Purification method using iodixanol (OptiPrep)-based density gradient significantly reduces cytokine chemokine production from human islet preparations, leading to prolonged beta-cell survival during pretransplantation culture

Purification is one of the most important steps in human islet isolation. Although Ficoll-based density gradients are widely used, OptiPrep-based density gradients are used in few centers. Cytokine/chemokine production from human islet preparations varies widely. Some cytokines/chemokines have been reported to have adverse effects on human islet preparations. Control of cytokine/chemokine production may be a key to improve islet quality and quantity, leading to better transplantation outcomes. The aim of the present study was to investigate the effects on islet preparations of purification methods using various density gradients on viability, cellular composition, and proinflammatory cytokine/chemokine production. After the digestion phase, the extracts were divided into 2 groups for purification using a semiautomated cell processor with Ficoll-based or OptiPrep-based density gradients. Islet preparations cultured for 2 days were assessed regarding islet cell viability (fluorescein diacetate/propidium iodide [FDA/PI]), fractional beta-cell viability by FACS, and beta-cell content using iCys. Cytokine/chemokine production from islet preparations was also measured by Bio-plex. After purification, the purity, islet equivalents (IEQ), and islet recovery rates were comparable between the 2 groups. Although FDA/PI and fractional beta-cell viability showed no significant difference, survival of beta cells during culture was significantly higher in the OptiPrep compared with the Ficoll-based density gradient group. There were significantly lower tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta, interferon (IFN)-gamma, IL-6, and MIP-1beta productions from the OptiPrep-based density gradient group. OptiPrep-based density gradients reduced cytokine/chemokine production by islet preparations. In addition, OptiPrep-based density gradient purification significantly reduced the loss of beta-cell mass during pretransplantation culture.

Domino Liver Transplantation in Living Donors

Domino liver transplantation (DLT) has been developed as a method to expand the donor pool. In living donors DLT, the prime concern is to avoid any disadvantage to the donor and the first recipient. Seven DLTs were performed among 211 patients who underwent living donor liver transplantation. The domino recipients included six with hepatocellular carcinoma and one with citrullinemia. The domino grafts were obtained from patients with familial amyloid polyneuropathy (FAP) including the left liver in three cases and the right liver in four. Among the seven domino recipients, a 64-year-old woman with advanced hepatocellular carcinoma died of lung metastasis. The other six domino recipients are alive without FAP symptoms. In living donor liver transplantation, because the vessels of the graft from the first donor are not long enough for anastomosis, the hepatic vessels must be left as long as possible when removing the liver from the FAP patients in order to ensure sufficient safety for vascular reconstruction. With careful decision making during the procedure, such as where to divide the vessels in the FAP patients, DLT may help address the shortage of liver grafts.

Conversion from tacrolimus to cyclosporine microemulsion therapy in liver transplant recipients

The calcineurin inhibitors cyclosporine and tacrolimus have distinct advantages and drawbacks. Therefore it is important to tailor their use to the patient's tolerance. In some patients, the need to ameliorate the adverse effects of tacrolimus may necessitate a switch to cyclosporine-based therapy. Rescue therapy with a cyclosporine microemulsion (Neoral)-based regimen for transplant patients intolerant of tacrolimus has been evaluated to assess the best method of switching and determine the initial and maintenance doses of Neoral in children and adults. Our aims were to evaluate not only these facets, but also the pharmacokinetics of Neoral in stable patients, including target 2-hour postdose blood concentrations (C2) of cyclosporine in liver transplant recipients. Eighteen liver transplant patients switched from tacrolimus to Neoral underwent a program of cyclosporine blood level monitoring. The conversions were conducted safely; the incidence of acute rejection episodes was low (11.1%). Statistical analysis showed that the C2 correlated with the area under the time-blood concentration curve of cyclosporine for 0 to 4 hours after dosing (R=0.970). We determined the maintenance doses of Neoral for pediatric and adult patients as well as the feasibility of C2 quantitated monitoring in liver transplantation.

Living donor liver transplantation: issues regarding left liver grafts

BACKGROUND

The necessity of widening the indications for living donor liver transplantation (LDLT) has been emphasised. Clarification of the advantages and limitations of using a left liver graft for LDLT in adults is essential for donor safety.

METHODS

Between June 1990 and November 2002, 185 patients underwent LDLT at Shinshu University Hospital, Japan. In 97 of these, the graft comprised the left liver with or without the left portion of the caudate lobe. The peri-hepatectomy profiles of the donors, significance of left liver grafts, postoperative courses of the donors and recipients, and survival of the recipients were investigated.

RESULTS

All the donors recovered well and returned to a normal lifestyle. None required banked-blood transfusion or repeat surgery, and postoperative liver function tests had satisfactory results. The cold ischaemic time for the graft was 127+/-54 minutes. The graft volumes (GVs) ranged from 230 to 625 ml, and GV/standard liver volume (SV) ratios varied from 22% to 65%, at the time of transplantation. Although 85% of the liver grafts had GV/SV ratios <50%, no patient developed immediate postoperative liver failure. Patient survival rates were 89%, 84% and 84% at 1, 3 and 5 years, respectively.

