Trend and outcome of Korean patients receiving overseas solid organ transplantation between 1999 and 2005

The disparity between patients awaiting transplantation and available organs forced many patients to go overseas to receive a transplant. Few data concerning overseas transplantation in Korea are available and the Korea Society for Transplantation conducted a survey to evaluate the trend and outcome of overseas transplantation. The survey, conducted on June 2006, included 25 hospitals nationwide that followed up patients after receiving kidney transplant (KT) or liver transplant (LT) overseas. The number of KT increased from 6 in 2001 to 206 in 2005 and for LT from 1 to 261. The information about overseas transplant came mostly from other patients (57%). The mean cost for KT was $21,000 and for LT $47,000. Patients were admitted for 18.5 days for KT and 43.4 days for LT. Graft and patient survival was 96.8% and 96.5% for KT (median follow up 23.1 months). Complication occurred in 42.5% including surgical complication (5.3%), acute rejection (9.7%) and infection (21.5%). Patient survival for LT was 91.8% (median follow up 21.2 months). Complication occurred in 44.7% including 19.4% biliary complication. Overseas KT and LT increased rapidly from 2001 to 2005. Survival of patients and grafts was comparable to domestic organ transplantation, but had a high complication rate.

More than a quarter of a century of liver transplantation in Kaohsiung Chang Gung Memorial Hospital

Liver transplantation has been an accepted treatment for end-stage liver disease since the 1980s. The development of living donor liver transplantation (LDLT) was driven by limited deceased donor organ donation and a response to the growing demand for the option of liver replacement. LDLT is now performed with high rates of success due to judicious donor and recipient selection, careful preoperative planning, excellent anesthesia management, and prompt detection and treatment of complications. The first successful liver transplantation in Asia was performed in 1984, in Chang Gung Memorial Hospital in a Taiwanese adolescent with Wilson's disease, complicated by end-stage liver cirrhosis. The longest Asian liver transplant survivor has now been living for 26 years and that patient's transplant was also performed in Chang Gung Memorial Hospital. Through December 31, 2011, a total of 924 (783 living donor, 141 deceased donor) liver transplants have been performed at the Kaohsiung Chang Gung Memorial Hospital, where both graft and patient survivals are excellent. For biliary atresia, hepatitis B virus cirrhosis, and hepatocellular carcinoma recipients, our 5-year LDLT survival rates are 98%, 94%, and 90%, respectively. Our overall (deceased and living donor) actuarial 3-year survival rate is 91%. Innovative techniques in LDLT represent technical refinements in hepatic vein, portal vein, hepatic artery, and biliary reconstruction approaches. Hepatic vein reconstruction is highlighted by venoplasty reconstructions in both graft hepatic vein orifices and recipient hepatic veins, to ensure adequate outflow and decrease ischemia times during implantation. Vascular interposition to reconstruct middle hepatic vein tributaries with either fresh or cryopreserved vessels is used when the middle hepatic vein is not routinely harvested with the graft. We have extended the routine use of microsurgical techniques, initially for hepatic artery reconstruction, to biliary reconstruction where the possibility of duct-to-duct reconstruction is performed with accuracy and precision in pediatric non-biliary atresia and in multiple, small bile ducts. Long-term survival has always been related to the immunosuppression regimen, which influences outcome. Newer drugs do not equate to lesser complications. Rather, improvement in how we can find new uses for old drugs is now the norm. Less immunosuppression, as long as hepatic function is maintained at an acceptable level, decreases the chances of long-term complications related to immunosuppression use.

Liver transplantation or Starzl's legacy. A look backward, a look forward

Since the first successful liver transplantation (LT) in 1963 by Starzl, enormous progresses have been made in this field of medicine. The author looks back at the recommendations put forward at the 1983 NIH Consensus conference on liver transplantation in order to show the enormous progresses that have been made in his field during the last four decades. Today almost none of the original indications and contraindications remain in place. Despite the extension of indications, results of LT continuously improved. The attention of the transplant physicians should from now onwards be focused on the achievement of an immunosuppressive free (or tolerant) status in order to further consolidate the excellent obtained long-term results.

