Inferior liver allograft survival from cadaveric donors >50 years of age?

The growing imbalance between the number of cadaveric organ donors and recipients has led to an increasing use of high-risk donors as an option to expand the donor pool. The aim of this study was to evaluate our experience with the use of older liver (donor>50 yr of age) allografts. The medical records, postreperfusion biopsies and laboratory results were reviewed of the 393 patients who underwent orthotopic liver transplantation between 1986 and 1997. The outcome of the 61 patients who received older livers (OL) was compared to that of the other 332 recipients. Increasing use of OL was evident from 1992 onwards. Recipients of OL were older than recipients of younger livers (YL, p<0.001) and more commonly had underlying chronic viral hepatitis (CVH) or fulminant hepatic failure (p<0.05). Patient and allograft survival were only slightly less in recipients of OL versus YL (p=NS). Although postperfusion biopsies showed more damage in OL than YL allografts (p<0.05), this was not associated with increased primary graft failure. OL allografts can be transplanted with acceptable results into recipients without the concern of early allograft loss. SUMMARY OF ARTICLE: This report of one centre's experience with 61 recipients of older donor liver allografts identifies recipient factors that may also have a negative impact on allograft outcome. These factors include a diagnosis of either CVH or fulminant hepatic failure at the time of transplantation. Postreperfusion biopsies of older donor allografts tend to show more damage, but this is not associated with primary non-function.

Factors in older cadaveric organ donors impacting on renal allograft outcome.

Transplantation of renal allografts (RA) from older donors has become more common, despite conflicting data on outcome between reports from large series versus individual centres. Factors other than donor age per se may contribute to RA outcome. The outcome of RA procured from 114 older donors over 55 yr of age in NSW, between 1990 and 1997, was analysed. Corresponding donor factors, including demographics, medical history, inotrope use, major hypotension and findings at procurement, were also analysed. Of the potential RA, 8% were discarded and the remainder transplanted. Factors significantly associated with renal discard were pre-transplantation donation biopsy abnormality (p < 0.001) and a history of cardiovascular (CV) disease in the donor (p < 0.02). Donor aortorenal atherosclerosis (AS; p < 0.09) and a donor age of 65 yr or older (p < 0.08) were common in the discard group. The never function rate was 7.6% and was associated with a history of a discarded partner kidney (p < 0.05). The delayed graft function rate was 33% and was associated with a history of donor CV disease. At a median follow up of 5 yr, the death censored allograft failure rate was 24%. Allograft failure was associated with a history of donor hypertension (p < 0.05). Donor AS (p < 0.7) tended to have been more common in the allograft failure group. A number of cadaveric organ donor factors documented at procurement may be associated with inferior outcome of RA. These include biopsy abnormality, history of donor CV disease and history of donor hypertension. A donor age of 65 yr or older or significant visible aortorenal AS may also be factors. This retrospective review of kidneys procured from 114 older cadaveric organ donors identifies factors apart from donor age, which may have a negative impact on both allograft utilisation and outcome. Theses factors include renal biopsy abnormality, history of donor CV disease, discard of a partner kidney and donor hypertension. Visible AS in the donor aorta documented at renal procurement may also be a factor.

Analysis of postrevascularization syndrome after orthotopic liver transplantation: the experience of an Australian liver transplantation center.

BACKGROUND/PURPOSE: We investigated the causes and examined patient outcomes following the postrevascularization syndrome (PRS) during orthotopic liver transplantation (OLTx). METHODS: PRS was defined as a fall in the mean arterial pressure at 5 min after revascularization to less than 70% of the baseline and lasting for 5 min. Data from 100 adult patients who underwent OLTx between January 1998 and September 2000 were analyzed. Analyzed data included donor and recipient demographic data, recipient operative and postoperative courses, and recipient outcome. RESULTS: Twenty-nine patients (29%) exhibited PRS during OLTx (PRS group). There was a higher incidence of older donors (>50 years) in the PRS group (48% vs 23%; P < 0.05). Postrevascularization hyperkalemia and metabolic acidosis were observed in both the PRS and non-PRS groups. Transaminase and lactate levels after revascularization were significantly higher in the PRS group ( P < 0.05). Alkaline phosphatase and gamma-glutamyl transpeptidase levels on day 7 tended to be higher in the PRS group; although the difference was not significant (p > or = 0.05). Serum creatinine was significantly elevated on day 7 in the PRS group ( P < 0.01). CONCLUSIONS: Our results indicate that PRS following OLTx tended to be more common in liver allografts from older donors and was associated with posttransplantation liver and renal dysfunction.

Liver transplantation in patients with transjugular intrahepatic portosystemic shunts.

