Favorable outcome of liver transplantation despite a high hepatitis B virus replication: beyond the limits?

Patients with end-stage liver disease due to chronic hepatitis B virus (HBV) infection with a persistent viral replication are generally denied liver transplantation (LT). We report the case of a patient who presented with the emergence of a YMDD escape mutant virus under lamivudine treatment, and developed terminal liver failure requiring LT. Pre-LT introduction of adefovir led to only a mild decrease in replication. The patient was treated with a combination of intravenous hepatitis B immune globulin (HBIG) that was started perioperatively, and also continued lamivudine and adefovir after LT. One year after LT, there was no evidence of HBV infection recurrence. This observation suggests that persistent high HBV replication might not be a contra-indication to LT, providing adequate and effective prophylaxis is given, using HBIG and antiviral drug combination therapy.

[Hemodynamic tolerance and rapid hypertrophy of a hepatic graft corresponding to less than 30% of the ideal mass in pigs]. / Tolérance hémodynamique et hypertrophie rapide d'un transplant hépatique de moins de 30% de la masse normale chez le porc grâce à une anastomose mésentérico-cave terminalisée.

BACKGROUND AND OBJECTIVE: Evaluation of a new pig liver transplantation technique for survival and hypertrophy of a small-sized graft by providing adapted and controlled venous portal flow. MATERIAL AND METHODS: [corrected] Twenty Large-White pigs underwent heterotopic liver transplantation after a mesocaval shunt and ligation of the superior mesenteric vein downstream from the shunt. The donor-to-recipient weight ratio was below 30%. Furthermore, recipient's biliary duct and portal vein into the hilum were tied. In a control group, no mesocaval shunt was performed and the graft received the entire splanchnic venous flow. RESULTS: The mesocaval shunt provided diversion of 60% of the splanchnic blood flow. The median survival of study pigs was 39 days (range: 8-98). Median serum bilirubin levels at 1 week were 12 micromol/L (range: 4-59). At autopsy, graft weight was increased to 2.7 times the initial weight and histological findings were normal. In the control group, all pigs died quickly from acute splanchnic congestion. CONCLUSION: In a model of heterotopic liver transplantation using small-sized grafts, complete diversion of mesenteric blood flow through a mesocaval shunt resulted in hemodynamic tolerance and hypertrophy of a graft corresponding to less than 30% of the ideal mass.

[Liver transplantation in infants and children. Evaluation of the first 40 cases (March 1991-March 1997)]. / La transplantation hépatique chez le nourrisson et l'enfant. A propos de 40 observations (mars 1991-mars 1997).

BACKGROUND: Liver transplantation (LT) is the treatment of end-stage liver disease in children. We report our experience with LT using grafts from living related (LRD) and cadaver donors (CD). POPULATION: From March 1991 to March 1997, 40 children and infants received a total of 42 liver grafts. A reduced-size liver was used in 28 cases. We studied pre-transplantation status, survival rate, and medical and surgical complications in these patients. RESULTS: The survival rate in our series was respectively 85 and 80% at 1 and 7 years after LT. Low weight infants required a prolonged ventilatory assistance. Five of the six deaths noticed during the first three months after LT occurred in children weighing less than 12 kg. One year after LT, no significant difference in the incidence of rejection was found, neither between low-weight children and the others, nor between patients transplanted from CD or LRD. Biliary tract stricture was the major surgical complication. CONCLUSION: This series consisted of a majority of low-weight children. The survival rate in the patients weighting less than 12 kg is lower than in the others. This may be explained by the nutritional status of these patients and early postsurgical complications. The use of grafts from living donors offers more flexibility since the operation is performed electively, but it did not seem to modify the incidence of acute rejections and surgical complications.

[Orthotopic liver transplantation from a living adult donor to an adult using the right hepatic lobe]. / Transplantation hépatique orthotopique à partir de donneur vivant d'adulte à adulte avec un foie droit.

STUDY AIM: In children, living donor liver transplantation has been shown to be efficient in treating end-stage liver diseases when the left lateral segment is harvested. In adults, more liver mass is needed to provide adequate hepatic function. The aim of this study is to report 2 successful cases of living donor liver transplantation using a right hepatic lobe from adult. PATIENTS AND METHODS: In 2 sons, the right hepatic lobe was harvested without the middle hepatic vein for transplantation in their fathers who were suffering from end-stage liver cirrhosis. Hepatectomy was done without vascular inflow occlusion after dissection of vascular and biliary structures, itself strictly restricted to the right side. In recipients, the graft was implanted orthotopically with preservation of the native inferior vena cava and after temporary porto-caval shunt. RESULTS: The duration of donors procedures was 7 h and 11 h 45 min; intra-operative transfusions comprised of 700 mL from cell-saver in the first case, and 1300 mL plus 1 autologous red blood cell unit in the second case. Graft weights were 770 g and 1100 g. None of the donors experienced liver failure and both were able to leave the hospital 9 days after the operation. In recipients, initial graft function was excellent in the first case and correct in the second case, despite the necessity to redo intra-operatively the hepatic vein anastomosis secondary to a twisting. Patients were discharged 20 and 40 days respectively following transplantation. CONCLUSION: Adult living donor liver transplantation using a right hepatic lobe is efficient and safe. This option could contribute to reducing the mortality of patients on the waiting list.

Reversal of early acute rejection with increased doses of tacrolimus in liver transplantation: a pilot study.

BACKGROUND: In this pilot study, we present the results of treatment of early (3 months after liver transplantation) acute rejection episodes by increasing only the tacrolimus doses. METHODS: Ten patients who received tacrolimus as primary treatment experienced acute mild (one case), moderate (four cases), or severe (five cases) rejection episodes. Tacrolimus dosing was increased 1-2 mg every 1 or 2 days until hepatic enzymes started to improve. Steroid basic daily doses were kept unchanged. RESULTS: With the daily dose of tacrolimus increased by a median 1.89-fold (range: 1.2-5), alanine aminotransferase, bilirubin, and gamma-glutamyltranspeptidase levels rapidly reached normal values within the first month. During a median follow-up time of 19.5 months (range: 14-24), none of the 10 patients died or lost their graft. Control liver biopsies were done 13.5 months (range: 7-19) after rejection episode in all patients, and none demonstrated evidence of rejection or sequela. CONCLUSION: This pilot study suggests that increasing tacrolimus dosage could be considered as treatment against early acute rejection episodes including the severe grade.