What is the optimal prophylaxis against postoperative deep vein thrombosis in the living donor to avoid complications and enhance recovery? - A systematic review of the literature and expert panel recommendations.

BACKGROUND: Deep venous thrombosis (DVT) prophylaxis is often employed to prevent the potentially serious complication of pulmonary embolism (PE). However, little data exist regarding the optimal DVT prophylaxis strategy for living donors undergoing hepatectomy for living donor liver transplantation. Here we present our consensus statement on DVT prophylaxis for living donors undergoing hepatectomy. OBJECTIVES: To identify the optimal DVT prophylaxis strategy, which reduces, risk of complications in living liver donors, and enhances recovery. METHODS: Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Of interest was the impact of DVT prophylaxis or lack of prophylaxis on living donors undergoing hepatectomy and subsequent rates of DVT, PE, and hemorrhagic complications. PROSPERO ID: CRD42021260720 RESULTS: The review of the literature identified three studies, which directly addressed thrombogenesis following living donor hepatectomy. All studies were observational in nature without randomization into treatments. The rate of DVT-PE in unscreened living donors with chemoprophylaxis was 5%. Furthermore, thromboelastography of living donors demonstrated sustained hypercoagulability for 50% of donors 10 days postoperatively. In line with CHEST (The American College of Chest Physicians) guidelines of chemoprophylaxis for surgical procedures with 3% or greater risk of DVT-PE, we conclude that a minimum of 10 days of postoperative chemoprophylaxis with unfractionated heparin or low-molecular weight heparin is recommended for patients undergoing living donor hepatectomy. The quality of evidence (QOE) for these recommendations based on the GRADE criteria is low, with a Grade of Recommendation of Strong. CONCLUSIONS: Chemoprophylaxis for DVT following living donor hepatectomy is associated with reduced adverse thrombotic events, (Quality of Evidence; Low | Grade of Recommendation; Strong).

Estimating the effect of increasing utilization of living donor liver transplantation using observational data.

There has been a recent increase in enthusiasm for expansion of living donor liver transplantation (LDLT) programmes. Using all adults initially placed on the waiting list in the United States, we estimated the risk of overall mortality under national strategies which differed in their utilization of LDLT. We used a generalization of inverse probability weighting which can estimate the effect of interventions in the setting of finite resources. From 2005 to 2015, 93 812 eligible individuals were added to the waitlist: 51 322 received deceased donor grafts while 1970 underwent LDLT. Individuals who underwent LDLT had more favourable prognostic factors, including lower mean MELD score at transplant (14.6 vs. 20.5). The 1-year, 5-year and 10-year cumulative incidence of death under the current level of LDLT utilization were 18.0% (95% CI: 17.8, 18.3%), 41.2% (95% CI: 40.8, 41.5%) and 57.4% (95% CI: 56.9, 57.9%) compared to 17.9% (95% CI: 17.7, 18.2%), 40.6% (95% CI: 40.2, 40.9%) and 56.4% (95% CI: 55.8, 56.9%) under a strategy which doubles LDLT utilization. Expansion of LDLT utilization would have a measurable, modest effect on the risk of mortality for the entire cohort of individuals who begin on the transplant waiting list.

The meaning of confounding adjustment in the presence of multiple versions of treatment: an application to organ transplantation.

Causal inference for treatments with many versions requires a careful specification of the versions of treatment. Specifically, the existence of multiple relevant versions of treatment has implications for the selection of confounders. To illustrate this, we estimate the effect of organ transplantation using grafts from donors who died due to anoxic drug overdose, on recipient graft survival in the US. We describe how explicitly outlining the target trial (i.e. the hypothetical randomized trial which would answer the causal question of interest) to be emulated by an observational study analysis helps conceptualize treatment versions, guides selection of appropriate adjustment variables, and helps clarify the settings in which causal effects of compound treatments will be of value to decision-makers.

