Liver transplantation for combined hepatocellular-cholangiocarcinoma: Outcomes and prognostic factors for mortality. A multicenter analysis.

INTRODUCTION: Combined hepatocellular-cholangiocarcinoma is rare and comprises features of hepatocellular carcinoma and cholangiocarcinoma. The treatment of choice has not yet been defined. The aim of the study was to analyze outcomes of patients with combined hepatocellular-cholangiocarcinoma, who underwent liver transplantation. MATERIAL AND METHODS: All patients with combined hepatocellular-cholangiocarcinoma, who underwent liver transplantation, from January 2001 to August 2018 were identified. Pre-, intra- and postoperative data were retrospectively assessed. A univariate analysis was performed to identify prognostic factors. RESULTS: A total number of 19 patients were included to this study. Perioperative death was seen in two patients (10.5%). Recurrent disease was reported in 11 patients (64.7%) within the median time of 4 months. One and three years survival rates were 57.1% (CI 0.301-1) and 38.1% (CI 0.137-1). Factors associated mortality were tumor size >3 cm, presence of lymphatic invasion, and prolonged ICU stay. Patients with mixed HCC-CC lesions have significantly better survival compared to patients with separate lesions of HCC and CCC in one liver (p = .025). CONCLUSION: Although overall survival rates are clearly decreased compared to HCC patients, liver transplantation should be taken under consideration for selected patients with early stage and real mixed HCC-CC, who are likely to benefit from liver transplantation.

The Optimal Parathyroid Hormone Cut-Off Threshold for Early and Safe Management of Hypocalcemia After Total Thyroidectomy.

OBJECTIVE: To define optimal intact parathyroid hormone (iPTH) cut-off threshold predictive of hypocalcemia after total thyroidectomy for safe and effective postoperative management. METHODS: This prospective single center study was done in 2 phases. In phase I, predictors of symptomatic hypocalcemia were analyzed and the receiver operating characteristic curve was used to define the optimal iPTH cut-off threshold predictive of hypocalcemia. Phase II studied giving prompt prophylactic supplemental calcium and vitamin D to all patients who had iPTH levels below the calculated threshold, while phase I patients were given prompt selective supplementation if they had postoperative hypocalcemia or symptoms. RESULTS: Univariate analysis of patients in phase I showed that postoperative iPTH was the only significant variable that can predict symptomatic hypocalcemia. Using receiver operating characteristic curve and Youden index, the confirmed optimal cut-off threshold predictive of hypocalcemia was iPTH 19.95 pg/mL, with area under the curve of 0.903, 100% sensitivity, negative predictive value, and highest Youden index, while iPTH 15 pg/mL and iPTH 10 pg/mL were less optimal. Symptomatic hypocalcemia occurred in 30% of the phase I cohort who received selective supplementation versus 3% of those in the phase II cohort who received prophylactic supplementation. Return to emergency department and need for intravenous calcium were also significantly better in phase II. CONCLUSION: iPTH cut-off for post-thyroidectomy hypocalcemia was 19.95 pg/mL. Low-risk patients were discharged with no supplementation while all high-risk patients received prompt calcium and vitamin D supplementation, which led to effective hypocalcemia management and safe 24-hour discharge.

First right lobe living-donor hepatectomy after sleeve gastrectomy.

