Niang-Cheng Lin

Hepatic Venous Congestion After Living Donor Liver Transplantation: Quantitative Assessment of Liver Stiffness Using Shear Wave Elastography—A Case Report

We report a 49-year-old right lobe liver transplant recipient, who developed a significant anastomotic stenosis of the right hepatic vein shortly thereafter. Shear wave elastography (SWE) was applied to investigate liver stiffness quantitatively. It showed increased stiffness in the anterior compared with the posterior segment of right lobe graft. The stenotic right hepatic venous anastomosis was then managed by angioplasty with stent placement. SWE after angioplasty showed a gradual decrease in stiffness of the anterior segment, which was almost equal to the posterior segment at 2 weeks thereafter. Our experience suggested that SWE may be a noninvasive tool to assess alterations in liver stiffness secondary to hepatic venous congestion after liver transplantation.

Liver Transplantation at a Small-volume Procedure Center-Preliminary Results from Taipei Veterans General Hospital

Background: Liver transplantation is a challenging procedure that is associated with perioperative morbidity and mortality, so it is justifiable to perform such a procedure in high‐volume procedure centers. Organ shortage remains a major issue in Taiwan. Due to the difficulty in establishing a high‐volume procedure center, it is important to review the overall outcome of patients undergoing liver transplantation at a small‐volume procedure center to determine if performing such a procedure is justified. Methods: Between April 2001 and May 2005, 26 adults underwent deceased donor liver transplantation at Taipei Veterans General Hospital. The overall outcomes were reviewed in terms of 90‐day mortality, 1‐year and 3‐year survival rates. In addition, the patients were divided into a hepatocellular carcinoma (HCC) group (n =12) and a benign end‐stage liver disease (ESLD) group (n =14). The clinical demographics, 90‐day mortality, 1‐year and 3‐year survival rates were reviewed and compared between the 2 groups. Results: The 90‐day mortality was 15.3% in the whole series, 8.3% in the HCC group and 18.7% in the ESLD group. The overall 1‐year and 3‐year survival rates were 76.9% and 63.5%, respectively, for the whole series. For the 2 groups, the respective 1‐year and 3‐year survival rates were 83.3% and 71.4% in the HCC group, and 71.4% and 57.1% in the ESLD group. The survival difference was not significant (p =0.319) between the 2 groups. In the HCC group, the 1‐year and 3‐year disease‐free survival rates were 88.9% and 71.1%, respectively. Conclusion: The survival rates between ESLD and HCC patients undergoing liver transplantation at a small‐volume procedure center were comparable. The results of the whole series were not satisfactory, but the results for the HCC group were acceptable. [J Chin Med Assoc 2008;71(4):186–190]

Minimization or withdrawal of immunosuppressants in pediatric liver transplant recipients.

BACKGROUND We aimed to minimize the dose of tacrolimus in pediatric patients undergoing liver transplantation prospectively. METHODS Pediatric liver transplant recipients with stable graft function >1year (transplant at <1year of age), or 2years (transplant at >1year of age) post transplant were screened. After baseline graft biopsy, patients were enrolled into our protocol for elective tacrolimus dose reduction. Patients were assessed by liver function test and protocol biopsy during and after tacrolimus dose reduction. RESULTS From January 2011 to December 2012, 16 patients were recruited, of whom 15 completed follow-up at a mean 40.75±5.98months. Six patients were preliminarily weaned off tacrolimus, and five remained tacrolimus-free for more than 2years. Of the 10 patients who were not weaned off tacrolimus, six experienced seven episodes of clinical rejection. Five patients had a reduction in tacrolimus dosage to an undetectable trough level, another five to a trough level <4ng/ml, including one patient who was off the study. At the last patient visit, all of the patients had normal liver function test results with no graft loss. Three patients had low-grade graft fibrosis. The patients with metabolic liver disease (p=0.039) and who were recruited earlier after transplantation (p=0.028) were more likely to be weaned off tacrolimus. CONCLUSION Tacrolimus withdrawal is feasible in select pediatric liver transplant recipients, and long-term follow-up for these patients is suggested.

A bidirectional approach for portal vein stent placement in a child with complete portal vein occlusion after living donor liver transplantation

Delayed PV complications are not rare in pediatric liver transplantation. Although PTPV offers a treatment and minimizes surgical revision, in case of complete PV thrombosis (PVT), the failure rate of PTPV is high. Herein, we report a successful technique of PTPV in a case of complete PVT with a stent placement using a bidirectional approach in a child with living donor liver transplantation.

Early Postoperative Spectral Doppler Parameters of Renal Transplants: The Effect of Donor and Recipient Factors

BACKGROUND The objective of this study was to explore the donor and recipient factors related to the spectral Doppler parameters of the transplant kidney in the early posttransplantation period. METHODS This retrospective study included 76 patients who underwent renal transplantation assessed using Doppler ultrasonography (US) on the first postoperative day. We compared spectral Doppler parameters (peak systolic velocity [PSV] and resistive index [RI]) of the segmental artery of the transplant kidney according to the type of renal transplant, level of serum creatinine (SCr) of donor prior to organ donation, and donor/recipient age. RESULTS RI was significantly higher in deceased-donor kidney transplantation (DDKT) as compared with living-donor kidney transplantation (LDKT; 0.73 ± 0.10 vs 0.66 ± 0.11; P = .007). In the DDKT recipients, multivariate analysis showed donor SCr was the only factor affecting PSV (P = .023), whereas recipient age was the only factor affecting RI (P = .035). In the LDKT recipients, multivariate analysis showed recipient age was the only factor affecting both PSV (P = .009) and RI (P = .018). CONCLUSION Spectral Doppler parameters in the early posttransplantation period are related to the type of renal transplant, donor renal function, and recipient age. These factors should be taken into consideration when interpreting the results of spectral Doppler US.

