Mahmoud El-Meteini

The safety of modern hydroxyethyl starch in living donor liver transplantation: a comparison with human albumin.

BACKGROUND:Intravascular volume replacement therapy is an important issue in the perioperative management of liver transplantation. There is paucity of data on the safety of hydroxyethyl starch (HES) in patients undergoing liver transplantation. We evaluated the safety of a new HES 130/0.4 in the perioperative management of liver transplantation, with a special emphasis on renal function. METHODS:Forty patients undergoing living donor liver transplantation were prospectively randomized into two groups. Patients in the ALB group (n = 20) received 5% human albumin. Patients in the HES group (n = 20) received third generation HES (6% HES 130/0.4). Total colloid administration was limited to 50 mL · kg−1 · d−1. The volume was given to maintain pulmonary artery occlusion pressure or central venous pressure between 5 and 7 mm Hg. If additional fluids were required, balanced crystalloid solution was used. Anesthetic and surgical techniques were standardized. Serum creatinine and cystatin C plasma levels were measured from arterial blood samples after induction of anesthesia, at the end of surgery, and on the first 4 postoperative days. RESULTS:All 40 enrolled patients completed the study. Demographic and intraoperative variables were comparable in both groups. Postoperatively, the mean ± sd volume was 6229 ± 1140 mL and 4636 ± 1153 mL in HES and ALB groups, respectively (P = 0.003). There was significantly larger net cumulative fluid balance in the ALB group 1100 ± 900 mL compared with the HES group 3047 ± 2000 mL, P = 0.029. Serum creatinine, creatinine clearance, and cystatin C plasma levels showed no significant differences between the two groups. One patient in each group developed acute renal failure requiring renal replacement therapy. CONCLUSION:The use of HES 130/0.4 as an alternative to human albumin resulted in equivalent renal outcome after liver transplantation.

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.

Biliary complications including single-donor mortality: experience of 207 adult-to-adult living donor liver transplantations with right liver grafts

BACKGROUND After right lobe donation, biliary complication is the main cause of morbidity. Mortality after right lobe donation has been estimated to be less than 0.5%. PATIENTS AND METHODS Between November 2001 and December 2008, 207 adult-to-adult living donor liver transplantations (ALDLT) were undertaken using right lobe grafts. Donors included 173 men and 34 women with a mean age of 28.4 +/- 5.2 years. RESULTS Siblings comprised 144 (69.6%) cases whereas unrelated donors comprised 63 (30.4%) with a mean body mass index (BMI) of 25.2 +/- 2.4. Single and multiple right hepatic ducts (RHD) were present in 82 (39.6%) and 125 (60.3%) donors, respectively. Mean operative time was 360 +/- 50 min with an estimated blood loss of 950 +/- 450 ml and returned cell-saver amount of 450 +/- 334 ml. Mean donor remnant liver volume was 33.5 +/- 3.2%. Mean intensive care unit (ICU) stay was 3 +/- 0.7 days and mean hospital stay was 14 +/- 3.5 days. Modified Clavien classifications were used to stratify all donor biliary complications The overall biliary complications occurred in 27 cases (13.0%). After modified Clavien classification, biliary complications were graded as grade I (n= 10), grade II (n= 2), grade III (n= 14) and grade V (n= 1). Grade I and II (n= 12) biliary complications were successfully managed conservatively. Grade III cases were treated using ultrasound-guided aspiration (USGA), endoscopic retrograde cholangiography (ERCP) and surgery in 10, 2 and 2 donors, respectively. Single donor mortality (Grade V) (0.4%) occurred after uncontrolled biliary leakage with peritonitis that necessitated exploration followed by ERCP with stent insertion but the donor died on day 43 as a result of ongoing sepsis. CONCLUSION Although the majority of biliary complications are minor and can be managed conservatively, uncontrolled biliary leakage is a serious morbidity that should be avoided as it could lead to mortality.

