Arnaud Deroover

End of life care in the operating room for non-heart-beating donors: organization at the University Hospital of Liège.

Non-heart-beating (NHB) organ donation has become an alternative source to increase organ supply for transplantation. A NHB donation program was implemented in our institution in 2002. As in many institutions the end of life care of the NHB donor (NHBD) is terminated in the operating room (OR) to reduce warm ischemia time. Herein we have described the organization of end of life care for these patients in our institution, including the problems addressed, the solution proposed, and the remaining issues. Emphasis is given to our protocol elaborated with the different contributors of the chain of the NHB donation program. This protocol specifies the information mandatory in the medical records, the end of life care procedure, the determination of death, and the issue of organ preservation measures before NHBD death. The persisting malaise associated with NHB donation reported by OR nurses is finally documented using an anonymous questionnaire.

Contribution of Donors After Cardiac Death to the Deceased Donor Pool: 2002 to 2009 University of Liege Experience

OBJECTIVE In this study, we have evaluated the organ procurement and transplantation activity from donors after cardiac death (DCD) at our institution over an 8-year period. Our aim was to determine whether this program influenced transplantation programs, or donation after brain death (DBD) activity. METHODS We prospectively collected our procurement and transplantation statistics in a database for retrospective review. RESULTS We observed an increasing trend in potential and actual DCD number. The mean conversion rate turning potential into effective donors was 58.1%. DCD accounted for 16.6% of the deceased donor (DD) pool over 8 years. The mean age for effective DCD donors was 53.9 years (range, 3-79). Among the effective donors, 63.3% (n = 31) came from the transplant center and 36.7% (n = 18) were referred from collaborative hospitals. All donors were Maastricht III category. The number of kidney and liver transplants using DCD sources tended to increase. DCD kidney transplants represented 10.8% of the DD kidney pool and DCD liver transplants made up 13.9% of the DD liver pool over 8 years. The DBD program activity increased in the same time period. In 2009, 17 DCD and 33 DBD procurements were performed in a region with a little >1 million inhabitants. CONCLUSION The establishment of a DCD program in our institution enlarged the donor pool and did not compromise the development of the DBD program. In our experience, DCD are a valuable source for abdominal organ transplantation.

Prognostic value of (18)F-FDG PET/CT in liver transplantation for hepatocarcinoma.

AIM To evaluate the prognostic value of pretreatment FDG positron emission tomography computed tomography (PET-CT) in patients with hepatocarcinoma treated by liver transplantation (LT). METHODS The authors retrospectively analyzed the data of 27 patients (mean age 58 ± 9 years) who underwent FDG PET-CT before LT for hepatocarcinoma. Mean follow-up was 26 ± 18 mo. The FDG PET/CT was performed according to a standard clinical protocol: 4 MBqFDG/kg body weight, uptake 60 min, low-dose non-enhanced CT. The authors measured the SUVmax and SUVmean of the tumor and the normal liver. The tumor/liver activity ratios (RSUVmax and RSUVmean) were tested as prognostic factors and compared to the following conventional prognostic factors: MILAN, CLIP, OKUDA, TNM stage, alphafoetoprotein level, portal thrombosis, size of the largest nodule, tumor differentiation, microvascular invasion, underlying cirrhosis and liver function. RESULTS Overall and recurrence free survivals were 80.7% and 67.4% at 3 years, and 70.6% and 67.4% at 5 years, respectively. According to a multivariate Cox model, only FDG PET/CT RSUVmax predicted recurrence free survival. Even though the MILAN criteria alone were not predictive, it is worth noting that none of the patients outside the MILAN criteria and with RSUVmax < 1.15 relapsed. CONCLUSION FDG PET/CT with an RSUVmax cut-off value of 1.15 is a strong prognostic factor for recurrence and death in patients with HCC treated by LT in this retrospective series. Further prospective studies should test whether this metabolic index should be systematically included in the preoperative assessment.