DISCUSSION

Although LDLT using a left liver graft imposes potential postoperative complications (a small liver is more vulnerable to injury, and recipients of small grafts are at higher risk of complications during recovery), such grafts have yielded acceptable results in adult LDLT, with minimal burden to the donors.

Fatal hemophagocytic syndrome after living-related liver transplantation: a report of two cases

BACKGROUND

Hemophagocytic syndrome (HPS) is a serious hematological disorder caused by activated T lymphocytes in immunologically compromised patients. There is no report of HPS in liver transplant recipients.

METHODS

Among 135 patients who underwent living-related liver transplantation between June 1990 and October 2000, HPS developed in two pediatric patients (1.5%) on the 15th and 134th postoperative day, respectively. The courses of these patients were evaluated.

RESULTS

The cause of HPS was unknown in patient 1 and suspected to be Epstein-Barr virus infection in patient 2. The course of patient 2 was also complicated by posttransplant lymphoproliferative disorder. Both patients had high fever, pancytopenia, coagulopathy, and marked elevation of serum-soluble interleukin 2 receptor, serum ferritin, and urine beta2-microglobulin levels. The diagnosis was established based on clinical findings, laboratory data, and bone marrow biopsy. Both patients died in an acute course despite intensive care.

CONCLUSIONS

HPS should be recognized as a severe hematological complication in liver transplant patients. Prompt institution of adequate treatment is necessary to prevent fatality.

Primary sclerosing cholangitis complicated with idiopathic thrombocytopenic purpura

We present a 66-year-old woman with primary sclerosing cholangitis (PSC) complicated with idiopathic thrombocytopenic purpura (ITP). Both PSC and ITP are considered to reflect an immunological disturbance. However, their coexistence is very rare and to the best of our knowledge this is only the second reported case. In Japan, PSC patients are rarely treated with liver transplantation. Fortunately, the present patient underwent successful hepatic transplantation from a brain-dead donor and simultaneous splenectomy. This case emphasizes the importance of liver transplantation as an effective treatment for primary sclerosing cholangitis.

Type II (adult onset) citrullinaemia: clinical pictures and the therapeutic effect of liver transplantation

OBJECTIVE

Adult onset type II citrullinemia is an inherited disorder of amino acid metabolism caused by a deficiency of liver specific argininosuccinate synthetase activity. Most of the patients with this disease were reported in Japan and therefore, this disease has not been well recognised outside this country. The detailed clinical pictures of the patients with type II citrullinaemia are reported and their outcomes after liver transplantation referred to.

METHODS

Ten patients with this disease were evaluated. Seven of them underwent liver transplants using a graft obtained from a healthy family member.

RESULTS

There were six men and four women; the age of onset of encephalopathy ranged from 17 to 51 years. The initial symptom in nine patients was sudden onset disturbance of consciousness, and one patient had long been regarded as having a chronic progressive psychotic illness. High concentrations of plasma citrulline and ammonia were commonly seen on admission. Although brain CT or MRI lacked any consistent findings, the EEG was abnormal in all patients, showing diffuse slow waves. Additionally, in five patients chronic pancreatitis preceded the onset of encephalopathy. After liver transplantation the metabolic abnormalities, including abnormal plasma concentrations of citrulline and ammonia, were immediately corrected and all neuropsychic symptoms soon disappeared, except for impaired cognitive function in one patient. Six out of these seven patients returned to their previous social lives, including work.

CONCLUSIONS

The clinical concept of adult onset type II citrullinaemia coincides well with the range of hepatic encephalopathy, and liver transplantation is a very promising therapeutic approach.

Long-term results of living-related donor liver graft transplantation: a single-center analysis of 110 transplants

BACKGROUND

Difficulties of cadaveric donation and serious donor shortage have led to the development and popularization of living-related donor liver graft transplantation (LRLT). Because the history of this procedure is rather short, important aspects specific to this procedure have not been sufficiently documented. The objective of this study was to analyze a single center's 10-year experience with 110 LRLT in pediatric and adult patients with end-stage liver diseases.

METHODS

The medical records of 110 consecutive patients who underwent LRLT were reviewed. The recipients were comprised of 72 children and 38 adults. The graft volume corresponded to 26-192% of the recipient's standard liver volume. The relationship between pretransplant covariates and patient and graft survival was analyzed. Actuarial patient/graft survival rates were determined at 1, 3, and 5 years. The type and incidence of posttransplant complications were analyzed, as was long-term graft function.