BACKGROUND: Obesity presents one of the leading causes of many chronic liver disorders and injuries. Nowadays, non-alcoholic steatohepatitis (NASH) demonstrates a challenging issue for the global health system. NASH can progress to life-threatening conditions such as cirrhosis and hepatocellular or cholangio carcinoma. Currently, NASH cirrhosis is a major indication for liver transplant (LT). CASE PRESENTATION: We present the case of a 37 year-old male who has lost 74 kg after undergoing successful laparoscopic sleeve gastrectomy (SG) four years ago. Recently, he underwent right hepatectomy in the course of living-donor liver transplantation for his sick father in our clinic. Before the SG was conducted four years ago, his weight was at 157 kg and his Body Mass Index (BMI) at 49 kg/m2. At that time, Ultrasound examination showed severe fatty liver changes and intraoperative inspection of the liver was consistent with that observation. At the time of surgery, he weighed 83 kg and his BMI was at 27 kg/m2. An effective weight reduction after bariatric surgery might protect NASH patients from further deterioration of their medical condition. CONCLUSION: To our knowledge, we report the first successful case of a right lobe living-donor hepatectomy in a patient who previously underwent successful laparoscopic sleeve gastrectomy (LSG).

Effects of mycophenolate mofetil introduction in liver transplant patients: results from an observational, non-interventional, multicenter study (LOBSTER).

The benefits of calcineurin inhibitor (CNI)-sparing regimens on renal function following liver transplantation (LT) have been demonstrated in clinical studies. This observational study assessed the real-life effects of mycophenolate mofetil (MMF) introduction in LT patients. Four hundred and ninety-seven patients in whom MMF was introduced according to local standards or clinical considerations were entered. Patients were grouped by time between transplantation and start of MMF (start of study): Group A (n = 263): ≤6 d; Group B (n = 64): >6 d to ≤1 month; Group C (n = 74): >1 month to ≤1 yr; and Group D (n = 96): >1 yr. CNI sparing occurred in all groups, particularly in Groups C and D. Mean MMF doses at 12 months were 1202.7, 1363.5, 1504.7, and 1578.1 mg/d, respectively, in Groups A-D. At introduction of MMF, median glomerular filtration rate was 73.3, 81.7, 62.7, and 53.7 mL/min/1.73 m(2) in Groups A-D. At 12 months, this decreased to 66 mL/min/1.73 m(2) in Groups A and B, remained stable in Group C, and increased in Group D (64.8 mL/min/1.73 m(2) ). Serious adverse drug reactions were lowest in Group D. In conclusion, MMF with a subsequent decrease in CNI was well tolerated and improved renal function even years after transplantation. A more forceful MMF dosing strategy with greater CNI sparing may further improve renal function.

Unexpected long-term survival of Stage IV pancreatic cancer patient with synchronic liver metastases after multimodal therapy including upfront surgery.

We report the case of a 56-year-old male with pancreatic cancer and 25 liver metastases. The patient underwent a distal pancreatectomy with 11 metastasectomies in the left liver lobe. Histological examination demonstrated a moderately differentiated ductal adenocarcinoma with pT3N0M1, Stage IVb. Three weeks later, we performed transarterial chemoembolization for the right lobe of the liver, and after 6 weeks we started systemic chemotherapy with FOLFIRINOX. After 31 months, computer tomography examination showed increases in size of the remaining lesions at segment VII/VIII of the right lobe. All liver metastases were surgically removed and a new chemotherapy was initiated. Nevertheless, after 40 months the patient developed two brain metastases. One was surgically resected and the smaller lesion was treated by gamma knife. Unfortunately, the patient died 42 months after the first presentation. Conclusively, in very selected patients with synchronic liver metastasis, multimodal treatment including repeated surgery, TACE and chemotherapy may prolong survival.

Does Liver Resection Remain a Viable Option in Patients With Pyogenic Liver Abscess? A Single-Center Experience.

