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Background There are long-standing controversies about the transplant indications for alcoholic liver disease (ALD), because of the recognition that ALD is fundamentally self-inflicted. However, it is unclear whether psychosocial characteristics of ALD are different from that of non-alcoholic liver disease (NALD) in the selection of liver transplantation (LT) recipients. We aimed to clarify the psychosocial characteristics of ALD recipients (ALD-R)/ALD recipient candidates (ALD-RC) and NALD recipients (NALD-R)/ NALD recipient candidates (NALD-RC). Methods From 2011 to 2019, 75 patients were enrolled in this prospective observational study (ALD-RC, n = 19; NALD-RC, n = 56), LT were carried out as follow; ALD-R, n = 6; NALD-R, n = 52. We evaluated psychosocial characteristics in the preoperative period and 3, 12 months after LT (ALD-R, n = 3/3; NALD-R, n = 28/25). The following scales were used to evaluate psychosocial characteristics: Visual Analogue Scale, Alcohol Use Disorders Identification Test, Hospital Anxiety and Depression Scale, Beck Depression Inventory, Brief Evaluation of Medication Influences and Beliefs, Social Support Questionnaire (SSQ), Temperament and Character Inventory, Parental Bonding Instrument (PBI), the Short Form Health Survey (SF-36). Results When evaluating on the basis of abstinence rule, a comparison of ALD-RC and NALD-RC in the preoperative period identified similar patterns of psychosocial characteristics, except that the NALD-RC scored higher on the PBI item “overprotection from mother” (P Conclusion The psychosocial characteristics of ALD-RC and NALD-RC may be similar when evaluated on the basis of Japan’s abstinence rule. This result also imply that the psychosocial characteristics of ALD-RC may differ from the previously reported psychosocial characteristics of alcohol dependent patients. These findings have the potential to provide helpful information for the evaluation of ALD-RC.

The present study investigated the possible risk factors, including relationship/HLA matching between donor and recipient, and immunosuppressive therapies on the recurrence of primary sclerosing cholangitis (PSC) after liver transplantation (LT). Subjects were 197 recipients of LT for PSC, among whom 180 surviving more than 1 year after LT were further analyzed for risk factors of recurrence. The 5- and 10-year patient- and graft survival rates were 83% and 68%, and 71% and 62%, respectively. The overall PSC recurrence rate was 25% with a 5- and 10-year graft survival rate of 34% and 18%, which was significantly lower than the survival rate of those without recurrence (P 0.001). Univariate analysis identified the following as risk factors for recurrence: donor age (P 0.001), cyclosporine use (P = 0.012), mono or no immunosuppressive agent (P 0.001), postoperative biliary complication (P 0.001), and active intestinal bowel disease after LT (P 0.001). Among these factors, donor age ≥45 years [hazard ratio (HR), 1.65; 95% confidence interval (CI), 1.21-2.69; P = 0.003] and mono or no immunosuppressive agent 1-year after LT (HR, 2.38; 95% CI, 1.23-3.45; P = 0.011) were identified as independent risk factors in the final multivariate Cox regression model. The results were similar in sub-analysis for ABO-identical/compatible adult living donor LT cases.

Highlights • We presented a novel anatomic variation of intrahepatic biliary tree, which had never been reported. • The computerized overlay visualization of MRCP and 3-D CT helped biliary anatomical understanding for operation planning. • Precise preoperative evaluation helped safe living donor surgery and living donor liver transplantation., Introduction Anatomic variations of the biliary tree are common, making precise anatomic evaluation important before hepatobiliary surgery. Presentation of case A 52-year-old woman with no medical history was admitted to our hospital for a live-liver donation to her husband. During her evaluation, magnetic resonance cholangiopancreatography (MRCP) revealed a previously unknown anatomic variation in her biliary system. Segment 2 of the bile duct (B2) independently drained into the posterior branch and formed a common channel (B2+posterior) before joining the anterior branch. Then, bile duct segments 3 and 4 (B3+4) drained into this B2+posterior+anterior channel to form a common hepatic duct. The computerized overlay features shown by MRCP and three-dimensional computed tomography clarified this anatomic variation. A right lobe donor graft was then obtained successfully, with intraoperative cholangiography confirming that the donated graft had two bile duct orifices (i.e., posterior and anterior branches). We thus avoided surgical missteps that would have disallowed bile drainage of B2 and B3+4 into the common hepatic duct. Discussion Precise evaluation is mandatory for hepatobiliary surgical planning to rule out, or discover, challenging bile duct anatomy. Conclusion Preoperative computerized overlay visualization of MRCP and computed tomography allowed definition of a previously unknown biliary tree variation.

Background Chronic high Epstein-Barr virus loads (CHEBV) are commonly observed in pediatric liver transplant patients. However, it is unclear how CHEBV impacts the liver graft. The aim of this study was to clarify the clinical and pathological impacts of CHEBV on the liver graft. Methods From 2012 through 2020, we retrospectively investigated 46 pediatric liver transplant patients (under 16 years old) who survived ≥ 6 months. The patients were divided into two groups: CHEBV group (EBV DNA >10,000 IU/mL of whole blood for ≥ 6 months) and NCHEBV group (patients who did not meet CHEBV criteria). Tacrolimus was reduced to 5,000 IU/mL. Blood biochemistry date and pathological findings, obtained at the time of protocol and episodic biopsy, were compared between the two groups. Results Out of 46 patients, 28 CHEBV and 18 NCHEBV patients were enrolled. The blood biochemical examination did not show a significant difference between the two groups. In addition, no significant differences between the two groups were found in the pathological findings, including frequency of late acute rejection and the progression of fibrosis at the time of both protocol and episodic biopsy. Appropriate adjustment of immunosuppression for CHEBV management may have contributed to the prevention of the progression of fibrosis. Conclusion CHEBV had little adverse effect on the liver graft. Graft fibrosis might have been avoided through optimal dose modification of tacrolimus. Further long-term monitoring is necessary because CHEBV may affect the pediatric liver graft in the long term. This article is protected by copyright. All rights reserved.

In living donor liver transplantation (LDLT), anastomotic biliary stricture is a serious and refractory complication. In this study, we reviewed the transition of post-LDLT anastomotic biliary strictures and evaluated long-term outcomes of stent placement inside the bile duct, which is referred to as an "inside-stent." Of 805 consecutive adult LDLT recipients in our institution (2000-2018), we reviewed 639 patients with duct-to-duct biliary reconstruction and analyzed chronological changes of post-LDLT biliary strictures. Moreover, we focused on the year 2006 when various surgical modifications were introduced and compared the details of post-LDLT biliary strictures before and after 2006, especially focusing on the long-term outcome of inside-stent placement. The proportion of left lobe grafts had increased from 1.8% before 2005 to 39.3% after 2006 (P < 0.001) to maximize the living donor safety. Overall, post-LDLT anastomotic biliary strictures occurred in 21.3% of the patients with a median follow-up period of 106.1 months, which was decreased from 32.6% before 2005 to 12.8% after 2006 (P < 0.001). Anastomotic biliary strictures were less frequent in patients with left lobe grafts than with right lobe grafts (9.4% versus 25.4%; P < 0.001). The overall technical success rate of inside-stent placement was 82.4%, with an improvement from 75.3% before 2005 up to 95.7% after 2006 (P < 0.01). Furthermore, the stricture resolution rate remained high at approximately 90% throughout the observation period. Increased use of left lobe grafts with several surgical modifications significantly reduced post-LDLT anastomotic biliary strictures, leading to favorable long-term outcomes of inside-stent placements for this condition.

