Double rarity: malignant masquerade biliary stricture in a situs inversus totalis patient.

BACKGROUND: Situs inversus totalis is a rare anatomical variation of both the thoracic and the abdominal organs. Common bile duct strictures can be caused by malignant and benign diseases as well. 7-18% of the latter ones are 'malignant masquerade' cases, as pre-operative differentiation is difficult. CASE PRESENTATION: We present the case of a 68y male patient with known situs inversus totalis and a recent onset of obstructive jaundice caused by a malignant behaving common bile duct stricture. Technically difficult endoscopic retrograde cholangiopancreatography, brush cytology, magnetic resonance cholangiopancreatography, endoscopic ultrasound, and percutaneous transhepatic drainage with stent implantation were performed for proper diagnosis. Cholecystectomy, common bile duct resection with hilar lymphadenectomy, and hepatico-jejunostomy have been performed following multidisciplinary consultation. The final histology report did not confirm any clear malignancy, the patient is doing well. CONCLUSION: In situs inversus patients, both diagnostic and therapeutic procedures can lead to various difficulties. Benign biliary strictures are frequently misdiagnosed preoperatively as cholangiocellular carcinoma. Surgery is usually unavoidable, involving a significant risk of complications. The co-existence of these two difficult diagnostic and therapeutic features made our case challenging.

Mapping nursing interventions using the Therapeutic Intervention Scoring System in bloodless liver transplantations.

BACKGROUND: The Simplified Therapeutic Intervention Scoring System adapted to liver transplantation by King's College Hospital rank 138 activities to determine the nursing workload, diagnostic, monitoring and therapeutic needs. OBJECTIVES: To evaluate nursing activities of "King's-TISS" score grouped in organ systems and nurse patient ratio in the perioperative 48 hours of blood product free liver transplantations (LT). METHODS: The "King's-TISS" score's were analysed by nursing procedures and grouped, scored according to organ systems. The nursing workloads were studied during LT (T1), on arrival on the ICU (T2) and 12-24-48 hours after LT (T3-T4-T5). RESULTS: The total of "King's-TISS" score points were decreased by ≥20% daily (p = 0.001). The mean score of 104 ± 3.5 points (CI:104-105) during LT decreased to 84.7 ± 12 points (CI:83-86) in 48 hours (T5). The "metabolic" and "haemostasis" points increased (p = ).01), the "immunology" points unchanged (T2-T5) postoperatively. A slight decrease was observed in case of "basic nursing care", "monitoring", "neurologic support", "renal support" and "cardiovascular support" points (T2-T5, p < .01). The "invasive intervention" and "ventilatory support" points strongly decreased (T2-T5, p < .001). One "King's-TISS" point was found to equal 7.4 minutes with a nurse patient ratio of 2:1 intraoperatively and 1:1 postoperatively. CONCLUSION: Absence of blood product administration in LT decreases the total and organ specific workload, except the metabolic, haemostasis, immunology and basic support requirement. It was not within the scope of the King's-TISS score to analyse the application of viscoelastic haemostasis test and coagulation factor concentrate administration.

How Much Is the Inevitable Loss of Different Coagulation Factors During Blood Product-Free Liver Transplantations?

BACKGROUND: Bloodless liver transplantations (LT) have already been reported, but special characteristics of hemostatic changes remain less defined. The aim of this study was to evaluate the "inevitable" loss of coagulation factors (CF) in blood product-free LT. METHODS: Blood product and CF concentrate-free LT patient data were analyzed in terms of the first 2 days of perioperative hemostasis kinetics (N = 59). CF levels (FI, II, V, VII, X, and XIII), platelet (PLT) levels, and hemoglobin levels were measured before LT (T1), on arrival at the intensive care unit (T2), and 12, 24, and 48 hours after LT (T3, T4, and T5, respectively). Thromboelastographic (TEG) parameters were determined before and at the end of LT (T1-T2). RESULTS: Fibrinogen levels decreased by 1.2 ± 0.6 g/L, prothrombin levels by 26% ± 14%, factor V levels by 40% ± 23%, VII levels by 29% ± 19%, and X levels by 39% ± 22% (P < .001). From T2 to T4 fibrinogen increased by 0.9 ± 0.6g/L for 24 hours (P < .001). Factor II, V, and VII levels increased by 20% ± 16%, 31% ± 32%, and 12% ± 27%, respectively, between T3 and T5 (P < .001). However, factor X reached only half of the T1 level (T3-T5, P < .001). Platelet count increased in 34 (58%) patients at T2 (P < .001). The TEG parameters remained in the normal range during LT (T1-T2). CONCLUSION: The major findings of this study advocate that "inevitable" levels of CF decrease during LT by an average of 1.2 g/L in terms of fibrinogen and 23% to 40% regarding factors II, V, VII, and X. The authors suggest that knowing the "magic numbers" and comparing them against baseline laboratory results might predict the possibility of blood product-free transplant, providing confidence and safety to the surgeon and the anesthetist.

