Patient Selection for Living Donor Liver Transplantation in Acute-on-chronic Liver Failure.

Background and objectives: Acute-on-chronic liver failure (ACLF) is associated with high short-term mortality without liver transplantation (LT). The selection criteria for LT in these patients are not well defined. The objective of this study was to determine factors associated with post-transplant survival in ACLF. Methods: This was a single-center retrospective study of patients who underwent living donor liver transplantation (LDLT) for ACLF between 2012 and 2022. Out of 1093 transplants, 110 patients had underlying ACLF, based on the European Association for the Study of the Liver-Chronic Liver Failure Consortium (EASL-CLIF) criteria. We looked at factors associated with 1-year posttransplant survival. Results: The median model for end-stage liver disease (MELD) score was 33.5 (31-38), and the 1-year posttransplant survival was 72%. Six risk factors were associated with posttransplant survival, namely, body mass index > 30 kg/m2 [HR, 4.4; 95% CI, 1.8-10.7], platelet count < 66,000/µl [HR, 2.91; CI,1.2-6.6], poor response to medical treatment [HR, 2.6; CI, 1.1-5.7], drug-resistant bacterial or fungal cultures [HR, 4.2; CI, 1.4-12.4], serum creatinine > 2.5 mg/dl [HR, 3.4; CI, 1.5-7.7], and graft-to-recipient weight ratio < 0.7 [HR, 4.8; CI, 1.4-16.3]. The 1-year post-transplant survival was 84% in patients with 0-2 risk factors (n = 89) and was 6% with 3 risk factors (n = 15) (P < 0.001). For 1-year posttransplant survival, the area under curve (AUC) for the current model was 0.8 (0.69-0.9). The AUC for CLIF-ACLF, Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA), and EASL-CLIF ACLF grades was < 0.5. Conclusion: In LT for ACLF, acceptable survival can be achieved when less than three high-risk factors are present.

Liver transplantation with interposition saphenous vein conduits for arterial reconstruction: Impact of morbidity and arterial ischemia time.

BACKGROUND: The outcomes of liver transplantation with hepatic arterial reconstruction using interposition saphenous vein conduits are not widely reported. Here, we share our experience using great saphenous vein conduits for hepatic arterial reconstruction in living donor liver transplantation. METHODS: This was a single-center retrospective review of patients who underwent living donor liver transplantation (n = 950). The saphenous vein conduits were used in 39 patients. We compared hepatic artery thrombosis, graft dysfunction, and 30-day and 1-year survival in the early (2012-2017) and late (2017-2020) transplant periods. RESULTS: Among 39 patients (of whom 30 [76.9%] were males, median Model for End-Stage Liver Disease was 24 [interquartile range, 17-27], median age was 50 [interquartile range, 43-54]), saphenous vein conduits were placed on supra celiac aorta in 7 (17.9%), infrarenal aorta in 25 (64.1%), and other arteries in 7 (17.9%) patients. The number of biliary and hepatic vein anastomoses, total arterial ischemia time, portal vein-hepatic artery reperfusion time, and duration of surgery was different in the 2 groups (P < .05). The 30-day mortality was 5/21 (23.8%) and 0 in the early and late periods (P = .05). The 30-day survival was >90% in patients with portal vein-hepatic artery reperfusion time <240 minutes, ≤2 grade 3 complications, no graft dysfunction, and later period of transplantation (P < .05). The 1-year survival with standard transplantation, transplantation with saphenous vein conduits in the early and late period was 87%, 62%, and 89% (P = .022). CONCLUSION: Liver transplantation with saphenous vein conduits is associated with acceptable outcomes. Major complications and arterial ischemia times are major determinants of outcomes.

Dual Graft Living Donor Liver Transplantation for High Acuity Patients: A Single-Center Experience.

Background: The outcomes of dual graft living donor liver transplantation (DGLDLT) in high acuity patients remain underreported. The objective of this study was to report long-term outcomes from a single center in this select group of patients. Methods: This was a retrospective review of patients who underwent DGLDLT between 2012 and 2017 (n = 10). High acuity patients were defined as patients with model for end stage liver disease (MELD) ≥30 or Child Pugh score ≥11. We looked at 90-day morbidity and mortality and 5-year overall survival (OS). Results: The median MELD score and Child Pugh score were 30 (26.7-35) and 11 (11-11.2). The median recipient weight was 105 (95.2-113.7) and ranged from 82 to 132 kg. Out of 10 patients, 4 (40%) required perioperative renal replacement therapy, and 8 (80%) required hospital admission for optimization. The estimated graft to recipient weight ratio (GRWR) with right lobe graft alone was <0.8 in all patients, between 0.75 and 0.65 in 5 (50%) patients, and <0.65 in 5 (50%) patients. The 90-day mortality was 3/10 (30%), and there were 3/10 (30%) deaths during long-term follow-up. Among 155 high acuity patients, the 1-year OS with standard LDLT, standard LDLT with GRWR <0.8, and DGLDLT was 82%, 76%, and 58%, respectively (P = 0.123). With a median follow-up of 40.6 (1.9-74.4) months, the 5-year OS for DGLDLT was 50%. Conclusion: The use of DGLDLT in high acuity patients should be prudent and low GRWR grafts should be considered a viable alternative in selected patients.

