Long-term medical and quality of life outcomes among voluntary liver donors.

BACKGROUND: Long-term medical and quality of life (QOL) outcomes in voluntary liver donors remain under investigated. The objective of the current study was to report long-term medical outcomes and re-evaluate QOL in living liver donors. METHODS: This was a single-center retrospective cohort study of donors who underwent donor hepatectomy between 2012 and 2018. We investigated long-term outcomes in 7 domains. These include medical problems, surgical procedures, work-related issues, pregnancy outcomes, psychiatric interventions, willingness to donate again, and long-term mortality. QOL was evaluated using short-form 36. RESULTS: The median follow-up time was 61.4 months (53.3-83.7). Among 698 donors, 80 (11.5%) experienced medical problems, 4 (0.6%) had work-related issues, and 20 (2.9%) needed psychiatric assistance. Surgery was performed in 49 donors (7%), and females were more likely to have undergone incisional hernia repair (5.8% vs 1.9%, P = .006). There were 79 postdonation pregnancies including 41 normal vaginal deliveries (51.9%), 35 cesarean sections (44.3%), and 3 miscarriages (3.8%). Willingness to donate again was reported by 658 donors (94.3%). Donors whose recipients were alive were more likely to donate again (95.5% vs 90.5%, P = .01). There were 3 deaths (0.4%) in the long-term. The mean physical composite score at initial and follow-up evaluation was 86.7 ± 13.9 and 76.5 ± 20.9 (P = .001), and the mean mental composite score at initial and follow-up evaluation was 92.1 ± 13.5 and 80.7 ± 16 (P = .001). CONCLUSION: The overall long-term outlook in living liver donors is promising. QOL parameters might deteriorate over time and frequent re-evaluation might be considered.

National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma.

A consensus meeting of national experts from all major national hepatobiliary centres in the country was held on May 26, 2023, at the Pakistan Kidney and Liver Institute & Research Centre (PKLI & RC) after initial consultations with the experts. The Pakistan Society for the Study of Liver Diseases (PSSLD) and PKLI & RC jointly organised this meeting. This effort was based on a comprehensive literature review to establish national practice guidelines for hilar cholangiocarcinoma (hCCA). The consensus was that hCCA is a complex disease and requires a multidisciplinary team approach to best manage these patients. This coordinated effort can minimise delays and give patients a chance for curative treatment and effective palliation. The diagnostic and staging workup includes high-quality computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography. Brush cytology or biopsy utilizing endoscopic retrograde cholangiopancreatography is a mainstay for diagnosis. However, histopathologic confirmation is not always required before resection. Endoscopic ultrasound with fine needle aspiration of regional lymph nodes and positron emission tomography scan are valuable adjuncts for staging. The only curative treatment is the surgical resection of the biliary tree based on the Bismuth-Corlette classification. Selected patients with unresectable hCCA can be considered for liver transplantation. Adjuvant chemotherapy should be offered to patients with a high risk of recurrence. The use of preoperative biliary drainage and the need for portal vein embolisation should be based on local multidisciplinary discussions. Patients with acute cholangitis can be drained with endoscopic or percutaneous biliary drainage. Palliative chemotherapy with cisplatin and gemcitabine has shown improved survival in patients with irresectable and recurrent hCCA.

Patient Selection for Living Donor Liver Transplantation in Acute-on-chronic Liver Failure.