RESULTS

The 1-, 3-, and 5-year actuarial patient and graft survival rates were 88%, 85%, and 85%, respectively. Log-rank test demonstrated that ABO-compatibility predicted patient survival rate, whereas patient age, underlying disease, patient's clinical status, donor-recipient relation, donor age, and graft volume/standard liver volume ratio did not. Long-term liver function remains excellent. All the donors have returned to normal daily lives with an uneventful course.

CONCLUSIONS

LRLT is an efficacious procedure that provides excellent short-term and long-term survival. The indication criteria for both recipient and donor were legitimate in this series, except for transplant across ABO-incompatibility. Cautious expansion of this procedure may be justified under the situation of serious shortage of cadaveric donor.

Recurrent cerebral embolism in a familial amyloid polyneuropathy patient who received partial liver transplantation from a living donor

Cerebral embolism in relation to cardiac amyloidosis has not been widely noted. A 47-year-old woman who had been suffering from familial amyloid polyneuropathy (FAP) for 7 years was treated with partial liver transplantation from a living donor and her early postoperative course was uneventful. During the 391st to 613th postoperative day she experienced recurrent cerebral infarctions, but clinical examinations revealed no disorders capable of producing cerebral embolism. At autopsy splenic infarction and intracardiac thrombi adhering to the mitral valve and left atrium were found, and these areas showed severe amyloid deposition. Amyloid heart is considered to be one possible cause of systemic embolism.

De novo infection of hepatitis B virus in patients with orthotopic liver transplantation: analysis by determining complete sequence of the genome

De novo infection of hepatitis B virus (HBV) occurs after liver transplantation from donors with HBV markers that suggest past infection. In the present study, the complete nucleotide sequences of HBV derived from a donor and recipients were determined to determine the clinical and virological characteristics. A total of 57 donor-recipient pairs, which underwent living-related orthotopic liver transplantation, were enrolled in the present study; all were negative for HBsAg before transplantation. HBV DNA was tested in serum, liver tissue, and peripheral blood mononuclear cells (PBMCs) by the polymerase chain reaction (PCR). The nucleotide sequence of HBV was determined based on PCR products and the phylogenetic analysis. De novo infection of HBV was found in 3 of the 57 recipients. Anti-HBc was positive in all donors of 3 recipients with the de novo infection but was positive only in 4 donors of the remaining 54 recipients (P=0.001). HBV DNA was detected in the liver but not in the serum or PBMCs in donor 3 whose recipient developed de novo HBV infection. The nucleotide sequence covering entire genome of HBV (3,215 bases) derived from the liver of donor 3 had a homology of 99.8-100% with that derived from the serum of corresponding recipient 3. The strain of recipient 3 showed the closest association with that of the donor 3 by phylogenetic analysis. Complete sequences from two recipients with de novo HBV infection including recipient 3 conserved the basic organisation of HBV genome. Analysis of the entire nucleotide sequence of HBV genome proved that HBV existed in the liver of the donor with anti-HBc, and it caused de novo infection in the corresponding recipient.

[Pathological examination for liver transplantation]

Liver biopsy plays an important role in the histopathological evaluation of the transplanted liver. In this review, we would like to describe the histological features of various forms of diseases such as allograft rejections occurring in transplanted livers. When severe steatosis is found in the donor liver, transplantation is contraindicated. Ischemic liver damage caused by transplant hypoperfusion is called harvesting or re-perfusion injury and characterized by the histological features of liver-cell ballooning, centrilobular cholestasis, and apoptosis of hepatocytes. Acute rejection occurring more commonly in the first few weeks after transplantation is defined by the diagnostic triad of portal inflammatory infiltrates, endothelialitis, and bile duct damage, whereas chronic rejection is characterized by the presence of ductopenia and foam cell arteriopathy. Obstruction of the hepatic artery leads to severe centrilobular necrosis of the allograft. Among viral infections affecting the allografts, cytomegalovirus infection occurs most frequently, and typical intranuclear or cytoplasmic inclusions are hallmarks of the infection. Post-transplantation lymphoproliferative disorders are closely associated with Epstein-Barr virus infection. Therapeutic drugs such as azathioprine and cyclosporin A also cause liver damage, but specific histological features of drug-induced injury have not yet been clarified. Recurrence of original diseases such as viral hepatitis or malignant tumors is also evaluated by the liver biopsy.

An alternative method of arterial reconstruction after hepatic arterial thrombosis following living-related liver transplantation

BACKGROUND

Hepatic artery thrombosis (HAT) remains an important cause of graft loss after liver transplantation. Emergency rearterialization methods are limited in cases of living-related liver transplantation in which the graft hepatic artery is thin and short.

CASE

A 19-year-old woman who underwent living-related liver transplantation for biliary atresia developed HAT on the 4th postoperative day. During the emergency laparotomy the recipient hepatic artery was found to be too short to anastomose, so the recipient's right gastroepiploic artery was anastomosed to the graft hepatic artery. The patient is now alive and well 6 months after reoperation, and she has experienced no further episode of HAT.