Background The purpose of this study was to examine the impact of pretreatments on outcomes after living donor liver transplantation (LDLT) for hepatocellular carcinoma (HCC). Methods From February 1999 to March 2015, 223 patients underwent LDLT for HCC. Until December 2006, there was no restriction in patient selection criteria regarding the number and size of tumors, following which we implemented the Kyoto criteria (tumor number ≤10, maximal diameter ≤5 cm, and des-gamma-carboxy prothrombin ≤400 mAU/ml) since January 2007. Results Of 223 patients, 156 had a history of pretreatments. Among 101 patients meeting the Milan criteria at the initial diagnosis, 38 progressed to beyond the criteria at liver transplantation (LT). Twenty-two out of 38 met the Kyoto criteria, and their survival and recurrence rates were significantly better than those of patients exceeding the Kyoto criteria (P = 0.004 and 0.035, respectively). Regarding the number of pretreatments (0 vs. 1-4 vs. ≥5), recurrence rate was significantly higher in the ≥5 pretreatments group than the 0 group. However, for patients meeting the Kyoto criteria, there were no significant differences in recurrence rates between these three groups. Conclusion Better outcomes will be achieved by performing LT for HCCs meeting the Kyoto criteria even after repeated pretreatments.

Aim Graft-versus-host disease (GVHD) following liver transplantation is rare but fatal. Therefore, it is important to identify possible risk factors before transplantation. Although it has been suggested that donor-dominant one-way human leukocyte antigen (HLA) matching of three loci (HLA-A/B/DR) is associated with the occurrence of GVHD, the precise significance of HLA matching including HLA-C/DQ/DP remains unclear. Methods We retrospectively analyzed the impact of donor-dominant one-way HLA matching at six HLA loci at the allele level on GVHD using clinical registry data from 1759 cases who underwent living donor liver transplantation between June 1990 and June 2019. We extracted cases with donor-dominant one-way HLA matching at the antigen level and reconfirmed them at the allele level using preserved DNA samples. Results Three of four cases (75%) who developed GVHD showed donor-dominant one-way HLA matching at three HLA-A/B/DR loci. These cases also showed donor-dominant one-way HLA matching at HLA-C/DQ/DP. Three of six cases (50%) with donor-dominant one-way HLA matching at three loci of HLA-A/B/DR developed GVHD. Notably, none of the cases with donor-dominant one-way HLA matching at one or two HLA-A/B/DR loci developed GVHD, irrespective of matching status at HLA-C/DQ/DP. The HLA matching status at the antigen level was revised in 22 of 56 cases, following reconfirmation at the allele level. Conclusions Pairing of donors and recipients with donor-dominant one-way HLA matching at three HLA-A/B/DR loci should be avoided to prevent GVHD. No impact of HLA-C/DQ/DP on GVHD was identified. For liver transplantation, HLA genotypes should be determined at the allele level.

BACKGROUND In the field of living donor liver transplantation (LDLT), it is important to ensure donor's psychological well-being. We report on clinical features and long-term outcomes of LDLT donors who developed psychiatric disorders after their donor operations. Additionally, we compare patient backgrounds, as well as surgical and perioperative aspects between LDLT donors with and without postoperative psychiatric complications. MATERIAL AND METHODS Between November 1998 and March 2018, we identified 254 LDLT donors at our hospital. Among these, we investigated those who had newly developed psychiatric complications and required psychiatric treatment after donor operation. RESULTS The median duration of follow-up was 4 years. Sixty-five donors were lost to follow-up. Eight donors (3.1%) developed postoperative psychiatric complications, including major depressive disorder in 4, panic disorder in 2, conversion disorder and panic disorder in 1, and adjustment disorder in 1. The median duration from donor surgery to psychiatric diagnosis was 104.5 days (range, 12 to 657 days) and the median treatment duration was 18 months (range, 3 to 168 months). Of those, 3 donors required psychiatric treatment over 10 years, and 4 donors remained under treatment. The duration of hospital stay after donor operation was significantly longer and perioperative complications with Clavien classification greater than grade IIIa were more frequent in donors with psychiatric complications than in those without psychiatric complications (P=0.02 and P=0.006, respectively). CONCLUSIONS Accurate diagnosis and appropriate treatment for psychiatric disorders by psychiatrists and psychologists are important during LDLT donor follow-up. Minimization of physiological complications might be important to prevent postoperative psychiatric complications in LDLT donors.

The delayed diagnosis of insulinoma remains a clinical issue. One of the main causes of such a delay is hypoglycemia unawareness. A 53-year-old woman fell unconscious during postprandial exercises. Flash glucose monitoring (FGM) systems revealed glucose profiles with fasting hypoglycemia, which facilitated the clinical diagnosis of insulinoma even though she was unaware of her hypoglycemia. The preoperative comparison of the blood glucose values provided by FGM with those obtained from capillary blood were consistent. Thus, FGM may have potential utility in revealing the presence of insulinoma-induced hypoglycemia.

Preoperative anemia was reportedly associated with increased morbidity and mortality after various types of surgeries. However, its impact on the outcomes after liver transplantation has not been thoroughly investigated. We retrospectively investigated the clinical outcome of 216 consecutive adult patients who underwent living donor liver transplantation at our institute between January 2010 and June 2017 and stratified them according to the hemoglobin level before transplant. Risk factors for 90-day patient mortality, especially infection-related mortality and early graft loss, were evaluated. We found that patients with preoperative hemoglobin below 10 g/dl required more intraoperative packed red blood cell transfusions (p = 0.002) and had significantly higher early 90-day postoperative mortality rate (p = 0.007), particularly infection-related mortality (p = 0.002), lower overall graft, and patient survival rates (p = 0.007, p = 0.013, respectively). Preoperative hemoglobin below 10 g/dl was an independent risk factor for increased post-transplant 90-day patient mortality (OR 2.92, p = 0.02), infection-related mortality (OR 6.81, p = 0.02), and early graft loss (OR 3.26, p = 0.01). Preoperative hemoglobin level below 10 g/dl is associated with poorer short-term outcomes after liver transplantation and should be corrected preoperatively if possible through safe and effective treatment modalities.

OBJECTIVE To investigate the influence of donor age on recipient outcome after living-donor partial liver transplantation (LDLT). BACKGROUND Donor age is a well-known prognostic factor in deceased donor liver transplantation; however, its role in LDLT remains unclear. METHODS We retrospectively analyzed 315 consecutive cases of primary adult-to-adult LDLT in our center between April 2006 and March 2014. Recipients were divided into 5 groups according to the donor age: D-20s (n = 60); D-30s (n = 72); D-40s (n = 57); D-50s (n = 94); and D-60s (n = 32). The recipient survival and the association with various clinical factors were investigated. RESULTS Recipient survival proportions were significantly higher in D-20s compared with all the other groups (P = 0.008, < 0.001, < 0.001, and = 0.006, vs D-30s, -40s, -50s, and -60s, respectively), whereas there was no association between recipient survival and their own age. There are 3 typical relationships between donors and recipients in adult-to-adult LDLT: from child-to-parent, between spouses/siblings, and from parent-to-child. The overall survival in child-to-parent was significantly higher than in spouses/siblings (P = 0.002) and in parent-to-child (P = 0.005), despite significantly higher recipient age in child-to-parent [59 (42-69) years, P < 0.001]. Contrastingly, parent-to-child exhibited the lowest survival, despite the youngest recipient age [26 (20-43) years, P < 0.001]. In addition, younger donor age exhibited significantly better recipient survival both in hepatitis C virus-related and in non-hepatitis C virus diseases. Univariate and multivariate analyses both demonstrated that donor age and graft-type (right-sided livers) are independent prognostic factors for recipient survival. CONCLUSIONS Donor age is an independent, strong prognostic factor in adult-to-adult LDLT.