Can we reduce ischemic cholangiopathy rates in donation after cardiac death liver transplantation after 10 years of practice? Canadian single-centre experience

Background: Outcomes in liver transplantation with organs obtained via donation after cardiocirculatory death (DCD) have been suboptimal compared to donation after brain death, attributed mainly to the high incidence of ischemic cholangiopathy (IC). We evaluated the effect of a 10-year learning curve on IC rates among DCD liver graft recipients at a single centre. Methods: We analyzed all DCD liver transplantation procedures from July 2006 to July 2016. Patients were grouped into early (July 2006 to June 2011) and late (July 2011 to July 2016) eras. Those with less than 6 months of follow-up were excluded. Primary outcomes were IC incidence and IC-free survival rate. Results: Among the 73 DCD liver transplantation procedures performed, 70 recipients fulfilled the selection criteria, 32 in the early era and 38 in the late era. Biliary complications were diagnosed in 19 recipients (27%). Ischemic cholangiopathy was observed in 8 patients (25%) in the early era and 1 patient (3%) in the late era (p = 0.005). The IC-free survival rate was higher in the late era than the early era (98% v. 79%, p = 0.01). The warm ischemia time (27 v. 24 min, p = 0.049) and functional warm ischemia time (21 v. 17 min, p = 0.002) were significantly lower in the late era than the early era. Conclusion: We found a significant reduction in IC rates and improvement in ICfree survival among DCD liver transplantation recipients after a learning curve period that was marked by more judicious donor selection with shorter procurement times.

Contexte: L'issue des greffes de foie suite à un don d'organe après décès cardiocirculatoire (DDC) a été sous-optimale comparativement aux dons suivant la mort cérébrale. Cela serait surtout attribuable à une forte incidence de cholangiopathie ischémique (CI). Nous avons évalué l'effet d'une courbe d'apprentissage échelonnée sur 10 ans sur les taux de CI chez des receveurs de greffe de foie après DDC dans un seul centre. Méthodes: Nous avons analysé toutes les greffes de foie consécutives à des DDC entre juillet 2006 et juillet 2016. Les patients ont été regroupés en 2 époques, la première, de juillet 2006 à juin 2011, et la seconde, de juillet 2011 à juillet 2016. Ceux pour lesquels on disposait de moins de 6 mois de suivi ont été exclus. Les paramètres principaux étaient l'incidence de CI et le taux de survie sans CI. Résultats: Parmi les 73 greffes de foie par suite de DDC, 70 receveurs répondaient aux critères de sélection, 32 pour la première époque et 38 pour la seconde époque. Des complications biliaires ont été diagnostiquées chez 19 receveurs (27 %). La cholangiopathie ischémique a été observée chez 8 patients (25 %) de la première époque et 1 patient (3 %) de la seconde (p = 0,005). Le taux de survie sans CI a été plus élevé pendant la seconde époque que pendant la première (98 % c. 79 %, p = 0,01). Le temps d'ischémie chaude (27 minutes c. 24, p = 0,049) et le temps d'ischémie chaude fonctionnelle (21 minutes c. 17, p = 0,002) ont été significativement plus courts durant la seconde époque que durant la première. Conclusion: Nous avons observé une réduction significative des taux de CI et une amélioration de la survie sans CI chez les receveurs de greffes de foie par DDC après une courbe d'apprentissage qui a été marquée par une sélection plus judicieuse des donneurs et des délais d'obtention plus courts.

The influence of functional warm ischemia time on DCD liver transplant recipients' outcomes.

BACKGROUND: Duration of functional warm ischemia (f-WIT) is thought to have a causal effect on outcomes in controlled donation after circulatory death (DCD) liver transplantation (LT). METHODS: A retrospective cohort study was conducted at five centers. Data were extracted on donor and recipient characteristics, with attention to parameters recorded during withdrawal of life support to in situ cold perfusion. F-WIT was the time elapsed from any of the hemodynamic and oxygenation parameters to the start of in situ cold perfusion. Parameters were as follows: MAP ≤ 50 mm Hg; SBP ≤ 50 mm Hg; and SPO2 ≤ 60%. The primary endpoint was a composite of disseminated ischemic cholangiopathy (IC), primary non-function (PNF), and early graft failure. RESULTS: 35 patients (14%) developed one or more of the primary outcomes. On univariate analysis, older donors and longer WITs were associated with greater likelihood of complications. Of the f-WIT variations analyzed, only f-WIT with SpO2 ≤ 60% was longer among patients with complications. On multivariate analysis, only donor age was a significant predictor of complications. CONCLUSION: This study demonstrates that, of the f-WITs, f-WIT with SpO2 ≤ 60% is most predictive of post-DCD complications. However, results suggest that there may be an alternate etiology for poor outcomes, and that donor age plays a key role.