Abdominal Compartment Syndrome After Liver Transplant in Drug-Induced Acute Liver Failure: A Case Report.

The incidence of drug-induced acute liver failure (ALF) has been increasing in recent years. Despite the complex intensive treatment, liver transplant should be performed in progressive cases. A systemic inflammatory response syndrome and the burden of surgical intervention promote abdominal compartment syndrome (ACS); observed preoperatively, they are significant negative prognostic factors. THE CASE: We demonstrate a young woman with liver transplant after ALF and a consecutive ACS. We presumed drug toxicity in the background of the rapidly progressive ALF, based on the preoperative hematologic examination and the histology of the removed liver. An ACS has occurred in the postoperative period that must have been resolved with mesh, and later, anatomic segment 2-3 resection had to be performed to further decrease the pressure. The patient left the hospital after 62 days with good graft function. DISCUSSION: A complex intensive care is mandatory in the case of orthotopic liver transplant for ALF. Outcomes are good after orthotopic liver transplant. An ACS might occur after surgery. In these rare cases a delayed abdominal closure or even a liver resection can be the only solution and sometimes an urgent need to resolve the life-threatening problem.

Management of Portal Hypertension After Liver Transplantation.

INTRODUCTION: Post-transplantation portal hypertension has severe complications, such as esophageal varix bleeding, therapy refractory ascites, extreme splenomegaly, and graft dysfunction. The aim of our study was to analyze the effectiveness of the therapeutic strategies and how to visualize the procedure. METHODS: A retrospective study involving liver transplantation patients from the Semmelweis University Department of Transplantation and Surgery was performed between 2005 and 2015. The prevalence, etiology, and leading complications of the condition were determined. The applied interventions' effects on the patients' ascites volume, splenic volume, and the occurrence of variceal bleeding were determined. Mean portal blood flow velocity and congestion index values were calculated using Doppler ultrasonography. RESULTS: The prevalence of post-transplantation portal hypertension requiring intervention was 2.8%. The most common etiology of the disease was portal anastomotic stenosis. The most common complications were esophageal varix bleeding and therapy refractory ascites. The patients' ascites volume decreased significantly (2923.3 ± 1893.2 mL vs. 423.3 ± 634.3 mL; P < .05), their splenic volume decreased markedly. After the interventions, only one case of recurrent variceal bleeding was reported. The calculated Doppler parameters were altered in the opposite direction in cases of pre-hepatic versus intra- or post-hepatic portal hypertension. After the interventions, these parameters shifted towards the physiologic ranges. CONCLUSION: The interventions performed in our clinic were effective in most cases. The patients' ascites volume, splenic volume, and the prevalence of variceal bleeding decreased after the treatment. Doppler ultrasonography has proved to be a valuable imaging modality in the diagnosis and the follow-up of post-transplantation portal hypertension.

Examinations of Factors Influencing Survival of Liver Transplantation for Hepatocellular Carcinoma: A Single-Center Experience From Budapest.

