K. Zieniewicz

Vascular complications after liver transplantation

Vascular complications following liver transplantation is reviewed based upon literature data and our own results. Our study conclusions are mostly based on literature data, because our center does not have the liver transplantation experience of other centers worldwide. Thus, we may conclude, that the number and character of complications does not differ from those reported by other centers. The enbloc technique used in liver harvesting minimizes the risk of arterial damage in case of vascular anomalies. Recipient retransplantation is the most effective treatment method in cases of hepatic arterial occlusion. Doppler ultrasound examinations are effective to monitor vascular blood flow in the transplanted liver.

Biliary tract complications following liver transplantation

INTRODUCTION Biliary tract complications, which occur in 5.8% to 24.5% of adult liver transplant recipients, remain one of the most common problems following transplantation. The aim of this study was to evaluate these problems and analyze methods of treatment. MATERIAL AND METHODS From 1989 to 2003, 36 (18.7%) among 193 patients who underwent orthotopic liver transplantations in our center developed biliary complications. Biliary strictures that developed in 18 cases (9.3%) were the most common complications. Clinical manifestations of strictures developed at 2 to 24 months after transplantation. Bile leaks occurred in 10 patients (5.2%), and were diagnosed in along the T-tube 4 cases and was not accompanied by any clinical manifestation. Bile leak to the peritoneum after T-tube removal occurred in 2 patients (1.1%). Solitary gallstone formation in one case (0.5%) was removed with the use of ECPW. One patient required retransplantation within 3 months after transplantation, because of the most severe complication-ischemic necrosis of biliary tract. RESULTS Uneventful recovery was achieved in 34 patients in the analyzed group (94.4%). There was no case of recurrence during outpatient follow up. Two patients died in late follow-up of unrelated causes: namely, gastrointestinal bleeding due to a duodenal ulcer and multi-organ failure (MOF) due to a third severe episode of acute liver transplant rejection. CONCLUSIONS Biliary complications remain an important problem in liver transplantation. Endoscopic and radiologic management are effective in the majority of cases. Surgical intervention is obligatory in selected cases.

Renal function after liver transplantation: calcineurin inhibitor nephrotoxicity

Renal failure, mainly due to calcineurin inhibitor (CNI) nephrotoxicity, is the most common complication following orthotopic liver transplantation (ltx). The aim of this study was to evaluate the incidence and course of renal failure in adult ltx patients. Severe acute renal failure in early postoperative period due to impaired hemodynamics and CNI nephrotoxicity, occurred in 14 patients, 3 of whom required dialysis. The creatinine clearance after ltx showed a tendency to decrease, but there was no statistically significant difference (P >.05) in the change in serum creatinine clearance levels between patients treated with tacrolimus (TAC) versus Cyclosporine (CsA) during the first 2 years of follow-up. Fourteen patients required conversion of their regimen because of CNI nephrotoxicity namely, dose reduction (n = 7) or discontinuation of CNI therapy with the replacement by mycophenolate mofetil (MMF) (n = 5) or SRL (n = 5). Dose reduction or CNI withdrawal significantly improved the creatinine clearance (P <.05) without affecting lives graft function. No episode of acute rejection was observed after conversion. Neither conversion of CsA to TAC nor the reverse maneuver significantly influenced the serum creatinine level (P >.05). Reduction of the CNI dose or CNI discontinuation or replacement with MMF or SRL in patients with stable liver but impaired renal function is safe, resulting in a significant improvement in renal function.

Results of treatment of acute liver failure patients with use of the prometheus FPSA system.

OBJECTIVE Herein we have presented the results of treatment of acute liver failure (ALF) patients with the use of the Prometheus FPSA dialysis system. MATERIALS AND METHODS To January 2009, we performed 278 FPSA procedures in 114 patients, including 52 experience and ALF. The patients who underwent the FPSA procedure consisted of 32 women and 20 men of overall mean age of 33 +/- 12 years. The causes of ALF were: Wilsons disease (n = 15), unknown origin ALF (n = 11), amanita phalloides intoxication (n = 7), paracetamol intoxication (n = 8), acute hepatitis B virus (HBV)/hepatitis C virus (HCV) infection (n = 7), liver insufficiency after parenchymal resection (n = 2) drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome (n = 1), rabdomyolysis (n = 1), or primary nonfunction (PNF) after orthotopic liver transplantation (OLT) (n = 1). All procedures were performed using the Prometheus 4008H Fresenius Medical Care liver support system. The average number of treatments per patient was 2.41 and the average time for each FPSA treatment was 6.3 hours. The average heparin dose used during the procedure was 750 IU/h. RESULTS After the whole treatment regimen, we observed significant improvements in the biochemical results. The average concentrations improved: serum ammonia (before 249.2 mug/dL versus after 109.7 mug/dL); serum bilirubin (before 21.53 mg/dL versus after 8.81 mg/dL), serum aspartate aminotransferase (AST; before 2456.4 U/L versus after 1068.8 U/L); serum alanine aminotransferase (ALT; before 2958.2 U/L versus after 1595.8 U/L); serum urea (before 58.5 mg/dL versus after 21.1 mg/dL); serum creatinine (before 2.9 mg/dL versus after 1.7 mg/dL); and pH value (before 7.11 versus after 7.32). After Prometheus treatment OLT was performed in 33 patients. Among the 28 who survived (53.8%), 22 underwent OLT and 6 did not have OLT. Among the 24 patients who died (46.2%), 13 were before OLT and 11 after OLT. CONCLUSION The Prometheus 4008H Fresenius Medical Care Liver support system was useful method of detoxification for patients with ALF, serving as an element of pretransplantation care.