BACKGROUND: In patients with intractable oesophageal variceal bleeding, transjugular intrahepatic portosystemic shunts (TIPSS) are being used increasingly as a bridge to orthotopic liver transplantation (OLTx). There is little information in the literature concerning variations in the operative techniques of OLTx required because of the presence of TIPSS. METHODS: A retrospective review of patients treated by TIPSS prior to OLTx was undertaken. The aims were to assess the effectiveness of TIPSS in bridging patients to OLTx and to examine whether TIPSS influence the operative management of OLTx. RESULTS: Over a 4-year period eight adult patients underwent TIPSS insertion prior to OLTx in the Australian National Liver Transplant Unit (ANLTU). Transplantation was performed at a mean of 14.6 (0.3-53.8) months after TIPSS insertion. Prevention of major recurrent variceal haemorrhage prior to transplantation was achieved in six cases. In two patients the stents were predominantly intrahepatic and they did not interfere with OLTx. In five patients the stents extended into the portal vein, requiring removal during OLTx either by division of the stent with the recipient portal vein, followed by removal of the fractured stent wires from the portal veins (n = 3), or by 'endarterectomy' of the recipient portal vein, allowing removal of the intact stent (n = 2). In one case where the stent extended into the suprahepatic inferior vena cava, removal was achieved by traction without difficulty. All patients are alive at a mean of 24 (7-53) months post-transplant and none has portal vein abnormalities. When compared to 178 adult patients who had no TIPSS and underwent primary OLTx during the same study period, there was no difference in the length of operating time or the usage of blood products during OLTx. CONCLUSION: Transjugular intrahepatic portosystemic shunts offer a bridge to OLTx by providing effective control of variceal haemorrhage. In the present series TIPSS did not increase surgical morbidity or mortality, but emphasis is placed upon the need for optimal TIPSS placement within the liver to facilitate subsequent OLTx.

Pancreatitis in adult orthotopic liver allograft recipients: risk factors and outcome.

Acute pancreatitis (AP) has been described after orthotopic liver transplantation but is uncommon in stable patients after the initial perioperative phase. The aim of this study is to review our experience with AP occurring more than 2 months after primary allografting and determine possible contributing factors plus patient outcome. A review of patient files and the unit database was performed. AP was diagnosed in 9 of 298 patients (3%) on 12 occasions. The incidence of AP was greater in men (8 of 163 men) than women (1 of 135 women; P <.04). Underlying factors to each episode of AP were biliary manipulation (4 of 12 episodes; 33%), history of recent alcohol ingestion (3 of 12 episodes; 25%), and malignancy in the region of the pancreas (2 of 12 episodes; 16%). AP was associated with a diagnosis of either hepatic artery thrombosis combined with biliary tract complications (P <.005) or malignancy (P <.004). In 7 of 12 episodes of AP (58%), conservative management alone was successful. In 3 of 9 patients (33%), subsequent surgery was required. One patient died of pancreatic malignancy. In conclusion, AP is uncommon in stable liver transplant recipients. Male sex, complications of hepatic artery thrombosis, and malignancy in the region of the pancreas are associated with AP in this study.

Liver transplantation for hepatocellular carcinoma in cirrhotic patients.

BACKGROUND: Hepatocellular carcinoma (HCC) in patients with cirrhosis, due to a limited liver reserve, is often deemed unresectable, even at an early stage. METHODS: In order to evaluate the ongoing transplant programme for cirrhotic patients with HCC at Royal Prince Alfred Hospital, the results of liver transplantation (LTx) for HCC were analysed and the patient actuarial survival was compared with that of those LTx patients without malignancy. RESULTS: A total of 441 LTx were performed in 404 patients between January 1986 and April 1998. Twenty-four LTx recipients (22 men; two women) of mean age 49 (15-62) years had HCC. Twenty-one had underlying aetiology for their cirrhosis (hepatitis B: n = 9; hepatitis C: n = 8; hepatitis B and C: n = 1; haemochromatosis: n = 1; autoimmune hepatitis: n = 1; alcoholism: n = 1), while three patients had cryptogenic cirrhosis. Six patients had incidental tumours and another two cases were of the fibrolamellar type. The average tumour size and tumour number were 2.9 (0.4-11.5) cm and 1.3 (1-4), respectively. Operative mortality was 4.2% (1/24). The HCC recurrence appeared in one (4.2%) patient (with a 11.5-cm HCC) who died 18 months after LTx. A further two patients died (one graft failure from recurrent hepatitis C and one from fungal sepsis) during follow-up. The overall 1- and 3-year actuarial patient survival rates were 87% and 76%, respectively, and that of patients with benign causes (n = 369) were 77% and 72% (P = NS). CONCLUSION: With careful patient selection, long-term tumour-free patient survival can be achieved. The results support an active transplant programme for selected HCC.

An active liver transplant programme for hepatocellular carcinoma in cirrhotic patients: is it justified?