INTRODUCTION: Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related death worldwide. Orthotopic liver transplantation (OLT) is the best therapy of choice for early, unresectable HCC. The Hungarian Liver Transplantation Program was launched in 1995 at the Department of Transplantation and Surgery, Semmelweis University, Budapest. From that time more than 60 patients underwent OLT for hepatic tumors, which in most cases were HCC. Our clinical examination was undertaken to analyze the possible influential factors of outcomes for our series of patients who received OLT for HCC. METHODS: We performed a review of all patients who underwent OLT for HCC at our department from 1996 to October 1, 2013. Disease extent was determined by preoperative computed tomography or magnetic resonance images. All explants were examined and categorized based on tumor number, size, distribution, HCC histologic grade, and vascular invasion. Patients with HCC were classified as having tumors either meeting Milan criteria, beyond Milan criteria but within UCSF criteria, or exceeding UCSF criteria. OLT was performed using standard techniques including orthotopic implantation with cross-clamp technique or with the piggyback technique. Postoperative immunosuppression included a triple drug regimen of calcineurin inhibitor (CNI), mycophenolate mofetil (MMF), and prednisone. mTOR inhibitors have been available since 2004. RESULTS: HCC most commonly occurs in the presence of cirrhosis as a result of longstanding chronic liver disease. Most of our patients who underwent OLT for HCC are 56 to 60 years old, and most also had underlying HCV cirrhosis. As of October 1, 2013, 21 of 49 (42.85%) patients had died after OLT for HCC. The main cause was the recurrence of the HCC in 38%, followed by sepsis in 33%, and HCV recurrence in 19%. One death each (4.7% of the total number of deaths) was caused by primary nonfunction of the graft, acute myocardial infarct, and de novo malignancy, respectively. Overall survival for the entire group at 1, 3, and 5 years after transplantation was 73.48%, 65.2%, and 50.08%, respectively. Using pretransplant imaging, 34 tumors (69.3%) were within Milan criteria, 8 (16.3%) were beyond Milan but within UCSF criteria, and 7 (14.3%) exceeded UCSF criteria. Based on explant pathology, 30 tumors (61.2%) were within Milan criteria, 7 (14,3%) were beyond Milan but within UCSF criteria, and 12 (24.3%) exceeded UCSF criteria. New onset, non-HCC malignant tumor developed in 2 cases (4%). There was no significant difference between the surgical techniques or the immunosuppressive strategies. Using the Cox analysis in our series, it can be seen that mortality was higher with tumors exceeding Milan criteria but within UCSF criteria compared with tumors within Milan criteria (Coef. = 0.5749 in Setting 1 and 0.1226 in Setting 2), and even higher with tumors beyond UCSF criteria compared with tumors within Milan criteria (Coef. = 0.7228 in Setting 1 and 0.1456 in Setting 2). Recurrence of the tumor causes higher mortality (Coef. = 1.709 in Setting 1 and 1.0256 in Setting 2). It seems that using an mTOR inhibitor has a beneficial impact on mortality (Coef. = -1.409 in Setting 1). Vascular invasion was associated with higher mortality (Coef. = 0.6581in Setting 1). Higher AFP levels correlated with higher mortality but not significantly (Coef. = 0.0002 in Setting 2). In our series, survival after OLT for HCC was best with tumors within Milan criteria comparing those exceeded Milan criteria (odds ratio = 4.000). CONCLUSION: According to our findings, the Milan criteria are still the safest criteria system; however, slightly expanded criteria do not have significantly worse results. Preoperative imaging methods sometimes show fewer or smaller tumors, and the explant histology reports the exact staging of HCC at the time of OLT. Histological examination especially of the lymphovascular invasion is mandatory to assess the estimated prognosis. Extremely high levels of AFP mean higher risk. HCC recurrence is an important factor on the outcome; therefore, continuous oncologic screening is mandatory. Immunosuppressant agents are chiefly responsible not just for higher risk of recurrence but for higher risk to develop de novo malignancies. Viral serology must be done periodically to catch HCV recurrence in time and begin adequate antiviral therapy. Potentially, mTOR inhibitors could be potent immunosuppressive agents after OLT for HCC due to this antiproliferative effect.

Analysis of Incretin Hormones After Orthotopic Liver Transplantation.