Pyogenic liver abscesses (PLAs) are relatively rare but often fatal if left untreated. Antibiotic therapy combined with percutaneous procedures has replaced surgery as the cornerstone of treatment. However, open surgical drainage or liver resection may be a last resort. This study aimed to review our experience in treating PLA, with a focus on the conditions requiring partial liver resection as the last viable curative option. Medical records of patients with PLA admitted to Jordan Hospital between October 2014 through October 2020 were retrospectively reviewed. Medical and demographic data of all 43 patients admitted to our facility with a diagnosis of PLA were extracted. We reviewed these patients and extracted the cases that required surgical intervention. Four (three males and one female) of the 43 patients with PLA required surgical intervention. The underlying causes of liver abscesses were as follows: one traumatic due to shrapnel injury from an explosion, one following chemoembolization for hepatocellular carcinoma, and two patients with no apparent etiology. All patients were diagnosed with a computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast. Two patients had negative cultures. All patients received broad-spectrum antibiotics, and all underwent CT- or ultrasound-guided percutaneous drainage or aspiration. All four patients required partial hepatic resection due to treatment failure or inaccessible percutaneous procedures with clinical improvement. Although antimicrobial and interventional therapy remains the primary treatment option in PLA, the surgical option with open surgical drainage or partial liver resection remains viable and curative in selected patients.

Ischemic Reperfusion Injury After Liver Transplantation: Is There a Place for Conservative Management?

Ischemic reperfusion injury (IRI) after liver transplantation is a common cause of early allograft dysfunction with high mortality. The purpose of this case report series is to highlight an unusual clinical course in which complete recovery can occur following the identification of severe hepatic IRI post-transplantation and the implications of this finding on management strategies in patients with IRI post-transplant. Here, we include three cases of severe IRI following liver transplantation that are putatively resolved without retransplantation or definitive therapeutic intervention. All patients recovered until their final follow-up visits to our institution and developed no significant complications from their injury throughout the course of patient care by our institution after discharge from the hospital.

Right portal vein ligation combined with in situ splitting induces rapid left lateral liver lobe hypertrophy enabling 2-staged extended right hepatic resection in small-for-size settings.

OBJECTIVE: To evaluate a new 2-step technique for obtaining adequate but short-term parenchymal hypertrophy in oncologic patients requiring extended right hepatic resection with limited functional reserve. BACKGROUND: Patients presenting with primary or metastatic liver tumors often face the dilemma that the remaining liver tissue may not be sufficient. Preoperative portal vein embolization has thus far been established as the standard procedure for achieving resectability. METHODS: Two-staged hepatectomy was performed in patients who preoperatively appeared to be marginally resectable but had a tumor-free left lateral lobe. Marginal respectability was defined as a left lateral lobe to body weight ratio of less than 0.5. In the first step, surgical exploration, right portal vein ligation (PVL), and in situ splitting (ISS) of the liver parenchyma along the falciform ligament were performed. Computed tomographic volumetry was performed before ISS and before completion surgery. RESULTS: The study included 25 patients with primary liver tumors (hepatocellular carcinoma: n = 3, intrahepatic cholangiocarcinoma: n = 2, extrahepatic cholangiocarcinoma: n = 2, malignant epithelioid hemangioendothelioma: n = 1, gallbladder cancer: n = 1 or metastatic disease [colorectal liver metastasis]: n = 14, ovarian cancer: n = 1, gastric cancer: n = 1). Preoperative CT volumetry of the left lateral lobe showed 310 mL in median (range = 197-444 mL). After a median waiting period of 9 days (range = 5-28 days), the volume of the left lateral lobe had increased to 536 mL (range = 273-881 mL), representing a median volume increase of 74% (range = 21%-192%) (P < 0.001). The median left lateral liver lobe to body weight ratio was increased from 0.38% (range = 0.25%-0.49%) to 0.61% (range = 0.35-0.95). Ten of 25 patients (40%) required biliary reconstruction with hepaticojejunostomy. Rapid perioperative recovery was reflected by normalization of International normalized ratio (INR) (80% of patients), creatinine (84% of patients), nearly normal bilirubin (56% of patients), and albumin (64% of patients) values by day 14 after completion surgery. Perioperative morbidity was classified according to the Dindo-Clavien classification of surgical complications: grade I (12 events), grade II (13 events), grade III (14 events, III a: 6 events, III b: 8 events), grade IV (8 events, IV a: 3 events, IV b: 5 events), and grade V (3 events). Sixteen patients (68%) experienced perioperative complications. Follow-up was 180 days in median (range: 60-776 days) with an estimated overall survival of 86% at 6 months after resection. CONCLUSIONS: Two-step hepatic resection performing surgical exploration, PVL, and ISS results in a marked and rapid hypertrophy of functional liver tissue and enables curative resection of marginally resectable liver tumors or metastases in patients that might otherwise be regarded as palliative.