Antibody-mediated rejection (AMR) is a refractory rejection after donor-specific antibody-positive or ABO blood-type incompatible (ABOi) organ transplantation. Rituximab dramatically improved the outcome of ABOi living-donor liver transplantation (LDLT); however, an effective treatment for posttransplant AMR, once occurred, is yet to be established. A 44-year-old woman with biliary cirrhosis underwent ABOi-LDLT from her sister (AB-to-A). Pretransplant rituximab diminished CD19/20-positive B lymphocytes to 0.6%/0.0%; however, AMR occurred on posttransplant day-6 with marked increase in both CD19/20 cells (17.1%/5.8%) and anti-B IgM/G-titers (1024/512). Despite rituximab readministration, steroid-pulse, intravenous immunoglobulin, and plasmapheresis, AMR was uncontrollable, with further increasing CD19/20 cells (23.0%/0.0%) and antibody-titers (2048/512). Bortezomib (1.0 mg/m2) was thus administered on posttransplant day-9, immediately ameliorating CD19/20 cells (1.3%/0.0%) and antibody-titers (

Introduction: Budd-Chiari syndrome (BCS) associated with hypereosinophilic syndrome (HES) is very rare, and only a few reports have described its treatment. Furthermore, no report to date has described the performance of liver transplantation for the treatment of BCS associated with HES. We herein describe a 54-year-old man who underwent deceased-donor liver transplantation (DDLT) for treatment of BCS associated with HES. Case: A 54-year-old man was found to have an increased eosinophil count during a medical check-up. After exclusion of hematopoietic neoplastic diseases and secondary eosinophilia, idiopathic hypereosinophilia was diagnosed. Oral prednisolone was administered to the patient, and his eosinophil count immediately decreased to a normal level. He had an uneventful course without complications for 11 months but then presented with bloating and malaise. Imaging studies including ultrasonography, enhanced computed tomography, and angiography revealed BCS associated with HES. Transjugular intrahepatic portosystemic shunt failed because of complete obstruction of the hepatic veins. Therefore, the patient was introduced to our hospital for liver transplantation. DDLT was performed with venovenous bypass 1 month after the patient was placed on the DDLT waiting list. The explanted hepatic veins were completely occluded and organized. The patient’s eosinophil count was maintained at a normal level with prednisolone treatment after DDLT. Conclusions: Liver transplantation can be a treatment option for BCS associated with HES if neoplastic diseases and secondary eosinophilia have been excluded. Life-long oral steroid therapy is required to control HES even after liver transplantation., ファイル公開：2020-11-01

Background. The ABO blood-type barrier in kidney and liver transplantation has been overcome by aggressive treatments such as B cell depletion using rituximab. However, the long-term effects of ABO-incompatible liver transplantation (ABO-I LTx) on immunological status have not previously been studied. Here, we assessed whether long-term immune hyporesponsiveness against ABO blood-group antigens was retained. Methods. We recruited 81 patients, 75 patients who had survived ABO-I LTx without retransplantation and 6 patients who had survived after retransplantation using blood type-compatible grafts. The time between ABO-I LTx and outpatient visits for blood sampling for this study ranged from 1.1 to 16.8 years. We also evaluated patients' backgrounds and postoperative therapies. Results. Overall, antidonor ABO antibody titers in the 75 patients without retransplantation decreased during long-term follow-up. In the subset of 40 patients with blood type O, anti-nondonor ABO antibody titers did not decrease and were significantly higher than antidonor ABO antibody titers. In addition, long-term antidonor ABO antibody titers were significantly lower in pediatric patients than in adult patients. In the 6 patients who were retransplanted with blood type–compatible grafts, antidonor ABO antibody immunoglobulin G titers remained low, but IgM titers increased slightly long after removal of the ABO-incompatible graft. Conclusions. These findings suggest that donor-specific hyporesponsiveness remains after ABO-I LTx, particularly in pediatric patients. Long-term persistence of blood antigens may contribute to this donor-specific hyporesponsiveness.

Purpose Novel diagnostic and therapeutic strategies for chronic lung allograft dysfunction (CLAD) are pressing priorities. We previously reported that CD26/DPP-4 inhibition attenuated ischemia-reperfusion injury, acute rejection and chronic fibrosis in mouse lung transplantation (LTx), and in our recent clinical study, a CD26/DPP-4 inhibitor improved CLAD-free survival (ISHLT 2020 abstract). To elucidate the mechanism of CD26/DPP-4 inhibitors in LTx, and apply them in the clinic, we investigated CD26 expression in CLAD clinical specimens. Methods Among patients who underwent LTx in our institution, we retrieved pathological specimens from re-LTx and autopsy cases. We also included two native lung samples from LTx recipients. We performed hematoxylin-eosin and Elastica-Masson staining and immunohistochemistry using a CD26 antibody. We evaluated the pathological findings and clinical characteristics. Results We evaluated 11 patients (6 females, 5 males) with a median age of 43 (8-58) years. The pathological samples were nine allografts and two native lung specimens. Of the allografts, six were obtained at autopsy, performed 38 (12-71) [median (range)] months after LTx, and three were obtained by resection during re-LTx, performed 20 (17-59) months after the initial LTx. Seven patients had diabetes mellitus, but none received CD26/DPP-4 inhibitors. Seven patients (four autopsy and three re-LTx cases) had CLAD with bronchiolitis obliterans (BO) pathology. Immunohistochemistry revealed clusters of CD26+ epithelial cells adjacent to the BO lesions or in the obstructed bronchial lumen in six of the seven CLAD patients. One CLAD patient without CD26 expression died from lung cancer, rather than CLAD, which was diagnosed at autopsy. In the non-CLAD or native lung samples, the CD26+ epithelial cell clusters were not detected. Conclusion Clusters of CD26+ epithelial cells were detected in CLAD, but not non-CLAD, samples. CD26 might be a novel biomarker and therapeutic target for CLAD.

Background Smaller size grafts for living donor liver transplantation (LDLT) can enhance donor safety and expand donor availability. We previously reported that modulation of portal venous pressure (PVP) was key for successful LDLT with small grafts, and that it actively lowered graft-to-recipient weight ratio (GRWR) for adult-to-adult LDLT. This retrospective study investigated the outcome of LDLT using small grafts with PVP modulation. Method This study analyzed 221 adult LDLT patients between March 2008 and December 2013 and divided them into 3 groups based on GRWR: large (L), GRWR ≥ 0.8% ( n = 154), medium (M), ≥ 0.7% GRWR n = 38); and small (S) GRWR n = 29). Donor and recipient factors, PVP, pressure gradient between PVP and central venous pressure (CVP), occurrence of small for size syndrome (SFSS), ascites, and posttransplant laboratory data were compared across the 3 groups. Patient and graft survival were compared using Kaplan–Meier methods. Results There was no difference in patient or graft survival between the 3 groups. Amount of posttransplant ascites and posttransplant International Normalized Ratio were similar, but the S and M groups had more prolonged cholestasis. SFSS was identified in 17%, 13%, and 13% in the S, M, and L groups, respectively ( P = NS). Patients with a final PVP of ≤15 mmHg had better survival than patients with a final PVP of >15 mmHg ( P 40 years old, final PVP of >15 mmHg, and pressure gradient of PVP-CVP >5 mmHg were risk factors for inferior patient survival. Conclusion We achieved satisfactory outcomes in LDLT with GRWR as low as 0.6% using PVP modulation. Thus, we currently set a lower limit of GRWR at 0.6% while protecting donor safety and expanding donor availability.