BACKGROUND: Several well-known risk factors play an important role in the development of new-onset diabetes mellitus after orthotopic liver transplantation (OLT). Immunosuppressant drugs and hepatitis C virus (HCV) infection have a direct effect on pancreatic beta cells resulting insulin hyposecretion. Steroids mainly cause peripheral insulin resistance. Although in type 2 diabetes mellitus the incretin-insulin axis is impaired and incretin hormones are advantageous targets of many antidiabetic drugs, the endocrinologic background of new-onset diabetes mellitus after transplantation (NODAT) is still not completely understood. METHODS: During the first postoperative year the oral glucose tolerance test (OGTT) was performed on 21 patients after OLT. Patients' glycemic metabolic status was determined according to the results of OGTT. The level of incretin hormones, namely glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP), were measured with competitive enzyme-linked immunoassay reaction. RESULTS: Six patients had normal glucose tolerance (NGT), 9 had impaired glucose tolerance (IGT, serum glucose 7.8-11.0 mmol/L), and 6 were diagnosed with NODAT (serum glucose >11.1 mmol/L). Fasting insulin and c-peptide levels were higher if IGT/NODAT was found. Insulin secretion was not further stimulated after OGTT. GIP and GLP-1 levels did not differ significantly, not even after glucose load. HCV infection had not influenced the levels of incretin hormones [GLP-1 (0 min): 1.21 ± 0.27 vs 1.38 ± 0.65; P = ns; GLP-1 (120 min): 1.46 ± 0.61 vs 1.07 ± 0.58; P = ns; GIP (0 min): 2.55 ± 0.95 vs 1.99 ± 0.63; P = ns, GIP (120 min): 2.62 ± 0.6 vs 2.33 ± 0.77; P = ns]. CONCLUSION: The stimulation of insulin secretion in NODAT is limited. Incretin hormones are present independently from the current glycemic status. The use of dipeptidyl peptidase-4 inhibitors through their positive effect on the incretin-insulin axis can be beneficial in the therapy of NODAT after liver transplantation.

Endogenous thrombin potential and examination of a further 31 analytes in liver transplant candidates.

BACKGROUND: To predict the change in patient status and differentation of the basic diseases, endogenous thrombin potential (ETP), clinical chemistry, and coagulation variables were measured in liver transplant-listed patients with different etiologies. METHODS: Differences in values of ETP and analytes of 30 control persons and 164 cirrhotic patients were examined by means of binary logistic regression. The relationship between the analytes and ETP parameters were analyzed by means of Spearman correlation. The different etiologies of cirrhosises were studied by factor and discriminant analyses. Binary logistic regression was applied to forecast changes in clinical status. Survival analysis was carried out with the appropriate variable. RESULTS: International Normalized Ratio and activated partial thromboplastin time values were higher, whereas the area-under-the-curve values were lower in cirrhosis than in healthy subjects. A strong relationship was found only between the peak height and the anti-thrombin III (ATIII) values. In the factor analysis, 3 factors were found, which explained 81.6% of the total variance. Combination of aspartate aminotransferase and ATIII mostly separated the basic disease groups from each other in the discriminant analysis. From 35 variables, the lactate dehydrogenase (LDH) and ATIII have been suited for predicting the change in patient status. Eighty percent of patients with low ATIII and high LDH levels had deterioration of their clinical status. CONCLUSIONS: Our study demonstrated that the ETP parameters did not provide additional information compared with "conventional" coagulation tests in cirrhosis. On the basis of our study, LDH and ATIII appear to be promising analytes to assess the clinical status of patients with cirrhosis. In our opinion, the classification system of liver transplant-listed patients can be improved with their use.

New-onset diabetes mellitus and the analysis of dipeptidyl-peptidase-4 after liver transplantation.