Background and objectives: Acute-on-chronic liver failure (ACLF) is associated with high short-term mortality without liver transplantation (LT). The selection criteria for LT in these patients are not well defined. The objective of this study was to determine factors associated with post-transplant survival in ACLF. Methods: This was a single-center retrospective study of patients who underwent living donor liver transplantation (LDLT) for ACLF between 2012 and 2022. Out of 1093 transplants, 110 patients had underlying ACLF, based on the European Association for the Study of the Liver-Chronic Liver Failure Consortium (EASL-CLIF) criteria. We looked at factors associated with 1-year posttransplant survival. Results: The median model for end-stage liver disease (MELD) score was 33.5 (31-38), and the 1-year posttransplant survival was 72%. Six risk factors were associated with posttransplant survival, namely, body mass index > 30 kg/m2 [HR, 4.4; 95% CI, 1.8-10.7], platelet count < 66,000/µl [HR, 2.91; CI,1.2-6.6], poor response to medical treatment [HR, 2.6; CI, 1.1-5.7], drug-resistant bacterial or fungal cultures [HR, 4.2; CI, 1.4-12.4], serum creatinine > 2.5 mg/dl [HR, 3.4; CI, 1.5-7.7], and graft-to-recipient weight ratio < 0.7 [HR, 4.8; CI, 1.4-16.3]. The 1-year post-transplant survival was 84% in patients with 0-2 risk factors (n = 89) and was 6% with 3 risk factors (n = 15) (P < 0.001). For 1-year posttransplant survival, the area under curve (AUC) for the current model was 0.8 (0.69-0.9). The AUC for CLIF-ACLF, Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA), and EASL-CLIF ACLF grades was < 0.5. Conclusion: In LT for ACLF, acceptable survival can be achieved when less than three high-risk factors are present.

Outcomes of hepaticojejunostomy for post-cholecystectomy bile duct injury.

OBJECTIVES: Long-term results of hepaticojejunostomy (HJ) for complex bile duct injury (BDI) remain under-reported. The objective of this study was to assess short-term and long-term outcomes of HJ for post-cholecystectomy BDI. METHODS: This was a retrospective cohort study and included patients who underwent Roux-en-Y HJ for BDI (n = 87). Short-term (90-day) and long-term morbidity and mortality were assessed. RESULTS: At presentation, 42 (48.2%) patients had E3 or E4 BDI, 27 (31%) patients had vascular injury, and liver resection was performed in 12 (13.7%) patients. The 90-day morbidity was 51.7% (n = 45), and the 90-day mortality was 2.3% (n = 2). The long-term mortality was 3.4% (n = 3). The 10-year estimated stricture-free survival was 95%. The 10-year estimated overall survival rate was 100% in patients who underwent major hepatectomy and 91% in patients who did not. The 10-year estimated overall survival rate was 100% in patients with vasculobiliary injury and was not reached in patients without vascular injury. CONCLUSIONS: Vascular injury with proximal BDI is not uncommon. Excellent long-term outcomes might be achieved with Roux-en-Y HJ for BDI with vascular injury and in patients requiring liver resection.

Textbook outcome among voluntary donors undergoing major living donor hepatectomy.

PURPOSE: Textbook outcome (TO) is a composite measure of outcome and provides superior assessment of quality of care after surgery. TO after major living donor hepatectomy (MLDH) has not been assessed. The objective of this study was to determine the rate of TO and its associated factors, after MLDH. METHODS: This was a single center retrospective review of living liver donors who underwent MLDH between 2012 and 2021 (n = 1022). The rate of TO and its associated factors was determined. RESULTS: Among 1022 living donors (of whom 693 [67.8%] were males, median age 26 [range, 18-54] years), TO was achieved in 714 (69.9%) with no donor mortality. Majority of donors met the cutoffs for individual outcome measures: 908 (88.8%) for no major complications, 904 (88.5%) for ICU stay ≤ 2 days, 900 (88.1%) for hospital stay ≤ 10 days, 990 (96.9%) for no perioperative blood transfusion, 1004 (98.2%) for no 30-day re-admission, and 1014 (99.2%) for no post-hepatectomy liver failure. Early donation era (before streamlining of donor operative pathways) was associated with failure to achieve TO [OR 1.4, CI 1.1-1.9, P = 0.006]. TO was achieved in 506/755 (67%) donors in the early donation era versus 208/267 (77.9%) in the later period (P = 0.001). CONCLUSION: Despite zero mortality and low complication rate, TO was achieved in approximately 70% donors. TO was modifiable and improved with changes in donor operative pathway.

Living donor liver transplantation for advanced hepatocellular carcinoma including macrovascular invasion.

