Hepatic Arterial Reconstruction Using Right Gastroepiploic Artery in Living Donor Liver Transplantation.

BACKROUND: Hepatic artery (HA) anastomosis is still a challenge in living donor liver transplantation due to the short- and small-caliber graft artery. PATIENTS AND METHODS: If the recipient HA is damaged, reconstruction of HA is a significant problem. This paper reports on the results of using our alternative artery source in patients who had HA depredation for a variety of reasons, including transarterial chemoembolization. We used the right gastroepiploic hepatic artery for HA reconstruction in 5 patients. RESULTS: None of the patients experienced HA thrombosis. Only one patient who underwent retransplantation due to chronic rejection had biliary leakage. The mean follow-up time was 7.4 months; no graft loss or patient mortality was observed. The right gastroepiploic hepatic artery can be used securely for HA reconstruction in patients with a damaged HA.

Takotsubo Cardiomyopathy Resulting in Cardiac Arrest in a Patient Undergoing Liver Transplantation.

Cardiac complications during and after liver transplantation are a common cause of death. Although considered to be uncommon, takotsubo cardiomyopathy, which is characterized by reversible left ventricular akinesis without coronary artery obstruction, is becoming increasingly reported. Herein we have presented a case of reversible stress-induced takotsubo cardiomyopathy resulting in cardiac arrest in a patient undergoing liver transplantation.

Liver Transplantation in Patients With Complete Portal Vein Thrombosis: Renoportal or Varicoportal Anastomosis Using Cryopreserved Vein Grafts.

BACKGROUND: Despite technical developments in transplantation surgery, complete portal vein thrombosis still remains a challenge for restoration of adequate portal vein inflow. Renoportal or varicoportal anastomosis provides an effective alternative solution for patients with complete portal vein thrombosis. This study describes our experience with renoportal and varicoportal anastomosis during liver transplantation. PATIENTS AND METHODS: Between January 2014 and May 2016, 5 patients with complete portal vein thrombosis underwent extra-anatomic portal anastomosis. In 3 cases, varicoportal anastomosis was performed and for the others, end-to-end renoportal anastomosis. We used iliac cryopreserved vein grafts to restore portal anastomosis in 3 cases. Epidemiology, risk factors, surgical techniques, complications, and outcomes of these procedures were evaluated over short- and long-term follow-ups. RESULTS: The follow-up time is 3 years for our first renoportal case, which was performed in a cadaveric liver transplantation; it was also first nationwide case. The other renoportal anastomosis was practiced in a living donor liver transplantation and the follow-up time is 8 months. The patient and graft survival rates were 100% at the last follow-up. The follow-up times are 10.9 and 4 months for the patients with varicoportal anastomosis. One of these patients died due to recurrence of hepatocellular carcinoma. The other two patients are alive with good graft functions. CONCLUSION: Our experience suggests that reno-varicoportal anastomosis is a useful technique for patients with complete portal vein thrombosis and cryopreserved grafts may be safely used.

The correlation between Doppler US measurement of hepatic arterial flow and the MELD score in patients with chronic liver disease.

OBJECTIVE: The aim of the study was to determine the relationship between the Model for End-Stage Liver Disease (MELD) score and hepatic arterial hemodynamic parameters measured via Doppler US. PATIENTS AND METHODS: Etiologic causes and hepatic artery hemodynamic parameters of 121 patients with chronic liver parenchymal disease were compared with MELD scores.  Doppler ultrasonography (US) was used to assess flow velocity, pulsatility index (PI) and resistance index (RI) in the hepatic artery (HA). Each patient's MELD scores were calculated at the time of Doppler ultrasound performed. RESULTS: There was statistically significant difference between MELD score and hepatic artery RI value (p < 0.001, r = 0.616). This difference was statistically more significant in the group which consisted of multiple etiologic causes (p < 0.001, r = 0.837). CONCLUSIONS: We found significant relation between MELD score and hepatic artery RI measurements in patients with chronic liver parenchymal disease.

Living-donor liver transplantation: results of a single center.

