Effect of Hemodynamic Monitoring Systems on Short-Term Outcomes after Living Donor Liver Transplantation.

Background and Objectives: To evaluate the effects of the pulse index continuous cardiac output and MostCare Pressure Recording Analytical Method hemodynamic monitoring systems on short-term graft and patient outcomes during living donor liver transplantation in adult patients. Materials and Methods: Overall, 163 adult patients who underwent living donor liver transplantation between January 2018 and March 2022 and met the study inclusion criteria were divided into two groups based on the hemodynamic monitoring systems used during surgery: the MostCare Pressure Recording Analytical Method group (n = 73) and the pulse index continuous cardiac output group (n = 90). The groups were compared with respect to preoperative clinicodemographic features (age, sex, body mass index, graft-to-recipient weight ratio, and Model for End-stage Liver Disease score), intraoperative clinical characteristics, and postoperative biochemical parameters (aspartate aminotransferase, alanine aminotransferase, total bilirubin, direct bilirubin, prothrombin time, international normalized ratio, and platelet count). Results: There were no significant between-group differences with respect to recipient age, sex, body mass index, graft-to-recipient weight ratio, Child, Model for End-stage Liver Disease score, ejection fraction, systolic pulmonary artery pressure, surgery time, anhepatic phase, cold ischemia time, warm ischemia time, erythrocyte suspension use, human albumin use, crystalloid use, urine output, hospital stay, and intensive care unit stay. However, there was a significant difference in fresh frozen plasma use (p < 0.001) and platelet use (p = 0.037). Conclusions: The clinical and biochemical outcomes are not significantly different between pulse index continuous cardiac output and MostCare Pressure Recording Analytical Method as hemodynamic monitoring systems in living donor liver transplantation. However, the MostCare Pressure Recording Analytical Method is more economical and minimally invasive.

Asymptomatic synthetic vascular graft migration to duodenum after living donor liver transplantation: report of two cases.

BACKGROUND: In this study, we present the results of two patients with vascular graft migration to the duodenum after liver transplantation. METHODS: The results of two patients who underwent living donor liver transplantation and vascular graft to the duodenum were evaluated. RESULTS: In our center, 201 liver transplants were performed, including 154 a right lobe living donor liver transplant. A synthetic graft was used to reconstruct segment 5 and 8 hepatic veins in 78 of the 154 LDLT. During the mean follow-up 19.6 ± 12.1 months (1-44 months), graft migrated to the duodenum in two patients who were present in this study. Contrary to the literature, it was followed nonoperatively. No problem was observed in the follow-up process. CONCLUSION: In patients with vascular graft migration to the duodenum after living liver transplantation, non-operative follow-up can be performed in appropriate patients.

Is the incision type important for the development of hernia in liver transplant patients?

OBJECTIVE: In this study, we aimed to investigate the rates and causes of incisional hernia that developed in the postoperative follow-up of patients who underwent liver transplantation. MATERIAL AND METHOD: The results of patients who underwent LT by using three different incisions at the Istanbul Yeni Yüzyil University Gaziosmanpasa Hospital organ transplant center between January 2015 and December 2019 were retrospectively analyzed. Patients were divided into Chevron (group-1), reverse T (group-2), and J incisions (group-3) and hernia development rates were examined. RESULTS: There was no significant difference in terms of incisional hernia in groups 1 and 2 according to the incision type (p = .723). Incisional hernia rate was significantly lower in the J incision group (p < .001). When the factors that increase the development of hernia in all LT patients were examined, it was seen that male gender (p = .021), high BMI rate (p = .003), postoperative bleeding (p = .018), and wound infection (p = .039) caused a significant increase in risk. CONCLUSION: The incision, which is made during liver transplant, is important for the development of hernia. The J incision has a low hernia development rate without causing access problems. Regardless of the incision, high BMI index, male gender, postoperative bleeding, and wound infection increase the development of incisional hernia in liver transplant patients.

Sequential Liver, Kidney, and Autologous Stem Cell Transplant for AL Amyloidosis: A Case Report.