Status of Liver Transplantation in the Arab World

The liver transplantation experience of 11 countries in the League of Arab States is presented in this Regional Perspective and provided in an ongoing series of such perspectives through the auspices of The Transplantation Society (1Y3). The history and current experience of 27 liver transplant centers throughout these 11 countries is a seminal recording of both deceased (DDLT) and living donor (LDLT) liver transplantation in the Arab World. The data of this report were assembled by responses to an email questionnaire from 26 of the 27 centers with information regarding the date of the first liver transplant (LT), the total number of LT (including DDLT and LDLT), and the most common indication for LT in those centers. The Arab World is composed of 22 countries in the League of Arab States founded in 1945. It has a combined population of approximately 350 million people and is united by Arabic language, culture, Islamic religion, and geographic contiguity. Additionally, certain Arab countries share a high prevalence of viral hepatitis with an increasing need for LT in those countries (4, 5). The first DDLT in the Arab World was performed in 1990 at Riyadh Military Hospital in Saudi Arabia (6). The first LDLTwas performed in 1991 at the National Liver Institute in Egypt (7). Between 1990 and August 2013, 3,804 liver transplants (3,052 [80%] LDLT and 752 [20%] DDLT) were performed at the 27 in 11 Arab countries (Table 1). The largest percentage of liver transplantation has been performed by 13 transplant centers in Egypt (56%) followed by four transplant centers in Saudi Arabia (35%) and two transplant centers in Jordan (5%). In the remaining eight Arab countries, liver transplant activity has been limited to one program in each country. The most common indication for LT in this series was end-stage liver cirrhosis caused by hepatitis C virus or hepatitis B virus, with or without hepatocellular carcinoma. More than 70% of the LDLT in this series were performed by the transplant centers in Egypt (Table 2) with five living donor deaths reported (0.2% rate of mortality) (8Y12). Egypt has the highest prevalence of hepatitis C virus (HCV) worldwide, estimated to be 15% and 26% of the population (13). More than 90% of the DDLT in this series were performed in Saudi Arabia; four liver transplant centers in Saudi Arabia have collectively performed 1,338 LT (52% DDLT and 48% LDLT), including 13 split LT procedures. There were no reported living donor deaths in Saudi Arabia (14, 15). A small number of transplants have been performed in Algeria, Tunisia, and Lebanon (16, 17). The initial transplant programs in Libya, Kuwait, and United Arab Emirates performed a few liver transplants, but they were subsequently suspended because of logistical and technical reasons. A program for LDLT has recently been developed in Iraq with a potential of performing 15 LDLT per year; also, a DDLT program has begun in Qatar with four transplants performed to date (18). Missing in this report are the current annual data of patient and allograft survival. The progress of liver transplantation Transplantation Society Regional Perspectives

Safety, Efficacy, and Tolerability of Sofosbuvir and Ribavirin in Management of Recurrent Hepatitis C Virus Genotype 4 After Living Donor Liver Transplant in Egypt: What Have We Learned so far?

Background Recurrence of HCV after living donor liver transplant (LDLT) is nearly universal, with almost one third of recipients developing cirrhosis and graft failure within 5 years after LDLT. Different studies have been published on the effect of sofosbuvir after liver transplantation on recurrent HCV with different genotypes. Objectives The aim of this study was to evaluate the efficacy, safety, and tolerability of sofosbuvir and ribavirin in LDLT recipients with recurrent HCV genotype 4. Patients and Methods Thirty-nine Egyptian LDLT recipients were treated for recurrent HCV after LDLT with nucleos(t)ide analog NS5B polymerase inhibitor, sofosbuvir, and ribavirin without pegylated interferon for 6 months (November 2014 to June 2015) in this intention-to-treat analysis. Results One recipient died 1 week after starting the treatment, but the remaining 38 patients completed 24 weeks of treatment and were then followed for 12 weeks after end of treatment (EOT). The sustained virological response (SVR) at week 12 after EOT was achieved in 76% (29/38) of recipients. SVR was significantly higher in treatment-naïve patients and in recipients with a low stage of fibrosis. Only 2 (5%) recipients developed severe pancytopenia and acute kidney injury. Conclusions We recommend initiating treatment as soon as possible after liver transplantation with newer combinations, such as ledipasvir/sofosbuvir or sofosbuvir/simeprevir, rather than sofosbuvir with Ribavirin, to achieve higher rates of SVR.

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.

The Use of Terlipressin for Management of Dynamic Left Ventricular Outflow Tract Obstruction Complicating Othotropic Liver Transplantation: A Case Report

We describe a patient with structurally normal heart who developed hemodynamic instability during orthotropic liver transplantation caused by severe dynamic left ventricular outflow tract obstruction. Successful management of this adverse event was facilitated by the use of intravenous terlipressin. The case highlights a role for terlipressin as a selective vasopressin receptor agonist with subsequent effects on systemic vascular resistance.

Living donor liver transplantation for high model for end-stage liver disease score: What have we learned?