Three liver grafts from a deceased whole liver

Although the lateral segment (LS) from the split-liver of a deceased donor or a live donor can increase the organ pool of pediatric patients awaiting liver transplantation, the shortage of organ donation in Asia countries is still serious and results in high death rates of pediatric patients. The medial segment (MS) of the liver is sacrificed during the standard technique of splitting a whole liver into an LS and an extended right liver because the cutting sites of portal vein, hepatic artery and bile duct are all in the bifurcation of the liver hilum to have adequate length of vascular and biliary pedicles for easier grafting. However, the surgical techniques of vascular and biliary reconstructions for liver transplantation, particularly from the experiences of living donor liver transplantation, have been much improved in the last decade. Therefore it may be possible for an additional MS of the liver to be an isolated graft for a small recipient on the premise that grafts of right lobe (RL) and LS are minimally injured. In light of detailed reviews of anatomies of hepatic arteries, hepatic veins, portal veins and bile ducts, the dissection and reconstruction of vessels and bile ducts for the MS can possibly be performed if the extra-hepatic length of the artery to the MS is long enough. As the artery for the MS, middle hepatic artery (MHA), usually derives from a branch of the left hepatic artery and often in the liver parenchyma, the length is usually too short to be reconstructed. If the MHA for the MS is isolated and its extra-hepatic length is more than 1cm, triple liver grafts from a deceased whole liver, consisting of the RL, MS and LS may be possible. The anatomies of the hepatic artery in abdominal computed tomography (CT) or magnetic resonance imaging (MRI) for live liver donors in our institution were retrospectively analyzed. The results showed that three types of hepatic arterial anatomies could be considered for possible recovery of triple segments: type I is an accessory left gastric artery to feed the lateral segment; type II is an isolated MHA; type III is an early bifurcation of the left hepatic artery and MHA.

Retrograde arterial flush of the liver graft in living donor liver transplantation may ameliorate post-transplantational cholestasis – a prospective randomized study

Liu C, Loong C‐C, Hsia C‐Y, Wang S‐C, Yeh Y‐C, Lin N‐C, Tsai H‐L, Tsou M‐Y. Retrograde arterial flush of the liver graft in living donor liver transplantation may ameliorate post‐transplantational cholestasis – a prospective randomized study. 
Clin Transplant 2011 DOI: 10.1111/j.1399‐0012.2011.01493.x. 
© 2011 John Wiley & Sons A/S.

Successful ABO-incompatible pediatric living donor liver transplantation in an infant with protein C deficiency

A male term baby, ABO blood group O, developed pulmonary hemorrhage with disseminated intravascular coagulation shortly after birth. Purpura fulminans with necrotic skin lesions soon developed. Aggressive transfusion of fresh frozen plasma (FFP) was given. His serum PC activity was <5%. Genetic testing revealed compound heterozygous PROC gene mutations (c.532G>C/c.679G>T). Multiple intracranial hematomas with right subretinal hematoma were found on magnetic resonance imaging. The patient was treated with regular subcutaneous Ceprotin and oral warfarin. At age 4 months, LT was considered due to unstable disease and a large Ceprotin requirement. His uncle (blood group B) was selected as a living related donor as the parents were heterozygotes. Due to previous massive FFP transfusions, the patient’s serum anti-B IgG titer was 1:256, which was successfully lowered to 1:64 after transfusing typeABFFP (20ml/kg/day). Ceprotin (2,000–4,000 IU/day), enoxaparin (300 IU/kg/day), and vitamin K1 (1 mg/day) were continued. A reduced lateral segment graft was implanted at age 5months and 19 days. The bodyweight at LTwas 5.9 kg and graft weightwas 205 g (graft-recipientweight ratio 0.0346). Tacrolimus and steroid were used for immunosuppression. Ceprotin was given intraoperatively (6,000 IU) and gradually reducedwith therapeutic targets of serumD-dimer<20mcg/ml, trough serum PC activity level >50%, and INR around 1.5. His PC activity level increased steadily (Fig. 1). At last follow-up, age 28months, he had been weaned

Living donor liver transplantation using a graft from a donor with Dubin-Johnson syndrome.

Liu C, Niu D‐M, Hsia C‐Y, Loong C‐C, Lin N‐C, Tsai H‐L, Tsou M‐Y, Chin T. Living donor liver transplantation using a graft from a donor with Dubin–Johnson syndrome. 
Pediatr Transplantation 2012: 16: E25–E29.

Liver transplantation for a patient with homocystinuria

Lin N‐C, Niu D‐M, Loong C‐C, Hsia C‐Y, Tsai H‐L, Yeh Y‐C, Tsou M‐Y, Liu C‐S. Liver transplantation for a patient with homocystinuria. 
Pediatr Transplantation 2012.