W.-T. Wang

Quality of life and psychologic distress of recipients after adult living-donor liver transplantation (LDLT)-A study from mainland China.

This cross-sectional study investigated potential factors impacting quality of life in 125 recipients after living-donor liver transplantation (LDLT). Health-related quality of life (HRQoL) was measured by using the Chinese version of Medical Outcomes Study Short Form-36 (SF-36), and psychologic symptoms by using the Symptom Checklist-90-Revised (SCL-90-R). Clinical and demographic data were collected from the records of the Chinese Liver Transplant Registry and via questionnaire. A total of 102 recipients (81.6%) completed the questionnaires. All SF-36 domain scores (except the mental health score) were lower in the study than in the general population of Sichuan. The mental quality of life was significantly lower in female than in male subjects (P = .000). Regarding the role-physical (P = .016), social functioning (P = .000), and role-emotional (P = .004) domains, recipients >1 year after transplantation scored higher than those <1 year. Bodily pain scores were lower in recipients with prior acute liver failure than those with hepatic carcinoma or hepatic cirrhosis (P = .032). Social functioning was poorer in recipients with than in those without complications (P = .039). Mental component summary scale (MCS) scores and some of physical component summary scale (PCS) significantly correlated with symptom dimension scores of the SCL-90-R (P < .05). In conclusion, gender, time since transplant, etiology of disease, complications, occupation, and some psychologic symptoms were possible factors influencing postoperative HRQoL of LDLT recipients.

Outcomes of Patients with Benign Liver Diseases Undergoing Living Donor versus Deceased Donor Liver Transplantation

Background/Aims The number of people undergoing living donor liver transplantation (LDLT) has increased rapidly in many transplant centres. Patients considering LDLT need to know whether LDLT is riskier than deceased donor liver transplantation (DDLT). The aim of this study was to compare the outcomes of patients undergoing LDLT versus DDLT. Methods A total of 349 patients with benign liver diseases were recruited from 2005 to 2011 for this study. LDLT was performed in 128 patients, and DDLT was performed in 221 patients. Pre- and intra-operative variables for the two groups were compared. Statistically analysed post-operative outcomes include the postoperative incidence of complication, biliary and vascular complication, hepatitis B virus (HBV) recurrence, long-term survival rate and outcomes of emergency transplantation. Results The waiting times were 22.10±15.31 days for the patients undergoing LDLT versus 35.81±29.18 days for the patients undergoing DDLT. The cold ischemia time (CIT) was 119.34±19.75 minutes for the LDLT group and 346±154.18 for DDLT group. LDLT group had higher intraoperative blood loss, but red blood cell (RBC) transfusion was not different. Similar ≥ Clavien III complications, vascular complications, hepatitis B virus (HBV) recurrence and long-term survival rates were noted. LDLT patients suffered a higher incidence of biliary complications in the early postoperative days. However, during the long-term follow-up period, biliary complication rates were similar between the two groups. The long-term survival rate of patients undergoing emergency transplantation was lower than of patients undergoing elective transplantation. However, no significant difference was observed between emergency LDLT and emergency DDLT. Conclusions Patients undergoing LDLT achieved similar outcomes to patients undergoing DDLT. Although LDLT patients may suffer a higher incidence of early biliary complications, the total biliary complication rate was similar during the long-term follow-up period.

Using the Clavien Grading System to Classify the Complications of Right Hepatectomy in Living Donors

INTRODUCTION The ratios of complications for living related liver donors after right hepatectomy differ widely among numerous single institutions. This study sought to use the Clavien classification system to define and graded the severity of these complications. MATERIALS AND METHODS This study retrospectively analyzed the outcomes of 160 consecutive living donor right hepatectomies performed between July 2002 and February 2008. Complications among living donors for liver transplantation after right hepatectomy were stratified according to the Clavien classification of postoperative surgical complications. RESULTS Fifty-two living donors displayed one or more perioperative complications Grade 1 complications were recorded in 18.1%; grade 2 in 6.3%; grade 3a in 5%; and grade 3b in 3.1%. Biliary complications were the most frequent. No donor mortality was present in this series. CONCLUSIONS The Clavien grading system is useful to comparise surgical outcomes. This study demonstrated that donor right hepatectomy was a relatively safe procedure, but reducing donor complications after right hepatectomy has to be the first priority during the entire process of living related transplantation.

