Learning curve of laparoscopic living donor right hepatectomy.

BACKGROUND: The feasibility and learning curve of laparoscopic living donor right hepatectomy was assessed. METHODS: Donors who underwent right hepatectomy performed by a single surgeon were reviewed. Comparisons between open and laparoscopy regarding operative outcomes, including number of bile duct openings in the graft, were performed using propensity score matching. RESULTS: From 2014 to 2018, 103 and 96 donors underwent laparoscopic and open living donor right hepatectomy respectively, of whom 64 donors from each group were matched. Mean(s.d.) duration of operation (252·2(41·9) versus 304·4(66·5) min; P < 0·001) and median duration of hospital stay (8 versus 10 days; P = 0·002) were shorter in the laparoscopy group. There was no difference in complication rates of donors (P = 0·298) or recipients (P = 0·394) between the two groups. Total time for laparoscopy decreased linearly (R2 = 0·407, ß = -0·914, P = 0·001), with the decrease starting after approximately 50 procedures when cases were divided into four quartiles (2nd versus 3rd quartile, P = 0·001; 3rd versus 4th quartile, P = 0·023). Although grafts with bile duct openings were more abundant in the laparoscopy group (P = 0·022), no difference was found in the last two quartiles (P = 0·207). CONCLUSION: Laparoscopic living donor right hepatectomy is feasible and an experience of approximately 50 cases may surpass the learning curve.

ANTECEDENTES: Se evaluó la viabilidad y la curva de aprendizaje de la hepatectomía derecha de donante vivo MÉTODOS: Se llevó a cabo una revisión de los donantes sometidos a hepatectomía derecha por un único cirujano. Las comparaciones entre el abordaje abierto y laparoscópico con respecto a los resultados operatorios, incluyendo el número of aberturas de los conductos biliares en el injerto se realizó utilizando un análisis de emparejamiento por puntaje de propensión. RESULTADOS: Desde 2014 a 2018, 96 y 103 donantes fueron sometidos a hepatectomía derecho de donante vivo por cirugía abierta y laparoscópica, respectivamente, de los cuales 64 donantes fueron emparejados para ambos grupos. La media del tiempo operatorio (304,3 ± 66,5 versus 252,2 ± 41,9 minutos, P < 0,001) y la mediana de la estancia hospitalaria fueron más cortas en el grupo de cirugía laparoscópica (10 versus 8 días, P = 0,002). No hubo diferencias entre ambos grupos en las tasas de complicaciones de los donantes (P = 0,298) o receptores (P = 0,394). El tiempo total de la laparoscopia disminuyó linealmente (R2= 0,407, ß = -0,914, P = 0,001) y esta disminución comenzó a partir aproximadamente de los 50 casos realizados cuando los casos fueron divididos en cuatro cuartiles (segundo a tercero y tercero a cuarto, P = 0,001 y P = 0,023, respectivamente). Aunque los injertos con aperturas de los conductos biliares fueron más numerosos en el grupo laparoscópico (P = 0,022), no se hallaron diferencias en los dos últimos cuartiles (P = 0,207). CONCLUSIÓN: La hepatectomía derecha de donante vivo por vía laparoscópica es viable, y una experiencia de aproximadamente 50 casos, puede superar la curva de aprendizaje.

Case-matched comparison of ABO-incompatible and ABO-compatible living donor liver transplantation.