Factors affecting outcomes of liver transplantation: an analysis of OPTN/UNOS database

This was a historic cohort analysis based on 110,521 patients who underwent liver transplant between 1987 and July 2011 in the United States and were reported to the UNOS registry. In addition to univariate Kaplan-Meier survival analyses, we used cox proportional hazard analysis and multiple logistic regression analysis to evaluate hazard ratios adjusted for clinical factors. The overall 5- and 10-year patient survival rates were 81% and 72%, respectively, for 4,412 recipients of living donor livers and 73% and 59%, respectively, for 106,109 recipients of deceased donor livers. Multivariate analyses suggest that these differences are due to demographics, including patient age rather than differences due to the donor organs. Recipients of zero HLA-mismatched livers had significantly worst graft survival (HR 1.29, p = 0.02) compared with those given an HLA mismatched graft. This appears to be due in part to graft versus host disease. Among recipients who experienced GVHD, multivariate analysis revealed that zero mismatch of HLA-A (HR 2.75), zero mismatch of HLA-B (HR 4.79), recipient age > 65 (HR 2.57) and Asian recipient (HR 2.70) were significant risk factors for GVHD respectively.

[Perspectives of pediatric liver and kidney transplantation in Japan]

In Japan, around one hundred and thirty pediatric living donor liver transplantations (LDLT) have been done every year, while cadaveric transplants are only 11 in the past 10 years. The indication has been extended to newborn babies as small as 2.5 kg of body weight. Five-year patient-survival of pediatric LDLT in Japan is 84.4%. Seventy pediatric kidney transplantations were done in 2008, 59 from living and 11 from cadaveric donors. Ten-year graft survival is improving in recent cases, and it is 79.4% in cases done after 1992. Living donor kidney transplantation has been possible in children as small as 7 or 8 kg of body weight. With such a technical success, discussion to enhance the preemptive renal transplantation has been started in Japan.

[Current status of and issues in pediatric liver transplantation in Japan]

Approximately 140 pediatric living donor liver transplantations (PLDLTs) are performed annually in Japan. The most common indication for PLDLT is biliary atresia. The 5-year patient survival rate after PLDLT has reached 84% with advances in surgical techniques, immunosuppressive therapy, and antiinfection therapy in the past two decades. Recently, although the number of PLDLTs performed for the treatment of fulminant hepatic failure and metabolic disease has increased, the optimal timing of surgery for each disease has led to better patient prognosis. However, patient survival rates after fulminant hepatic failure of unknown origin and hepatoblastoma are still poor in comparison with other indications. A multidisciplinary treatment regimen including postoperative medical therapy therefore needs to be established for these conditions. In the outpatient clinic, regular and continuing imaging examination is indispensable for the diagnosis of mid/long-term complications such as vascular anastomotic stenosis and biliary stricture in addition to standard liver function tests. These complications can be treated with interventional radiology if diagnosed in the early stage. Protocol biopsy is also important to confirm graft fibrosis over the long term after PLDLT. Patients with graft fibrosis should receive more potent immunosuppressants to maintain permanent graft function.

Liver transplantation: where we are and where we are heading

Outcomes after liver transplantation are outstanding; however, the limiting factor is the shortage of organs. Recently, the utilization of donors after cardiac death has been encouraged; however, such transplants are associated with a high complication rate, mainly a high incidence of biliary complications, particularly ischemic cholangiopahty, a serious complication that often leads to retransplantation. The second problem is the morbidity associated with the use of immunosuppressive drugs. In this manuscript, the current status of clinical protocols for induction of tolerance is briefly discussed. Furthermore, the future of research in transplantation will involve basic scientists and clinical scholars working in concert as has been developed at Stanford School of Medicine with the creation of the Institute for Immunity, Transplantation and Infection.

Improved results of transplantation for hepatocellular carcinoma: a report from the International Registry of Hepatic Tumors in Liver Transplantation

Improved outcome after liver transplantation (LTX) for hepatocellular carcinoma (HCC) made LTX a legitimate treatment of the disease. We analyzed trends of LTX for HCC with tumors known before transplantation in 902 patients in a large international registry across 3 periods: 1983-1990, 1991-1996, and 1997-2005. Patient survival improved gradually across eras, with 5-year survival rates of 25.3%, 44.4%, and 67.8%, respectively (P < 0.0001), and the 5-year tumor recurrence rate declined from 59% to 41.3% and 15%, respectively (P < 0.0001). The number of HCC nodules and tumor size decreased over time, and there were fewer moderately or poorly differentiated tumors. Tumors > 5 cm decreased from 54.5% to 31.7% and 11.7%, respectively (P < 0.0001), and LTX with >or=4 nodules decreased from 38.9% to 23.5% and 15.1%, respectively (P = 0.0044). Poorly differentiated tumors decreased from 37.2% to 31.8% and 20.3%, respectively (P = 0.0005). Tumor microvascular invasion remained at 21.2% to 23.8% despite changes in patient selection over time (P = 0.7124). Stepwise Cox regression analysis (n = 502) showed significant risk for tumor recurrence and patient survival for transplants before 1997 [hazard ratio (HR), 1.82 and 1.88, respectively], tumor size > 6 cm (HR, 2.09 and 1.76), microvascular invasion (HR, 1.75 and 1.69, respectively), and alpha-fetoprotein > 200 (HR, 2.45 and 2.32, respectively). In conclusion, outcome after LTX for HCC has improved continuously over the past 20 years. Improved perioperative care and better patient selection may partially explain the improved outcome after LTX for HCC.

