Comparison of Biliary Complications Rates After Brain Death, Donation After Circulatory Death, and Living-Donor Liver Transplantation: A Single-Center Cohort Study

Application of combi-elastography for follow-up after pediatric liver transplantation: A prospective study

OBJECTIVE

To investigate the use of combi-elastography in children after liver transplantation.

METHODS

Thirty-five children who underwent liver transplantation at our hospital were prospectively selected. Donor livers were divided into fatty liver and nonfatty liver groups according to the degree of fatty liver. Recipients were categorized into groups with (10 patients) and without complications (25 patients) according to the presence or absence of complications within 6 months after surgery. Combi-elastography was performed on each donor liver, and each patient underwent combi-elastography at the time of surgery and at 1 day, 7 days, 1 month, 3 months, and 6 months after surgery; the results of liver function tests were recorded at the same time points.

RESULTS

Despite the rapid recovery of liver function in the group without complications, the combi-elastography indices were still high in the early stage and gradually stabilized after 3 months but were still higher than those of the donor liver at 6 months. In the fatty liver group, the postoperative 1-day combi-elastography values were significantly higher than those in the nonfatty liver group, and in the group with complications, the postoperative 1-day combi-elastography values were significantly higher than those in the group without complications. The receiver operating characteristic (ROC) curve analysis revealed that the areas under the curves (AUCs) of the combi-elastography values for predicting complications in children at 6 months after liver transplantation were 8.41 kPa for Young's modulus (E) (with a sensitivity of 90 % (9/10 and a specificity of 76 % (19/25)) 1.26 for the F-index (FI) value (sensitivity 80 %(8/10), specificity 80 % (20/25)), and 1.05 kPa for the A-index (AI) value (sensitivity 80 %(8/10), specificity 72 % (18/25)).

CONCLUSIONS

Combi-elastography is useful for assessing changes in liver stiffness in the early period after liver transplantation and should therefore be considered for the follow-up of children who undergo liver transplantation.

A nomogram for predicting early biliary complications in adult liver recipients of deceased donor grafts: Integrating artery resistive index and clinical risk factors

BACKGROUND

This study aimed to identify predictors of biliary complications within 90 days after liver transplantation in adult recipients of deceased donor grafts.

METHODS

The study retrospectively analyzed adult patients who underwent liver transplantation from January 2016 to December 2021 using deceased donor grafts in our center. Patients were randomly divided into training and validation cohorts (7:3 ratio). A nomogram was developed using least absolute shrinkage and selection operator logistic regression for feature selection, followed by a 2-way stepwise approach in multivariate logistic regression. Model performance was assessed with the C-index, receiver operating characteristic area under the curve, calibration curves, and decision curve analysis.

RESULTS

A total of 757 patients were included, of whom 76 developed early biliary complications. Least absolute shrinkage and selection operator binary logistic analysis showed that postoperative day 1 arterial resistance index, acute rejection, acute-on-chronic liver failure, hepatic artery thrombosis, recipient body mass index, and donor age were independent predictors of biliary complications within 90 days. A nomogram was established on the basis of these factors. The C-index for the final nomogram was 0.822. The area under the curve in the training cohort was 0.837 (95% confidence interval, 0.780-0.893) and 0.771 (95% confidence interval, 0.677-0.865) in the validation cohort. Calibration curves demonstrated good agreement between predicted and actual outcomes. Decision curve analysis confirmed the clinical utility of the nomogram.

CONCLUSION

Low arterial resistance index (≤0.57) on the first postoperative day is a predictor of biliary complications within 90 days after liver transplantation in adult recipients of deceased donor grafts. The nomogram provides a practical tool for predicting complications and guiding clinical decisions.

The Effect of a Kasai Procedure on Liver Transplantation in Children with Biliary Atresia: A Cohort Study

Background/Objectives: Biliary atresia (BA) is the most common etiology for pediatric liver transplantation (LT). However, whether a previous Kasai hepatoportoenterostomy (KP) and its timing influence the outcomes of BA patients who undergo LT remains controversial. Methods: Pediatric patients with BA who underwent LT at Beijing Friendship Hospital, Capital Medical University, between June 2013 and November 2022 were recruited. The patients were divided into non-KP, early-KP (before 90 days of life), and late-KP subgroups. The clinical data were compared among the groups. A nomogram to predict the 1-, 3-, and 5-year graft survival probabilities based on a multivariate Cox model was constructed and validated. Results: Among the 475 BA patients, the no-KP group accounted for 31.8%, the early KP for 60.4%, and the late KP for 7.8%, respectively. The incidences of LT complications were comparable among the groups. From the multivariate Cox analyses, an intensive care unit (ICU) stay and bleeding were identified as the independent risk factors for postoperative patient survival, and the LT type, graft type, vascular complications, and biliary complications were those for graft survival. A nomogram for graft survival was constructed, with a C-index of 0.82, and areas under the curves (AUCs) of 0.829, 0.824, and 0.824 for the 1-, 3-, and 5-year survival nomograms, respectively. The calibration and decision curve analysis (DCA) curves showed good discrimination ability and clinical applicability. A risk classification system was further developed, and the Kaplan-Meier curves demonstrated high discrimination between the high- and low-risk groups (p < 0.0001). Conclusions: A previous KP has no impact on patients or graft survival after LT in BA patients. The established nomogram may be helpful for counseling BA patients about their clinical prognosis after LT.

