Effect of Portal Venous Pressure on Liver Function of Donors in Living Donor Liver Transplantation.

BACKGROUND We assessed the alterations in portal hemodynamics associated with donor right hepatectomy and its effects on functional regeneration of the remnant liver. MATERIAL AND METHODS This prospective study included 30 adult living donors who underwent right hepatectomy in the Liver Transplantation Unit, Faculty of Medicine, Cairo University from June 2015 to October 2016. During donor surgery, portal venous pressure (PVP) was measured using an antithrombotic catheter inserted into the main portal vein, and was measured before and after clamping of the right portal vein. Postoperatively, liver function tests were done daily until normalization. The outcome measures were the time to normalization of liver function tests and effect of residual volume and steatosis on PVP. RESULTS All donors had normal PVP before clamping and changed significantly after clamping (p<0.001). After clamping, 25 donors (83%) had a PVP above 12 mmHg; i.e. had high portal pressure. The median percentage of change was 55%. There were obvious increases in liver enzymes and bilirubin after surgery, but albumin and international normalized ratio showed progressive decreases postoperatively. The percent change in PVP was positively correlated with the levels of liver enzymes, time to normalization of liver enzymes, albumin, and bilirubin, and with the degree of steatosis, bit it was negatively correlated with residual liver volume. CONCLUSIONS During living donor liver transplantation, PVP increases by over 50% after clamping of the right portal vein of the donor's liver. This increase is associated with temporary delay of normalization of liver function of the donors.

Evaluation of acoustic radiation force impulse (ARFI) elastography as non-invasive diagnostic tool in living donor liver transplantation.

BACKGROUND AND AIMS: Role of acoustic radiation force impulse (ARFI) elastography, in transplant setting, is not well established. We aimed to define the normal mean values of the liver stiffness by ARFI Elastography in healthy liver donors and to evaluate ARFI elastography as predictor of graft fibrosis post living donor liver transplant (LDLT) in comparison to other non-invasive methods (transient elastography [TE], APRI and FIB4). PATIENTS AND METHODS: A total of 100 subjects (70 recipients and 30 donors) were recruited. APRI and FIB4 scores were calculated for all recipients. TE and ARFI elastography (Siemens Acuson S2000 Ultrasound System, Germany) were performed to all subjects. All donors and only 30 recipients had liver biopsy. Significant fibrosis was defined as ≥ F2. RESULTS: The mean ARFI velocity among the donors was 1.05 ± 0.09 m/s. Regarding the recipients: mean age was 49.5 ± 8.49 years, 85.7% males, fibrosis stages < F2 were the most frequent stages by liver biopsy (86.7%) and TE (67.1%). ARFI median was significantly correlated with TE median, APRI and FIB-4 (r = 0.888, p = 0.000; r = 0.62, p = 0.000, and r = 0.585, p = 0.000, respectively). ARFI performed well in discriminating patients with ≥ F2 (AUROC = 0.93, 95% CI 0.86-0.99, p < 0.01) with best cutoff median value of 1.34 m/s (sensitivity 90%, specificity 82%). CONCLUSION: ARFI can be used as a reliable method in assessment of significant fibrosis post-LDLT.

Longitudinal assessment of hepatic fibrosis in responders to direct-acting antivirals for recurrent hepatitis C after liver transplantation using noninvasive methods.

Successful eradication of recurrent hepatitis C virus (HCV) infection following liver transplantation (HCV) improves graft survival. This study aimed at evaluation of hepatic fibrosis changes among long-term responders to DAA therapy for recurrent HCV after liver transplantation using noninvasive methods. Patients with significant hepatic fibrosis (≥F2) who achieved SVR12 after treatment with DAAs for recurrent HCV were included (n = 52). Hepatic fibrosis status was assessed, noninvasively, by calculation of fibrosis-4 score (FIB-4) and Aspartate Aminotransferase Platelet Ratio Index (APRI) and by measurement of graft stiffness using FibroScan at baseline and 12 and 18 months post-treatment. Acoustic radiation force imaging (ARFI) was done for all patients 12 and 18 months post-treatment. Patients were classified into two groups based on baseline liver stiffness measurement (LSM) by FibroScan; significant fibrosis (F2; n = 28) and advanced fibrosis groups (≥F3). Over 18-month follow-up period, there was serial improvement of FIB-4, APRI, and LSM by FibroScan in both groups. Higher baseline LSM and delayed initiation of antiviral therapy were significant predictors of lack of fibrosis regression (P-value 0.01 and 0.04, respectively). Fibroindices and LSM improved over time in liver transplant recipients who responded to DAAs. Baseline LSM can predict post-treatment fibrosis regression.

