Should Calcineurin Inhibitors/Sirolimus Be Ceased Completely In Posterior Reversible Encephalopathy Syndrome?

BACKGROUND: To investigate the relationship between immunosuppressive treatments and posterior reversible encephalopathy syndrome (PRES) in transplant patients. METHODS: We presented a retrospective study of 4 cases of PRES in transplant patients. Patient records were reviewed to identify potential risk factors, clinical presentations, radiological findings, and immunosuppressive treatments used. RESULTS: Our analysis revealed a potential association between immunosuppressive treatments and the development of PRES in transplant patients. Specifically, we found that adjusting or switching immunosuppressive treatments can improve outcomes and prevent the recurrence of PRES. CONCLUSION: Our findings highlight the importance of recognizing PRES as a potential complication of immunosuppressive treatments in transplant patients. Early detection and management, including a review of immunosuppressive treatments, may improve patient outcomes and prevent further complications.

Donor bile duct evaluation with magnetic resonance cholangiography in living-donor liver transplantation: a novel anatomical classification for predicting surgical techniques.

PURPOSE: To propose a novel, inclusive classification that facilitates the selection of the appropriate donor and surgical technique in living-donor liver transplantation (LDLT). METHODS: The magnetic resonance cholangiography examinations of 201 healthy liver donors were retrospectively evaluated. The study group was classified according to the proposed classification. The findings were compared with the surgical technique used in 93 patients who underwent transplantation. The Couinaud, Huang, Karakas, Choi, and Ohkubo classifications were also applied to all cases. RESULTS: There were 118 right-lobe donors (58.7%) and 83 left-lateral-segment donors (41.3%). Fifty-six (28.8%) of the cases were classified as type 1, 136 (67.7%) as type 2, and 7 (3.5%) as type 3 in the proposed classification; all cases could be classified. The number of individuals able to become liver donors was 93. A total of 36 cases were type 1, 56 were type 2, and 1 was type 3. Of the type 1 donors, 83% required single anastomosis during transplantation, whereas six patients classified as type 1 required two anastomoses, all of which were caused by technical challenges during resection. Moreover, 51.8% of the cases classified as type 2 required additional anastomosis during transplantation. The type 3 patient required three anastomoses. The type 1 and type 2 donors required a different number of anastomoses (P < 0.001). CONCLUSION: The proposed classification in this study includes all anatomical variations. This inclusive classification accurately predicts the surgical technique for LDLT.

Living Donor-Initiated Domino Split-Liver Transplantation in Pediatric Setup: A Case Report With Literature Review.

BACKGROUND: In patients undergoing liver transplantation for metabolic diseases, removing the patient's liver for transplantation to another recipient is called "domino liver transplantation." The extracted liver can be divided and transplanted into 2 recipients, which is called domino split-liver transplantation in the literature. However, in our study, the domino liver was obtained from a pediatric patient. METHODS: A patient with maple syrup urine disease (MSUD) underwent a living donor liver transplant, and the explanted liver was divided in situ into right and left lobes and transplanted to 2 separate patients. Demographic data, surgical techniques, postoperative period, and patient follow-ups were evaluated. RESULTS: The father's left lobe liver graft was transplanted into a 12-year-old boy with MSUD. The removed liver was divided in situ into right and left lobes. The left lobe was transplanted to a 14-year-old male patient, whereas the right lobe was transplanted to a 67-year-old male patient. The donor and the first recipient were discharged on postoperative days 5 and 22. The second pediatric patient who underwent domino split-left lobe transplantation was discharged on postoperative day 23. The adult patient who underwent domino split-right lobe transplantation died on postoperative day 12 owing to massive esophageal variceal bleeding. CONCLUSION: Patients who underwent liver transplantation due to MSUD are among the best donor choices for domino liver transplantation. If the extracted liver has a sufficient volume and anatomic features for a split, it can be used in "selected cases."

Literature Review and 2 Cases of Isolated Chylothorax After Pediatric Living-Donor Liver Transplant.

OBJECTIVES: Chylothorax without chylous ascites after liver transplant is rare. We present 2 cases of isolated chylothorax after liver transplant and a literature review. MATERIALS AND METHODS: We compiled a literature review of chylothorax cases after abdominal surgery and analyzed the cases related to liver transplant. The demographic information, follow-up results, and treatment details of our 2 cases of chylothorax after living-donor pediatric livertransplant were discussed. RESULTS: An 8-month-old child and a 15-month-old child with cholestatic liver disease and urea cycle defect, respectively, underwent living-donor left lateral segment liver transplant. Patients who presented with chylothorax after discharge were treated conservatively. CONCLUSIONS: Isolated chylothorax is rare complication after abdominal surgery, which is mostly possible to treat with conservative methods. Interventional procedures and a surgical approach should only be performed in resistant cases when conservative treatment has failed.

