Living related liver transplantation: medical and social aspects of a controversial therapy

The Post-Traumatic Growth of Primary Caregivers of Patients after Liver Transplantation

Liver transplantation is a very important surgery. In many cases, it involves two loved ones (receiver and donor in the same family) and causes stress and feelings of burden in family caregivers. The purpose of this study was to investigate post-traumatic growth in primary caregivers of liver transplant patients. A cross-sectional research design was adopted to recruit 84 participants. The Perceived Stress Scale, Short-Form Coping Strategies Scale, and Post-traumatic Growth Scale were used. The results revealed that the total score of perceived stress of the main caregivers of liver transplantation was 27.27 ± 6.63; problem-oriented coping and emotion-oriented coping were used as the main coping strategies, and the traumatic growth score was 42.01 ± 13.84. All three variables were significant predictors of post-traumatic growth (F = 13.71, p < 0.05), explaining 38% of the total variance. This study can help nurses understand the post-traumatic growth status and related factors of the main caregivers of liver transplant patients. It can also help caregivers understand their own perceived pressure and then take relevant care measures to reduce the degree of physical and mental load and achieve a balanced state.

Living Donation Versus Donation After Circulatory Death Liver Transplantation for Low Model for End-Stage Liver Disease Recipients

In this era of organ scarcity, living donor liver transplantation (LDLT) is an alternative to using deceased donors, and in Western countries, it is more often used for recipients with low Model for End-Stage Liver Disease (MELD) scores. We sought to compare the patient survival and graft survival between recipients of liver transplantation from living donors and donation after circulatory death (DCD) donors in patients with low MELD scores. This is a retrospective cohort analysis of adult liver transplant recipients with a laboratory MELD of ≤20 who underwent transplantation between January 1, 2003 and March 31, 2016. Recipients were categorized by donor graft type (DCD or LDLT), and recipient and donor characteristics were compared. Ten-year patient and graft survival curves were calculated using Kaplan-Meier analyses, and a mixed-effects model was performed to determine the contributions of recipient, donor, and center variables on patient and graft survival. There were 36,705 liver transplants performed: 32,255 (87.9%) from DBD donors, 2166 (5.9%) from DCD donors, and 2284 (6.2%) from living donors. In the mixed-effects model, DCD status was associated with a higher risk of graft failure (relative risk [RR], 1.27; 95% confidence interval [CI], 1.16-1.38) but not worse patient survival (RR, 1.27; 95% CI, 0.96-1.67). Lower DCD center experience was associated with a 1.21 higher risk of patient death (95% CI, 1.17-1.25) and a 1.13 higher risk of graft failure (95% CI, 1.12-1.15). LDLT center experience was also predictive of patient survival (RR, 1.03; 95% CI, 1.02-1.03) and graft failure (RR, 1.05; 95% CI, 1.05-1.06). In conclusion, for liver transplant recipients with low laboratory MELD, LDLT offers better graft survival and a tendency to better patient survival than DCD donors.

A New Chemical Compound, NecroX-7, Acts as a Necrosis Modulator by Inhibiting High-Mobility Group Box 1 Protein Release During Massive Ischemia-Reperfusion Injury

BACKGROUND

Necrotic cell death is common in a wide variety of pathologic conditions, including ischemia-reperfusion (IR) injury. The aim of this study was to develop an IR injury-induced hepatic necrosis model in dogs by means of selective left hepatic inflow occlusion and to test the efficacy of a new chemical compound, NecroX-7, against the IR injury-induced hepatic damage.

METHODS

A group of male Beagle dogs received intravenous infusions of either vehicle or different doses of NecroX-7 (1.5, 4.5, or 13 mg/kg) for a 20-minute period before a 90-minute left hepatic inflow occlusion followed by reperfusion.

RESULTS

The gross morphology in the NecroX-7-treated groups after occlusion appeared to be less congested and less swollen than that in vehicle-treated control group. Circulating alanine transaminase and aspartate transaminase levels in the control group were elevated during the course of IR, and were effectively blocked in the 4.5 and 13 mg/kg NecroX-7-treated groups. The serum levels of high-mobility group box 1 protein showed a peak at 8 hours after occlusion in control group, and this elevation was significantly blunted by 4.5 mg/kg NecroX-7 treatment. Histologic analysis showed a marked ischemia or IR injury-induced hepatocytic degenerations, sinusoidal and portal vein congestions, and inflammatory cell infiltrations in the control group, whereas the treatment groups showed significantly diminished histopathology in a dose-dependent manner.

