Percutaneous Transhepatic Radiologic Intervention of Biliary Complications following Liver Transplantation: A Single-center Experience.

Background: Biliary complications are the leading cause of morbidity and mortality in patients undergo¬ing Liver Transplantation (LT). Post-biliary transplantation strictures (BSs) are a severe problem with a high risk of graft failure. However, management of these BSs has remained controversial, and consid¬erable variability has been reported in Percutaneous Transhepatic Radiological Interventions (PTRIs) related to broad differences in technical procedures. Objective: This study aimed to evaluate the efficacy of percutaneous treatments in managing post-LT BSs in a center in Shiraz. Methods: PTRIs including balloon dilatation, metallic stent, and internal or internal-external hand-made plastic stent insertion were done for 34 transplanted patients with BSs referring to the Interventional Radiology Unit of Shiraz Namazi Hospital. Technical success rate, patency rates, and complications were evaluated. Results: The. In this study, 31 strictures were successfully treated without any significant difference between the anastomotic and non-anastomotic types of stricture (success rate: 91.2%). Based on the results, 12- , 24-, and 36-month primary patency rates were 90.1%, 84.5%, and 76.8%, respectively. The secondary patency rate was 100% at 12 and 24 months and 93.3% at 36 and 60 months. The rate of minor complica¬tions (mild cholangitis and hemobilia) was 6.4%, and no major complications were detected. Conclusion: According to the findings, PTRI is an effective method for treating anastomotic and non-anas- tomotic strictures with a high success rate and low complications.

Importance of miR-UL-148D Expression Pattern in Cytomegalovirus Infected Transplant Patients.

Background: MicroRNAs (miRNAs) are endogenous, 18-22 nucleotide non-coding RNA molecules. Human cytomegalovirus (HCMV) is a ubiquitous and particular herpes virus that encodes miRNAs, which increases gradually in the presence of infection. One of the important viral miRNAs is HCMV-miRUL-148D, which plays a role in establishing and maintaining viral latency. Objective: The current study aimed to evaluate the expression levels of HCMV-miRUL-148D in active and inactive HCMV infected transplant patient groups compared to healthy individuals. Methods: Total RNA was extracted from blood samples of 60 solid organ transplant patients and 30healthy controls. In-house SYBR Green Real-Time PCR evaluated the expression levels of studied miRNAand gene. Results: The expression level of the UL-148D gene was significantly higher in the active HCMV infectedpatients (p=0.001) compared to other groups. While the miRUL-148D expression level significantly increased in the inactive HCMV-infected patients (p<0.001) compared to other groups. Conclusion: Increased miRUL-148D expression level in the inactive HCMV-infected transplant patients indicates the potential role of this miRUL-148D as a biomarker of the HCMV latent stage.

Association between Interleukin-21, 23 and 27 Expression and Protein Level with Cytomegalovirus Infection in Liver Transplant Recipients.

BACKGROUND: Cytokines have regulatory crosstalk with CMV infection leading to manage of post-liver transplantation virus-related outcomes. OBJECTIVE: To investigate the link between IL-21, IL-23 and IL-27 mRNA and protein level with active CMV infection, which was evaluated in reactivated and non-reactivated liver transplant recipients. METHODS: Two groups of liver transplant recipients were enrolled in this study-54 without and 15 with active CMV infection. 3 EDTA-treated blood samples were taken on day 1, 4, and 7 post-liver transplantation. Plasma and buffy coats of all samples were separated. All samples were analyzed for CMV reactivation using antigenemia technique. The separated plasma of positive samples was used for viral DNA extraction and protein evaluation. For evaluating the mRNA expression level by real-time PCR, RNA extraction and cDNA synthesis were done for all samples. Also, the protein level of studied genes was estimated by ELISA. RESULTS: The expression level of IL-21, IL-23A and IL-27A cytokine genes was increased in CMV reactivated liver transplant recipients in comparison with CMV non-reactivated ones; IL-27A expression pattern was significant (p=0.001) at all sampling times. IL-21 significantly increased on the 2nd and 3rd (p=0.028 and 0.01, respectively) sampling days in CMV reactivated compared with non-reactivated patients. The expression level of IL-23A cytokine significantly increased on the 3rd (p=0.017) sampling day in CMV reactivated compared with non-reactivated liver transplant recipients. CONCLUSION: Elevation in the expression level of IL-21, IL-23A and IL-27A mRNA and protein level in CMV reactivated patients emphasized on the antiviral role of these cytokines in CMV reactivated liver transplant recipients.