In the absence of cadaveric donor liver transplantation, living-donor liver transplantation (LDLT) is an alternative option for patients with end-stage liver disease. The objective of this study was to evaluate the outcome of LDLT at a single medical center in Turkey. We retrospectively analyzed the results of 101 LDLTs in 99 recipients with end-stage liver disease. We transplanted 49 right liver lobes, 16 left lobes, and 36 hepatic segments II and III. Most donors (46%) were parents of the recipients. Seventeen recipients had concomitant hepatocellular carcinoma and cirrhosis. Retransplantation was performed in two recipients. Ten hepatic arterial thromboses, 1 hepatic arterial bleeding, and 12 biliary leaks occurred in the early postoperative period. Most complications were treated with interventional techniques. Three hepatic vein stenoses, three portal vein stenoses, one hepatic arterial stenosis, and six biliary stenoses developed during the late postoperative period. Recipients with those complications were treated with interventional techniques. Mean follow-up was 14.2 +/- 10.9 months. During that time, no tumor recurrence was detected in any recipient with hepatocellular carcinoma. Twenty-two recipients died during the follow-up. At this time, the remaining 77 recipients (77%) are alive, exhibiting good graft function. In general, complication rates are slightly higher after LDLT than after cadaveric liver transplantation. However, most complications can be treated with interventional techniques. LDLT continues to be a life-saving option in countries without satisfactory cadaveric donation rates.

Duct-to-duct biliary reconstruction in pediatric liver transplantation: one center's results.

In pediatric liver transplantation, both for cadaveric and living-related patients, the Roux-en-Y hepaticojejunostomy is often preferable to biliary reconstruction. Duct-to-duct biliary reconstruction in pediatric patients has been utilized only in a limited numbers of studies. Here, we retrospectively review our experience with duct-to-duct biliary reconstruction in pediatric liver transplantation patients. Since September 2001, 46 liver transplantations have been performed in 44 patients (29 boys and 15 girls of mean age, 8.4 +/- 5.5 years). For the anastomoses, a corner-saving suture technique was used with 6-0 or 7-0 polypropylene monofilament nonabsorbable suture. A T tube was used in three patients, and in 11 patients, a straight feeding tube was inserted from the recipient common bile duct to the anastomotic site. A transhepatic biliary catheter insertion technique was used in 28 patients for external bile drainage; the remaining four patients had no tubes or stents. Four patients developed bile leakage in the early postoperative period. Three of these patients were treated with percutaneous drainage with excellent outcomes; the remaining patient required reoperation with a Roux-en-Y hepaticojejunostomy for bile leakage. Four biliary stenoses occurred in the late postoperative period. All biliary stenoses were successfully treated with balloon dilatation. There was no mortality or graft loss due to biliary complications. Of the 44 original patients, 36 (82%) are well at this time, with optimal liver function during follow-up (2-34 months). The remaining eight (18%) died during the study from acute respiratory distress syndrome (n=2), sepsis with multiorgan failure (n=5), and intracranial bleeding (n=1). Our results showed that duct-to-duct biliary reconstruction is a safe and easy technique for pediatric patients.

Higher graft-to-host ratio may decrease posttransplant mortality in patients with a high MELD score.

The aim of this study was to determine whether scores from the model for end-stage liver disease (MELD) can be used in the preoperative strategic planning of transplantation surgery. We retrospectively analyzed the outcomes of 62 adult liver transplantation patients whose operation was performed at our center between January 2001 and June 2006. All patients had MELD scores between 8 and 35 with an average value of 20. We compared postoperative mortality among patients who had MELD scores higher than 20 as determined by their graft-to-host ratios. We separately grouped the patients whose graft-to-body weight ratio (GBWR) was equal to or lower than 1 and whose GBWR was higher than 1. The GBWRs associated with mortality after living-donor liver transplantation in the early postoperative period were considered significant (P=.005). MELD scores were also found to be associated with mortality (P=.006). Mortality rates in patients with high MELD scores and a low GBWR were highest among the other combinations. In conclusion, we found that GBWR lower than 1 and MELD score higher than 20 are significant risk factors for mortality after living donor liver transplantation. Patients with low MELD scores can undergo transplantation when their GBWR is lower than 1, but recipients with high MELD scores should receive grafts only when their GBWR is higher than 1.

Effect of rapamycin on wound healing: an experimental study.

