Comparison of Glucose Loads and Blood Glucose Changes in Patients With and Without Diabetes Mellitus Undergoing Living Donor Liver Transplantation.

BACKGROUND AND PURPOSE: The purpose of this study was to identify the quantitative amount of glucose load, which maintained the blood glucose levels between 100 and 180 mg/dL in patients with and without diabetes mellitus (DM) undergoing living donor liver transplantation (LDLT). METHODS AND PATIENTS: The anesthesia records of 477 adult LDLT patients were reviewed retrospectively. The total amount of glucose loads and the changes in blood glucose between groups were compared by using Mann-Whitney U test. One-year patient survival between groups was compared with Pearson's χ2 test. A P value of <.05 was considered statistically significant. RESULTS: Eighty patients diagnosed with DM, who were all type II except one, were placed in group 1 (G1); and 397 patients without DM were placed in group 2 (G2). Table 1 shows that G1 received significantly less glucose loads in comparison to G2, but all the measured blood glucose levels, except in the reperfusion phase, were significantly higher in G1 than in G2. Both groups received glucose loads of 0.342 ± 0.191 and 0.774 ± 0.191 mg/kg/min for G1 and G2, respectively. No difference in 1-year survival between groups was observed. CONCLUSION: Patients with DM required significantly lower glucose loads compared to patients without DM.

Anesthetic Fluid Management of Patients With Hyponatremia Undergoing Living Donor Liver Transplantation.

OBJECTIVE: The objective of this study is to evaluate the changes in serum sodium levels in adult recipients with and without hyponatremia undergoing living donor liver transplantation (LDLT) without using hypertonic solution. METHODS: Patients were divided into 2 groups according to serum sodium level higher (GI) or lower (GII) than 130 mEq/L. The changes of serum sodium levels during an LDLT procedure and total sodium loads were compared between groups by using the Mann-Whitney U test, while the changes in the same group were paired by using the Student t test. A P value <.005 was considered significant. RESULTS: The total sodium load for GI (n = 438) and GII (n = 28) were 2737 ± 2159 mEq and 4017 ± 2830 mEq, respectively. Although GI received a significantly lower sodium load than GII, the serum sodium levels during the procedure were always within a normal range and higher than GII at all the measured time points; however, the changes of serum sodium level in GI from one point to the next measured point in the same group were unremarkable, while that of GII increased significantly between the 2 measured time points during the procedure. The mean total increase of serum sodium in GII was 5.57 ± 4.9 mEq/L in 14 hours of the LDLT procedure. None of the patients developed central pontine myelinosis (CPM) postoperatively. CONCLUSION: Patients with hyponatremia can be managed safely without using a hypertonic solution during liver transplantation. The mean increase of serum sodium of GII was of 5.57 ± 4.9 mEq/L, which was still within the acceptable and safe level. No postoperative CPM was observed in our GII patients.

Acute Kidney Injury in Adult Living Donor Liver Transplantation Performed with Different Methods of Inferior Vena Cava Clamping Maneuvers.

OBJECTIVE: The aim of this retrospective study is to evaluate and compare the incidence of acute kidney injury (AKI), defined as increase serum creatinine (SCr) of 0.3 mg/dl or increase in SCr to ≥1.5 times from baseline within 48 hour, in adult living donor liver transplantation patients performed with total cross clamp vs side clamp of the inferior vena cava (IVC). METHODS AND PATIENTS: Sixty adult living donor liver transplantation (LDLT) patients were divided into 2 groups: 30 patients in total IVC clamping (G1) and 30 in IVC side clamping (G2) during the anhepatic phase. Patients' characteristic, hemodynamic changes in percentage (%) as a result of different methods of IVC clamping, urine output during anhepatic phase were compared by using the Student t test, and the incidence of AKI were compared by using the χ2 test between groups. P value <.05 was regarded as significant. RESULTS: The negative impact of the 2 different ways of IVC clamping was significantly more severe in G1 compared to G2; consequently, the urine output of G1 was significantly less than G2. Although there was significantly more urine output of G2 during the anhepatic phase, the incidence of the postoperative AKI between groups was similar. CONCLUSION: The side clamp of the IVC had a significantly less negative impact on the hemodynamic parameters and provided sufficient urine output during the anhepatic phase (2.24 ± 3.17 vs 0.39 ± 0.33 mL/kg/h) compared to the total clamp of the IVC. But this favorable data did not protect the patient suffering from postoperative AKI in LDLT.