Interleukin 2 receptor antagonists for liver transplant recipients: a systematic review and meta-analysis of controlled studies.

UNLABELLED: Interleukin 2 receptor antagonists (IL-2Ra) are frequently used as induction therapy in liver transplant recipients to decrease the risk of acute rejection while allowing the reduction of concomitant immunosuppression. We conducted a systematic review of prospective, controlled studies to test the hypothesis that the use of IL-2Ra is associated with a decrease in acute rejection and/or a decrease in the side effects of concomitant medication. We performed a search of all major databases and secondary sources from inception to December 2010. Random effects models were used to assess the incidence of acute rejection, graft loss, patient death, and adverse side effects, with or without IL-2Ra. Subgroup analysis and meta-regression were used to explore differences in effect and sources of heterogeneity. Eighteen studies (13 randomized and 5 nonrandomized) met the inclusion and exclusion criteria. Acute rejection at 12 months or later favored the use of IL-2Ra (relative risk [RR] 0.83; 95% confidence interval [CI] 0.76-0.94) and steroid-resistant rejection was also less frequent in patients receiving IL-2Ra (RR 0.66; CI 0.48-0.91). Graft loss and patient death did not differ significantly between treatments. Patients who received IL-2Ra in addition to reduced or delayed calcineurin inhibitors had better renal function (mean difference of estimated glomerular filtration rate: 6.29 mL/min; CI 1.66-10.91) and a lower incidence of renal dysfunction (RR 0.46; CI 0.27-0.78). The use of IL-2Ra was also associated with a lower incidence of posttransplant diabetes mellitus, whereas the incidence of other adverse events was similar. CONCLUSION: The use of IL-2Ra is associated with a lower incidence of acute rejection after transplantation. Concomitant immunosuppression can be reduced, avoiding long-term side effects of immunosuppression.

Role of biliary complications in chronic graft rejection after living donor liver transplantation.

Postoperative biliary complications remain a substantial challenge after living donor liver transplantation, especially due to its heterogeneous clinical presentation.

Hepatic and portal vein transection by vascular stapler in open living donor hepatectomy - A retrospective cohort study.

Background: In an effort to increase donor safety in living donor liver transplantation, the utilization of vascular staplers for the division of the right portal and hepatic veins in patients undergoing right lobe liver donation for living donor liver transplantation (LDLT) was implemented. In here we report our experience with vascular staplers in patients undergoing LDLT and evaluate the subsequent feasibility and safety for donors. Material and methods: 17 cases of living donor liver transplant were retrospectively analyzed. The right portal vein was transected directly at the bifurcation of the main portal vein, the right hepatic vein was resected directly at the wall of the inferior vena cava using a vascular stapler device. Results: We registered a complication rate of 41.2% (7 donors). According to the Clavien-Dindo classification, grade II and grade III complications were each observed in 5.9% and grade IIIb complications in 29.4%, whereas catastrophic bleeding, complications with residual disability or the necessity of re-laparatomy did not occur. Upon 6 weeks, all donors were able to return to their previous occupation in fully recovered condition. Conclusions: The utilization of vascular staplers in donors during open LDLT presents an encouraging alternative to manual over-sewing of vascular stumps. Apart from its timesaving aspect, the technique reduces the potential risk of life-threatening clamp slippage with subsequent uncontrolled blood loss.

Outcome of patients with ischemic-like cholangiopathy with secondary sclerosing cholangitis after liver transplantation.