Optimizing associated liver partition and portal vein ligation for staged hepatectomy outcomes: Surgical experience or appropriate patient selection?

BACKGROUND: Early reports of associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) outcomes have been suboptimal. The literature has confirmed that learning curves influence surgical outcomes. We have 54 months of continuous experience performing ALPPS with strict selection criteria. This study aimed to evaluate the impact of the learning curve on ALPPS outcomes. METHODS: We retrospectively compared patients who underwent ALPPS between April 2012 and March 2016. Patients were grouped into 2 24-month (early and late) periods. All candidates had a high tumour load requiring staged hepatectomy after chemotherapy response, a predicted future liver remnant (FLR) less than 30% and good performance status. RESULTS: Thirty-three patients underwent ALPPS during the study period: 16 in the early group (median age 65 yr, mean body mass index [BMI] 27) and 17 in the late group (median age 60 yr, mean BMI 25). Bilobar disease was comparable in both groups (94% v. 88%, p > 0.99). Duration of surgery was not statistically different. Intraoperative blood loss and need for transfusion were significantly lower in the late group (200 ± 109 mL v. 100 ± 43 mL, p < 0.05). The late group had a higher proportion of monosegment ALPPS (4:1). There were no deaths within 90 days in either cohort. Rates of postoperative complications were not statistically significant between groups. The R0 resection rate was similar. The entire 1-year disease-free and overall survival were 52% and 84%, respectively. CONCLUSION: Excellent results can be obtained in innovative complex surgery with careful patient selection and good technical skills. Additionally, the learning curve brought confidence to perform more complex procedures while maintaining good outcomes.

CONTEXTE: Les premiers résultats sur l'association de la partition hépatique et de la ligature portale pour l'hépatectomie en 2 temps (ALPPS) sont sous-optimaux. La littérature a confirmé que les courbes d'apprentissage influencent les résultats des interventions chirurgicales. Notre étude reposait sur 54 mois consécutifs d'utilisation de la technique ALPPS selon des critères de sélection rigoureux. Elle visait à évaluer l'effet de la courbe d'apprentissage sur les résultats liés à l'ALPPS. MÉTHODES: Nous avons procédé à une comparaison rétrospective des patients traités par l'ALPPS entre avril 2012 et mars 2016. Nous avons divisé les patients en 2 groupes de 24 mois (précoce et tardif). Tous les candidats avaient une charge tumorale élevée nécessitant une hépatectomie en 2 temps après une réponse à la chimiothérapie, un volume estimé de futur foie résiduel (FFR) inférieur à 30 % et un indice fonctionnel favorable. RÉSULTATS: Trente-trois patients ont été traités par l'ALPPS pendant la période de l'étude : 16 dans le groupe précoce (âge médian 65 ans, indice de masse corporelle [IMC] moyen 27) et 17 dans le groupe tardif (âge médian 60 ans, IMC moyen 25). Le taux de maladie bilobaire était comparable entre les 2 groupes (94 % c. 88 %, p > 0,99). La durée de la chirurgie n'était pas statistiquement différente. Les pertes de sang peropératoires et le besoin de transfusion étaient significativement inférieurs dans le groupe tardif (200 ± 109 mL c. 100 ± 43 mL, p < 0,05). Le groupe tardif avait une proportion plus élevée d'ALPPS mono-segmentaires (4:1). Il n'y a eu aucun décès dans les 90 jours parmi les 2 cohortes. Les taux de complications postopératoires n'étaient pas statistiquement significatifs entre les groupes. Le taux de résection R0 était similaire. Les taux de survie sans récidive après une année complète et de survie globale étaient de 52 % et de 84 %, respectivement. CONCLUSION: L'innovation dans le domaine des chirurgies complexes peut donner d'excellents résultats lorsqu'on sélectionne attentivement les patients et que l'on possède de bonnes habiletés techniques. De plus, la courbe d'apprentissage a eu pour effet d'accroître la confiance dans la capacité de réaliser des interventions complexes tout en produisant de bons résultats.

