Should a lower quality organ go to the least sick patient? Model for end-stage liver disease score and donor risk index as predictors of early allograft dysfunction.

BACKGROUND: There is a global tendency to justify transplanting extended criteria organs (ECD; Donor Risk Index [DRI] ≥ 1.7) into recipients with a lower Model for End-Stage Liver Disease (MELD) score and to transplant standard criteria organs (DRI < 1.7) into recipients with a higher MELD scores. There is a lack of evidence in the current literature to justify this assumption. METHODS: A review of our prospectively entered database for donation after brain death (DBD) liver transplantation (n = 310) between January 1, 2006, and September 30, 2010, was performed. DRI was dichotomized as <1.7 and ≥ 1.7. Recipients were divided into 3 strata, those with high (≥ 27), moderate (15-26), and low MELD (<15) scores. The recently validated definition of early allograft dysfunction (EAD) was used. We analyzed EAD and its relation with donor DRI and recipient MELD scores. RESULTS: The overall incidence of EAD was 24.5%. Mortality in the first 6 months in recipients with EAD was 20% compared with 3.4% for those without EAD (relative risk [RR], 5.56, 95% confidence interval [CI], 1.96-15.73; P < .001). Graft failure rate in the first 6 months in those with EAD was 27% compared with 5.8% for those without EAD (RR, 4.63; 95% CI, 2.02-10.6; P < .001). In patients with low MELD scores, a significantly increased rate of EAD (25%) was seen in patients transplanted with a high DRI liver compared with those transplanted with a low DRI liver (6.25%; P = .012). In moderate and high MELD recipients, there was no significant difference in the rate of EAD in patients transplanted with a high DRI liver (62%) compared with those transplanted with a low DRI liver (59%). CONCLUSION: These results suggest that contrary to common belief it is not justified to preferentially allocate organs with higher DRI to recipients with lower MELD scores.

Assessment of the longevity of the liver using a rat transplant model.

To assess the longevity of the liver, arterialized, orthotopic liver grafts were performed using syngeneic male BN/BiRij rats. Young (5-month-old) livers were transplanted into 5-month-old recipients (group I, n = 27), and old (28-month-old) livers were transplanted into 5-month-old rats (group II, n = 28). Recipient survival after transplantation was similar in both groups. The average age of the livers at the time of death was 16.7 months in group I and 39.1 months in group II. Four of the livers in group II survived for more than 4 years (48.1 to 52.4 months). Early deaths (less than 1 year) after transplantation were most commonly caused by biliary obstruction and cholangitis in both groups. Late deaths (more than 1 year) after grafting were mainly from heart failure or tumors. None of the animals died of liver failure or liver disease. Weight gain in the rats, total serum protein levels, and alanine transaminase levels after transplantation did not differ significantly between the two groups. There was a trend for the histological features of aging of the liver-fibrosis, bile duct proliferation, and pigment deposition-to become more prevalent as the livers became very old (mean age, 46 months). Nevertheless, typical aging changes, as individual findings, were absent in nearly half of the oldest organs. The alterations in morphology had no apparent effect on the ability of the livers to sustain the lives of the recipients. The liver of the BN/BiRij rat was capable of surviving far beyond the maximum life span of BN/BiRij rats, and rats in general. It did not become diseased in the process.

Human orthotopic small intestine transplantation: radiologic assessment.

The authors describe the postoperative anatomy and review the radiologic examinations of five patients who underwent orthotopic small intestine or combined orthotopic liver and small intestine transplantation. Mucosal thickening of the transplanted intestine was demonstrated on the first postoperative contrast material-enhanced images and was due to submucosal edema. This resolved within 2 weeks in the long-term survivors. Bowel peristalsis appeared normal as early as 31 days after transplantation. Contrast-enhanced examinations of the intestine were useful to exclude surgical complications such as anastomotic leaks or strictures, but were insensitive for biopsy-proved cytomegalovirus enteritis or rejection.

Patent ductus venosus: problems in assessment and management.

A congenitally patent ductus venosus is the rarest form of portosystemic shunt. Although it occurs in the absence of serious parenchymal liver disease, it may be associated with hepatic encephalopathy. This case report describes a 49-year-old man with a patent ductus venosus who presented with recurrent bouts of encephalopathy but few other features of chronic liver disease. Ligation of the shunt was followed by life-threatening complications. The portal venous system must be carefully assessed before closure of a patent ductus venosus is attempted.

Radiologic assessment of bile duct complications in liver transplantation: initial experience.

Four of the first 24 patients who received 31 orthotopic liver transplantations in our institution developed complications at the site of the surgical anastomosis in the common bile duct. There was one anastomotic stricture, one anastomotic stricture with "bile sludge" deposition, and two cases of bile sludge formation without stricturing at the anastomotic site. The two cases of stricturing required surgical revision while both those of bile sludge accumulation without stricture were successfully managed conservatively. Familiarity with the postoperative appearance of the common bile duct anastomosis and its complications is necessary for the proper assessment of these patients.