Comparisons of liver transplant from DCD outcomes in high-utilization centers versus low-utilization centers in the US: a systematic review and meta-analysis

Purpose/Objective

Donation after Cardiac Death (DCD) grafts are considered to be inferiors compared to Donation after Brain Death (DBD) grafts. Consequently, many transplant centers employ highly selective criteria for utilizing DCD, while others use them more liberally, potentially gaining greater expertise with this procedure. This disparity in approach raises questions about the impact of organ selection versus the benefits of increased experience with DCD organs. We performed a systematic review and meta-analysis to evaluate various outcomes in centers with high and low utilization rates of DCD.

Materials/Methods

Electronic databases PubMed, Embase, and Cochrane Library were systematically searched up to May 24th, 2023, for studies related to liver transplantation (LT). This search was conducted in accordance with PRISMA guidelines. The inclusion criteria focused on studies involving controlled DCD published within the last five years, and reporting on at least one of the outcomes of interest. Data was extracted and analyzed using a random-effects generalized linear mixed model with a 95% confidence interval (CI). The primary outcomes assessed were patient survival and graft survival. Heterogeneity among the included studies was evaluated using the I2 test, with I2>40% considered significant, and further explored through influence analysis. Subgroup meta-analysis by DCD utilization rate was done for each outcome. An analysis of the Organ Procurement & Transplantation Network (OPTN) database was performed on October 30th to determine the DCD rates and percentiles.

Results

Seven studies encompassing 898 patients were analyzed. In parallel, data from 151 centers were examined using the OPTN database, determining the rates of DCD utilization in each center over the past five years. Centers from the seven studies were divided into five high-utilization centers (HUC) and two low-utilization centers (LUC), with the 80th percentile (13.33% DCDs/Total LT) used as the threshold for high-utilization. Overall, the 1-year patient survival rate was 94.5% (95%CI: 92.4-96.1; I2 = 0%). HUCs had a rate of 94.6% (95%CI: 92.4-96.1; I2 = 0%), and LUCs had 93.7% (95%CI: 79.1-99.2; I2 = 0%), with a p=0.84. The overall 1-year graft survival rate was 90.6% (95% CI: 88.4-92.4; I2 = 0%). HUCs showed a 1-year graft survival of 90.9% (95%CI: 88.4-92.9; I2 = 0%), and LUCs showed 89.4% (95%CI: 83.8-93.2; I2 = 0%), p=0.54. The overall incidence of ischemic cholangiopathy was 10.3% (95% CI:7.9-13.3; I2 = 0%). The total rate of primary nonfunction was 1.5% (95% CI: 0.7-3.1%; I2 = 46%).

Conclusion

Our findings indicate no statistical difference in outcomes between high and low-utilization centers for DCD liver transplants, possibly suggesting that the higher selection in low-utilization centers is compensated by a greater experience in high-utilization centers.

Challenges and opportunities in organ donation after circulatory death

In recent years, there has been resurgence in donation after circulatory death (DCD). Despite that, the number of organs transplanted from these donors remains low due to concerns about their function and a lack of an objective assessment at the time of donation. This overview examines the current DCD practices and the classification modifications to accommodate regional perspectives. Several risk factors underscore the reluctance to accept DCD organs, and we discuss the modern strategies to mitigate them. The advent of machine perfusion technology has revolutionized the field of DCD transplantation, leading to improved outcomes and better organ usage. With many strategies at our disposal, there is an urgent need for comparative trials to determine the optimal use of perfusion technologies for each donated organ type. Additional progress in defining therapeutic strategies to repair the damage sustained during the dying process should further improve DCD organ utilization and outcomes. However, there remains wide variability in access to DCD donation and transplantation, and organizational efforts should be doubled up with consensus on key ethical issues that still surround DCD donation in the era of machine perfusion.

