Reuse of liver grafts following the brain death of the initial recipient.

AIM: To determine if there is a reasonable prospect of success of a re-use liver transplantation. METHODS: We systematically searched for reports of liver graft re-use using electronic searches of PubMed and Web of Knowledge. We performed hand searches of references lists of articles reporting re-use of grafts. RESULTS: A systematic review of the literature reveals 28 liver transplantations using previously transplanted grafts. First and second recipients ranged in age from 4 to 72 years and 29 to 62 years respectively. Liver disease in the first recipient was varied including 5 (18%) patients with fulminant liver failure who died subsequently of cerebral edema. The second transplantation was performed after a median interval of 5 d (one day-13 years). Viral hepatitis was present in 3 (11%) of the initial recipients and in 8 (29%) of final recipients. Hepatocellular carcinoma was present in 6 (21%) of the final recipients. Early survival after the final transplantation was 93%, whereas long-term survival was 78% with a mean follow-up of 23.3 (3-120) mo. CONCLUSION: Outcomes of transplantation using previously transplanted grafts in this select population are similar to those seen with conventional grafts.

Evaluation of renal function in liver transplant recipients receiving daclizumab (Zenapax), mycophenolate mofetil, and a delayed, low-dose tacrolimus regimen vs. a standard-dose tacrolimus and mycophenolate mofetil regimen: a multicenter randomized clinical trial.

Posttransplant chronic renal failure, secondary to calcineurin inhibitor agents, is emerging as a major problem in liver transplantation. We report a randomized clinical trial comparing daclizumab, delayed low-dose tacrolimus (target trough level 4-8 ng/mL, starting day 4-6), Investigational Arm (n = 72), to standard tacrolimus induction/maintenance dosing, Standard Arm (n = 76), with mycophenolate mofetil and tapering corticosteroids in both study arms. The end-points were renal function indicated by the Modification of Diet in Renal Disease (MDRD). There was no significant difference in patient survival (86.6% Investigational Arm vs. 92.9% Standard Arm; P = 0.21) or acute rejection (23.2% vs. 27.7%, respectively; P = 0.68). Statistically significant differences in median glomerular filtration rate (GFR) were found in favor of the Investigational Arm. With the CG equation, the GFR at the end of the first week was 110.7 vs. 89.6 mL/min (P = 0.019) without significant differences thereafter. With the MDRD, statistically significant differences extended to the first posttransplant month (86.8 vs. 70.1 mL/min/1.73 m(2); P < 0.001) with and was seen at month 6 (75.4 vs. 69.5 mL/min/1.73 m(2); P = 0.038). In conclusion, delayed low-dose tacrolimus, in combination with daclizumab and mycophenolate mofetil, preserves early renal function post-liver transplantation without the cost of increased acute rejection.

Retransplantation for recurrent hepatitis C: the argument against.

1. Cirrhosis from chronic hepatitis C is the most common indication for liver grafting today. The course of hepatitis C is accelerated after liver transplantation, and no current therapy reliably prevents or arrests it. 2. It is anticipated that 20% or more of hepatitis C virus-positive transplant recipients will develop allograft cirrhosis, and the only solution will be retransplantation. 3. Results of retransplantation are inferior to primary transplantation. 4. Recipient risk factors that adversely affect mortality after repeated liver grafting include age older than 50 years, renal insufficiency, and severity of hyperbilirubinemia. When present, they reduce survival after retransplantation to approximately 40% or less. 5. Retransplantation on a large scale for recurrent hepatitis C is problematic from the perspectives of outcome, resource utilization, and fairness to candidates awaiting primary grafts.

Practical considerations of right lobe living donor liver transplantation in adults.

The practice of living donor liver transplantation in adults has developed rapidly over the past five years and brings with it a set of unique technical and ethical challenges. The evaluation of potential donors focuses on their health and motives, and the results of noninvasive imaging, with the objective of ensuring the best outcomes for both donors and recipients. Graft volume is critical to success, and venous outflow reconstruction is paramount, although there is no consensus on the preferred method. Biliary tract complications occur in 30% of recipients. Complications that may interfere with recovery or delay the return to well-being occur in one of every four or five donors. The precise risk of donor death cannot be stated with certainty because comprehensive data on all cases are not available. It is clear, however, that donation of the right lobe of the liver carries with it a much greater risk of mortality than kidney donation. The paucity of details reported on donors who have died make it impossible to determine to what extent the deaths were preventable. The option of living donation is an invitation to expand the criteria for recipient selection to include, for example, patients with tumours that exceed traditional transplant guidelines. The risk-benefit ratios for donors become especially problematic when post-transplant recipient survival is below current standards.

Cavoportal transposition for portal vein thrombosis in a pediatric living-related liver transplantation.

We report a case of a living-related liver transplantation in a child in whom diffuse thrombosis of the portal venous system required the use of recipient vena cava to perfuse the donor portal vein (cavoportal transposition). An 8 (1/2)-month-old infant with biliary atresia received the left lateral segment of his father's liver. The child's portal vein was irretrievably thrombosed, as were the splenic and superior mesenteric veins. A cavoportal anastomosis provided excellent flow to the liver, and there was no engorgement of the graft, which had good immediate function. The main postoperative problem was loss of 3 to 3.5 liters of ascitic fluid through the drain for 2 weeks. The ascites eventually resolved over a period of 4 weeks. Twenty-four months after transplantation, the child is thriving on a normal diet and has no ascites. A Doppler examination showed good flow in the cavoportal anastomosis.