CONCLUSION

The right gastroepiploic artery can be used easily and safely for hepatic graft revascularization without causing ischemia of the stomach. An additional skin incision is not required, and the artery is long enough to anastomose to the graft artery directly. The method of hepatic graft rearterialization described here is an important option for patients who undergo living-related or split liver transplantation.

First case of cadaveric liver transplantation in Japan

The first case of liver transplantation from a brain-dead donor in Japan is described. The recipient was a 43-year-old man with familial amyloid polyneuropathy who manifested various neuropathic symptoms and autonomic dysfunction at the time of transplantation. The graft had three arteries, for which a single trunk was created at the back table. A side-to-side cavacaval anastomosis was performed as an outflow reconstruction. To avoid portal congestion, a temporary shunt between the right posterior branch of the portal vein and the vena cava was constructed, instead of a venovenous bypass. The graft preservation time was 7.2 h and the operation time was 12.2 h. Although sufficient blood flow in the hepatic artery, portal vein, and hepatic vein was confirmed intra- and postoperatively, using Doppler ultrasound, transient graft dysfunction was observed immediately after surgery, but there was spontaneous improvement. The patient was discharged 100 days after transplantation.

Living-related liver transplantation for patients with fulminant and subfulminant hepatic failure

The prognosis for patients with fulminant (FHF) or subfulminant hepatic failure (SFHF) has improved since the introduction of liver transplantation. However, the death rate of patients awaiting liver transplantation is high, possibly because of the difficulty in obtaining grafts in a timely manner, given the relative shortage of cadaveric donors. Between June 1990 and June 1999, 106 patients underwent living-related liver transplantation (LRLT) at Shinshu University Hospital. Among them, 8 patients had FHF and 6 had SFHF; these 14 patients are the subjects of this report. The graft volumes (GV) ranged from 231 mL to 625 mL, corresponding to 35% to 105% of the recipients' standard liver volume (SLV). The postoperative courses of all donors were uneventful. Following liver transplantation, all grafts functioned favorably, with normalization of serum total bilirubin within 3 to 5 days and normalization of coagulation profiles within 4 to 7 days. Thirteen of the 14 recipients are still alive. The actuarial 6-month, 1-year, and 5-year survival rates were 100%, 90%, and 90%, respectively. In the present study, when the ratio of the GV to the recipient's SLV was more than 35%, the graft was able to support the patient's metabolic demand after liver transplantation for FHF or SFHF. Because of the urgent nature of liver transplantation in this clinical condition, concerns over informed consent may be even greater than for elective LRLT. Nevertheless, the high success rate and low donor risk may justify this option for pediatric patients, as well as for a limited population of adult patients suffering from FHF or SFHF.

Partial-liver transplantation to treat familial amyloid polyneuropathy: follow-up of 11 patients

BACKGROUND

Recently, liver transplantation has been used to treat patients with familial amyloid polyneuropathy (FAP).

OBJECTIVE

To describe the clinical course of patients with FAP who received partial-liver transplantation from living donors.

DESIGN

Case series.

SETTING

University hospital in Matsumoto, Japan.

PATIENTS

11 patients with FAP who underwent partial-liver transplantation. The transthyretin gene abnormality in all 11 patients was the substitution of methionine for valine at position 30.

INTERVENTION

Partial liver transplantation from living donors.

MEASUREMENTS

Preoperative and follow-up (3 to 64 months) clinical data, including routine laboratory data, nerve conduction velocity tests, and sural nerve histology.

RESULTS

All 7 patients who had severe gastrointestinal autonomic disorders or polyneuropathy localized to the lower limbs for less than 4 years showed improvement. Three of 4 patients with polyneuropathy involving both the upper and lower limbs had adverse outcomes, including two deaths. The preoperative duration of their illness was more than 6 years. These 3 patients also had marked decreases in creatinine clearance and nerve conduction velocities and severe loss of myelinated fibers in sural nerves.

CONCLUSION

Preoperative clinical severity and duration of illness are associated with outcomes after liver transplantation for FAP.

Living-related donor liver transplantation in adults: experience at Shinshu University Hospital

Several considerations and improved techniques for performing LRLT in adults have been discussed. Taking into account the worldwide shortage of cadaveric organ grafts, the significance of LRLT for adult patients will probably never diminish. Further study is needed to clarify the factors governing the outcome of adult-to-adult LRLT.

