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The liver is the major organ for the metabolism of homocysteine (Hcy) and production of insulin-like growth factor 1 (IGF-1). Hcy metabolism and IGF-1 synthesis may be impaired in chronic liver diseases. The study investigated the regulatory effect of a Chinese herbal suppository, Vitalliver, on Hcy and IGF-1, as well as their relationship in patients with hepatitis B infection. Forty patients with chronic hepatitis B virus (HBV) infection without cirrhosis, 25 males and 15 females, were observed for changes in Hcy and IGF-1 after the administration of Vitalliver (one nightly) for a period of 3 months. Serum levels of Hcy, IGF-1 and IGFBP-3 were measured at baseline, and at 1 month and 3 months after treatment. Vitalliver reduced Hcy levels significantly (p = 0.001) from 9.7 +/- 2.8 to 9.0 +/- 2.1 micromol/L after treatment of 3 months. Furthermore, the IGF-1 levels increased significantly (p < 0.001) from 170.2 +/- 81.8 to 212.8 +/- 80.9 ng/mL at 1 month and 187.5 +/- 72.3 ng/mL at 3 months (p = 0.001) after treatment. In conclusion, it is speculated Vitalliver may have a self-regulatory effect on the release of IGF-1 in HBV patients without liver cirrhosis.

The possibility of using animal organs in transplantation has been attractive for a long time. Most experts believe that the pig will provide the most suitable solid organs and tissues for needy human recipients. Although porcine organs are known to be rapidly rejected by the process ‘hyperacute rejection’, there is now hope that several therapeutic strategies that are already available will overcome this problem. However, there are remaining hurdles to overcome. Delayed immune reaction, ethical concerns, physiological incompatibility and animal viruses will determine whether xenotransplantation will become a practical solution to the chronic shortage of allografts in clinical transplantation.

A patient with chronic hepatitis B underwent liver transplantation for end-stage cirrhosis. The donor liver graft had moderate steatosis and fibrosis. He was placed on lamivudine for hepatitis B prophylaxis but developed viral relapse due to emergence of a lamivudine-resistant mutant at week 72 posttransplantation. Results of liver biochemistry were normal liver histology revealed minimal steatosis and inflammation at weeks 151 and 128, respectively. This report illustrates that the use of a steatotic donor liver and the emergence of lamivudine resistance posttransplantation are not necessarily associated with significant graft damage. A marginal donor graft can be considered due to the donor shortage. Lamivudine monoprophylaxis for hepatitis B virus-related liver diseases post liver transplantation can be used in areas where hepatitis B immunoglobulin is not affordable.

Background: We aimed to investigate the clinical outcome of patients who develop lamivudine resistant hepatitis B virus mutants (YMDD mutants) after liver transplantation. Methods: Patients who received liver transplantation for hepatitis B-related liver diseases from 1999 to 2002 were studied. All patients received lamivudine monotherapy before and after liver transplantation. HBsAg and HBV DNA were regularly monitored, and YMDD mutation was detected by direct sequencing. Results: Twenty patients were followed up for median 94 wk (range: 15–177 wk) post-liver transplantation. Six patients developed YMDD mutants, and the cumulative probability of developing YMDD mutations post-liver transplantation was 21% in 1 yr and 34% in 2 yr. One patient developed YMDD mutants before liver transplantation and died of hepatitis reactivation and liver failure 15 wk post-transplantation. The other five patients developed YMDD mutants 32–72 wk after liver transplantation. Two of them developed severe hepatitis which responded promptly to adefovir dipivoxil. The remaining three patients with YMDD mutants had minimal to mild hepatitis. The cumulative survival for patients with YMDD mutants was 83% and 28% at 1 and 2 yr, respectively. Only one patient who did not develop YMDD mutants died at week 119 due to chronic rejection. The post-transplant survival for patients with YMDD mutants was significantly poorer than those without YMDD mutants (log rank test p = 0.083). Conclusions: The emergence of YMDD mutants after liver transplantation on lamivudine monoprophylaxis had wide range of clinical presentations and was associated with increased mortality.

Background: It is generally believed that positioning of the patient in a head-down tilt (Trendelenberg position) decreases the likelihood of a venous air embolism during liver resection. Methods: The physiological effect of variation in horizontal attitude on central and hepatic venous pressure was measured in 10 patients during liver surgery. Hemodynamic indices were recorded with the operating table in the horizontal, 20 degrees head-up and 20 degrees head-down positions. Results: There was no demonstrable pressure gradient between the hepatic and central venous levels in any of the positions. The absolute pressures did, however, vary in a predictable way, being highest in the head-down and lowest during head-up tilt. However, on no occasion was a negative intraluminal pressure recorded. Conclusion: The effect on venous pressures caused by the change in patient positioning alone during liver surgery does not affect the risk of venous air embolism.

Living related liver transplantation (LRLT) has gained popularity, especially in Asian countries as the primary mode of liver transplantation. LRLT, however, carries the inherent problem of potential donor harm. In view of reports of donor deaths and significant donor morbidity (as high as 67%), we examined donor complication rates in our LRLT program. All sixteen LRLT donors between February 2000 and January 2003 were retrospectively analyzed. The 16 donors (13 men, 3 women) of mean age 30 years (range, 18–49 years) included 5 donations from siblings, 2 from parents, and 9 from offsprings. The portion of liver donated was L hepatectomy (n = 4) R hepatectomy (n = 7), and Modified Extended R hepatectomy (n = 5) with the weight of resected liver being 618.9 g (range, 380–1000). The mean blood loss was 936 mL (range, 400–1900 mL), but only 2 donors required transfusion of banked blood. The mean intensive care unitstay was 1.06 days (range, 1–2 days) and the mean hospital stay was 9.12 days (range, 7–14 days). There was no case of reoperation and no mortality. There was no biliary or vascular complication. Four of 16 (25%) donors had a minor morbidity; 2 of 16 (12.5%) had a morbidity requiring intervention. In conclusion, with meticulous preoperative, intraoperative, and postoperative management, successful LRLT can be performed with minimal donor morbidities.