AL type amyloidosis is a systemic disease characterized by the accumulation of amyloid fibrils that can affect many organs such as the skin, gastrointestinal tract, heart, lungs, liver, and kidney. The most frequently involved organ in amyloidosis is the kidney, but cardiac amyloidosis with the poor prognosis is amyloid organ involvement. In this study, we present the treatment of a 40-year-old female patient with acute Budd-Chiari syndrome and very severe proteinuria with sequential liver, kidney, and autologous stem cell transplant after the diagnosis of systemic amyloidosis. To reduce the effects of massive proteinuria and very severe hypoalbuminemia, bilateral renal artery embolization was performed first. After the evaluation of the patient, she underwent liver transplant from a deceased donor, and then kidney transplant was performed from her son 1 month later. Afterward, the patient was discharged without any problems and underwent chemotherapy and stem cell transplant for primary AL amyloidosis. She was followed up without any problem in terms of liver, kidney, and stem cell at the 24th postoperative month. This case shows that autologous stem cell transplant after kidney and liver transplant may be a good treatment option in a selected patient with stem cell involvement diagnosed as having AL amyloidosis.

Factors Affecting Bile Complications After Liver Transplantation: Single-Center Experience.

Objectives: In this study, we aimed to investigate the surgical technique and biochemical parameters that affect biliary complications in liver transplants from live and cadaver in our center. Methods: In this study, 141 patients who underwent liver transplants at Istanbul Yeni Yüzyil Universty Gaziosmanpasa Hospital organ transplant center between January 2018 and January 2020 were included in the study. The patients were monitored for 12-24 months. The patients included in the present study were examined retrospectively. Factors that may cause biliary tract complications and treatment modalities for complications were examined. Results: In this study, liver transplantation from 124 living donors and 17 cadavers was performed. Twenty-three patients were under the age of 18. Only seven of 39 biliary complications were operated on. The rate of finding the right graft in patients with biliary complications was higher (p<0.05). There was no statistically significant difference between the groups concerning left, left lateral, and whole graft presence (p=0.561, p=0.172, and p=0.057, respectively). Double biliary anastomosis was to be higher in the biliary complication group, but there was no statistically significant difference (p=0.086). Conclusion: Biliary complications are common, especially in liver transplants taken from the right lobe. Significant patient survival can be achieved with an early diagnosis and an appropriate treatment approach.

Analysis of Hepatic Arterial Reconstruction Technique Using Surgical Loupes for Living-Donor Liver Transplantation: Results From a Single Center.

BACKGROUND: The reconstruction of the hepatic artery (HA) is the most complex step in living-donor liver transplantation (LDLT) owing to the artery's smaller diameter and the increased risk for HA-related complications. In this study, we presented our HA anastomosis technique for LDLT, which employed interrupted sutures using magnifying loupes. MATERIALS AND METHODS: Since January 2019, we retrospectively analyzed 179 LDLTs that were performed at our center. HA anastomosis was performed under a loupes magnifier (2.5 or 4.5 × ) by the same surgeon. RESULTS: There were 65 female and 114 male recipients with a mean age of 41.6 ± 21.6 years. Of the recipients, 34 were children. HA thrombosis (HAT) was seen in 3 recipients (1.67%; 1 child and 2 adults) in this series. HAT occurred on the third, sixth, and seventh days after LDLT. HAT was successfully treated with interventional radiologic technique. All recipients are still alive with a patent HA. CONCLUSION: The use of magnifying surgical loupes and interrupted sutures to perform HA reconstruction is safe, feasible, and yields a low rate of HAT. Also, endovascular treatment can be used safely for treatment of HAT within the first week after LDLT with a high success rate and is not associated with major complications.

Grafts With Multiple Renal Arteries in Kidney Transplantation.

BACKGROUND: Renal grafts with multiple renal arteries (MRA) are a compelling issue in surgery of kidney transplantation. Transplantations using "grafts with MRA" have conflicting results. Here, we present our experiences on the issue. METHOD: This is a single-center, observational, descriptive study. One hundred ninety-nine patients with end-stage renal disease received a kidney graft from their living- or deceased-related donors in our center between July 2016 and May 2017. We included all recipients to the study. Patients were divided into the following 2 groups: Group 1, recipients who received a renal graft with single renal artery, and Group 2, recipients who received a renal graft with MRA. Groups were compared for estimated glomerular filtration rates (months 1-3 and 12), delayed graft function, and graft survival. Data were analyzed by using SPSS for Windows version 15. RESULTS: One hundred ninety-five recipients with all documented data were analyzed. Graft function was compared between 2 groups in months 1, 3, and 12 and found both to have similar outcomes. MRA has been indicated to have no impact on delayed graft function, higher risk for vascular injury, and biopsy-proven acute tubular necrosis. Also, anastomosis sides have been found to have no importance on graft function in recipients with MRA (P > .05 between all sides). CONCLUSION: Our study indicates grafts with MRA and grafts with a single renal artery have comparable results in the first post-transplant year.