CONCLUSIONS

These results demonstrated that NecroX-7 attenuated the hepatocyte lethality caused by hepatic IR injury in a large animal setting. We conclude that NecroX-7 may provide a wide variety of therapeutic options for IR injury in human patients.

Living Kidney Donor Decision Making: State of the Science and Directions for Future Research

Background

The Federal government and transplantation organizations have called for further study of living donation at a time when 3 new living donor protocols are being introduced throughout the United States that promise to significantly increase the donor pool and change the face of living donation. Donation to a once incompatible and sometimes unknown recipient may now occur through the use of plasmapheresis therapy or paired and nondirected living donor protocols.

Objective

To describe the state of the science on living kidney donor decision making, and to provide recommendations for future research to guide donor education and care.

Data Sources

Automated literature search using PubMed and CINAHL scientific literature databases.

Study Data Extraction

Research papers on living donor decision making from 1997 to 2003. Studies available only as abstracts were excluded. Data Synthesis Studies of living kidney donor decision making and outcomes have been limited in scope, with small sample sizes and inconsistent reports of racial and ethnic characteristics of the sample. The retrospective nature of the majority of living donor studies is a significant limitation.

Conclusions

Future prospective studies that are diverse by sex, race, and ethnicity will contribute to our knowledge of factors that influence the decision to be a living kidney donor.

Comparative accuracy of CT, dual-echo MRI and MR spectroscopy for preoperative liver fat quantification in living related liver donors

Background:

It is of significant importance to assess the extent of hepatic steatosis in living donor liver transplant (LDLT) surgery to ensure optimum graft regeneration as well as donor safety.

Aim:

To establish the accuracy of non-invasive imaging methods including computed tomography (CT), dual-echo in- and opposed-phase magnetic resonance imaging (MRI), and MR spectroscopy (MRS) for quantification of liver fat content (FC) in prospective LDLT donors with histopathology as reference standard.

Settings and Design:

This retrospective study was conducted at our institution on LDLT donors being assessed for biliary and vascular anatomy depiction by Magnetic Resonance Cholangiopancreatography (MRCP) and CT scan, respectively, between July 2013 and October 2014.

Materials and Methods:

Liver FC was measured in 73 donors by dual-echoT1 MRI and MRS. Of these, CT liver attenuation index (LAI) values were available in 62 patients.

Statistical Analysis:

CT and MRI FC were correlated with histopathological reference standard using Spearman correlation coefficient. Sensitivity, specificity, positive predictive value, negative predicative value, and positive and negative likelihood ratios with 95% confidence intervals were obtained.

Results:

CT LAI, dual-echo MRI, and MRS correlated well with the histopathology results (r = 0.713, 0.871, and 0.882, respectively). An accuracy of 95% and 96% was obtained for dual-echo MRI and MRS in FC estimation with their sensitivity being 97% and 94%, respectively. False-positive rate, positive predictive value (PPV), and negative predicative value (NPV) were 0.08, 0.92, and 0.97, respectively, for dual-echo MRI and 0.03, 0.97, and 0.95, respectively, for MRS. CT LAI method of fat estimation has a sensitivity, specificity, PPV, and NPV of 73%, 77.7%, 70.4%, and 80%, respectively.

Conclusion:

Dual-echo MRI, MRS, and CT LAI are accurate measures to quantify the degree of hepatic steatosis in LDLT donors, thus reducing the need for invasive liver biopsy and its associated complications. Dual-echo MRI and MRS results correlate better with histological results in the study, as compared to CT LAI method for fat quantification.

Evidence-based review of the management of hepatic hydrothorax

Hepatic hydrothorax (HH) is an example of a porous diaphragm syndrome. Portal hypertension results in the formation of ascitic fluid which moves across defects in the diaphragm and accumulates in the pleural space. Consequently, the treatment approach to HH consists of measures to reduce the formation of ascitic fluid, prevent the movement of ascitic fluid across the diaphragm, and drain or obliterate the pleural space. Approximately 21-26% of cases of HH are refractory to salt and fluid restriction and diuretics and warrant consideration of additional treatment measures. Ideally, liver transplantation is the best treatment option; however, most of the patients are not candidates and most of those who are eligible die while waiting for a transplant. Treatment measures other than liver transplantation may not only provide relief from dyspnea but also improve patient survival and serve as a bridge to liver transplantation.