Severe acute respiratory syndrome (SARS) struck 1755 patients in Hong Kong and developed into a global health crisis. Although the World Health Organization and national health authorities are sparing no effort to contain the disease and to find a cure for the potentially deadly infection, SARS has an impact on our liver transplantation (LTx) program. Before the SARS outbreak, an average of 1 LTx was performed per month in our center. For 6 months since the outbreak, there had been no LTx performed. The intensive care unit had to be dedicated to patients with SARS. Two of the LTx team members were struck by SARS. A survey conducted among LTx recipients and their family members (n = 45) demonstrated symptoms of anxiety and stress in all. Some LTx recipients were treated at the Emergency Department for suspected SARS, which were later confirmed to be false alarms. Many LTx patients were too frightened to come back for follow-up. A new strain of coronavirus was identified as the causative agent. The origin of this virus is uncertain but the probability of zoonoses is being seriously discussed. Not only are immunosuppressed patients exposed to higher risk of infection, but also the waiting list mortality is also expected to increase. The SARS outbreak has demonstrated the vulnerability of an organ transplantation service and reminds us of the fearful possibility of zoonoses in future xeno-transplantation.

With a high prevalence of chronic hepatitis B and a low cadaveric organ donation rate, living donor liver transplantation (LDLT) remains the only option for many patients in Hong Kong. In such cases, the liver graft volume is smaller owing to a partial liver graft; therefore, a problem of small-for-size grafts often occurs. Between September 1999 and April 2003, 25 cadaveric, 16 living related, and 1 auto-LTs were performed at our center. The outcomes of LDLT were analyzed to assess the critical graft size and functional recovery. Among the 16 LDLT recipients (mean age, 44.4 +/- 14.4 years; mean weight, 61.9 +/- 11.4 kg), 1 patient received a graft from a donor left lobe (weight, 400 g) in an auxillary partial orthotopic LT (APOLT), 12 received right lobes, and 3 received left lobes. Besides the APOLT case, the overall graft/recipient weight ratio (GRWR) for the 15 LDLTs was 1.11 (0.76 to 1.75). The GRWR in the 25 cadaveric LTs was 1.92 (1.05 to 3.69) (P.001). Among the 12 successful LDLTs, there were 5 (41.7%) cases of small-for-size graft syndrome: 3 of 3 (100%) in GRWRor = 0.8%; 5 of 6 (83.3%) in GRWR1%; and 0 of 6 with GRWR1%. The initial post-LT graft function parameters were significantly higher among the LDLT group: International normalized ratio (INR), 1.42 vs 1.24, P = .03; alanine aminotransferase (ALT, 387 vs 201 IU/L, P = .005, and bilirubin, 170 vs 48 micromol/L, P.001 as compared to the cadaveric transplant group). Small-for-size graft syndrome can be avoided if GRWR1%, but often occurs when GRWR0.8%. Graft function in LDLT recovers more slowly than in cadaveric liver transplant.

Liver transplantation (LT) is an acceptable mode of treatment for selected patients with unresectable hepatocellular carcinoma (HCC). However, due to the scarcity of cadaveric donor organs, it is considered desirable for patients to opt for living donor liver transplantation (LDLT) or, for those not being transplanted soon, to have some form of tumor control therapy. Such an approach in our program is analyzed and reported. At our institution, 42 LTs were performed between October 1999 and April 2003. Of these, 18 recipients (15 men, 3 women) had 27 HCC. The average number and size of HCC was 1.59 (1 to 4) and 2.31 (0.2 to 6.5) cm, respectively. Thirteen (72%) patients were transplanted primarily for the HCC, whereas five (28%) others were incidental HCC cases. Seven patients (5 LRLT, 2 cadaveric LT) were transplanted soon after listing, and thus did not require tumor control therapy. Six patients waited for 11 (6 to 19) months before LT. Three patients underwent microwave coagulation therapy, and one had additional alcohol injections. One patient received the novel PIAF (cisplatin, interferon, adriamycin, and 5-FU) chemotherapy regimen followed by selective internal irradiation (SIR) treatment. One patient received conformal radiation therapy and another received SIR treatment before LT. Besides 2 postoperative deaths, the remaining 16 patients have been well, with a mean follow-up of 20.4 (3.6 to 41.2) months. In conclusion, for patients with unresectable HCC, in areas with poor cadaveric donor rate, living donation should be the first option. If a suitable live donor is not available, aggressive multimodality therapy is recommended while waiting for cadaveric LT.

THE HIGH prevalence of viral hepatitis B and its associated chronic complications in Hong Kong has produced many patients in need of liver transplantation. However, similar to other Asian countries, the persistent shortage of donor livers is a problem. Chinese people have the tradition of not parting with their organs after death. Consequently, requests for organ donation have only been successful in about 25% to 30% of cases during the past few years. Meanwhile, suboptimal management of potential donors has also resulted in graft losses. Potential organ donors are often not admitted to intensive care units, partly due to inadequate resources. Inadequate awareness of organ donation and transplantation within the medical profession has also been reported previously.