Risk Factors, Diagnosis, and Treatment of Lymphocele After Renal Transplantation: A Retrospective Study.

INTRODUCTION: Despite recent advances, lymphoceles are the most frequent complications following renal transplantation (RT), with an incidence of 0.6% to 51%. In this study, we present risk factors, treatments, and outcomes for lymphoceles after RT at our center. MATERIAL AND METHODS: Since January 2018, 461 RTs were performed at our center. Nine recipients were excluded. The remaining 452 RTs were analyzed retrospectively. Recipients were divided into 2 groups: a lymphocele group (n = 29) and a nonlymphocele group (n = 423). Lymphoceles were diagnosed by ultrasound. Statistical analyses were made using the SPSS 15 software program. RESULTS: Twenty-nine (6.4%) of the 452 recipients developed lymphoceles. Seven of these 29 (24.1%) recipients were asymptomatic. The most common symptom was hydronephrosis (34.4%). Percutaneous drainage was performed in 21 recipients; sclerotherapy with percutaneous drainage was used in the remaining 8. In 5 (17.2%) recipients, there was a recurrence of lymphoceles. There were significant differences with respect to age (50-65 years; P = .016), use of a drainage catheter (P = .044), and polycystic kidney diseases (P = .049). CONCLUSION: Lymphoceles can be treated successfully using the percutaneous drainage technique alone or in combination with povidone iodine. Drainage use, polycystic kidney disease, and age (50-65 years) were established as risk factors for lymphocele development.

Results of Haberal's Corner-Saving Ureteral Anastomosis Technique for Renal Transplantation: A Retrospective Study.

BACKGROUND: Urological complications after renal transplantation (RT), including urine leaks, remain the most common type of surgical complications in the early post-transplant period. In this study we evaluated 324 consecutive RTs recipients in whom Haberal's corner-saving anastomosis technique was used for ureteroneocystostomy. MATERIAL AND METHODS: Since January 2018, 461 RTs were performed at our center. Haberal's corner-saving anastomosis technique was used in 324 of these 461 RTs and the effectiveness of the technique was analyzed retrospectively. There were 115 female patients and 209 male patients, with a mean age of 42.1 ± 13.9 years. The most common etiology resulting in RT was hypertension among the recipients. RESULTS: We observed 8 (2.4%) ureteral complications in 7 recipients as follows: ureteral stenosis in 2 recipients (0.6%), anastomotic leaks in 1 (0.3%), concomitant leak-stenosis in 1 (0.3%), and vesicoureteral reflux in 3 (0.9%). Six complications were treated with interventional radiological techniques and 2 were treated surgically. There was no graft and patient loss in the event of urological complications. CONCLUSION: Because of the low complication rate, we believe that Haberal's corner-saving ureteral anastomosis technique is a safe method for performing a ureteroneocystostomy.

COVID-19 Disease in a Kidney Transplant Recipient With Diffuse Intrarenal Hemorrhage.

Presentation of COVID-19 in renal transplant recipients is similar to that shown in the nonimmunocompromised population; almost all recipients who have this disease present with symptoms of the respiratory system. Acute kidney injury has been found prevalent in transplant recipients with COVID-19. In those with severe COVID-19 disease who transfer to an intensive care unit prevalence of acute kidney injury is more than 50%. The pathophysiological mechanisms of kidney involvement and the type of involvement are unclear. Here, we present a 71-year-old kidney transplant recipient who was admitted to our hospital with pulmonary and renal involvement. A kidney allograft biopsy demonstrated diffuse intrarenal hemorrhage, capillary congestion, and severe acute tubular injury. COVID-19 RNA was detected by real-time polymerase chain reaction from lysed allograft tissues, but no findings of acute or chronic cellular or antibody-mediated rejection were detected. This case indicates that COVID-19 may involve the allograft by causing hemorrhage within the renal parenchymal via direct or indirect pathways.