BACKGROUND: The indications for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) continue to evolve. The aim of this study was to report outcomes in patients who underwent living donor liver transplantation (LDLT) for HCC outside traditional criteria including macrovascular invasion (MVI). METHODS: We reviewed outcomes in patients who met the University of California San Francisco (UCSF) criteria (n = 159) and our center-specific criteria (UCSF+) (largest tumor diameter ≤ 10 cm, any tumor number, AFP ≤ 1000 ng/ml) (n = 58). We also assessed outcomes in patients with MVI (n = 27). RESULTS: The median follow was 28 (10.6-42.7) months. The 5 year overall survival and risk of recurrence (RR) in the UCSF and UCSF + group was 71% vs 69% (P = 0.7) and 13% vs 36% (P = 0.1) respectively. When patients with AFP > 600 ng/ml were excluded from the UCSF + group, RR was 27% (P = 0.3). Among patients with MVI who had downstaging (DS), 4/5(80%) in low-risk group (good response and AFP ≤ 100 ng/ml) and 2/10 (20%) in the high-risk group (poor response or AFP > 100 ng/ml) were alive at the last follow-up. When DS was not feasible, 3/3 (100%) in the low-risk group (AFP ≤ 100 ng/ml + Vp1-2 MVI) and 1/9 (9.1%) in the high-risk group (AFP > 100 or Vp3 MVI) were alive. The 5 year OS in the low-risk MVI group was 85% (P = 0.003). CONCLUSION: With inclusion of AFP, response to downstaging and degree of MVI, acceptable survival can be achieved with LDLT for HCC outside traditional criteria.

Risk Score Model for Liver Transplant Outcomes after Preoperative Locoregional Therapy for Hepatocellular Carcinoma.

PURPOSE: The role of preoperative locoregional therapy (LRT) for hepatocellular carcinoma (HCC) before liver transplantation (LT) remains unclear. Moreover, LRT in the setting of living donor liver transplantation (LDLT) merits further exploration. The objective of the current study was to determine risk factors for poor outcomes after LDLT in patients who received locoregional therapy (LRT). METHODS: We reviewed patients (n = 46) who underwent LDLT after LRT. Multivariate analysis was performed to determine independent predictors of recurrence-free survival (RFS). Risk scores were developed to define prognostic groups. RESULTS: Median tumor size was 3.7 (1.2-12) cm and tumor number was 1 (1-6). Macrovascular invasion was seen in 10/46 (21.7%) patients. There was a significant difference in 5-year RFS with > 3 tumor nodules (P = 0.005), tumors outside University of California San Francisco criteria (P = 0.03), bilobar disease (P = 0.002), AFP > 600 ng/ml (P = 0.006), and poor response to LRT (P = 0.007). On multivariate analysis, bilobar disease (HR = 2.9, P = 0.01), AFP > 600 ng/ml (HR = 2.3 P = 0.008), and poor response to LRT (HR = 2, P = 0.02) were predictors of 5-year RFS. The 5-year RFS in low risk (score = 0), intermediate risk (score = 1-3), and high risk (score = 4-7) groups was 86%, 76%, and 9% (P < 0.0001). There was no recurrence seen in 4/4 (100%) patients with macrovascular invasion in the low-intermediate risk group. The 5-year RFS in the low-intermediate risk group within and outside Milan criteria was 100% and 74% (P = 0.1). CONCLUSIONS: LDLT can provide excellent long-term RFS in patients after preoperative LRT in the low and intermediate risk groups.

Clinical Profile and Treatment of Hepatocellular Carcinoma: A Single-Center Experience.

Background Very few centers in Pakistan have all established treatments for hepatocellular carcinoma (HCC) available under one roof. With a dedicated hepato-pancreato-biliary surgery and liver transplant unit, we have gathered one of the largest data on HCC in our population. Aims The objective of the current study was to assess the clinical spectrum of HCC in Pakistani patients. Settings and Design This retrospective review of patients diagnosed with HCC was conducted between 2011 and 2016. Materials and Methods Patients were allocated to treatment groups based on the Barcelona clinic liver cancer (BCLC) staging algorithm and our local guidelines. The treatment options were grouped as curative (radiofrequency ablation [RFA], percutaneous ethanol injection [PEI], liver resection, and liver transplantation), palliative (transarterial chemoembolization [TACE]/sorafenib), and the best supportive care (BSC). Statistical Analysis Kaplan-Meier curves were used for the statistical analysis. Results The mean age was 57.9 ± 10.1 years (range: 18-90 years). The male-to-female ratio was (1,099/391) 2.8:1. Hepatitis B and hepatitis C were the most common underlying etiological factor in 1,350 of 1,490 (90.6%) patients. Macrovascular invasion (MVI) was seen in 492 of 1,490 (33%) patients. Out of the total, 191 (12.8%) additional patients were offered potentially curative treatments when compared with BCLC recommendations. The actuarial 5-year overall survival for patients who underwent liver transplant, RFA/PEI, TACE, sorafenib, and BSC was 87, 64, 18, 5, and 0%, respectively. Alpha fetoprotein cut-off of 400 ng/mL had a significant impact on survival irrespective of treatment received (41 vs. 11%, p < 0.0001). Conclusion MVI is the most frequent poor prognostic marker in our patients with HCC. Local treatment guidelines are effective in yielding comparable outcomes to BCLC.