Clinical Beneficial Effects of Using Crystalloid only in Recipients of Living Donor Liver Transplantation.

OBJECTIVE: Liver transplantation (LT) is a major surgery associated with intraoperative massive fluid shift, which is usually replaced by crystalloid, 5% albumin (colloid) and blood products. We studied 15 patients from 477 consecutive recipients of adult living donor liver transplantation. Each patient received crystalloid only during LT. Whether LT provides any clinical benefit is not clear and must be determined. METHODS AND PATIENTS: The anesthesia records of 477 adult LDLT were reviewed retrospectively. The patients were divided into three groups according to the fluids received. Group I (GI) had received blood products, 5% albumin and crystalloid, group II (GII) received 5% albumin and crystalloid, and group III (GIII) received crystalloid only. The characteristic intraoperative variable and postoperative acute rejection and survival rate were compared amongst groups by using One Way ANOVA post hoc with Bonferroni and by Ficher's Exact test and Chi-square χ² test. RESULTS AND CONCLUSIONS: GIII had less intraoperative ascites and blood loss; they also had more stable hemodynamics. Furthermore, they could be extubated significantly earlier than GI, and the one- and three-year survival rates were excellent, with 100% in GIII, while that of GI and GII were 94.1%, 90.5% and 98.6%, 94.5%, respectively.

Effect and Outcome of Intraoperative Fluid Restriction in Living Liver Donor Hepatectomy.

BACKGROUND The purpose of this study was to evaluate the effect and outcome of intraoperative fluid restriction in living liver donor hepatectomy, regarding changes in intraoperative CVP levels, blood loss, and postoperative renal function. MATERIAL AND METHODS The charts of 167 patients were reviewed and analyzed retrospectively. Intraoperative central venous pressure levels, blood loss, fluids infused, and urine output per hour, before and after the liver allograft procurement, were calculated. Perioperative renal functions were also analyzed. RESULTS Fluid infused before and after liver allograft procurement was 3.21±1.5 and 9.0±3.9 mL/Kg/h and urine output was 1.5±0.7 and 1.8±1.4 mL/Kg/h, respectively. Intraoperative estimated blood loss was 91.3±78.9 mL. No patients required blood transfusion. Their preoperative and postoperative hemoglobin were 12.3±2.7 and 11.7±1.7 g/dL. CVP levels decreased gradually from 10.4±3.0 to a low of 8.1±1.9 mmHg at the time of transection of the liver parenchyma. Renal functions were not significantly affected based on the determination of BUN and creatinine levels. CONCLUSIONS The methods used to lower CVP are moderate and slow, with 2 main goals achieved: minimal blood loss (91.3±78.9 ml) and no blood transfusion. Furthermore, it did not have any negative effect on renal function.

Extensive Adhesions in Living Donor Liver Transplantation: A Retrospective Analysis.

