Imaging Validation of Drug-Eluting Beads Transarterial Chemoembolization of Hepatocellular Carcinomas in Living Donor Liver Transplantation.

OBJECTIVE: The aim of this study is to determine whether post-transarterial chemoembolization imaging (computed tomography or magnetic resonance imaging) could accurately predict the tumors' necrosis on pathologic specimens. BACKGROUND: Transarterial chemoembolization with drug-eluting beads has been proven to be an effective way to bridge patients with hepatocellular carcinomas to liver transplantation. MATERIALS AND METHODS: From September 2012 to June 2017, 59 patients with a total of 78 hepatocellular carcinomas, who received transarterial chemoembolization with drug-eluting beads before liver transplantation in Kaohsiung Chang Gung Memorial Hospital, were included in the study. All patients and hepatocellular carcinomas have pre-transarterial chemoembolization and post-transarterial chemoembolization images (computed tomography or magnetic resonance imaging) and pathological findings for correlation. Tumor response was evaluated according to modified Response Evaluation Criteria in Solid Tumors. The ranges of necrotic percentage are 100%, 91-99%, 51-90%, and <50%. RESULTS: The accuracy rate between the imaging and pathology correlation was 40% for computed tomography and 42% for magnetic resonance imaging. The recurrent rate of the complete respond group is 11.5%, the partial respond group is 16.0%, and the stationary group is 28.6%. CONCLUSION: Computed tomography and magnetic resonance imaging sensitivity is not satisfactory for microscopic evaluation of residual tumors after transarterial chemoembolization with drug-eluting beads. However, survival is good after liver transplantation no matter what the microscopic findings were.

Pharmacokinetic Analysis of Dynamic Contrast-Enhanced Magnetic Resonance Imaging for Distinguishing Hepatocellular Carcinoma From Cholangiocarcinoma in Pre-Liver Transplantation Evaluation.

OBJECTIVE: Liver transplantation for intrahepatic cholangiocarcinoma is notorious for rapid recurrence with poor survival rate postoperatively and has therefore been discontinued in most centers. The purpose of this study is to distinguish hepatocellular carcinoma (HCC) from cholangiocarcinoma in pretransplantation imaging evaluation by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). MATERIALS AND METHODS: From January 2014 to September 2015, 19 patients were included in the study, with a mean age of 62.8 years. All subjects underwent pretransplantation DCE-MRI and surgical excision or core biopsy. The DCE-MRI parameters were measured using the Tofts model 1999. Statistical analysis included nonparametric tests and area under the curve for the receiver operating characteristic. RESULTS: Fourteen HCCs and 5 cholangiocarcinomas were diagnosed by surgical pathology. The mean size of tumor was 6.4 cm (range, 1.5 cm to 13.7 cm). All DCE-MRI parameters were calculated as the ratio between the tumor and normal liver parenchyma and K(trans) (1/min) was used as a distinguishing parameter between the two tumors. K(trans) was higher in the cholangiocarcinoma group (1.89 ± 1.13) than in the HCC group (0.46 ± 0.35). Univariate analysis revealed that K(trans) has a high significant difference (P = .001). The optimal K(trans) value cutoffs were 1 or more (area under the curve = 0.971) for detection of HCCs or cholangiocarcinomas. CONCLUSION: The analysis of DCE-MRI with the kinetic model (Tofts, 1999) presents a new and practical approach indiscrimination of HCC from cholangiocarcinoma for pretransplantation imaging evaluation.

Asp68His mutation in the A1 domain of human factor V causes impaired secretion and ineffective translocation.

Congenital factor V (FV) deficiency is a rare inherited disorder. We determined the mechanism of a missense mutation, Asp68His, in the A1 domain of the FV protein, is associated with severe FV deficiency. We characterized the mutant FV-Asp68His protein using in vitro expression studies by using specific secretion and degradation pathway inhibitors and analysed the intracellular translocation of the mutant protein by immunofluorescence staining. The Asp68His mutation caused very low levels of FV protein in the conditioned media, with normal specific FV activity. Similar mRNA degradation rates between FV-wild-type (wt) and FV-Asp68His mRNA showed that the Asp68His mutation does not affect FV expression at the transcriptional level. A specific secretion pathway inhibitor, brefeldin A, was used to demonstrate that the lower efficiency of transport to the outside of the cell for FV-Asp68His mutant protein compared with that of the FV-wt protein. Furthermore, we showed that the Asp68His mutation resulted in increased intracellular degradation through a MG132-mediated proteasomal degradation pathway. In the transfected cell lysates, FV-wt protein had multiple posttranslational modified forms, but the FV-Asp68His protein was not completely glycosylated. We further observed that the FV-Asp68His protein was retrieved in the endoplasmic reticulum only and did not undergo transport to the Golgi apparatus, leading to impaired secretion. These results strongly suggest that the Asp68His mutation may result in intracellular defective trafficking and enhanced degradation, and impaired secretion of FV protein.