A Significant Expansion of CD8+ CD28- T-Suppressor Cells in Adult-to-Adult Living Donor Liver Transplant Recipients

BACKGROUND The appearance of human regulatory CD8(+) CD28(-) T-suppressor (Ts) cells has been associated with a reduced need for maintenance immunosuppression in cadaveric heart- kidney transplant recipients and pediatric liver-intestine transplant recipients. However, few data are available in adult-to-adult living donor liver transplantation (A-A LDLT). MATERIALS AND METHODS To study the population of CD8(+) CD28(-) Ts cells in A-A LDLT, we performed flow cytometry on whole blood specimens obtained from 20 transplant recipients, 18 end-stage liver disease patients, and 20 normal controls. Meanwhile, we measured the trough levels of immunosuppressants and monitored graft function in transplant recipients. We retrospectively reviewed the clinical data of the 20 recipients. RESULTS A significant expansion of CD8(+) CD28(-) Ts cells was observed among recipients of A-A LDLT as compared with a disease control group (P = .000) or healthy individuals (P = .000). All recipients were free of acute cellular rejection episodes. During the follow-up period, no grafts were lost due to acute or chronic rejection. CONCLUSION Expansion of CD8(+) CD28(-) Ts cells in A-A LDLT seemed to be associated with a decreased occurrence of acute or chronic rejection and sustained good graft function. Based on our low dosages of immunosuppressants for recipients of A-A LDLT, we suggest that this strategy may promote expansion of CD8(+) CD28(-) Ts cells, which can conversely maintain the low immunosuppressant dosages.

Arterial Complications After Living-Related Liver Transplantation: Single-Center Experience From West China

Vascular complications after liver transplantation remain a major source of morbidity and mortality for recipients. In particular, patients receiving living-related liver transplantation (LRLT) experience a higher rate of vascular complications owing to the complex vascular reconstruction. Between July 2001 and December 2005, LRLTs were performed in our center on 33 patients with end-stage liver diseases. The 23 men and 10 women had a mean age of 32.6 +/- 11.3 years (range = 5 to 58 years). Of the 33 patients, the percentage of vascular complications was 9.09% (3 cases), including hepatic arterial thrombosis (HAT), hepatic arterial stenosis (HAS), or hepatic artery pseudoaneurysm (HAP) in one patient, respectively. No portal vein or hepatic vein complication occurred in our patients. Thrombectomy was performed in the patient with thrombosis. The patient with stenosis was treated with balloon angioplasty and endoluminal stent placement. The pseudoaneurysm was also successfully embolized to restore the blood flow toward the donor liver. Mean follow-up for all patients after LRLT was 18.0 +/- 5.4 months. The overall postoperative 30-day mortality rate was 6.06% (2/33). The 1-year survival rate was 86.36% in 22 patients with benign diseases and 72.73% in 11 patients with malignant diseases. However, no death was associated with vascular complications. Careful preoperative evaluation and intraoperative microsurgical technique for hepatic artery reconstructions are the keys to prevent vascular complications following LRLT. Immediate surgical intervention is required for acute vascular complications, whereas late complications may be treated by balloon angioplasty and endoluminal stent placement. Embolization may be a safe and effective approach in the treatment of a pseudoaneurysm of the hepatic artery.

Body Mass Index Evaluating Donor Hepatic Steatosis in Living Donor Liver Transplantation

INTRODUCTION Evaluation of graft hepatic steatosis is important for the safety of the donor and the recipient in living donor liver transplantation. It is necessary to establish a noninvasive evaluation method to avoid performing a liver biopsy for donor safety. The aim of this study was to identify independent factors that correlated with hepatic steatosis to create a noninvasive method to evaluate hepatic steatosis. METHODS We retrospectively collected data from 105 living donors. No prisoners were used to obtain the grafts, all of which underwent postoperative histological evaluation for hepatic steatosis. Preoperative clinical and biochemical variables were examined with univariate analyses, and filtered variables further examined with ordinal regression analysis. RESULTS Eighty (76.2%) donors showed no hepatic steatosis, 15 (14.3%), mild steatosis, and 10 (9.5%), moderate steatosis. In ordinal stepwise regression analysis, body mass index (BMI; P = .000) was the only independent factor that correlated with the grade of hepatic steatosis. Preoperative biochemical parameters were not significantly correlated with hepatic steatosis. A regression model based on BMI was created to evaluate hepatic steatosis grade. Furthermore, individuals with a BMI > 27.5 were most likely to show moderate steatosis, and those with BMI < 23 likely to display no or mild steatosis. CONCLUSION BMI can help to identify the grade of hepatic steatosis among living donors. BMI is also useful to select living donors for a preoperative liver biopsy before liver transplantation.

Diabetes mellitus after living donor liver transplantation: data from Mainland China.

Most reported data on posttransplantation diabetes mellitus (PTDM) are from Western countries with patients who underwent deceased donor liver transplantation. A retrospective study was performed to assess the prevalence and predictive factors of PTDM in the context of living donor liver transplantation (LDLT) in the Chinese population using the definition of PTDM proposed in 2003 by the World Health Organization and the American Diabetes Association. The prevalence of DM after LDLT in our study was 25% (21/84), and the incidence of PTDM was 14.9% (11/74) with 64% of cases diagnosed within 3 months after LDLT; 9.5% were observed to show impaired fasting glucose postoperatively. Multivariate analysis identified body mass index >or= 25 kg/m(2) before LDLT as the only independent risk factor for developing PTDM. Only one patient was operated for hepatitis C virus (HCV) infection. Hepatitis B virus (HBV)-related diseases were common in our study population, accounting for 78.6% of all patients. Both HCV and HBV infection status were not independent risk factors for developing PTDM. In addition, a greater tacrolimus trough blood level in the PTDM group versus no-DM group was observed at 3 months post-LDLT (11.03 ng/mL vs 4.87 ng/mL). The mean tacrolimus dose was not significantly different between the two groups. In conclusion, PTDM was prevalent among Chinese LDLT recipients.