Feasibility and diagnostic performance of the FibroScan XL probe for liver stiffness measurement in overweight and obese patients.

UNLABELLED: Failure of liver stiffness measurement (LSM) by transient elastography (TE, FibroScan) and unreliable results occur in ≈ 5% and 15% of patients, respectively, mainly due to obesity. In this multicenter study, we evaluated the feasibility and performance of the novel FibroScan XL probe in 276 patients with chronic liver disease (42% viral hepatitis, 46% nonalcoholic fatty liver disease [NAFLD]) and a body mass index (BMI) ≥ 28 kg/m(2) . Patients underwent liver biopsy and TE with the standard M and XL probes. TE failure was defined as no valid LSMs and unreliable examinations as <10 valid LSMs or an interquartile range (IQR)/LSM >30% or success rate <60%. Probe performance for diagnosing ≥ F2 fibrosis and cirrhosis (F4) versus biopsy were examined using areas under receiver operating characteristic curves (AUROC). FibroScan failure was less frequent with the XL probe than the M probe (1.1% versus 16%) and the XL probe was more often reliable (73% versus 50%; both P < 0.00005). Reliable results with the XL probe were obtained in 61% of patients in whom the M probe was unreliable. Among 178 patients with ≥ 10 valid LSMs using both probes, liver stiffness was highly correlated between probes (ρ = 0.86; P < 0.0005); however, median liver stiffness was lower using the XL probe (6.8 versus 7.8 kPa; P < 0.00005). The AUROC of the XL and M probes were similar for ≥ F2 fibrosis (0.83 versus 0.86; P = 0.19) and cirrhosis (0.94 versus 0.91; P = 0.28). CONCLUSION: Compared with the M probe, the FibroScan XL probe reduces TE failure and facilitates reliable LSM in obese patients. Although the probes have comparable accuracy, lower liver stiffness cutoffs will be necessary when the XL probe is used to noninvasively assess liver fibrosis.

Discordance in fibrosis staging between liver biopsy and transient elastography using the FibroScan XL probe.

BACKGROUND & AIMS: The FibroScan XL probe facilitates liver stiffness measurement (LSM) by transient elastography (TE) in obese patients, yet factors affecting its accuracy have not been described. Our objectives were to examine the prevalence, risk factors, and causes of discordance between fibrosis estimated by the FibroScan XL probe and biopsy. METHODS: Two hundred and ten patients with chronic liver disease (45% viral hepatitis, 55% nonalcoholic fatty liver disease (NAFLD) and a body mass index (BMI) ≥ 28 kg/m(2)) underwent liver biopsy and TE with the FibroScan XL probe. Predictors of discordance ≥ 2 fibrosis stages between measures, which occurred in 11% of patients (n=24), were identified by comparing patient, TE, and biopsy characteristics of discordant and non-discordant cases. RESULTS: Fibrosis estimated by the FibroScan XL probe was greater than biopsy in 75% (18/24) of discordant cases. Although biopsy quality was not associated with discordance, discordant cases were less likely to have ≥ 10 valid shots (75% vs. 97%; p=0.001), a success rate ≥ 60% (67% vs. 95%; p <0.0005), and an interquartile range over median liver stiffness (IQR/M) <21% (37% vs. 57%; p=0.07) than non-discordant cases. However, only increased BMI (odds ratio [OR] 1.09 per kg/m(2); 95% confidence interval [CI] 1.01-1.18; p=0.04) was independently associated with discordance; liver stiffness was of borderline significance (OR 1.73 per log(10)-transformed value; 95% CI 0.95-3.18; p=0.08). Discordance was 4- to 5-fold more frequent among patients with severe obesity (BMI ≥ 40 kg/m(2): 32% vs. 8%) and liver stiffness above the median of 7.0 kPa (20% vs. 4%; both p <0.0005). CONCLUSIONS: Discordance between liver fibrosis estimated by biopsy and TE using the FibroScan XL probe was infrequent in this obese population. Patients with severe obesity and elevated liver stiffness have the greatest risk of discordance.