Long term outcomes after pancreaticoduodenectomy: A single center experience from Pakistan.

OBJECTIVE: To report long-term outcomes after pancreaticoduodenectomy from a single centre. METHODS: The retrospective study was conducted at Shifa International Hospital, Islamabad and comprised pancreaticoduodenectomy procedures performed by four surgeons at a single centre from January 2011 to June 2019. Outcome was assessed on the basis of morbidity, in-hospital mortality and survival. Data was analysed using SPSS 20. RESULTS: Of the 155 patients, 103(66.5%) were males. The overall mean age was 56.8±13.5 years (range: 8-85 years). Overall morbidity was 84 (54.2%). Multivisceral and venous resections were performed in 22(14.2%) and 20(12.9%) patients respectively. Grade B pancreatic fistula was seen in 5(3.2%) patients and grade C in 6(3.8%). In-hospital mortality was 5(3.2%). The difference between the estimated 5-year overall survival for pancreatic and non-pancreatic cancers was non-significant (p=0.2), while the difference in the estimated 3-year overall survival rate was significant (p<0.05). CONCLUSIONS: With standardisation of operative technique and peri-operative management, low in-hospital mortality and acceptable long-term outcomes were achieved with standard and extended pancreaticoduodenectomy.

Lung Biopsy in Coronavirus-19 Pneumonia: A Case Report and Review of Literature.

Pneumonia is one of the major manifestations of infection by the novel coronavirus (COVID-19) virus. CT scans are used as first line investigation in suspected cases. Biopsies are almost never done. The gross and microscopic pathology has been studied mostly on autopsy specimens in fatal cases. We present a case of a mildly symptomatic adult male, who was a chronic liver disease patient awaiting liver transplant. His lung biopsy was done for diagnosis of a lesion, suspected to be a fungal infection. He was tested for COVID-19 and was PCR-negative at the time. His biopsy showed patchy changes of viral pneumonia. One week later, he tested positive for COVID-19 on PCR. He became asymptomatic soon and the ground glass lung opacities cleared up within another week without any treatment in spite of having a serious comorbid condition.   Key Words: Viral pneumonia, COVID-19, Lung biopsy.

Clinical Utility of Protein Induced by Vitamin K Absence-II in Patients with Hepatocellular Carcinoma.

OBJECTIVE: Despite moderate sensitivity, alpha fetoprotein (AFP) is widely used in screening and prognostication for hepatocellular carcinoma (HCC). The objective of the current study was to assess clinical utility of Prothrombin induced by Vitamin K absence-II (PIVKAII) in addition to AFP in patients with HCC. METHODS: We retrospectively reviewed 244 patients with documented AFP, PIVKA II and dynamic imaging of the liver. Using ROC curves, cutoff values for AFP and PIVKAII for HCC detection, tumor grade and microvascular invasion (MVI) were assessed. In patients who underwent liver transplantation (LT) for HCC, survival was determined using Kaplan Meier curves. RESULTS: The median PIVKAII in healthy living donors was 28.6mAU/ml (15.9-55). In cirrhotics, the sensitivity of an AFP cutoff of 7.6 ng/ml or PIVKAII  cutoff of 250 mAU/ml for HCC detection was 91.7% (176/192) and specificity was 62.9%(68/108) (p <0.0001). In patients with HCC, PIVKAII values were significantly elevated with tumor size > 5 cm (P < 0.0001), tumor nodules > 3(P=0.01), and macrovascular invasion(p <0.0001).  The high risk group (patients with AFP ≥ 40 ng/ml + PIVKAII ≥ 350 mAU/ml), had a sensitivity of (23/33) 69.6% and specificity of (22/22)100% for MVI (P <0.001). The estimated 3 year RFS after LT in the low risk group (AFP.