BACKGROUND AND AIMS: Sclerosing cholangitis in critically ill patients (SC-CIP) with sepsis and acute respiratory distress syndrome (ARDS) is a cholestatic liver disease with a rapid progression to liver cirrhosis and hepatic failure. Data on outcome of these patients after liver transplantation (LT) are sparse. PATIENTS AND METHODS: Eleven patients (46 ± 12 years; mean labMELD-score: 27 ± 7) with SC-CIP underwent LT. Six patients had severe polytrauma with multiple bone fractures, sepsis and ARDS. Five non-traumatic patients acquired SC-CIP during long-term intensive-care-unit stays due to sepsis and ARDS. Time to diagnosis, the microbiologic results and the survival rates after LT were evaluated. RESULTS: SC-CIP was diagnosed by endoscopic retrograde cholangiopancreatography (ERCP) within 3 ± 1 months after manifestation of cholestasis and histologically confirmed in explanted livers. The predominant microorganisms isolated in bile were: Enterococcus and Candida albicans. Mean follow-up after LT was 28 ± 20 months. One female patient (non-traumatic) died due to sepsis 26 days after LT. All other patients left the hospital alive, but two (non-traumatic) patients died from sepsis, and one (traumatic) patient died in a hemorrhagic shock, thereafter. Seven of 11 patients (5 with polytrauma) are still alive and have a good quality of life. The survival of the SC-CIP patients after LT was comparable with that of patients transplanted due to alcoholic liver cirrhosis. CONCLUSION: SC-CIP develops rapidly within several months. Enterococcus and C. albicans were the main isolated microorganisms in the bile. Sepsis was the main cause of death after LT. Overall, SC-CIP is a good indication for LT in selected patients.

Dental care and oral health in solid organ transplant recipients: a single center cross-sectional study and survey of German transplant centers.

Aim of this study was to collect information about oral health of patients before and after SOT as well as information about center-based recommendations for dental care. In a single center cross-sectional study, the oral situation of 20 patients before and 20 after SOT were examined including dental (DMF-T), periodontal (PSR(®)/PSI), and oral hygiene findings (modified QHI). In a second project, a survey among 50 transplant centers in Germany was questioned regarding their recommendations for dental care of SOT recipients. Patients before and after SOT showed similar quality of dental findings (DMF-T), but worse compared to the general population. In addition, most patients in both groups showed pronounced periodontal treatment need (PSR(®)/PSI score 3 or 4). Oral hygiene findings (modified QHI) after SOT were significantly worse than in patients on the waiting list (P = 0.032). In a second project, the questionnaire was returned by 28 of 50 centers. Interpretation of data showed that 89% carry out a dental examination before SOT and 67% contacted the patients' dentists. After SOT, 83% of the transplant centers recommend antibiotic cover before dental measures. The results of our study revealed lacks in the dental care of SOT recipients. Consistent recommendations regarding the dental care of patients before and after SOT should be determined.

Liver transplantation in patients with liver cirrhosis and active pneumonia: an observational study.

Patients with chronic liver disease are at high risk for severe infection because of increased bacterial translocation and immune suppression associated with liver dysfunction. Patients presenting with severe pneumonia and acute decompensation of cirrhosis are generally not considered for liver transplantation because it is unknown if these patients can recover from infection while under immunosuppression. We performed an observational study where patients with cirrhosis of the liver remained on the waiting list, although suffering from active pneumonia. Nine patients were included, but only six patients improved under goal-directed therapy and subsequently underwent liver transplantation. All six patients recovered quickly from infection; five patients recovered without sequelae and one patient died because of late complications. We propose that in patients with chronic liver disease and active pneumonia transplantation is a treatment option that should not hastily be abandoned.

Living donor liver transplantation in adults in the MELD era in Germany--a multi-center retrospective analysis.