Tokyo Metro Co., Ltd. (hereinafter, Tokyo Metro) comprises nine lines operating over 195.1km and 179 stations, and is used by 7.07 million passengers per day. Tokyo Metro operates on the belief that security equals safety plus service. In regard to safety, special effort is devoted toward countermeasures for natural disasters. In light of recent extreme weather events, countermeasures for heavy rains are particularly important. It was reported in the updated expectations for flood damage published in 2009 that metropolitan area's 17 lines and 97 stations and 147km of the tunnels will be completely submerged underwater. In response to expectations, we are developing and installing various waterproofing facilities at all tunnel entrances, ventilation openings, underground station entrances and other openings. Among these, underground station entrances are expected to suffer the most damage. Most Tokyo Metro station entrances are situated on sidewalks, there are many obvious spatial restrictions. In light of these restrictions, conventional waterproofing doors (hinged doors that apply positive pressure against floodwater pressure) cannot be used to improve all entrances, thus we have continued to develop counterpressure doors, hinged double doors, shutters, bi-fold doors and other types of waterproofing doors that fit the environments of individual entrances. In addition, few of the many buildings to which Tokyo Metro tunnels connect underground are prepared for the updated expectations for flood damage, meaning that Tokyo Metro must take action on its own property to prevent flood water inundation from such buildings. This means taking flood control measures in underground concourses with severe spatial limitations. Thus, we have developed counterpressure sliding doors capable of withstanding water pressure from flooding up to 15 m deep. This report describes updated expectations for floods, Tokyo Metro's improvement policy and descriptions of various types of underground waterproofing doors and the performance required of them.

Niemann-Pick disease type C (NPC) is a rare autosomal recessive inherited disease characterized by lysosomal accumulation of free cholesterol in macrophages within multiple organs. Infantile-onset NPC often presents with jaundice and hepatosplenomegaly from birth, but these symptoms usually improve during early childhood, and it rarely progresses to liver failure. We report three cases from different hospitals in Japan; the patients developed neonatal-onset NPC, and liver transplantation (LT) was performed as a life-saving procedure. LT was performed at 19 days, 59 days, and 4 months of age, respectively. The last patient was diagnosed with NPC before LT, while the first two patients were diagnosed with neonatal hemochromatosis at LT. In these two patients, the diagnosis of NPC was made more than a year after LT. Even though oral administration of miglustat was started soon after the diagnosis of NPC, all patients showed neurological regression and required artificial respiratory support. All patients survived more than one year after LT; however, one patient died due to tracheal hemorrhage at 4.5 years of age, and another one patient was suspected as recurrence of NPC in liver graft. In conclusion, while LT may be a temporary life-saving measure in patients with neonatal-onset NPC leading to liver failure, the outcome is poor especially due to neurological symptoms. A preoperative diagnosis is thus critical.

Prophylactic measures are used to reduce DNHB after HBsAg-negative patients receive anti-HBc-positive liver grafts. This study investigated the incidence of DNHB and clinical outcomes in pediatric LT recipients under HBIG prophylaxis, with or without hepatitis B vaccination. Between 1995 and 2013, 51 HBsAg-negative pediatric recipients underwent living-donor LT from anti-HBc-positive donors. The median (range) age was 4 (0.1-17) years, 23 (45%) were male, and 71% were negative for both anti-HBc and anti-HBc. During a median follow-up of 12.1 (0.06-19.9) years, 13 (25.4%) developed DNHB; 7 of the 13 achieved HBsAg seroconversion after administration of LAM or ETV. Among studied patients, 20 (39%) received hepatitis B vaccination, and 2 of them (10%) developed DNHB. At last follow-up, 41% (21/51) discontinued HBIG either after successful HBV vaccination (n = 17) or retransplantation with anti-HBc-negative grafts (n = 4). In conclusion, pediatric LT recipients of anti-HBc-positive grafts, most of them were naive to HBV infection, were at high risk of DNHB, and consistent monitoring for the early detection of DNHB was necessary. A combination use of post-LT vaccination is promising prophylactic strategy against DNHB.

Background The impact of human leukocyte antigen (HLA) compatibility and positive lymphocyte cross-match (LCM) on organ transplantation is well-recognized particularly in kidney and heart transplantation; however, it is still debatable in liver transplantation (LT). So, the aim of this study was to evaluate the impact of HLA mismatch and positive LCM on the outcome of LT. Methods We retrospectively analyzed the data of all adult recipients who underwent living donor LT at our institute between January 2010 and July 2016. We excluded all ABO blood group incompatible LDLT patients and patients with incomplete data regarding HLA genotyping (n = 134). The type and degree of HLA-A, HLA-B, HLA-C, HLA-DR, HLA-DQ mismatch and LCM were assessed in each donor-recipient pair and their relationship to the occurrence of rejection, CMV infection and graft survival was evaluated. Results A higher percentage (>50%) of donor-recipient pairs had 1 HLA mismatch at each locus in the host-vs-graft direction and seventeen recipients (13%) had positive LCM. Human leukocyte antigen mismatch and positive LCM were not correlated with increased incidence of acute rejection (P = .37, P = .6, respectively), CMV infection post-transplant (P = .52, P = .76, respectively), or graft failure (HR 1.22, P = .68 and HR 1.73, P = .34, respectively). Conclusion Positive LCM and HLA mismatches did not affect the overall graft survival after adult-to-adult LDLT and should not be considered as contraindications for liver transplantation.

LT has contributed to an elevation in cure rates for patients with unresectable HB; however, patients with recurrent HB after LT have poor prognosis. To analyze the prognostic and therapeutic factors that influence the clinical outcome of patients with HB receiving LT, we retrospectively analyzed 24 patients with HB who underwent LT between 1997 and 2015. The 5-year OS rate of all patients was 69.6±9.7%. The 5-year OS rate of 11 patients receiving salvage LT for recurrent tumor after a primary resection was comparable to that of 13 patients receiving primary LT. Among 12 evaluable patients receiving primary LT, six of 10 patients with a decline of serum AFP >95% at LT are currently alive and in remission, whereas two patients with a decline of AFP ≤95% experienced post-LT relapse. Among 9 evaluable patients receiving salvage LT, all three patients with any decline of AFP at LT are currently alive in remission, and three of six patients with no response to pre-LT salvage chemotherapy are also alive and in remission. Response to chemotherapy may be a reliable marker for prediction of post-LT relapse, even for patients receiving salvage LT.

