De novo malignancies after liver transplantation: a single-center experience

The recipients of liver transplantation [LT] are subjected to lifelong immunosuppression with its many drawbacks. De novo and recurrent malignancy in transplant recipients are attributed to attenuation of immunosurveillance. In the present study, we present our experience with de novo malignancies encountered after both deceased and living donor liver transplantations. Retrospective study of patients referred to LT center between April 2001 and January 2010. Various data were collected including type of malignancy and histopathologic features, immunosuppression regimen, and patient survival. Of 248 LT procedures performed in 238 patients [10 retransplants], 8 patients [3.4%] developed de novo post-LT malignancies. De novo malignancies included post-LT lymphoproliferative disorders [PTLD] in 5 patients who were all Epstein-Barr virus [EBV] positive, and who were treated successfully with anti-CD20 monoclonal antibody therapy, reduction of immunosuppression, and control of EBV activity; urinary bladder cancer in 1 patient who was treated with radical surgical resection and chemotherapy but died of bone and lung metastasis within 1 year of diagnosis; endometrial carcinoma in 1 patient who was treated with radical surgical resection; and Kaposi sarcoma in 1 patient who was successfully treated with surgical excision and reduction of immunosuppression. EBV-associated PTLD is the most frequently encountered de novo malignancy after LT and is easily treatable by chemotherapy and reduction of immunosuppression

Recurrence of hepatitis C virus genotype-4 infection following orthotopic liver transplantation: natural history and predictors of outcome

There are few reports on hepatitis C virus genotype 4 [HCV-4] recurrences after orthotopic liver transplantation [OLT]. Therefore, we undertook a study to determine the epidemiological, clinical and virological characteristics of patients with biopsy-proven recurrent HCV infection and analyzed the factors that influence recurrent disease severity. We also compared disease recurrence and outcomes between HCV-4 and other genotypes. All patients who underwent OLT [locally or abroad] for HCV related hepatic cir-rhosis from 1991 to 2006 and had recurrent HCV infection were identified. Clinical, laboratory and pathological data before and after OLT were collected and analyzed. Of 116 patients who underwent OLT for hepatitis C, 46 [39.7%] patients satisfied the criteria of recur-rent hepatitis C. Twenty-nine [63%] patients were infected with HCV genotype 4. Mean [SD] for age was 54.9 [10.9] years. Nineteen of the HCV genotype 4 patients [65.5%] were males, 21 [72.4%] received deceased donor grafts, and 7 [24.1%] developed >1 acute rejection episodes. Pathologically, 7 [24.1%] and 4 [13.8%] patients had inflammation grade 3-4 and fibrosis stage 3-4, respectively. Follow-up biopsy in 9 [31%] HCV genotype 4 patients showed stable, worse and improved fibrosis stage in 5, 2 and 2 patients, respectively. Of the 7 patients in the recurrent HCV group who died, 6 were infected with genotype 4 and 4 of them died of HCV-related disease. This analysis suggests that HCV recurrence following OLT in HCV-4 patients is not significantly different from its recurrence for other genotypes

Clinicopathologic features of hepatic neoplasms in explanted livers: a single institution experience

Hepatic neoplasms can be the primary indication for hepatic transplantation. The tumors can also be incidentally identified in explanted livers. We explored the clinicopathologic features of hepatic neoplasms identified in explanted livers. All explanted livers resected between 2001 and 2006 were evaluated for the presence of neoplasms and their clinicopathologic features were examined. In 98 liver transplants, 15 neoplasms [15.3%] were identified. Patient ages ranged from 5 to 63 years [median, 56 years]. The primary etiology of hepatic disease was hepatitis C virus in 12 cases, hepatitis B virus in 1 case, cryptigenic cirrhosis in 1 case and congenital hepatic fibrosis in 1 case. Serum alpha-fetoprotein was significantly elevated [>400 U/L] in only 2 cases. CA19-9 was not elevated in any of the cases. The tumors included hepatocellular carcinoma [HCC] in 13 cases, 1 case of choloangiocarcinoma and 1 case of combined HCC and hepatoblastoma. The tumors in size from 0.5 to 5 cm [median 1.4 cm] and were multifocal in 5 of the cases [33%]. Tissue alpha-fetoprotein expression was only seen in the cases associated with elevated serum levels. In our institution hepatic neoplasms are seen in more than 15% explanted livers. They can be incidentally indentified, are frequently not associated with elevated serum levels of alpha-fetoprotein and CA19-9, are commonly multifocal but small, and are associated with good prgonosis. Elevated serum alpha-fetoprotein, albeit specific, is not a very sensitive marker in the detection of hepatic neoplasms