BACKGROUND: New-onset diabetes mellitus after transplantation (NODAT) is a common complication after orthotopic liver transplantation (OLT). The diabetogenic effect of hepatitis C virus (HCV) infection is well known. The aim of this study was to analyze the glucose homeostasis before and after OLT. The oral glucose tolerance test (OGTT) was carried out, and dipeptidyl-peptidase-4 (DPP-4) activity was measured. METHODS: The study period was from 2012 to 2014. We enrolled 49 non-diabetic patients from the waiting list (group A) and 21 patients after OLT (group B). Seven patients were monitored continuously both before and after OLT. According to our preoperative OGTT results, 13 patients in group A had newly diagnosed diabetes mellitus (group A/DM) and 11 had impaired glucose tolerance (group A/IGT). In 25 cases, normal glucose tolerance was diagnosed (group A/NGT). The calculated homeostasis model assessment insulin resistance (HOMA2-IR) values were both in group A/DM and-IGT higher compared with group A/NGT (2.42 ± 0.81 vs 2 ± 0.98 vs 1.28 ± 0.67; P = .001). In the case of HCV infection (n = 14; 29%) DM and IGT were more frequent. RESULTS: Six patients in group B had NODAT. In 9 cases, IGT and in 6 cases NGT was detected. In the case of HCV infection (n = 9; 43%), DPP-4 levels were higher compared with that in patients with all other indications for OLT (15.5 ± 5.2 vs 8.7 ± 3.5; P = .008). We evaluated the same individuals before and after OLT (n = 7), and a decrease in ß-cell function was noted. CONCLUSIONS: Preoperative OGTT is an important and easy investigation to rule out glucose imbalance before OLT. The HOMA2 calculation can also be useful both in preoperative and postoperative risk assessment. In our results, DPP-4 activity is not specific for the type of glucose homeostasis imbalance, but, in HCV infection, it is higher. DPP-4 inhibitors can be effective in the therapy of NODAT, especially in HCV-infected patients.

Retransplantations in the Hungarian liver transplant program.

Retransplantation of the liver (ReOLT), not infrequent consequence of transplantation, was analyzed from 512 patient records between 1995 and 2012. The 34 cases (33 secondary and 1 tertiary). Of ReOLT all employed cadaveric donor organs. The 34 reOLT were performed in 31 adults and 3 children. The original indication for OLT, among these patients was usually primary sclerosing cholangitis (PSC) and acute liver failure (ALF): there were no alcoholic liver disease (ALD) patients. The indication for early reOLT (within 3 months) was hepatic artery thrombosis while the late reOLTs beyond 3 months after primary transplantation was nonanastomotic biliary stenosis. The cumulative patient versus graft survivals were 61%, 52%, and 52% versus 61%, 52%, and 52% in contrast with primary OLT rates of 81%, 75%, and 70% versus 79%, 72%, and 61% respectively at (P = .03). In conclusion, our data suggested that the characteristics and number of early reOLTs did not change over time. However, the rate of late reOLTs increased. This can be explained by the increased rate of late onset biliary complications in spite of proper interventional radiological treatment. The second conclusion is that hepatitis C virus (HCV) recurrence did not become a main indication among late reOLT. Since a center policy states that patients with an early, cholestatic HCV recurrence are not referred for a secondary transplantation.

Technical risk factors for hepatic artery thrombosis after orthotopic liver transplantation: the Hungarian experience.

Hepatic artery thrombosis (HAT) significantly affects graft loss and mortality after orthotopic liver transplantation (OLT). The aim of this study was to analyze the risk factors of HAT in our program, with special regard to the personal-technical factor. We retrospectively analyzed the data of 500 adult liver transplant recipients between 1995 and 2011. Operations were performed by a certain group of surgeons, with standardized technique. The incidence rate of HAT decreased since 1995 from 12% to 7.8%. In accordance with the literature, HAT associated with acute rejection, polytransfusion, and the duration of the hepatectomy, arterial variations/reconstructions, tiny arteries, and furthermore, the timing of the anastomosis in Hungary. However we did not find an association with other parameters, like cytomegalovirus infection, and hepatocellular carcinoma as indication. We created a "difficulty index" that consists of the technical parameters. The difficulty index together with surgical experience (number of OLTs performed) had an outstanding association with HAT. In conclusion, the incidence and risk factors for HAT are similar to the results published by others. However, personal factors, such as experience, timing, given anatomy, and tiredness, might also play a significant role in the occurrence of HAT.

Biliary complications after orthotopic liver transplantation: the Hungarian experience.