SEVENTY-TWO HOURS HYPOTHERMIC INTESTINAL PRESERVATION STUDY USING A NEW PERFLUOROCARBON EMULSION

We investigated the effect of a perfluorocarbon emulsion (FC) added to the University of Wisconsin (UW) solution on hypothermic (4°C, 12–72h) preservation of rat small bowel grafts. The FC was 90%w/v perfluorooctylbromide, 2%w/v egg yolk phospholipids and 1.4%w/v mixed fluorocarbon-hydrocarbon molecular dowels. Four groups were defined: [1] UW flush and UW storage; [2] UW flush and FC storage; [3] flush with FC diluted 2 times with UW (FU) and FU storage; [4] FU flush and storage in oxygenated FU. Preservation was estimated with a histological score based on villus epithelium adhesion, on villus sloughing and on crypt cell adhesion to the basal membrane. Antioxidant potential was estimated by measurement of total thiol functions (SH) and activities of glutathione-peroxidase (GSH-P), superoxide dismutase (SOD) and catalase. FC in flush improved preservation during the first 24h (p<0.01). Storage in FC appeared superior to UW for the first 24h (p<0.01). Oxygenation (100% O2) of the storage medium yielded superior results at 12h and 24h (p<0.01 and p<0.001 versus group [1] respectively). After 72h, SOD and catalase activities increased in groups [3] and [4], and SOD decreased in group [1] (p<0.05). SH progressively decreased in group [1] (p<0.05) and GSH-P increased at 24 and 48h in groups [3] and [4] (p<0.01). The increase of O2 in the perfusion flush or storage medium ameliorated the preservation status and protected the antioxidant potential of the small bowel.

Liver transplantation for acute hepatic failure due to chemotherapy-induced HBV reactivation in lymphoma patients

Hepatitis B (HBV) reactivation induced by chemotherapy is problem encountered recently in the management of malignant diseases. Chemotherapy-induced HBV reactivation may ultimately lead to terminal acute liver failure. Liver transplantation (LT) currently remains the only definitive treatment option for such cases, but is generally denied to patients suffering from malignancy. Here, the authors describe 2 cases of cancer-free and HBV graft re-infection-free survival after LT performed for terminal liver failure arising from HBV reactivation induced by chemotherapy for advanced stage lymphoma. These 2 cases, and some other reports in the literature, may suggest that patients suffering from hematologic malignancies and terminal liver disease can be considered for LT if the prognosis of their hematologic malignancy is good.

Liver transplantation for hepatic trauma: Discussion about a case and its management

Liver transplant for trauma is a rare condition with 19 cases described in the literature. We report the case of a 16-year-old patient who suffered a gradeV liver injury with a vena cava tear after a car crash. After a computerized tomography (CT) scan, the patient was directly sent to the operating room where the surgeon performed a right hepatectomy extended to segment IV with a venous repair under discontinued hilar clamping. On day five, the patient developed acute liver failure and was put on an emergency transplant waiting list. He had a successful liver transplant 2 days later. Fifteen months after his transplant, the patient is alive and asymptomatic. This case report focuses on the patient’s initial management, the importance of damage control surgery and the circumstances which finally led to the transplant.

Evolution of native kidney function after pancreas transplantation alone.

INTRODUCTION This study investigated changes in kidney function over time among a cohort of patients undergoing pancreas transplantation alone (PTA) from January 2002 to December 2011. PATIENTS AND METHODS Ten of eighteen PTA patients bearing functioning grafts for at least 1 year were recruited for the analysis. Primary endpoints were changes in mean serum creatinine (SCr, mg/L) and mean estimated glomerular filtration rate (eGFR) using the 4-variable Levey-MDRD equation (mL/min/1.73 m(2)) comparing baseline (pretransplantation) to 6-month, 1-year, 3-year, and 5-year posttransplantation values. Mean follow-up time was 75.7 ± 20.5 months (range, 46-106.5). RESULTS Baseline eGFR was 89.3 ± 27.9 (range, 58-145). eGFR decreased to 75.7 ± 26.2, 71 ± 20.6, 66.5 ± 14.8, and 62.1 ± 11.2 at 6 months, 1, 3, and 5 years representing -15.2%, -20.5%, -15.8%, and -22.6% percentage decreases respectively (P < .05 for all pairwise comparisons). The Baseline SCr was 8.6 ± 2.3 mg/L (range, 5-13). SCr progressively increased to 10.1 ± 3, 10.5 ± 3.1, 10.9 ± 3.1, and 11.3 ± 1.7 at 6 months, 1, 3, and 5 years a 17.1%, 22%, 16.6%, and 19.9% increase respectively (P < .05 for all pairwise comparisons). One of ten, 2/8, and 3/7 patients displayed an eGFR <60 at transplantation versus 3 and 5 years thereafter, respectively. No patient developed a SCr > 25 mg/L or eGFR <30 or needed dialysis or kidney transplantation. Five of ten patients had micro-albuminuria or proteinuria before transplantation. Tacrolimus levels were within recommended therapeutic ranges over time. CONCLUSION Kidney function deteriorated significantly after PTA. Understanding of risk factors for the development of renal impairment is important to preserve kidney function and to select appropriate candidates for PTA.