The acoustic radiation force impulse elastography evaluation of liver fibrosis in posttransplantation dysfunction of living donor liver transplantation.

BACKGROUND: The acoustic radiation force impulse elastography (ARFI) is a new technology of elastography integrated into B-mode ultrasonography. It has been a reliable method to evaluate liver fibrosis of chronic liver disease in recent years, but less applied in the posttransplantation liver. The aim of the study was to evaluate liver fibrosis by the ARFI with correlation of pathological stages in living donor liver transplantation (LDLT). MATERIALS AND METHODS: From August 2010 to August 2012, there were 57 LDLT patients with liver biopsy (LB) due to posttransplantation dysfunction; all patients also received posttransplantation ARFI liver stiffness measurement (LSM) after transplantation for liver fibrosis staging. The ARFI elastography was performed using a Siemens Acuson S2000 ultrasound system with 4V1 transducers (Acusion, Siemens Medical Systems Co. Ltd. Erlangen, Germany). The ARFI LSM value was presented by shear wave velocity (SWV, m/s). The fibrosis staging as F0 to F4 was in accordance with the Metavir scoring system. RESULTS: A total of 57 patients had both posttransplantation LB and effective ARFI fibrosis staging for correlation. The ARFI LSM value increased with severity of liver fibrosis and had significant linear correlation with the results of histological fibrosis staging. The ARFI LSM sensitivities (Se), specificities (Sp), and cutoff values based on receiver-operator characteristic curve were F0: 0.75 m/s (Se: 93.8%, Sp: 4%), F1: 1.06 m/s (Se: 95.5%, Sp: 25.7%), F2: 1.81 m/s (Se: 50%, Sp: 83.6%) and F3: 2.33 m/s (Se: 100%, Sp: 92.9%). Predictive value of ARFI LSM reported a significant difference between early fibrosis stage (F0-F1) and advanced fibrosis stage (F ≧ 2) (P < .05). CONCLUSION: In this study, ARFI demonstrated a strong linear correlation and severity of liver fibrosis with LB pathologic staging. ARFI can be an alternative and compensatory method for frequent LB in the posttransplantation liver.

Hemodynamics of portal venous stenosis before and after treatment in pediatric liver transplantation: evaluation with Doppler ultrasound.

AIM: The aim of this study was to evaluate portal vein stenosis (PVS) in pediatric liver transplantation (PLT) using Doppler ultrasound (DUS) before and after interventional management for hemodynamic changes. MATERIALS AND METHODS: From 2000 to 2010, we encountered 11 PVS cases among 180 PLT that were evaluated using DUS and computed tomography (CT) angiography (CTA); all underwent portal stenting. DUS was used to monitor portal hemodynamics. For the diagnosis of PVS, we investigated multiple parameters including stenotic size (SS), stenotic ratio (SR) (SR [%]=PRE-SS/PRE [PRE=stenotic size]), portal flow velocity ratio (VR) (VR=VS/PRE [PRE=velocity at prestenotic site; VS=peak velocity at stenotic site]), spleen size, and platelet count. RESULTS: The incidence of PVS was 5.6% (11/180). The PV was 2.5 mm using DUS and 2.7 mm using CTA. The average SR was 65% fitting the criterion. Low prestenotic portal flow<12 cm/sec and high peak velocity in the stenotic segment (up to 147 cm/sec) were observed in 6 cases. The VR value was high at 7.5:1 and there was splenomegaly with thrombocytopenia. After portal vein stenting, hyperperfusion occurred might after reopening the stenosis: the flow increased to an average of 34 cm/sec and then flow decreased slowly to a stable level 2 weeks later. The size of the spleen decreased from 17 to 12 cm and the thrombocytopenia also improved with platelet counts increasing from 67×10(3) to 178×10(3)/µl at 2 months follow-up. The changes in portal flow, portal vein size, spleen size, and platelet count were significant (P<.05). CONCLUSION: PVS is diagnosed using DUS by increased intrahepatic PV dilatation, peak flow at the stenotic site, discrepant VR. Early portal stenting showed a better prognosis. DUS is essential and effective for hemodynamic monitoring and management of PVS.

