Rodrigo Mateo

Live donor liver transplantation without blood products: strategies developed for Jehovah's Witnesses offer broad application.

Objective:Developing strategies for transfusion-free live donor liver transplantation in Jehovahs Witness patients. Summary Background Data:Liver transplantation is the standard of care for patients with end-stage liver disease. A disproportionate increase in transplant candidates and an allocation policy restructuring, favoring patients with advanced disease, have led to longer waiting time and increased medical acuity for transplant recipients. Consequently, Jehovahs Witness patients, who refuse blood product transfusion, are usually excluded from liver transplantation. We combined blood augmentation and conservation practices with live donor liver transplantation (LDLT) to accomplish successful LDLT in Jehovahs Witness patients without blood products. Our algorithm provides broad possibilities for blood conservation for all surgical patients. Methods:From September 1998 until June 2001, 38 LDLTs were performed at Keck USC School of Medicine: 8 in Jehovahs Witness patients (transfusion-free group) and 30 in non-Jehovahs Witness patients (transfusion-eligible group). All transfusion-free patients underwent preoperative blood augmentation with erythropoietin, intraoperative cell salvage, and acute normovolemic hemodilution. These techniques were used in only 7%, 80%, and 10%, respectively, in transfusion-eligible patients. Perioperative clinical data and outcomes were retrospectively reviewed. Data from both groups were statistically analyzed. Results:Preoperative liver disease severity was similar in both groups; however, transfusion-free patients had significantly higher hematocrit levels following erythropoietin augmentation. Operative time, blood loss, and postoperative hematocrits were similar in both groups. No blood products were used in transfusion-free patients while 80% of transfusion-eligible patients received a median of 4.5+/− 3.5 units of packed red cell. ICU and total hospital stay were similar in both groups. The survival rate was 100% in transfusion-free patients and 90% in transfusion-eligible patients. Conclusions:Timely LDLT can be done successfully without blood product transfusion in selected patients. Preoperative preparation, intraoperative cell salvage, and acute normovolemic hemodilution are essential. These techniques may be widely applied to all patients for several surgical procedures. Chronic blood product shortages, as well as the known and unknown risk of blood products, should serve as the driving force for development of transfusion-free technology.

Caval preservation with reconstruction of the hepatic veins using caval-common iliac bifurcation graft for domino liver transplantation

Domino liver transplantation has been performed routinely from livers procured from patients with Familial Amyloidosis (FA). Some technical modifications have been made on the recipient of Amyloid Hepatic Allograft (AHA) to overcome the cuff limitation such as the use of side to side cava-caval anastomosis with closure of the suprahepatic and infrahepatic cava. These technical innovations in the recipient AHA however have no benefit for the FA patient undergoing the hepatectomy and may in fact adversely affect the safety of the harvesting procedure by requiring high dissection of the IVC into the diaphragm. In addition the IVC is removed with the liver, therefore requiring complete supra-renal vena caval clamping and the use of veno-venous bypass. We describe a safe and simple technique to recover the AHA without the IVC.

To Do or Not to Do Living Donor Hepatectomy in Jehovah's Witnesses: Single Institution Experience of the First 13 Resections

Living donor liver transplantation has come to be an acceptable alternative to deceased donor transplants. Several ethical issues related to living donation have been raised in the face of reported perioperative morbidity and mortality. We report our experience in 13 consecutive Jehovahs Witness (JW) donor hepatectomies. From June 1999 to April 2004, 13 adult JW donors underwent donor hepatectomies at the USC–University Hospital. Nine donors underwent right lobectomy with a 62% mean volume of the liver resected. Four donors underwent a left lateral segmentectomy with a mean volume of 17.8%. Cell scavenging techniques, acute normovolemic hemodilution and fractionated products were used. The mean hospital stay was 6.2 days. All donors are alive and well at a median follow‐up time of 3 years and 4 months. Live liver donation can be done safely in JW population if performed within a comprehensive bloodless surgery program.

Transfusion-free techniques in pediatric live donor liver transplantation

Patients of the Jehovah’s Witness faith are unwilling for religious reasons to accept transfusion with blood or blood products. In pediatric patients of the Jehovah’s Witness faith, blood products can be used under court mandate if deemed medically imperative. However, transfusion under court order is obviously fraught with concerns for physicians and parents. This report describes medical and surgical techniques that have been used to avoid transfusion in adult Jehovah’s Witness patients and their successful use in two pediatric patients undergoing liver transplantation (1).

Management of an Abdominal Aortic Aneurysm in a Patient with End-Stage Liver Disease

Concomitant abdominal aortic aneurysms and cirrhosis that need surgical attention are rare. Currently there are no guidelines with regards to the appropriate timing of the repair of these aneurysms and transplantation. In addition it also raises the issue of which procedure takes precedence. With the advent of endovascular repairs, this issue was resolved with relative ease, by doing the orthotopic liver transplantation (OLT) first and subsequent endovascular stenting on post‐operative day 7 during the same hospitalization. This is the first case report of stenting an abdominal aortic aneurysm (AAA) in a liver transplant recipient. The rationale for the OLT and then AAA repair are discussed and formal guidelines are offered.

Gastroduodenal artery pseudoaneurysm secondary to pancreatic head biopsy.

Pseudoaneurysms of the gastroduodenal artery are rare. 1 They are usually postoperative or postprocedure complications or secondary to pancreatitis. Abdominal pain and gastrointestinal bleeding are the most common symptoms. Once diagnosed, pseudoaneurysms require immediate treatment because they have a potential to rupture, which is associated with a high rate of mortality. Transcatheter selective embolotherapy is the procedure of choice for this clinical entity. We report the case of an 80-year-old woman in whom a visceral artery pseudoaneurysm developed secondary to a percutaneous pancreatic head biopsy. Computed tomography (CT) and sonography provided the initial diagnosis for a pseudoaneurysm of the gastroduodenal artery, which was confirmed by celiac arteriography and successfully treated by arterial embolization. We discuss the pathogenesis, diagnosis, and treatment of visceral pseudoaneurysms.

Organ, cellular, and molecular approaches to glycemic control

As an option for the management of chronic diabetes, pancreas transplantation has been shown to improve quality of life consistently, and remains unparalleled in glycemic control. Methodological and ethical issues may impede prospective, randomized, and controlled studies on the effects of pancreas transplantation on diabetic secondary complications, and Gaber and Moore (pp. 84–87) provide insight into the difficulties in establishing definitive proof to support a benefit. They discuss the use of calcineurin inhibitors and steroids as potential confounders in studying these effects, as the use of calcineurin inhibitors may result in nephrotoxicity, excess vasoreactivity, neurotoxicity and insulin resistance, each of which can also be attributable to the primary disease. In addition, imperfections and inconsistencies in the biometrics of disease outcomes have hindered efforts to correlate results between studies.

Using hepatitis-positive donors for solid organ transplantation.

Purpose of reviewOrgans procured from donors with positive viral serology are currently underused. Defining the risk of transmission will enhance the use of such organs. Recent findingsRecent data point to the overall safety of using such organs. Prophylaxis and prevention of reactivation of the viruses have been looked at, and more studies are underway. However, one needs to define the criteria and the population suitable to receive organs from hepatitis-positive donors. SummaryIn this article, we attempt to get to the basics by discussing the antigens and antibodies as they relate to the transplant surgeons. Analysis of the current data from individual centers and the United Network of Organ Sharing database is used to delineate some guidelines. Judicious judgment will allow many of these organs with positive viral serology to be transplanted into appropriate recipients with minimal incremental risk.