Amr Abdelaal

The use of terlipressin during living donor liver transplantation: Effects on systemic and splanchnic hemodynamics and renal function.

Objectives: To assess the effect of the intraoperative use of terlipressin on splanchnic hemodynamics and postoperative renal function in patients undergoing liver transplantation. Design: Open-label, prospective, randomized study. Setting: Single-center study. Patients: Thirty patients who underwent elective, living-donor liver transplantation with portal pressure >20 mm Hg. Interventions: Patients were assigned randomly to one of two equal groups. The control group received saline, whereas the treatment group (TP group) received an initial bolus dose of terlipressin (1 mg over 30 mins) followed immediately by a continuous infusion of 2 &mgr;g·kg−1·h−1 for 48 hrs. Measurements and Main Results: Portal pressure and gas exchange (radial artery, portal vein, and hepatic vein, blood gas analyses, and lactate concentration) were assessed at baseline (after ligation of the hepatic artery) and 2 hrs after drug administration. Systemic hemodynamic data and calculated tissue oxygenation parameters were compared throughout the procedure. Renal function was assessed by measurement of serum cystatin C after induction of anesthesia and on the first 2 days postoperatively. After the infusion of terlipressin, portal venous pressure decreased significantly from 26.3 ± 3.3 to 21.3 ± 3.6 mm Hg (p < .001). The mean arterial pressure and systemic vascular resistance were significantly higher in the TP group than in the control group, whereas heart rate and cardiac index were comparable between the groups. Portal and hepatic base excess, and the level of serum lactate, did not differ between the two groups. The serum levels of both cystatin C and creatinine were significantly higher in the control group than in the TP group on postoperative day 2. Conclusion: Perioperative use of terlipressin abrogates the early postoperative decline in renal function of patients who have chronic liver disease and undergo liver transplantation without any detrimental effect on hepatosplanchnic gas exchange and lactate metabolism.

A Novel Mutation of the Ornithine Transcarbamylase Gene Leading to Fatal Hyperammonemia in a Liver Transplant Recipient

Ornithine transcarbamylase (OTC) deficiency (OTCD) is an X‐linked urea cycle disorder. Being an X‐linked disease, the onset and severity of the disease may vary among female carriers. Some of them start to develop the disease early in life, whereas others remain asymptomatic throughout their lives. Our patient was a 42‐year‐old man who developed severe hyperammonemia and fatal brain edema after receiving a right lobe graft from an asymptomatic female living donor with unrecognized OTCD. The donor developed hyperammonemia and disturbed level of consciousness that was managed successfully by hemodialysis. Molecular testing of the OTC gene in the donor revealed a heterozygous nonsense mutation (c.429T > A) in exon 5.

Intraoperative Terlipressin Therapy Reduces the Incidence of Postoperative Acute Kidney Injury After Living Donor Liver Transplantation

OBJECTIVE To evaluate the effect of intraoperative infusion with terlipressin on the incidence of acute kidney injury (AKI) after living donor liver transplantation (LDLT). DESIGN Retrospective case-controlled study. SETTING Government hospital. PARTICIPANTS The medical records of 303 patients who underwent LDLT were reviewed retrospectively. INTERVENTIONS Patients were divided into 2 groups on the basis of intraoperative administration of terlipressin. The primary outcome was AKI, as defined by the Acute Kidney Injury Network criteria. Secondary outcomes included the requirement for postoperative dialysis and in-hospital mortality. MEASUREMENTS AND MAIN RESULTS The incidence of AKI was 38% (n = 115); AKI occurred in 24 (24.2%) patients who received terlipressin versus 91 (44.6%) in the control group (p = 0.001). The incidence of postoperative dialysis was 9.2% (n = 28). Postoperative dialysis was needed by 8 patients (8.1%) in the terlipressin group versus 20 patients (9.8%) in the control group (p = 0.62). Multivariate logistic regression analysis indicated that terlipressin protected against AKI (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.2-0.8; p = 0.013) but not the need for dialysis (OR, 0.7; 95% CI, 0.2-2.2; p = 0.53) or the in-hospital mortality (OR, 1.1; 95% CI, 0.5-2.3; p = 0.7). Adjustment, using the propensity score, did not alter the association between the use of terlipressin and AKI reduction (OR, 0.46; 95% CI, 0.22-0.89; p = 0.03). CONCLUSION These results suggested that intraoperative terlipressin therapy is associated with significant reductions in the risk of AKI in LDLT patients.