Superparamagnectic iron oxide-enhanced magnetic resonance for tumor surveillance in cirrhotic liver before liver transplantation with explanted liver correlation.

OBJECTIVE: The aim of this study was to determine the accuracy of superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance imaging (MRI) in the detection of liver tumors in patients with liver cirrhosis before liver transplantation (LT). PATIENTS AND METHODS: Twenty-one patients with moderate to severe liver cirrhoses (Child-Pugh score B or C) underwent SPIO-enhanced MRI before LT. SPIO-enhanced MRI was composed of SPIO-enhanced T1-weighted images, T2-weighted turbo spin-echo, and T2*-weighted sequences. The detection of malignant liver tumor was based on hepatic lesions that remain with hyper-signal intensity on SPIO-enhanced delayed T2 and T2*-weighted images. The imaging was compared with findings during histopathologic evaluation of the explanted liver. RESULTS: Forty-two liver nodules were found in 16 of the 21 patients. Thirty-six malignant hepatic neoplasms were detected at histopathologic evaluation. SPIO-enhanced MRI depicted 30 of 36 malignant hepatic neoplasms. Patient-based analysis showed that the sensitivity, specificity, and accuracy of MRI were 93.75%, 100%, and 95.2%, respectively. For lesion-based analysis, the sensitivity, specificity, and the area under the receiver operating characteristic (ROC) curve were 90%, 100%, and 0.95, respectively, for lesions >2 cm. CONCLUSIONS: SPIO-enhanced MRI can be used as an additional diagnostic tool for the detection and characterization of malignant tumors in cirrhotic livers. This diagnostic evaluation is accurate to triage patients for LT.

Doppler ultrasound evaluation of postoperative portal vein stenosis in adult living donor liver transplantation.

AIM: To evaluate the postoperative portal vein stenosis (PVS) and the diagnostic efficiency of Doppler ultrasound (DUS) in adult living donor liver transplantation (ALDLT). MATERIALS AND METHOD: From January 2007 to December 2008, 103 ALDLTs were performed and postoperatively followed by routine DUS. The morphologic narrowing at the anastomotic site (AS) of the PVS was analyzed. We calculated the PV stenotic ratio (SR) using the following formula: SR (%)=PRE-AS/PRE (PRE=pre-stenotic caliber). An SR>50% was defined as the critical point for PVS. We also calculated the velocity ratio (VR) between the AS and PRE, and set the significant VR as >3:1. Statistical analyses were carried out to determine clinical significance. RESULTS: Using the definition of morphologic PVS by DUS, there were total 20 cases (19.4%) in this series with SR>50%, which included 17 cases with VR>3:1. Eight cases of severe PVS had a stenotic AS>5 mm and subsequently underwent interventional management. Doppler criteria of SR and VR values were elevated up to 75.8% and 7.5:1, respectively, in these treated cases. Two cases of severe PVS subsequently developed PV thrombosis. Intervention by balloon dilation and/or stenting was performed successfully in this PVS case. CONCLUSION: DUS is the most convenient and efficient imaging modality to detect and follow postoperative PVS in ALDLT. The Doppler criteria of SR and VR are both sensitive but less specific. Cases of AS<5 mm require interventional management for good long-term graft survival.

Effects of hemorrhagic shock in early and late partial posthepatectomy rats.

INTRODUCTION: The purpose of the study was to determine the compensatory function of the remnant liver as a blood reservoir after 70% hepatectomy in rats to counteract hemorrhagic shock and reperfusion. METHODS AND MATERIALS: One hour of hemorrhagic shock followed by 1 hour of resuscitation induced in normal rats (group I) was compared with animals that had undergone 70% hepatectomy at postoperative day 3 (group II) and day 7 (group III). We compared the total blood loss, the blood pressure before hemorrhagic shock, hemoglobin, hemotocrit, and mortality. Liver function such as aspartate transferase (AST), alanine transferase, and lactate dehydrogenase (LDH) were also compared among groups by one-way analysis of variance with post hoc correction. A P value less than .05 was regarded as significant. RESULTS: The results showed a lower volume of drawn blood induced hemorrhagic shock in group II compared with group I or group III hosts. The blood loss was 15.6+/-1.0, 5.68+/-2.5, and 13.2+/-1.6 mL for groups I, II, and III, respectively. The mortality due to hemorrhagic shock was significantly higher in group II compared with group I or group III. Liver function tests showed that the AST and LDH were significantly higher after resuscitation in group II. CONCLUSION: In the early postoperative period (day 3) after 70% hepatectomy, rats were more vulnerable to a high mortality after hemorrhagic shock compared with hosts in the late postoperative period (day 7). Significantly higher AST and LDH in group II indicated that the remnant liver was more injured after hemorrhagic shock in the early postoperative period.