Biliary complications (BC) significantly affect morbidity and mortality after orthotopic liver transplantation (OLT). The aim of this study was to analyze the incidence and types of biliary complications after OLT in Hungary. We retrospectively analyzed data of 471 adult liver transplant recipients between 1995 and 2011. Biliary complications occurred in 28% of patients. The most frequent BCs were bile duct stricture, stenosis (19%), biliary leakage (12%), and necrosis (BN: 6.4%). Biliary complications were associated with the incidence of acute rejection (51% vs 31%; P = .003), hepatic artery thrombosis (43% vs 11%; P < .001), and hepatic artery stenosis (26% vs 11%; P = .002). When cold ischemic time was longer than 12 hours, leakage (10% vs 3%; P = .043), ischemic type biliary lesion (20% vs 3.4%; P = .05), and BN (12% vs 3%; P = .067) were more often diagnosed post-OLT. Most of the biliary complications were treated by radiologic interventions (70%). Bile duct necrosis was associated with lower graft and patient survival. In conclusion, acute rejection, hepatic artery thrombosis/stenosis and cold ischemic time longer than 12 hours increase the incidence of BCs. Successful management of these risk factors can reduce the incidence of biliary complications and improve mortality.

Measurement and clinical significance of interleukin 28B in hepatitis C virus-infected liver transplant patients.

One-third of the liver transplantations are performed because of hepatitis C cirrhosis all over the world and also in Hungary. The recurrence rate is practically 100%, influencing graft and patient survivals; within 5 years cirrhosis develops again in 20% to 30% of cases. The therapy is pegylated interferon α-2a and α-2b plus ribavirin as for nontransplanted subjects with the goal to eradicate the virus and maintain graft function. In 25% to 45% of treated patients, it is possible to achieve a sustained virological response (SVR). The response is influenced by viral, donor, and recipient factors. We investigated the genotype of 68 liver recipients transplanted because of hepatitis C virus (HCV) infection between September 1998 and February 2011. We focused on the interleukin (IL) 28B gene locus single nucleotide polymorphism found on chromosome 19; the rs12979860 minor allele (homozygous [wild TT and CC], heterozygous [CT]) in relation to the interferon response. Ten percent of the patients belonged to the CC, 62% to the CT, and 28% to the TT group, and 83% of the CC group became negative or therapy is still ongoing. The CT genotype reached 15.4% SVR with ongoing treatment for most patients. In TT carriers showed a 23.5% SVR. Our patients formed a homogenous group regarding the surgical team, the therapy, and the HCV genotype. Ninety percent belonged to the possible "hard to treat" group. The 10% CC group gave the highest number of SVR and HCV polymerase chain reaction negativity upon antiviral therapy. Regarding our results, one has to take in consideration the small patient number and the fact that the cirrhotic patients were listed for transplantation where they could not be treated or became therapy-resistant. IL28B is just one predictive factor among others for successful posttransplant HCV therapy; further examinations are needed to fully understand its role.

Significance of mycophenolate monitoring in liver transplant recipients: toward the cut-off level.

Mycophenolate mofetil blocks the "de novo" -purine synthesis to reduce the incidence and severity of acute rejection episodes. There has been an increased interest in utility of monitoring mycophenolic acid (MPA) levels, however currently the MPA monitoring is not part of the protocol following liver transplantation. We assessed whether trough MPA monitoring could be advisable in liver transplant patients or not. For this reason MPA levels of 56 liver transplants were measured on 3, 5, 10, 14, 21, 30, 60, and 180 posttransplant days. The optimal cut-off of MPA level (≥1.73 mg/L) for all (56) and ≥1.34 mg/L for ciclosporin-treated- and ≥1.98 mg/L for the tacrolimus-treated transplants were calculated by statistical analysis to reduce the incidence of acute rejection. MPA concentrations of 3 days period before the day of clinical diagnosis acute rejection were well below the cut-off value. Only 3 (16%) out 19 patients with acute rejection had higher MPA levels than the cut-off value on the day of diagnosis of acute rejection. In conclusion, our data suggests that MPA predose level monitoring, especially in the early "filling phase" after transplantation, is applicable in liver allograft recipients given adjunctive MMF, protecting them from the ineffective immunosuppression.