Improvement of liver stiffness measurement, acoustic radiation force impulse measurements, and noninvasive fibrosis markers after direct-acting antivirals for hepatitis C virus G4 recurrence post living donor liver transplantation: Egyptian cohort.

Progression of recurrent hepatitis C is accelerated in liver transplant (LT) recipients. Direct-acting antivirals (DAAs) have recently emerged as a promising therapeutic regimen for the treatment of hepatitis C virus infection. Rates of sustained virological response (SVR) have drastically improved since the introduction of DAAs. The aim is to elucidate the changes in liver stiffness measurement (LSM) by transient elastography (TE) as well as acoustic radiation force impulse (ARFI) elastography and fibrosis scores after DAA treatment in LT recipients with hepatitis C virus recurrence. A single-center, prospective study including 58 LT recipients with hepatitis C recurrence who received different sofosbuvir-based treatment regimens. Transient elastography and ARFI elastography values were recorded as well as fibrosis 4 score (FIB-4) and aspartate aminotransferase-to-platelet ratio index were calculated at baseline and SVR at week 24 (SVR24). The outcome was improvement in LSM and at least a 20% decrease in LSM at SVR24 compared with baseline. The sustained virological response was 98.1%. There was improvement of platelet counts, alanine aminotransferase, and aspartate aminotransferase, which in turn caused improvement in fibrosis scores at SVR24. LSM by TE and ARFI elastography decreased from the baseline median value of 6.3 kPa (interquartile range [IQR]; 4.6 to 8.8 kPa) and 1.28 m/s (IQR; 1.07 to 1.53 m/s) to an SVR24 median value of 6.2 kPa (IQR; 4.85 to 8.9 kPa) and 1.12 (IQR; 0.97 to 1.30 m/s), respectively. Logistic regression analysis showed that baseline viral load was the only significant predictor of improvement in LS after DAA therapy at SVR24. Sofosbuvir-based treatment resulted in an early improvement in parameters of liver fibrosis in post-LT patients with hepatitis C recurrence.

Biliary Complications in Recipients of Living-Donor Liver Transplant: A Single-Center Review of 120 Patients.

OBJECTIVES: Biliary complications are common after living-donor liver transplant. This retrospective study reviewed our experience with biliary complications in recipients of living-donor liver transplant. MATERIALS AND METHODS: Over our 9-year study period, 120 patients underwent living-donor liver transplant. Patients were divided into 2 groups, with group A having biliary complications and group B without biliary complications. Both groups were compared, and different treatment modalities for biliary complications were evaluated. RESULTS: Group A included 45 patients (37.5%), whereas group B included 75 patients (62.5%). Biliary complications included bile leak in 17 patients (14.2%), biliary stricture in 11 patients (9.2%), combined biliary stricture with bile leak in 15 patients (12.5%), and sphincter of Oddi dysfunction and cholangitis in 1 patient each (0.8%). Cold ischemia time was significantly longer in group A (P = .002). External biliary drainage was less frequently used in group A (P = .031). Technical success rates of endoscopic biliary drainage and percutaneous transhepatic biliary drainage were 68.3% and 41.7%. Survival rate following relaparotomy for biliary complications was 62.5%. CONCLUSIONS: Graft ischemia is an important risk factor for biliary complications. Bile leaks can predispose to anastomotic strictures. The use of external biliary drainage seems to reduce the incidence of biliary complications. Endoscopic and percutaneous trans-hepatic approaches can successfully treat more than two-thirds of biliary complications. Relaparotomy can improve survival outcomes and is usually reserved for patients with intractable biliary complications.

Outcome of Living-Donor Liver Transplant for Hepatocellular Carcinoma: 15-Year Single-Center Experience in Egypt.