BACKGROUND: ABO-incompatible (ABO-I) living donor liver transplantation (LDLT) has a high success rate. There are few detailed comparisons regarding biliary complications, infective complications and patient survival between ABO-compatible (ABO-C) and ABO-I LDLT. The aim was to compare the outcomes of ABO-I LDLT with those of ABO-C LDLT using the matched-pairs method. METHODS: Patients who underwent ABO-I LDLT procedures between 2010 and 2013 were studied. They were matched for significant variables with patients who had ABO-C LDLT (1:2 matching). RESULTS: Forty-seven ABO-I LDLT procedures were included. Ninety-four patients who had ABO-C LDLT were selected as a comparator group. The incidence of cytomegalovirus, bacterial and fungal infections during the first 3 months was similar after ABO-I LDLT and ABO-C LDLT (85 versus 76 per cent, 28 versus 37 per cent, and 13 versus 20 per cent, respectively). Antibody-mediated rejection occurred after two procedures within 2 weeks of transplantation, but liver function improved with plasma exchange in both patients. There were no differences in the rate of acute rejection and biliary complications between ABO-I and ABO-C groups (P = 0.478 and P = 0.511 respectively). Three patients who had ABO-I LDLT developed diffuse intrahepatic biliary complications and progressed to graft failure. The 1-, 2- and 3-year patient survival rates after ABO-I LDLT and ABO-C LDLT were 89 versus 87 per cent, 85 versus 83 per cent, and 85 versus 79 per cent, respectively. CONCLUSION: The short-term outcomes of ABO-I LDLT were comparable to those of ABO-C LDLT in this study. ABO-I LDLT is an effective and safe transplant option with the potential to expand the pool of live donors.

Influence of hepatitis B virus reactivation on the recurrence of HBV-related hepatocellular carcinoma after curative resection in patients with low viral load.

It is unclear whether the reactivation of hepatitis B virus (HBV) influences the prognosis of hepatocellular carcinoma (HCC) after resection in patients with chronic hepatitis B. The aim of this study was to identify the influence of HBV reactivation on the recurrence of hepatitis B-related HCC after curative resection in patients with low viral load (HBV DNA <2000 IU/mL). We retrospectively analysed a total of 130 patients who underwent curative resection for HBV-related early stage HCC (single nodule; <5 cm/two or three nodules; <3 cm) with pre-operative HBV DNA levels <2000 IU/mL with serial HBV DNA tests. The predictive factors including HBV reactivation for the recurrence of HBV-related HCC after curative resection were investigated. Fifty-three patients (41%) had HBV reactivation after resection among 130 patients. HBV reactivation was observed in 22 of 53 patients with undetectable baseline HBV DNA and in 31 of 77 patients with detectable baseline HBV DNA. Cumulative recurrence rates after resection at 1, 2 and 3 years were 17.0%, 23.3% and 31.4%, respectively. The multivariable analysis demonstrated that the risk factors for the recurrence were the presence of microvascular invasion (hazard ratio (HR) 2.62, P = 0.003), multinodularity (HR 4.61, P = 0.005), HBV reactivation after resection (HR 2.03, P = 0.032) and HBeAg positivity (HR 2.06, P = 0.044). HBV reactivation after curative resection is associated with the recurrence of HBV-related HCC in patients with low viral load.

Serpin peptidase inhibitor clade A member 1 is a biomarker of poor prognosis in gastric cancer.

BACKGROUND: In a previous study, we reported that serpin peptidase inhibitor clade A member 1 (serpinA1) is upregulated in Snail-overexpressing gastric cancer. Although serpinA1 has been studied in several types of cancer, little is known about its roles and mechanisms of action. In this study, we examined the role of serpinA1 in the migration and invasion of gastric cancers and determined its underlying mechanism. METHODS: Expression levels were assessed by western blot analyses and real-time PCR. Snail binding to serpinA1 promoter was analysed by chromatin immunoprecipitation (ChIP) assays. The roles of serpinA1 were studied using cell invasion and migration assays. In addition, the clinicopathologic and prognostic significance of serpinA1 expression were validated in 400 gastric cancer patients using immunohistochemical analysis. RESULTS: Overexpression of Snail resulted in upregulation of serpinA1 in gastric cancer cell lines, AGS and MKN45, whereas knockdown of Snail inhibited serpinA1 expression. Chromatin immunoprecipitation analysis showed that overexpression of Snail increased Snail recruitment to the serpinA1 promoter. Overexpression of serpinA1 increased the migration and invasion of gastric cancer cells, whereas knockdown of serpinA1 decreased invasion and migration. Moreover, serpinA1 increased mRNA levels and release of metalloproteinase-8 in gastric cancer cells. Serpin peptidase inhibitor clade A member 1 was observed in the cytoplasm of tumour cells and the stroma by immunohistochemistry. Enhanced serpinA1 expression was significantly associated with increased tumour size, advanced T stage, perineural invasion, lymphovascular invasion, lymph node metastases, and shorter overall survival. CONCLUSIONS: Serpin peptidase inhibitor clade A member 1 induces the invasion and migration of gastric cancer cells and its expression is associated with the progression of gastric cancer. These results may provide a potential target to prevent invasion and metastasis in gastric cancer.