Surgical Procedures for Management of Right Portal Venous Branching in Right Lobe Living Donor Liver Transplantation

OBJECTIVE This study sought to describe the surgical management of right portal venous (PV) branches encountered among 104 cases of right lobe living donor liver transplantation (LDLT). METHODS From January 2002 to September 2007, we performed 104 cases of right-lobe LDLT including 11-donors who had anomalous right portal venous branches (APVB). One recipient had PV sponginess hemangioma. The donor right PV branches were type I in 93 cases, type II (trifurcation) in nine cases, and type III in two cases. Except one narrow bridge of tissue excision, the PV branches were transected on the principal of donor priority: PV branches were excised approximately 2 to 3 mm from the confluence while leaving the donors main portal vein and confluence intact. In type II APVB, donor PV branches were obtained with two separate openings in six cases; with two separate openings joined as a common orifice at the back table in two cases, with one common opening with a narrow bridge of tissue in one case. In type III APVB, the donor right anterior and posterior PV branches were obtained with separate openings. The donor right PV branches with one common opening in 92 cases of type I PV branches and a joined common orifice in three cases of type II APVB were anastomosed to the recipients main portal vein or to right branching. As the unavailable recipient PV for sponginess hemangioma, one case of type I right PV branches was end-to-end anastomosed to one of the variceal lateral veins of about 1 cm diameter in a pediatric patient. The PV were reconstructed as double anastomoses in six type II APVB and in one type III APVB obtained with two separate PV openings. In the another type III APVB reconstruction, we successfully utilized a novel U-shaped vein graft interposition. RESULTS The type II APVB donor receiving a narrow bridge of portal vein tissue excision developed portal vein thrombosis on the third postoperative day and underwent reexploration for thrombectomy. There were no vascular complications, such as portal vein thrombosis or stricture among other donors or all recipients. The velocity of blood flow in the U-graft was normal. The anastomosis between the type I donor right portal vein and recipient variceal lateral vein was unobstructed. CONCLUSION Right PV branches should be excised on the principal of donor priority while leaving the donors main portal vein and confluence intact. Single anastomoses was the fundamental procedure of right branch reconstruction. Double anastomoses could be used as the main management for type II and type III APVB reconstruction. U-graft interposition may be a potential procedure for type III APVB reconstruction. Single anastomoses between the donor right portal vein and the recipient variceal lateral vein may be performed when recipient portal vein is unavailable. These innovations for excision and reconstruction of right PV branches were feasible, safe, and had good outcomes.

Preliminary Experience With Indications for Liver Transplantation for Hepatolithiasis

OBJECTIVE The aim of this study was to explore the indications for liver transplantation among patients with hepatolithiasis. PATIENTS AND METHODS Data from 1,431 consecutive patients who underwent surgical treatment from January 2000 to December 2006 were retrospectively collected for analysis. Surgical procedures included T-tube insertion combined with intraoperative cholangioscopic removal of intrahepatic stones, hepatectomy, cholangiojejunostomy, and liver transplantation. RESULTS Nine hundred sixty-one patients who had a stone located in the left or right intrahepatic duct underwent hepatectomy or T-tube insertion combined with intraoperative cholangioscopic removal of intrahepatic stones. The rate of residual stones was 7.5%. Four hundred seventy patients who had a stone located in the bilateral intrahepatic ducts underwent surgical procedures other than liver transplantation; the rate of residual stones was 21.7%. Only 15 patients with hepatolithiasis underwent liver transplantation; they all survived. According to the degree of biliary cirrhosis, recipients were divided into 2 groups: a group with biliary decompensated cirrhosis (n = 7), or group with compensated cirrhosis or no cirrhosis (n = 8). There were significant differences in operative times, transfusion volumes, and blood losses between the 2 groups (P < .05). In the first group, 6 of 7 patients experienced surgical complications, and in the second, 8 recipients recovered smoothly with no complications. Health status, disability, and psychological wellness of all recipients (n = 15) were significantly improved at 1 year after transplantation compared with pretransplantation (P < .05). CONCLUSIONS Liver transplantation is a possible method to address hepatolithiasis and secondary decompensated biliary cirrhosis or difficult to remove, diffusely distributed intrahepatic duct stones unavailable by hepatectomy, cholangiojejunostomy, and choledochoscopy.

Risk factors and outcomes of massive red blood cell transfusion following living donor liver transplantation

OBJECTIVES:  To identify the factors influencing blood loss and secondary blood transfusion and to investigate the outcomes of patients who underwent a massive blood transfusion (MBT) following living donor liver transplantation (LDLT).