Controlled Attenuation Parameter (CAP): a noninvasive method for the detection of hepatic steatosis based on transient elastography.

BACKGROUND: Accurate tools for the noninvasive detection of hepatic steatosis are needed. The Controlled Attenuation Parameter (CAP) specifically targets liver steatosis using a process based on transient elastography. METHODS: Patients with chronic liver disease and body mass index (BMI) ≥28 kg/m(2) underwent biopsy and liver stiffness measurement (LSM) with simultaneous CAP determination using the FibroScan(®) M probe. The performance of the CAP for diagnosing steatosis compared with biopsy was assessed using areas under receiver operating characteristic curves (AUROC). RESULTS: A total of 153 patients were included: 69% were male, median BMI was 32 kg/m(2); 47% had nonalcoholic fatty liver disease (NAFLD); and 65% had significant (≥10%) steatosis. The CAP was significantly correlated with the percentage of steatosis (ρ = 0.47) and steatosis grade (ρ = 0.51; both P < 0.00005). The median CAP was higher among patients with significant steatosis (317 [IQR 284-339] vs. 250 [227-279] dB/m with <10% steatosis; P < 0.0005) and the AUROC for this outcome was 0.81 (95% CI 0.74-0.88). At a cut-off of 283 dB/m, the CAP was 76% sensitive, 79% specific, and had positive and negative predictive values of 87% and 64%, respectively. CAP performance was not influenced by measurement variability, but was higher in patients with mild (F0-F1) fibrosis (AUROC 0.89 vs. 0.72 with F2-F4; P = 0.03). The AUROCs of the CAP for ≥5%, >33% and >66% steatosis were 0.79, 0.76 and 0.70, respectively. CONCLUSIONS: The CAP is a promising tool for the noninvasive detection of hepatic steatosis. Advantages of CAP include its ease of measurement, operator-independence and simultaneous availability with LSM for fibrosis assessment.

Representing complexity well: a story about teamwork, with implications for how we teach collaboration.

OBJECTIVES: In order to be relevant and impactful, our research into health care teamwork needs to better reflect the complexity inherent to this area. This study explored the complexity of collaborative practice on a distributed transplant team. We employed the theoretical lenses of activity theory to better understand the nature of collaborative complexity and its implications for current approaches to interprofessional collaboration (IPC) and interprofessional education (IPE). METHODS: Over 4 months, two trained observers conducted 162 hours of observation, 30 field interviews and 17 formal interviews with 39 members of a solid organ transplant team in a Canadian teaching hospital. Participants included consultant medical and surgical staff and postgraduate trainees, the team nurse practitioner, social worker, dietician, pharmacist, physical therapist, bedside nurses, organ donor coordinators and organ recipient coordinators. Data collection and inductive analysis for emergent themes proceeded iteratively. RESULTS: Daily collaborative practice involves improvisation in the face of recurring challenges on a distributed team. This paper focuses on the theme of 'interservice' challenges, which represent instances in which the 'core' transplant team (those providing daily care for transplant patients) work to engage the expertise and resources of other services in the hospital, such as those of radiology and pathology departments. We examine a single story of the core team's collaboration with cardiology, anaesthesiology and radiology services to decide whether a patient is appropriate for transplantation and use this story to consider the team's strategies in the face of conflicting expectations and preferences among these services. CONCLUSIONS: This story of collaboration in a distributed team calls into question two premises underpinning current models of IPC and IPE: the notion that stable professional roles exist, and the ideal of a unifying objective of 'caring for the patient'. We suggest important elaborations to these premises as they are used to conceptualise and teach IPC in order to better represent the intricacy of everyday collaborative work in health care.