MRI for evaluation of potential living liver donors: a new approach including contrast-enhanced magnetic resonance cholangiography

OBJECTIVES

To assess the feasibility of a comprehensive MRI protocol using intrabiliary contrast medium (gadolinium-EOB-DTPA) for evaluation of living liver donors.

MATERIAL AND METHODS

In this prospective study, 30 donor candidates for living-related liver transplantation (17 men; 13 women, mean age 37 ± 10.9 years) underwent MRI including MR-angiography (MRA) as well as a conventional T2-weighted MR-cholangiography (MRC) and a contrast-enhanced sequence for depiction of the biliary structures. MRC and MRA images were evaluated for quality on a four-point-scale (score of 0 indicated poor and a score of 3, excellent image quality). Anatomic variants of the arterial, venous, portal venous, and biliary structures were identified.

RESULTS

Image quality was diagnostic in all examinations except for 4 of 30 MRA data sets. Intrahepatic biliary structures, especially with regard to the intrahepatic bile ducts of 2nd and 3rd order could be identified with significantly increased image quality than in conventional T2-weighted MRC sequences (P = 0.005 and P = 0.035). A high percentage rate of anatomic variants regarding the biliary, arterial, venous, and portal venous anatomy was found.

CONCLUSION

This protocol allows the evaluation of liver donors especially with regard to the biliary structures. However, the depiction of the arterial anatomy requires further technical developments.

Effect of necrosis modulator necrox-7 on hepatic ischemia-reperfusion injury in beagle dogs

OBJECTIVE

The liver is susceptible to ischemia-reperfusion (IR) injury during inflow occlusion for hepatectomy. There is no effective pharmacologic agent available to prevent the release of high-mobility-group box 1 (HMGB1) or to ameliorate IR injury. This pilot study sought to develop a model in beagle dogs for the purpose of testing the efficacy of a necrosis modulator, necrox-7, to prevent hepatic IR injury in beagle dogs.

METHODS

Six male beagle dogs were randomly assigned to the control group (group A; n = 3) or the treatment group (group B; n = 3). Under general anesthesia, group B received intravenous infusion of necrox-7 (13 mg/kg over 20 minutes) followed by 60 minutes of left hepatic inflow occlusion and 60 minutes of reperfusion. Both groups were tested for serum biochemicals, hematology values, liver biopsies, and plasma HMGB1 levels over a 48-hour period.

RESULTS

The maximum alanine transferase (ALT), aspartate transferase (AST), and lactate dehydrogenase (LDH) levels among group A versus group B were: ALT 868.3 ± 337.4 IU/L vs 274.3 ± 72.6 IU/L (P = .041); AST 1,024.7 ± 246.5 IU/L vs 505.3 ± 66.7 IU/L (P = .024); and LDH 962.7 ± 226.2 IU/L vs 552.7 ± 62.4 IU/L (P = .039). Liver biopsy demonstrated marked necrosis and inflammatory infiltrates in group A, whereas group B showed little evidence of IR injury. The plasma HMGB1 concentration was significantly lower among group B versus A.

CONCLUSION

This pilot study developed a hepatic IR injury model, demonstrating that necrox-7 reduced hepatic necrosis secondary to IR injury in a large animal setting.

[Living donor liver transplantation]

Sixteen years after its first successful application, living donor liver transplantation now has a small but well-established role in treatment for liver failure in Germany. It remains problematic in both child and adult patients concerning effort, expected results, and assessment of risks to the donor. Therefore the method shall remain limited to more research-oriented institutions for the time being before it can be established more broadly as an alternative to postmortal donation. In Germany it presents generally the same limitations as living donor kidney transplantation.