Survival of patient with late onset hepatic failure by living-related liver transplantation from maternal donor with incompatible blood type

A 14-year-old girl with blood type B with late onset hepatic failure (LOHF) of unknown cause has survived through living-related liver transplantation (LRLT). No hepatitis virus, including HAV, HBV, HCV, and HGV, was positive at the onset of LOHF. Autoimmune hepatitis was thought to be the cause because of positive results for serum anti-nuclear antibody at 80 times dilution and elevated gamma-globulin, but treatment with glucocorticoid did not suppress the progressive hepatic failure. Supportive therapy, including pulse therapy with 1g methylprednisolone for 3 days, ursodesoxycholic acid, branched-chain amino acid, and azathioprine did not resolve the hepatic failure. She was treated by repeated plasmapheresis and plasma absorption for 10 months, and then received the left lobe of her mother's liver. (Her mother's blood type was AB). The patient had been well, being treated with tacrolimus and prednisolone, although the serum titer of anti-blood type B antibody was high just after LRLT and mild liver dysfunction continued for more than 3 years after LRLT. Follow-up biopsy 3 years after LRLT revealed chronic hepatitis and progression to liver cirrhosis. Re-transplantation is now under consideration; the patient is now aged 19 years.

[Recent advances in living-related liver transplantation and in liver transplantation for patients with liver cirrhosis and hepatocellular carcinoma]

Living-related-donor liver transplantation has been performed in more than 700 patients in Japan. This article deals with recent advances in living-related-donor liver transplantation and the strategy for liver transplantation for patients with liver cirrhosis and hepatocellular carcinoma. The indication for living-related-donor liver transplantation has gradually widened to include urgent cases as well as adult patients. In living-related-donor liver transplantation for adults, limitation of graft volume has led to the use of left hepatic lobe grafts including the caudate lobe, or right hepatic lobe grafts. The results of liver transplantation for patients with hepatitis B cirrhosis, hepatitis C cirrhosis and hepatocellular carcinoma have improved, due mainly to advances in patient selection and perioperative medical Care. The widespread use of liver transplants from both living and cadaveric donors is necessary in Japan, where adult patients with viral hepatitis and hepatocellular carcinoma account for the majority of patients with end-stage liver disease.

Relationship between in vivo FK506 clearance and in vitro 13-demethylation activity in living-related liver transplantation

BACKGROUND

Although it is important to maintain an appropriate blood concentration of FK506 after liver transplantation, significant interindividual variability in the actual FK506 dosage has been observed, presumably due to the wide variability of cytochrome P450 3A4 activity in liver microsomes.

METHODS

A study was conducted in patients undergoing living-related liver transplantation and their donors to investigate the relationship between the in vitro FK506 demethylation activity in graft liver microsomes and the in vivo blood clearance of FK506. Liver biopsy tissue was obtained from 17 living donors to measure the in vitro formation rate of 13-demethyl derivative (M-I: the major metabolite of FK506). Erythromycin N-demethylation activity in vitro was also assessed in 11 cases. The FK506 blood clearance (CLss) was calculated from its constant infusion rate and steady-state blood concentration on day 4 after transplantation in 17 recipients.

RESULTS

The FK506 infusion rate varied 4.6-fold from 8.3 to 38.4 ng/min/kg. The mean CLss of FK506 was 22.1+/-10.8 ml/min (10.1-45.2 ml/min). The M-I formation rate showed a wide variability, ranging from 0.098 to 0.571 nmol/min/mg protein. A significant correlation was observed between the in vitro estimated total metabolic ability of the graft for FK506 (M-I formation rate x graft weight) and the in vivo CLss of FK506 (r=0.770, P<0.001). Erythromycin N-demethylation (0.066-0.443 nmol/min/mg protein) showed a strong correlation with the M-I formation rate (r=0.891, P<0.01).

CONCLUSIONS

The in vivo FK506 clearance can mainly reflect in vitro FK506 demethylation activity.

Concomitant caudate lobe resection as an option for donor hepatectomy in adult living related liver transplantation

In this article, we describe a successful adult living related partial liver transplantation (LRLT) using the left lobe with the left-side caudate lobe (the Spiegel lobe and the left side of the paracaval portion). The size of the donor's left lobe was 29% of the recipient's standard liver volume and did not seem to meet our criteria for adult-to-adult LRLT. However, the donor had a thick left-side caudate lobe. The estimated volume of the left lobe with the left-side caudate lobe was 32%, which met our criteria for the adult recipient. The recipient's CT scan on day 87 after transplantation showed the preserved blood flow and no biliary congestion in the left-side caudate lobe, which suggests maintenance of lobe function. This procedure may be an option for adult-to-adult LRLT in which the donor has a thick left-side caudate lobe.

Living related liver transplantation in adults

OBJECTIVE

To evaluate the outcome of living related liver transplantation (LRLT) in adult patients and to assess graft size disparity and graft regeneration.

SUMMARY BACKGROUND DATA

Although LRLT has been accepted as an optional life-saving procedure for pediatric patients with end-stage liver disease, the feasibility of LRLT for adult patients has not been reported with reference to a clinical series.

METHODS

Adult-to-adult LRLT was performed using whole left lobar grafts in 13 patients (5 with primary biliary cirrhosis, 6 with familial amyloid polyneuropathy, 1 with biliary atresia, and 1 with citrullinemia). The 13 donors comprised 5 husbands, 3 sons, 2 sisters, 2 fathers, and 1 mother. The ratio of the graft volume to standard liver volume (GV/SV ratio) was calculated for use as a parameter of graft size disparity.