Pten regulates neuronal soma size: a mouse model of Lhermitte-Duclos disease.

Somatic inactivation of PTEN occurs in different human tumors including glioblastoma, endometrial carcinoma and prostate carcinoma. Germline mutations in PTEN result in a range of phenotypic abnormalities that occur with variable penetrance, including neurological features such as macrocephaly, seizures, ataxia and Lhermitte-Duclos disease (also described as dysplastic gangliocytoma of the cerebellum). Homozygous deletion of Pten causes embryonic lethality in mice. To investigate function in the brain, we used Cre-loxP technology to selectively inactivate Pten in specific mouse neuronal populations. Loss of Pten resulted in progressive macrocephaly and seizures. Neurons lacking Pten expressed high levels of phosphorylated Akt and showed a progressive increase in soma size without evidence of abnormal proliferation. Cerebellar abnormalities closely resembled the histopathology of human Lhermitte-Duclos disease. These results indicate that Pten regulates neuronal size in vivo in a cell-autonomous manner and provide new insights into the etiology of Lhermitte-Duclos disease.

Laparoscopic right posterior sectionectomy versus laparoscopic right hemihepatectomy for hepatocellular carcinoma in posterior segments: Propensity Score Matching Analysis.

BACKGROUND AND AIMS:: This study was designed to analyze the feasibility of laparoscopic right posterior sectionectomy compared to laparoscopic right hemihepatectomy in patients with hepatocellular carcinoma located in the posterior segments. MATERIAL AND METHODS:: The study included patients who underwent either laparoscopic right posterior sectionectomy or laparoscopic right hemihepatectomy for hepatocellular carcinoma located in segment 6 or 7 from January 2009 to December 2016 at Samsung Medical Center. After 1:1 propensity score matching, patient baseline characteristics and operative and postoperative outcomes were compared between the two groups. Disease-free survival and overall survival were compared using Kaplan-Meier log-rank test. RESULTS:: Among 61 patients with laparoscopic right posterior sectionectomy and 37 patients with laparoscopic right hemihepatectomy, 30 patients from each group were analyzed after propensity score matching. After matching, baseline characteristics of the two groups were similar including tumor size (3.4 ± 1.2 cm in laparoscopic right posterior sectionectomy vs 3.7 ± 2.1 cm in laparoscopic right hemihepatectomy, P = 0.483); differences were significant before matching (3.1 ± 1.3 cm in laparoscopic right posterior sectionectomy vs 4.3 ± 2.7 cm in laparoscopic right hemihepatectomy, P = 0.035). No significant differences were observed in operative and postoperative data except for free margin size (1.04 ± 0.71 cm in laparoscopic right posterior sectionectomy vs 2.95 ± 1.75 cm in laparoscopic right hemihepatectomy, P < 0.001). Disease-free survival (5-year survival: 38.0% in laparoscopic right posterior sectionectomy vs 47.0% in laparoscopic right hemihepatectomy, P = 0.510) and overall survival (5-year survival: 92.7% in laparoscopic right posterior sectionectomy vs 89.6% in laparoscopic right hemihepatectomy, P = 0.593) did not differ between the groups based on Kaplan-Meier log-rank test. CONCLUSION:: For hepatocellular carcinoma in the posterior segments, laparoscopic right posterior sectionectomy was feasible compared to laparoscopic right hemihepatectomy when performed by experienced laparoscopic surgeons.

Clinical significance of posttransplantation vesicoureteral reflux during short-term period after kidney transplantation.