Donors' Quality of Life after Living Donor Liver Transplantation: Shiraz Organ Transplant Center Experience.

BACKGROUND: Probable effects of living donor liver transplantation on the wellbeing of the donor and psychological difficulties are necessary to be understood. OBJECTIVE: To assess the quality of life of living donors after liver donation. METHODS: 140 living donors who underwent hepatectomy between 2012 and July 2015 were enrolled in this study. Donors were asked to complete the Short Form 36-question Health Survey (SF-36) through face to face or by telephone interview. RESULTS: The mean±SD age of donors at transplantation was 32.1±7.3 years; 83 (59.3%) of donors were female. 134 (95.7%) were married. The mean±SD BMI was 23.8±3.5 (kg/m2). "Mother-to-child" was the most frequent relationship (n=79, 56.4%). 22 (15.7%) complications were reported by participants. The mean±SD score of Physical Component Summary and Mental Component Summary were 48.8±14.6 and 50.1±6.9, respectively. CONCLUSION: Most living donors sustain a near average quality of life post-donation. It seems that living donation does not negatively affect the quality of life.

Effects of Different Cold Preservation Solutions on the Functions of Cultured Isolated Human Hepatocytes.

BACKGROUND: Hepatocyte transplantation using isolated human hepatocytes is an alternative source that can be used for the treatment of metabolic diseases and acute liver failure as a time bridge to liver transplantation. These cells can also be used for bioartificial liver systems and in vitro study of drug toxicity. OBJECTIVE: To determine which cold preservation solution is better maintain the liver function. METHODS: We prepared 4 cold preservation solutions made of different combination of antioxidants, chelating, membrane protective, and anti-apoptotic agents as well as inhibitor of cyclophilin D. For hepatocyte isolation, we used livers obtained from unused deceased donor livers and the liver of patients with Crigler-Najjar syndrome who were candidates of partial liver transplantation. After culture and cold preservation, the level of albumin, and urea production were measured as indices of liver functionality. RESULTS: We found that albumin production significantly decreased after cold preservation in solution 1. There was no significant difference in urea production after cold preservation in solution 1 compared with control 24 h. No significant differences in albumin production were found after cold storage in solution 2 and solution 4 compared with control 24 h. Urea production significantly decreased after cold storage in solutions 2 and 4 compared with control 24 h. As a whole albumin and urea production were significantly decreased after cold preservation. Although albumin and urea production were decreased after cold preservation, but the results of albumin production of two solutions were not significantly different from that of the control group (p=0.109 and 0.951). CONCLUSION: Cold preservation of cultured human hepatocytes in solution 2 and solution 4 could maintain the function of albumin production better than other cold preservation solutions in our experiments; solution 1 was more effective on urea production of cultured human hepatocytes at 4 °C for 24 h. To determine if these hepatocytes are suitable candidates for transplantation, further studies should be performed.

Severe Cutaneous Candidiasis in a Liver Transplant Patient.

Candida infections are common diseases in immunocompromised patients. A 19-year-old boy with liver transplantation, necrotic skin lesion, jaundice, dyspnea, and ascites was admitted to Namazi Hospital, Shiraz, southern Iran. The mycological examination for the skin lesion was requested. The skin sample was cultured on Sabouraud dextrose agar and evaluated by direct microscopic smear. Identification of isolated yeast was performed with RFLP-PCR. In direct smear, pseudohyphae, blastopores and yeasts were observed. Candida species was isolated from the media and identified as Candida albicans by molecular method. He died before starting any treatments. A skin lesion may present as the only sign of a systemic fungal infection in immunocompromised people. Careful attention and follow up are therefore recommended.