The role of hepatitis B immunoglobulin in hepatitis B related liver transplantation: Canadian Transplant Centre Position Paper.

INTRODUCTION: Hepatitis B virus (HBV) related liver transplant (LT) recipients face a high risk of HBV reinfection in the absence of continuous post-operative HBV prophylaxis. Combination HBV prophylaxis with hepatitis B immune globulin (HBIg) and nucleos(t)ide anti-viral agents prevents HBV recurrence in 90 to 100% of patients who undergo transplantation for hepatitis B and is considered the standard of care in Canada. Post liver transplant HBV prophylaxis protocols vary with regard to the dosing, duration and routes of HBIg administration. All Canadian transplant centres managing liver transplant patients were surveyed as to their HBV transplant protocols. RESULTS: Results of the survey showed that the majority of the Canadian transplant centres use an oral antiviral in combination with long term or indefinite HBIg for prevention of HBV recurrence post liver transplantation. Studies were done to test new protocols using lower HBIg doses given intramuscularly or subcutaneously alone or in combination with antiviral agents.
Conclusion. Long term HBIg administration post transplantation in combination with antiviral agents is an integral part of Canadian HBV related liver transplant protocol.

Ranking in Canadian gastroenterology residency match: what do residents and program directors want?

BACKGROUND: Matching to a gastroenterology (GI) fellowship position in Canada is increasingly competitive. OBJECTIVE: To identify factors that determine how residents rank programs across the country, and how program directors rank their applicants. METHODS: Using input from several current GI trainees and former program directors, two separate surveys were developed. An online survey was sent one month after the match to every resident matched to an adult GI program in the 2007 match. A separate online survey was simultaneously sent to all program directors of 14 accredited GI programs in Canada. Two subsequent cohorts (2008 and 2009) of matched residents were surveyed during the annual GI fellow endoscopy course at McMaster University (Hamilton, Ontario). RESULTS: The overall response rate was 64 of 91 (70%) for residents and 11 of 15 (73%) for program directors (one program had codirectors). Using a five-point Likert scale for rating the importance of various factors influencing their decision, residents from three years ranked the following factor as most important: suitable location for spousepartnerfamily (median score = 5). The overall least important factor was an opportunity for pediatric elective (median score = 2). Using the same scale, program directors ranked the following factors as most important (median score = 5) in ranking residents to their program: the ability to get along with others, outstanding reference letters, exceptional curriculum vitae and applying to only one specialty. CONCLUSIONS: Several factors important for GI applicants and program directors were identified, as well as a few less-important factors. Based on these results, GI training programs can more effectively market their programs to applicants in the future, and residents applying to GI programs can strengthen their applications in the ever competitive match process.

Kidney and liver transplants from donors after cardiac death: initial experience at the London Health Sciences Centre.

BACKGROUND: The disparity between the number of patients waiting for an organ transplant and availability of donor organs increases each year in Canada. Donation after cardiac death (DCD), following withdrawal of life support in patients with hopeless prognoses, is a means of addressing the shortage with the potential to increase the number of transplantable organs. METHODS: We conducted a retrospective, single-centre chart review of organs donated after cardiac death to the Multi-Organ Transplant Program at the London Health Sciences Centre between July 2006 and December 2007. In total, 34 solid organs (24 kidneys and 10 livers) were procured from 12 DCD donors. RESULTS: The mean age of the donors was 38 (range 18-59) years. The causes of death were craniocerebral trauma (n = 7), cerebrovascular accident (n = 4) and cerebral hypoxia (n = 1). All 10 livers were transplanted at our centre, as were 14 of the 24 kidneys; 10 kidneys were transplanted at other centres. The mean renal cold ischemia time was 6 (range 3-9.5) hours. Twelve of the 14 kidney recipients (86%) experienced delayed graft function, but all kidneys regained function. After 1-year follow-up, kidney function was good, with a mean serum creatinine level of 145 (range 107-220) micromol/L and a mean estimated creatinine clearance of 64 (range 41-96) mL/min. The mean liver cold ischemia time was 5.8 (range 5.5-8) hours. There was 1 case of primary nonfunction requiring retransplantation. The remaining 9 livers functioned well. One patient developed a biliary anastomotic stricture that resolved after endoscopic stenting. All liver recipients were alive after a mean follow-up of 11 (range 3-20) months. Since the inception of this DCD program, the number of donors referred to our centre has increased by 14%. CONCLUSION: Our initial results compare favourably with those from the transplantation of organs procured from donors after brain death. Donation after cardiac death can be an important means of increasing the number of organs available for transplant, and its widespread implementation in Canada should be encouraged.