Liver transplantation in Asia: past, present and future

With the technical advances and improvements in perioperative management and immunosuppressants, liver transplantation is the standard treatment for patients with end-stage liver diseases. In Asia, a shortage of deceased donor liver grafts is the universal problem to be faced with in all transplant centres. Many surgical innovations are then driven to counteract this problem. This review focuses on 3 issues that denote the development of liver transplantation in Asian countries. These include living donor liver transplantation (LDLT), split liver transplantation (SLT) and liver transplantation for hepatocellular carcinoma (HCC). Minimal graft weight, types of liver graft to donate and the inclusion of the middle hepatic vein with the graft are the main issues to be established in LDLT. The rapid growth and wide dissemination of LDLT has certainly alleviated the supply-and-demand problem of liver grafts in Asia. SLT is another attractive approach. Technical expertise, donor selection and graft allocation are the main determinants for its success. Liver transplantation plays a key role in the management of HCC in Asia. LDLT would be the main strategy in this aspect. The issue of extending the selection criteria for HCC patients for LDLT is still controversial. On the whole, future developments to increase the donor pool for the expanding recipient need in Asia would involve transplantation from non-heart beating donor and ABO incompatible transplantation.

The development of perioperative practices for liver transplantation: advances and current trends

Transplantation is a young medical specialty that has grown rapidly over the past 50 years. Anesthesiologists, surgeons and hepatologists are all essential partners in the process of determining patient outcome. Each specialty has made landmark improvements in patient outcome. However, there is still variability in practice patterns in each of the 3 major specialties. This review will use a historic perspective to explore the unique forces that shaped specific transplant practices and those that gave rise to differences in perioperative practices. Anesthesiologists and surgeons have made significant improvements in the management of blood loss, and coagulation monitoring and intervention. This has improved operative survival and early patient outcome. Perioperative survival has improved despite a worldwide shortage of donor organs and a trend to transplant sicker patients. A smaller pool of donor organs is required to meet the needs of an expanding waiting list. The innovations to reduce deaths on the transplant wait list are reviewed along with their impact on overall patient outcome. The evolving organ shortage is the pinnacle point in shaping future transplant practices. Currently, institutional-specific practices may be reinforced by the informal "tutorship" that is used to train physicians and by the resources available at each site of practice. However, there is evidence that specific intraoperative practices such as the use of a low central venous pressure, selection of vasopressors and certain surgical techniques can modify patient outcome. Further investigation is needed to determine whether the good or the bad associated with each practice prevails and in what unique circumstance.

Interventional radiology in liver transplant

An increased number of transplant centers now actively perform deceased-donor as well as living-related liver transplants. Although postoperative vascular and nonvascular complications after liver transplant have been well documented, early diagnosis and intervention are important to increase graft and recipient survival. With improvements in interventional radiologic techniques and a multidisciplinary approach to liver transplant, management of complications by percutaneous and endovascular techniques is possible with less morbidity and mortality. This article outlines the recent developments in, and applications of, interventional radiologic techniques in liver transplant patients.

The evolution of liver transplantation for hepatocellular carcinoma (past, present, and future)