Even at an early stage, hepatocellular carcinoma (HCC) in patients with cirrhosis is often deemed unresectable because of limited liver reserve. In these circumstances, liver transplantation (LTx) offers some hope for palliation or cure. The results of LTx for selected cirrhotic patients with HCC were analysed. The outcomes were compared with those of patients who underwent LTx for other forms of hepatic malignancy and those who underwent LTx for non-malignant conditions. Four hundred and eighty LTx were performed in 441 patients between January 1986 and December 1998. Twenty-eight LTx recipients (25 males, 3 females) of mean age 51 (14 63) yr had cirrhosis and HCC. Twenty-seven patients had underlying predisposing conditions (11 had hepatitis B, 10 had hepatitis C, 2 had hepatitis B and C, 1 had haemochromatosis, 1 had autoimmune hepatitis, 1 had alcoholic cirrhosis and 1 had alpha-1 antitrypsin deficiency). In 22 patients, HCC was diagnosed pre-LTx, and in 6 patients, the cancers were discovered incidentally. The average tumour size and number were 2.8 (0.4-11.5) cm and 1.3 (1-4), respectively. Two patients with known HCC died during and shortly after the LTx operation. Of the other patients, 3 died; 1 died of HCC recurrence 18 months post-LTx, 1 died of graft failure from recurrent hepatitis C and 1 died of fungal sepsis. Twenty-three (82%) patients survived to 22.5 (0.5-96) months post-LTx without HCC recurrence and with 1- and 3-yr actuarial patient survival rates of 87 and 76%, respectively. Equivalent survival rates of patients who underwent LTx for other malignancies (n = 11) were 82 and 46% (p = NS), and for those who underwent LTx for benign causes (n = 402), they were 77 and 73% (p = NS). All 15 patients with known HCC, who met the selection criteria now in use, survived. LTx can result in prolonged. cancer-free survival in a good proportion of patients with cirrhosis and HCC, particularly when the cancers are incidental, or when diagnosed pre-LTx, conforming to established selection criteria. An active LTx programme for this group of patients is justified.

Evaluation of the loin pain/hematuria syndrome treated by renal autotransplantation or radical renal neurectomy.

Some patients with the loin pain/hematuria syndrome suffer incapacitating flank pain. No effective therapy has been reported. Uncertainty persists concerning the authenticity of the pain and the role of surgery in treatment. Forty-six patients with loin pain/hematuria syndrome and intractable pain were evaluated following treatment either by renal autotransplantation (30 patients, 10 bilaterally) or by renal denervation (20 patients, four bilaterally) over a 13-year period. All patients had concomitant renal nerve excision and ligation and capsulotomy. There were 37 (80%) women and nine men aged 18 to 61 years (mean age, 33 years). Excretion urography and angiography were normal in all patients. Nineteen of 25 (76%) patients in whom renal autotransplantation was successfully accomplished and who completed a follow-up questionnaire were free of pain, including eight of 10 with bilateral procedures. The follow-up periods ranged from 1 to 13 years (mean, 8.4 years). Six patients have been free of pain for 10 to 13 years. Of 18 patients treated with renal neurectomy who were available for follow-up examination, 12 (67%) developed recurrent renal pain, including four who had pain relief on the other side following previous renal autotransplantation. The follow-up period for these patients ranged from 6 to 9.9 years (mean, 8.0 years). Three of four patients with recurrent renal pain following neurectomy were treated successfully by renal autotransplantation. The loin pain/hematuria syndrome is a rare cause of incapacitation, predominantly of relatively young females. The pain of the syndrome is organic. Renal autotransplantation achieves pain relief in three quarters of patients, but the procedure is often (30%) required bilaterally and has significant complications. Renal neurectomy is followed by an excessive incidence of recurrent renal pain.

Cadaveric liver procurement using aortic perfusion only.

BACKGROUND: To test the effectiveness of a simpler surgical technique for cadaveric liver procurement for liver transplantation, a prospective randomized study was carried out between August 1994 and December 1995, to compare aortic perfusion only (APO) for flush-preservation of the liver with the conventional combined aortic and portal perfusion (APP) technique. METHODS: Forty multiple organ donors were enrolled with 20 in each arm of the trial. Donor parameters (age, bodyweight, liver function tests), surgeons performing the operations, the involvement of other procurement teams and the total ischaemic times were similar in the two groups. The liver recipients had a wide range of native liver pathology but were of similar age, sex and bodyweight in the two groups. RESULTS: The mean procurement operation times for the APO and APP groups were 126.7+/-38.6 and 137.8+/-55.9 min, respectively (P=ns). The perfusion took longer to complete in the APO group (10.2+/-1.7 vs 7.2+/-1.4 min (APP), P < 0.001). The liver temperature fell to its lowest level (12.5+/-3.4 degrees C (APO) vs 11+/-3 degrees C (APP), P=ns) in a similar time (11.9+/-3.8 min (APO) vs 9.3+/-3.4 mins (APP), P=ns). There was no graft primary non-function or graft arterial injury in either group. There was no significant difference between the APO and APP initial graft outcomes. The 3-month patient survival rate was identical in the two groups (95%); 81% of renal grafts from the APO donors functioned well from the time of transplantation as did 76% of those from APP donors. CONCLUSIONS: It is concluded that the APO procurement technique produces equivalent results to those achieved with the APP method. The simplicity of the APO technique makes it the preferred technique.