The impact of Milan criteria on liver transplantation for hepatocellular carcinoma: first 15 years' experience of the Hungarian Liver Transplant Program.

In addition to hepatitis C, hepatocellular carcinoma. is a leading indication for orthotopic liver transplantation (OLT). The indications for OLT in HCC remains a topic of debate. The successful Milan criteria are still accepted as the gold standard to select candidates with a good chance for long-term survival. The Hungarian Liver Transplant Program launched in 1995 reached 45 OLT/year in 2010. Among 412 first OLTs, there were 49 cases of a malignant tumor, including 41 among which the indication was the tumor. Of the 412 patients, 154 (37.4%) were hepatitic C virus (HCV) positive, including 29 with HCC and 23 cases in which HCC was the indication itself. Half of the HCC patients were within the Milan criteria; 50% exceeded the criteria. We observed a solitary HCC in 36% of cases: 2 foci in 18%; 3 in 7%, 4 in 14%, and ≥5 in 25%. Only 12 patients underwent a "down-staging" treatment before OLT: 8 radiofrequency ablation (RFA) and 4 transarterial chemoembolization (TACE). Cumulative 1-, 3-, and 5-year patient survivals were 62%, 54%, and 43%, respectively in HCC/HCV-positive patients and they were 74%, 67%, and 61% among non-HCC HCV-positive subjects. The cumulative HCC patient survival rates of 64%, 64%, and 53% among Milan criteria were superior to those of 57%, 40%, and 27% among subjects exceeding the Milan criteria (P=.01). Pre-OLT "down-staging" treatment increased the 1-year patient survival from 64% to 70%; however, it did not affect the long-term results. Among items of the Milan criteria tumor size had less impact on outcomes then number of foci. The majority of cases who exceeded the Milan criteria had been transplanted before 2003. Our results suggested that the Milan criteria should be applied for the selection of candidates in order to promise good survival after OLT for HCC.

Volumetric hemodynamic changes and postoperative complications in hypothermic liver transplanted patients.

INTRODUCTION: Hepatic diseases decrease the liver's involvement in thermoregulation. Removal of the liver during transplantation increases the incidence of hypothermia during the surgery. The aims of the present study were to analyze the hemodynamic changes among hypothermic liver transplantations and to determine its relationship to postoperative complications. METHODS: Conventional and volumetric hemodynamic monitoring and intramucosal pH measurements were performed during 54 liver transplantations. According to the core temperature until graft reperfusion, patients were classified into group A, hypothermic patients (temperature < 35 °C; n=25) versus group B, normothermic patients (temperature > 36 °C; n=29). We examined the relationships between central venous pressure (CVP), intrathoracic blood volume index, cardiac index (CI), and oxygen delivery index, oxygen consumption index, as well as the fluctuation of the mean arterial pressure (MAP) and gastric intramucosal pH and activated clotting time. We recorded prolonged ventilation time, vasopressor and hemodialysis requirements, occurrence of infections, and intensive care days. RESULTS: There were no significant differences in the MELD scores. More Child-Pugh class C patients (P<.01) showed significantly higher APACHE II scores (P<.02) among group A. During hepatectomy and at the same intrathoracic blood volumes, the hypothermic group showed significantly higher CVP levels (P<.02). During the anhepatic and postreperfusion phases, the decreased CI levels (P<.05) were associated with increased MAP values (P<.05). Without differences in oxygen delivery, the oxygen consumption was lower in group A (P<.05). The intramucosal pH levels were the same in the both groups during the whole examination period. More instances of infection, intensive care, and hemodialysis treatment days, were observed as well as significantly longer vasopressor requirements and coagulopathy among the hypothermic group (P<.007).

Liver transplantation for acute liver failure: the Hungarian experience.

Acute liver failure (ALF) counts for 9%-11% of activity in leading liver transplant programs. We have summarized the Hungarian Liver Transplant Program experience for ALF among 412 consecutive orthotopic liver transplantations (OLTs). All OLTs were performed without an extended international donor background. The proportion of ALF among the indications for OLT was lower (5.8% vs 9%) and early mortality higher than the European Liver Transplant Registry (1 year cumulative patients survival is 70% in ELTR vs 60% in the HU LT Program). The waiting time for a donor was longer than expected in the Eurotransplant community. Regarding postoperative complications, there was a higher incidence of initial poor function, bacterial infection, sepsis, and multiorgan failure. We conclude that ALF can be managed with reasonable results but requires an extended donor pool with an integrated international network to improve postoperative morbidity and mortality.