Experience with 122 consecutive liver transplant procedures at king Faisal specialist hospital and research center

Saudi Arabia is a leading country in the Middle East in the field of deceased-donor liver transplantation [DDLT] and living-donor liver transplantation [LDLT]. We present out experience with DDLT and LDLT at King Faisal Specialist Hospital and Research Center [KFSHRC] for the period from April 2001 to January 2007. We performed 122 LT procedures [77 DDLTs and 45 LDLTs] in 118 patients [4 re-transplants] during this period of time. The number of adult and pediatric procedures was 107 and 11, respectively. The overall male/female ratio was 66/52 and the median age of patients was 43 years [range, 2-63 years]. In the DDLT group, the median operating time was 8 hours [range, 4-19], the median blood transfusion was 6 units [range, 0-40], and the median hospital stay was 13 days [range, 6-183]. In the DDLT group, after a mean follow-up period of 760 days [range, 2-2085], the overall patient and graft survival rate was 86%. In the LDLT group, the median opera ting time was 11 hours [range, 7-17], the median blood transfusion was 4 units [range, 0-65], and the median hospital stay was 15 days [range, 7-127]. In the LDLT group, and after a mean follow-up period of 685 days [range, 26-1540], the overall patient and graft survival rates were 90% and 80%, respectively with no significant difference in patient and graft survivals between groups. Biliary complications were significantly higher in LDLT compared to DOLT [P<0.05]. Vascular complications were also significantly higher in LDLT compared DDLT [P<0. 05]. Both DDLT and LDLT are being successfully performed at KFSHRC with early experience indicating a higher rate of biliary and vascular complications in the LDLT group

Perioperative anesthetic management of liver transplantation: a retrospective analysis of King Faisal Hospital experience

Background: Liver transplantation is the accepted standard of care for patients with End Stage Liver Disease [ESLD]. Since the liver transplant programme restarted in King Faisal Specialist Hospital and Research centre in 2001 and results have been improving. We review the overall results of liver transplantation over the last 6 years

Patients and Methods: Characteristic of patient population: Data retrospectively reviewed between April 2001 to January 2007 years, our center performed 122 liver transplantations, 77 from deceased donors [DDL T], and 45 from living donors [LDLT], in 118 patients 4 cases were retransplanted. Perioperative Management: All patients were evaluated preoperatively according to the institute protocol. All patients received general anesthesia according to our protocol. Swan Ganz‘catheterization and Rapid Infusion System [RIS] only used when clinically indicated most of the patients were assisted by mechanical ventilation in Medical Surgical Intensive Care Unit [MSICU] postoperatively. Fluid therapy and vasoactive agents were managed according to haemodynamic parameters

Results: The patients were 68 male and 54 female. Their median age was 43 years, ranging from 2 to 63 years. 111 patients were adult and 11 patients were pediatrics. In DDLT the median operating and anesthesia time were 8 hours [range 4-19], and 9 hours [range 5-20] respectively, median MSICU discharge time 15 hours [range 9-85] and hospital stay was 13 days [range, 6-183]. After a median fol/ow-up period of 760 days [range, 2-2085], the overall patient and graft survival rates was 86%. Deaths were due to primary non-function in 4 patients, central pontine myelinolysis in one patient, chronic rejection in one patient, recurrent malignancy in 2 patients, and recurrent HCV infection in 3 patients. In the LDLT group; median operating and Anesthesia time were 11 hours [range, 7-17] and 12 [range 818] respectively. Median MSICU discharge time was 16 hours [range 4-76] and median hospital stay was 15 days [range, 7-127]. After follow-up period of 685 days [range, 26-1540], the overall patient and graft survival rates were 90% and 80% respectively. Graft failure and deaths were due to hepatic an‘ery thrombosis in 2 cases, biliaIy complication in one patient, uncontrollable bleeding in one patient, portal vein thrombosis in 2 cases, and smalI-for-size-syndrome in 3 patients. Four patients were successfully retransplanted using cadaveric organs. The median intraoperative packed red blood cells [PRBCs] transfused was 6 units [range 0-40] and 4 units [range 0-65] in DDLT and LDLT groups respectively

Conclusions: Both DDLT and LDLT are being successfully performed at KFSH and RC with good outcomes. Our early experience indicates higher rate of biliary and vascular complications in the LDLT group. Intraoperative Packed Red cells, blood products, fluid replacement and estimated blood loss in both groups were matching the international centers results