Vascular stents in the management of portal venous complications in living donor liver transplantation.

To evaluate the efficacy of stent placement in the treatment of portal vein (PV) stenosis or occlusion in living donor liver transplant (LDLT) recipients, 468 LDLT records were reviewed. Sixteen (10 PV occlusions and 6 stenoses) recipients (age range, 8 months-59 years) were referred for possible interventional angioplasty (dilatation and/or stent) procedures. Stent placement was attempted in all. The approaches used were percutaneous transhepatic (n = 10), percutaneous transsplenic (n = 4), and intraoperative (n = 2). Technical success was achieved in 11 of 16 patients (68.8%). The sizes of the stents used varied from 7 mm to 10 mm in diameter. In the five unsuccessful patients, long-term complete occlusion of the PV with cavernous transformation precluded catherterization. The mean follow-up was 12 months (range, 3-24). The PV stent patency rate was 90.9% (10/11). Rethrombosis and occlusion of the stent and PV occurred in a single recipient who had a cryoperserved vascular graft to reconstruct the PV during the LDLT operation. PV occlusion of >1 year with cavernous transformation seemed to be a factor causing technical failure. In conclusion, early treatment of PV stenosis and occlusion by stenting is an effective treatment in LDLT. Percutaneous transhepatic and transsplenic, and intraoperative techniques are effective approaches depending on the situation.

Hospital-based surveillance and molecular epidemiology of rotavirus infection in Taiwan, 2005-2007.

To determine the distribution of rotavirus strains and facilitate vaccine policy decisions in Taiwan, active hospital-based gastroenteritis surveillance was conducted in three sentinel hospitals. From 1 January 2005 to 31 December 2007, a total of 3435 children less than 5 years old with gastroenteritis were enrolled. The presence of rotavirus was documented by enzyme immunoassay (EIA), and the G and P genotypes were determined by reverse transcription-polymerase chain reaction (RT-PCR) and sequencing methods. Results confirmed that 856 (25%) of these gastroenteritis admissions were EIA-positive for rotavirus and 448 (52%) of the rotavirus positive admissions were less than 2 years old. The most prevalent rotavirus genotypes were G1P[8] (40%), followed by strains G3P[8] (27%), and G9P[8] (17%). These data will help inform decisions as to whether rotavirus vaccine should be considered for inclusion into Taiwan's National Immunisation Programme.

Liver graft regeneration in right lobe adult living donor liver transplantation.

Optimal portal flow is one of the essentials in adequate liver function, graft regeneration and outcome of the graft after right lobe adult living donor liver transplantation (ALDLT). The relations among factors that cause sufficient liver graft regeneration are still unclear. The aim of this study is to evaluate the potential predisposing factors that encourage liver graft regeneration after ALDLT. The study population consisted of right lobe ALDLT recipients from Chang Gung Memorial Hospital-Kaohsiung Medical Center, Taiwan. The records, preoperative images, postoperative Doppler ultrasound evaluation and computed tomography studies performed 6 months after transplant were reviewed. The volume of the graft 6 months after transplant divided by the standard liver volume was calculated as the regeneration ratio. The predisposing risk factors were compiled from statistical analyses and included age, recipient body weight, native liver disease, spleen size before transplant, patency of the hepatic venous graft, graft weight-to-recipient weight ratio (GRWR), posttransplant portal flow, vascular and biliary complications and rejection. One hundred forty-five recipients were enrolled in this study. The liver graft regeneration ratio was 91.2 +/- 12.6% (range, 58-151). The size of the spleen (p = 0.00015), total portal flow and GRWR (p = 0.005) were linearly correlated with the regeneration rate. Patency of the hepatic venous tributary reconstructed was positively correlated to graft regeneration and was statistically significant (p = 0.017). Splenic artery ligation was advantageous to promote liver regeneration in specific cases but splenectomy did not show any positive advantage. Spleen size is a major factor contributing to portal flow and may directly trigger regeneration after transplant. Control of sufficient portal flow and adequate hepatic outflow are important factors in graft regeneration.