Results and complications after living related kidney transplantation in Hungary: 30 years' experience.

The number of patients suffering from kidney disorders is increasing the need for kidney transplantation. Kidneys originating from living donors (LD) show substantially better results than those originating from cadaveric donors (CD). We performed 3000 kidney transplantations between November 1973 and December 2007, including 154 from LD (5.13%). The early kidney function as measured by the delta creatinine clearance was significantly better among the LD group (P < .001). There was no significant difference in the immunologic data between the LD and the CD groups (P = .047). Four years after transplantation the glomerular filtration rate (GFR) and the serum creatinine level treated to be better among the LD group with tacrolimus versus cyclosporine immunosuppression (P = .089). In the LD group, the acute rejection rate was lower with tacrolimus- versus cyclosporine based immunosuppression (P = .014).

Small difference in international normalized ratio may yield a significant impact on prioritizing patients listed for liver transplantation.

Priority for liver transplantation is currently based on the Model for End-stage Liver Disease (MELD) score. The aim of our study was to assess in detail the contribution of international normalized ratio (INR) differences for MELD scores because of interlaboratory variability. The samples from 92 cirrhotic patients were measured on different systems combining three coagulometers and three thromboplastin products to determine variations in INR and MELD score. The INR differences among the first four systems varied between 0 and 0.2, resulting in MELD differences of 0 to 2. The MELD scores of 92 patients changed only among 10 possible integers so that normally 2 to 10 patients shared the same MELD value. In some cases, one MELD score difference resulted in a 10 superpositioning on the waiting list. Including one more system (mechanical vs optical) into our investigations achieved a five MELD difference. Supposing an extreme situation where one patient competes with his or her lowest, all the other with their highest possible score (and visa versa), the difference may be even 20 positions, overturning the complete waiting list. In conclusion substantial interlaboratory differences in MELD score have profound clinical consequences.

Outcome of liver transplantation based on donor graft quality and recipient status.

BACKGROUND: Availability of suitable donor organs has always limited the number of liver transplantations performed. Use of marginal donor organs is an alternative to overcome organ shortage. OBJECTIVE: To analyze the effect of various combinations of donor organ quality and recipient status on the outcome of liver transplantation. MATERIALS AND METHODS: Data from 260 whole-liver transplantations performed between January 2003 and September 2009 were analyzed retrospectively. Study groups were established according to donor organ quality (marginal score 0-1 vs 2-5) and recipient status (Model for End-Stage Liver Disease [MELD] score <17 or >17). In patients at low risk, 102 received optimal grafts (good-to-good group [G/G], and 75 received marginal grafts (bad-to-good group [B/G]. In patients at high risk, 46 received optimal grafts (good-to-bad group [G/B], and 37 received marginal grafts (bad-to-bad group [B/B]. RESULTS: No differences were observed in cumulative patient and graft survival rates; however, total survival differed in the early period after transplantation, that is, within 1 year. There was a higher rate of overall postoperative complications including initial poor graft function, bleeding, infection, and kidney failure in group B/B compared with group G/B (25 of 37 patients [67.5%] vs 27 of 46 patients [59.0%]), group B/G (25 of 37 patients [68%] vs 39 of 75 patients [52%], and group G/G (25 of 37 patients [68%] vs 43 of 102 patients [42%]) (P = .04). Patients with a high MELD score (G/B and B/B) demonstrated increased risk of postoperative complications. Use of donor organs with marginal score of 2 or higher in patients with high MELD scores increased early patient mortality. CONCLUSION: In summary, patients with a high MELD score (G/B and B/B) are at an increased risk of post-OLT complications. In contrast, use of marginal grafts (B/G and B/B) increased the rate of hepatitis C virus recurrence and decreased the response rate to antiviral therapy. The combination of impaired donor grafts and recipients at high risk should be avoided.