Reduced mortality with right-lobe living donor compared to deceased-donor liver transplantation when analyzed from the time of listing

Right lobe living donor liver transplantation (RLDLT) is not yet a fully accepted therapy for patients with end-stage liver failure in the Western hemisphere because of concerns about donor safety and inferior recipient outcomes. An outcome analysis from the time of listing for all adult patients who were listed for liver transplantation (LT) at our center was performed. From 2000 to 2006, 1091 patients were listed for LT. One hundred fifty-four patients (LRD; 14%) had suitable live donors and 153 (99%) underwent RLDLT. Of the remaining patients (DD/Waiting List; n = 937), 350 underwent deceased donor liver transplant (DDLT); 312 died or dropped off the waiting list; and 275 were still waiting at the time of this analysis. The LRD group had shorter mean waiting times (6.0 months vs. 9.8 months; p < 0.001). Although medical model for end-stage liver disease (MELD) scores were similar at the time of listing, MELD scores at LT were significantly higher in the DD/Waiting List group (15.4 vs. 19.5; p = 0.002). Patients in Group 1 had a survival advantage with RLDLT from the time of listing (1-year survival 90% vs. 80%; p < 0.001). To our knowledge, this is the first report to document a survival advantage at time of listing for RLDLT over DDLT.

Adult-to-adult living donor liver transplantation

The present review outlines the principles of living donor liver transplantation, donor workup, procedure and outcomes. Living donation offers a solution to the growing gap between the need for liver transplants and the limited availability of deceased donor organs. With a multidisciplinary team focused on donor safety and experienced surgeons capable of performing complex resection/reconstruction procedures, donor morbidity is low and recipient outcomes are comparable with results of deceased donor transplantation.

Medical community preferences concerning adult living related donor liver transplantation

OBJECTIVES

To assess acceptance and acceptable estimated mortality levels for right lobe adult-to-adult living related liver transplantation for the medical and allied professions.

METHODS

A paper questionnaire was sent to the physicians practicing with the French Graft Agency (Etablissement Français des Greffes) and to all nurses and ancillary staff of the Paul Brousse Hospital Hepatobiliary Center. Responses were received from surgeons: 38/73; internists specialized in hepatology: 44/120; nurses: 98/100; health care assistants: 45/86; others: 17/20.

RESULTS

Acceptance of living donor transplantation is above average for all professional categories and indications may be extended including patients with cancer. Acceptable mortality for the donor was 4%, except among internists (0.7%). Currently, the real risk of mortality for the donor (1%) is lower. Acceptable mortality for the recipient was between 15 and 20%.

CONCLUSIONS

Acceptance of adult living donor liver transplantation among health care professionals is clearly above average. Thus the psychological involvement of transplantation teams, which is very strong in such situations, should not hamper the development of this type of transplantation.

Living related liver transplantation: the ultimate technique to expand the donor pool?

Today, living donor liver transplantation (LDLT) is well established in many centers as a therapeutic method for end-stage liver disease. LDLT is an option for selected cases and is still under development. From the beginning of LDLT until now, many innovations have been presented and as a consequence both the surgical and medical complications in both donors and recipients reduced greatly. As a benefit, this procedure enriches the donor organ pool and reduces the imbalance between the scarcity of organ resource and organ demand; however, LDLT will not solve the problem of organ shortage. Because the modality of LDLT is still associated with morbidity and mortality of the donors, recipient's graft-size match problems and substantial surgical complications, ethical issues of live organ donation must be discussed. Nevertheless, estimates of patient survival and complications in both donors and recipients should incorporate waiting time mortality. With this background, the extended indications for LDLT compared with cadaveric liver transplantation would have to be discussed in many cases. In this brief review, we focus on potential complications for both donors and recipients after adult-to-adult LDLT, discuss ethical problems and controversies with special interest on the perspective and potentials of this surgical method.

Evaluation of Living Liver Donors with an All-inclusive 3D Multi–Detector Row CT Protocol

PURPOSE

To prospectively assess parenchymal, vascular, and biliary anatomy of potential living liver donors with an all-inclusive multi-detector row computed tomographic (CT) approach.

MATERIALS AND METHODS

A total of 250 potential living liver donors (112 women, 138 men; mean age, 37 years) underwent three-phase, dual-enhancement multi-detector row CT to delineate biliary, vascular, and parenchymal morphology according to an institutional review board-approved protocol. Informed consent was obtained from all subjects. For display of the biliary system, the first CT image set was collected after the infusion of a biliary contrast agent. CT angiography was subsequently performed, after automated injection of a conventional iodinated contrast agent, to display the arterial and portal-hepatic venous systems. All data sets were reconstructed in 1-mm sections. Data analysis was based on source images, multiplanar reconstructions, and three-dimensional postprocessing images; was performed in consensus by two radiologists; and was focused on the detection of biliary and vascular variants, exclusion of focal liver lesions, and determination of hepatic volumes. Preoperative findings were correlated with intraoperative findings (available in 62 subjects).

