Retransplantation for end-stage liver disease: a single-center Asian experience

First Series of Living Donor Liver Retransplants From India: Challenges and Outcomes

Background

There is a paucity of Indian data on long-term survival after living donor liver transplant (LDLT) or the need for retransplant (re-LT). In this article, we report the first series of retransplants from India with focus on indications, technical challenges and results.

Methods

A retrospective study on 29 patients undergoing a liver retransplant (re-LT) was analysed with respect to survival outcomes and postoperative complications. Patients were divided into early and late retransplant groups based on whether re-LT was performed within or beyond 30 days of primary transplant.

Results

Liver retransplant was performed in 29 (0.81%) patients out of a total of 3563 liver transplants (28 living donor and one deceased donor liver transplant). The primary transplant was an LDLT in 27 (93%) patients. Retransplant was performed at a median of 26 days after the first transplant. Re-LT was performed early (within 30 days) in 17 (59%) patients and late (beyond 30 days) in 12 (41%). Hepatic artery thrombosis (53%) and early graft dysfunction (47%) were the indications for early retransplant, while biliary complications (50%) and chronic rejection (33%) were primary indications for late retransplant. Postretransplant complications occurred in 22 (75%) patients, the commonest being gram-negative bacterial sepsis. The 30-day mortality after retransplant was 27% (8/29). The primary cause of mortality was gram-negative septicaemia. The mortality in the late retransplant group (2, 16.6%) was lower than in the early retransplant group (6, 35%).

Conclusion

Retransplant using living donors is a viable option in properly selected patients with prior LDLT.

Graft-recipient-weight ratio and lowered immunosuppression is important for the success of adult liver retransplantation

This study analyzed the risk of liver retransplantation and factors related to better outcome. Adult liver transplantations performed during 1996-2021 were included. Comparison between first transplantation and retransplantation were performed. Among retransplantation cases, comparison between whole liver and partial liver graft was performed. Multivariable Cox analyses for analyzing risk factors for primary graft and overall patient survival were performed for the entire cohort as well as the subgroup of patients with retransplantation. A total 2237 transplantations from 2135 adults were included and 103 cases were retransplantation. A total of 44 cases (42.7%) were related to acute graft dysfunction while 59 cases (57.3%) were related to subacute or chronic graft dysfunction. Retransplantation was related poor primary graft (HR 3.439, CI 2.230-5.304, P < 0.001) and overall patient survival. (HR 2.905, CI 2.089-4.040, P < 0.001) Among retransplantations, mean serum FK506 trough level ≥ 9 ng/mL was related to poor primary graft (HR 3.692, CI 1.288-10.587, P = 0.015) and overall patient survival. (HR 2.935, CI 1.195-7.211, P = 0.019) Graft-recipient-weight ratio under 1.0% was related to poor overall patient survival in retransplantations. (HR 3.668, CI 1.150-11.698, P = 0.028). Retransplantation can be complicated with poor graft and patient survival compared to first transplantation, especially when the graft size is relatively small. Lowering the FK506 trough level during the first month can be beneficial for outcome.

Liver Retransplantation Associated With Kidney Transplantation for End-stage Liver Graft Disease and Renal Insufficiency: A Morbid Procedure on a Unique Subgroup of Patients

BACKGROUND

Chronic renal disease (CKD) jeopardizes the long-term outcomes of liver transplant recipients. In patients with end-stage liver graft disease and CKD, liver retransplantation associated with kidney transplantation (ReLT-KT) might be necessary. Yet, this specific subset of patients remains poorly described.

METHODS

Indications, perioperative characteristics, and short- and long-term outcomes of patients undergoing ReLT-KT at 2 transplantation units from 1994 to 2012 were analyzed. Risk factors for postoperative mortality and long-term survivals were evaluated.

RESULTS

Among 3060 patients undergoing liver transplantation (LT), 45 (1.5%) underwent ReLT-KT. The proportion of ReLT-KT among LT recipients continuously grew throughout the study period from 0.3% to 2.4% (P < 0.001). Median time from primary LT to ReLT-KT was 151.3 (7.5-282.9) months. The most frequent indications for liver retransplantation were recurrence of the primary liver disease and cholangitis in 15 (33.3%) cases each. CKD was related to calcineurin inhibitors toxicity in 38 (84.4%) cases. Twelve (26.7%) patients died postoperatively. D-MELD (donor age × recipients' MELD) was associated with postoperative mortality (HR: 8.027; 95% CI: 2.387-18.223; P = 0.026) and optimal cut-off value was 1039 (AUC: 0.801; P = 0.002). Overall 1, 3, and 5 years survivals were 68.8%, 65.9%, and 59.5%, respectively. D-MELD > 1039 was the only factor associated with poor survival (P = 0.021).

CONCLUSIONS

ReLT-KT is a highly morbid increasingly performed procedure. Refinements in the selection of grafts and transplant candidates are required to limit the postoperative mortality of these patients.

Living donor liver transplantation in Taiwan-challenges beyond surgery

Taiwan has a high prevalence of hepatitis B and C viral infections, and consequently a high burden of chronic liver diseases. Liver transplantation (LT) began in Taiwan in 1984, and living donor liver transplantation (LDLT) in 1994. Education and collaboration between physicians on a national and international scale were important factors in the development of transplantation in East Asia. Technical innovations in donor hepatectomy, vascular and biliary reconstruction, and interventional radiology, perioperative management of transplant patients and development of associated specialties have enabled achievement of excellent results after both adult and pediatric LDLT. The establishment of rigorous protocols to withstand strict medico-legal scrutiny, combined with technical excellence has contributed to excellent surgical outcomes. The socioeconomic development of Taiwan and the first nationwide hepatitis B vaccination program in the world have also contributed to the decrease in disease burden and improvement of quality of healthcare. This article examines the factors enabling the development of LT in Taiwan, the innovations that have contributed to excellent outcomes, and indicates the future prospects of LDLT in Taiwan.