The aim of this study was to investigate the effects of rapamycin (RAPA) on the healing of bladder and abdominal wound closures. Fourteen male Sprague Dawley rats were randomized to receive either RAPA (3 mg/d) or placebo. A midline laparotomy was performed. The bladder was cut and closed with 4-0 Vicryl in a double layer. The fascia was closed with 0 nylon suture, and the skin closed with a subcuticular 2-0 nylon suture. The mean RAPA level was 9.1 ng/mg. Eosinophil and neutrophil infiltration, and the presence and degree of myofibroblast proliferation were significantly higher in the bladder, fascia, and dermis of the control group. Lymphocyte infiltration was similar in each group. Mean microvessel density as well as the percentage of cells expressing vascular endothelial growth factor in the bladder, fascia, and dermis were significantly lower among the RAPA group. Both proliferating cell nuclear antigen labeling indices for inflammatory cells in the fascia, dermal fibroblasts, and epithelial cells in the placebo group were significantly higher. No difference was observed for hydroxyproline levels in both the bladder and fascia between the groups. In conclusion, we found that RAPA treatment affected all steps of the wound healing process by decreasing the inflammatory cell number, angiogenesis, and myofibroblast proliferation, so the wound healing process was delayed and consequently the tensile strength of the wound decreased.

Tacrolimus-related seizure in the early postoperative period after liver transplantation.

The aim of this study was to analyze liver transplant patients who had tacrolimus (TAC)-related seizures at our institution during the early postoperative period. Between September 2001 and June 2006, liver transplantation (LT) was performed in 132 patients. All received a TAC-based immunosuppressive protocol after LT. Twelve (9%; 1 woman, 11 men; mean age 20 +/- 12 years; range, 12-49 years) of those 132 patients had a seizure during the first month. Three of these patients had received grafts from cadaveric donors and nine from living donors. All patients presented with generalized tonic-clonic seizures, and most had minor symptoms just hours before the attack. Blood TAC levels were within the therapeutic range, and there were no other factors that could have initiated a seizure at that time. Eleven patients were changed from TAC to cyclosporine (CsA), and one was switched to sirolimus. They also received antiepileptic therapy. All patients recovered and seizures disappeared. There were no nephrotoxicity or surgical complications related to drug conversion. Death (unrelated to seizure) occurred in one patient at 2 months after LT. Eleven patients are alive with good graft function at a mean follow-up of 20 +/- 19.7 months (range, 1-52 months). In conclusion, during the early posttransplant period, each neurologic disturbance, even a minor one, should alert the clinician, as it might be a warning sign of a coming seizure. These patients should be followed closely, and the clinician should not hesitate to do a drug conversion in suspicious cases.

Safety of multidetector computed tomography in calculating liver volume for living-donor liver transplantation.

Living-related liver transplantation was developed to overcome the organ shortage for both children and adults with end-stage liver disease. Because impaired liver function after resection and transplantation is caused by insufficient liver volume, the reliable volumetric assessment of the hepatic segments of potential living donors is a critical element in preoperative evaluation. In this study, we compared the results of multidetector computed tomographic (CT) volumetry with the intraoperative findings from 80 liver transplantations performed at our center. Resection borders were determined preoperatively with the aid of CT by manual delineation in which the hepatic vessels were used as guides. Resected liver grafts were weighed intraoperatively, and the calculation of their volume was based on the specific weight of 1 g/mL. Statistical analyses were performed with Pearson's correlation test; P < .05 was considered significant. The study subjects consisted of 48 women and 32 men (mean age, 35.6 +/- 9.7 years; range, 23-56 years). Forty-one donors underwent right lobectomy, 22 underwent left lobectomy, and 17 underwent left lateral segmentectomy. Manual volumetric measurement was completed within 15 minutes. No significant differences were found between the results of preoperative volumetry and the intraoperative measurement. We therefore concluded that manual CT volumetric calculation is a reliable method of calculating liver volume for living-donor liver transplantation.

Stent placement in pediatric patients with hepatic artery stenosis or thrombosis after liver transplantation.

