Liver Transplantation in Hepatocellular Carcinoma: Experiences from the Shiraz Transplant Center.

BACKGROUND: Studies evaluating liver transplantation (LT) in hepatocellular carcinoma (HCC) in the Middle East have been scarce, mainly due to intricacy of this type of surgery. OBJECTIVE: In here we report our experiences with LT among patients with HCC cirrhosis.Methods: All patients who underwent LT with primary diagnosis of HCC older than 18 years old, during 2004 to 2019, were initially included in our study. RESULTS: Overall, 124 patients entered our study, among which majority were males (86.3%). Mean (SD) age of patients was 53.1±10.6 years old. Most common underlying liver diseases were HBV (55.6%) and HCV infections (12.1%). Mean MELD score of patients was 18±5.5. Child-Pugh score of most patients was class B (50%). Mean (SD) duration of hospitalization was 12.1±3.5 days. Patients were followed for a median of 32 (9, 62) months. The most common causes of death were recurrence of HCC (47.7%) and sepsis (34.1%). Median (IQR) duration to recurrence and death were 18 (4, 34) months and 17.5 (5.7, 44.5) months, respectively. One-year survival (89%, 86.4%, and 63.2%, respectively) (p=0.011) and one-year DFS (89%, 86.4%, and 57.9%, respectively) (p=0.001) was significant different between those who were selected based on the Milan, UCSF and extended criteria. CONCLUSION: Our study provides valuable experiences on LT and HCC from one of the largest LT centers in the world. Accordingly, we found that the Milan criterion provides the best survival compared to the UCSF and our extended criteria for patient selection.

Virtual Crossmatching in Kidney Transplantation, Shiraz Experience in Development of a Web-Based Program.

BACKGROUND: Kidney transplantation can increase survival and quality of life in patients with end-stage renal disease. In any allocation system, the crossmatch test plays an essential role in donor-recipient compatibility. OBJECTIVE: In this study, we aim to test the benefits of a web-based program that captures HLA antibody analyses and provides a report to allow fast and accurate virtual crossmatches. METHODS: One hundred potential recipients in the waiting list of renal transplants were selected. The included patients all had a complete HLA antibody profile. Also, 10 potential donors from previous kidney transplants (2020), with available HLA typing results for A, B, and DR locus, were also selected. A comparison was made between 100 recipients against ten potential donors, and virtual crossmatching (VXM) was performed by the web-based program and manually by an experienced immunologist. RESULTS: The average time for a manual VXM was 30 minutes per patient, while the virtual cross web-based program took 5 minutes per patient. In 12% of the manual VXM cases, a secondary review of data improved final results. In two manual virtual crossmatches, the VXM results had errors in matching recipient antibodies with the donor HLA typing that could affect the final decision for transplantation. CONCLUSION: In conclusion, a web-based VXM program that assesses HLA data can accurately perform a VXM with fewer human errors. It is especially true for highly sensitized candidates.

Multivisceral and small bowel transplantation at shiraz organ transplant center.

BACKGROUND: Multivisceral transplantations were initially done in animal models to understand the immunological effects. Later on, in human beings, it has been considered a salvage procedure for unresectable complex abdominal malignancies. With advancement in surgical techniques, availability of better immunosuppressive drugs, and development of better post-operative management protocols, outcomes have been improved after these complex surgical procedures. OBJECTIVE: To analyze and report results of multivisceral, modified multivisceral, and small bowel transplantations done at Shiraz Organ Transplant Center, Shiraz, southern Iran. METHODS: Medical records of all patients who underwent multivisceral, modified multivisceral, and small bowel transplants were retrospectively analyzed. RESULTS: There were 18 patients. The most common indications for the procedure in our series were unresectable carcinoma of pancreas followed by short bowel syndrome. 10 patients were alive after a median follow-up of 8.7 (range: 3-32) months. The remaining 8 patients died post-operatively, mostly from septicemia. CONCLUSION: Multivisceral and small bowel transplantations are promising treatments for complex abdominal pathologies.

Multivisceral transplantation for the treatment of intra-abdominal tumors.