BACKGROUND: Adhesions are abnormal fibrous bands of scar tissue between internal organs and tissues. With respect to recipient hepatectomy in living donor liver transplantation (LDLT), we defined extensive adhesions as adhesions in at least two separate locations that required more than 5 % of the total surgical time to lyse. We aimed to identify the etiology and consequences of this preventable burden. METHODS: A simple retrospective case-control study of all cases with extensive adhesions from August 2011 to September 2014 matched by age, sex, and diagnosis at surgery. RESULTS: A total of 380 cases were studied. Thirty-eight and five patients had extensive adhesions from surgical and non-surgical causes, respectively. The incidence and complications in pediatric patients were far less than in adults. In the adult group, the mean operative time was increased by 75 min (12.3 %) and blood loss by 2.5 L.The incidence of bowel perforation and biliary infections were increased in adults, while there was no significant difference in the rate of ascitic or wound infections. The 1-year survival was slightly less (92 %) than the control group (100 %). CONCLUSIONS: The most common cause of extensive adhesions at LDLT was prior liver resection. Extensive adhesions caused increased morbidity by increased blood loss, transfusion requirements, and increased cold ischemia time. There is also a higher risk of bowel perforation during enterolysis. The use of commercially available barrier techniques is advisable in adults at high risk of developing adhesions with a possibility of liver transplantation, such as liver resection for HCC.

Temporary abdominal closure and delayed biliary reconstruction due to massive bleeding in patients undergoing liver transplantation: an old trick in a new indication.

BACKGROUND: Massive bleeding during liver transplantation (LT) is difficult to manage surgical event. Perihepatic packing (PP) and temporary abdominal closure (TAC) with delayed biliary reconstruction (DBR) can be applied in these circumstances. METHOD: A prospective database of LT in a major transplant center was analyzed to identify patients with massive uncontrollable bleeding during LT that was resolved by PP, TAC, and DBR. RESULTS: From January 2009 to July 2013, 20 (3.6%) of 547 patients who underwent LT underwent DBR. Mean intraoperative blood loss was 20,500 ml at the first operation. The DBR was performed with a mean of 55.2 h (16-110) after LT. Biliary reconstruction included duct-to-duct (n = 9) and hepatico-jejunostomy (n = 11). Complications occurred in eight patients and included portal vein thrombosis, cholangitis, severe bacteremia, pneumonia. There was one in-hospital death. In the follow-up of 18 to 33 months we have seen one patient died 9 months after transplantation. The remaining 18 patients are alive and well. CONCLUSIONS: In case of massive uncontrollable bleeding and bowel edema during LT, the combined procedures of PP, TAC, and DBR offer an alternatively surgical option to solve the tough situation.

Propofol-enhanced autophagy increases motility and angiogenic capacity of cultured human umbilical vascular endothelial cells.

AIMS: Propofol (PPF), an intravenous anesthetic agent, is previously reported to attenuate oxidative stress- and inflammation-induced endothelial cell dysfunction. This study investigated its effect on endothelial cell biology. MAIN METHODS: Cultured human umbilical vein endothelial cells (HUVECs) were treated with PPF and subject to measurements for nitric oxide (NO) production, autophagy flux, signal transduction, migration, and in vitro angiogenesis. KEY FINDINGS: Non-cytotoxic PPF treatment was found to significantly upregulate inducible nitric oxide synthase (NOS2) but downregulate constitutive NOS3 expression. It also potentiated LPS-induced ICAM-1 overexpression and NO overproduction. Mechanistically, the PPF-activated signal transduction in PI3K/Akt, ERK1/2, p38 MAPK, and JNK pathways were involved in the PPF-driven NO overproduction. PPF exhibited a stimulatory effect on autophagy flux by increasing expression of autophagy markers including mTOR, Beclin-1, Atg5, and LC3I/II, as well as a late endosomal indicator, Rab7. However, PPF appeared to antagonize the Rab7 upregulation by LPS. Functionally, PPF enhanced in vitro migratory and angiogenic capacities of HUVECs, but this enhancement was drastically abrogated by the presence of autophagy inhibitors, indicating a pro-angiogenic contribution of PPF-enhanced autophagy in cultured HUVECs. SIGNIFICANCE: Our findings support the notion that PPF enhances motility and angiogenic capacity of cultured HUVECs through an autophagy-involved regulatory mechanism.

Impact of Early Release of the IVC Clamp from Different IVC Clamping Maneuvers on Changes in Hemodynamic Parameters in Living Donor Liver Transplantation.