Hepatic artery stenosis (HAS) and thrombosis (HAT) after orthotopic liver transplantation remain significant causes of graft loss. Postoperative HAT follows approximately 5% to 19% of orthotopic liver transplantation. It is seen more frequently in pediatric patients. In the past, repeat transplantation was considered the first choice for therapy. Recently, interventional radiological techniques, such as thrombolysis, percutaneous transluminal angioplasty, or stent placement in the hepatic artery, have been suggested, but little data exist related to stent placement in the thrombosed hepatic artery during the early postoperative period in pediatric patients. Between March 2000 and March 2005, percutaneous endoluminal stent placement was performed in seven pediatric liver transplant patients. HAT or HAS initially diagnosed in all cases by Doppler ultrasound then confirmed angiographically. We intervened in four cases of hepatic artery stenosis and three cases of hepatic artery occlusion. Stents were placed in all patients. Three ruptures were seen during percutaneous transluminal angioplasty of the hepatic artery using a covered coronary stents on the first, fifth day, or 17th postoperative day. In one patient, dissection of the origin of the common hepatic artery developed owing to a guiding sheath, and a second stent was placed to cover the dissected segment. The other two hepatic artery stents remained patent. In one stent became occluded at 3 months after the intervention with no clinical problems. Follow-up ranged from 9 to 40 months. In conclusion, early and late postoperative stent placement in the graft hepatic artery was technically feasible.

Results of biliary reconstructions in liver transplantation at our center.

Biliary complications are some of the most critical problems in liver transplantation. Despite various refinements in surgical technique, different types of liver transplantations are associated with significant numbers of biliary problems. In this study, we analyzed the results of biliary reconstructions in 127 liver transplant recipients at our center from April 2001 to May 2006. Through November 2004, we used different techniques for biliary reconstruction in 66 of these patients, including duct-to-duct (DD) anastomoses, Roux-en-Y hepaticojejunostomy (RYHJ), anastomoses over T tubes or stents, and anastomoses without stenting. During the first period, we used a DD anastomosis in 15 cadaveric whole liver grafts and in 25 right lobe and 12 left lobe or left lateral segment grafts from living-related donors. RYHJ was preferred in 2 cadaveric and 12 left lateral segment grafts. Beginning in November 2004, we employed intraoperative transhepatic biliary catheter insertion in 61 patients (29 children, 32 adults). In the most recent 61 cases of 13 liver grafts from cadavers and 48 from living-related donors, 14 patients (2 children and 12 adults) received whole-liver grafts, 22 (all adults) a right lobe, and 26 (all children) a left lateral or left lobe. Intraoperative transhepatic biliary catheter insertion was performed with DD anastomosis in 55 cases and with RYHJ in 6 cases. The mean complication rate decreased from 24% to 8.1% during the period using a new biliary reconstruction technique. Five biliary complications occurred in four patients. The new technique of biliary reconstruction using intraoperative biliary catheter insertion has significantly reduced the biliary complication rate. Transhepatic biliary stenting prevents biliary complications and maintains percutaneous access when problems arise. Intraoperative transhepatic biliary catheter insertion at the back table is a safe way to provide good biliary drainage after liver transplantation.

Bilateral drop-foot after orthotopic liver transplant.

Patients may demonstrate various neuromuscular abnormalities after liver transplantation. We report a patient who developed bilateral drop foot after orthotopic liver transplantation. He was diagnosed with critical illness polyneuropathy. During follow-up, his complaints gradually recovered and his electrodiagnostic findings improved.

Cadaveric transplantation activities in our centers.

Baskent University is one of the most important transplantation centers in Turkey. This study assesses the contribution that Baskent University Hospital Network is currently making to the national solid organ pool. The National Coordinating Center (NCC) was founded in 2001, and data from the Baskent University transplantation center from January 2001 to through May 2005 were retrospectively analyzed. The number of brain-dead patients in this period was 36 and the number of family consent was 20. For all brain-death cases, the rate of consent for donation was 55.6%. Of the 64 total grafts collected in this study period, 85.9% were transplanted at this center and 14.1% were offered to the NCC. The rate of heart and liver grafts offered to the NCC was 9.4% and 4.7%, respectively. According to the results, 29.6% of all heart grafts, 4.5% of all liver grafts, and 4.5% of all kidney grafts in Turkey are performed from donors identified by Baskent University. The current rate of consent for cadaver organ donation is high compared with other centers. The majority of these grafts were used in our center, but we also made some contribution to the national donor organ pool. The transplantation activities in our network will hopefully lead to a larger organ pool and shorter waiting lists.

Recurrent glomerular diseases after renal transplantation.