BACKGROUND: Some intra-abdominal or retroperitoneal tumors such as low-grade slow-growing malignancies may seem unresectable due to major vessel encasement or presence of intra-abdominal dissemination, but the slow growth rate and to some extent long life expectancy of the patients urge us to find some strategies to cure the patients or at least achieve tumor remission or symptom palliation. En bloc resection, followed by multivisceral or liver-sparing "modified" multivisceral transplantation has recently been used for treatment of these patients. RESULTS: Between May 2010 and October 2012, 3 multivisceral and 3 modified multivisceral transplantations were performed in 6 patients (aged 14 to 55 years; mean, 32 years) with some slow growing intra-abdominal malignancies (2 neuroendocrine tumors, 2 gastrointestinal stromal tumors, 1 desmoid tumor, and 1 low-grade sarcoma). All patients survived the procedure. One patient died of pancytopenia 2 months after transplantation and another died with pulmonary emboli at 4 months. The remaining 4 patients are alive without any evidence of disease recurrence. CONCLUSIONS: Although large intra-abdominal desmoid tumors, well-differentiated neuroendocrine tumors, and gastrointestinal stromal tumors are slow growing, they tend to invade locally, especially to the mesenteric root and/or celiac axis and other abdominal viscera. Complete resection followed by multivisceral transplantation could be a therapeutic option for these advanced tumors.

Comparison of health status and quality of life of related versus paid unrelated living kidney donors.

The aim of this cross-sectional study was to assess the health status and quality of life (QOL) of paid unrelated versus related living kidney donors postdonation at Shiraz Transplant Center in Iran. We invited all donors (n = 580, 347 paid unrelated, 233 related) who underwent donor nephrectomy at our center from 2004 to 2010 to participate in a health survey and physical examination. Of 580 donors, 144 consented to participate; participation of paid unrelated donors was significantly lower than related (52/347 vs. 92/233; p < 0.001). Participants underwent a complete physical examination, QOL assessment (using a 36-item short form health survey [SF-36] questionnaire) and laboratory work-up. The paid unrelated donors compared with related donors were younger (34.2 ± 7.2 vs. 40.7 ± 9.7 years, p < 0.001), had shorter time since donation (2.9 ± 1.6 vs. 3.8 ± 2 years, p = 0.004), had higher estimated GFR (72.6 ± 22 vs. 63.8 ± 15.3 mL/min/1.73 m(2), p = 0.006) and had a higher percentage of patients with microalbuminuria (35% vs. 0%, p < 0.001). Additionally, general health and social functioning scores among paid unrelated donors were significantly lower (p < 0.001 and p = 0.02, respectively) than related donors. Other SF-36 scores, although lower in paid unrelated donors, did not reach statistical significance. Iranian paid unrelated donors have lower QOL and higher incidence of microalbuminuria compared with related donors.

Cutaneous metastasis of cholangiocarcinoma: report of two cases.

Cutaneous metastasis of cholangiocarcinoma is extremely rare. It can be seen at distant locations or at the site of biliary drainage. To the best of our knowledge less than 30 cases have so far been reported in the English literature. This event should be considered in every skin lesion in a patient with cholangiocarcinoma and be treated promptly by resection and chemotherapy to increase the patient's survival. Herein, we report our experience with two patients with cholangiocarcinoma and cutaneous metastasis at the site of biliary drainage.

Isolated renal mucormycosis after liver transplantation:an unusual case report.

Mucormycosis is a rare complication of immunosuppression. Most of the reported cases have been rhinocerebral or disseminated. Isolated renal involvement is extremely rare and until now less than 30 patients have been reported in the English literature. Isolated renal mucormycosis with renal artery rupture in a liver transplant patient has not been reported so far. Herein we report an extremely rare case of isolated renal mucormycosis in a liver transplant patient who was successfully treated with nephrectomy.

Liver transplantation for caroli disease.

Caroli disease is a rare congenital disorder characterized by multifocal, segmental dilatation of intrahepatic bile ducts. Patients with Caroli disease who have recurrent bouts of biliary infection, particularly those who also have complications related to portal hypertension may require liver transplantation. In liver transplant ward of Shiraz University of Medical Science we had 4 patients with Caroli disease who were transplanted. Herein, we describe the demographic characteristics and post-transplant course of the patients. These patients presented with liver failure, recurrent cholangitis and portal hypertension sequelae unresponsive to medical treatment. The mean age of patients was 24.5 (range: 18-36) years, the mean MELD score was 17.5 (range: 11-23), three patients were female; one was male. All of the patients had good post-transplantation course except for one patient who developed post-operative biliary stricture for whom biliary reconstruction was done.