Living Donor Liver Transplantation During the COVID-19 Pandemic: an Evolving Challenge.

BACKGROUND: Maintaining standards of living donor liver transplantation (LDLT) can be a challenge during the corona virus disease 2019 (COVID-19) pandemic. Center-specific protocols have been developed and transplant societies propose limiting elective LDLT. We have looked at outcomes of LDLT during the pandemic in an exclusively LDLT center. METHODS: Patients were grouped into pre-COVID (January 2019-February 2020) (n = 162) and COVID (March 2020-January 2021) (n = 53) cohorts. We looked at patient characteristics, 30-day morbidity, and mortality. Outcomes were also assessed in donors and recipients who underwent surgery after recovery from COVID-19. RESULTS: The average number of transplants reduced from 11.5/month to 4.8/month. Fewer patients with MELD > 20 underwent LDLT in the COVID cohort (41.3% versus 24.5%, P = 0.03). Out of nine patients with a positive pretransplant COVID-19 PCR, there were 2 (22.3%) deaths on the waiting list. Seven patients underwent LT after recovery from COVID-19 with one 30-day mortality due to biliary sepsis. Three donors with positive COVID-19 PCR underwent uneventful donation after testing negative for COVID-19. No significant difference in 30-day survival was observed in the pre-COVID and COVID cohorts (93.2% versus 90.6%) (P = 0.3). Out of two recipients who developed COVID-19 pneumonia within 30 days after LT, there was one mortality. The 1-year survival for the entire cohort with a MELD cutoff of 20 was 90% and 84% (P = 0.2). CONCLUSION: Despite comparable outcomes, fewer sick patients might undergo LDLT during the pandemic. Individuals recovered from COVID-19 might be safely considered for donation or transplantation.

When to call it off: defining transplant candidacy limits in liver donor liver transplantation for hepatocellular carcinoma.

BACKGROUND: Living donor liver transplantation (LDLT) is an acceptable treatment option for hepatocellular carcinoma (HCC). Traditional transplant criteria aim at best utilization of donor organs with low risk of post transplant recurrence. In LDLT, long term recurrence free survival (RFS) of 50% is considered acceptable. The objective of the current study was to determine preoperative factors associated with high recurrence rates in LDLT. METHODS: Between April 2012 and December 2019, 898 LDLTs were performed at our center. Out of these, 242 were confirmed to have HCC on explant histopathology. We looked at preoperative factors associated with ≤ 50%RFS at 4 years. For survival analysis, Kaplan Meier curves were used and Cox regression analysis was used to identify independent predictors of recurrence. RESULTS: Median AFP was 14.4(0.7-11,326.7) ng/ml. Median tumor size was 2.8(range = 0.1-11) cm and tumor number was 2(range = 1-15). On multivariate analysis, AFP > 600 ng/ml [HR:6, CI: 1.9-18.4, P = 0.002] and microvascular invasion (MVI) [HR:5.8, CI: 2.5-13.4, P <  0.001] were independent predictors of 4 year RFS ≤ 50%. When AFP was > 600 ng/ml, MVI was seen in 88.9% tumors with poor grade and 75% of tumors outside University of California San Francisco criteria. Estimated 4 year RFS was 78% for the entire cohort. When AFP was < 600 ng/ml, 4 year RFS for well-moderate and poor grade tumors was 88 and 73%. With AFP > 600 ng/ml, RFS was 53% and 0 with well-moderate and poor grade tumors respectively (P <  0.001). CONCLUSION: Patients with AFP < 600 ng/ml have acceptable outcomes after LDLT. In patients with AFP > 600 ng/ml, a preoperative biopsy to rule out poor differentiation should be considered for patient selection.

Recipient Outcomes with Younger Donors Undergoing Living Donor Liver Transplantation.