The Genotype Frequency of CYP2C19 Enzyme after Liver Transplantation.

BACKGROUND: Liver transplant recipients are treated with various drugs, the metabolism of which is dependent on the cytochrome P450 polymorphic genotype. OBJECTIVE: To identify the polymorphic variety of CYP2C19 genotype in liver allograft before and after transplantation. METHODS: The study was conducted on 88 liver recipients. The CYP2C19 genotypes in donors and recipients were the same in 32 and different in 56 recipients. Extracted genomic DNA from the leukocytes and liver graft tissues were analyzed by TaqMan SNP genotyping assay. The distributions of homozygote, heterozygote, poor and ultra-rapid metabolizers' genotypes were investigated in both groups. RESULTS: The distributions of CYP2C19 genotypes before transplantation in the blood and liver graft were within the normal range. After transplantation, in patients with different CYP2C19 genotype in donors and recipients, the genotypes of homozygote and ultra-rapid metabolizers were significantly decreased (p=0.024); the heterozygotes and poor metabolizer genotypes were significantly increased (p=0.017). CONCLUSION: The variety in CYP2C19 genotyping must be considered in patients with different genotypes in donor and recipients to predict the dosage regimens, optimize the treatment and decrease toxicity.

The Effects of Cold Preservation Solutions Supplemented with UDCA and α-Lipoic Acid on the Viability and Function of Isolated Human Hepatocytes.

BACKGROUND: Liver transplantation is the only treatment for end-stage and genetic liver diseases. The main burden of this treatment is the shortage of both living and cadaveric liver donors. An alternative treatment is using liver cell transplantation, which can be obtained from unused livers for transplantation. These hepatocytes should be kept ready in viable and functional situation in a frozen state to be instantly used when they would be needed. In our previous experience, we had isolated hepatocytes from unused livers. OBJECTIVE: To find a preserving solution for increasing viability and function of the isolated hepatocytes that are stored to be transplanted. METHODS: 9 cadaveric donor livers, which were not used for transplantation due to various causes such as severe steatosis, were selected to isolate hepatocytes. Various cold storage solutions were tried to find the best temperature for more viability and functionality for preservation of hepatocytes. University of Wisconsin (UW) solution and Williams E media were used as control media. 2 anti-apoptotic and anti-oxidative solutions, i.e., α-lipoic acid and ursodeoxycholic acid (UDCA), were used as cold preservatives solutions. The numbers of viable hepatocytes were estimated by trypan blue method; the functionality was assessed by the cells ability to produce urea. RESULTS: The highest number of viable and functional hepatocytes was obtained from freshly isolated cells. However, after preservation, the number of these viable hepatocytes and their functionality were not significantly different in cold storage solutions comparing to the control media used. Functionality of the isolated hepatocytes stored in UW with and without UCDA solution was similar to freshly isolated hepatocytes. CONCLUSION: Preservatives with anti-apoptotic and antioxidant activity could not increase the number of viable hepatocytes. Functionality of cold storing hepatocytes could be preserved similar to freshly isolated hepatocytes by UW solution with and without UCDA.

Liver failure and the need for transplantation in three patients with hepatoportal sclerosis.

Hepatoportal sclerosis (HPS) is one of the causes of noncirrhotic portal hypertension. In most patients, hepatic synthetic dysfunction does not occur; rarely they may require liver transplantation. In this study, we have reported the clinicopathologic characteristics of 3 patients diagnosed with HPS after examination of the explanted liver. Small liver volume, significant portal fibrosis, and phlebosclerosis may contribute to hepatic synthetic dysfunction in patients with HPS.

Prevalence of CYP2C19 Genetic Polymorphism among Normal People and Patients with Hepatic Diseases.