Liver Transplantation: A Test of Cellular Physiology, Preservation, and Injury

Liver transplantation has evolved into a mature clinical field, but scarcity of usable organs poses a unique challenge. Expanding the donor pool requires novel approaches for protecting hepatic physiology and cellular homeostasis. Here we define hepatocellular injury during transplantation, with an emphasis on modifiable cell death pathways as future therapeutics.

Comparison of Biliary Complications Between Living and Deceased Donor Liver Transplantations: A Systematic Review and Meta-analysis

To understand if the risk of biliary complications is higher with living donor liver transplantation (LDLT) compared to deceased donor liver transplantation (DDLT), the present meta-analysis was conducted to analyze the differences between these two types of liver transplantations. Three databases were searched from inception to September 2023 for comparative studies reporting biliary complications with LDLT and DDLT. Odds ratios (OR) with 95% confidence intervals were calculated for all the dichotomous outcomes. Twenty-eight studies were included in the final analysis. LDLT was associated with a significantly higher incidence of biliary complications than DDLT (OR 1.96, 95% CI: 1.56-2.47). However, on subgroup analysis, only studies published in or before 2014 reported a higher incidence of biliary complications with LDLT, but not with studies published after 2014. An analysis of individual adverse events showed that LDLT was associated with a higher incidence of both bile leak (OR 3.38, 95% CI: 2.52-4.53) and biliary stricture (OR 1.75, 95% CI: 1.20-2.55). LDLT was associated with a higher incidence of overall biliary complications, including bile leak and biliary stricture. With advances in surgical techniques, there has been a reduction in the risk of biliary complications.

Biliary Complications in Liver Transplant Recipients With a History of Bariatric Surgery

OBJECTIVES

Bariatric surgery can greatly ameliorate obesity and its associated metabolic disorders. Alteration of foregut anatomy, as is seen after Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch, renders traditional access to the biliary tree difficult, if not impossible. This may complicate management of anastomotic biliary complications after liver transplant.

MATERIALS AND METHODS

In this single-center study, we retrospectively reviewed all adult patients with a history of any bariatric surgery who underwent liver transplant during the period January 2017 to December 2022. We obtained demographic information of donors and recipients. Outcomes of interest included the modality in which the anastomotic biliary complications were managed.

RESULTS

Of 261 patients who underwent liver transplant at our center during the study period, 9 had a history of bariatric surgery. Anastomotic biliary complications occurred in 3 of 9 patients (33%). No significant differences were shown in donor age, ischemia time, etiology of liver disease, or Model for End-Stage Liver Disease sodium score at time of transplant between the 2 groups. All anastomotic biliary complications occurred in patients with a history of Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch. Interventions included advanced endoscopy, endoscopic ultrasonography, and lumen-apposing metal stent to access the remnant stomach and biliopancreatic limb (n = 2) and surgical revision following percutaneous transhepatic biliary drain placement (n = 1). At the end of the study, none experienced recurrent stricture.

CONCLUSIONS

Anastomotic biliary complications are well-described after liver transplant. A multidisciplinary approach with interventional radiology and inter-ventional gastroenterology can be beneficial to address strictures that arise in recipients with a history of Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch.

Current Understanding of Marginal Grafts in Liver Transplantation

End-stage liver disease (ESLD), stemming from a spectrum of chronic liver pathologies including chronic liver failure, acute cirrhosis decompensation and hepatocellular carcinoma, imposes a significant global healthcare burden. Liver transplantation (LT) remains the only treatment for ESLD. However, the escalating mortality on transplant waitlists has prompted the utilization of marginal liver grafts in LT procedures. These grafts primarily encompass elderly livers, steatotic livers, livers from donation after circulatory death, split livers and those infected with the hepatitis virus. While the expansion of the donor pool offers promise, it also introduces concomitant risks. These encompass graft failure, biliary and cardiovascular complications, the recurrence of liver disease and reduced patient and graft survival. Consequently, various established strategies, ranging from improved donor-recipient matching to surgical interventions, have emerged to mitigate these risks. This article undertakes a comprehensive assessment of the current landscape, evaluating the viability of diverse marginal liver grafts. Additionally, it synthesizes approaches aimed at enhancing the quality of such marginal liver grafts. The overarching objective is to augment the donor pool and ameliorate the risk factors associated with the shortage of liver grafts.

Liver transplantation with interposition saphenous vein conduits for arterial reconstruction: Impact of morbidity and arterial ischemia time

BACKGROUND

The outcomes of liver transplantation with hepatic arterial reconstruction using interposition saphenous vein conduits are not widely reported. Here, we share our experience using great saphenous vein conduits for hepatic arterial reconstruction in living donor liver transplantation.