Multicenter Belgian survey on donor morbidity and mortality in adult-to-adult living donor liver transplantation

O-098 – Table 1. LTx in patients with incidental PPHT Indication labMELD mPAP at induction (mmHg) hospital stay (days) Medical treatment post-LTx Outcome Follow-up (months) m/54yr Post-ethyl cirrhosis 32 44 38 Spontaneous resolution Alive and well 15 f/37yr Post-ethyl cirrhosis 26 26 40.6 42 Epoprostenol IV during 13 months Alive and well 13 f/62yr HBV 31 46.7 92 Sildenafil PO during 9 months Alive and well 12 m/61yr Post-ethyl cirrhosis and HCC 12 36.7 6 Extra-corporeal membrane oxygenation †6d post-LTx – f/67yr Sarcoidosis 36 34.3 – Aborted LTx †1d post-LTx – f/54yr Post-ethyl cirrhosis 24 35.3 22 Spontaneous resolution Alive and well 16 f/53yr Postethyl + HBV cirrhosis 19 37.3 19 Spontaneous resolution Alive and well 55 f/53yr PBC 17 51.7 58 Sildenafil PO Alive and well 6 m/42yr HCV 17 53.3 – Listed for combined heart/lung/LTx Alive and well 120 Eleven (9.9%) patients did not even achieve 65% of the predicted target heart rate, and notably all of them were on β-blockers. Thirty (73.1%) of 41 patients who achieved the target heart rate had MELD score ≤15 compared with 11 (26.9%) patients with MELD score > 15 (p < 0.05). Conclusions: Chronotropic incompetence on DSE is frequent in patients with ESLD. In absence of any cardiac symptoms or/and ECG findings during DSE, a lower cut-off for target heart rate may be acceptable when patients are on βblockers or/and MELD score >25 to avoid unnecessary further investigations. Large prospective studies are needed to support these findings. O-098 INCIDENTAL PORTOPULMONARY HYPERTENSION DISCOVERED AT THE START OF LIVER TRANSPLANTATION, “TO GO AHEAD OR TO LET GO...” Filip Gryspeerdt, Marion Dupont, Wim Laleman, Raymond Aerts, Dieter Mesotten, Geert Meyfroidt, Marleen Verhaegen, Arne Neyrinck, Frederik Nevens, Jacques Pirenne, Diethard Monbaliu. Leuven liver Transplant Team, University Hospitals Leuven, Leuven, Belgium Background: Portopulmonary hypertension (PPHT) is the association of pulmonary hypertension (mean pulmonary artery pressure [mPAP] >25 mmHg) and portal hypertension with or without chronic liver disease. Moderate PPHT (mPAP >35 mmHg) is associated with higher morbidity/mortality and severe PPHT (mPAP> 45mmHg) is generally considered a contra-indication for Liver Transplantation (LTx). Moderate to severe PPHT may develop during the waiting time of LTx period. A retrospective analysis was done to review the shortterm outcome of LTx in patients with incidental PPHT (e.g. diagnosed at the start of LTx and unkown at time of listing). Methods: All medical records of patients with incidental PPHT were reviewed. Lab-MELD at time of LTx, mPAP immediately pre-LTx, post-LTx hospital stay, type/length of post-LTx medical treatment for PPHT and patient survival were analyzed (see Table 1). Results: Between 2000-2011, 9/653 patients were diagnosed with moderate to severe PPHT at time of LTx induction. LTx was pursued in 7 patients. Of those, 6 had uneventful post-LTx recovery with spontaneous or medically assisted (vasodilators) resolution of PPHT; and 1 succumbed to complications of extra-corporeal membrane oxygenation. LTx was started but aborted in 1 due to hemodynamic unstability. LTx was not started in 1 who later received combined heart/lung/LTx. Conclusion: The incidental discovery of a previously unknown moderate to severe PPHT at the start of LTX is a possibility that LTx teams should be aware of. PPHT has usually been seen as a contra-indication for LTx. However, favorable outcome in 6/7 recipients suggests that LTx should not necessarily be aborted in case of incidental PPHT. 28 Oral Sessions Oral Session 13: Liver / intestine miscellaneous O-099 LIVER INMUNOPROTECTIVE EFFECT ON THE KIDNEY ALLOGRAFT IN SIMULTANEOUS LIVER AND KIDNEY TRANSPLANTATION Nuria N. Esforzado 1, Ana Yurena A.Y. Sánchez 1, José Vicente J.V. Torregosa 1, Nuria N. Serra 1, Rafael R. Pascualin 1, Jaume J. Martorell 2 , Federico F. Oppenheimer 1 , Josep Maria J.M. Campistol 1 . 