Overcoming Hepatic Artery Thrombosis After Living Donor Liver Transplantations: An Experience from Asan Medical Center.

BACKGROUND Hepatic artery (HA) reconstruction in living donor liver transplantation (LDLT) is more technically demanding than deceased donor LT (DDLT) because of the small diameter and short HA stump of the partial liver graft. Hence, hepatic artery thrombosis (HAT) can occur infrequently even though the HA is reconstructed microscopically. HAT is closely related to graft failure and mortality. Therefore, HAT should be detected early and HA flow reconstituted using several arterial inflows. We successfully performed redo HA reconstruction in LDLT and report our management process and outcomes. MATERIAL AND METHODS The right gastroepiploic artery (RGEA) was used in 15 patients, previous native HA in 3, and interposition graft from the aorta in 1. All HA reconstructions were performed under a microscope using the end-to-end interrupted suture method. We reviewed technical feasibility, cause of hepatic artery revision (HAR), patency of redo HA flow, graft salvage rate, time of revision, biliary complications, and mortality. RESULTS Ten of 21 cases were salvage LT. Biliary complications developed in 6 cases. The mean interval of HAR with the RGEA was 1.5±1.2 postoperative days. All patients were alive without lethal complications of HAT during the mean follow-up period of 23.3 months. In the other 6 cases of HAR without using the RGEA, we performed redo HA reconstruction after thrombectomy with the native right HA (n=2), right gastric artery, left HA, gastroduodenal artery, and jump graft from the aorta (n=1, respectively). Among them, 3 died from biliary sepsis, graft dysfunction from large-sized ischemic injury, and pneumonia. CONCLUSIONS HAR with the RGEA is feasible for HAT management in LDLT patients without adequate hepatic arteries. When all inflows mentioned are unavailable, jump graft from the aorta using a cadaveric fresh iliac artery may be feasible.

Efficacy and safety of prolonged-release versus immediate-release tacrolimus in de novo liver transplant recipients in South Korea: a randomized open-label phase 4 study (MAPLE).

Background: Prolonged-release tacrolimus is associated with better long-term graft and patient survival than the immediate-release formulation in liver transplant patients. However, no clinical data are available to assess the efficacy and safety of early conversion from twice-daily, immediate-release tacrolimus to once-daily, prolonged-release tacrolimus in de novo liver transplant recipients in Korea. Methods: A 24-week, randomized, open-label study was conducted in 36 liver transplant recipients. All patients received immediate- release tacrolimus (0.1-0.2 mg/kg/day, divided into two doses) for 4 weeks after transplantation, at which time 50% of the patients were converted, at a ratio of 1 mg to 1 mg, to prolonged-release tacrolimus (once-daily). The primary efficacy endpoint was the incidence of biopsy-confirmed acute rejection (BCAR) from weeks 4 to 24 after transplantation (per-protocol set). Medication adherence, adverse event profiles, laboratory tests, vital signs, and physical changes were also recorded. Results: BCAR frequency at 24 weeks was similar between the two treatment groups; two cases (mean±standard deviation, 0.14±0.53 cases) of BCAR were reported in one patient treated with prolonged-release tacrolimus (n=14), while no such cases were reported among patients treated with immediate-release tacrolimus (n=12). The tacrolimus blood concentration at weeks 12 and 24, medication adherence, and adverse event profiles were also similar between the formulations, with no unusual laboratory test results, vital signs, or physical changes reported. Conclusions: Early conversion to a simplified, once-daily, prolonged-release tacrolimus regimen may be an effective treatment option for liver transplant recipients in Korea. Larger-scale studies are warranted to confirm non-inferiority to immediate-release tacrolimus formulation in de novo liver transplant recipients.