OBJECTIVES: Liver transplant performed for hepatocellular carcinoma must adhere to criteria for the size and number of focal hepatic lesions to lower the incidence of recurrence and achieve survival rates comparable to patients transplanted for other indications. Since the Milan criteria were established in 1996, there have been many less restrictive criteria yielding similar results. Our aim was to identify the prognostic factors for patient survival and for recurrence of hepatocellular carcinoma for patients within and beyond the Milan criteria. MATERIALS AND METHODS: This retrospective and prospective analysis was conducted in 60 adult patients who underwent right lobe living-donor liver transplant for cirrhosis complicated by hepatocellular carcinoma at Dar Al Fouad Hospital, 6th of October City, Egypt, between August 2001 and June 2012. The median follow-up was 39.5 months. RESULTS: Overall 1-, 3-, and 5-year survival rates were 98.3%, 93.5%, and 71.4%. Overall disease-free survival rates at 1, 3, and 5 years were 96.6%, 93.5%, and 64.2%. There was no statistically significant difference in overall survival time between patients within and beyond the Milan criteria. Factors affecting recurrence were the tumor grade, lobar distribution, size of the largest nodule, and the total tumor burden in the explanted liver. Recurrence adversely affected survival. CONCLUSIONS: Using our criteria of a single tumor ≤ 6 cm, or 2 to 3 tumors with the largest ≤ 4.5 cm, or 4 to 5 tumors with the largest ≤ 3 cm and total tumor size ≤ 8 cm resulted in overall survival comparable to patients within the Milan criteria.

A portal pressure cut-off of 15 versus a cut-off of 20 for prevention of small-for-size syndrome in liver transplantation: A comparative study.

AIM: Portal hypertension has recently been implicated in the pathogenesis of small-for-size syndrome (SFSS) in adult-to-adult living-donor liver transplantation (A-LDLT). The aim of our study is to compare the portal venous pressure (PVP) cut-off values of 15 mmHg and 20 mmHg in terms of prevention of SFSS in A-LDLT. METHODS: Seventy-six patients underwent A-LDLT. A PVP <20 mmHg at the end of the operation was targeted using graft inflow modulation. Patients were divided into two groups: group A, final PVP <15 mmHg; and group B, final PVP 15-19 mmHg. Peak serum bilirubin and peak international normalized ratio in the first month after A-LDLT, as well as hepatic encephalopathy, SFSS, 90-day morbidity, and mortality were observed in both groups. RESULTS: Final PVP was well controlled below 20 mmHg in all patients (group A, n = 39; group B, n = 37). Six patients suffered SFSS in group B (16.2%) compared to one patient (2.6%) in group A (P = 0.04). Nine patients died in group B (24.3%), four of whom died of SFSS, compared to three patients in group A (7.7%) (P = 0.047). CONCLUSION: A PVP cut-off of 15 mmHg seems to be a more appropriate target level than a cut-off of 20 mmHg for prevention of postoperative SFSS in A-LDLT.

Pneumatosis intestinalis following pediatric live-related liver transplant: a case report and successful conservative approach.

PI has been rarely reported following pediatric live-related liver transplantation. Such a disorder is characterized by accumulation of gas in the bowel wall. The cause of PI has not been yet established; however, it has been strongly linked with steroid therapy. In this report, we present a case of PI following pediatric live-related liver transplantation that has been successfully managed conservatively.

A retrospective evaluation of causes of exempting living liver donors in an Egyptian centre.

BACKGROUND AND STUDY AIMS: Living-related liver transplantation has helped to solve the problem of shortage of deceased organ donors. However, studies showed significant donor complications occurring with adult living liver donation. This study aims at assessing different causes of exclusion of potent living donor transplantation in Egypt. PATIENTS AND METHODS: The data of 158 living donors (corresponding to 50 consecutive transplanted cases) were retrospectively studied. RESULTS: Only 50 donors were found to meet all the preoperative assessment criteria while 108 potential donors were excluded at various assessment steps. Majority of the excluded potential donors were due to anatomical variations (52/108) followed by hepatic steatosis (19/108) and positive hepatitis B or C virus serology (11/108). Regarding the anatomic variations, biliary anomalies were ranked as the first cause to exclude donors with the majority of them having the type C biliary variant. Portal vein variations were the second most common cause of exclusion due to portal vein trifurcation. Hepatic artery variations were detected in a lesser number of excluded donors. No donors were excluded for hepatic vein anomalies. CONCLUSION: Anatomical variations are the most common causes to exempt living liver donors. Preoperative evaluation of anatomical variations, viral serology and hepatic steatosis plays the major role to accept or exclude the potential donors.

