Liver transplantation for acute liver failure in children: 8-year experience in a single center / 器官移植

Objective To evaluate the efficacy of liver transplantation for acute liver failure (ALF) in children. Methods Clinical data of 15 children with ALF who underwent liver transplantation were collected and retrospectively analyzed. The proportion of ALF among children undergoing liver transplantation during the same period was calculated. The characteristics, postoperative complications and clinical prognosis of ALF children receiving liver transplantation were analyzed. Results In the same period, the proportion of ALF was 2.0% (15/743) among pediatric recipients undergoing liver transplantation. All 15 children had acute onset of ALF, and most of them were accompanied by fever, diarrhea and progressive yellowing of skin and sclera. Thirteen children were complicated with hepatic encephalopathy before operation (6 cases of stage Ⅳ hepatic encephalopathy), and two children were complicated with myelosuppression and granulocytopenia before liver transplantation. Ten children underwent living donor liver transplantation with relative donor liver, 4 received liver transplantation from donation after cardiac death (DCD), and 1 underwent Domino donor-auxiliary liver transplantation. Of 15 children, 12 recipients had the same blood type with their donors, 1 recipient had compatible blood type with the donor and 2 cases had different blood type with their donors. Among 15 children, 10 cases developed postoperative complications. Postoperative cerebral edema occurred in 5 cases, of whom 4 cases died of diffuse cerebral edema, and the remaining case was in a persistent vegetative state (eyes-open coma). Postoperative cytomegalovirus (CMV) infection was seen in 5 cases. Two children presented with aplastic anemia and survived after bone marrow transplantation, 1 case died of CMV hepatitis and viral encephalitis, and 2 cases died of diffuse brain edema. One child developed graft-versus-host disease (GVHD) after liver transplantation, and died of septic shock after bone marrow transplantation. Nine children survived and obtained favorable liver function during postoperative follow-up. Conclusions Liver transplantation is an efficacious treatment for ALF in children, which may enhance the survival rate. Brain edema is the main cause of death in ALF children following liver transplantation, and treatment such as lowering intracranial pressure, improving brain metabolism and blood purification should be actively performed. Liver transplantation should be promptly performed prior to the incidence of irreversible neurological damage in ALF children, which might prolong the survival and enhance long-term prognosis.

Recipient's Killer Cell Immunoglobulin-like Receptor Genotype and Human Leukocyte Antigen C Ligand Influence the Clinical Outcome following Living Donor Liver Transplantation

PURPOSE: The design of this study was to determine the most influential factor(s) on post-transplant immunological consequences, particularly with regard to the role of killer cell immunoglobulin-like receptors (KIRs) and their ligands (type I human leukocyte antigen (HLA)) in unstable liver function. METHODS: Retrospectively collected data from 319 recipients undergoing adult living donor liver transplantation (LDLT) using a right lobe graft between January 2002 and August 2008 were analyzed. Patients were categorized according to the serum alanine transaminase (ALT) pattern; stable ALT pattern was defined as ALT pattern during 3 months post-transplantation, except for initial 2 weeks post-transplantation, in which 2 times or less additional elevation(s) of serum alanine transaminase (ALT) (> or =80 IU/L) were observed. When a serum ALT pattern showed fluctuating and/or unpredictable nature, it was defined as an unstable pattern. In addition, genetic information of KIRs and HLA-C allotypes received from 68 recipients and 59 donors was analyzed by way of polymerase chain reaction using sequence-specific primers (PCR-SSP) to determine the factor(s) influencing a serum ALT pattern. RESULTS: Among 319 LDLT recipients included in this study, the actual incidences of AR and unstable ALT pattern were 13.4% (43/319) and 42.3% (135/319), respectively. Unstable ALT pattern correlated with poorer survival following LDLT than stable pattern (P<0.000). Genetically, unstable ALT pattern was related to recipients carrying KIR2DL2(+)/KIR2DS2(+) combined with the heterogeneous HLA-C allotype (HLA-C1/C2), (relative risks 45.0, 95% confidence interval 2.160~937.321; P=0.013). CONCLUSION: This study indicates that, when performing LDLT, pretransplant determination of recipient's KIRs and HLA-C allotypes may be beneficial in coping with post-transplant immunological circumstances.

Two Cases of Percutaneous Transhepatic Choledochoscopy Treatment of Intrahepatic Duct Stones that Occurred after Living Donor Liver Transplantation / 대한소화기내시경학회지

Percutaneous transhepatic cholangioscopy (PTCS) is the primary treatment option for general cases of intrahepatic duct stones. However, there are no reports on the use of PTCS for intrahepatic duct stones in patients who had undergone living donor liver transplantation (LDLT). We experienced two cases of successful intrahepatic stone removal by the use of PTCS in LDLT patients. With these cases, we have confirmed that PTCS management can be safely performed not only for a general bile duct stone, but also for a bile duct stone that develops in a patient that had previously undergone liver transplantation.

