Junichi Togashi

Recurrence of primary sclerosing cholangitis after living donor liver transplantation

Background/aims: Cumulative experience in deceased donor liver transplantation for end‐stage liver disease due to primary sclerosing cholangitis (PSC) suggests that liver transplantation is the treatment of choice with excellent results. Reports on the outcome of live donor liver transplantation (LDLT) for PSC, however, remain anecdotal.

Bloodstream infection after living donor liver transplantation

There are no detailed studies on the prevalence or clinical magnitude of bloodstream infection (BSI) following living donor liver transplantation (LDLT). The study aimed to assess the incidence and analyze the risk factors for BSI after LDLT. Univariate and multivariate analyses were performed to identify the independent risk factors for postoperative BSI. Postoperatively, 26 episodes of BSI occurred in 21 of 242 studied adult patients by median postoperative d 35. Five patients had primary BSI. The source was unknown in 3 patients and an intravascular catheter in 2. The other 16 patients had secondary BSI. Secondary BSI was caused by surgical site infection in 8 patients, followed by intra-abdominal infection in 5, pneumonia in 2, and both surgical site infection and intra-abdominal infection in 1. The most frequent pathogen isolated was MRSA, which was detected in 4 patients. Surveillance culture detected the same isolates prior to BSI in 14 of 26 (50%) episodes. Diabetes mellitus and serum albumin level less than 2.4 g/dl independently predicted postoperative BSI. Perioperatively, screening for and taking actions against pathogen including MRSA should be performed in LDLT patients.

Portal vein complications after adult-to-adult living donor liver transplantation

Successful management of portal vein (PV) complications after liver transplantation is crucial to long‐term success. Little information is available, however, regarding the incidence and treatment of PV complications after adult‐to‐adult living donor liver transplantation (LDLT). Between January 1996 and October 2006, 310 adult LDLTs were performed at our institution. PV thrombus was present in 54 patients at the time of LDLT. The incidence of PV complications, choice of therapeutic intervention, and outcomes were retrospectively analyzed. Among the 310 recipients, PV complications were identified in 28 (9%). Risk factors included smaller graft size, presence of PV thrombus at the time of LDLT, and use of jump or interposition cryo‐preserved vein grafts for PV reconstruction. When divided into early (within 3 months, n = 11) and late (after 3 months, n = 17) complications, the use of vein grafts for PV reconstruction predisposed to the occurrence of late, but not early, PV complications. Portal vein thrombosis occurred more frequently in the early period (eight out of 11, 73%), whereas stenosis occurred more frequently in the later period (14 out of 17, 82%). Surgical interventions were favored in the earlier period, whereas interventional radiologic approaches were selected for later events. Overall 3‐ and 5‐year survival rates were 81% and 77%, respectively, in patients with PV complications and 88% and 84%, respectively, in those without PV complications (P = 0.21, log‐rank test). PV complications are a significant problem following LDLT with both early and late manifestations. Acceptable long‐term results, however, are achievable with periodic ultrasonographic surveillance and timely conventional therapeutic interventions. The use of cryo‐preserved vein grafts for reconstructing portal flow should be discouraged.

Coagulation and fibrinolytic profiles and appropriate use of heparin after living-donor liver transplantation.

Abstract:  Heparin is widely used to reduce the incidence of vascular thrombosis after liver transplantation. Appropriate use of heparin based on changes in coagulation and fibrinolytic profiles, however, has not yet been discussed in detail. We performed living‐donor liver transplantation for 128 adult patients. In this series, dalteparin (25 IU/kg/d) was administered until post‐operative day (POD) 2. On POD 3, the anticoagulant drug was changed to heparin (unfractionated heparin sodium, 5000 U/d), the dose of which was changed according to the level of activated clotting time (ACT) targeted between 130 and 160 s. The plasma level of plasmin‐alpha2 plasmin inhibitor complex, thrombin‐antithrombin III complex (TAT), and fibrin degradation product D‐dimer (FDP‐DD) were monitored in the 21 patients. Predictors for heparin doses were analyzed among clinical parameters (n = 128). Four patients (3%) were complicated with thrombosis despite the above‐mentioned anticoagulation protocol. Transfusion and/or relaparotomy for hemostasis were necessary for bleeding in 19 patients (15%). The TAT level markedly elevated until POD 3 and FDP‐DD peaked later. The required heparin dose to maintain adequate ACT levels increased linearly until POD 8, and kept constant thereafter, which correlated with the weight of the liver graft (p = 0.01). Thus, frequent monitoring of the heparin dosage is necessary to keep the ACT level in the target range in the first post‐operative week. High hemorrhage complications in our series indicate that the lower target ACT range may be preferable in the second post‐operative week.