BACKGROUND: Urinary tract infection (UTI) may occur in the form of asymptomatic bacteruria but severe cases may cause life-threatening pyelonephritis or sepsis in immunosuppressed kidney transplant recipients. Vesicoureteral reflux (VUR) is one risk factor in the transplanted kidney. But controversy exists regarding the effect of VUR in terms of graft outcomes. The objective of this study was to analyze the clinical outcomes among patients with posttransplantation VUR. PATIENTS AND METHODS: Between April 2005 and June 2006, we examined 75 patients with functioning grafts for more than 1 year by voiding cystourethrography at 1 year for the grade of posttransplantation VUR: group A, absent (n = 28) including grade I (n = 6) and II (n = 22); group B, including grade III (n = 17) and IV (n = 2). Patient characteristics included etiology of end-stage renal disease, duration of dialysis before transplantation, serum creatinine, creatinine clearance at 1 and 12 months after transplantation, and postoperative complications. The presence/absence of UTI, acute rejection, and graft loss were compared for significance. RESULT: Posttransplantation VUR present in 47/75 patients (61.3%) was over grade III in 19 patients. There was no difference in significant risk factors between the groups as well as between the reflux subgroups. VUR did not influence graft function with the only significant factor being acute cellular rejection. CONCLUSION: We failed to confirm a risk of developing posttransplantation VUR. Posttransplantation VUR did not negatively affect graft function; acute cellular rejection was the only factor that influenced it. Longer follow-up needs to be performed to clarify the long-term effects of posttransplantation VUR on graft function.

Renal transplantation in patients with a small bladder.

BACKGROUND: In patients undergoing kidney transplantation with a small bladder, many surgeons are faced with technical difficulties about the implantation as well as about satisfactory bladder rehabilitation. The objective of this study was to clarify the clinical outcomes of patients with end-stage renal disease who had a bladder capacity of less than 100 mL on preoperative voiding cystourethrogram after renal transplantation using extravesical ureteroneocystostomy. PATIENTS AND METHODS: We retrospectively studied 345 patients with end-stage renal disease who underwent renal transplantation between April 2002 and June 2006. These patients were classified into two groups according to their preoperatively estimated bladder capacity using a voiding cystourethrogram. Group A had a bladder capacity of less than 100 mL (n = 23; 6.7%) and group B had a capacity of 100 mL or more (n = 322; 93.3%). For each group, the clinical outcome, including serum creatinine level at 1 month and 1 year after transplantation, bladder capacity, surgical complications, and prevalence of urinary tract infection (UTI) requiring hospital admission were recorded and the graft survival rate calculated. RESULTS: Compared with group B, group A had undergone a longer duration of dialysis and required cadaveric kidney transplantation more frequently (P < .05). Postoperative surgical complications occurred in nine cases. There was no difference in the frequency of surgical complications and UTI requiring hospital admission between group A and group B. At 1 year posttransplant, bladder capacity was 342.0 +/- 43.8 mL (range, 300-400 mL) and 429.1 +/- 75.9 mL (range, 200-500 mL), respectively (P = .015). There was no statistical difference between the groups in the serum creatinine level and the graft survival rate at 5 years after transplantation (100% vs 92.4%). CONCLUSIONS: Similar to patients with a normal bladder size, renal transplantation can be successfully achieved in patients with a small bladder. Attempts to increase the bladder capacity by programmed training of the bladder and bladder expansion by surgical intervention seem unnecessary.

Peroneal neuropathy after liver transplantation.