Hepatocellular adenoma(s) arising in nodular regenerative hyperplasia in a patient with systemic lupus erythematosus.

Hepatocellular adenoma (HCA) is a rare benign tumor of the liver with low risk of malignant transformation. It is associated with oral contraceptives/anabolic steroid use, metabolic disease, and rarely, vascular abnormalities. We report an interesting case of HCA arising in a background of diffuse hepatic nodular regenerative hyperplasia (NRH) in a 40-year-old female patient with systemic lupus erythematosus (SLE). She presented with sudden-onset refractory ascites, elevated liver enzymes, diffuse hepatic nodularity and mass lesions on imaging concerning for malignancy. Targeted biopsies of the mass lesion were performed with inconclusive diagnoses. The patient ultimately underwent resection of the mass, which was confirmed as HCA, inflammatory type, arising in a background of NRH. It is not uncommon for SLE patients to have liver manifestations such as NRH, but HCA arising in NRH has not been previously reported. Our case reveals an unusual relationship between HCA and hepatic vasculopathy in the clinical context of a systemic inflammatory condition, the mechanism by which is not fully understood.

Long-term outcomes of emergency liver transplantation for acute liver failure.

Acute liver failure continues to be associated with a high mortality rate, and emergency liver transplantation is often the only life-saving treatment. The short-term outcomes are decidedly worse in comparison with those for nonurgent cases, whereas the long-term results have not been reported as extensively. We report our center's experience with urgent liver transplantation, long-term survival, and major complications. From 1994 to 2007, 60 patients had emergency liver transplantation for acute liver failure. The waiting list mortality rate was 6%. The mean waiting time was 2.7 days. Post-transplantation, the perioperative mortality rate was 15%, and complications included neurological problems (13%), biliary problems (10%), and hepatic artery thrombosis (5%). The 5- and 10-year patient survival rates were 76% and 69%, respectively, and the graft survival rates were 65% and 59%. Recipients of blood group-incompatible grafts had an 83% retransplantation rate. Univariate analysis by Cox regression analysis found that cerebral edema and extended criteria donor grafts were associated with worse long-term survival. Severe cerebral edema on a computed tomography scan pre-transplant was associated with either early mortality or permanent neurological deficits. The keys to long-term success and continued progress in urgent liver transplantation are the use of good-quality whole grafts and a short waiting list time, both of which depend on access to a sufficient pool of organ donors. Severe preoperative cerebral edema should be a relative contraindication to transplantation.

Is serum hepcidin causative in hemochromatosis? Novel analysis from a liver transplant with hemochromatosis.