Donor rejection before living donor liver transplantation: causes and cost effective analysis in an egyptian transplant center.

Background: In the living donor liver transplant setting, the preoperative assessment of potential donors is important to ensure the donor safety. Objectives: The aim of this study was to identify causes and costs of living liver-donors rejection in the donation process. Materials and Methods: From June 2010 to June 2012, all potential living liver donors for 66 liver transplant candidates were screened at the Ain Shams Center for Organ Transplantation. Potential donors were evaluated in 3 phases, and their data were reviewed to determine the causes and at which phase the donors were rejected. Results: One hundred and ninety two potential living liver donors, including 157 (81.7%) males, were screened for 66 potential recipients. Of these, 126 (65.6%) were disqualified for the donation. The causes of rejection were classified as surgical (9.5 %) or medical (90.5 %). Five donors (3.9 %) were rejected due to multiple causes. Factor V Leiden mutation was detected in 29 (23 %) rejected donors (P = 0.001), 25 (19.8 %) donors had positive results for hepatitis serology (P = 0.005), and 16 (12.7 %) tested positive for drug abuse. Portal vein trifurcation (n = 9, 7.1%) and small size liver graft estimated by CT volumetric analysis (n = 6, 4.8 %) were the main surgical causes which precluded the donation. Conclusions: Among potential Egyptian living liver donors, Factor V Leiden mutation was a significant cause for live donor rejection. A stepwise approach to donor assessment was found to be cost-effective.

Potential ultrastructure predicting factors for hepatocellular carcinoma in HCV infected patients

ABSTRACT Hepatitis C virus represents one of the rising causes of hepatocellular carcinoma (HCC). Although the early diagnosis of HCC is vital for successful curative treatment, the majority of lesions are diagnosed in an irredeemable phase. This work deals with a comparative ultrastructural study of experimentally gradually induced HCC, surgically resected HCC, and potential premalignant lesions from HCV-infected patients, with the prospect to detect cellular criteria denoting premalignant transformation. Among the main detected pathological changes which are postulated to precede frank HCC: failure of normal hepatocyte regeneration with star shape clonal fragmentation, frequent elucidation of hepatic progenitor cells and Hering canals, hepatocytes of different electron density loaded with small sized rounded monotonous mitochondria, increase junctional complexes bordering bile canaliculi and in between hepatocyte membranes, abundant cellular proteinaceous material with hypertrophied or vesiculated rough endoplasmic reticulum (RER), sequestrated nucleus with proteinaceous granular material or hypertrophied RER, formation of lipolysosomes, large autophagosomes, and micro-vesicular fat deposition. In conclusion, the present work has visualized new hepatocytic division or regenerative process that mimic splitting or clonal fragmentation that occurs in primitive creature. Also, new observations that may be of value or assist in predicting HCC and identifying the appropriate patient for surveillance have been reported. Moreover, it has pointed to the possible malignant potentiality of liver stem/progenitor cells. For reliability, the results can be subjected to cohort longitudinal study.

Hydatid Disease of the Liver : Laparoscopic Approach , Initial Results in Egypt

This prospective study assessed the laparoscopic approach for treatment of HHC in Ain Shams University Hospitals from January 2010 to April 2012. Laparoscopic partial cystectomy was performed in all patients; no conversion to open technique or anaphylaxis was recorded. The mean operative time was 60 minutes with no perioperative mortality, while postoperative morbidity was recorded in 4 patients (36%). The mean length of hospital stay was 4.5 days. Radiological and serological tests showed no recurrences at a median follow up period of 18 months. Laparoscopic management of HHC is feasible gaining all the benefits of laparoscopy with no added morbidities or increased risk of recurrence. Careful patient selection is madrdatory to achieve successful results.