BACKGROUND: Patients with hepatic diseases are treated with numerous drugs metabolized by cytochrome P450. OBJECTIVE: To evaluate the frequencies of CYP2C19 variant alleles (*2, *3, and *17), genotypes, and phenotypes, and the relationship between the frequency of these alleles and the underlying hepatic diseases among patients with advanced liver diseases who were candidates for liver transplantation. METHODS: The Study was conducted on 120 patients suffering from various hepatic disorders, candidates for liver transplantation, and 52 healthy volunteers. DNA was extracted from blood samples and analyzed by TaqMan SNP genotyping assay. The CYP2C19 genotypes were classified into poor, extensive, intermediate, and ultra-rapid metabolizer phenotypes. RESULTS: Viral hepatitis was the most common cause of liver disease among studied patients. The frequencies of CYP2C19 alleles *1, *17, and *2 were 66.7% (160/240), 20.8% (50/240) and 12.5% (30/240), respectively. Allele CYP2C19*3 was not found in the studied population. The most prevalent genotypes were CYP2C19 *1/*1 (47.5%) and *1/*17 (24.2%). The predicted CYP2C19 phenotypes were extensive metabolizer (47.5%), heterozygote extensive metabolizer (45.9%), ultra-rapid metabolizer (5%), and poor metabolizer (1.6%). There was no significant difference between the frequencies of CYP2C19 genotypes between healthy people and patients. The distribution of CYP2C19 genotype frequencies was not significantly associated with the underlying disease conditions (p=0.472). CONCLUSION: The distribution of CYP2C19 genotype frequencies in Iranian healthy people and patients with various hepatic diseases was not significantly different. This may allow the physicians to predict a tailoring dose regimens based on the individual's metabolic capacity, decrease the risk of harmful side effects of the drugs, and optimize the treatment.

Value of Histopathologic Findings of Post-reperfusion Liver Needle Biopsies.

BACKGROUND: Histopathologic changes of post-reperfusion liver needle biopsies in patients with liver transplantation have rarely been reported and most of the previous reports have been in less than 200 cases. OBJECTIVE: In this study, we evaluated 408 post-perfusion liver needle biopsies for the histopathologic changes attributable to reperfusion injury and compared them with early post-liver transplantation outcome, to find out the value of these findings. METHODS: In 408 patients who underwent liver transplantation, post-perfusion liver needle biopsy was taken within one hour of vascular anastomosis. The specimens were fixed in formalin and evaluated by a hepatopathologist blinded to the outcome of transplantation for hepatocellular necrosis, apoptosis, ballooning degeneration, cholestasis, neutrophilic infiltration, and steatosis. These were compared with cold and warm ischemic time, levels of AST, ALT, alkaline phosphatase, bilirubin, presence or absence of rejection, and duration of hospital stay. RESULTS: Hepatocellular ballooning degeneration, apoptosis, and necrosis did not show any significant correlations with early post-transplantation outcome and reperfusion injury. However, presence of neutrophilic infiltration in the post-reperfusion liver biopsy was well correlated with liver function tests and other clinical and paraclinical findings. Presence of steatosis in post-reperfusion liver needle biopsy was also associated with high liver function tests and long hospital stay. CONCLUSION: Presence of PMN leukocytes in the post-perfusion liver needle biopsy of transplanted liver is associated with poor early outcome and reperfusion injury, so it should be recorded in the pathology report and should be considered a high-risk sign for the clinicians.

Association between IRF1 Gene Expression and Liver Enzymes in HBV-infected Liver Transplant Recipients with and without Experience of Rejection.

BACKGROUND: Liver function indices and anti-viral immune regulatory markers can both improve graft outcomes, which lead to better post-transplantation management and increase the possibility of surveillance in liver transplant recipients with chronic hepatitis B virus (HBV) infection. OBJECTIVE: To determine the association between the interferon regulatory factor 1 (IRF1) mRNA levels and liver enzymes in HBV-infected liver transplant recipients with and without experience of rejection. METHODS: A total of 46 chronic HBV-infected patients who had undergone liver transplant surgery was divided into 2 groups of recipients "with rejection" and "without rejection.". Blood samples were collected form each patient on days 1, 4, and 7 post-transplantation. A SYBER GREEN real-time PCR was used to evaluate the expression level of IRF1 in liver recipients. Liver enzyme activities were also measured in all patients. RESULTS: The expression of IRF1 in the patients with rejection was up-regulated at all 3 follow-up days compared with those without rejection. The serum levels of ALT and AST were more than normal levels at 3 follow-up times in both study groups. Significant differences were found in IRF1 gene expression levels and also serum ALT levels between those with and without rejection after 7 days post-transplantation. CONCLUSION: The IRF1 expression and serum ALT levels were increased significantly in patient with rejection compared to those without rejection. IRF1, an inflammatory factor, may also intensify induction of inflammatory pathways in engrafted liver and promote liver inflammation and injuries leading to liver enzymes elevation in patients with graft rejection.