Experience of kidney transplantation to a patient with Bernard Soulier syndrome: A case report.

Renal transplantation could be a challenging operation in patients with haemorrhagic diathesis, with predictable difficulties or even with unpredictable hurdles. Bernard Soulier Syndrome (BSS) is one of the ethiologies of the thrombocytopenia and it is a rare hereditary disease associated with defects of the platelet glycoprotein complex glycoprotein Ib/V/IX and characterized by large platelets, thrombocytopenia, and severe bleeding symptoms. Here, we present a challenging renal transplantation in BSS.

Anesthesia Management in Laparoscopic Donor Hepatectomy: The First Report from Turkey.

BACKGROUND: We aimed to report a single-center experience in laparoscopic donor left-side and right-side hepatectomy cases regarding preoperative evaluation, perioperative and anesthetic management protocols, and postoperative follow-up. METHODS: Laparoscopic donor left-side and right-side hepatectomy cases were included in the study because of their excessive transection area and bleeding potential. Medical records of living donors were reviewed in terms of age, sex, body mass index (BMI), presence of consanguinity with the recipient, perioperative and early postoperative biochemical parameters, hemodynamic changes during surgery, duration of surgery, the ratio of liver volume to total liver volume, perioperative complications, and length of hospital stay. RESULTS: Eighty-one laparoscopic living-donor hepatectomy procedures were performed in our unit between 2018 and 2022. Six laparoscopic donor right-side cases and two left-side cases were retrospectively reviewed. Donors' mean age and BMI were 29.6 ± 8.6 years and 23.1 ± 4.3, respectively. The average weights of the right and left lobe liver grafts were 727 g and 279 g, respectively, constituting 65.8% and 22.7% of the total liver volume, respectively. The mean operation time was 593 ± 94 minutes, and the mean volume of blood loss was 437 ± 294 mL. A major complication, namely portal vein stenosis, developed in 1 donor (1/8), and portal vein patency was achieved postoperatively. CONCLUSIONS: Anesthesia management and teamwork between surgeons and anesthesiologists are the most important building blocks for donor safety, which is of the utmost priority. Effective communication and cooperation in the operating room may prevent potential donor complications and improve postoperative recovery time.

Hepatic Artery Intimal Dissection During Living Donor Liver Transplantation: A New Modified Approach.

Ensuring optimal arterial flow in solid organ transplantation is very important. Insufficient flow causes important problems such as bile duct problems, intrahepatic abscess formation, and organ loss. Arterial intimal dissection is an important factor that negatively affects organ blood flow. In this study, hepatic artery dissections that we detected in patients who underwent living donor liver transplantation in our clinic were defined, and the microvascular intima-adventitial fixation technique, which can be considered a new approach, was described.

Hand-assisted laparoscopic donor nephrectomy: 1864 cases in 15 years of experience.

BACKGROUND: To evaluate hand-assisted laparoscopic donor nephrectomy (HALDN) in terms of intraoperative and postoperative results. METHODS: After institutional review board approval was obtained, a total of 1864 HALDN operations performed between March 2007 and January 2022 were retrospectively analyzed. Age, sex, body mass index (BMI), status of smoking and presence of previous abdominal surgery, laterality, operative time, transfusion requirement, port counts, length of extraction incision, time until mobilization, time until oral intake, donor serum creatinine levels before and one week after the surgery, length of postoperative hospital stay, intraoperative complications, and postoperative recovery and complications were recorded and statistically analyzed. Multiple renal arteries, BMI, right nephrectomy and male sex were also separately evaluated as risk factors for complications and operative time. RESULTS: A total of 825 (44.26%) male and 1039 (55.74%) female patients were enrolled in the study. The mean age of the patients was 45.79 ± 12.88 years. There were a total of 143 complications (7.67% of the total 1864 cases) consisting of 68 (3.65%) intraoperative and 75 (4.02%) postoperative complications. Open conversion was necessary for 10 patients (0.53%) to manage intraoperative complications. Reoperation was needed for 1 patient due to bleeding 6 h after the operation. Multiple renal arteries were a risk factor for intraoperative complications and prolonged operative time. Right nephrectomy and male sex were also related with longer operative times. DISCUSSION: HALDN is a safe procedure associated with low complication rates.