Long-term culture-initiating cells (LTC-IC) produced from CD34+ cord blood cells with limiting dilution method.

OBJECTIVE: Even though much progress has been made in defining primitive hematologic cell phenotypes by using flow cytometry and clonogenic methods, the direct method for study of marrow repopulating cells still remains to be elusive. Long Term Culture-Initiating Cells (LTC-IC) are known as the most primitive human hematopoietic cells detectable by in vitro functional assays. METHODS: In this study, LTC-IC with limiting dilution assay was used to evaluate repopulating potential of cord blood stem cells. RESULTS: CD34 selections from cord blood were completed succesfully with magnetic beads (73,64%±9,12). The average incidence of week 5 LTC-IC was 1: 1966 CD34+ cells (range 1261-2906). CONCLUSION: We found that number of LTC-IC obtained from CD34+ cord blood cells were relatively low in numbers when compared to previously reported bone marrow CD34+ cells. This may be due to the lack of some transcription and growth factors along with some cytokines and chemokines released by accessory cells which are necessary for proliferation of cord blood progenitor/stem cells and it presents an area of interest for further studies.

Two Renal Transplants From Living Donors With Horseshoe Kidneys.

OBJECTIVE: To present details of 2 living-related donors and our fusion division technique, where half of the horseshoe kidney (HSK) was retrieved and transplanted. METHODS: Since January 2018, 461 renal transplantations have been performed at our center. In 2 of these 461 renal transplantations, which were analyzed retrospectively, a living donor, who had HSK, was used. Both donors had vascular anomalies, and the first donor also had urinary anomalies. RESULTS: The transplanted kidney was placed in the recipient's contralateral iliac fossa. After perfusing for both grafts, no urine leakage was detected from the transected surfaces, and the graft began producing urine. There were no complications after surgery in the donor and recipients. The recipients were discharged on the 7th and 5th day after surgery with a creatinine level of 0.8 mg/dL and 0.9 mg/dL, respectively. The follow-up period was 24 months for the first recipient, and 12 months for the second. At the time of writing, both recipients and donors were alive with normal renal function. CONCLUSION: In addition to expanding the donor pool for end-stage renal disease patients, a donor with HSK can be accepted for transplantation if no other donor option presents. Preoperative evaluation should be undertaken carefully for anatomy and HSK complications.

Kidney Transplantation From Donors with Resectable Renal Cell Carcinoma: Two Case Reports.

BACKGROUND: The existence of renal cell cancer (RCC) in a donated kidney may cause some confusion for clinicians. We aim to present our clinical experiences with 2 recipients who received an RCC-containing kidney from their living related donors. METHODS: Two male patients received a kidney containing resectable size RCC from their living related donors. The recipients were discharged with well-functioning kidneys and currently are being monitored on standard follow-up protocols, and there is no evidence of RCC in their grafts. RESULTS: The kidneys with resectable sizes of renal cell carcinoma were transplanted to the recipients after nephron-sparing surgery, with no sign of recurrent RCC in the 12-month follow-up period. CONCLUSIONS: In the era of transplantation, the shortage of organ sources is the major barrier for the provision of organs to recipients. To enhance the graft donation pool, kidneys with resectable size RCC might be used in providing grafts to patients with end-stage kidney disease.

Analysis of risk factors affecting coagulopathy after donor hepatectomy in a newly established liver transplant center.