Prevention of renal impairment by continuous infusion of human atrial natriuretic peptide after liver transplantation

Background. Acute renal failure occurring immediately after liver transplantation and requiring hemodialysis is a major problem resulting in a poor prognosis. We investigated the efficacy of human atrial natriuretic peptide, which has potent natriuretic effects and unique protective effects for glomeruli in preventing acute renal failure after liver transplantation. Methods. Thirty-seven patients who underwent live donor liver transplantation with model for end-stage liver disease scores greater than 15 were the subjects of the study. Subjects were prospectively randomized into two groups: patients that received synthetic human atrial natriuretic peptide infusion (Group H: n=19) and those that received conventional diuretics, furosemide and potassium canrenoate (Group C: n=18). The peri- and postoperative changes in hemodynamic status and renal function were compared between the two groups. Results. There were no statistical differences in the changes in hemodynamic status between groups. Hemodialysis was required after liver transplantation in nine patients, two in Group H and seven in Group C (P=0.04). Postoperative creatinine clearance was higher in Group H (P=0.03). Aldosterone level was suppressed in group H (P=0.006). Conclusions. Continuous infusion of synthetic human atrial natriuretic peptide might be effective for preventing acute renal failure requiring hemodialysis after liver transplantation.

Living donor liver transplantation for fulminant hepatic failure.

Aim:  The aim of this study was to investigate the safety of living donor liver transplantation (LDLT) for fulminant hepatic failure (FHF) patients.

Incidence and management of biliary complications after adult-to-adult living donor liver transplantation

Kyoden Y, Tamura S, Sugawara Y, Matsui Y, Togashi J, Kaneko J, Kokudo N, Makuuchi M. Incidence and management of biliary complications after adult‐to‐adult living donor liver transplantation.
Clin Transplant 2010: 24: 535–542.
© 2009 John Wiley & Sons A/S.

Noninvasive estimation of hepatic steatosis in living liver donors: usefulness of visceral fat area measurement.

Background. Hepatic steatosis in the donor liver is associated with an increased risk of complications after liver transplantation. Mandatory liver biopsy for all potential donors, however, remains controversial. To define clinico-pathological correlation, we reviewed our criteria for liver biopsy and examined the use of visceral fat area (VFA) estimation by computed tomography image. Methods. Our criteria for biopsy are as follows: an aspartate aminotransferase/alanine aminotransferase ratio of less than 1, a body mass index more than or equal to 25 kg/m2, and a suspected fatty liver on ultrasonography. Dietary intervention is indicated for overweight donor candidates and for those with more than 10% hepatic steatosis. Clinical data of consecutive 78 potential donors who underwent percutaneous liver biopsy (biopsy group) and 70 donors whose biopsy were omitted (control group) were reviewed. Results. Donors in biopsy group were male dominant with a median age of 35 (20–63) years. Hepatic steatosis more than or equal to 10% was seen in nine of 78 donors; older age (P=0.012), ultrasonographic findings (P=0.002), VFA (P=0.008), and percent VFA (VFA/[VFA+subcutaneous fat area]; P=0.009) were associated with more than 10% hepatic steatosis. The area under the receiver operating characteristics curve of VFA and percent VFA for detecting hepatic steatosis more than or equal to 10% were 0.803 and 0.778, respectively. Hepatic steatosis was successfully reduced to less than 10% through dietary intervention in six of the nine donor candidates. Conclusions. Our current biopsy criteria are acceptable to select donor candidates at risk for hepatic steatosis. Visceral fat measurement can be used as an additional factor to narrow donors at risk and to monitor visceral fat reduction during dietary intervention.

Outcome of living donor liver transplantation for post‐Kasai biliary atresia in adults

Previous reports described the effectiveness of living donor liver transplantation (LDLT) for post‐Kasai biliary atresia (BA) in the pediatric population. Information on the outcome of LDLT in patients that have reached adulthood after the Kasai procedure, however, is limited. A recent report postulated a poorer long‐term outcome of LDLT in these adults. We reviewed our experience to evaluate the validity of this hypothesis. Between January 1996 and October 2006, 385 LDLTs were performed at our institution. There were 80 post‐Kasai BA cases in the series; 60 (75%) were pediatric, and 20 (25%) were adults. There were no ABO blood type–incompatible cases. None were complicated with severe hepatopulmonary syndrome, portopulmonary hypertension, or hepatocellular carcinoma. The 5‐year overall survival rates were 90% for the adults and 90% for the children (P > 0.99). The median follow‐up period was 7 years in the adults and 11 years in the children. There was no donor mortality. The outcome of LDLT in adult post‐Kasai BA patients in the present series was satisfactory; that is, adult and pediatric patient survival rates were not different. This finding suggests that for post‐Kasai BA patients without serious comorbidity at the time of transplantation, LDLT can be performed safely in all age groups. Liver Transpl 14:186–192, 2008.

Positive Lymphocytotoxic Crossmatch Does Not Adversely Affect Survival in Living Donor Liver Transplantation

Background/Aims: The influence of lymphocytotoxic crossmatch on survival or acute rejection in liver transplantation remains controversial. Data regarding graft survival and acute rejection of living donor liver transplantation (LDLT) are limited. Methods: We retrospectively examined the influence of a positive T or B lymphocytotoxic crossmatch on survival and acute rejection in patients using a database of 414 consecutive LDLT cases. Results: The rejection-free rate at 90 days after LDLT was lower in patients that were T crossmatch-positive compared to patients that were both T and B crossmatch-negative (52 vs. 74%, p = 0.03). No patients with a positive lymphocytotoxic crossmatch died due to immunologic causes. The crossmatch results had no effect on graft survival. Conclusion: In the positive crossmatch groups, there was no acute rejection that was untreatable or that caused graft loss. These findings indicate that a positive crossmatch graft should not be considered a contraindication for LDLT.