AIM To assess the impact of model for end-stage liver disease (MELD) score on patient survival and morbidity post living donor liver transplantation (LDLT). METHODS A retrospective study was performed on 80 adult patients who had LDLT from 2011-2013. Nine patients were excluded and 71 patients were divided into two groups; Group 1 included 38 patients with a MELD score < 20, and Group 2 included 33 patients with a MELD score > 20. Comparison between both groups was done regarding operative time, intra-operative blood requirement, intensive care unit (ICU) and hospital stay, infection, and patient survival. RESULTS Eleven patients died (15.5%); 3/38 (7.9%) patients in Group 1 and 8/33 (24.2%) in Group 2 with significant difference (P = 0.02). Mean operative time, duration of hospital stay, and ICU stay were similar in both groups. Mean volume of blood transfusion and cell saver re-transfusion were 8 ± 4 units and 1668 ± 202 mL, respectively, in Group 1 in comparison to 10 ± 6 units and 1910 ± 679 mL, respectively, in Group 2 with no significant difference (P = 0.09 and 0.167, respectively). The rates of infection and systemic complications (renal, respiratory, cardiovascular and neurological complications) were similar in both groups. CONCLUSION A MELD score > 20 may predict mortality after LDLT.

Psychiatric and surgical outcome in Egyptian donors after living-donor liver transplantation

IntroductionLiving-donor liver transplantation has emerged as a life-saving alternative for those with end-stage liver disease. However, surgical complications may lead to physical, mental, and psychosocial complications that could affect the quality of life and psychological outcomes of living donors after transplantation. AimThe aim of the study was to assess the satisfaction of donors with the decision to donate and their willingness to donate again and its relation with postoperative complications, and consequently the effect on psychiatric morbidity and quality of life of the donors. Patients and methodsThe present study evaluated 33 donor candidates who were introduced to donation after being subjected to all medical and psychological tests, which were free of cost. All participants were interviewed using a questionnaire on personal history, relationship to recipient, and satisfaction with donation, a General Health Questionnaire, the SCID-I, Beck Depression Inventory, the Taylor Manifest Anxiety Scale, the PCASEE Quality of Life Questionnaire, and the Clavien classification for surgical complications. ResultsAmong donors 33% reported that they would donate again. One week after surgery, 6% had grade 2 and 6% had grade 3a complications; 3 months postoperatively, 3% had grade 2 and 3% had grade 3a complications. Psychiatric morbidity was 15% (6% anxiety disorders, 6% major depression, and 3% adjustment disorder). No relation was found between quality of life and postoperative complications, whereas depression and anxiety were highly correlated. ConclusionSurgeons and psychiatrists have to work together to select donors, provide assistance in decision making, and minimize any postoperative complications either surgically or psychiatrically.

Assessment of HCV - Induced Insulin Resistance in Egyptian HCV End - Stage Cirrhotic Patients before and after Living Donor Liver Transplantation ( LDLT )

HCV virus has been shown to induce insulin resistance (IR) itself. The aim of this work: was to evaluate HCV-induced IR in Egyptian HCV cirrhotic patients after LDLT and correlate the occurrence of IR with the level of HCV-RNA viremia and the status of HCV disease recurrence post LDLT. 67 patients had received LDLT from November 2010 to November 2012. 17 of them were included in this prospective research by the following criteria :1) Patients with HCV related End Stage Liver Disease , who were eligible for liver transplantation . 2) Patients with an estimate of IR using HOMA-IR level more than or equal 2 +/- [impaired fasting plasma glucose (FPG) and/or impaired oral glucose tolerance test (OGTT)] .Patients were followed up with the following schedule : FPG , OGTT and HOMA were routinely done 3 , 6 and 12 months post LDLT. HCV RNA level by PCR was performed 1 , 6 and 12 months to follow up the level of viremia post LDLT . Protocol liver biopsies were taken 6 and 12 months post LDLT. The median HOMA value showed reduction during the first year post LDLT , which was not significant at 3 months post LDLT (p value = 0.055) , was highly significant at 6 months post LDLT (p value =0.002) and was again significant at 12 months post LDLT (p value = 0.028) . Recurrence of HCVdisease was documented histologically in 9 patients (52.9%) at 6 months and 10 patients (58.8%) 1 year post LDLT. There was no statistically significant relation between median HOMA values and either level of HCV-RNA viremia or histological recurrence of HCV 6 and 12 months post LDLT. To our knowledge , this is the first study of HCV-induced IR that was conducted on LDLT recipients. HCV-induced insulin resistance is improved 1 year after after LDLT.