Plasma exchange therapy for thrombotic thrombocytopenic purpura in pediatric patients with liver transplantation.

PURPOSE: Sporadic cases of thrombotic thrombocytopenic purpura (TTP) have been reported in bone marrow and solid organ transplant patients receiving cyclosporine (CsA). We reported our experience with TTP using plasma exchange (PE) therapy in patients with liver transplantation (OLT). METHODS: Between March, 1993, and May, 2007, 400 patients underwent OLT, including 146 pediatric living-donor liver transplantation (LDLT). Four pediatric patients developed TTP after OLT: three were males and one female of mean age at the time of transplantation of 7.8 +/- 3.6 years. The four recipients had the following indications for OLT: two glycogen storage disease, one biliary atresia, and one fulminant hepatic failure. Four patients initially received triple drug immunosuppression consisting of CsA, azathioprine, and steroids. RESULTS: Four (1%) patients developed TTP after OLT. All four patients were pediatric in the age group. The mean age at the time of TTP diagnosis was 8.0 +/- 3.2 years, with a mean postoperative interval to TTP of 78.8 +/- 114.2 days. The mean baseline platelet count was 7.0 +/- 7.1 x 10,000. The eventual platelet count was 21.1 +/- 20.8 x 10,000 after PE. These patients received PE 6.0 +/- 4.2. The mean baseline serum creatinine was 0.8 +/- 0.8 mg/dL. The mean peak serum creatinine was 2.3 +/- 2.3 mg/dL. The mean serum CsA level was 717.5 +/- 106.0 ng/mL before TTP diagnosis. Four patients were diagnosed by blood peripheral smears. The causes of TTP were CsA-associated in three patients and venoocclusive disease (VOD) in one patient. Three patients improved their platelet counts after PE therapy. Two patient changed from CsA to FK 506, one underwent reduced CsA dosage, and one stopped CsA. Three patients died of recurrent VOD, infection, and intrapulmonary hemorrhage. Only one patient survived. CONCLUSIONS: The incidence of TTP in our series was lower. It only developed in pediatric patients. The causes of TTP were associated with CsA and/or VOD. The mortality was high after the TTP diagnosis. We concluded that TTP was a potentially fatal condition, but an early diagnosis with prompt institution of therapy with invasive PE therapy may reduce its mortal consequences.

The reaction of posttransplant denervated liver on the hemorrhagic shock in rats.

OBJECTIVE: The aims of the study were to determine the effects of denervation on the function of the liver transplantation as a blood reservoir and to define its vulnerability to ischemic-reperfusion (I/R) injury after hemorrhagic shock. MATERIALS AND METHODS: Hemorrhagic shock with a mean arterial blood pressure (MAP) of 40 to 50 mm Hg was induced by withdrawing blood at a rate of approximately 1 mL/min among 10 posttransplant denervated rats and 10 sham rats for 1 hour. The rats were then resuscitated by retransfusing the drawn blood with sacrifice under deep anesthesia at 1 hour after resuscitation. The total amount of blood required to achieve hemorrhagic shock was compared between groups as well as the vulnerability and reactions of the posttransplant denervated liver to I/R injury after hemorrhagic shock as assessed by gene expressions of c-jun, c-fos, tumor necrosis factor (TNF)-alpha, interleukin (IL)6, IL-10, and heat-shock protein 70 (HSP70). RESULTS: The volume of blood that had to be drawn to reach a MAP of 40 to 50 mm Hg was not significantly different between the groups. One hour of hemorrhagic shock followed by resuscitation resulted in significant increases in the genes expression of c-fos, TNF-alpha, IL-6, IL-10, and HSP70 in comparison to the control values, but no difference was observed between experimental and sham groups. CONCLUSION: We suggest that the function of the liver as a blood reservoir and the gene expressions of c-fos and pro- and anti-inflammatory cytokines, as well as the protective protein HSP70 in response to I/R injury, were not altered by liver transplantation.

Development of malignant lymphoma subsequent to breast cancer.