BACKGROUND: Hepcidin is a circulating hepatic hormone that regulates iron balance. It has been speculated that hepcidin insufficiency or dysregulation may be the primary defect in genetic hemochromatosis. METHODS: A 62-year-old woman underwent elective liver transplantation for chronic hepatitis C cirrhosis. Genetic testing for hemochromatosis was subsequently performed on the donor and recipient. Liver iron concentration was measured in the donated liver at the time of transplantation, and at day 2 and day 652 post-transplant. Serum hepcidin was measured at day 935 in the recipient and in three other liver transplant recipients. RESULTS: The donor was discovered to have significant iron overload without fibrosis, with a liver iron concentration of 326 micromol/g (normal is 0 micromol/g to 35 micromol/g). Genetic testing confirmed that the 89-year-old female donor was a typical C282Y homozygote for hemochromatosis. The recipient did not carry either the C282Y or the H63D mutation of the HFE gene for hemochromatosis. Liver biopsy was performed on the recipient on day 2 and day 652 post-transplant; the liver iron concentrations were 333 micromol/g and 253 micromol/g, respectively. Serum hepcidin in the recipient was elevated at 111 ng/mL compared with that of the three other ambulatory liver transplant recipients (66 ng/mL, 76 ng/mL and 81 ng/mL). CONCLUSION: The liver transplant recipient described in the present report demonstrated a slight decrease in liver iron concentration over a 1.8-year follow-up period without specific therapy. Hepcidin insufficiency as a primary cause of genetic hemochromatosis seems unlikely based on the clinical profile of the present patient and the hepcidin measurements.

Tobacco Use is a Modifiable Risk Factor for Post-Transplant Biliary Complications.

PURPOSE: Biliary complications following liver transplantation are a significant source of morbidity, potentially leading to graft failure necessitating retransplantation. We sought to evaluate smoking as an independent risk factor for post-transplant biliary complications. METHODS: The clinical course of all adult primary deceased donor liver transplants at our center from 1992 to 2012 was reviewed. Eligible patients were assigned to cohorts based on their lifetime tobacco exposure: never smokers indicating 0 pack-year exposure and all others were ever smokers. Biliary complications were defined as strictures, leaks, or bilomas requiring intervention. Complication rates were analyzed using univariate regression models correlated with donor and recipient characteristics. Associations found during univariate analysis were included in the final multivariate Cox model. RESULTS: Eight hundred sixty-five subjects were followed for a median of 65 months; 482 (55.7%) of patients had a positive smoking history at the time of transplant. In univariate analysis, positive tobacco smoking history (HR = 1.36; p = 0.037) and increased time from quit date to transplantation (HR = 0.998; p = 0.011) were positive and negative predictors of biliary complication, respectively. Lifetime tobacco exposure remained a significant predictor of biliary complication on multivariate analysis (HR = 1.408; p = 0.023). CONCLUSIONS: Smoking status is an independent predictor of post-transplant biliary complications, and the data presented reinforces the importance of early smoking cessation in the pre-transplantation period.

Interpreting Outcomes in DCDD Liver Transplantation: First Report of the Multicenter IDOL Consortium.

BACKGROUND: In the United States, 5% of adult liver transplant recipients receive a graft donation after circulatory determination of death (DCDD). Concerns for ischemic cholangiopathy (IC), a disease of diffuse intrahepatic stricturing limits broader DCDD use. Single-center reports demonstrate large variation in outcomes. METHODS: Retrospective deidentified data collected between 2005 and 2013 were entered electronically by 10 centers via a Research Electronic Data Capture database. Our primary outcome was development of intrahepatic biliary strictures consistent with IC. RESULTS: Within 6 months post-DCDD transplant, 162 (21.8%) patients developed a biliary stricture, of which 88 (11.8%) exhibited intrahepatic structuring consistent with IC. Unadjusted 6-month IC rate among the 10 centers varied significantly (P = 0.006) from 6.3% to 25.9%. The only factor associated with increased risk of IC within 6 months was Roux-en-Y hepaticojejunostomy (vs duct-to-duct) (odds ratio, 3.06; 95% confidence interval, 1.52-6.16; P = 0.002). Graft failure by 6 months was more than 3 times higher for DCDD recipients with IC (odds ratio for IC, 3.36; 95% confidence interval, 1.95-5.79). CONCLUSIONS: This first report of the large combined experience with DCDD from the Improving DCDD Outcomes in Liver Transplant consortium demonstrates significant differences in IC among centers, the importance of biliary strictures as a risk factor for graft failure, and does not validate other risk factors for IC found in smaller studies.