Using Pericholedochal Varix Inflow for Complete Portal Vein Thrombosis in Living Donor Liver Transplantation: A Case Report.

One of the crucial steps of liver transplantation is to provide the portal inflow. Portal vein thrombosis is the most challenging factor to achieve. Using a pericholedochal varix for portal inflow in a patient with complete portal vein thrombosis in living donor liver transplantation (LDLT) is a rare technique. We present our experience of a LDLT with PVT.

Evaluation of pulmonary arterial stiffness and comparison with right ventricular functions in patients with cirrhosis preparing for liver transplantation.

OBJECTIVE: Pulmonary complications are common in patients with liver cirrhosis. Devolopment of pulmonary hypertension (PH) is associated with a poor prognosis in these patients. Pulmonary arterial stiffness (PAS) is considered an early sign of pulmonary vascular remodeling. The aim of this study is to investigate PAS and compare it with right ventricular (RV) functions in patients with cirrhosis who are scheduled for liver transplantation. METHODS: The study included 52 cirrhosis patients (mean age 51.01 ± 12.18 years, male gender 76.9%) who were prepared for liver transplantation and 59 age and sex matched (mean age 51.28 ± 13.63 years, male gender 62.7%) healthy individuals. Patients with left ventricular ejection fraction (LVEF) less than 55%, ischemic heart disease, more than mild valvular heart disease, chronic pulmonary disease, congenital heart disease, rheumatic disease, moderate to high echocardiographic PH probability, rhythm or conduction disorders on electrocardiography were excluded from the study. In addition to conventional echocardiographic parameters, PAS value, pulmonary vascular resistance (PVR) and RV ejection efficiency was calculated by the related formulas with transthoracic echocardiography (TTE). RESULTS: Demographic characteristics and cardiovascular risk factors of the groups were similar. PAS, PVR, and sPAP values were found to be significantly higher in the patient group (20.52 ± 6.52 and 13.73 ± 2.05; 1.43 ± 0.15 and 1.27 ± 0.14; 27.69 ± 3.91 and 23.37 ± 3.81 p < 0.001, respectively). RV FAC and RV Ee were significantly lower and RV MPI was significantly higher in the patient group (45.31 ± 3.85 and 49.66 ± 3.62, p < 0.001; 1.69 ± 0.35 and 1.85 ± 0.23, p = 0.005; 0.39 ± 0.07 and 0.33 ± 0.09, p = 0.001, respectively). PAS was significantly correlated with RV FAC and MPI (r = -0.423, p < 0.001; r = 0.301, p = 0.001, respectively). CONCLUSIONS: Increased PAS in cirrhosis patients may be associated with early pulmonary vascular involvement. Evaluation of RV functions is important to determine the prognosis in these patients. FAC, MPI, and RV Ee measurements instead of TAPSE or RV S' may be more useful in demonstrating subclinical dysfunction. The correlation of PAS with RV FAC and MPI may indicate that RV subclinical dysfunction is associated with early pulmonary vascular remodeling in patients with liver cirrhosis.

Split Liver Transplant From Deceased Marginal Donor: A Case Report.

The relative paucity of deceased donor organs and the progressive increase in patients with cirrhosis have led transplant centers to consider organs from marginal donors (elderly donors, prolonged stay in the intensive care unit (ICU), liver steatosis-steatotic grafts, severe hypernatremia, and use of inotropes). Recently, the use of those marginal grafts has increased, but splitting liver is still debatable. Herein, we present a 28-year-old deceased donor who had a history of traumatic brain injury. The patient stayed in ICU for 3 days with high sodium level (188 mEq/L) and was hemodynamically supported with single inotrope. At the time of procurement, core biopsies were taken from the right lobe and left lateral segment of the liver, with results demonstrating 5% necrosis. A decision was made for split liver transplant as left lateral sector and extended right lobe. Liver graft was divided into a left lateral segment to be transplanted to a 4-year-old child with secondary biliary cirrhosis due to previous liver transplant and a right extended liver lobe for an adult patient with hepatocellular carcinoma waiting 10 months on the waiting list. Both liver transplants were performed uneventfully. Patients were discharged on the 11th and 56th days after transplant. The liver function tests remained normal during the follow up period of 2 years. A marginal graft with more than one risk factor should not be discarded liberally. Splitting such grafts could be considered in a highly selective recipients.