Supplemental digital content is available in the text., Background Primary sclerosing cholangitis (PSC) is a progressive cholestatic liver disease, with liver transplantation being the sole life-saving treatment for end-stage PSC-related liver disease. However, recurrence of PSC after liver transplantation is a common complication, with the risk factors for recurrence being controversial. Methods We conducted a retrospective chart review of 45 patients who had undergone liver transplantation for PSC at our institute. The risk factors for PSC recurrence and graft failure after liver transplantation were analyzed. Results The graft survival rates were 55.4% at 5 years and 32.8% at 10 years after liver transplantation for PSC. PSC recurrence was diagnosed in 16 (40%) of 40 patients, at a median 30 months (range, 9-70 months) after liver transplantation. The cumulative incidence rate of PSC recurrence was 24.5% at 3 years, 39.3% at 5 years, and 45.8% at 6 years. Among the 16 patients diagnosed with PSC recurrence, the graft survival rate was 56.3% at 5 years, and 21.9% at 10 years after the recurrence. Active inflammatory bowel disease after liver transplantation was identified as an independent risk factor for PSC recurrence. Age younger than 30 years at the time of PSC diagnosis and bacteremia were factors significantly associated with graft failure after liver transplantation on multivariate analysis. Conclusions PSC frequently recurred and progressed to graft failure after liver transplantation for PSC. Maintaining an inactive status of inflammatory bowel disease might offer protection against PSC recurrence.

Aim Hepatitis B virus (HBV) reactivation after liver transplantation in HBV patients, or in HBV negative recipients of anti-hepatitis B core (HBc) positive grafts, has been prevented by prophylactic use of hepatitis B immunoglobulin (HBIG) and/or nucleoside/nucleotide analogs (NA). Vaccination against HBV is an alternative that may provide a chance to discontinue prophylaxis by producing anti-hepatitis B surface (HBs) antibodies. Methods We retrospectively reviewed 40 HBV positive recipients (HBV+ group) and 27 HBV negative recipients of anti-HBc positive grafts (HBV−/anti-HBc+ graft group), who were administrated double-dose hepatitis B vaccination. Recipients were regarded as responders when anti-HBs greater than 100 IU/L was maintained for 6 months or more without HBIG. Response rates of vaccine and long-term outcomes were analyzed. Results Eighteen of the 40 patients in the HBV+ group (45%) and 18 of the 27 patients in the HBV−/anti-HBc+ graft group (67%) responded to vaccination after a median of four and three times, respectively. Younger age was the only independent factor associated with vaccine response in the HBV−/anti-HBc+ graft group (P = 0.03), whereas no factor was found to be an independent predictor for vaccine response in the HBV+ group. Among the 18 responders in the HBV+ group, 17 remained without NA or HBIG 8.2 years after the start of vaccination. Ten of those required periodic booster vaccination. All 18 responders in the HBV−/anti-HBc+ graft group remained free from HBV prophylaxis 6.2 years after the start of vaccination. Conclusion Younger recipients have a greater chance to develop sufficient anti-HBs after double-dose HBV vaccination, leading to discontinue HBV prophylaxis.

BACKGROUND Many pediatric patients who receive a living-donor liver transplant undergo withdrawal of immunosuppression (IS). For them, the high incidence of long-term progressive graft fibrosis is of particular concern. METHODS We conducted a cross-sectional study including 81 pediatric patients who underwent IS withdrawal after living-donor liver transplant at Kyoto University Hospital and whose serum samples and pathological data could be obtained during the analysis period. We examined the association of donor-specific anti-human leukocyte antigen (HLA) antibody (DSA) and angiotensin II type 1 receptor antibody (anti-AT1R Ab) with posttransplant graft fibrosis. Normalized mean fluorescence intensity (MFI) 5,000 or higher and anti-AT1R Ab concentrations 17 U/mL or higher were both considered high level. The patients were classified into an advanced fibrosis group (AFG) (Ishak score ≥ 3) and a control group (CG) (Ishak score ≤ 2). RESULTS Only one patient demonstrated DSA class I. Among those who demonstrated DSA class II, more AFG patients than CG patients demonstrated high-level mean fluorescence intensity, although the difference was not significant (64% vs. 39%; P=0.053). The incidence of high-level DSA-DRB1, however, was significantly higher in the AFG than that in the CG (40% vs. 4%; P

Early allograft dysfunction (EAD) defined by serum total bilirubin (TB) of 10 mg/dL or greater or prothrombin time-international normalized ratio (PT-INR) of 1.6 or greater on postoperative day 7 (POD 7) or aminotransferase greater than 2000 IU/L within the first week, is associated with early graft loss after deceased-donor liver transplantation. We aimed to determine the prognostic impact of the EAD definition in living-donor liver transplantation (LDLT).We analyzed the validity of the EAD definition and its impact on early graft survival in 260 adult recipients who underwent primary LDLT.Eighty-four (32.3%) patients met the EAD criteria; 59 (22.7%) and 46 (17.7%) patients had TB of 10 mg/dL or greater and PT-INR of 1.6 or greater on POD 7, respectively, and 22 (8.5%) patients satisfied both criteria. Graft survival differed significantly when stratified according to TB of 10 mg/dL or greater and PT-INR of 1.6 or greater (P0.0001). PT-INR of 1.6 or greater resulted in higher graft mortality (risk ratio [RR], 3.87; P0.0001 at 90 days; RR, 2.97; P0.0001 at 180 days), as did TB of 10 mg/dL or greater (RR, 1.89; P = 0.027 at 90 days; RR, 1.91; P = 0.006 at 180 days). Coexistence of TB of 10 mg/dL or greater and PT-INR of 1.6 or greater was strongly associated with early graft loss (59.1%, RR, 6.97 at 90 days; 68.2%; RR, 5.75 at 180 days). In Cox regression analysis, PT-INR of 1.6 or greater and TB of 10 mg/dL or greater on POD 7 were significant risk factors for early graft loss (hazard ratio, 4.10; 95% confidence interval, 2.35-7.18; P0.0001, and hazard ratio, 2.43; 95% confidence interval, 1.39-4.24; P = 0.0018, respectively).TB of 10 mg/dL or greater and/or PT-INR of 1.6 or greater on POD 7 predicted early graft loss after LDLT, and their coexistence worsened patient outcomes.

We aimed to compare the early results of i.v. with p.o. TAC as a primary immunosuppressant in pediatric patients undergoing LT. This retrospective study enrolled 75 children who underwent LT and received TAC-steroid regimens as a primary immunosuppressant between September 2011 and October 2015 at our institution. Thirty-five recipients received TAC i.v. and 40 received TAC p.o. Early results were evaluated and compared, including ACR, EBV, or CMV infection; renal adverse effects; and hospital stay. Comparisons of 90-day post-transplant results showed that the rates of overall viral (74% vs 40% P

Indocyanine green fluorescent image-guided surgery was developed to identify primary and metastatic nodules of various malignancies. However, currently, surgeons need to identify the fluorescent image on a monitor, which impedes surgical procedures. Herein, we developed a novel projection mapping device that can cast the real-time fluorescent image onto the surface of the targeted organ. We performed surgical resection of a lung metastasis of hepatoblastoma using this technique. The projection mapping technique clearly detected the pulmonary lesion, and no other lesions were identified in the ipsilateral thorax. The patient is well and free of recurrence 2 years after surgery.