OBJECTIVE: As might be expected, living donor liver surgery is associated with serious morbidity and mortality risks. Coagulopathy after donor hepatectomy is an important risk factor affecting morbidity. In this study, risk factors affecting the development of coagulopathy after donor hepatectomy was evaluated in a newly-established liver transplant center. MATERIAL AND METHODS: A retrospective evaluation of 46 liver donors to whom hepatectomy was applied in Medipol Universty of School of Medicine Department of Organ Transplantation between April 2014 and July 2015 was made. Coagulopathy was defined as prothrombin time ≥15 sec. or platelet count <80000/mm3 on postoperative day 3. Donors were separated into 2 groups as those with (n=24) and without (n=22) coagulopathy. Preoperative, intraoperative and postoperative factors acting on coagulopathy were analyzed. RESULTS: In the intergroup analysis, it was seen that remnant liver volume, remnant liver volume % and remnant liver volume to body weight ratio were factors associated with coagulopathy. The cut-off values for these 3 parameters were calculated as 773.5 cm3, 40.5% and 0.915 cm3/kg, respectively. Only remnant liver volume % was determined as a risk factor for coagulopathy after donor hepatectomy on multiple logistic regression analysis. CONCLUSION: The results of this study showed that the most important risk factors affecting coagulopathy after donor hepatectomy were the parameters associated with remnant liver volume.

Ex Vivo Resection and Renal Autotransplantation for the Treatment of a Large Renal Vein Aneurysm Causing Recurrent Pulmonary Embolism and a Coexisting Vascular Malformation: A Case Report.

A 36-year-old young woman with a medical history of recurrent pulmonary embolism and chronic pelvic pain was admitted to our hospital. Contrast-enhanced imaging techniques revealed a large left renal vein aneurysm with a coexisting vascular mass. The patient was operated on electively, and the left kidney was autotransplanted to the right ileac fossa following the ex vivo resection of the vascular mass and the left renal vein aneurysm. Herein, we report an unusual coexistence of a vascular mass and recurrent pulmonary embolism treated successfully with our surgical treatment strategy.

Methylation profile analysis of DNA repair genes in hepatocellular carcinoma with MS-MLPA.

Hepatocellular carcinoma (HCC) is one of the rare tumors with well-defined risk factors. The multifactorial etiology of HCC can be explained by its complex molecular pathogenesis. In the current study, the methylation status of 7 genes involved in DNA repair mechanisms, namely MLH1, PMS2, MSH6, MSH2, MGMT, MSH3, and MLH3, was investigated in tumor samples from HCC patients, using the methylation-specific-multiplex ligated probe amplification method and the results were correlated with available clinical findings. The most common etiological factor in these cases was the presence of hepatitis B alone (47.2%). Among the 56 cases that were studied, promoter methylation was detected in at least one of the genes in 27 (48.2%) cases, only in 1 gene in 13 (23.2%) cases, and in >1 gene in 14 (25%) cases. Of the 7 genes investigated, methylation was most frequently observed in MSH3, in 14 (25%) cases. Methylation of at least 1 gene was significantly more frequent in patients with single tumors than multifocal tumors. There were significant differences regarding hepatitis B status, Child Class, tumor number, grade, and TNM stage in cases where PMS2 methylation was detected. Our results suggest that methylation of genes involved in mismatch repair may be responsible in the pathogenesis of HCC, and evaluating changes in multiple genes in these pathways simultaneously would be more informative. Despite being a robust and relatively inexpensive method, the methylation-specific-multiplex ligated probe amplification assay could be more extensively applied with improvements in the currently intricate data analysis component.

Amyloid accumulation in the toxic nodule of the thyroid gland in a patient with end stage renal failure.

Amyloidosis is characterized by accumulation of amorphous, proteinaceous material in various organs and tissues of the body. Amyloid may accumulate in the thyroid gland in cases of medullary thyroid carcinoma and systemic amyloidosis. Amyloid accumulates extracellularly in the thyroid parenchyma and disrupts the normal follicular patterns. Most of the cases reported up to now were clinically euthyroid, but many presentation forms and overlaps have been reported. Herein we present a patient with toxic nodular goiter with amyloid deposition in the toxic nodule as well as the remaining thyroid tissue.

Long-term results of incidental hepatocellular carcinoma after liver transplant.