Best achievable results need territorial familiarity: Impact of living donor liver transplant experience on outcomes after pancreaticodoudenectomy.

BACKGROUND: Recently, benchmarks for pancreatic surgery have been proposed. Living donor liver transplantation (LDLT) is thought to have a positive impact on PD outcomes. The objective of the current study was to determine if the proposed benchmark cutoffs are achievable in an LDLT program with low to medium volumes for PD. METHODS: We retrospectively reviewed patients who underwent PD between 2011 and 2018 (N = 116). Their outcomes were assessed and compared with benchmark cutoffs for pancreatic surgery based on results from high volume centers (HVC) for PD. During the same period, 759 LDLTs were performed in our center. Outcomes were further compared based on whether PD was performed in low volume (≤76/year) (Group 1) or high volume (>76/year) (Group 2) transplant years. RESULTS: Out off 20 benchmarks, 15 (75%) were met while 19/20 (95%) were within range reported from HVC-PD. Benchmarks remained within range for biochemical leak (15.5% vs 13%, 1.3-22.7%), grade 4 complications (12.1% vs 5%, (0-14%), hospital mortality (3.8% vs 1.6%, 0-4%) and failure to rescue (24.4% vs 9%, 0-25%). There was a significant reduction in blood transfusion rate (69% vs 39.5%, P = 0.003) in group 2 while patients with at least one complication (45.5% vs 66.7%) (P = 0.04), median hospital stay (9 vs 11, P = 0.004), and median comprehensive complication index (CCI) (0 vs 20.9, P = 0.005) increased. CONCLUSION: Best achievable results for PD can be reproduced in LDLT programs with low to moderate PD volumes. Transition to a high volume transplant center does not confer additional improvement in outcomes.

Recipient Outcomes with Younger Donors Undergoing Living Donor Liver Transplantation.

Introduction The impact of donor age on liver transplantation is well known. Data on an appropriate donor age cut-off for living donor liver transplantation (LDLT) with a background of hepatitis C (HCV) is generally limited. The objective of this study was to determine whether limiting donor age to less than 35 years improved outcomes in patients with HCV-related end-stage liver disease (ESLD). Methods This was a retrospective review of 169 patients who underwent LDLT for HCV-related ESLD. The patients were divided into two groups based on whether they received grafts from donors ≤ 35 (Group 1) or > 35 (Group 2) years of age. Kaplan Meier curves were used to determine survival. Uni and multivariate analysis were performed to determine independent predictors of mortality. Results Mean donor age was 25.1 ± 5.2 and 40.1 ± 3.4 years (P < 0.0001). Early allograft dysfunction (EAD) was seen in 11.7% patients in Group 1 versus 29.6% in Group 2 (P = 0.02). A significant difference in mortality was present between the two groups, i.e., 33.3% versus 15.8% (P = 0.04). The estimated four-year overall survival (OS) was 78% and 64% (P = 0.03). Upon doing univariate analysis, the donor age (P = 0.04) and EAD (P = 0.006) were found to be significant variables for mortality. On multivariate analysis, EAD was the only independent predictor of mortality (Hazard ratio: 2.6; confidence interval: 1.1 - 5.8; P = 0.01). Conclusion Opting for younger donors (≤ 35 years) for HCV-related ESLD patients lowers the risk of EAD and improves overall survival.

Living Donor Liver Transplantation for Hepatocellular Carcinoma: A Single-Center Experience from Pakistan.

BACKGROUND: Living donor liver transplantation (LDLT) is an established treatment for patients with cirrhosis and hepatocellular carcinoma (HCC) within Milan criteria. Acceptable outcomes have been demonstrated in patients fulfilling extended criteria. Here, we share our experience with LDLT for patients with HCC within and beyond Milan criteria, with emphasis on poor prognostic factors. METHODS: We retrospectively reviewed patients who underwent LDLT between 2012 and 2017 and had HCC proven on explant liver histopathology. A total of 117 patients were included. Patients who died early after transplant (in <30 days) were excluded. For outcomes, patients were divided into prognostic groups. These groups were based on (1) alpha fetoprotein >600, (2) poor differentiation, and (3) the presence of lymphovascular invasion. Recurrence-free survival (RFS) was determined using Kaplan-Meier curves. RESULTS: Median age was 53 (30-73) years. Median follow-up was 20.3 (1-63.2) months. Median model for end stage liver disease (MELD) score was 19 (9-34). Of a total of 117 patients, 74 (63.2%) patients met Milan criteria. Recurrence rate was 12/117 (10.3%). Actuarial 5-year RFS was 88% and 82% (P = 0.3) in patients within and outside Milan criteria. There was no difference in 3-year RFS in patients with 0, 1, or 2 poor prognostic factors within Milan criteria (92%, 87%, and 75%, respectively; P = 0.3). However, a significant difference in RFS was seen in patients outside Milan criteria (92%, 93%, and 53%; P = 0.03). CONCLUSIONS: Patients within Milan criteria have acceptable RFS even in the presence of poor prognostic factors. However, the presence of two or more poor prognostic variables significantly impacts RFS of patients outside Milan criteria.