Background The cause of late graft dysfunction has not been elucidated. Although an antibody-mediated reaction is suspected as a potential mechanism, the target antigens have not been clarified. Methods To clarify the etiology of idiopathic posttransplantation hepatitis (IPTH), we simultaneously examined the presence of antibodies that react with liver tissue (ARLT) by means of indirect immunofluorescence staining, as well as the presence of donor-specific anti-human leukocyte antigen antibodies (HLA-DSA). A subanalysis of the IPTH group was also performed. Within the IPTH group, the correlation between ARLT titer and clinical data were analyzed. Results In the sera of patients with IPTH (30 patients), ARLT were found at a significantly higher frequency than in patients without IPTH (42 patients; P < 0.001). Moreover, the ARLT titer appeared to be correlated with the severity of hepatitis or hepatic injury. In contrast, the frequency of HLA-DSA was significantly lower in patients with IPTH than in patients without IPTH (P = 0.001). Conclusion Our findings indicate that ARLT, and not HLA-DSA, profoundly influence the etiology of IPTH., The authors show that antibodies that react with liver tissue and not donor-specific anti-human leukocyte antigen antibodies, profoundly influence the etiology of idiopathic posttransplantation hepatitis in children providing a rationale for therapy.

We report that coupling of molecular biaxiality and chirality is effective for blue phase stabilization. We show a U-shaped binaphthyl derivative with a cubic blue phase and some T-shaped compounds with an amorphous blue phase III (BPIII). We designed a ternary system consisting of a conventional nematic mixture, a T-shaped BPIII stabilizer, and a chiral dopant. BPIII of the system exhibited high transmittance, submillisecond response, and hysteresis-free switching at room temperature. Amorphous BPIII, with a level of symmetry equal to that of an isotropic liquid, is thought to have a superior potential for use in next-generation displays.

[Purpose]Uncontrollable hepatic hydrothorax and massive ascites (H&MA) requiring preoperative drainage are sometimes encountered in liver transplantation (LT). We retrospectively analyzed the characteristics of such patients and the impact of H&MA on the postoperative course. [Methods]We evaluated 237 adult patients who underwent LT in our institute between April 2006 and October 2010. [Results]Recipients with uncontrollable H&MA (group HA: n = 36) had more intraoperative bleeding, higher Child–Pugh scores, lower serum albumin concentrations and higher blood urea nitrogen concentrations than those without uncontrollable H&MA (group C:n = 201). They were also more likely to have preoperative hepatorenal syndrome and infections. The incidence of postoperative bacteremia was higher (55.6 vs. 46.7 %, P = 0.008) and the 1- and 3-year survival rates were lower (1 year: 58.9 vs. 82.9 %; 3 years: 58.9 vs. 77.7 %; P = 0.003) in group HA than in group C. The multivariate proportional regression analyses revealed that uncontrollable H&MA and the Child–Pugh score were independent risk factors for the postoperative prognosis. [Conclusions]Postoperative infection control may be an important means of improving the outcome for patients with uncontrollable H&MA undergoing LT, and clinicians should strive to perform surgery before H&MA becomes uncontrollable., First online: 08 February 2014

Antibody-mediated rejection (AMR) is difficult to diagnose after ABO-compatible or ABO-identical (ABO-C) liver transplantation. To determine whether complement component 4d (C4d) immunostaining would be useful for diagnosing AMR, we compared the results of C4d immunohistochemistry for allograft biopsy samples with assays for anti-donor antibodies performed at the time of biopsy. One hundred fourteen patients with ABO-C grafts and 29 patients with ABO-incompatible (ABO-I) grafts were included. Linear C4d endothelial staining (identifiable with a 4× objective lens) or staining seen in 50% or more of the portal tracts was considered positive. Five of the 114 patients (4%) with ABO-C grafts and 15 of the 29 patients (52%) with ABO-I grafts showed C4d positivity. In the ABO-C cases, C4d positivity in late biopsy samples (≥30 days after transplantation) was associated with stage 2 or higher fibrosis (METAVIR score; P = 0.01) and with the presence of donor-specific anti–human leukocyte antigen DR antibodies (HLA-DR DSAs) with a mean fluorescence intensity > 5000 according to the Luminex single-antigen bead assay (P = 0.04). Conversely, the presence of HLA-DR DSAs was associated with the presence of stage 2 or higher fibrosis, acute cellular rejection, and C4d positivity. During the 2-year follow-up, neither C4d positivity nor HLA-DR DSAs were related to graft loss. Among ABO-I patients, C4d positivity was not associated with allograft dysfunction or fibrosis. Only 3 of the 15 C4d-positive patients (20%) showed periportal hemorrhagic edema, which could be a histological sign of AMR in ABO-I grafts, and they were the only cases associated with elevations in anti-donor A/B antibody titers. In conclusion, C4d endothelial positivity among ABO-C patients is an uncommon event that could be associated with chronic graft damage with or without clinical AMR. C4d positivity is common among ABO-I patients and may not be associated with allograft dysfunction if alloantibody titers are not elevated. Liver Transpl 20:200-209, 2014. © 2013 AASLD.

PV reconstruction is an important aspect of LDLT, with post-transplant outcomes depending on PV reconstruction methods. However, it is unclear whether the preferential selection of these techniques is dependent on preoperative recipient characteristics. This retrospective study assessed whether preoperative recipient factors differed in pediatric patients who did and did not receive VGs for PV reconstruction. Of 113 pediatric patients who underwent LDLT from January 2010 to July 2015, 31 (27%) underwent PV reconstruction with VGs and the other 82 (73%) without VGs. The presence of collateral vessels (P

Purpose Lung transplantation is an effective therapy for end-stage patients with chronic respiratory failure due to various benign lung diseases. The organ shortage crisis is a serious problem, so it is required to develop alternative therapies. There have been reports of organ organoids ameliorating organ function but there have been few reports of lung organoids being capable of restoring respiratory function. We therefore hypothesized that immature mouse fetal lungs would ameliorate severe respiratory failure and connect the airways between recipient and donor lungs. Methods Lungs from the fetuses of pregnant GFP-C57BL/6 mice at 13.5 days gestation were injected into the left lungs of recipient mice. Severe lung injury was induced by paraquat, and we analyzed survival rate, pulmonary function, PaO2/FiO2, lung cytokine levels and pathohistological findings with light-sheet microscopy after 1 month. Results At 4 weeks after orthotopic implantation histopathological findings showed that there was no airway connection between recipient lung and immature fetal lungs of mice. However, hematoxylin and eosin staining showed reduced lung inflammatory cells, reduced lung edema, and active cell proliferation of fetal lung cells. Maximum airway pressures of the sham, vehicle and therapy groups (n=3, 1 and 6 respectively) were 8.91±1.47, 9.75, and 9.21±1.22 mmHg after one month. The airway compliance of the sham, vehicle and therapy groups were 0.041±0.017, 0.036 and 0.037±0.008 mmHg. The arterial partial blood pressures in the left ventricle of the sham, vehicle and therapy groups under FiO2 1.0 were 449±13.4, 516 and 427±28.4 mmHg. The survival rate of the therapy group increased from 5.9% to 39%, compared with that of the vehicle group (p=0.0338 by log-rank test). There was no difference of lung cytokine levels between the vehicle and therapy groups. The low number of mice and the high standard deviation affected the results of lung cytokine levels. The level of cytokines of some treated mice showed severe lung injury, however, other mice showed decreased cytokine levels. Conclusion Immature fetal lungs did not self-organize airway structures, however, they improved the survival rate of mice with paraquat-induced severe lung injury.