The aim of this analysis was to provide an update on the current trend in living donor liver transplantation (LDLT) for adult recipients in the model of end stage liver disease (MELD) era in Germany and to encourage a wider implementation of LDLT. We descriptively analysed the data of LDLTs in Germany from 15 December 2006 to 31 December 2009 using a multi-center retrospective analysis via a questionnaire and data provided by Eurotransplant. Ten German centers performed LDLTs in adults. Eighty four transplantations in 50 male recipients and 34 female recipients were performed during the review period, ranging from 1 to 16 LDLTs per center. Hepatocellular carcinoma in cirrhosis (15/84) was the most common transplantation indication. The recipient mean lab-MELD score was 15 (±8). Six re-transplantations were necessary after initial LDLTs. The 1-year patient survival was 81%. We obtained data of 79/84 donors. The incidence of complications was 30.4% (n = 24). There were no grade 5 complications according to the Clavien classification. LDLT is an established treatment option that may reduce the waiting time, provides high quality split liver grafts and should be advocated in the MELD era to reduce organ shortage and 'death on the waiting list'.

Prospective evaluation of biliary reconstruction with duct-to-duct continuous suture in adult live donor liver transplantation.

PURPOSE: Biliary reconstruction remains the Achilles' heel of adult live donor liver transplantation (LDLT). The study aims to investigate the feasibility of duct-to-duct hepaticocholedochostomy in LDLT. METHODS: Perioperative data from 30 consecutive LDLT aiming at duct-to-duct reconstruction of the biliary tract using a continuous suture technique were prospectively collected. Nineteen recipients (63.3%) had one graft bile duct. Eleven recipients (36.7%) had two or three graft bile ducts. The median follow-up was 50 months. RESULTS: The overall biliary complication rate was 23.3%. Two recipients developed biliary stricture (6.7%), and two recipients (6.7%) presented with biliary leakage in early posttransplant phase (<90 days). One recipient suffered from bilioma (3.3%), and two recipients (6.7%) presented with biliary stricture in later posttransplant phase (>90 days). No correlation was found between the number of graft bile ducts and the incidence of biliary complications. No biliary complication-associated necessity for re-transplantation or mortality was observed. On multivariate analysis, no single risk factor associated with biliary complication could be identified. All biliary complications were successfully treated with Roux-en-hepaticojejunostomy and/or with endoscopic interventions. CONCLUSION: Duct-to-duct hepaticocholedochostomy with continues suture represents a safe and feasible procedure for biliary reconstruction in LDLT. Recipients may benefit from aggressive management of biliary complications with Roux-en-hepaticojejunostomy as compared with repeated endoscopic interventions in early posttransplant phase.

Posterior cavoplasty: a new approach to avoid venous outflow obstruction and symptoms for small-for-size syndrome in right lobe living donor liver transplantation.

PURPOSE: A common and serious problem after living donor liver transplantation (LDLT) of small grafts is small-for-size syndrome (SFSS). Although hyperdynamic portal inflow and portal hypertension are cornerstones in the development of SFSS, inadequate outflow may aggravate SFSS. Therefore, enlargement of the portal outflow tract by incision of the anterior rim of the orifice of the right hepatic vein (RHV) has been advocated for right lobe LDLT. But backwards tilt of a small graft into a large abdominal cavity may lead to a choking of the otherwise large anastomosis and thus we propose posterior enlargement of the orifice of the RHV. METHOD: In this test-of-concept study, we evaluated portal vein pressure (PVP), clinical parameters, and laboratory measurements in 22 patients that underwent right lobe LDLT and either received standard end-to-end anastomosis of the RHV or posterior cavoplasty. RESULTS: In patients that underwent posterior cavoplasty, we observed significantly lower PVP and less hyperbilirubinemia. There was a non-significant trend to lower incidence of SFSS. Other laboratory measurements and clinical parameters were not significantly different. CONCLUSION: We recommend posterior cavoplasty for enlargement of the hepatic venous outflow tract in right lobe LDLT as a method to avoid portal hypertension, hyperbilirubinemia, and possibly SFSS, especially in patients that receive small grafts.