The development of malignant lymphoma following breast cancer has not been described before. Here we report the development of malignant lymphoma at the ipsilateral chest wall subsequent to the surgical treatment of breast cancer. A 48-year-old woman underwent modified radical mastectomy due to breast carcinoma. Tamoxifen (10 mg twice daily) was given 3 years after the operation and continued for about 3 years. The patient was well until she recently (17 years after the initial operation) noted a small lump at her left anterior chest wall near the axilla. The local tumour mass was initially assumed to be a local recurrent lesion of breast cancer. Excisional biopsy was performed and eventually was histologically diagnosed to be malignant lymphoma. In view of the therapeutic implication, the development of second malignancy should not be mistaken as a progression of the known primary malignancy. Only with the awareness of such entity, can the prompt diagnosis and proper treatment be achieved.

Active immunization to prevent de novo hepatitis B virus infection in pediatric live donor liver recipients.

This study aims to evaluate the efficacy of HBV vaccination as an alternative preventive measure against de novo HBV infection in pediatric living donor liver transplantation (LDLT). Sixty recipients were enrolled in this study. Thirty received grafts from anti-HBc(+) donors, and another 30 received grafts from anti-HBc(-) donors. HBV vaccine was given pretransplant to every candidate. Posttransplant, lamivudine was routinely given to recipients receiving anti-HBc(+) grafts for about 2 years. Forty-seven (78%) recipients achieved high levels of anti-HBs titer (>1000 IU/L). Two (3.3%) recipients developed de novo HBV infection where one received an anti-HBc(-) graft and another received an anti-HBc(+) graft. Both recipients were in the lower anti-HBs titer group (<1000 IU/L). The incidence of de novo HBV infection was significantly higher in the lower titer group (15.4% vs. 0%, p = 0.04). The median follow-up period was 51 months in recipients with anti-HBc(-) grafts and 57 months in those with anti-HBc(+) grafts. Active immunization is an effective method to prevent de novo HBV infection. It can result in high levels of anti-HBs titer (>1000 IU/L) which may prevent de novo HBV infection in pediatric patients with efficient primary vaccination undergoing LDLT.

Liver graft-to-recipient spleen size ratio as a novel predictor of portal hyperperfusion syndrome in living donor liver transplantation.

Portal hyperperfusion in a small-size liver graft is one cause of posttransplant graft dysfunction. We retrospectively analyzed the potential risk factors predicting the development of portal hyperperfusion in 43 adult living donor liver transplantation recipients. The following were evaluated: age, body weight, native liver disease, spleen size, graft size, graft-to-recipient weight ratio (GRWR), total portal flow, recipient portal venous flow per 100 g graft weight (RPVF), graft-to-recipient spleen size ratio (GRSSR) and portosystemic shunting. Spleen size was directly proportional to the total portal flow (p = 0.001) and RPVF (p = 0.014). Graft hyperperfusion (RPVF flow > 250 mL/min/100 g graft) was seen in eight recipients. If the GRSSR was < 0.6, 5 of 11 cases were found to have graft hyperperfusion (p = 0.017). The presence of portosystemic shunting was significant in decreasing excessive RPVF (p = 0.059). A decrease in portal flow in the hyperperfused grafts was achieved by intraoperative splenic artery ligation or splenectomy. Spleen size is a major factor contributing to portal flow after transplant. The GRSSR is associated with posttransplant graft hyperperfusion at a ratio of < 0.6.

Living donor liver transplantation for biliary atresia: a single-center experience with first 100 cases.

The aim of this study is to present our institutional experience in living donor liver transplantation (LDLT) as a treatment for end-stage liver disease in children with biliary atresia (BA). A retrospective review of transplant records was performed. One hundred BA patients (52 males and 48 females) underwent LDLT. The mean follow-up period was 85.5 months. The mean age was 2.4 years. The mean preoperative weight, height, and computed GFR were 12.2 kg, 82.5 cm, and 116.4 ml/min/1.73 m2, respectively. Twenty-seven patients were below 1 year of age, and 49 patients were below 10 kg at the time of transplantation. Ninety-six had had previous Kasai operation prior to transplant. The mean recipient operative time was 628 min. The mean recipient intraoperative blood loss was 176 ml. Thirty-five did not require blood or blood component transfusion. The left lateral segment (64) was the most common type of graft used. There were 27 operative complications which included 3 reoperations for postoperative bleeding, 9 portal vein, 4 hepatic vein, 4 hepatic artery, and 7 biliary complications. There was one in-hospital mortality and one retransplantation. The overall rejection rate was 20%. The overall mortality rate was 3%. The 6-month, 1-year and 5-year actual recipient survival rates were 99%, 98% and 98%, respectively.

