H. Bohorquez

Interpreting outcomes in DCDD liver transplantation: First report of the multicenter IDOL consortium

Background In the United States, 5% of adult liver transplant recipients receive a graft donation after circulatory determination of death (DCDD). Concerns for ischemic cholangiopathy (IC), a disease of diffuse intrahepatic stricturing limits broader DCDD use. Single-center reports demonstrate large variation in outcomes. Methods Retrospective deidentified data collected between 2005 and 2013 were entered electronically by 10 centers via a Research Electronic Data Capture database. Our primary outcome was development of intrahepatic biliary strictures consistent with IC. Results Within 6 months post-DCDD transplant, 162 (21.8%) patients developed a biliary stricture, of which 88 (11.8%) exhibited intrahepatic structuring consistent with IC. Unadjusted 6-month IC rate among the 10 centers varied significantly (P = 0.006) from 6.3% to 25.9%. The only factor associated with increased risk of IC within 6 months was Roux-en-Y hepaticojejunostomy (vs duct-to-duct) (odds ratio, 3.06; 95% confidence interval, 1.52-6.16; P = 0.002). Graft failure by 6 months was more than 3 times higher for DCDD recipients with IC (odds ratio for IC, 3.36; 95% confidence interval, 1.95-5.79). Conclusions This first report of the large combined experience with DCDD from the Improving DCDD Outcomes in Liver Transplant consortium demonstrates significant differences in IC among centers, the importance of biliary strictures as a risk factor for graft failure, and does not validate other risk factors for IC found in smaller studies.

Excellent liver retransplantation outcomes in hepatitis C-infected recipients

Survival outcomes for liver retransplantation (LRTx) after graft loss in HCV patients (HCV‐LRTx) are generally considered inferior to those after non‐HCV‐LRTx. Between January 1, 2005 and June 30, 2011, our center performed 663 LTx, including 116 (17.5%) LRTx, 41 (35.3%) of which were more than 90 d after the LTx. Twenty‐nine (70.7%) LRTx were performed in HCV antibody–positive individuals. We compared patient demographics, baseline characteristics and outcomes of our HCV‐LRTx group with the HCV‐LRTx patients from the most recent OPTN database covering the same time period. Our Kaplan–Meier HCV‐LRTx one‐, three‐, and five‐yr HCV‐LRTx patient survival rates were 86.2%, 79.0%, and 72.4%, respectively compared with the OPTN one‐, three‐, and five‐yr HCV‐LRTx survival rates of 73.3%, 59.0%, and 51.3% respectively. Likewise, our graft survival rates were higher than OPTN rates at all time points studied. We performed a higher percentage of HCV‐LRTx as simultaneous liver/kidney transplants (SLK) (37.9% vs. 21.8%) and recorded shorter warm (30 ± 4 vs. 45 ± 23 min) and cold ischemic times (5:44 ± 1:53 vs. 7:36 ± 3:12 h:min). Conclusion: In our experience, HCV‐LRTx patient and graft survival rates are comparable to LTx survival rates and are higher than the rates described by OPTN.

Outcomes Utilizing Imported Liver Grafts for Recipients with Hepatocellular Carcinoma.

Liver transplantation (LT) offers the best chance of survival in selected patients with hepatocellular carcinoma (HCC). Wait‐list mortality or dropout due to tumor progression can be significant, and therefore, timely transplantation is critical. Liver grafts discarded by outside organ procurement organizations are a potential source of grafts for low Model for End‐Stage Liver Disease tumor patients. The primary aim of this study was to assess the disease‐free and overall survival of patients with HCC transplanted with imported liver grafts (ILGs). Review of all patients transplanted for HCC between June 2005 and December 2014 was performed. Data on demographics, survival, and HCC recurrence were analyzed. During this time period, 59 out of 190 (31%) recipients with HCC received ILG. Of these 59 grafts, 54 were imported from within the region and 5 were from national offers (outside the region). The mean cold ischemia time for local liver grafts (LLGs) was 4.1u2009±u20091.5 hours versus 5.1u2009±u20091.4 hours for ILG (Pu2009<u20090.001). The 1‐, 3‐, and 5‐year patient survival was 90%, 85%, and 83% and 85%, 80%, and 79% for LLG and ILG (Pu2009=u20090.08), respectively. The observed disease recurrence rate for both LLG and ILG recipients was equivalent. The median wait‐list time for HCC recipients was 43 days (range, 2‐1167 days). In conclusion, with careful graft assessment, the use of ILGs results in comparable outcomes following LT and no increased risk of HCC recurrence. Use of ILGs maximizes the donor pool and results in a higher rate of transplantation for HCC recipients. Liver Transplantation 23 299–304 2017 AASLD.

Which Is the Better Predictor of Hepatic Reserve Prior to Liver Resection: MELD or the Child-Pugh Score?

Critical assessment of the hepatic reserve is essential prior to liver resection especially in patients with chronic liver disease. Development of liver dysfunction post resection can result in a significant increase in associated complications resulting in prolonged length of hospital stay and increased hospital costs. In addition, the development of liver failure is almost universally fatal unless the patient can undergo liver transplantation. Several scoring systems have been identified which assess the degree of liver disease including the Child-Turcotte-Pugh scoring system (CTP) and the Model for End Stage Liver Disease (MELD). Both of these scoring systems have been used to predict mortality post liver resection. Based on the current available literature, MELD appears to be the best predictor of postoperative liver dysfunction/failure in patients with cirrhosis, and patients with MELD scores ≥9 should not be considered for hepatic resection. Other factors not included in MELD such as platelet count, presence of portal hypertension, extent of liver resection (and the resulting residual liver volume) and the presence of ascites should also be considered when selecting patients with chronic liver disease to undergo liver resection.

Using on-site liver 3-D reconstruction and volumetric calculations in split liver transplantation

BACKGROUNDnSplit liver transplantation increases the number of grafts available for transplantation. Pre-recovery assessment of liver graft volume is essential for selecting suitable recipients. The purpose of this study was to determine the ability and feasibility of constructing a 3-D model to aid in surgical planning and to predict graft weight prior to an in situ division of the donor liver.nnnMETHODSnOver 11 months, 3-D volumetric reconstruction of 4 deceased donors was performed using Pathfinder Scout© liver volumetric software. Demographic, laboratory, operative, perioperative and survival data for these patients along with donor demographic data were collected prospectively and analyzed retrospectively.nnnRESULTSnThe average predicted weight of the grafts from the adult donors obtained from an in situ split procedure were 1130 g (930-1458 g) for the extended right lobe donors and 312 g (222-396 g) for left lateral segment grafts. Actual adult graft weight was 92% of the predicted weight for both the extended right grafts and the left lateral segment grafts. The predicted and actual graft weights for the pediatric donors were 176 g and 210 g for the left lateral segment grafts and 308 g and 280 g for the extended right lobe grafts, respectively. All grafts were transplanted except for the right lobe from the pediatric donors due to the small graft weight.nnnCONCLUSIONSnOn-site volumetric assessment of donors provides useful information for the planning of an in situ split and for selection of recipients. This information may expand the donor pool to recipients previously felt to be unsuitable due to donor and/or recipient weight.