Plasma cell hepatitis (PCH) is an idiopathic disorder characterized by plasma cell infiltration in the allografts of patients who have undergone liver transplantation. Although an increasing number of cases of PCH have been reported in liver transplant recipients with hepatitis C recurrence treated with interferon, it is unclear whether PCH is induced by interferon itself. Here, we describe the cases of two patients who developed PCH just after the termination of antiviral therapy for recurrent hepatitis C after living donor liver transplantation. Liver dysfunction appeared at 1 month in one patient and 2 months in the other patient after pegylated interferon plus ribavirin therapy, and liver histology showed interface hepatitis with plasma cell-rich lymphoid aggregates. Both patients recovered after steroid therapy and achieved sustained virological response. These cases suggest that PCH could be induced by the alteration of the immune condition resulting from the termination of antiviral therapy. PCH should be considered when the transaminase levels increase after antiviral therapy, and it should be carefully distinguished from hepatitis C relapse.

Few studies have examined the long-term outcomes and prognostic factors associated with pediatric living living-donor liver transplantation (LDLT) using reduced and hyper-reduced left lateral segment grafts. We conducted a retrospective, single-center assessment of the outcomes of this procedure, as well as clinical factors that influenced graft and patient survival. Between September 2000 and December 2009, 49 patients (median age: 7 months, weight: 5.45 kg) underwent LDLT using reduced (partial left lateral segment; n = 5, monosegment; n = 26), or hyper-reduced (reduced monosegment grafts; n = 18) left lateral segment grafts. In all cases, the estimated graft-to-recipient body weight ratio of the left lateral segment was more than 4%, as assessed by preoperative computed tomography volumetry, and therefore further reduction was required. A hepatic artery thrombosis occurred in two patients (4.1%). Portal venous complications occurred in eight patients (16.3%). The overall patient survival rate at 1, 3 and 10 years after LDLT were 83.7%, 81.4% and 78.9%, respectively. Multivariate analysis revealed that recipient age of less than 2 months and warm ischemic time of more than 40 min affected patient survival. Pediatric LDLT using reduced and hyper-reduced left lateral segment grafts appears to be a feasible option with acceptable graft survival and vascular complication rates.

It is now known that post-transplant graft function after deceased-donor liver transplantation and living-donor liver transplantation (LDLT) differ; however, there is no report assessing the relationship between graft function and the development of new-onset diabetes mellitus after transplantation (NODAT). We conducted this study to identify the predictive risk factors for NODAT, including graft function after LDLT. The subjects of this study were 175 adult recipients who underwent LDLT at Kyoto University Hospital between 2006 and 2010, and survived for more than 3 months (median observation period, 1046 days). The 1-, 2-, and 3-year incidences of NODAT after LDLT were 26.1, 32.0, and 33.4%, respectively. Pre-transplant diabetes was associated with poor survival (p = 0.0048), whereas NODAT was not associated with patient survival. In the multivariate analysis, recipient age ≥40, a tacrolimus trough level ≥8 ng/mL 3 months after LDLT, and cholinesterase (ChE)

AIM: Hepatitis B recurrence after liver transplantation can be reduced to less than 10% by combination therapy with lamivudine (LAM) and hepatitis B immunoglobulin (HBIG). The aim of this study was to evaluate the efficacy and safety of prophylaxis with entecavir (ETV), which has higher efficacy and lower resistance rates than LAM, combined with HBIG in preventing hepatitis B recurrence after living-donor liver transplantation (LDLT). METHODS: Twenty-six patients who received ETV plus HBIG (ETV group) after LDLT for hepatitis B virus (HBV)-related end-stage liver disease were analyzed by comparing with 63 control patients who had received LAM plus HBIG (LAM group). RESULTS: The survival rates of the patients treated with ETV plus HBIG was 73% after both 1 and 3 years, and there was no statistical difference between the patients in the ETV group and LAM group. No HBV recurrence was detected during the median follow-up period of 25.1 months in the ETV group, whereas the HBV recurrence rate was 4% at 3 years and 6% at 5 years in the LAM group. No patients had adverse effects related to ETV administration. CONCLUSION: ETV combined with HBIG provides effective and safe prophylaxis in preventing hepatitis B recurrence after LDLT.

An outflow obstruction of the hepatic vein is a critical complication after living donor liver transplantation (LDLT) and occasionally leads to hepatic failure. Here we introduce a simple method for preventing outflow obstructions by patch plasty in adult LDLT. Between September 2001 and May 2010, 468 adult LDLT procedures were performed at Kyoto University Hospital. We harvested each recipient's portal vein (PV) from the extirpated liver for a patch. We intended to re-form several orifices of the hepatic veins into a single, large orifice. The patch was attached to the anterior wall of the re-formed orifice on the bench. After we put in the liver graft, the procedure for the hepatic vein anastomosis to the inferior vena cava was simple enough that the warm ischemia time was reduced. Three of the 468 cases were diagnosed with an outflow obstruction. All 3 cases underwent hepatic vein reconstruction without patch plasty. In contrast, none of the 159 cases that underwent LDLT with patch plasty suffered from an outflow obstruction, regardless of the liver graft type. The procedure for hepatic vein plasty using a patch from the native PV is simple and elegant and results in excellent outcomes. We propose this as the standard procedure for hepatic vein reconstruction in adult LDLT.

Complications due to infections, including bacteremia, often arise after liver transplantation (LT) and are the most frequent causes of in-hospital death. Hydrolyzed whey peptide (HWP), a protein complex derived from milk, has anti-inflammatory effects. The present study retrospectively analyzes the effects of early enteral nutrition with a new immunomodulating diet (IMD) enriched with HWP in patients after living-donor LT (LDLT). Data from 76 consecutive adult patients who underwent LDLT at our institute between September 2009 and March 2011 were retrospectively analyzed. The new IMD enriched with HWP and a conventional elemental diet were administered enterally to 40 (HWP group) and 36 (control group) patients, respectively, within the first 24 h after surgery. The characteristics of patients and surgical parameters did not differ between the two groups. The incidence of bacteremia was significantly lower in the HWP (15%) than in the control group (47%) (p = 0.002). The in-hospital mortality due to infection was a little lower in the HWP group than in the control group, although there was no statistical difference (p = 0.145). The fasting blood glucose level at postoperative day 7 was significantly lower in the HWP group than in the control group (p = 0.005). The incidence of acute cellular rejection was similar between the two groups (p = 0.858). Early enteral nutrition with the new IMD enriched with HWP can prevent post-transplant bacteremia and post-transplant hyperglycemia without increasing the incidence of acute cellular rejection.

Treatment of Budd–Chiari syndrome consists of medical management, surgical shunt, transjugular intrahepatic portosystemic shunt (TIPS), and liver transplantation. Liver transplantation is indicated only when other treatments have failed. A 36-year-old Japanese man underwent living-donor liver transplantation after radiologic intervention procedures. Because of the position of the TIPS stent and the damaged vascular lesion of Budd–Chiari syndrome, a supradiaphragmatic approach was employed to achieve a safe total hepatectomy. Moreover, after resection of damaged portion of the inferior vena cava (IVC), an artificial vascular graft was utilized to fill the IVC gap. The postoperative course was uneventful; no serious complications were experienced within 2 years after liver transplantation. This supradiaphragmatic IVC approach and IVC reconstruction technique emphasized the option of surgical techniques to decrease the operative risk during liver transplantation for Budd–Chiari syndrome.