Introduction The impact of donor age on liver transplantation is well known. Data on an appropriate donor age cut-off for living donor liver transplantation (LDLT) with a background of hepatitis C (HCV) is generally limited. The objective of this study was to determine whether limiting donor age to less than 35 years improved outcomes in patients with HCV-related end-stage liver disease (ESLD). Methods This was a retrospective review of 169 patients who underwent LDLT for HCV-related ESLD. The patients were divided into two groups based on whether they received grafts from donors ≤ 35 (Group 1) or > 35 (Group 2) years of age. Kaplan Meier curves were used to determine survival. Uni and multivariate analysis were performed to determine independent predictors of mortality. Results Mean donor age was 25.1 ± 5.2 and 40.1 ± 3.4 years (P < 0.0001). Early allograft dysfunction (EAD) was seen in 11.7% patients in Group 1 versus 29.6% in Group 2 (P = 0.02). A significant difference in mortality was present between the two groups, i.e., 33.3% versus 15.8% (P = 0.04). The estimated four-year overall survival (OS) was 78% and 64% (P = 0.03). Upon doing univariate analysis, the donor age (P = 0.04) and EAD (P = 0.006) were found to be significant variables for mortality. On multivariate analysis, EAD was the only independent predictor of mortality (Hazard ratio: 2.6; confidence interval: 1.1 - 5.8; P = 0.01). Conclusion Opting for younger donors (≤ 35 years) for HCV-related ESLD patients lowers the risk of EAD and improves overall survival.

Living Donor Liver Transplantation for Hepatocellular Carcinoma: A Single-Center Experience from Pakistan.

BACKGROUND: Living donor liver transplantation (LDLT) is an established treatment for patients with cirrhosis and hepatocellular carcinoma (HCC) within Milan criteria. Acceptable outcomes have been demonstrated in patients fulfilling extended criteria. Here, we share our experience with LDLT for patients with HCC within and beyond Milan criteria, with emphasis on poor prognostic factors. METHODS: We retrospectively reviewed patients who underwent LDLT between 2012 and 2017 and had HCC proven on explant liver histopathology. A total of 117 patients were included. Patients who died early after transplant (in <30 days) were excluded. For outcomes, patients were divided into prognostic groups. These groups were based on (1) alpha fetoprotein >600, (2) poor differentiation, and (3) the presence of lymphovascular invasion. Recurrence-free survival (RFS) was determined using Kaplan-Meier curves. RESULTS: Median age was 53 (30-73) years. Median follow-up was 20.3 (1-63.2) months. Median model for end stage liver disease (MELD) score was 19 (9-34). Of a total of 117 patients, 74 (63.2%) patients met Milan criteria. Recurrence rate was 12/117 (10.3%). Actuarial 5-year RFS was 88% and 82% (P = 0.3) in patients within and outside Milan criteria. There was no difference in 3-year RFS in patients with 0, 1, or 2 poor prognostic factors within Milan criteria (92%, 87%, and 75%, respectively; P = 0.3). However, a significant difference in RFS was seen in patients outside Milan criteria (92%, 93%, and 53%; P = 0.03). CONCLUSIONS: Patients within Milan criteria have acceptable RFS even in the presence of poor prognostic factors. However, the presence of two or more poor prognostic variables significantly impacts RFS of patients outside Milan criteria.

Living Donor Liver Transplantation for Acute on Chronic Liver Failure Based on EASL-CLIF Diagnostic Criteria.