Impact of Tumor Characteristic on the Outcome of Liver Transplantation in Patients With Hepatocellular Carcinoma

INTRODUCTION Orthotopic liver transplantation (OLT) is a well-established treatment for cirrhotic patients with hepatocellular carcinoma (HCC) who meet the Milan criteria. The aim of this study was to identify predictors of survival among 65 patients with HCC in cirrhotic livers who underwent liver transplantation (OLT). METHODS From January 2001 to December 2008, we performed 655 OLT in 615 patients. HCC was diagnosed in 58 patients before OLT and in 65 by histological examination of the explanted livers; 74% of the patients met Milan criteria by histological examination. RESULTS The median follow-up was 27 months (range = 1-96). We analyzed patient age and gender, etiology of liver disease, Child score at transplantation, rejection episodes, tumor number/size, vascular invasion, and differentiation grade. There was no significant difference in survival among patients grouped according to the Model for End-stage Liver Disease staging system for HCC. The 5-year survival of patients with low differentiated (G3) HCC was significantly worse than that of those with moderately differentiated (G2) or well-differentiated (G1) HCC: 50%, 81%, and 86% respectively, (P < .01). Patients with microvascular invasion displayed a worse 5-year survival than those without vascular invasion (42% vs 80%; P < .01). CONCLUSIONS The analysis indicated that the histological grade of the tumors and evidences of microscopic vascular invasion were the most useful predictive factors for overall survival among patients with cirrhosis after liver transplantation for HCC.

1000 liver transplantations at the Department of General, Transplant and Liver Surgery, Medical University of Warsaw--analysis of indications and results.

THE AIM OF THE STUDY was to analyze indications and results of the first one thousand liver transplantations at Chair and Clinic of General, Transplantation and Liver Surgery, Medical University of Warsaw. MATERIAL AND METHODS Data from 1000 transplantations (944 patients) performed at Chair and Clinic of General, Transplantation and Liver Surgery between 1994 and 2011 were analyzed retrospectively. These included 943 first transplantations and 55 retransplantations and 2 re-retransplantations. Frequency of particular indications for first transplantation and retransplantations was established. Perioperative mortality was defined as death within 30 days after the transplantation. Kaplan-Meier survival analysis was used to estimate 5-year patient and graft survival. RESULTS The most common indications for first transplantation included: liver failure caused by hepatitis C infection (27.8%) and hepatitis B infection (18%) and alcoholic liver disease (17.7%). Early (< 6 months) and late (> 6 months) retransplantations were dominated by hepatic artery thrombosis (54.3%) and recurrence of the underlying disease (45%). Perioperative mortality rate was 8.9% for first transplantations and 34.5% for retransplantations. Five-year patient and graft survival rate was 74.3% and 71%, respectively, after first transplantations and 54.7% and 52.9%, respectively, after retransplantations. CONCLUSIONS Development of liver transplantation program provided more than 1000 transplantations and excellent long-term results. Liver failure caused by hepatitis C and B infections remains the most common cause of liver transplantation and structure of other indications is consistent with European data.

Menstrual Function in Female Liver Transplant Recipients of Reproductive Age

BACKGROUND AND AIM End-stage liver failure is associated with severe abnormalities in menstrual and reproductive function. These abnormalities may be reversed by successful orthotopic liver transplantation (OLT). The aim of the study was to investigate menstrual patterns and sex hormone profiles among female liver transplant recipients of reproductive age. METHODS The study group consisted of 24 women of reproductive age with end-stage liver failure who underwent successful OLT. Menstrual patterns and sex hormone profiles were analyzed before as well as 3 and 12 months after OLT. Twenty-seven healthy women of reproductive age served as controls. Biochemical parameters of liver function were assessed before and after OLT. RESULTS Amenorrhea was the most commonly observed abnormality of menstrual cycle in women with end-stage liver failure (71% of patients). The recurrence of regular menstrual cycles was observed in 35% of patients 3 months after OLT. The percentage increased to 70% at 1 year after grafting and was clearly associated with stabilization of liver function. Similar levels of follicle stimulation hormone (FSH), luteinizing hormone (LH), prolactine (PRL), and testosterone (T) as well as lower levels of estradiol (E(2)), dehydroepiandrostendione sulphate (DHEA-S), and progesterone, (P) were observed in patients with liver failure compared with healthy women. We observed normalization of E(2) and DHEA-S levels after OLT. CONCLUSIONS Amenorrhea, the most common menstrual disturbance in women with end-stage liver failure, may be reversed by OLT. One year after OLT menstrual bleedings were noted in 74% of patients of reproductive age. The recurrence of reproductive function indicated the need for effective and safe family planning methods in that group of patients.