RESULTS

Although the liver graft was markedly small for size (GV/SV ratio 32%-59% at the time of LRLT), none of the 13 patients developed postoperative liver failure. Eleven of the patients are still alive and well with satisfactory graft function 2 to 35 months after LRLT. Graft liver volume increased rapidly after LRLT and approximated the standard liver volume with time.

CONCLUSIONS

Our LRLT program for adult patients has produced good results. LRLT in adults can be indicated for selected donor-recipient combinations.

Urgent living-related liver transplantation using a graft with multiple intrahepatic arterioportal fistulae

BACKGROUND

We describe the case of a man with intrahepatic arterioportal fistulae located in the left lobe, whose left lateral segment was transplanted into his son who was suffering from severe acute hepatitis B.

METHODS

A male infant with severe acute hepatitis B was considered to be a candidate for liver transplantation. The father was willing to be the donor. Preoperative evaluation of the donor revealed intrahepatic arterioportal fistulae, however, duplex ultrasonography showed normograde portal blood flow. A living-related liver transplantation was performed.

RESULTS

The postoperative course for both the donor and recipient was uneventful. The recipient is free of recurrent hepatitis B and has normograde portal blood flow.

CONCLUSIONS

The present case suggests that there may be a symptomless population with intrahepatic arterioportal fistulae, which cause various degrees of disruption of the portal blood flow. Duplex ultrasonography might be helpful in the evaluation of candidates for liver donation.

Peripheral nerves regenerated in familial amyloid polyneuropathy after liver transplantation

BACKGROUND

Liver transplantation holds promise as a treatment for familial amyloid polyneuropathy.

OBJECTIVE

To determine whether peripheral nerves regenerate in patients with familial amyloid polyneuropathy after liver transplantation.

DESIGN

Case report.

SETTING

University hospital in Matsumoto, Japan.

PATIENT

A 34 year-old-women with familial amyloid polyneuropathy who had liver transplantation and showed marked clinical improvement 3 years after surgery.

MEASUREMENTS

Histopathologic examination and morphometric analysis of biopsy specimens taken from sural nerves.

RESULTS

Diffuse fiber loss and amyloid deposits were seen in a biopsy specimen of the left sural nerve obtained before liver transplantation (total number of myelinated fibers, 1326/mm2 of the endoneurial area). In the biopsy specimen of the right sural nerve, which was obtained 3 years after transplantation, amyloid deposits remained but the number of myelinated fibers was markedly increased (total number of myelinated fibers, 4740/mm2).

CONCLUSION

Peripheral nerves regenerated in a patient with familial amyloid polyneuropathy after liver transplantation.

Hepatic artery reconstruction in living donor liver transplantation from the microsurgeon's point of view

Microvascular surgery for the reconstruction of the hepatic artery in living donor liver transplantation is discussed from the microsurgeon's point of view. A refined operative procedure to improve the safety of the anastomosis is described. In living donor liver transplantation, the hepatic artery of the graft is short and small, the operative site is deep and mobile, and the anatomic arrangement of the graft left hepatic artery may differ from that of the recipient's dilated hepatic artery. To create a safe anastomosis under these conditions, recipient arteries that were slightly smaller than the graft artery were dissected. Without the size discrepancy, and end-to-end anastomosis could be created. Some refinements to create a good operative field made the anastomosis easy. The apparatus and techniques used in free-flap transfer facilitated a clean anastomosis. We anastomosed 44 arteries in 40 patients undergoing living donor liver transplantation using microsurgical techniques. Neither a decrease in the arterial blood flow nor hepatic artery thrombosis was noted. The refined operative procedure we describe in this report can be used to overcome the problems associated with the hepatic artery anastomosis in living donor liver transplantation.

Efficacy of quantitative analysis of Epstein-Barr virus-infected peripheral blood lymphocytes by in situ hybridization of EBER1 after living-related liver transplantation: a case report

BACKGROUND

We describe a 1-year-old female who underwent living-related liver transplantation for biliary atresia and developed Epstein-Barr virus (EBV)-related posttransplant lymphoproliferative disorder. This disorder was resolved after withdrawal of immunosuppression therapy and administration of a high dose of acyclovir.

METHODS

To quantify the extent of EBV activation and EBV load in peripheral blood, we measured the levels of EBV-infected peripheral lymphocytes by in situ hybridization (ISH) of EBV-encoded small mRNA 1 (EBER1).

RESULTS

The decline in the number of EBER1-positive lymphocytes (from 362/50,000 mononuclear cells to 0/50,000) after treatment was in accord with the patient's clinical improvement.

