timing of retransplantation did not affect the long-term survival.Further effort should be made to reduce WIT and massive blood transfusion as they contributed to poor survival after retransplantation.

Liver retransplants using living donors:An approach for management

Background and aims:Many centers do not offer living donor transplants for patients in need of a liver retransplant.We aimed to study our liver retransplant outcomes using living donors and compared them with those of retransplants performed using deceased donors.Methods:This study retrospectively analyzed all retransplants performed at our center between 2009 and 2023,and outcomes of living donor retransplants were compared with deceased donor retransplants using standard statistical tests.Results:Between January 2009 and March 2023,a total of 77 retransplants,60 with deceased donors and 17 with living donors,were performed.Important demographic differences between the two groups included a higher model for end-stage liver disease score in the deceased donor group(32.1±6.1 vs.19.4±5.7,P<0.001)and a higher number of early retransplants(within 3 months of the initial transplant),which accounted for 35% of deceased donor transplants but 0 of living donor transplants(P<0.01).Overall,the patient and graft survival rates were comparable between the two groups.The patient survival rates at 1 and 3 years after transplant were 73% and 67% in the deceased donor group and 84% and 73% in the living donor group,respectively(P=0.57).The hospital length of stay and blood product use were both better in the living donor group.Biliary complications did not show significant different between the two groups(P=0.33).Conclusions:Living donors can provide acceptable outcomes for those in need of a retransplant,with results comparable to those seen with deceased donors.A systematic approach to the patient in the pre-,peri-,and post-transplantation period is important in these complicated cases.