Prognostic Factors of Liver Transplantation for HCC: Comparative Literature Review.

PURPOSE: The aim of the review study is investigation of the prognostic factors of the liver transplantation for hepatocellular carcinoma. METHODS: A literature review has been made, especially in countries where dominantly living donor liver transplantation is performed, such as Turkey. Liver transplantation from deceased donor and from living donor has been evaluated about as advantages and disadvantages, and their effects on prognosis have been compared. In addition, hepatocellular carcinoma series of Koç University Liver Transplantation center has been presented. RESULTS: Liver transplantation is still the best treatment option with 5-year 50% survival rate for hepatocellular carcinoma even in patient who has locally advanced tumor. The patient's survival is not only an important issue but also the living donor's safety is controversial particularly when expectation of recipient's 5-year survival is below 50% due to donor complication. CONCLUSION: Detailed preoperative examination, appropriate patient selection, and timing of surgery are seen the most important issues in liver transplant's patients with hepatocellular carcinoma.

Patient With Hemophilia A Undergoing Consecutive Coronary Bypass and Live Donor Liver Transplantation: A Case Report.

Liver transplantation surgery due to cirrhosis in patients with hemophilia is rare and there are limited cases in the literature. We present a case of a patient with hemophilia A who underwent 2 consecutive surgeries owing to coronary artery disease and cryptogenic cirrhosis with hepatocellular carcinoma. After these surgeries, no bleeding or other complications were seen, and the factor VIII levels have not changed since liver transplantation in the follow-up.

Cardiac Intervention Before Liver Transplantation.

BACKGROUND: Cardiovascular complication is one of the leading causes of mortality after liver transplantation (LT). Thus, a thorough cardiac evaluation is a must before proceeding to a liver transplant surgery. Percutaneous coronary intervention (PCI) with stent and to a lesser extent coronary artery bypass grafting (CABG) are both valuable treatment options for patients with coronary artery disease. METHODS: A retrospective, single-center study that included patients who underwent cardiac intervention and subsequent LT for end-stage liver disease. All patients who had PCI or CABG were included in the study. RESULTS: Twenty-nine adult patients out of 51 had a cardiac intervention before liver transplantation. Twenty-four patients had a diagnostic PCI, 3 patients had therapeutic PCI with stent, and 2 had failed PCI and proceeded to CABG before liver transplant. The mean age of the patients was 60.5 years. There were 24 men. All patients had cirrhosis. The 2 CABG cases were done during the same admission with a 13- and 18-day interval between the CABG and the transplantation. Both cases were live-related liver transplantation. No mortality was reported. CONCLUSION: In case of PCI failure, CABG may be a valuable and safe treatment option for cirrhotic patients as a preparation for liver transplantation. Live donor liver transplantation may be a good back-up for those patients in case they develop hepatic decompensation.

Extreme living donation: A single center simultaneous and sequential living liver-kidney donor experience with long-term outcomes under literature review.

OBJECTIVES: Living liver and kidney donor surgeries are major surgical procedures applied to healthy people with mortality and morbidity risks not providing any direct therapeutic advantage to the donor. In this study, we aimed to share our simultaneous and sequential living liver-kidney donor experience under literature review in this worldwide rare practice. MATERIAL AND METHODS: Between January 2007 and February 2018, a total of 1109 living donor nephrectomies and 867 living liver donor hepatectomies were performed with no mortality to living-related donors. Eight donors who were simultaneous or sequential living liver-kidney donors in this time period were retrospectively reviewed and presented with their minimum 2- year follow-up. RESULTS: Of the 8 donors, 3 of them were simultaneous and 5 of them were sequential liver-kidney donation. All of them were close relatives. Mean age was 39 (26-61) years and mean BMI was 25.7 (17.7-40). In 3 donors, right lobe, in 4 donors, left lateral sector, and in 1 donor, left lobe hepatectomy were performed. Median hospital stay was 9 (7-13) days. Two donors experienced early and late postoperative complications (Grade 3b and Grade 1). No mortality and no other long-term complication occurred. CONCLUSION: Expansion of the donor pool by utilizing grafts from living donors is a globally-accepted proposition since it provides safety and successful outcomes. Simultaneous or sequential liver and kidney donation from the same donor seems to be a reasonable option for combined liver-kidney transplant recipients in special circumstances with acceptable outcomes.

Hand-assisted laparoscopic donor nephrectomy in kidneys with multiple renal arteries versus a single renal artery: An analysis of vascular complications from 1,350 cases.