HLA tissue typing has no effect on the outcome of patients undergoing a living-donor liver transplant: a single-center experience in Egypt.

OBJECTIVES: To analyze the effect of human leukocyte antigen tissue typing on outcome of live-donor liver transplant. MATERIALS AND METHODS: Fifty recipients underwent live-donor liver transplant in the Dar Al-Fouad Hospital in Egypt and were retrospectively evaluated. Patients were classified into 2 groups: those with human leukocyte antigen +ve, and those with human leukocyte antigen -ve and donors. Hepatitis C virus-related end-stage liver disease was the main indication for transplant. Demographic data, preoperative laboratory data, results of human leukocyte antigen tissue typing, Child score, model for end-stage liver disease score, graft/recipient weight-ratio, ischemia times, surgical complications, postoperative laboratory data, liver biopsy, immunosuppression, and pulse steroids were collected. Graft and patient survivals were studied using Kaplan-Meier curves. RESULTS: The mean model end-stage liver disease score was 18 ± 3.61 in group 1 and 17.73 ± 3.72 in group 2, with no significant difference. Graft/recipient weight ratio, ischemia times, and postoperative complications showed P = NS. Cyclosporine and tacrolimus were used in 5/9, 8/41, and 4/9 in group 1, and 32/41 in group 2 (P = NS). Rejection and pulse steroids were reported in 3/9 and 12/41 of group 1, and 3/12 and 11/41 of group 2 (P = NS). Hepatitis C virus-recurrence was diagnosed in 5/9 of patients (55%) and 8/41 of patients (29.5%) in groups 1 and 2 (P < .05). No statistical difference was found regarding mortality; 5-year patient and graft survival was 35/50 (70% in group 1 [human leukocyte antigen +ve]), 7/9 (77.8%), and 28/41 in group 2 (68.3%) (human leukocyte antigen -ve). CONCLUSIONS: Positive human leukocyte antigen typing before live-donor liver transplant has no effect on the incidence of postoperative complications, rejection episodes, and patient or graft survival. Recipients with positive human leukocyte antigen typing may have increased risk of hepatitis C virus-recurrence after live-donor liver transplant.

Recurrence of hepatitis C virus (genotype 4) infection after living-donor liver transplant in Egyptian patients.

OBJECTIVES: The recurrence of hepatitis C virus infection after liver transplant is common and may endanger both graft and patient survival. We investigated the frequency and outcome of and risk factors for the recurrence of that virus after living-donor liver transplant in hepatitis C virus positive recipients. MATERIALS AND METHODS: Seventy-four adult hepatitis C virus positive subjects were monitored for 36 months after living-donor liver transplant and demographic and laboratory data for the recipients and donors were evaluated. Recurrent hepatitis C virus infection was diagnosed on the basis of viral replication revealed by polymerase chain reaction after transplant, elevated levels of transaminases, and the results of liver biopsy. RESULTS: Hepatitis C virus recurrence was identified in 31.1% of the patients studied. Histopathologic recurrence was mild, and 91% of the subjects had a fibrosis score of < or = F2. No recipient exhibited cirrhosis or clinical decompensation during followup. Recurrent hepatitis C virus infection was associated with pretransplant and posttransplant viral load and antibody positive to hepatitis B core antigen. No other risk factors (sex, donor or recipient age, pretransplant Child-Pugh or Model for End-Stage Liver Disease scores, immunosuppressive drug therapy, and treatment with pulse steroids) were significantly correlated with the frequency of hepatitis C virus recurrence, the grade of the histologic activity index, or the stage of fibrosis. CONCLUSIONS: In living-donor liver transplant recipients, patient and graft survival rates associated with hepatitis C virus (genotype 4) related cirrhosis were comparable to those in deceased-donor liver transplant recipients reported in the literature. Recurrent infection with hepatitic C virus after living-donor liver transplant was mild. After transplant, a higher viral load and the presence of antibody to hepatitis B core antigen could be risk factors for hepatitis C virus recurrence. Long-term follow-up in a large number of patients is required.