Comparison of Child-Turcotte-Pugh and pediatric end-stage liver disease scoring systems to predict morbidity and mortality of children awaiting liver transplantation.

BACKGROUND: The pediatric end-stage liver disease (PELD) scoring system has been used widely for prioritizing children awaiting orthotopic liver transplantation (OLT). The aim of the present study was to compare the Child-Turcotte-Pugh scoring system with PELD to predict morbidity and mortality of children scheduled for OLT before the organ was available. MATERIALS AND METHODS: From 1999 to 2006, 83 infants and children were evaluated and scheduled for OLT. Child and PELD scores were determined according to the initial assessment at the time of listing. Outcome was examined using records and follow-up data. RESULTS: Among 83 patients, 12% were Child A; 53%, Child B; and 35%, Child C. The mean PELD score at listing was 19.8+/-12.8. Patients with Child scores A, B, and C displayed mean PELD scores of 7.1+/-4.9, 15.7+/-9.3, and 30.5+/-11.7, respectively. Child classification and scoring showed a positive correlation with the PELD score (Spearman's correlation coefficient: 0.666, P=.001). A higher PELD score was associated with greater morbidity and mortality. CONCLUSION: Child classification has several shortcomings; therefore, PELD scores appear to be the best metric to prioritize children listed for OLT.

Does donor's fatty liver change impact on early mortality and outcome of liver transplantation.

BACKGROUND: The effect of donor fatty liver on graft survival is still uncertain. The aim of this study was to determine the influence of steatosis on the outcomes of OLT among our recipients. METHODS: In this retrospective study, we evaluated the effect of donor liver steatosis on postoperative liver function and prognosis. Data obtained from liver transplantation data registry of our organ transplant center. Liver biopsies taken before transplantation were reviewed by two pathologists. Pathology reports were divided into four groups: normal pathology; mild fatty change (10%-30%); moderate (30%-60%); and severe steatosis (>60%). Livers with severe steatosis were excluded from transplantation. Factors determining transplantation outcome, such as early mortality, duration of intensive care unit (ICU) and hospital stay, clinical rejection episodes, and graft surgical complications, were compared between subjects who received donor liver, with various degrees of steatosis. RESULTS: Three-month survival rates in recipients without donor liver fatty change, subjects with mild fatty change (10%-30%) and those with moderate (30%-60%) steatosis were 68%, 72%, and 76%, respectively, which were not significantly different (P>.05). Furthermore, short-term (hospital) mortality (20%, 14.3%, and 21.2%), hospital stay (30.89, 29.93, and 23.62 days), and length of ICU admission (5.06, 5.89, and 4.39 days) were not significantly different. In addition, Child score of recipients, pre- and postoperative liver function enzyme changes were similar. CONCLUSION: Mild-to-moderate (up to 60%) liver fatty change was not found to be associated with a worse prognosis in OLT.

Comparison of early outcome and histologic findings of enteric drainage with bladder drainage in pancreas transplantation of dogs.

