Morphological features of advanced hepatocellular carcinoma as a predictor of downstaging and liver transplantation: an intention-to-treat analysis.

In selected patients, locoregional therapy (LRT) has been successful in downstaging advanced hepatocellular carcinoma (HCC) so that the conventional criteria for liver transplantation (LT) can be met. However, the factors that predict successful treatment are largely unidentified. To determine these factors, we analyzed our experience with multimodal LRT in downstaging advanced HCC before LT in a retrospective cohort study. Thirty-two patients with advanced HCC exceeding conventional and expanded criteria for LT underwent therapy, but only those patients whose tumors were successfully downstaged were considered for LT. Eighteen patients (56%) had their tumors successfully downstaged; 14 patients (44%) did not. No intergroup differences existed with respect to patient characteristics or the types and number of treatments. However, mean alpha-fetoprotein levels were significantly higher in the non-downstaged group than in the downstaged group (P < 0.048), and significantly more patients in the non-downstaged group had infiltrative tumors (P = 0.0001). The median survival time was 42 and 7 months for the downstaged and non-downstaged groups, respectively (P = 0.0006). Fourteen patients (43.3%) underwent LT. After a median follow-up period of 35 months (range, 1.5-50 months) after LT, 2 patients (14.2%) developed tumor recurrence. The Kaplan-Meier survival rates after LT were 92% at 1 year and 75% at 2 years. The noninfiltrative expanding tumor type was the sole predictor of successful downstaging and improved outcome on univariate and multivariate analyses. Our study suggests that, in patients with advanced HCC, morphological characteristics of the tumor may predict a good response to downstaging and an improved outcome after LT.

Report of a national conference on liver allocation in patients with hepatocellular carcinoma in the United States.

A national conference was held to better characterize the long-term outcomes of liver transplantation (LT) for patients with hepatocellular carcinoma (HCC) and to assess whether it is justified to continue the policy of assigning increased priority for candidates with early-stage HCC on the transplant waiting list in the United States. The objectives of the conference were to address specific HCC issues as they relate to liver allocation, develop a standardized pathology report form for the assessment of the explanted liver, develop more specific imaging criteria for HCC designed to qualify LT candidates for automatic Model for End-Stage Liver Disease (MELD) exception points without the need for biopsy, and develop a standardized pretransplant imaging report form for the assessment of patients with liver lesions. At the completion of the meeting, there was agreement that the allocation policy should result in similar risks of removal from the waiting list and similar transplant rates for HCC and non-HCC candidates. In addition, the allocation policy should select HCC candidates so that there are similar posttransplant outcomes for HCC and non-HCC recipients. There was a general consensus for the development of a calculated continuous HCC priority score for ranking HCC candidates on the list that would incorporate the calculated MELD score, alpha-fetoprotein, tumor size, and rate of tumor growth. Only candidates with at least stage T2 tumors would receive additional HCC priority points.

Split-liver transplantation: results of statewide usage of the right trisegmental graft.

Split-liver transplantation (SLT) effectively expands the cadaveric donor pool for children. The remaining right trisegmental (RTS) graft can be transplanted into adults. Limited information exists regarding the outcomes of RTS allografts. Sixty-five RTS graft recipients from five adult transplant programs in Texas were identified. Donor and recipient information were analyzed retrospectively. Most livers (75%) were originally allocated to pediatric recipients. Liver splitting occurred via the in situ (72%) and ex situ (28%) techniques. Arterial reconstruction of RTS grafts was common (52%). Patient and graft survival at 3 months were comparable for the in situ and ex situ techniques (p = 0.2). Cox regression showed only in situ splitting to be a predictor of outcome longer than 3 months posttransplant. Sharing of grafts between centers was frequent (37% of total). One-year patient and allograft survival (87.1% and 85.4%) were excellent with no cases of primary nonfunction. SLT consistently generates two functional liver allografts with excellent recipient survival. In situ splitting of the liver is the preferred technique. Decreased survival is observed with RTS graft use in higher risk recipients. Broader application of SLT with increased sharing is feasible and safely expands the number of liver allografts that can be transplanted.

Hypophosphatemia after 95 right-lobe living-donor hepatectomies for liver transplantation is not a significant source of morbidity.

BACKGROUND: Hypophosphatemia appears to be a universal event after right hepatic lobectomy for live-donor adult liver transplantation according to one report. Because hypophosphatemia appears to contribute to increased postoperative complications, routine hyperalimentation with supratherapeutic levels of phosphorus was advocated. METHODS: From July 2000 to May 2002, we performed 95 right-lobe living-donor hepatectomies for 95 adult liver-transplant recipients, the largest single institutional experience. We reviewed our data that were collected prospectively. RESULTS: We did not find profound hypophosphatemia (<1.0 mg/dL) to be prevalent in our donors. At least six (6.3%) donors did not have postoperative hypophosphatemia. In addition, there appears to be no increased morbidity related to hypophosphatemia when aggressively corrected with intravenous or oral phosphates in our group of donors that underwent right-lobe hepatectomies. CONCLUSIONS: We, therefore, cannot endorse the routine administration of hyperalimentation with supratherapeutic phosphorus because of its potential morbidity.

Hepatic arterial reconstruction in 95 adult right lobe living donor liver transplants: evolution of anastomotic technique.

The success of adult right-lobe living donor liver transplants (RLDLT) would not have been possible without the experience of the early pioneers of pediatric living donor liver transplants (LDLT). Our experience with 95 RLDLTs from July, 2000 to May, 2002 at a single institution is reported with specific emphasis on arterial reconstruction. The evolution of technique using the autogenous Y extension graft and the reverse extension bifurcated graft for arterial revascularization, which we believe has reduced the incidence of hepatic artery thrombosis, is described. Outcome and the incidence of hepatic artery thrombosis are reported.

Trasplante renal: experiencia en la Fundacion Santa Fe de Bogota / Renal transplantation: experience in Fundacion Santa Fe de Bogota

La Fundacion Santa Fe de Bogota dio al servicio el programa de trasplante renal en 1985. Desde entonces y hasta ahora se han realizado 48 trasplantes de rinon cuya experiencia se analiza en el presente articulo. Se presenta la incidencia etiologica en nuestra serie, la cual como en lo informado en la literatura mundial obedece mayormente a glomerulonefritis. Se analiza el tipo de origen del trasplante renal en nuestro programa en donde solo hasta el presente hemos logrado un avance en el numero de donantes cadavericos, haciendo notar que esto se debe gracias a haber conformado un Servicio de Trasplantes del Area de Bogota (STAB) encargado de la promocion y comportamiento de organos para trasplante. Se detallan las enfermedades asociadas mas comunes en nuestro programa haciendo enfasis en la presencia de hepatitis B y sus implicaciones en el trasplante renal y en la sobrevida del receptor. Analizamos la compatibilidad inmunologica de los receptores con los donantes tanto en donante vivo relacionado (DVR), como en cadaverico, la profilaxis antibiotica e inmunosupresora que utilizamos, el diagnostico y tratamiento del rechazo, incluido el metilprednisolona-resistente, y las complicaciones y sobrevida actuarial de pacientes e injerto en nuestro programa. En resumen, la Fundacion Santa Fe de Bogota puede mostrar un programa de trasplante renal de 5 anos de evolucion con excelentes resultados basados en protocolos definidos y actualizados