INTRODUCTION: Recurrent glomerular diseases are important causes of graft dysfunction after renal transplantation. As the outcomes of transplantation continue to improve, the problem of recurrent diseases in the transplanted kidney have become evident. The purpose of our study was to determine the risk factors for and the incidence of recurrence in the posttransplant period as well as their impact on graft survival rates. METHOD: We retrospectively analyzed 49 patients with glomerular diseases due to membranoproliferative glomerulonephritis (n = 26); focal segmental glomerulosclerosis (FSGS, n = 18); and systemic lupus erythematosus (n = 5). The mean follow-up was 9.5 years. RESULTS: Recurrent disease was detected in 30 of 49 patients after a mean posttransplant follow-up of 28.1 months (range = 1 to 157) and their average graft survival was 41.3 months. Nineteen patients were recurrence-free with a mean graft survival of 79.4 (range = 15 to 158) months (P < .05). One patient with FSGS, showed disease-recurrence in her third transplant after having experienced recurrences in the former grafts. In all six patients with HLA haplotype B8, recurrence was observed at a mean of 19.5 +/- 9.8 months. The only risk factor that was identified was this HLA haplotype. CONCLUSION: Recurrent disease a significant problem after renal transplantation is associated with decreased graft survival. The donor HLA type may be associated with risk, which should be clearly discussed with both the living donor and the recipient candidate.

Lamivudine therapy in kidney allograft recipients who are seropositive for hepatitis B surface antigen.

BACKGROUND: There are numerous recent reports on the use of lamivudine for hepatitis B virus (HBV) infection after renal transplantation. However, the optimal strategy (prophylactic, preemptive, or salvage approach) for starting lamivudine treatment in this patient group has not been determined. The aim of this study was to assess how the timing of lamivudine therapy affected the HBV serological status and the transaminase levels in renal allograft recipients with chronic HBV infection. METHODS: We investigated outcomes for patients who were seropositive for hepatitis B surface antigen (HBsAg) and underwent transplantation before or after October 2004 (the date our institution implemented a prophylactic lamivudine treatment strategy against HBV). The data included serum liver enzyme levels and polymerase chain reaction (PCR) screening results for HBV-DNA in serum. RESULTS: Fifteen patients (11 before October 2004, four after October 2004) were included in the study. Preoperatively all patients had normal transaminases levels and 2 of 15 patients had detectable HBV-DNA on PCR. Eight of the 15 total HBsAg-positive patients in our series were not placed on lamivudine at the time of renal transplantation. Half of those who were not treated initially showed transaminase elevations in the first year of follow-up requiring lamivudine therapy at that time. In contrast, all seven individuals who received lamivudine at the time of transplantation were negative for HBV-DNA throughout the follow-up. CONCLUSION: To prevent viral replication in HBsAg-positive patients who are scheduled for renal transplantation, it is best to initiate lamivudine therapy before or immediately after transplantation.

A corner-saving ureteral reimplantation technique without stenting.

In this study we present our new technique, which will simplify reconstruction of even a small-caliber ureter. Our transplantation team has performed 1523 renal transplantation since 1975. From 1975 to 1983, we performed 300 ureteroneocystostomies using the modified Politano-Leadbetter technique. Since 1983, the extravesical Lich-Gregoir technique was used in combination with temporary ureteral stenting in 1141 patients. After September 2003, we began a corner-saving technique. Eighty-two (62 living related, 20 cadaver) renal transplantations have been performed since September 2003. The mean recipient age was 32.2 +/- 10.9 years (range, 7 to 63). Mean donor age was 38.9 +/- 13.1 years. For ureteral reimplantation, a running suture is started from 3 mm ahead from the middle of the posterior wall and finished 3 mm afterward. After the last stitch, both ends of the suture material are pulled and the posterior wall of the ureter and bladder are approximated tightly. The anterior wall is sewn either with the same suture or another running suture. Since using this technique, we have not employed a double J or any other stent to prevent ureteral complications at the anastomosis side. We have seen only two (2.4%) ureteral complications. In conclusion, due to the low complication rate, we believe that our new technique is the safest way to perform a ureteroneocyctostomy.

Urologic complications in 1523 renal transplantations: The Baskent University experience.