RESULTS

Technical failures were experienced in 10 of 250 examinations. Twenty-seven subjects had moderate adverse reactions related to the biliary contrast agent. Benign hepatic lesions were detected in 61 candidates; one candidate had a renal cell carcinoma. Underlying biliary and vascular anatomy was displayed at least to the second intrahepatic branch in all but seven patients. Detected anatomic variants involved the biliary (38.8%), arterial (40.0%), portal venous (21.4%), and hepatic venous (43.5%) systems. Correlation with intraoperative findings was excellent. Some biliary (n = 4), arterial (n = 5), portal venous (n = 1), and hepatic venous (n = 6) variants were missed or misinterpreted at initial reading of preoperative data; however, variants could be retrospectively depicted in all but one biliary case and one hepatic venous case.

CONCLUSION

The outlined three-phase, dual-enhancement multi-detector row CT protocol represents an all-inclusive approach to evaluate potential living liver donors in a single diagnostic step.

Variability of preoperatively determined hepatic volumes in potential living liver donors

RATIONALE AND OBJECTIVES

The aim of the study is to evaluate variability in hepatic volumes during the preoperative period in potential liver donors.

MATERIALS AND METHODS

Eight potential living liver donors underwent preoperative multirow-detector computed tomographic assessment of hepatic transplant volumes twice. Intraindividual delay between the two examinations range was 3-62 days (mean, 30.1 days). Liver volumes were determined in a blinded fashion by an experienced radiologist and a transplantation surgeon. Results were compared and correlated with time of data acquisition during the day.

RESULTS

Interobserver variability for assessments of liver volumes range was 6-32 mL (mean, 16 mL). Intraindividually, the difference between the two volume assessments ranged between -103 and +45 mL (mean, -19 mL), corresponding to percentages of alteration between -7.5% and +3.2%. There was no statistical correlation evident concerning volume alterations and specific time of data acquisition.

CONCLUSION

Neither time of data acquisition nor waiting period for the surgical procedure seems to affect the accuracy of liver volume calculation. Apparent volume variations likely are in the range of the method error of the applied technique.

Applicability of adult-to-adult living donor liver transplantation

BACKGROUND/AIMS

The applicability of adult-to-adult living donor liver transplantation has not been established yet. We report the first data in a European center of the process leading to this procedure from the first moment the patients were informed about it.

METHODS

In phase 1 of the process, 121 adult patients enlisted for cadaveric liver transplantation and their relatives were informed of the technical aspects, advantages and risks of living donor liver transplantation, and the essential criteria for living donation. In phase 2, potential donors identified in phase 1 were evaluated in depth.

RESULTS

Twenty-one (17%) patients underwent living donor liver transplantation. This procedure was not performed in 60 patients (50%) for reasons concerning the patients themselves, especially their refusal to receive living donor liver transplantation from a relative (30%). Forty patients (33%) did not undergo living donor liver transplantation for reasons concerning potential donors: donors were not identified (14%), declined the donation (13%), or were refused for technical reasons (6%). The expected waiting time to transplantation was longer in patients who underwent living donor liver transplantation than in those who did not.

CONCLUSIONS

The applicability of adult-to-adult living donor liver transplantation is low, mainly because of reasons related to potential recipients.

"All-in-one" imaging protocols for the evaluation of potential living liver donors: comparison of magnetic resonance imaging and multidetector computed tomography