Early Hepatic Artery Thrombosis After Living Donor Liver Transplant: A 13-Year Single-Center Experience in Jordan.

OBJECTIVES: Early hepatic artery thrombosis is a serious complication that may follow living donor liver transplant. Acute graft loss and patient morbidity and mortality are possible consequences. The therapeutic algorithm includes surgical or interventional revascularization, conservative approaches, or retransplantation. MATERIALS AND METHODS: Among 155 patients who underwent living donor liver transplant at our transplant center from 2004 to 2020, there were 5 who developed hepatic artery thrombosis. From our 13- year experience, we herein present their demographic and clinical characteristics, radiological imaging findings, perioperative courses, and the postoperative follow-up. RESULTS: All patients displayed advanced liver disease with a Child-Pugh score of C and a mean Model for End-Stage Liver Disease score of 32. Underlying causes for end-stage liver disease included hepatitis B and C infection and cryptogenic liver cirrhosis. The mean patient age was 49 years; 2 patients were female. Living donor liver transplant was performed with donor tissue from immediate kin, according to Jordanian allocation rules. The diagnosis of hepatic artery thrombosis was made by Doppler ultrasonography and confirmed via computed tomography. After surgical revision of the anastomosis, our first patient experienced thrombotic recurrence. All patients received interventional catheterization with local thrombolysis and subsequently developed rethrombosis. Despite prevalent thrombosis, 4 patients achieved long-term survival without further deterioration of liver function. Cumulative 1-year, 5-year, and 10-year survival rates were 80%, 80%, and 60%, respectively. Spontaneous recanalization of the hepatic artery was observed in 1 patient. CONCLUSIONS: Favorable long-term outcomes are achievable in patients with persistent hepatic artery thrombosis. When retransplant is not feasible and interventional approaches fail, conservative treatment with careful observation of liver function should be implemented. Attentive observation of collateral circulation toward the liver, distal of the thrombosis, may be beneficial to both graft and patient survival.

"Rescue allocation offers" in liver transplantation: is there any reason to reject "unwanted" organs?

To increase the number of transplanted organs, the Eurotransplant foundation uses a so-called "rescue-organ-allocation" procedure for organs that had been rejected by at least three consecutive transplant centers for medical reasons. The transplant center that finally accepts such an organ can then freely choose a patient from its own waiting list, without being bound to regular allocation criteria. Almost 30% of deceased donor livers are now allocated through this process in the Eurotransplant region. We report our results of 38 "rescue-allocation" livers (RA livers) transplanted at our institution (2003-2007), compared to a group of 115 regularly allocated organs within the same period. From our data, RA livers have the same results as regularly allocated livers. Type and frequency of postoperative morbidity did not differ between both groups, though the analysis of subgroups showed a tendency toward reduced survival of RA livers in patients with viral hepatitis. Interestingly, the Donor Risk Index (DRI) showed no difference between RA livers and regularly allocated livers. Although preliminary due to small numbers, we conclude that RA livers can be safely transplanted without increased mortality or morbidity. However, no donor specific criteria which would justify rejecting a RA liver were found. This highly challenges the applicability of the RA procedure in its current form.

Fourteen-year survival of a renal graft reused 2 years after initial transplantation: a case report.

We report on the successful regrafting of a transplanted kidney. The donor kidney was first transplanted into a 32-year-old patient with renal atrophy. More than 2 years later, he suffered from severe grand mal seizure with brain edema and the patient met the criteria for brain death. The well-functioning graft was recovered and subsequently transplanted into a 66-year-old woman with chronic glomerular nephritis. Neither the first nor the second recipient experienced any acute rejection. To date, more than 14 years later, she is in good health with excellent graft function. This case report implies that excellent long-term graft function is viable in a graft reused 2 years after the initial transplantation.