CONCLUSIONS

This finding showed that quantitative analysis of EBV-infected peripheral lymphocytes by ISH of EBER1 is very useful for monitoring the EBV load and response to treatment of patients with EBV-related disorders. Furthermore, ISH may become an important tool for the early diagnosis and prevention of life-threatening posttransplant lymphoproliferative disorder in posttransplant patients.

Long-term survival after surgery for advanced intrahepatic cholangiocarcinoma: a case report

Intrahepatic cholangiocarcinoma has a tendency to disperse intrahepatically and extrahepatically, therefore, resectability is limited and prognosis is generally poor. A 68-year-old female was diagnosed as intrahepatic cholangiocarcinoma in the right lobe based on systematic images including computed tomography, magnetic resonance imaging, ultra-sonography, endoscopic retrograde cholangiography, angiography, chest X-ray, as well as laboratory data. Tumor invasion to the right diaphragm, lung and chest wall was suspected pre-operatively. After pre-operative portal embolization, extended right hepatectomy with partial resection of the involved organs including diaphragm, lung, and chest wall was done en bloc. The patient made an uneventful postoperative recovery and there has not been any evidence of recurrence at present, over four and a half years after surgery. Experience in the present case indicates that radical surgery may be a potential approach to yield a hopeful outcome for patient with intrahepatic cholangiocarcinoma, even if the tumor invades adjacent organs directly.

Complete neurological recovery of an adult patient with type II citrullinemia after living related partial liver transplantation

Type II citrullinemia is an adult-onset hepatocerebral disease caused by a deficiency of argininosuccinate synthetase in liver. A 25-year-old Japanese man suddenly developed encephalopathy, showing disorientation and flapping tremor. Plasma concentrations of ammonia and citrulline were extremely high, and hepatic argininosuccinate synthetase activity was deficient. The patient's condition deteriorated rapidly in spite of intensive medications. Therefore, we performed a partial liver transplantation using a graft obtained from his healthy 61-year-old father. After surgery, his neurological symptoms soon disappeared and plasma levels of ammonia and citrulline were normalized within 3 months after operation. Type II citrullinemia is one fulminant form of various liver-based metabolic diseases, and immediate liver transplantation is necessary to rescue patients with this disease. As liver transplantation from cadaveric donor is still not possible in Japan, it seems justifiable to use living related partial liver transplantation for our patient.

Should all hepatic arterial branches be reconstructed in living-related liver transplantation?

BACKGROUND

Because graft arteries are smaller and shorter in living-related liver transplantation (LRLT) than in whole or reduced-size liver transplantation from cadavers, arterial reconstruction is thought to be one of the critical points for success.

METHODS

Thirty LRLT patients were classified into two groups: those in whom all graft hepatic arteries were reconstructed (group A), and those whom only had some were reconstructed (group B). In group A 17 patients had a single hepatic artery and three had two hepatic arteries. In group B the thickest one of several arteries was reconstructed, but the others were ligated after pulsatile back-bleeding from their cut stumps had been confirmed. The clinical results were compared between the two groups.

RESULTS

Neither arterial thrombosis nor liver dysfunction related to the arterial blood supply was observed during the postoperative course. One case of bile leakage and two cases of bile duct stenosis occurred in group A. No significant difference was noted in the postoperative values of aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase between the two groups. Overall patient and graft survival was 90%.

CONCLUSIONS

Although several hepatic arteries may supply the potential allograft in LRLT, it is not always necessary to reconstruct all of them.

Extended lateral segmentectomy using intraoperative ultrasound to obtain a partial liver graft

The important features of extended lateral segmentectomy to obtain a partial liver graft comprising the left lateral segment and the left half of the medial segment are described with special reference to anatomical variation of the hepatic venous system. Ramification patterns of the hepatic vein tributaries around the juncture of the major hepatic veins with the inferior vena cava are delineated before starting liver resection, using intraoperative ultrasound. The left medial vein draining the left part of the medial segment is recognized close to the confluence of the middle and left hepatic veins. This tributary flows into the left hepatic vein in the majority of cases, but sometimes into the middle hepatic vein. The liver transection line is established in order to obtain the graft, including the drainage area of the left medial vein. Intraoperative ultrasound is indispensable for identifying the left medial vein in extended lateral segmentectomy.

