The beneficial role of simultaneous splenectomy in living donor liver transplantation in patients with small-for-size graft

Dual living donor liver transplantation with ABO-incompatible and ABO-compatible grafts to overcome small-for-size graft and ABO blood group barrier

ABO blood group compatibility has been regarded as an essential prerequisite for successful adult living donor liver transplantation (LDLT). Novel strategies for overcoming the ABO blood group barrier, however, have markedly improved the results of ABO-incompatible (ABOi) LDLT. We describe our strategies for dual graft LDLT to cope with ABO-incompatibility and small-for-size graft syndrome in 3 patients who underwent dual graft LDLT with ABOi and ABO-compatible (ABOc) grafts. One patient received a modified right lobe graft from an ABOi living donor and a left lateral section graft from an ABOc deceased donor, whereas the other 2 patients received 2 left lobe or left lateral section grafts from ABOi and ABOc living donors. To overcome the ABO-blood barrier, each patient was treated with preoperative anti-CD20 antibody (rituximab 375 mg/m(2)), perioperative plasma exchange, and hepatic arterial infusion. All 3 patients were males, of mean age 47.7 years (range, 40 approximately 52 years) and mean Model for End-Stage Liver Disease score 12.3 (range, 9 approximately 15). The mean graft-to-recipient weight ratio was 0.99%. All patients remain alive after a mean follow-up period of 9.5 months (range, 8.0 approximately 10.7 months). All 6 grafts have functioned normally. There were no episodes of antibody-mediated rejection or biliary complication. Dual LDLT with ABOi and ABOc grafts can be a feasible solution for simultaneously overcoming both the ABO blood group barrier and small-for-size graft syndrome.

Impact of antithrombin III concentrates on portal vein thrombosis after splenectomy in patients with liver cirrhosis and hypersplenism

OBJECTIVE

The aim of this study was to determine the role of antithrombin III (AT-III) in portal vein thrombosis (PVT) after splenectomy in cirrhotic patients.

SUMMARY BACKGROUND DATA

There is no standard treatment for PVT after splenectomy in liver cirrhosis.

METHODS

A total of 50 consecutive cirrhotic patients who underwent laparoscopic splenectomy for hypersplenism were enrolled into this study. From January 2005 to December 2005, 25 cirrhotic patients received no prophylactic anticoagulation therapy after the operation (AT-III [-] group). From January 2006 to July 2006, 25 cirrhotic patients received prophylactic administration of AT-III concentrates (1500 U/d) on postoperative day (POD) 1, 2, and 3 (AT-III [+] group).

RESULTS

In AT-III (-) group, 9 (36.0%) patients developed PVT up to POD 7, and risk factors for PVT were identified as: low platelet counts, low AT-III activity, and increased spleen weight. Although there were no significant differences in the clinical characteristics, including the above risk factors, between the 2 groups, only 1 (4.0%) patient developed PVT on POD 30 in AT-III (+) group, and the incidence of PVT was significantly lower than in AT-III (-) group (P = 0.01). In AT-III (-) group, AT-III activity was significantly decreased from POD 1 to POD 7, as compared with the preoperative level, whereas AT-III concentrates prevented the postoperative decrease in AT-III activity.

CONCLUSIONS

These results demonstrate that low AT-III activity and further decreases in this activity are associated with PVT after splenectomy in cirrhotic patients, and that treatment with AT-III concentrates is likely to prevent the development of PVT in these patients.

A graft to body weight ratio less than 0.8 does not exclude adult-to-adult right-lobe living donor liver transplantation

Many centers require a minimal graft to body weight ratio (GBWR) >or= 0.8 as an arbitrary threshold to proceed with right-lobe living donor liver transplantation (RL-LDLT), and there is often hesitancy about transplanting lower volume living donor (LD) liver grafts into sicker patients. The data supporting this dogma, based on the early experience with RL-LDLT at Asian centers, are weak. To determine the effect of LD liver volume in the modern era, we investigated the impact of GBWR on the outcome of RL-LDLT with a GBWR as low as 0.6 at the University of Toronto. Between April 2000 and September 2008, 271 adult-to-adult RL-LDLT procedures and 614 deceased donor liver transplants were performed. Twenty-two living donor liver transplantation (LDLT) cases with a GBWR of 0.59 to 0.79 (group A) were compared with 249 LDLT cases with a GBWR >or= 0.8 (group B) and with 66 full-graft deceased donor liver transplants (group C), who were matched 3:1 according to donor and recipient age, Model for End-Stage Liver Disease score, and presence of hepatitis C and hepatocellular carcinoma with the low-GBWR group. Portal vein shunts were not used. Markers of reperfusion injury [aspartate aminotransferase (AST) and alanine aminotransferase (ALT)], graft function (international normalized ratio and bilirubin), complications graded by the Clavien score, and graft and patient survival were compared. As expected, LD recipients had a significantly shorter cold ischemia time (94 +/- 43 minutes for A, 96 +/- 57 minutes for B, and 453 +/- 152 minutes for C, P = 0.0001). However, the peak AST, peak ALT, absolute decrease in the international normalized ratio, day 7 bilirubin level, postoperative creatinine clearance, complication rate graded by the Clavien score, and median hospital stay were similar in all groups. The rate of biliary complications was higher with LD grafts than deceased donor grafts (19% for A versus 10% for B and 0% for C, P = 0.2). Patient survival was similar in all groups at 1, 3, and 5 years (91% for A versus 89% for B and 93% for C at 1 year, 87% for A versus 81% for B and 89% for C at 3 years, and 83% for A versus 81% for B and 87% for C at 5 years, P = 0.63). A Cox proportional regression analysis revealed only hepatitis C virus as a risk factor for poorer graft survival and not GBWR as a continuous or categorical variable. In conclusion, we found no evidence of inferior outcomes with smaller size grafts versus larger size LD grafts or full-size deceased donor grafts. Further studies are warranted to examine the factors affecting the function of smaller grafts for living liver donation and thereby define the safe lower limits for transplantation.