METHODS

This was a single-center retrospective review of patients who underwent living donor liver transplantation (n = 950). The saphenous vein conduits were used in 39 patients. We compared hepatic artery thrombosis, graft dysfunction, and 30-day and 1-year survival in the early (2012-2017) and late (2017-2020) transplant periods.

RESULTS

Among 39 patients (of whom 30 [76.9%] were males, median Model for End-Stage Liver Disease was 24 [interquartile range, 17-27], median age was 50 [interquartile range, 43-54]), saphenous vein conduits were placed on supra celiac aorta in 7 (17.9%), infrarenal aorta in 25 (64.1%), and other arteries in 7 (17.9%) patients. The number of biliary and hepatic vein anastomoses, total arterial ischemia time, portal vein-hepatic artery reperfusion time, and duration of surgery was different in the 2 groups (P < .05). The 30-day mortality was 5/21 (23.8%) and 0 in the early and late periods (P = .05). The 30-day survival was >90% in patients with portal vein-hepatic artery reperfusion time <240 minutes, ≤2 grade 3 complications, no graft dysfunction, and later period of transplantation (P < .05). The 1-year survival with standard transplantation, transplantation with saphenous vein conduits in the early and late period was 87%, 62%, and 89% (P = .022).

CONCLUSION

Liver transplantation with saphenous vein conduits is associated with acceptable outcomes. Major complications and arterial ischemia times are major determinants of outcomes.

DCD liver transplant in patients with a MELD over 35

Introduction

Donation after circulatory death (DCD) liver transplantation (LT) makes up well less than 1% of all LTs with a Model for End-Stage Liver Disease (MELD)≥35 in the United States. We hypothesized DCD-LT yields acceptable ischemia-reperfusion and reasonable outcomes for recipients with MELD≥35.

Methods

We analyzed recipients with lab-MELD≥35 at transplant within the UCSF (n=41) and the UNOS (n=375) cohorts using multivariate Cox regression and propensity score matching.

Results

In the UCSF cohort, five-year patient survival was 85% for DCD-LTs and 86% for matched-Donation after Brain Death donors-(DBD) LTs (p=0.843). Multivariate analyses showed that younger donor/recipient age and more recent transplants (2011-2021 versus 1999-2010) were associated with better survival. DCD vs. DBD graft use did not significantly impact survival (HR: 1.2, 95%CI 0.6-2.7). The transaminase peak was approximately doubled, indicating suggesting an increased ischemia-reperfusion hit. DCD-LTs had a median post-LT length of stay of 11 days, and 34% (14/41) were on dialysis at discharge versus 12 days and 22% (9/41) for DBD-LTs. 27% (11/41) DCD-LTs versus 12% (5/41) DBD-LTs developed a biliary complication (p=0.095). UNOS cohort analysis confirmed patient survival predictors, but DCD graft emerged as a risk factor (HR: 1.5, 95%CI 1.3-1.9) with five-year patient survival of 65% versus 75% for DBD-LTs (p=0.016). This difference became non-significant in a sub-analysis focusing on MELD 35-36 recipients. Analysis of MELD≥35 DCD recipients showed that donor age of <30yo independently reduced the risk of graft loss by 30% (HR, 95%CI: 0.7 (0.9-0.5), p=0.019). Retransplant status was associated with a doubled risk of adverse event (HR, 95%CI: 2.1 (1.4-3.3), p=0.001). The rejection rates at 1y were similar between DCD- and DBD-LTs, (9.3% (35/375) versus 1,541 (8.7% (1,541/17,677), respectively).

Discussion

In highly selected recipient/donor pair, DCD transplantation is feasible and can achieve comparable survival to DBD transplantation. Biliary complications occurred at the expected rates. In the absence of selection, DCD-LTs outcomes remain worse than those of DBD-LTs.

Biliary and Vascular Complications after Liver Transplantation-From Diagnosis to Treatment

The last decades have brought impressive advances in liver transplantation. As a result, there was a notable rise in the number of liver transplants globally. Advances in surgical techniques, immunosuppressive therapies and radiologically guided treatments have led to an improvement in the prognosis of these patients. However, the risk of complications remains significant, and the management of liver transplant patients requires multidisciplinary teams. The most frequent and severe complications are biliary and vascular complications. Compared to vascular complications, biliary complications have higher incidence rates but a better prognosis. The early diagnosis and selection of the optimal treatment are crucial to avoid the loss of the graft and even the death of the patient. The development of minimally invasive techniques prevents surgical reinterventions with their associated risks. Liver retransplantation remains the last therapeutic solution for graft dysfunction, one of the main problems, in this case, being the low number of donors.