Prevention of hepatic artery thrombosis in pediatric liver transplantation

Hepatic artery thrombosis after orthotopic liver transplantation is a serious complication, especially in children. We report our experience with intensive anticoagulant therapy during and after living-related liver transplantation in pediatric recipients. Twenty-four patients between 5 months and 15 years of age were studied. The mean diameter of the anastomosed hepatic arteries was 2.7 mm. The anticoagulant therapy consisted of low-molecular-weight heparin, antithrombin III concentrates, prostaglandin E1, fresh frozen plasma, and a protease inhibitor. The profiles of the coagulation and fibrinolytic systems were monitored by measuring several parameters, including plasma levels of thrombin-antithrombin III complex, antithrombin III, plasmin-alpha 2 plasmin inhibitor complex, fibrin degradation product D-dimer, tissue type-plasminogen activator, and plasminogen activator inhibitor-1. Acceleration of the coagulation system and delayed recovery of the fibrinolytic system were observed during the early postoperative days. The plasma level of antithrombin III activity was maintained within the normal range by the administration of antithrombin III concentrates. None of the recipients developed hepatic artery thrombosis. Children have been reported to be at a greater risk of developing hepatic artery thrombosis than adults due to the small diameters of their hepatic arteries and the postoperative hypercoagulable state. We believe that the intensive anticoagulation therapy described in this study, the main concept of which is the early correction of imbalance between the coagulant and anticoagulant systems, could become a model for the prevention of hepatic artery thrombosis in pediatric liver transplantation patients.

[Changes in coagulation parameters during the clinical courses of recipients of living-related partial liver transplantation]

We had rare opportunities to examine changes in fibrin degradation products (FDP)-D-dimer (DD), thrombin-antithrombin III complex (TAT), plasmin-alpha 2-plasmin inhibitor complex (PIC) and other coagulation parameters during the clinical courses of living-related partial liver transplantation (LRPLT). In seven out of eight recipients without severe rejection and/or disseminated intravascular coagulation (DIC), FDP-DD values reached their maximum at 5 to 10 days after transplantation, then gradually decreased. On the other hand, TAT values rose to the maximum at anhepatic or reperfusion phase of liver transplantation. These data represent hypercoagulation in consequence of tissue thromboplastin activation after extensive operation. Changes in PIC, tissue-type plasminogen activator, and plasminogen activator inhibitor-1 (PAI-1) in the clinical course of case 1 suggested that fibrinolysis was suppressed by relatively elevated level of PAI-1 around the operation, but thereafter was adversely accelerated by relatively lower levels of PAI-1. In comparison with patients with DIC, TAT was much higher but PIC was significantly lower in recipients of LRPLT. These findings indicated that marked hypercoagulation and mild to moderate hyperfibrinolysis occurred in recipients of LRPLT.

Calculation of child and adult standard liver volume for liver transplantation

Despite refinements in surgical techniques for liver transplantation, liver size disparity remains one of the most common problems in pediatric patients. Optimal liver graft size remains unknown and the volume of diseased liver in the recipient is not indicative of the volume (standard liver volume [LV]) optimal for the recipient's metabolic demands. To establish a formula for calculating the standard LV in the pediatric and adult populations for liver transplantation, whole LVs were measured using computed tomography (CT) in 96 patients (65 pediatric and 31 adolescent or adult subjects) with normal liver whose disease conditions did not seem to affect body weight (BW) or LV. In the 96 subjects, the ratio of estimated LV to BW decreased gradually as age increased until approximately 16 years, when it started to level off. On the other hand, there seemed to be a directly proportional relationship between the estimated LV in vivo and body surface area (BSA) (r = .981; r2 = .962; P < .0001) in the subjects as a whole, and the formula, LV (mL) = 706.2 x BSA (m2) + 2.4, was established from the measured data by simple regression analysis. Another predicting equation, LV (mL) = 2.223 x BW (kg)0.426 x body height (BH) (cm)0.682, was produced by multiple regression analysis (r2 = .969; P < .0001). Considering its simplicity of use, we adopted the first formula for predicting standard LV in an individual patient.

[Studies on the blood coagulation factor XIII in patients with increased levels of FDP D-dimer]

Antigen levels of blood coagulation factor XIII (XIII) were determined in plasmas from patients with increased levels of fibrin degradation products-D-dimer (FDP-DD), including disseminated intravascular coagulation (DIC), by latex photometric immunoassay using polyclonal anti-XIII a subunit antibody-coated latex reagent. Since stable fibrin is directly degradated by plasmin and FDP-DD is produced, plasma FDP-DD levels correlate with plasmin-alpha 2-plasmin inhibitor complex levels, but not with thrombin-antithrombin III complex (TAT) or XIII levels. In order to clarify other causes of discordant relationships among the related three parameters, we studied the changes in plasma XIII, TAT and FDP-DD levels in fourteen DIC patients induced by various primary disorders. Only in two cases, XIII levels changed up and down irrelevant to the fluctuating levels of TAT and FDP-DD. In seven cases, plasma XIII levels remained low during the clinical courses, indicating possibilities that elevated condition of XIII consumption continued and/or production of XIII was low. On the other hand, in four patients, including two patients with nephrosis, XIII might be produced at higher rate than that of consumption. Same phenomenon was observed in one of eight recipients with living-related liver transplantation who showed remarkably increased levels of FDP-DD without DIC. In conclusion, plasma XIII level in patients with elevated FDP-DD may be influenced by the balance between consumption of XIII by unstable fibrin and/or surgical stress and the following tissue recovery etc. and production of XIII in liver, megakaryocytes and monocytes.