New prediction factors of small-for-size syndrome in living donor adult liver transplantation for chronic liver disease

Small-for-size syndrome (SFSS), which is characterized by synthetic dysfunction and prolonged cholestasis, is a major cause of worse short-term prognoses after living donor adult liver transplantation (LDALT). However, the risks of SFSS remain unclear. The aim of this study was to clarify the risks of SFSS, which were analysed in 172 patients who underwent LDALT for chronic liver disease. Graft types included left lobe with caudate lobe graft (n = 110) and right lobe graft (n = 62). Thirty-four cases (24 with left lobe grafts and 10 with right lobe grafts) were determined as SFSS. SFSS developed even if the actual graft-to-recipient standard liver volume ratio was >40%. Logistic regression analysis revealed three independent factors associated with SFSS development in left and right lobe grafts: donor age, actual graft-to-recipient native liver volume ratio, and Child's score. Donor age and actual graft-to-recipient native liver volume ratio may become predictive factors for SFSS development in left and right lobe grafts in patients undergoing LDALT.

Liver transplantation: Issues for the next 20 years

The growing numbers of potential transplant recipients on waiting lists is increasingly disproportionate to the supply of cadaveric donor organs. The hope for the next 20 years is that supply will satisfy demand. This requires both a reduction in indications for the procedure and an increase in the transplants performed. A multi-pronged approach is needed to increase cadaveric organ donation, generating enthusiasm for donation among both the general public and hospital staff. Accurate assessment of marginal grafts with stringent criteria known to predict graft function will diminish wastage of organs. Methods of rehabilitating marginal grafts during extracorporeal perfusion will increase organ availability. Supply of non-heart beating donors can be greatly expanded and protocols developed with ethical consent to optimize their initial function despite warm ischemia. Splitting livers that fulfill selection criteria, thus providing for two recipients, should be universally applied with acceptable incentives to those units who do not directly benefit. A proportion of recipients, though not those transplanted for autoimmune disease, will be spared the side-effects of immunosuppression thanks to immune tolerance. Protocols for close monitoring of those patients for rejection during treatment withdrawal must be carefully observed. In addition to gene therapy, it is highly likely that hepatocyte transplantation will replace orthotopic grafting in patients without cirrhosis, especially for inherited metabolic diseases. It is much more difficult to envisage that heterologous stem cell transplantation or xenotransplantation will have clinical impact in the next 20 years, although research in those areas has obvious long-term potential.

Rituximab, IVIG, and plasma exchange without graft local infusion treatment: a new protocol in ABO incompatible living donor liver transplantation

BACKGROUND

Although graft local infusion (GLI) treatment via the portal vein or the hepatic artery has been the pivotal strategy in ABO incompatible (ABOi) living donor liver transplantation (LDLT) in Japan, the procedure is associated with a high rate of catheter-associated complications.

METHODS

A new ABOi-LDLT protocol has been implemented using rituximab, intravenous immune globulin (IVIG), plasma exchange (PE), and splenectomy, without using GLI, on four patients, since 2007. Three other patients, treated before 2007, received GLI.

RESULTS

Three of the four patients with liver cirrhosis received rituximab over 3 weeks before LDLT, followed by PEs and post-LDLT IVIG, resulting in no rebound elevation of the isoagglutinin titers. The remaining patient, with fulminant hepatitis, received rituximab 3 days before the LDLT, resulting in antibody-mediated rejection, successfully treated by IVIG and PE. All four patients that were treated with the new protocol are alive, 26, 8, 6, and 5 months after ABOi-LDLT with normal liver function. Two of the three other patients with GLI, before 2007, had catheter-associated complications, including one graft loss.