Evaluation of growth and body mass index in children following kidney transplantation.

Growth retardation is common among children with chronic kidney disease (CKD). Renal transplantation has beneficial effects on height and weight gain of children, but height gain occurs especially for those children who are transplanted at a younger age. This study was conducted for a cross-sectional evaluation of growth and body mass index (BMI) in children following kidney transplantation. All children who had been transplanted in our center and had regular follow-up were entered in this study. Those with primary non-functioning grafts were excluded from the study. Weight and height at transplantation and at 20 years of age or at a pre-determined period (1-4-2008 to 30-6-2008) were recorded. Their height, weight, BMI, standard deviation score (SDS) of height and weight at their pre- and post-transplantation period were compared. SPSS 15.1 software and paired t-test were used for comparison of means. Seventy-one children, 43 boys and 28 girls, were involved in this study. The mean age at transplantation was 12.6 ± 3.45 years, ranging from 3 to 19 years, and age at last visit was 16.9 ± 3.15 years. They had been followed-up for 7-175 months (mean, 51.6 ± 30.75 months). Their primary renal diseases were as follows: reflux, obstruction and dysplasia 29 (41%), hereditary 25 (35%), glomerular disease 14 (20%), unknown 3 (4%). Source of donor was living related in 27 (38%), with 15 being mothers, deceased in 35 (49%) and living unrelated in 9 (13%). SDS height improved dramatically in post-transplantation evaluation, but this did not happen for SDS weight and BMI. We can conclude that despite a dramatic effect of transplantation on growth, catch-up growth only occurred in a minority of the children.

The effect of ischemic preconditioning of the pancreas on severity of ischemia/reperfusion-induced pancreatitis after a long period of ischemia in the rat.

BACKGROUND: The role of ischemia/reperfusion injury in the pathogenesis of acute pancreatitis is still ill-defined. It is accepted, however, that ischemia/reperfusion induces the development of postimplantation pancreatitis that is responsible for considerable morbidity. Preconditioning by brief exposure to ischemia protects the organ against damage evoked by subsequent severe ischemia. This study was undertaken to examine whether two brief ischemic periods protect the pancreas against severe ischemia/reperfusion-induced pancreatitis. MATERIALS AND METHODS: This study was performed on 30 rats in three groups. The first group (control) underwent a laparatomy without clamping of any artery. The second group underwent 30-minute clamping of the inferior splenic artery followed by 1-hour reperfusion of the pancreas, and the third group underwent clamping of inferior splenic artery (2 x 5 minutes with 5-minute interval) as ischemic preconditioning and then 30-minute clamping of inferior splenic artery followed by 1-hour reperfusion. RESULTS: Exposure to 30-minute pancreatic ischemia followed by 1-hour reperfusion led to the development of severe alterations greater than the other group that underwent ischemic preconditioning and then ischemia/reperfusion. Ischemia preconditioning applied prior to induction of pancreatitis reduced plasma lipase and interleukin-1beta concentrations as well as less histological signs of pancreatic damage. CONCLUSION: We concluded that pancreatic ischemic preconditioning reduced the severity of ischemia/reperfusion-induced pancreatitis. This effect seemed to be related at least in part to the release of the proinflammatory mediator interleukin-1beta.

Primary T-cell lymphoma of the breast with lymphoepithelial lesion. A case report.

Fine-needle aspiration, histomorphologic and immunologic findings in a case of primary T-cell lymphoma of the breast are reported. The tumor cells were diagnosed as large cell lymphoma with lymphoepithelial lesion and no nuclear multilobulation. No serologic evidence of HTLV-1 infection was detected. After simple mastectomy, lymph node dissection and chemotherapy, the patient is now doing well, having been followed for 30 months. To our knowledge, this is the first case report of primary T-cell lymphoma of the breast with prominent lymphoepithelial lesion, no nuclear lobularity, and an indolent clinical course.