In order to compare the performance of "all-in-one" magnetic resonance imaging (MRI) and "all-in-one" multidetector computed tomography (MDCT) in the preharvest evaluation 25 potential living donors underwent both MRI and MDCT. MRI was performed on a high-performance 1.5-T scanner, computed tomography (CT) on a 4-row multidetector-scanner. Both scan protocols included angiography of the arterial and venous hepatic systems. CT additionally included infusion of a biliary contrast agent. Data analysis was performed by 4 reviewers, based on source images, multiplanar reformats, and three-dimensional (3D) postprocessing. Determination of image quality was based on a 4-point image quality rating (IQR) scale, ranging from 1 = nondiagnostic to 4 = excellent. Preoperative and intraoperative (n = 13) findings were correlated. Magnetic resonance (MR) examinations were generally well tolerated. Within the CT scan, 2 candidates presented moderate adverse reaction to the biliary contrast agent. MRI and CT showed the same benign parenchymal lesions (IQR MR: 3.7; IQR CT: 3.4). Determination of liver volumes was easier based on CT (IQR MR: 3.3; IQR CT: 3.6). Magnetic resonance angiography (MRA) revealed 10 variants of the arterial liver supply (IQR: 3.0) and computed tomographic angiography (CTA) revealed 13 variants (IQR: 3.5). Magnetic resonance cholangiopancreatography (MRCP) identified 4 biliary variants (IQR: 1.3) and CT cholangiography identified 17 (IQR: 3.5). MRI and CT each showed 4 hepatic and portal venous variants (IQR MR: 3.4, CT: 2.8). CT and MR findings correlated well with intraoperative findings. In conclusion, both techniques proved to be efficient to evaluate potential living liver donors' anatomy in a single diagnostic step. The main advantage of CT lies in the ability to accurately assess the biliary anatomy.

Bildgebende Diagnostik bei Lebertransplantationen

Complimentary to orthotopic liver transplantation (OLT), living donor liver transplantation (LDLT) is increasingly considered a therapeutic option in the therapy of end-stage liver disease. Accurate pre- and postoperative imaging is crucial for the transplantation success and represents an established part of the current evaluation algorithms. This article summarizes the most important requirements and the current imaging standards. Preoperative imaging is important for exclusion of transplantation contraindications in the recipient and for reliable assessment of anatomical variants in the donor. The main purpose of postoperative imaging is the early detection and characterization of complications. In both instances, multislice CT currently represents the most versatile and reliable imaging modality, still superior to MRI. For postoperative follow-up, the imaging modality of first choice is still bedside ultrasound; however, unclear findings usually need to be further assessed by CT.

Living kidney donor decision making: state of the science and directions for future research

BACKGROUND

The Federal government and transplantation organizations have called for further study of living donation at a time when 3 new living donor protocols are being introduced throughout the United States that promise to significantly increase the donor pool and change the face of living donation. Donation to a once incompatible and sometimes unknown recipient may now occur through the use of plasmapheresis therapy or paired and nondirected living donor protocols.

OBJECTIVE

To describe the state of the science on living kidney donor decision making, and to provide recommendations for future research to guide donor education and care.

DATA SOURCES

Automated literature search using PubMed and CINAHL scientific literature databases. STUDY DATA EXTRACTION: Research papers on living donor decision making from 1997 to 2003. Studies available only as abstracts were excluded.

DATA SYNTHESIS

Studies of living kidney donor decision making and outcomes have been limited in scope, with small sample sizes and inconsistent reports of racial and ethnic characteristics of the sample. The retrospective nature of the majority of living donor studies is a significant limitation.

CONCLUSIONS

Future prospective studies that are diverse by sex, race, and ethnicity will contribute to our knowledge of factors that influence the decision to be a living kidney donor.

Volumetric and functional recovery of the liver after right hepatectomy for living donation

Our objective was to study the kinetics of recovery of the liver volume and liver function after right hepatectomy (RH) for living donation, comparing conventional and quantitative liver function tests, i.e., galactose elimination capacity (GEC). A total of 27 donors underwent RH averaging 61% of the whole liver volume. The conventional and quantitative liver function tests, as well as magnetic resonance imaging volumetric studies, were performed preoperatively at postoperative day (POD) 10, 90, 180, and 360. Mean residual volume increased by 88% within 10 days from RH and thereafter did not show any significant variation. After 1 year, only 83% of the original volume was reached. GEC per milliliter of liver volume expressed in percent of initial value (GEC/mL) showed a decrease of 25% at POD10, an increase up to 125% at POD 180, and returned to normal values at POD 360. Liver biochemistries, International Normalized Ratio (INR), and bilirubin returned to normal in 10 days. Cholinesterase showed a similar course like GEC. In conclusion, within 10 days of 61% loss of its initial volume, the liver is capable of regenerating a volume necessary to its function, although it corresponds to only 74% of the initial one. It takes only 10 days to normalize liver biochemistries, while cholinesterase and albumin recover over 90 days. However, a direct measure of the cytosolic liver function obtained by GEC shows that functional recovery occurs much more gradually than the recovery of volume and liver biochemistries.