Living donor hepatectomy [LDH]: comparative study between two different anesthetic techniques

Living donor hepatectomy [LDH] is now widely used to meet the need for liver grafts due to the shortage of cadaveric livers. Donor safety and perioperative anesthetic management are our major concern. The aim of our study was to compare two anesthetic techniques for management of living donor hepatectomy. After ethical committee approval and informed written consent, 20 donors ASA I physical status undergoing hepatectomy for living-relative liver transplant were allocated randomly to one of two groups. Group A where anesthesia was induced with fentanyl 2 micro g/kg and propofol 2-3 mg/kg -1, and maintained with isoflurane 0.8-1.2% and fentanyl infusion 1-2mcg/kg -1/h -1. In group B anesthesia was induced with sufentanyl 0.2mcg/kg -1, and propofol 2-3mg/kg -1, and maintained with propofol infusion 6-12 mg/kg -1/h -1, and sufentanyl infusion 0.2-0.4mcg/kg -1/h -1. Atracurium was the muscle relaxant for intubation and maintenance in both groups. There were no perioperative mortality in both groups, no significant statistical differences between both groups as regard demographic data, duration of surgery, duration of anesthesia, hospital stay, intraoperative hemodynamics, blood loss, liver function tests [PT, AST, and ALT] measured in the first, third, and seventh days postoperative. In conclusion, our study demonstrated that both anesthetic techniques were well tolerated for living donor hepatectomy, with no blood transfusion required, with short and safe discharge from PACU and short hospital stay, but with significant laboratory changes reflecting transient impairment in metabolic liver function. These procedures have proven useful as an important alternative to the cadaveric liver transplantation. Both techniques can be used as fast tract technique for living donor hepatectomy

Eyolution of living doner liver transplantation in Egypt

To date, cadaveric organ donation is illegal in Egypt. Therefore, Egypt recently introduced living donor liver transplantation [LDLT], aiming to save those who are suffering from end stage liver disease. Herein, we study the evolution of LDLT in Egypt. In Egypt, between August 2001 and February 2004, we approached all centers performing LDLT through personal communication and sent a questionnaire to each center asking for limited information regarding their LDLT experience. We identified and approached 7 LDLT centers, which collectively performed a total of 130 LDLT procedures, however, 3 major centers performed most of the cases [91%]. Overseas surgical teams, mainly from Japan, France, Korea, and Germany, either performed or supervised almost all procedures. Out of those 7 LDLT centers, 5 centers agreed to provide complete data on their patients including a total of 73 LDLT procedures. Out of those 73 recipients, 50 [68.5%] survived after a median follow-up period of 305 days [range 15-826 days]. They reported single donor mortality. Hepatitis C virus cirrhosis, whether alone or mixed with schistosomiasis, was the main indication for LDLT. Egypt recently introduced LDLT with reasonable outcomes; yet, it carries considerable risks to healthy donors, it lacks cadaveric back up, and is not feasible for all patients. We hope that the initial success in LDLT will not deter the efforts to legalize cadaveric organ donation in Egypt

Long-term follow-up after liver transplantation in Egyptians transplanted abroad

To study the long-term outcome after liver transplantation [LT] in Egyptian patients who underwent LT outside Egypt. Between May 1993 and February 2004, over 150 Egyptians underwent LT outside Egypt. Data of 67 recipients were collected in Egypt through personal communications with the Overseas Liver Transplant Centers and through the records of the Egyptian Liver Transplant Association. Most patients underwent LT in Europe [73.1%], few in the United State of America [17.9%] and in Japan [9%]. Sixty-one patients underwent cadaveric LT and the remaining 6 patients underwent living related liver transplantation [LDLT]. The male to female ratio was 58:9. Median age was 45 [3-63 years]. Hepatitis C virus [HCV] cirrhosis whether alone or mixed with schistosomiasis was the main indication for LT. Out of those 67 recipients, 52 [77.6%] survived after a median follow-up period of 4.6 years [rang 1-10.5 years]. Deaths were due to primary non-function in 3 patients, postoperative bleeding in one patient, recurrent hepatitis C virus [HCV] in 10 patients, and chronic rejection in one patient. Egyptians underwent LT abroad showed a good long-term outcome. Due to the high prevalence of HCV, we expect a growing need for LT in Egypt. Although LDLT has been introduced recently in Egypt, cadaveric liver donation is still not legalized by the government. Efforts should be directed to expanding LDLT, legalizing cadaveric LT and also to the prevention and control of HCV infection in Egypt in order to avoid its devastating effect on the society as well as its enormous negative impact on Egypt's economy and future development