INTRODUCTION: The incidence of peroneal neuropathy (PN), occurring predominantly in the left leg, increases after the incorporation of intermittent pneumatic compression (IPC) devices among adult liver transplantation (OLT) recipients in our hospital. The aim of this study was to investigate the possible risk factors for PN and the reason for the left-leg predominance. METHODS: We retrospectively reviewed the medical records of 501 OLT recipients. The patients were first divided into 2 groups, PN (n = 33) and non-PN (n = 468), to assess possible risk factors. The patients were then categorized into IPC (n = 262) and non-IPC (n = 239) groups according to the use of IPC devices. In a subsequent prospective study, we measured the degree and duration of the tilt of the operating table during OLT to investigate their relationship to the predominant left-leg PN. RESULTS: The rate of IPC device use was significantly greater among the PN than non-PN group (78.8% vs 50.4%, P < .01). The incidence of PN was significantly higher among the IPC than non-IPC group (9.9% vs 2.9%, P < .01). The degree and duration of left tilt of the operating table were greater and longer than the right tilt. CONCLUSIONS: The use of IPC devices during OLT increased the occurrence of PN and the left tilt of the operating table was strongly related to the predominant left-leg PN. Careful protection of the vulnerable point and minimization of the tilting of the operating table is advised during OLT, especially when IPC devices are used.

Isolation and characterization of mouse mesenchymal stem cells.

OBJECTIVE: Mesenchymal stem cells (MSCs) have been studied in regenerative medicine because of their unique immunologic characteristics. However, before clinical application in humans, animal models are needed to confirm their safety and efficacy. To date, appropriate methods and sources to obtain mouse MSCs have not been identified. Therefore, we investigated MSCs isolated from 3 strains of mice and 3 sources for the development of MSCs in a mouse model. MATERIALS AND METHODS: Male BALB/c, C3H and C57BL/6 mice were used to isolate MSCs from various tissues including bone marrow (BM), compact bone, and adipose tissue. The MSCs were maintained in StemXVivo medium. Immunophenotypes of the MSCs were analyzed by FACS and their growth potential estimated by the number of colony-forming unit fibroblasts. RESULTS: All MSCs that were isolated from BM, compact bone, and adipose tissue showed plastic-adherent, fibroblastic-like morphologic characteristics regardless of the mouse strain or cell source. However, culture of BM MSCs was less successful than the other tissue types. The FACS phenotype analysis revealed that the MSCs were positive for CD29, CD44, CD105, and Sca-1, but negative for CD34, TER-119, CD45, and CD11b. According to the results of the characterization, the adipose tissue MSCs showed higher growth potential than did other MSCs. CONCLUSION: The results of this study showed that culture of adipose tissue and compact bone-MSCs was easier than BM MSCs. Based on the results of immunophenotype and growth potential, C57BL/6 AT-MSCs might be a suitable source to establish a mouse model of MSCs.

Reconstitution of human lymphocytes following ex vivo expansion of human umbilical cord blood CD34+ cells and transplantation in Rag2-/- gamma c-/- mice model.

BACKGROUND: Due to ethical issues, in vivo studies of the human immune system have been difficult. Thus, small-animal xenotransplantation models have been employed, although they scarcely sustain a human immune response. In this study, we compared human cell repopulation tendencies and functionality in Rag2-/- gamma c-/- mice following various ex vivo expanded human hematopoietic stem cells (HSCs). METHODS: Human umbilical cord blood (UCB) CD34+ cells were cultured for 7 days with a cytokine combination of stem cell factor, Flk2/Flt3 ligand, and thrombopoietin, with absence or presence of rhIL-3, then transplanted into Rag2-/- gamma c-/- mice. Reconstituted human lymphocytes were analyzed based on the expression of CD45 as well as CD3, CD19, and CD56 in peripheral blood (PB) until 16 weeks after transplantation. BrdU assay and functional analysis of reconstituted human lymphocytes used PHA- or rhIL-2-stimulated splenocytes and bone marrow cells from recipient mice. RESULTS: The percentage of human CD45dim cells, not CD45bright cells, in PB of mice transplanted with cultured HSCs with rhIL-3 was much higher than in the group without rhIL-3 (approximately 2.5-fold at week 10 posttransplantation). The humanized mice showed systemic repopulation with a comprehensive array of human lymphohematopoietic cells, including T, B, natural killer (NK) cells, and even dendritic cells. However, the expression level was also dim. The number of CD3+ T cells and CD56+ NK cells was especially increased in the presence of rhIL-3. In addition, after in vitro restimulation proliferation assays and NK activity of interferon-gamma secretion showed greater effects in the presence of rhIL-3. CONCLUSION: These data suggested that the development of a diverse repopulation of human lymphocytes was possible in Rag2-/- gamma c-/- mice after transplantation of cultured UCB CD34+ HSCs with interleukin-3.