Clinical Review of Post-transplantation Diabetes Mellitus after Liver Transplantation / 대한이식학회지

PURPOSE: Liver transplantation (LT) can cure abnormality of glucose metabolism, but cause altered glucose metabolism with immunosuppressive treatment. Up to now, almost all studies have been performed in cadaveric donor liver transplantation (CDLT). We underwent study in CDLT and also living donor liver transplantation (LDLT) recipients. METHODS: Among 397 adult-to-adult LT recipients between January 1994 and August 2001, we selected 81 patients who could be followed more than 12 months by using the table of random sampling numbers. We reviewed the change of blood glucose and risk factors, complications and survival retrospectively between post-transplantation diabetes mellitus (PTDM) and no PTDM patients. RESULTS: Clinical data showed 34 : 47 in frequency of PTDM to no PTDM. Age, family history of DM, preoperative DM history over 6 months had a significant risk of PTDM. There was no difference of PTDM frequency between CDLT and LDLT and its subgroup. The worse post-transplant graft function causes the more incidence of PTDM (P=0.051). FK506 had higher relation with PTDM than cyclosporine and mycophenolate mofetile (P=0.058). The incidence of DM after operation has been decreased by 6 months, but thereafter no further. There were 18 of De Novo DM among 34 PTDM patients, and only 1 preoperative DM patient improved after LT. Between PTDM and no PTDM group, there were no significant difference of complication rate and 5-year survival rate. CONCLUSIONS: The types of graft would not affect the incidence of PTDM if the graft function were preserved. Other clinical data showed similar results to previous reports.

Liver Retransplantation: The AMC Experience

PURPOSE: Although there has been recent progress in surgical techniques, such as perioperative management, immunosuppresive regimen and intervention radiology, a liver retransplantation remains as the only therapeutic option for patients with a failing liver allograft. The purpose of this study was to review our clinical experiences of liver retransplantation, performed at the Asan Medical Center. METHODS: Between August 1992 and March 2001, 400 cases of liver transplantations, including 331 in adults and 69 in pediatrics, were performed. Of the 331 adult cases, 10 cases of liver retransplantation, during the same period, were retrospectively analyzed. RESULTS: In the 331 cases of adult liver transplantation, 232 cases of living donor and 99 of cadaveric liver transplantations were carried out. The 331 adult cases also included 10 liver retransplantations. Therefore, the overall liver retransplantation rate was 3%. Primary non-function (PNF) was the leading cause of retransplantation. The conversion of living donor liver transplantation to a cadaveric liver retransplantation was the most common type of retransplantaion, with a cadaveric to cadaveric type the second most common. The in-hospital mortality was 40%. The causes of in-hospital mortality were hepatic artery pseudoaneurysm rupture, Aspergillus pneumonia, and multiple organ failure, initiated by jejuno-jejunostomy site bleeding and massive hepatic necrosis. CONCLUSION: In the current era of extreme organ shortage, retransplantation is the only therapeutic alternative for irreVersible graft failure, especially if the patient has no multiple organ failure (MOF) prior to the operation. Therefore, the careful selection of patients for a retransplantation is required. They should be given superurgent priority if the circumstances permit, and living donor liver transplantation (LDLT) offer a promising alternative.

Biliary Complications after Living Donor Liver Transplanstation

PURPOSE: Living donor liver transplantation (LDLT) has several difficulties in biliary reconstruction of the small and thin bile duct, the short stump, and multiple openings. METHODS: 76 cases of LDLT performed in Asan Medical Center from Jan. 1999 to Feb. 2000 were reviewed retrospectively. RESULTS: The causative diseases in this group were hepatitis B associated cirrhosis 47, hepatoma 16, fulminent hepatic failure 6, secondary biliary cirrhosis 3, alcoholic cirrhosis 2, hepatitis C associated cirrhosis 1, and Wilson's disease 1cases. Right lobe graft was done in 54 cases, and a left lobe graft was done in 22. All bile duct reconstructions were done as Roux-en-Y hepaticojejunostomy, single anastomosis in 59, a double anastomosis in 15, and a triple anastomosis in 2cases. Biliary leakage occurred in 7 cases (10.4%), and percutaneous drainage subsequently being done. Post leakage bile duct stricture occurred in 2 cases (2.6%). Delayed bile duct stricture occurred in 3 cases. All stricture cases were treated with PTBD and repeated balloon dilatation. There was no difference between the right and left lobe graft in terms of bile leakage. However, stricture, occurred only in the right lobe graft. Bile duct stricture occurred more frequently in the multiple bile ducts (5% in single duct, 13.3% in double ducts, but there's no significance). CONCLUSION: The prevalence of biliary complication of LDLT was about 10%. In addition, there were more complicationsin the right lobe and multiple bile duct openings. Therefore, careful design and delicate hepatic parenchymal dissection is important to obtain a single duct and safe cut surface of the graft. To avoid severe complications such as an intrahepatic abscess or stone, early diagnosis and treatment of biliary complications is essential.

Major Complications after Orthotopic Liver Transplantations

A retrospective study was conducted to determine the incidence of major complications after liver transplantations which had been performed at Asan Medical Center from August 1992 to October 1996. Among the 43 orthotopic liver transplantations(OLTs), 27 were cadaveric donor liver transplantation(CDLT) including one retransplantation, 16 were living donor liver transplantation(LDLT). The over-all incidence of major complication was 52.4%, and there were no statistical difference between CDLT and LDLT. But the one-year cumulative survival was better in LDLT than CDLT(86.2% vs 63.3% : p < 0.1). To reduce the incidence of major complications after OLT, proper management of donors, early transplantation of recipients and shortening of cold ischemic time are mandatory especially in CDLT.