BACKGROUND: The European association for the study of the liver and chronic liver failure consortium (EASL-CLIF) recently proposed diagnostic criteria for acute on chronic liver failure (ACLF). There is lack of data regarding liver transplant outcomes in ACLF patients based on these criteria. The objective of this study was to determine outcome following living donor liver transplantation (LDLT) in ACLF patients. METHODS: We retrospectively reviewed patients who underwent LDLT for ACLF based on European association for the study of the liver and chronic liver failure consortium (EASL-CLIF) diagnostic criteria (group 1) (N = 60) and compared them with ACLF patients who did not undergo transplantation (group 2) (N = 59). The primary outcome of interest was 30 day mortality. We also looked at one year survival in these patients. Survival was calculated using Kaplan-Meier curves and Log rank test was used to determine significance between variables. RESULTS: Median MELD scores for group 1 and 2 patients in ACLF grade 1 was 28 (20-38) and 31 (24-36), in ACLF grade 2 was 35 (24-42) and 36 (24-42) and in ACLF grade 3 was 36 (29-42) and 38 (32-52). For group 1 and 2, 30 day mortality in ACLF grade 1, 2 and 3 was 2/43(4.6%) versus 9/15(60%) (P < 0.001), 1/15 (6.6%) versus 13/19 (68.4%), 0/2 (0%) versus 20/25 (80%) (P < 0.001). Actuarial 1 year overall survival was 92% versus 11% (P < 0.001) in patients who underwent transplantation versus those who did not. One year survival in patients with grade 1 and 2 ACLF who received transplant versus medical treatment was 91% versus 13% and 93% versus 15% (P < 0.001) respectively. CONCLUSION: LDLT has excellent outcomes in patients with EASL-CLIF grade 1 and 2 ACLF. Without transplantation, ACLF patients have a very poor prognosis.

Living Donor Liver Transplantation in South Asia: Single Center Experience on Intermediate-Term Outcomes.

BACKGROUND: There is paucity of data on intermediate-term post liver transplant outcomes from South Asia. The objective of this study was to determine survival outcomes in patients who underwent living donor liver transplantation (LDLT) in a busy liver transplant center in Pakistan. METHODS: This study was a review of patients who underwent LDLT between 2012 and 2016. A total of 321 patients were included in this study. Early (within 90 days) and late (>90 days) morbidity and mortality was assessed. Estimated 1- and 4-year survival was determined. RESULTS: Median age was 48 (18-73) years. Male to female ratio was 4.5:1. Out of total 346 complications, 184 (57.3%) patients developed 276 (79.7%) complications in early post-transplant period, whereas there were 70 (21.3%) late complications. Most common early complication was pleural effusion in 46 (16.6%) patients. Biliary complications were the most common late complication and were seen in 31/70 (44.2%) patients. Overall 21.4% patients had a biliary complication. The 3-month mortality was 14%. The estimated 1- and 4-year OS for a MELD cutoff of 30 was 84.5 versus 72 and 80 versus 57% (P = 0.01). There was no donor mortality. CONCLUSION: Acceptable intermediate-term post-transplant outcomes were achieved with LDLT. There is a need to improve outcomes in high-MELD patients.

Failure to rescue in living donor liver transplantation: Patterns and predictors.

BACKGROUND: As a quality assessment tool, failure to rescue (FTR) has been employed in various surgical specialties. However, its role in liver transplantation has only recently been explored. To the best of our knowledge, role of FTR in living donor liver transplant (LDLT) has not been assessed previously. The objective of the current study was to determine failure to rescue (FTR) rate and it's predictors in an LDLT center. MATERIALS AND METHODS: We reviewed a prospectively maintained database of patients who underwent LDLT at our center between 2012 and 2016. Patients who experienced grade 3B or above complications on Clavien-Dindo grading were included in this study. Primary outcome of interest was FTR rate in these patients. FTR was defined as a preventable major complication followed by death within one year after transplantation. We also looked at independent predictors of FTR in our patients and a multivariate analysis was performed. RESULTS: Median age was 48.4(18-73) years. Male to female ratio was 3.3:1. Median MELD score was 17(6-42). The FTR rate in the current study was 52/131 (39.6%). Infectious complications were more common in the FTR group i.e. 22/32(68.8%) versus 10/32 (31.2%) (P < 0.0001). Biliary complications were more common in the non-FTR group i.e. 49/62 (79.1%) versus 13/62 (20.9%) (P < 0.0001). On multivariate analysis, there was a 60% increase in mortality following a major complication in the presence of early allograft dysfunction (Hazard ratio: 1.6, Confidence interval; 1.2-2.2, P = 0.002). A 40% reduction in FTR was seen in patients with a biliary complication versus other complications (Hazard ratio: 0.6, Confidence interval = 0.4-0.8, P = 0.009). CONCLUSION: Early allograft dysfunction and biliary complications are independent predictors of FTR in LDLT.