Regular tai chi chuan exercise enhances functional mobility and CD4CD25 regulatory T cells.

BACKGROUND: The duration and vigour of physical exercise are widely considered to be critical elements that may positively or negatively affect physical health and immune response. OBJECTIVES: To investigate the effect of a 12 week programme of regular tai chi chuan exercise (TCC) on functional mobility, beliefs about benefits of exercise on physical and psychological health, and immune regulation in middle aged volunteers. METHODS: This quasi-experimental research design involving one group with testing before and after the programme was conducted to measure the effect of 12 weeks of TCC exercise in 14 men and 23 women from the normal community. RESULTS: Regular TCC exercise had a highly significant positive effect on functional mobility (p = 0.001) and beliefs about the health benefits of exercise (p = 0.013) in the 37 participants. Total white blood cell and red blood cell count did not change significantly, but a highly significant (p<0.001) decrease in monocyte count occurred. A significant (p = 0.05) increase in the ratio of T helper to suppressor cells (CD4:CD8) was found, along with a significant (p = 0.015) increase in CD4CD25 regulatory T cells. Production of the regulatory T cell mediators transforming growth factor beta and interleukin 10 under specific antigen stimulation (varicella zoster virus) was also significantly increased after this exercise programme. CONCLUSIONS: A 12 week programme of regular TCC exercise enhances functional mobility, personal health expectations, and regulatory T cell function.

Increased plasma concentration of nitric oxide in type 2 diabetes but not in nondiabetic individuals with insulin resistance.

OBJECTIVE: Insulin resistance (IR) is a key element in the pathogenesis of type 2 diabetes. The results of recent experiments on insulin-mediated vasodilatation have suggested that vascular insensitivity is a component of IR. However, it is still controversial that patients with type 2 diabetes have a decreased ability of insulin to increase endothelial nitric oxide (NO) release. METHOD: Plasma concentration of NO was examined in 26 patients with type 2 diabetes and 78 nondiabetic volunteers during an insulin suppression test. The test measured the efficacy of insulin in promoting disposal of the infused glucose load, in which the steady state plasma glucose (SSPG) during the 150-180 min of the test was used as an index of IR. Plasma NO levels were assayed by measurement of the stable end products of their metabolism. Comparison of plasma NO levels between groups were performed by Mann-Whitney test and relationships between SSPG and different variables were analyzed by partial correlations. RESULTS: Our results showed that the plasma NO levels were significantly higher in the diabetic group. When the nondiabetic subjects were analyzed according to their SSPG levels, there was no difference of plasma NO levels between those with SSPG>160 mg/dl and those with SSPG<160 mg/dl. There were also no difference of NO levels between those with a family history of type 2 diabetes and those without. In the nondiabetic group, SSPG correlated with BMI, fasting insulin, triglyceride and HDL-cholesterol, but neither with plasma NO levels nor fasting plasma glucose. CONCLUSION: Our data suggests that the impairment of NO activity in patients with type 2 diabetes is due to an impaired effect rather than its production. This altered NO signaling pathway is not an early event in insulin resistant individuals. Any such changes will not be apparent until type 2 diabetes with overt hyperglycemia develops.

Liver transplantation from an uncontrolled non-heart-beating donor maintained on extracorporeal membrane oxygenation.

Liver transplantation, a definitive treatment for end-stage liver disease, has achieved excellent results. However, potential recipients on the waiting list outnumber donors. To expand the donor pool, marginal grafts from older donors, steatotic livers, and non-heart-beating liver donors (NHBD) have been used for transplantation. Reducing the warm ischemia time of NHBD is the critical factor in organs preservation. Liver transplantation using grafts from NHBD have been reported to display a high incidence of primary graft nonfunction and biliary complications. The authors report a liver graft donor who was maintained on extracorporeal membrane oxygenation (ECMO) after successful cardiopulmonary resuscitation. Core body temperature was 5 degrees C. Procurement of the liver using a rapid flush technique was performed 4 hours after instituting ECMO. Graft function recovered fully after transplantation. In conclusion, ECMO may be used to reduce warm ischemia time in liver grafts obtained from uncontrolled NHBD, thereby increasing graft salvage rates.