Comparison of Posttransplant Outcomes in Living Donor Liver Transplantation for Obese and Nonobese Recipients.

BACKGROUND: Although living donor liver transplantation for obese recipients has increased, it has not been determined that posttransplant outcomes in obese recipients are inferior compared with nonobese recipients. METHODS: From January 2001 to December 2016, there was a total of 58 (6%) obese patients (body mass index ≥30) in a cohort of 973 adult patients that underwent living donor liver transplantation. Propensity score matching and classification were performed based on the type of obesity, and there were 58 patients in the obese group and 141 patients in the nonobese group. We performed comparative analysis of posttransplant outcomes including Model for Early Allograft Function (MEAF) scoring and early allograft dysfunction (EAD). RESULTS: EAD was found in 11 (19%) and 31 (22%) patients in the obese and nonobese groups, respectively (P = .71). The obese group had a higher MEAF score than the nonobese group (5.2 vs 4.5, P = .007). The mean hospitalization of the obese group was shorter than in the nonobese group (32 vs 42 days, P = .003). Other posttransplant outcomes were similar between the obese and nonobese groups, including acute cellular rejection (8 vs 10 cases, P = .17), early graft failure (8 vs 12 cases, P = .30), index hospital mortality (6 vs 11 cases, P = .58), and comprehensive complication index (26.0 vs 24.6, P = .76). CONCLUSION: Posttransplant outcomes of the obese group were not inferior to the nonobese group. However, obesity can impact the severity of EAD and the incidence of early graft failure, based on significantly higher MEAF scores.

Early Vs Late Liver Retransplantation: Different Characteristics and Prognostic Factors.

BACKGROUND: East Asia is a known endemic area for hepatitis B, and living donor liver transplantation is mainly performed. Liver retransplantation (ReLT) is expected to become an increasing problem because of a shortage of organs. This study aimed to compare early and late ReLT with consideration of specific circumstances and disease background of East Asians. METHODS: Between October 1996 and January 2015, 51 patients underwent ReLT; we performed a retrospective analysis of data obtained from medical records of the patients. Clinical characteristics, indication, causes of death, survival rate, and prognostic factors were investigated. RESULT: The survival rate for early ReLT (n = 18) was 51.5% and that for late ReLT (n = 33) was 50.1% at 1 year postoperatively. Continuous venovenous hemodialysis and the use of mechanical ventilators were more frequent, and pre-retransplant intensive care unit stay and prothrombin time was longer in early ReLT than in late ReLT. Operation time was longer and the amount of intraoperative blood loss was greater in late ReLT than in early ReLT. Multivariate analysis showed that a higher C-reactive protein level increased mortality in early ReLT (P = .045), whereas a higher total bilirubin level increased the risk of death in late ReLT (P = .03). CONCLUSION: Patients with early ReLT are likely to be sicker pre-retransplantation and require adequate treatment of the pretransplant infectious disease. On the other hand, late ReLT is likely to be technically more difficult and should be decided before the total bilirubin level increases substantially.

Early postoperative renal dysfunction in the adult living donor liver transplantation.