Over the past quarter-century, liver transplantation (LT) has been established as a durable therapy for all forms of end-stage liver disease. LT appears ideally suited for hepatocellular carcinoma (HCC), as it involves complete oncologic resection and correction of the underlying liver dysfunction. Since LT based on the Milan criteria has been shown to provide good disease-free survival, LT is considered the optimal treatment for small HCC, especially in patients with underlying chronic liver disease. However, because there is a severe shortage of organ donors, not all patients in need can be offered LT. Transplant listing criteria must simultaneously determine the greatest number of suitable candidates for LT while rejecting the smallest number of those who could benefit from LT. The amended model for end-stage liver disease allocation policy has had a positive effect on liver transplant candidates with HCC, and their number has been increasing significantly over the past several years. To minimize dropout from the waiting list, the treatment of HCC with procedures such as chemoembolization, radiofrequency ablation, or ethanol injection in patients awaiting LT have become widespread. It is currently accepted that liver resection is the best option for the treatment of small HCC when liver function is well preserved, and that LT is preferred when liver function is severely impaired (Child-Pugh class B or C). However, the question arises as to what is the best option for Child-Pugh class A patients with early HCC eligible for both resection and LT, especially in Western countries. HCC is a major indication for living donor liver transplantation (LDLT), because the risk of dropout while waiting is negligible. Extension of the Milan criteria in the setting of LDLT may offer more patients a potentially curative treatment without reducing the donor pool of organs for patients on the waiting list with nonmalignant liver disease. However, imprudent expansion of the selection criteria may result in more patients with HCC being cured at the expense of a higher incidence of recurrence.

Hepatology: a personal story

When I first began my career in hepatology in October 1959, investigative and treatment measures for patients with liver disease were limited. It was not until the discovery of hepatitis B virus in 1967 and hepatitis C virus in 1989 that the specialty began to expand, particularly with the development of effective antiviral therapy. Phenomenal advances in the knowledge of immune reactions also led to advances in our understanding and treatment of autoimmune disorders affecting the liver and in the continued development of liver transplantation--a major success story. The new liver support devices are currently showing promise but on the negative side is the rising prevalence of alcohol-related liver disease and non-alcoholic fatty liver disease.

[Some factors, with an impact on the outcome of the Hungarian Liver Transplant Program, with special consideration of the hepatitis C virus]

The author retrospectively evaluated the outcome of the Hungarian Liver Transplant program from 1995 to 2006. Liver transplants in the context of HCV positive cirrhosis were analysed separately. Furthermore, fulminant recurrence of HCV infection in the implanted graft was also investigated. The possible association among the serum titer of the HCV RNA, the histological patterns, the clinical course and the expression of the endoplasmatic chaperones in HCV graft biopsies (which is responsible for the endoplasmatic stress response) was also investigated. The number of liver transplants showed a four-fold yearly increase in the last 10 years. The 1, 3 and 5 years cumulative patient survival were 55%, 45% and 39% (1995-1997), 72%, 64% and 61% (1998-2000), and 78%, 77% and 77% (2001-2004), respectively. Total mortality decreased from 53% to 31%, mortality within 60 days decreased from 24% to 5%. Cumulative survival for HCV positive patients was respectively 64%, 55% and 51%, versus other chronic indications, which was 73%, 66% and 63%, respectively. Virus recurrence was 43% within 1 year. Factors with an impact on patient survival were calculated with Cox-regression multivariate analysis: postoperative kidney failure, hepatic artery thrombosis, biliary necrosis, cholangitis, pulmonary infection, abdominal infection, amount of intraoperative colloid use and transfusions. All chaperones (XBP1, ATF6, HSP70, GRP98, GP96, Calnexin and Calreticulin) were upregulated in the graft biopsies of HCV positive patients, irrespectively of the serum HCV-RNA titer. This upregulation decreased significantly after 1 year of interferon treatment. In case of acute rejection, upregulation of all chaperones was significantly higher than in HCV recurrence. An association was demonstrated between the serum HCV-RNA titer and the early recurrence. An RNA cut off point was identified to predict unfavourable histological and clinical prognosis, and a worse survival as well.

A decade of liver transplantation at Mayo Clinic in Florida

We have utilized deceased donor livers to maintain low mortality on the wait list, to provide a significantly high transplant rate, and to achieve excellent graft and patient outcomes at 3 months, one year, and 3 years, surpassing the national and expected averages. We have also shown that reLT remains a durable option for patients with recurrent disease including recurrent HCV, that DCD livers continue to be a viable source of donor grafts, and that LT in patients with high BMI produces acceptable outcomes.

Liver transplantation at UCSF--a 20-year experience

Overall, the liver transplant experience at UCSF has been a highly successful one. The program has made major contributions to the advancement of liver transplantation as a field. The UCSF has pushed the envelope in, at times, including recipients that were thought to have absolute contraindications for liver transplantation. The program is a tribute to the many physicians, surgeons and ancillary personnel, as well as those that preceded them, and participated in their training that these past 20 years has been as rewarding and as productive as they have been.