1Renal Transplant Unit, 2Inmunology Unit, Hospital Clinic, Barcelona, Spain Background: Simultaneous liver-kidney transplantation (SLK) has less incidence of renal graft rejection and inmunological graft lost against the receptors of an isolated renal transplantation (RT). In addition, a low rejection incidence and a good renal graft evolution have ben reported in cross-match (CM) positive (+) SLK patients. The low prevalence of immunological complications in high-risk immune (“HRI”) SLK patients, suggests a liver’s inmunoprotective effect on the kidney graft. Material and methods: We present our experience in “HRI” SLK patients, defined as CM by cytotoxicity (CDC) post DTT + and/or “HRI” + pre transplantion (Tx). From May 1993 until December 2010, 58 SLK Tx were made (27 retransplanted patients), and eight patients had CM + pre Tx and other four patients had negative CM but positive “HRI”. Results: Of 12 “HRI” patients, 3 (25%) patients had graft dysfunction related to humoral acute rejection (HAR) during the first month after SLK Tx. Only one of these patients (33%) received Apheresis and Rituximab treatment with a good response. In the other two patients, HAR was resolved without specific treatment. None of 12 patients after 45±40 months follow-up, loss graft related to inmunological etiology. Six of 8 CM + pre Tx patients became negative post Tx. Conclusion: High-risk inmune SLK patients have a low prevalence of immunological complications which suggests an inmunoprotector role of the liver on the kidney allograft in these patients. O-100 EVOLUTION OF KIDNEY FUNCTION AFTER LIVER TRANSPLANTATION FOR ADULT POLYCYSTIC LIVER DISEASE AND INDICATIONS FOR COMBINED LIVER AND KIDNEY TRANSPLANTATION Tom Darius 1, Alexander Patris 1, Ziad Hassoun 1, Diethard Monbaliu 2, Tania Roskams 2, Olga Ciccarelli 1, Yves Pirson 1, Yves Vanrenterghem 2 , Frederik Nevens 2, Jacques Pirenne 2, Jan Lerut 1 . 1Abdominal Transplant Unit, University Hospitals Saint Luc, Brussels, Belgium; 2Liver Transplant programme, University Hospitals Gasthuisberg, Leuven, Belgium Background: Adult polycystic liver disease (PLD) is frequently associated with autosomal dominant polycystic kidney disease (ADPKD). Established indication for combined liver and kidney transplantation (CLKTx) is end stage renal failure. If renal insufficiency is less advanced, indications for combined kidney transplantation (KTx) are controversial. We reviewed our experience with isolated liver transplantation (LTx) and CLKTx in patients with PLD. Methods: Between 1995-2008, 56 patients originating from 2 collaborating centers underwent LTx for PLD. 7 patients with isolated PLD received LTx alone. Of 49 patients with combined PLD and ADPKD, 31 underwent isolated LTx and 18 CLKTx. Among the 18 CLKTx recipients, 11 were dialysisdependent pre-transplant whereas 7 had a creatinine clearance (CrCl) between 15 and 38 mL/min. Results: Median follow up is 34 months (range, 26-167). 