Living donor liver transplantation (LDLT) is a widely accepted treatment for end-stage liver diseases. Renal dysfunction, a frequent complication after liver transplantation, has an unfavorable effect on the prognosis. Despite special characteristics of LDLT, such as small-for-size graft syndrome (SFS), the relations between graft size and postoperative renal dysfunction have not been evaluated. So we described the relevance of previously known risk factors with SFS (graft-recipient body weight ratio [GRWR] < 0.8%) and early postoperative renal dysfunction in LDLT. The study population consisted of adults who received LDLT from May 1996 to November 2005. The 284 patients who were followed to 3 months after LDLT were classified as group I (n = 201, creatinine < 1.5 mg/dL) versus group II (n = 83, creatinine > or = 1.5 mg/dL). Univariate analysis showed renal dysfunction in the early postoperative period was related to preoperative total bilirubin, blood urea nitrogen, creatinine, prothrombin time level, model for end-stage liver disease (MELD) score, GRWR, presence of preoperative renal dysfunction, transfusion of packed red blood cell, fresh frozen plasma, cryoprecipitate, reoperation, and the need for renal replacement therapy (RRT). Upon multivariate analysis, MELD score, GRWR, preoperative renal dysfunction, and need for RRT were related to early postoperative renal dysfunction. In conclusion, there was a significant relationship between SFS (GRWR < 0.8) and early postoperative renal dysfunction.

Feasibility of C2 monitoring in Korean renal transplantation.

BACKGROUND: In spite of efforts for simplified and optimal monitoring, variability of cyclosporine (CsA) absorption has shown limited clinical impact. We performed the present study to evaluate the feasibility of C2 monitoring and the optimal target C2 level in Korean recipients. PATIENTS AND METHODS: Sixty recipients who underwent first living donor kidney transplantations between December 2003 and May 2005 and who were treated with a regimen of CsA, mycophenolate mofetil, and steroid were enrolled in this study. CsA dose was adjusted according to conventional trough levels. Blood samples were collected just before (C0) and at 1, 2, 3, 4, 6, 8, and 12 hours (C1, C2, C3, C4, C6, C8 and C12) after dosing on days 2, 3, and 7 posttransplantation. On days 14 and 28, we determined C0, C1, C2, C3, and C4. We compared CsA levels between a no rejection versus a rejection group. RESULTS: In 8 recipients there were 1 or more acute rejection episodes (13.3%). C2 levels correlated closely with AUC0-4 on each day (r=.892-.944, P<.01), but C2 levels were not significantly different between the no rejection and the rejection group (P>.05). Mean C2 level on days 3 to 28 was significantly different between the 2 groups. (P=.045). One recipient (5.3%) with a mean C2 level greater than 1000 ng/mL underwent acute rejection. CONCLUSIONS: CsA concentration monitored as mean C2 levels early posttransplantation rather than a single point concentration on a single day was a predictor of acute rejection in kidney transplantation. Within the first month posttransplantation, the target C2 level is recommended to be over 1000 ng/mL for Korean recipients.

Long-term Outcomes for Liver Transplant Recipients in Terms of Hepatic Encephalopathy.

BACKGROUND: Liver transplantation (LT) is thought to resolve cognitive deficit due to hepatic encephalopathy (HE). The aim of this study was to determine the factors associated with the outcomes of patients with HE after LT. METHODS: The authors reviewed the medical records of 388 patients with HE who underwent LT from 1996 to 2014. RESULTS: There were 282 patients with grade 1-2 HE and 106 patients classified as grade 3-4. Patients in the latter group had a tendency for a more decompensated hepatic condition than patients with grade 1-2 HE. HE sequelae were only associated with grade 3-4 HE with borderline significance (P = .05). The cumulative 1-, 3-, and 5-year overall survival (OS) of patients with grade 1-2 HE were 81.9%, 77.3%, and 74.6%, whereas those of in patients with grade 3-4 HE were 77.4%, 73.3%, and 72.2%, respectively (P = .75). CONCLUSION: The sequelae of HE were only associated with the grade 3-4 HE. Aggressive treatment of HE prior to LT may prevent patients from deteriorating into high-grade HE, which could further contribute to improving the outcomes after LT.

Prognostic Factors Predicting Poor Outcome in Living-Donor Liver Transplantation for Fulminant Hepatic Failure.