Living Donor Liver Transplantation for Acute on Chronic Liver Failure Based on EASL-CLIF Diagnostic Criteria.

BACKGROUND: The European association for the study of the liver and chronic liver failure consortium (EASL-CLIF) recently proposed diagnostic criteria for acute on chronic liver failure (ACLF). There is lack of data regarding liver transplant outcomes in ACLF patients based on these criteria. The objective of this study was to determine outcome following living donor liver transplantation (LDLT) in ACLF patients. METHODS: We retrospectively reviewed patients who underwent LDLT for ACLF based on European association for the study of the liver and chronic liver failure consortium (EASL-CLIF) diagnostic criteria (group 1) (N = 60) and compared them with ACLF patients who did not undergo transplantation (group 2) (N = 59). The primary outcome of interest was 30 day mortality. We also looked at one year survival in these patients. Survival was calculated using Kaplan-Meier curves and Log rank test was used to determine significance between variables. RESULTS: Median MELD scores for group 1 and 2 patients in ACLF grade 1 was 28 (20-38) and 31 (24-36), in ACLF grade 2 was 35 (24-42) and 36 (24-42) and in ACLF grade 3 was 36 (29-42) and 38 (32-52). For group 1 and 2, 30 day mortality in ACLF grade 1, 2 and 3 was 2/43(4.6%) versus 9/15(60%) (P < 0.001), 1/15 (6.6%) versus 13/19 (68.4%), 0/2 (0%) versus 20/25 (80%) (P < 0.001). Actuarial 1 year overall survival was 92% versus 11% (P < 0.001) in patients who underwent transplantation versus those who did not. One year survival in patients with grade 1 and 2 ACLF who received transplant versus medical treatment was 91% versus 13% and 93% versus 15% (P < 0.001) respectively. CONCLUSION: LDLT has excellent outcomes in patients with EASL-CLIF grade 1 and 2 ACLF. Without transplantation, ACLF patients have a very poor prognosis.

Living Donor Liver Transplantation in South Asia: Single Center Experience on Intermediate-Term Outcomes.

BACKGROUND: There is paucity of data on intermediate-term post liver transplant outcomes from South Asia. The objective of this study was to determine survival outcomes in patients who underwent living donor liver transplantation (LDLT) in a busy liver transplant center in Pakistan. METHODS: This study was a review of patients who underwent LDLT between 2012 and 2016. A total of 321 patients were included in this study. Early (within 90 days) and late (>90 days) morbidity and mortality was assessed. Estimated 1- and 4-year survival was determined. RESULTS: Median age was 48 (18-73) years. Male to female ratio was 4.5:1. Out of total 346 complications, 184 (57.3%) patients developed 276 (79.7%) complications in early post-transplant period, whereas there were 70 (21.3%) late complications. Most common early complication was pleural effusion in 46 (16.6%) patients. Biliary complications were the most common late complication and were seen in 31/70 (44.2%) patients. Overall 21.4% patients had a biliary complication. The 3-month mortality was 14%. The estimated 1- and 4-year OS for a MELD cutoff of 30 was 84.5 versus 72 and 80 versus 57% (P = 0.01). There was no donor mortality. CONCLUSION: Acceptable intermediate-term post-transplant outcomes were achieved with LDLT. There is a need to improve outcomes in high-MELD patients.

Breast conservative therapy in Pakistani women: Prognostic factors for locoregional recurrence and overall survival.

OBJECTIVES: Breast conservative therapy (BCT) is an established method of treating early stage invasive breast cancer. Survival after BCT in Pakistani population has not been reported. This study was carried out to report locoregional control and overall survival (OS) after BCT for invasive breast cancer and analyze prognostic factors in Pakistani population. MATERIALS AND METHODS: Patients who received BCT between 1997 and 2009 were included in the study. Patients' follow-up, demographics, prognostic variables and treatment modalities were assessed. Data were analyzed for locoregional and distant relapse and estimated 10-year locoregional recurrence free survival (LRRFS) and OS was calculated using Kaplan Meier curves. To determine the significance of prognostic variables, univariate and multivariate analysis was performed. RESULTS: A total of 902 patients underwent BCT. Median age was 42 (17-82) years and the median follow-up was 51 (1.4-187) months. There were 484 (53.6) poorly differentiated and 194 (21.5) triple negative tumors. T3/T4 tumors were found in 128 (14.1) patients and 441 (44.8) patients had nodal involvement. Among adverse events, 58 (6.3) locoregional failures, 152 (16.8) distant failures and 155 (17.1) deaths were observed. Estimated 10 years LRRFS- was 88% while OS was 70%. On multivariate analysis, tumor size and nodal involvement were independent predictors of locoregional recurrence-free and OS. In addition, hormonal therapy significantly affected OS. CONCLUSION: BCT has acceptable long-term results in Pakistani women. Tumor size and nodal involvement are independent predictors of survival.