BACKGROUND: The clinical and pathological findings of enteric-drained (ED) versus bladder-drained (BD) pancreas transplantation are still controversial. In this study, we compared early outcome and histological findings of these 2 methods. METHODS: In an experimental animal model, after diabetization, 16 dogs were randomly divided into 2 groups. In the first group, the pancreas was transplanted with enteric drainage, and in the second group, with bladder drainage. We evaluated early clinical and pathological outcomes. RESULTS: The mean survival time was 11.25 +/- 5.0 (range, 5-20) days for group 1 and 13.6 +/- 7.2 (range, 3-23) days for group 2 (P>.05). Fasting blood sugar values (FBS) before transplantation were 279 +/- 26.8 mg/dL versus 278 +/- 41.6 mg/dL, respectively (P>.05). Two weeks postoperative serum FBS had decreased to 84.9 +/- 2.9 versus 84.2 +/- 0.98, respectively (P>.05). Serum amylase in the BD and ED groups were 378.5 +/- 328 versus 422.6 +/- 54.7 mg/dL, respectively (P>.05). Early leakage was not observed in dogs with BD, whereas it was 37.5% among dogs with ED (P<.05). Clinical and pathological evidences of pancreatic necrosis occurred in 37.5% of dogs with BD versus 62.5% of dogs with ED (P>.05). DISCUSSION: Although the early outcomes of these drainage methods (ED vs BD) were statistically similar more dogs with ED experienced early complications than with BD.

Transplantation of a cadaveric liver allograft with right lobe cavernous hemangioma, without back-table resection: a case report.

UNLABELLED: The use of extended criteria liver donors has become a necessity in an era of organ scarcity for transplantation. We present here a case report of orthotopic liver transplantation using a liver with a giant right lobe hemangioma without backtable resection. CASE REPORT: There were no data regarding the liver mass before organ procurement. The donor liver function tests and electrolyte profile were normal. During donor exploration a hemangioma was identified in segments V-VI, occupying approximately 20% of the total liver volume. It was prepared for transplantation on a sterile backtable without performing backtable hemangioma resection. A standard orthotropic liver transplant procedure was performed uneventfully, without veno-veno bypass. There was no bleeding from the hemangioma. The ischemic time was 9 hours and 20 minutes. Postoperative course was uneventful and the patient was discharged at 19 days after the operation. The hemangiomas showed evolution with some decrease in size upon later follow-ups. No clinically important complication was observed. CONCLUSION: Our case and other previous reports show that even large hemangiomas should not be considered to be a contraindication to organ procurement. These benign lesions either could be left in situ and observed or resected.

Are large nonfunctional kidneys risk factors for posttransplantation urinary tract infection in patients with end-stage renal disease due to autosomal dominant polycystic kidney disease?

OBJECTIVES: The objective of this study was to evaluate the effect of bilateral nephrectomy on posttransplantation urinary tract infection (UTI) among patients with end-stage renal disease (ESRD) due to autosomal dominant polycystic kidney disease (ADPKD). METHODS: In a retrospective case-control design, 62 patients with ESRD with ADPKD were divided into 2 groups: (A) 24 patients who underwent bilateral nephrectomies, and (B) 38 patients in whom bilateral nephrectomies had not been done. Pretransplantation and posttransplantation urine cultures were evaluated for UTI. RESULTS: Sixty-two patients with ESRD with ADPKD were enrolled in this study. The average age was 42 years (range, 6-60 years). Forty patients (64.5%) were male and 22 (35.5%) were female. The mean duration of hemodialysis was 24 months (range, 2-120 months), which was the same for both groups. Bilateral nephrectomies were done for 24 participants (38.7%). There were 38 patients (61.3%) in group B who did not have the operation. UTI occurred in 23 patients (37.1%): 6 patients (25%) in group A and 17 patients (44.7%) in group B. The incidence of UTI was not statistically different between the 2 groups (P>.05). Furthermore, no relationship was found between age, gender, blood group, and UTI in patients with ADPKD (P>.05). CONCLUSION: According to our study, the presence of large nonfunctional kidneys is not a risk factor for posttransplantation UTI in patients with ADPKD and ESRD.

Early hepatic artery thrombosis after liver transplantation: diagnosis and treatment.