BACKGROUND: Living-donor liver transplantation (LDLT) has been accepted as feasible treatment for fulminant hepatic failure (FHF), although it has generated several debatable issues. In this study, we investigated the prognostic factors predicting fatal outcome after LDLT for FHF. METHODS: From April 1999 to April 2011, 60 patients underwent LT for acute liver failure, including 42 patients for FHF at Samsung Medical Center, Seoul, Korea. Among 42 patients, 30 patients underwent LDLT for FHF, and the database of these patients was analyzed retrospectively to investigate the prognostic factors after LDLT for FHF. RESULTS: Among 30 patients, 7 patients (23%) died during the in-hospital period within 6 months, and 23 patients (77%) survived until recently. In univariate analyses, donor age (>35 years), graft volume (GV)/standard liver volume (SLV) (<50%), cold ischemic time (>120 minutes), hepatic encephalopathy (grade IV), hepato-renal syndrome (HRS), and history of ventilator care were associated with fatal outcome after LDLT for FHF. In multivariate analyses, HRS, GV/SLV (<50%), and donor age (>35 years) were significantly associated with fatal outcome. Although the statistical significance was not shown in this analysis (P = .059), hepatic encephalopathy grade IV also appears to be a risk factor predicting fatal outcome. CONCLUSIONS: The survival of patients with FHF undergoing LDLT was comparable to that in published data. In this study, HRS, GV/SLV <50%, and donor age >35 years are the independent poor prognostic factors.

Comparative Analysis of the Clinical Outcomes of Liver Transplantation for Probable and Definite Auto-immune Hepatitis by International Diagnostic Scoring Criteria.

BACKGROUND: Liver transplantation (LT) is an effective treatment for patients with end-stage liver disease caused by auto-immune hepatitis (AIH). However, diagnosis of AIH can be challenging for patients with end-stage liver disease at the time of transplantation. We classified patients into "probable" or "definite" AIH groups, using the diagnostic criteria of the International Autoimmune Hepatitis Group, and compared the clinical outcomes of AIH after LT in these 2 groups. METHODS: We performed a retrospective study of 18 patients who were diagnosed with AIH and underwent LT from March 2003 to March 2015 at a single institute. Of the 18 patients, 8 were diagnosed with definite AIH and 10 were diagnosed with probable AIH, according to the international scoring criteria. We evaluated the patient characteristics, recurrence rate, graft loss, and survival rates after LT. RESULTS: The mean follow-up duration was 59.3 months. Age, sex, medical condition at transplantation, warm ischemic time, cold ischemic time, and Model for End-Stage Liver Disease score did not differ significantly between the 2 groups. No patient died after LT in either group, but 1 patient in the definite AIH group had graft failure. In Kaplan-Meier analysis, the 5-year recurrence rates of the definite and probable groups were 14.3% and 0%, respectively (P = .992). CONCLUSIONS: The recurrence of definite AIH appeared to be higher than that of probable AIH. However, careful immunosuppressive therapy allowed the long-term survival of both definite and probable AIH patients after LT.

Prognosis after liver transplantation predicted by preoperative MELD score.

The model for end-stage liver disease (MELD) has been an excellent predictor of 3-month mortality among cirrhotic patients awaiting orthotopic liver transplantation (OLT). The aim of this study was to evaluate whether the preoperative MELD score predicts short-term prognosis after OLT. We enrolled 98 adult liver transplant patients performed at our center from January 2001 to December 2002. In univariate analysis of risk factors for death within 3 and 6 months after liver transplantation, serum total bilirubin, creatinine, MELD score, hyponatremia with ascites, Child-Turcotte-Pugh (CTP) score were statistically significant parameters (P < .05). By logistic regression, none of the risk factors were subjected to multivariate analysis showed statistical significance. The odds ratios of the MELD score, hyponatremia with ascites, CTP score within 3 months were 0.997, 1.151, and 0.726 with 95% confidence intervals of [0.899, 1.105], [0.102, 12.959], and [0.389, 1.352], respectively. The odds ratio of MELD score, hyponatremia with ascites, CTP score within 6 months were 0.996, 0.914, and 0.764, with 95% confidence intervals of [0.901, 1.102], [0.089, 9.369], and [0.417, 1.401], respectively. Although MELD score has been a good predictor of short-term prognosis before OLT, MELD did not show an influence on the short-term prognosis after liver transplantation in this study.