CONCLUSION

The new ABOi-LDLT protocol using rituximab, IVIG, and PE, without the use of GLI, therefore seems to be a safe and an effective treatment modality.

Technical standardization of laparoscopic splenectomy harmonized with hand-assisted laparoscopic surgery for patients with liver cirrhosis and hypersplenism

BACKGROUND/PURPOSE

The aims of this study were to standardize the techniques of laparoscopic splenectomy (LS) to improve safety in liver cirrhosis patients with portal hypertension.

METHODS

From 1993 to 2008, 265 cirrhotic patients underwent LS. Child-Pugh class was A in 112 patients, B in 124, and C in 29. Since January 2005, we have adopted the standardized LS including the following three points: hand-assisted laparoscopic surgery (HALS) should be performed in patients with splenomegaly (> or =1,000 mL), perisplenic collateral vessels, or Child-Pugh score 9 or more; complete division and sufficient elevation of the upper pole of the spleen should be performed before the splenic hilar division; and when surgeons feel the division of the upper pole of the spleen is too difficult, conversion to HALS should be performed.

RESULTS

There were no deaths related to LS in this study. After the standardization, conversion to open surgery significantly reduced from 11 (10.3%) of 106 to 3 (1.9%) of 159 patients (P < 0.05). The average operation time and blood loss significantly reduced from 259 to 234 min (P < 0.01) and from 506 to 171 g (P < 0.01), respectively.

CONCLUSIONS

With the technical standardization, LS becomes a feasible and safe approach in the setting of liver cirrhosis and portal hypertension.

Graft size and donor age are independent factors for graft loss in adult-to-adult living-donor liver transplantation using the left liver

BACKGROUND/PURPOSE

Graft survival is affected by various factors, such as preoperative state and the ages of the recipient and donor, as well as graft size. The objective of this study was to analyze the risk factors for graft survival.

METHODS

From September 1997 to July 2005, 24 patients who had undergone living-donor liver transplantation (LDLT) were retrospectively analyzed. Sixteen patients survived and the eight graft-loss cases were classified into two groups according to the cause of graft loss: graft dysfunction without major post-transplantation complications (graft dysfunction group; n = 3), and graft dysfunction with such complications (secondary graft dysfunction group; n = 5). Various factors were compared between these groups and the survival group.

RESULTS

Mean donor age was 31.9 years in the survival group and 49.2 years in the secondary graft dysfunction group (P = 0.024). Graft weight/recipient standard liver volume ratios (G/SLVs) were 36.7% in the survival group, and 26.2% in the graft dysfunction group (P = 0.037). The postoperative mean PT% for 1 week was 48.6% in the survival group and 38.1% in the secondary graft dysfunction group (P = 0.05).

CONCLUSIONS

Our surgical results demonstrated that G/SLV and donor age were independent factors that affected graft survival rates.

Preoperative assessment of the risk factors that help to predict the prognosis after living donor liver transplantation

BACKGROUND

The purpose of this study was to analyze various risk factors and to assess the preoperative risk score, which can predict the prognosis after living donor liver transplantation (LDLT).

METHODS

From February 2002 to August 2007, 84 adult to adult living donor liver transplantation donors and recipients were analyzed. First, the donor, recipient, and intraoperative factors were examined by univariate and multivariate analyses. We then gave a score of one point for each significant marginal factor (total point scores were called "risk score") and each risk score was examined by univariate analyses.

RESULTS

Recipients with the donor age 50 years or older, Model for End-Stage Liver Disease (MELD) score (> or =21), and hepatitis C virus-positive status had a significantly poor survival. Recipients between the risk score of 0 vs. scores of 2 + 3 (p < 0.001, log-rank) and risk score of 1 vs. scores of 2 + 3 (p = 0.003, log-rank) had significantly different survival.

CONCLUSIONS

Preoperative assessment of the risk score might help to predict recipient outcomes after living donor liver transplantation.

Current concept of small-for-size grafts in living donor liver transplantation

The extended application of living donor liver transplantation (LDLT) has revealed the problem of graft size mismatching called "small-for-size (SFS) graft syndrome." The initial trials to resolve this problem involved increasing the procured graft size, from left to right, and even extension to include a right lobe graft. Clinical cases of living right lobe donations have been reported since then, drawing attention to the risks of increasing the liver volume procured from a living donor. However, not only other modes of increasing graft volume such as auxiliary or dual liver transplantation, but also control of the increased portal pressure caused by an SFS graft, such as a portosystemic shunt or splenectomy, have been trialed with some positive results. To establish an effective strategy for transplanting SFS grafts and preventing SFS graft syndrome, it is essential to have precise knowledge and tactics to evaluate graft quality and graft volume, when performing these LDLTs with portal pressure control. We reviewed the updated literature on the pathogenesis of and strategies for using SFS grafts.