OBJECTIVES: The incidence of detecting hepatocellular carcinoma in a removed recipient liver after a liver transplant is not rare. Here, we sought to evaluate incidental hepatocellular carcinoma at our center. MATERIALS AND METHODS: Among 296 patients who had undergone a liver transplant between September 2001 and November 2010, we retrospectively analyzed the outcomes of 6 patients with incidental hepatocellular carcinoma. The proportion of incidental hepatocellular carcinoma was 2%. The rate of incidental hepatocellular carcinoma among all hepatocellular carcinoma patients is 11.5%. There were 3 children and 3 adults (mean age, 28.3 ± 26 years; age range, 1-57 years). Two of the 6 patients were 1 year old. Alpha-fetoprotein levels were mildly elevated in 3 patients. RESULTS: The results of preoperative imaging studies in all patients were normal, except for those that demonstrated regenerative or dysplastic nodules. One of the grafts was from a deceased donor, the remaining 5 were from living-related donors. We encountered no complications after the transplants. Pathology findings showed a mean tumor size of 0.8 ± 0.3 cm (range, 0.5-1.2 cm) and multiplicity in 1 patient. One patient with multiple tumors had microvascular invasion. According to the Tumor Node Metastasis staging system, 5 patients had Stage I, and the remaining patient had Stage II carcinoma. There were no recurrences of hepatocellular carcinoma, and no deaths occurred during a mean follow-up of 63 ± 16.5 months (range, 33-79 months). CONCLUSIONS: The incidence of hepatocellular carcinoma in patients with cirrhosis who have undergone a liver transplant at our hospital is similar to those reported in other studies. Incidentally found hepatocellular carcinomas showed less-invasive pathologic features and better prognoses than did preoperatively found hepatocellular carcinomas.

Acute appendicitis after diaphragmatic hernia after pediatric liver transplant.

Multiple complications in liver transplant have been described in the literature. However, appendicitis and diaphragmatic hernia have rarely been reported after solid-organ transplant. The clinical presentation of appendicitis is similar to that of nontransplant patients, but complications are more frequent, because the majority of the patients do not have leukocytosis. Diaphragmatic hernia can present with a variety of atypical clinical symptoms. In this report, 1 patient who developed a diaphragmatic hernia and appendicitis after liver transplant is presented. A 2-year-old boy with end-stage liver cirrhosis owing to progressive familial intrahepatic cholestasis type-2 received a living-donor liver transplant. The posttransplant course was complicated. The diagnosis of diaphragmatic hernia was confirmed by thoracoabdominal computed tomography, and we decided to proceed with surgical repair. The patient had evidence of perforation, and the appendix was removed. After repositioning the intestine in the abdomen, a chest tube was placed, and the defect repaired with interrupted polypropylene sutures. The patient recovered after surgery without untoward sequelae.

Steroid-resistant acute rejections after liver transplant.

OBJECTIVES: Liver transplant is the definitive treatment for the end-stage liver disease. Although effective immunosuppressants are available, steroid-resistant acute rejection can be encountered. MATERIALS AND METHODS: Between September 2001 and April 2010, 285 adult and pediatric liver transplants were done on 279 patients from deceased donors and living-related donors at our center. All patients received tacrolimus-based immunosuppressive therapy. Steroids were tapered in 3 months. Liver biopsy was done to confirm acute rejection after vascular or biliary complications had been excluded. High-dose steroids were administered for acute rejections. If there was no response to steroids, acute rejection was defined as steroid-resistant acute rejection. After confirming steroid-resistant acute rejection by a second biopsy, antithymocyte globulin was given to patients until liver functions return to normal level with ganciclovir prophylaxis. RESULTS: Acute rejection was detected in 87 liver transplants (30.5%). Steroid-resistant acute rejections were detected in 12 of 87 patients (7 male, 5 female; 8 pediatric, 4 adult patients; mean age, 16.08 +/- 12.1 years) (13.7%). Mean time from transplant to steroid-resistant acute rejection was 73.58 +/- 59.24 days (range, 20-181 days). The predominant cause of liver disease before liver transplant in patients who had steroid-resistant acute rejection was fulminant hepatic failure. Steroid-resistant acute rejection therapy was successful in 10 of 12 patients (83.3%). Two patients did not respond to therapy; therefore, they advanced to chronic rejection. Adverse effects due to cytokine release were the most frequently encountered reactions in the early period of antithymocyte globulin treatment. The mean follow-ups after steroid-resistant acute rejection treatment were 38.2 +/- 26 months (range, 2-85 months). We did not encounter any serious reaction, serious infection, or long-term adverse effect after antithymocyte globulin treatment. CONCLUSIONS: According to our experience, antithymocyte globulin can be considered as a good therapeutic option in steroid-resistant acute rejection with acceptable adverse effects.