BACKGROUND: Hepatic artery thrombosis (HAT) occurs in 3% to 9% of all liver transplantations with acute graft failure as a possible sequel. METHODS: Eleven episodes of HAT were identified among 256 orthotropic liver transplantations (whole, LDCT, split) performed on 253 patients between April 1993 and July 2006. HAT was suspected clinically and confirmed by Doppler ultrasonography, magnetic resonance angiography, angiography, or reexploration. One patient was excluded due to poor follow-up. Treatment options included exploration with HA thrombectomy plus thrombolysis, retransplantation, or conservative treatment of hepatic and biliary complications. RESULTS: Among 11 patients of mean age 29.98 +/- 17.14 years (range, 10 months to 56 years). 2 had split right lobe liver transplantations and 9 received whole organs. None of LDLTs were identified to have HAT. The causes of liver cirrhosis among HAT patients were autoimmune hepatitis (n=3), cryptogenic (n=3), Wilson (n=1), PBC (n=1), biliary atresia (n=1), and HBs (n=1). HAT was diagnosed at 5.9 +/- 4.43 (range, 2 to 16) days after operation. Most patients developed right upper quadrant (RUQ) pain at presentation. Two patients developed acidosis, fever, or SIRS and underwent retransplantation. Four underwent exploration of HA and 1 was treated conservatively. Three cases expired due to HAT complications. CONCLUSION: We found RUQ pain to be the presenting sign of early HAT in majority of cases. RUQ pain has been reported to occur in late HAT. Whenever HAT is confirmed, liver transplanted patients should be revascularized or even retransplanted. Intra-arterial thrombolysis and thrombolytic therapy for HAT should be done cautiously due to the potential risk of hemorrhage.

The effect of clamping of inferior vena cava and portal vein on urine output during liver transplantation.

BACKGROUND: Intraoperative hypotension, massive transfusion, liver disease, coexistent renal dysfunction, and decreased glomerular filtration rate during the anhepatic phase are major hazards for kidney function. We undertook this study to determine the change in urine output during clamping. METHOD: Twenty-four patients without preexistent renal disease, who were undergoing liver transplantation using the piggyback method, were enrolled in this study. Patients with a serum creatinine level >1.2 mg/dL were excluded. Urine output was monitored over 30 minutes before inferior vena cava and portal vein clamping, during clamping, and for 30 minutes after declamping. None of the patients had a clamping time >70 minutes. Our goal was to maintain mean arterial blood pressure and heart rate just by fluid administration diuretics were avoided. RESULTS: Participants had a mean age of 39.12 +/- 13.52 years (range, 15-67 years) with a male to female ratio of 1:4. Urine output 30 minutes before clamping was 3.64 +/- 3.58 (range, 1.25-15.18) mL/kg/h, decreased to 1.28 +/- 2.58 (range, 0-11.39) mL/kg/h during clamping (P=.00), and increased to 3.56 +/- 3.64 (range, 0.51-15.18) mL/kg/h 30 minutes after declamping (P=.00). CONCLUSION: Urine output was significantly reduced in all patients after clamping of the IVC and portal veins. This observation may be explained by increased venous pressure leading to decreased renal perfusion pressure. It has been stated that one of the advantages of veno-veno bypass (VVB) is increased renal perfusion pressure. However, if the clamping time in the piggyback method is <70 minutes and patients have normal preoperative renal function, the decreased renal perfusion pressure will not cause postoperative kidney dysfunction.

Role of Histopathologist in Liver Transplantation.

A successful liver transplantation team consists of several specialists to work closely together. The histopathologist (anatomical pathologist) is one of the key players in this multidisciplinary team. This role starts with the pre-transplantation evaluation of the recipient's liver by diagnosis or confirming the underlying liver disease and continues with the evaluation of the explanted recipient's liver for any further information about the underlying liver disease including malignancies such as hepatocellular carcinoma, cholangiocarcinoma, or any other incidental findings. The evaluation of the new donor liver begins with determining the suitability of the donor liver for transplantation during or before the operation and continues throughout the entire post-transplantation period by evaluating not only the allograft diseases but also evaluating other tissues for infections, malignancies, etc. It is worthy to note that in many of the above-mentioned situations, histopathology is the gold-standard diagnostic test. In this review, we present on various tasks of a histopathologist according to the current literature and our own experience in the largest liver transplantation center in Iran.