OBJECTIVE: Laparoscopic donor nephrectomy (LDN) has been shown to be a safe approach with better morbidity results. Impact of multiple renal arteries (MRAs) and anatomical variations has been reviewed by many authors. In our study, the relationship between the donors with MRAs and risk of perioperative vascular complications related to donor nephrectomy was investigated. MATERIAL AND METHODS: Patients who underwent hand-assisted LDNs between January 2007 and February 2018 were reviewed retrospectively. Patient age, sex, body mass index (BMI), waist circumference, side of donor nephrectomies, donors with MRAs, intraoperative vascular complications, conversion rates, hospitalization durations, and operative times were extracted. Risk factors for perioperative vascular complications were defined. RESULTS: There were MRAs in 288 kidney donors (21.3%). The number of patients who underwent a right donor nephrectomy was 113 (8.4%). BMI, waist circumference, and postoperative hospital stay were not significantly different between donors with one artery and those with MRAs (p>0.05). The renovascular complication rate and overall conversion rate to open surgery were significantly higher in donors with MRAs (p<0.05). CONCLUSION: Perioperative safety of the kidney donors is of crucial importance. Surgeons performing LDNs must be aware of the potential risks. Our analysis suggests that procurement of kidneys from donors with MRAs is a risk factor for renovascular complications.

Risk factors for febrile urinary tract infections in the first year after pediatric renal transplantation.

Urinary tract infection is the most common infectious complication following kidney transplant. Anatomic abnormalities, bladder dysfunction, a positive history of febrile urinary tract infection, and recipient age are reported risk factors. The aim of this study was to determine the risk factors for fUTI, which necessitated hospitalization in the first year after renal transplantation in our pediatric transplant population. A retrospective review of 195 pediatric patients who underwent kidney transplant between 2008 and 2017 from a single institution was performed. All patients admitted to the hospital with fUTI were marked for further analyses. The risk factors including age, gender, dialysis type, history of urologic disorders, and preoperative proteinuria for fUTI in the first year after kidney transplantation and graft survivals were investigated. Independent-sample t test and chi-square tests were used for univariate analysis. Exhaustive CHAID algorithm was used for multivariate analysis. The data of 115 male and 80 female patients were retracted. The mean ages of our cohort for males and females were 9.5 ± 5.1 and 10 ± 4.8 years, respectively. The age of the patients at transplant and their gender were found to be a statistically significant risk factors for developing fUTIs. Multivariate analysis showed that fUTI was common in female patients and a subgroup of male patients who had preoperative proteinuria, but no neurogenic bladder had higher risk compared with male patients without proteinuria. Patient surveillance and antibiotic prophylaxis algorithms can be developed to prevent febrile urinary tract infections seen after pediatric kidney transplantation in risky population.

Living Kidney Donors With Adrenal Incidentalomas: Are They Appropriate Donors?

OBJECTIVE: To determine the incidence of adrenal incidentalomas (AIs) in a single-center series of living renal donors, to describe an evaluation algorithm for AIs in this patient population, and to compare the complication rates of hand-assisted laparoscopic donor nephrectomy (HALDN) with those of combined HALDN and adrenalectomy. METHODS: We performed a single-center, retrospective study of consecutive living kidney donors who underwent laparoscopic nephrectomy for transplantation, with or without simultaneous ipsilateral adrenalectomy, between January 2008 and September 2014. RESULTS: During the study period, AIs were detected in 18 of 1033 potential living renal donors who underwent computerized tomographic angiography. Application of additional donor selection criteria and of an adrenal mass assessment algorithm resulted in 849 HALDN, of which 13 were combined with simultaneous adrenalectomy. The hospital length of stay (2.4 vs 2.6 days), perioperative (0.025 vs 0.077), early (0.073 vs 0.077), and late (0.014 vs 0.077) postoperative complication rates, and conversion to open donor nephrectomy (0.008 vs 0.00) were not significantly different. Mean operative time was significantly longer in the adrenalectomy group. None of the adrenal masses were malignant. CONCLUSION: Here, we presented our algorithm to manage the living kidney donors with AIs. Although donor population with AIs was relatively small in number, simultaneous adrenalectomy and ipsilateral nephrectomy seemed to be technically safe and conferred no identifiable increased risk of malignancy for the kidney transplant donor, when the incidentaloma is nonfunctional and less than or equal to 4 cm as assessed by preoperative imaging.