BACKGROUND The aim of this study was to evaluate the impact of different methods of inferior vena cava (IVC) clamping and release of the cross clamp on hemodynamic parameters of recipients during living donor liver transplantation. MATERIAL AND METHODS Ninety-six adult living donor liver transplantation patients were divided into 3 groups according to cross-clamp of the IVC for all the hepatic vein and portal vein reconstruction (G1), cross-clamp of the IVC only for hepatic vein reconstruction (G2), and side-clamp of the IVC for hepatic vein reconstruction (G3). In G2 and G2, the reconstructed hepatic vein was clamped instead of the IVC for portal vein reconstruction. The hemodynamic parameters among groups were compared by 1-way ANOVA and the complications in each group were compared using the Kruskal-Wallis test. RESULTS Changes in percentage of MAP and CO in G3 were significantly less than that of G1 and G2 for hepatic vein reconstruction. Hemodynamic parameters of G2 and G3 normalized to pre-clamped values during portal vein reconstruction, while the hemodynamics of G1 remained unstable. CONCLUSIONS Hemodynamic changes were less pronounced in LT with side-clamp of the inferior cava vein versus total cross-clamp. Early release of the IVC clamp minimized the hemodynamic changes. There were no differences in terms of outcome (morbidity and mortality).

Living donor liver transplantation with body-weight more or less than 10 kilograms.

AIM: To compare the outcomes of pediatric patients weighing less than or more than 10 kg who underwent liver transplantation. METHODS: Data for 196 pediatric patients who underwent living donor liver transplantation between June 1994 and February 2011 were reviewed retrospectively. The information for each patient was anonymized and de-identified before analysis. The data included information regarding the pre-transplant conditions, intraoperative fluid replacement and outcomes for each patient. The 196 patients were divided into two groups: those with body weights of less than 10 kg were included in group 1 (G1; n = 101), while those with body weights of more than 10 kg were included in group 2 (G2; n = 95). For each group, the patients' ages, body weights, heights, pediatric end stage liver disease scores, anesthesia times, and warm and cold ischemic times were analyzed. In addition, between-group comparisons were also made. Mann-Whitney U tests were used to compare all the variables except for complications and survival rates, which were analyzed using χ(2) tests and Kaplan-Meier tests, respectively. RESULTS: The general medical conditions of the G1 patients were worse than those of the G2 patients, as shown by the higher pediatric end stage liver disease scores and poorer Z-scores. In addition, the pre-operative Hb and serum albumin levels were all lower for the G1 patients than for the G2 patients. The G1 patients also had significantly more intraoperative blood loss than the G2 patients. In addition, the intraoperative fluid requirements for the G1 patients, including leukocyte poor red blood cell transfusions, 5% albumin infusions and crystalloid infusions, were significantly higher than those for the G2 patients. The risk of intraoperative portal vein thrombosis was higher for the patients in G1 than for those in G2. However, the one-year survival rates (95.9% and 96.8% for G1 and G2, respectively) and three-year survival rates (94.9% and 94.6% for G1 and G2, respectively) for both groups were similar. CONCLUSION: Patients weighing less than 10 kg typically have poorer conditions, but their survival rates are comparable to those of children weighing more than 10 kg.

The effectiveness of prophylactic attachment of adhesive defibrillation pads in adult living donor liver transplantation.