Summary. Approximately 30% of patients who have recurrent hepatitis C after liver transplantation achieve sustained virological response (SVR) by taking a combination therapy of pegylated interferon and ribavirin. For the remaining non-SVR patients, an effective management treatment has not yet been established. In this study, efficacy of long-term peginterferon maintenance therapy for non-SVR patients was evaluated. Forty patients who had previously received the combination therapy for hepatitis C after living donor liver transplantation were classified into one of the following three groups: the SVR group (n = 11); the non-SVR-IFN group (n = 17), which received low-dose peginterferon maintenance therapy for non-SVR patients; and the non-SVR-Withdrawal group (n = 12), which discontinued the interferon treatment. We then compared histological changes among these three groups after 2 or more years follow-up. Activity grade of liver histology improved or remained stable in patients in the SVR and non-SVR-IFN groups, but deteriorated in half of the patients in the non-SVR-Withdrawal group. Fibrosis improved or remained stable in 10 of 11 SVR patients and in 13 of 17 non-SVR-IFN patients, but deteriorated in all non-SVR-Withdrawal patients. Mean changes in fibrosis stage between pretreatment and final liver biopsy were −0.18, +0.06 and +2.2 in the SVR, non-SVR-IFN and non-SVR-Withdrawal groups, respectively. Fibrosis stage deteriorated to F3 or F4 significantly more rapidly in the non-SVR-Withdrawal group than in the other two groups. In conclusion, continuing long-term maintenance therapy with peginterferon prevented histological progression of hepatitis C in patients who had undergone living donor liver transplantation.

Antiferroelectric liquid crystals (AFLCs) composed of low-mass mesogens do not show the nematic (N) phase. Recently, it has been reported that an AFLC containig dimeric molecules may show the N phase. However, it is not obvious why the antiferroelectric SmC (SmCA) and N phases may coexist in the phase sequence of the dimeric LCS. In this study, the molecular alignment structure has been investigated by X-ray diffractometry (XRD) and polarized Fourier transform infrared spectroscopy (FT-IR). As a result, It is found that dimeric LCs, mPY11OCB (m = 6 and 8), have the same layer spacing between the SmA and SmCA phases, and therefore, the molecular shape is bent even in the SmA phase. The difference between both phases is due to the thermal motion of bent molecules around the molecular axis. Furthermore, it is obvious that in the SmCA phase, the alignment of dimeric LC molecules can be localized in two directions in a cell with rubbed alignment films. Furthermore, we tried to estimate the bent angle of the di...

To prevent small-for-size syndrome in adult-to-adult living donor liver transplantation (A-LDLT), larger grafts (ie, right lobe grafts) have been selected in many transplant centers. However, some centers are investigating the benefits of portal pressure modulation. Five hundred sixty-six A-LDLT procedures using right or left lobe grafts were performed between 1998 and 2008. In 2006, we introduced intentional portal pressure control, and we changed the graft selection criteria to include a graft/recipient weight ratio >0.7% instead of the original value of >0.8%. All recipients were divided into period I (1998-2006, the era of unintentional portal pressure control; n = 432) and period II (2006-2008, the era of intentional portal pressure control; n = 134). The selection of small-for-size grafts increased from 7.8% to 23.9%, and the selection of left lobe grafts increased from 4.9% to 32.1%. Despite the increase in the number of smaller grafts in period II, 1-year patient survival was significantly improved (87.9% versus 76.2%). In 129 recipients in period II, portal pressure was monitored. Patients with a portal pressure or=15 mm Hg (n = 43, 66.3%). The recovery from hyperbilirubinemia and coagulopathy after transplantation was significantly better in patients with a portal pressure

We performed protocol kidney biopsies for the early diagnosis of asymptomatic histopathological acute rejection (AR), commonly defined as subclinical rejection and drug nephrotoxicity. Forty-seven kidney recipients that had asymptomatic and stable kidney function underwent protocol biopsies both one month and one yr after kidney transplantation. The protocol biopsies one month after transplantation revealed borderline change in 13 of 47 cases (27.6%). AR la was observed in eight cases (17.2%) and AR 1b was observed in three cases (6.4%). The AR la and AR 1b groups were treated with methyl prednisolone pulse and deoxyspergualin. Toxic tubulopathy was found in four cases (8.5%). In the cases of nephrotoxicity, cyclosporine or tacrolimus was reduced. The borderline change group was observed without any additional treatment. Every case diagnosed with acute rejection one month after transplantation improved histopathologically one yr after transplantation, and the borderline change group partially remained borderline change and partially improved histopathologically one yr after transplantation. The nephrotoxicity group improved histopathologically one yr after transplantation. In our institution, protocol biopsies one month and one yr after kidney transplantation proved useful in screening for subclinical rejection and toxic tubulopathy and subsequently effective in improving long-term graft survival.

An antiferroelectric liquid crystal (AFLC) with dimeric molecules which take a bent molecular structure may show the nematic (N) phase. However, it has not been obvious yet why the antiferroelectric chiral SmC (SmC* A ) and N phases may coexist in the phase sequences of the dimeric AFLC. In this study, the molecular alignment structure of both liquid-crystalline phases has been researched in detail with a polarized Fourier transform infrared spectroscopy (FT-IR). In 8PY11OCB, the directors of both mesogenic moieties are oriented to the rubbing direction due to high thermal motion in the N and SmA phases, that is the molecular shape is almost rod like. In the SmC A phase, a herringbone alignment of the mesogenic moieties appears because the bent molecular structure becomes stable due to lower thermal motion. In the case of OBnCB, we obtain also almost the same results and discussion.

We prepared a homologous series of non-symmetric dimesogenic compounds 1-(4- fluorophenyl)-4-{ω -{4-[4-(4-hexylphenyl)-2,3-difluorophenyl]phenyloxy}alkyloxy} benzene ( I-n ) and investigated the physical properties. For comparison, we also prepared a compound ( II-6 ) possessing a 4-(4-cyanophenyl)benzene unit instead of the 4-(4- fluorophenyl)benzene unit. All the compounds exhibited an enantiotropic nematic phase. When an electric AC field was applied, a striped pattern that was similar to Williams domain appeared in the nematic phases of compounds I-n , whereas such a pattern was not observed in the nematic phase of II-6 . We discuss structure-property correlations of the polar liquid crystal oligomers.

Purpose To retrospectively evaluate long-term outcomes of percutaneous transhepatic biliary drainage (PTBD) followed by balloon dilation and placement of an internal drainage tube for anastomotic stricture in pediatric patients who underwent living donor liver transplantation (LDLT) with Roux-en-Y hepaticojejunostomy (RYHJ). Materials and Methods Fifty-two patients (23 male, 29 female; median age, 5 y) with anastomotic biliary stricture were treated with PTBD followed by balloon catheter dilation and long-term placement of an internal drainage tube, which was removed upon cholangiographic confirmation of free flow of bile into the small bowel. Clinical success, tube independence rate, risk factors of recurrent biliary stricture, and patency rates were evaluated. Results Thirty-nine patients (75%) had no stricture recurrence. Of 13 patients (25%) with recurrence, six were treated again with the same percutaneous biliary interventions and showed no further recurrence. Clinical success was noted in 43 of 52 patients (83%). Drainage tubes were removed from 49 patients (94%). Multivariate logistic regression analysis indicated that serum alanine aminotransferase level > 53 IU/L at discharge after the initial series of percutaneous biliary interventions was a significant risk factor for recurrent biliary stricture ( P = .002). Kaplan–Meier analysis showed 1-, 3-, 5-, and 10-year primary and primary assisted patency rates of 75%, 70%, 70%, and 68%, and 94%, 92%, 88%, and 88%, respectively. Conclusions PTBD followed by balloon dilation and internal drainage may be an effective treatment for anastomotic biliary stricture after pediatric LDLT with RYHJ.