1 and 5-year patient and liver graft survival were 96% and 94%, and 96% and 90%, respectively. The 1 and 5-year kidney graft survival (death censored) is 100%. Of the 31 patients who underwent isolated LTx for combined PLD and ADPKD, 29% (n=9) developed terminal renal failure post-LTx. Their mean pre-LTx CrCl was 76 mL/min (range, 48-110). The mean pre-LTx CrCl in the 71% patients who display stable kidney function post-LTx was 78 mL/min (range, 47-153). Pre-LTx CrCl was not a significant factor for the development of renal failure after isolated LTx for combined PLD and ADPKD (p=0,835). Conclusion: This series demonstrates that short& long-term survival after LTx and CLKTx for PLD is excellent. In patients with clearly-proven & evolving renal impairment pre-transplant, CLKTx is the preferred option, anticipating the need for later KTx. In patients with preserved/mildly disturbed renal function, nephron sparing strategies are essential since evolution towards renal failure is seen in 29%, without clear prognosis factors. O-101 LIVER TRANSPLANTATION (LTx) FOR TRANSTHYRETIN SYSTEMIC AMYLOIDOSIS DISORDERS: ANALYSIS FROM THE FAMILIAL AMYLOIDOTIC POLYNEUROPATHY WORLD TRANSPLANT REGISTER (FAPWTR) Bo-Göran Ericzon. Transplantation Surgery, Karolinska Institutet, Stockholm, Sweden Background: Transthyretin (TTR) systemic amyloidosis disorders are treatable with Ltx. The FAPWTR was established in 1993 to assemble data on such patients. Methods/Results: By December 2009, 1798 patients/1953 liver transplantations were reported to the FAPWTR from 72 centers in 19 different countries. Most transplantations were done in Portugal (n=866), France (n=216), Sweden (n=130) and Brazil (n=91). More than 45 different TTR-variants have been reported, the commonest being Val30Met (85%) followed by Ser77Tyr, Thr60Ala and Tyr114Cys. Gastrointestinal, cardiovascular and extraneurological manifestations appear more often in non-Val30Met than in Val30Met patients. 15% of the non-Val30Met patients underwent liver and heart transplantation compared to 0.1% of the Val30Met patients. Different countries show varying age at onset in Val30Met patients, with Brazil having the youngest patients and Sweden the oldest (32 years and 45 years, respectively). After Ltx, 80-90% of the ValMet30 patients reported stable or improved clinical symptoms compared to 60-65% in non-Val30Met patients. The overall 5-, 10and 15-year patient survival is 79%, 70% and 64%, respectively. Most common cause of death is cardiac. Val30Met patients with a disease duration >7 years disclose inferior 5-year survival than patients with a duration ≤7 years (58.2% and 84.7%, respectively p<0.001). Results improve when analyzing patients transplanted in the last 5 years, but the 5-year survival still remains significantly better in patients with less than 7 years disease duration (72.1% and 88.7%, respectively p<0.05). Conclusion: LTx is lifesaving in patients with TTR amyloidosis. Val30Met and non-Val30Met TTR mutations differ clinically. Cardiac related post transplant death i

Transplantation of a liver graft from a living donor with early gastric cancer.

We read with great interest the article of Fujiwara et al., published in the March issue of this journal (1). This case report described the life-saving liver transplantation of a 9-month-old Japanese baby with a partial liver graft from the only potential parental living donor, who was diagnosed with early gastric cancer during the pre-donation work-up. Curative partial gastrectomy was performed just before partial liver retrieval, during the same anesthesia. Both the donor and the recipient were reported alive and well at 1-year follow-up. We believe that this interesting case might raise several important issues and might deserve some comments.