BACKGROUND: The aim of current study is to present the effectiveness of prophylactic attachment of adhesive defibrillation electrode pads in adult living donor liver transplantation. MATERIAL AND METHODS: We divided 487 adult living donor liver transplantation patients into 2 Eras according to the history of without (Era 1) and with (Era 2) pre-attachment of adhesive defibrillation pads. The incidences of intraoperative cardiac events requiring cardioversion or defibrillation, its management, and outcome between Era 1 and 2 were compared. RESULTS: Two cases out of 124 patients (1.6%) in Era 1 had cardiac arrest. The closed chest cardiac massage in 1 cardiac arrest in Era 1 required trans-diaphragmatic open-chest cardiac massage followed by internal cardiac defibrillation due to difficulty in performing external defibrillation. Both patients of Era 1 had in-hospital mortality. Four patients of Era 2 (n=363) received electrical treatment (1.01%); 2 had paroxysmal tachycardia requiring cardio-version and the other 2 had ventricular fibrillation requiring closed-chest cardiac massage and external defibrillation. All 4 patients in Era 2 regained sinus rhythm after electrical treatment, tolerated the subsequent operation well, and had 100% survival to date. CONCLUSIONS: Our results show that prophylactic attachment of adhesive defibrillation pads allows the immediate performance of cardioversion, conventional closed-chest CPR, and defibrillation if indicated without any delay and without interference with the sterility of the operation field. Our preliminary result is clear and encouraging.

Young age, male sex, and end-stage renal disease with secondary hyperparathyroidism as risk factors for intraoperative hyperkalemia during parathyroidectomy.

STUDY OBJECTIVE: The aim of this study was to investigate the risk factors of intraoperative hyperkalemia in end-stage renal disease patients undergoing parathyroidectomy (PTx) with autotransplantation (AT). DESIGN: Prospective observational study. SETTING: Operating room of a tertiary care medical center. PATIENTS: Thirty-two adult, American Society of Anesthesiologists physical status 2 and 3 patients with secondary hyperparathyroidism aged between 31 and 72 years scheduled for PTx with AT. MEASUREMENTS: Laboratory chemistries (intact parathyroid hormone, Na, K, Ca, P, arterial blood gas) were obtained before surgery and at 2 time points during surgery. The first chemistry levels during surgery were checked after the first 2 parathyroid glands had been removed, and the second levels were checked after wound closure. Statistical analysis was performed using t test, Fisher exact test, the receiver operating characteristic curve method, as appropriate. MAIN RESULTS: Eight patients (25%) developed hyperkalemia during surgery. The hyperkalemia patients had younger age (42±11.44 years vs 52.58±11.83 years, P=.044) and a male dominance (odds ratio, 11.4; P=.01; 95% confidence interval, 1.74-74.65). The cutoff for age was 40.5 years, according to the highest value for sensitivity plus specificity of the receiver operating characteristic curve. There was a higher incidence of intraoperative hyperkalemia in younger patients than in older patients (odds ratio, 8.33; P=.023; 95% confidence interval, 1.39-49.87) as well as a significant increase in potassium level during surgery in younger male patients (P=.005 and .002, respectively). CONCLUSIONS: The anesthesiologist should be aware of the complications of intraoperative hyperkalemia during PTx with AT, especially in male end-stage renal disease patients younger than 40 years.

Review of anesthesia in liver transplantation.

Liver transplantation (LT) is a well-accepted treatment modality of many end-stage liver diseases. The main issue in LT is the shortage of deceased donors to accommodate the needs of patients waiting for such transplants. Live donors have tremendously increased the pool of available liver grafts, especially in countries where deceased donors are not common. The main ethical concern of this procedure is the safety of healthy donors, who undergo a major abdominal surgery not for their own health, but to help cure others. The first part of the review concentrates on live donor selection, preanesthetic evaluation, and intraoperative anesthetic care for living liver donors. The second part reviews patient evaluation, intraoperative anesthesia monitoring, and fluid management of the recipient. This review provides up-to-date information to help improve the quality of anesthesia, and contribute to the success of LT and increase the long-term survival of the recipients.

Acquired hyponatremia in pediatric living donor liver transplantation.