Protection of the liver during hepatic surgery

Very few areas in medicine have seen as many controversies as the evaluation and treatment of patients with liver diseases. Many novel therapies, often marketed before conclusive demonstration of their efficacy, have been developed to enable selective destruction of liver tumors to minimize the risk of liver failure associated with major surgery. Whether these techniques are effective and result in lesser complications often remains speculative. Persisting challenges in selecting the optimal therapy are the evaluation of the risk of surgery in patients with normal or diseased liver and the preparation for surgery. A panel of hepato-biliary surgeons experienced in the management of complex cases convened at the annual meeting of the American Hepato-Pancreato-Biliary Association in Boston, MA, to address the rapidly evolving field of protective strategies for hepatic surgery.

Impact of adult living donor liver transplantation on waiting time survival in candidates listed for liver transplantation

Studies comparing adult living donor liver transplantation to deceased donor liver transplantation have focused on post-transplant survival. Our aim was to focus on the impact of living donor liver transplant on waiting time mortality and overall mortality. We analyzed the affect of living donor liver transplantation on waiting time mortality and overall mortality (from listing until last follow up) in a cohort of 116 transplant candidates. Fifty-eight candidates who had individuals present as potential living donors (volunteer group) were matched by MELD score to 58 liver transplant candidates who did not have individuals present as a potential living donor (no volunteer group). Twenty-seven percent of candidates in the no volunteer group and 62% of candidates in the volunteer group underwent liver transplantation, p = 0.0003. One-year waiting list mortality for the volunteer group and no volunteer group was 10% and 20%, respectively, p = 0.03. Patient survival from the time of listing to last follow up was similar between the two groups. In our study group, living donor liver transplantation is associated with a higher rate of liver transplantation and lower waiting time mortality. In the era of living donor liver transplantation, estimates of patient survival should incorporate waiting time mortality.

The process of adult living liver donation

OBJECTIVE

To evaluate both the opinion that living liver donors have of the process and the psychological, economic, and social consequences of donation.

MATERIAL AND METHODS

Six months after the donation, an anonymous survey was sent to 22 donors of the right liver lobe between March 2000 and December 2002.

RESULTS

15 surveys were returned with all of the questions answered. Almost all the donors had no prior knowledge of living donation. When they were considered to be suitable donors, all of them felt happy, 21% were scared and 15% felt joy and insecurity. The information provided was well understood and accurately described the experiences of 93% of donors. All donors understood the vital risk, and 93% understood that transplantation is not always completely successful. All donors would repeat the experience. Mean hospital stay was 12.6 days. Mean convalescence was 50.6 days. Salaried donors were on sick leave for a mean of 96.4 days (21-150 days), causing financial problems in six cases (36%), due to no financial compensation and compulsory redundancy in one case. All donors had completely recovered at six months after donation.

DISCUSSION

Adult living donation of the right liver lobe is an accepted therapeutic alternative. In order to regulate medical and economic protection to avoid additional disturbances after donation, the public, patients, and physicians require more complete information about living donation.

The transplantation donation process in the Centro de Investigaciones Medico Quirurgicas of Cuba: 1999-2002

OBJECTIVE

In 1998 in the Centro de Investigaciones Medico Quirurgicas the Transplant Coordination Office (TCO) was created, with the aim to organize a system to support a hepatic transplantation program. This organization, which changed the transplantation-donation process not only in our center but in the whole country, is described in this article.

METHOD

The files of donors generated in our hospital were studied together with the transplant coordination records, from 1999 till the first half of 2002.

RESULTS

In the period studied, 21 potential donors were diagnosed with brain death, yielding a donation rate of 71.4%. Brain death was most frequently caused by vascular brain disease; however, in the realized donor group, the cranioencephalic trauma predominated. The typical donor was a man of average age 39.2 years (range, 18-86 years). Among the potential donors, 24% were excluded based on medical criteria, and 5% due to family objections. Forty liver transplantation were performed in 36 patients including 1 liver-kidney simultaneous procedure. The principal etiologies for transplant included hepatitis C virus cirrhosis, 22%; alcoholic, 19%; and acute hepatic failure, 13%. Kidney transplantations were performed in 70 patients, including 41 from cadaveric donors (53.6%) and 29 from living related donors (41.4%). In 2001, a pancreas-kidney transplantation program was started.

CONCLUSION

The creation of the TCO has been of paramount importance to optimize transplantation program functions.