Urologic complications, observed since the beginning of renal transplantation, cause significant morbidity and mortality. In the first few years the procedure was performed, incidence of urologic complications was reported to be 10% to 25%. Recently, the incidence of urologic complications after renal transplantation has decreased to 2.5% to 12.5%; unfortunately, a higher incidence exists in pediatric recipients, reaching approximately 20% with an associated 58% and 74% graft survival rates for cadaveric and living-related transplantation, respectively. We retrospectively analyzed the postoperative urologic complications reported in the medical charts of 1523 consecutive kidney transplantations (1130 men, 74.2%; 393 women, 25.8%; mean age, 31.9 +/- 10.9 years; range, 7 to 64 years; 354 cadaveric, 23.2%; 1169 living, 76.8%) performed by our team since 1975. The first 321 procedures took place at Hacettepe University Hospital in Ankara, Turkey, and the remaining 1202 were performed at Baskent University Hospital in Ankara. Urologic complications occurred in 46 (3%) recipients. Twenty-three (1.5%) of these patients had urine leakage, 15 (1%) had urinary obstruction due to ureteral stricture, 6 (0.4%) had distal ureter necrosis, and 2 (0.1%) developed renal calculi in the late postoperative period. Twenty-four out of 46 required reoperation for urologic complications. The remaining 22 patients were treated conservatively in our interventional radiology department with excellent results. In conclusion, urologic complications will always occur in the posttransplant period. Early diagnosis by experienced personnel and use of interventional radiology can greatly reduce the need for surgical treatment.

Hypophosphatemia in living liver donors.

BACKGROUND AND AIM: Some patients who undergo donor hepatectomy for adult living donor liver transplantation develop hypophosphatemia postoperatively. Since this imbalance appears to be a factor in postoperative complications, some authors advocate routine supratherapeutic phosphorus repletion. The purpose of this study was to determine the frequency of hypophosphatemia after elective donor lobectomy for liver transplantation and to assess whether phosphorus repletion is necessary in this patient group. METHODS: The cases of 26 patients who donated 19 right lobe and seven left lateral lobe grafts between August 2004 and March 2005 were evaluated. Postoperative phosphorus levels and other relevant data were obtained from our institution's transplant database. Presence/severity of hypophosphatemia was categorized as follows: normal (>2.5 mg/dL), mild (1.5 to 2.5 mg/dL), moderate (1.1 to 1.5 mg/dL), and profound (<1.0 mg/dL). RESULTS: No patients undergoing donor hepatectomy suffered profound or life-threatening hypophosphatemia and no donor required hyperalimentation for phosphate repletion. Twenty one donors (80.7%) did not have postoperative hypophosphatemia. In addition there appears to be no increased morbidity related to hypophosphatemia. A left lateral segment donor (3.8%) had moderate hypophosphatemia that alleviated with oral intake gradually. Four patients (15.5%; three of right lobe donor, one of left lateral segment donor) had mild hypophosphatemia. We also appropriately corrected the hypophosphatemia with encouragement of normal oral intake. By postoperative day 5, essentially all donor phosphorus levels were corrected to normal range. CONCLUSIONS: The results suggest that hypophosphatemia after donor hepatectomy is not as common as previously reported. We find that appropriate early oral intake postoperatively effectively prevents/minimizes hypophosphatemia in patients who undergo donor hepatectomy.

Human leukocyte antigen-G, a new parameter in the follow-up of liver transplantation.

Human leukocyte antigen-G (HLA-G) displays immunotolerogenic properties toward effector cells in graft rejection through inhibition of natural killer (NK) and cytotoxic T lymphocyte (CTL)-mediated cytolysis and CD4+ T-cell alloproliferation. CD4(+)CD25(+)high regulatory T (Treg) cells are pivotal for the maintenance of self-tolerance of pathogenic alloresponses after solid organ or bone marrow transplantation in murine model systems. The aim of this study was to investigate whether there was an association between soluble and membrane-bound HLA-G levels on Treg cells and liver graft prognosis. For this purpose, we studied 37 liver transplant patients and 13 healthy blood donors. To investigate the expression of HLA-G on the surface of peripheral mononuclear (PMNL) cells, we have used monoclonal antibodies in flow cytometry to estimate CD4, CD25, CD45, and HLA-G content. HLA-G serum levels were determined by ELISA. We observed a correlation between sHLA-G serum levels and liver function tests. After a month of HLA-G decrease in serum levels, liver function tests such as aspartate aminotransferase (AST), alanine aminotransferase (ALT), direct bilirubin (DB), total bilirubin (TB), and alkaline phosphatase (ALP) were above normal levels, suggesting liver dysfunction or rejection. Considering these results, we concluded that the increased sHLA-G in serum and on cell surfaces may afford preliminary data on the prognosis and response to treatment in liver transplant patients.