BACKGROUND: The aim of this study was to evaluate the incidence of acquired hyponatremia (AH) in our pediatric living donor liver transplantation (LDLT) patients, and to identify the potential predictive risk factors of the causes of AH. MATERIAL/METHODS: The 189 pediatric LDLT patients were divided into 2 groups: serum sodium level at the end of the surgery lower than 130 mEq/L in GI (n=16) and higher than 130 mEq/L in GII (n=173). Patients' data were analyzed by Mann-Whitney U test, univariate analysis, and multiple binary logistic regression model. The Hosmer-Lemeshow goodness-of-fit test was used to evaluate the logistic model formulated. P value <0.05 was regarded as statistically significant. RESULTS: In the multiple binary logistic regression model, the hypotonic solution administration rate (ml/kg/h) was the only independent predictor of AH with a p<0.017. Receiver operating curve (ROC) analysis indicated that giving more than 3.5 ml/kg/h hypotonic solution infusion may cause AH. Preoperative hyponatremia did not increase the incidence of acquired hyponatremia. CONCLUSIONS: Increasing the administration of hypotonic solution by 1 ml/kg/h in pediatric LDLT would increase the risk of developing AH by 1.272 times. The critical administration rate of hypotonic solution was 3.5 ml/kg/h.

Should abnormal coagulation data found in thromboelastography be corrected during liver transplantation? Experience of two cases.

Coagulopathy is common in patients with end-stage liver disease requiring liver transplantation (LT). Thromboelastography (TEG) test results are used for analyzing coagulation data and making a decision about the transfusion requirements. However, whether it is necessary to correct the abnormal coagulation profile during LT is a matter of considerable debate. Herein, we report our experience with two patients who had LT without blood product transfusion despite TEG results showing abnormal coagulation data. The TEG was performed four times during LT. Although blood product transfusion was necessary according to the TEG guidelines, it was avoided. At the end of operation, the hemoglobin level was 8.5 g/dL and 9.5 g/dL for Patient 1 and Patient 2, respectively. The patients tolerated LT well and their subsequent recovery was uneventful. We suggest that TEG should be used cautiously to make a decision about blood transfusion, as it can be totally avoided in selected cases involving living donor LT.

Involvement of the nuclear high mobility group B1 peptides released from injured hepatocytes in murine hepatic fibrogenesis.

This study investigated the pro-fibrogenic role of high mobility group box 1 (HMGB1) peptides in liver fibrogenesis. An animal model of carbon tetrachloride (CCl4)-induced liver fibrosis was used to examine the serum HMGB1 levels and its intrahepatic distribution. The increased serum HMGB1 levels were positively correlated with elevation of transforming growth factor-ß1 (TGF-ß1) and collagen deposition during fibrogenesis. The cytoplasmic distribution of HMGB1 was noted in the parenchymal hepatocytes of fibrotic livers. In vitro studies confirmed that exposure to hydrogen peroxide and CCl4 induced an intracellular mobilization and extracellular release of nuclear HMGB1 peptides in clone-9 and primary hepatocytes, respectively. An uptake of exogenous HMGB1 by hepatic stellate cells (HSCs) T6 cells indicated a possible paracrine action of hepatocytes on HSCs. Moreover, HMGB1 dose-dependently stimulated HSC proliferation, up-regulated de novo synthesis of collagen type I and α-smooth muscle actin (α-SMA), and triggered Smad2 phosphorylation and its nuclear translocation through a TGF-ß1-independent mechanism. Blockade with neutralizing antibodies and gene silencing demonstrated the involvement of the receptor for advanced glycation end-products (RAGE), but not toll-like receptor 4, in cellular uptake of HMGB1 and the HMGB1-mediated Smad2 and ERK1/2 phosphorylation as well as α-SMA up-regulation in HSC-T6 cells. Furthermore, anti-RAGE treatment significantly ameliorated CCl4-induced liver fibrosis. In conclusion, the nuclear HMGB1 peptides released from parenchymal hepatocytes during liver injuries may directly activate HSCs through stimulating HSC proliferation and transformation, eventually leading to the fibrotic changes of livers. Blockade of HMGB1/RAGE signaling cascade may constitute a therapeutic strategy for treatment of liver fibrosis.

Section 1. Image evaluation of fatty liver in living donor liver transplantation.