Immunohistochemical and electron microscopic morphometric image analysis of hepatocellular carcinoma in association of HCV infection

ABSTRACT Early detection of hepatocellular carcinoma (HCC) is crucial for successful therapy. The present work examined the value of ultrastructural morphometric image analysis of hepatocyte nuclei in patients with chronic hepatitis C virus (HCV) versus HCC cases with chronic HCV and the corresponding surgical tumor-free safe margins (TFMs), to highlight any early predictive signs of neoplastic cellular transformation. This work also performed an immunohistochemical assessment of cytokeratin 19 (CK19) and Ki-67-positive cells to visualize any associated proliferative activity in the examined groups. The results showed significant decrease in the hepatocyte nuclear surface areas in the HCC and TFMs versus those in the HCV cases. The hepatocyte nucleolar surface area was significantly increased in the HCC cases versus that in the HCV cases. This increase was associated with a significant increase in Ki-67-positive cells in the HCC cases compared to those in the other groups. Conversely, the mean number of CK 19-positive cells was significantly reduced in the HCC cases compared to the cell numbers in TFMs and HCV cases with severe hepatic fibrosis. Liver progenitor cells (LPCs) were discerned in the reactive ductules and canaliculo-ductular junctions that characterized TFMs. LPCs were sporadically distributed in the liver lobules and reactive bile ductules in the HCC samples. In conclusion, CK 19 represents an important marker for distinguishing between dysplastic and malignant liver nodules. Electron microscopic morphometric image analysis may be considered as adjunct factor for assessing hepatocyte malignant transformation. Wider scale studies are needed to authenticate these results.

P.127 Transplantation hépatique adulte à partir de donneur vivant : transfert de compétence et effet de la courbe d’apprentissage (étude à partir de 128 cas consécutifs)

Introduction La transplantation hepatique adulte a partir de donneur vivant (THDVA) est une alternative pour augmenter l’acces a la transplantation (et reduire la mortalite sur liste d’attente) ; elle est la seule modalite de transplantation dans certains pays, en particulier en Asie, Afrique ou au Moyen-Orient, ou le prelevement sur donneur cadaverique est impossible. Le but de cette etude etait de rapporter l’experience d’une procedure de transfert de competence depuis un centre francais vers un centre egyptien, en particulier l’importance de l’effet de courbe d’apprentissage. Patients et Methodes Entre decembre 1998 et decembre 2006, 128 THDVA ont ete realisees a Lyon (hopital Edouard Herriot) ou au Caire (Wady El-Neel Hospital). Les patients ont ete separes en 3 groupes : 1 (malades greffes a Lyon (formation initiale de l’equipe egyptienne), 2 (malades greffes au Caire par l’equipe francaise et transfert progressif a l’equipe egyptienne) et 3 (malades greffes au Caire par l’equipe egyptienne). Les patients de chaque groupe ont ete separes en 2 phases successives : A (phase initiale) et B (seconde phase). Ont ete compares les resultats des groupes 1A et 3A pour evaluer la faisabilite du transfert de competence, et les phases A aux phases B pour etudier l’effet de courbe d’apprentissage. Resultats La comparaison des groupes 1A et 1B mettait en evidence une reduction significative de la duree operatoire du donneur, du temps d’ischemie froide, des besoins transfusionnels du donneur et du receveur. De meme, le taux de complications post-operatoires chez le donneur etait significativement inferieur dans le groupe B : complications majeures (16 % vs 12,5 %), et complications mineures (36 % vs 25 %), ainsi que les complications post-operatoires chez le receveur : complications biliaires (28 % vs 8,3 %) et toutes complications (60 % vs 33 %) et la mortalite a 1 an (12 % vs 0 %). Les memes resultats etaient retrouves en comparant les groupes 3A et 3B. La comparaison des groupes 1A et 3A ne mettait pas en evidence de difference significative concernant les donnees peri-operatoires (duree operatoire du donneur, temps d’ischemie froide, besoins transfusionnels du donneur et du receveur), ni les complications post-operatoires du donneur et du receveur. Conclusion Nos resultats montrent que le transfert de competence en THDVA est faisable relativement rapidement, meme vers un centre n’ayant pas d’experience en transplantation a partir de donneur cadaverique, apres une phase d’apprentissage qui est la meme que dans un contexte de developpement de la THDVA dans un centre experimente en transplantation hepatique.