Detection of active bile leak with Gd-EOB-DTPA enhanced MR cholangiography: Comparison of 20–25 min delayed and 60–180 min delayed images

OBJECTIVES The purpose of this study was to assess the value of contrast-enhanced magnetic resonance cholangiography (MRC) performed in different time delays after injection of gadoxetic acid disodium (Gd-EOB-DTPA) for the diagnosis of active bile leak. METHODS This retrospective analysis included Gd-EOB-DTPA enhanced MR images of 34 patients suspected of bile leak. Images were acquired 20-25 min after Gd-EOB-DTPA injection. If there was inadequate contrast in the bile ducts then delayed images after 60-90 min and 150-180 min were obtained. Results were correlated with intraoperative findings, ERCP results, clinical data, laboratory tests, and follow-up examinations. RESULTS Gd-EOB-DTPA enhanced MRC yielded an overall sensitivity of 96.4%, specificity of 100% and accuracy of 97.1% for the diagnosis of an active bile leak. The sensitivity of 20-25 min delayed MR images was 42.9%, of combined 20-25 min and 60-90 min delayed images was 92.9% and of combined 20-25 min, 60-90 min and 150-180 min delayed images was 96.4%. CONCLUSIONS Gd-EOB-DTPA enhanced MRC utilizing delayed phase images was effective for detecting the presence and location of active bile leaks. The images acquired 60-180 min post-injection enabled identification of bile leaks even in patients with a dilated biliary system or moderate liver dysfunction.

Negative outcomes after liver transplantation in patients with alcoholic liver disease beyond the fifth post‐transplant year

Although up to 50% of patients with alcoholic liver disease (ALD) resume alcohol consumption after liver transplantation (LT), numerous studies indicate that long‐term results are not compromised. This study focused on evaluating the impact of ALD on outcomes up to and beyond the fifth year after LT. Among the 432 primary LT recipients included in this study, 97 underwent transplantation for ALD. Alcohol relapse rate at 10 yr was 33.5%, with younger recipient age being the only independent predictor (p = 0.019). Survival of patients with ALD (77.0%) was similar to those without (79.0%) up to the fifth post‐transplant year (p = 0.655) but worse during the five subsequent years among the five‐yr survivors (70.6% vs. 92.9%; p = 0.002). ALD was an independent risk factor for poorer survival beyond the fifth post‐transplant year (p = 0.049), but not earlier (p = 0.717). Conversely, alcohol relapse increased the risk of death only during the first five post‐transplant years (p = 0.039). There were no significant differences regarding graft failure incidence between ALD and non‐ALD recipients up to the fifth post‐transplant year (7.3% vs. 11.6%; p = 0.255) and beyond (12.9% vs. 5.0%; p = 0.126). In conclusion, pre‐transplant diagnosis of ALD yields negative effects on post‐transplant outcomes beyond the fifth post‐transplant year, not attributable to recidivism.

Incidence, pattern and clinical relevance of microbial contamination of preservation fluid in liver transplantation

BACKGROUND Transmission of pathogens via preservation fluid (PF) is a potential cause of infection among liver transplant recipients. Here, we evaluated the incidence and pattern of microbial contamination of PF and its impact on postoperative graft function after liver transplantation. MATERIAL/METHODS This longitudinal study included data from 41 primary liver transplantations and 5 re-transplantations performed between December 2010 and September 2011. Results of microbiological analyses of 92 PF samples collected before and after the back-table procedure were evaluated in order to establish the incidence and pattern of contamination. The impact of positive PF cultures on early graft function and rate of pathogen transmission was assessed. Post-transplant antibiotic protocol was based on piperacillin/tazobactam administration for a minimum of 10 days. RESULTS The incidence of contamination was 84.8% (39/46), both for samples collected before and after the back-table procedure. Gram-positive low-virulence organisms typical for superficial saprophytic flora, mainly coagulase-negative staphylococci, were predominant. There were no cases of pathogen transmission from PF to the recipient. Positive cultures of PF samples obtained after the back-table procedure were associated with significant elevation of aspartate (p=0.034) and alanine aminotransferase (p=0.048) on the first 5 postoperative days. No significant differences were found regarding serum bilirubin concentration (p=0.335) and international normalized ratio (p=0.137). CONCLUSIONS Despite high incidence of PF contamination, infections caused by pathogens isolated from PF were not observed. However, presence of pathogens in PF might lead to temporary impairment of graft function.