Preoperative evaluation of donors for living-donor liver transplantation aims to select a suitable donor with optimal graft quality and to ensure donor safety. Hepatic steatosis, a common finding in living liver donors, not only influences the outcome of liver transplantation for the recipient but also affects the recovery of the living donor after partial hepatectomy. Histopathologic analysis is the reference standard to detect and quantify fat in the liver, but it is invasive, and results are vulnerable to sampling error. Imaging can be repeated regularly and allows assessment of the entire liver, thus avoiding sampling error. Selection of appropriate imaging methods demands understanding of their advantages and limitations and the suitable clinical setting. This article describes potential clinical applications for liver fat quantification of imaging methods for fat detection and quantification, with an emphasis on the advantages and limitations of ultrasonography, computed tomography, and magnetic resonance imaging for quantifying liver fat.

Section 8. Management of portal venous complications in pediatric living donor liver transplantation.

Portal vein (PV) complications after living donor liver transplant (LDLT) have been a major concern in pediatric liver transplantation. The incidence of PV complications is more in pediatric (0%-33%) than in adult recipients. Early diagnosis and treatment of PV complications may ensure optimal graft function and good recipient survival. Small preoperation PV size (<4 mm) and slow portal flow (<10 cm/s) combined with lower hepatic artery resistance index (<0.65) are strong warning signs that may predict the development of post LDLT PV complications. Portal vein angioplasty/stenting is conventionally performed through the percutaneous transhepatic approach; however, this can also be performed through transjugular, trans-splenic, and intraoperative approaches. Depending on the situation, using optimal method is the key point to minimize complication (5%) and gain high success rate (80%). PV occlusion of greater than 1 year with cavernous transformation seems to be a factor causing technical failure. Good patency rate (100%) with self-expandable metallic stents was noted in long-term follow-up. In conclusion, PV stent placement is an effective, long-term treatment modality to manage PV complications after pediatric LDLT. Early diagnosis and treatment are essential to maximize the use of stent placement and achieve good success rates.

Section 18. Professional framework for liver transplantation for overseas patients: traveling for living donor liver transplantation.

BACKGROUND: Liver transplantation (LT) in overseas patients is a sensitive issue because of the possibility of organ trafficking and transplant tourism. In the Istanbul Summit, there was a call to develop standardized professional frameworks to prevent these practices. OBJECTIVES: Our objectives are three-fold, to critically evaluate our professional framework, to study the demographic profiles, and to identify the outcome and impact of LT in overseas patients. METHODS: Recipient and donor case records, e-mail communications, and medico-legal records were collected and analyzed for management strategy, demographic profile, donor and recipient characteristics, and outcome. RESULTS: Only 5% of our total LT operations were for overseas patients. Forty-two (79%) were pediatric cases for which 39 (93%) were due to biliary atresia (P<0.001). Sixty-eight percent were from the Philippines. Thirty-seven (70%) of the donors were first-degree relative. The average hospital days of a pediatric living donor liver transplant (LDLT) recipient was 65.48±28.7, and average cost was 44,602 USD. An adult LDLT recipient stayed for 52.09±11.3 days and spent around 75, 013 USD. A donor of pediatric LDLT stayed in the hospital for 17.42±5 days and spent round 8,176 USD. A donor for adult LDLT was admitted for 15.5±4 days and spent an average 9,612 USD. The total cost for recipient and donor were 56,615 USD (range, 28,976-82,056) for pediatric LDLT and 84,483 USD (range, 64,851-108,467) for adult LDLT. Actuarial survival rates were 91% at 1 year, 88% at 3 years, and 86% at 5 years and 10 years. CONCLUSION: Travelling for LDLT may be a wise and cost-effective step for patients with end-stage liver disease seeking alternative ways from their country. Our professional framework is effective to prevent practice of organ trafficking and transplant tourism. It may be useful to develop international guidelines for the practice of LT in overseas patients.