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The number of organs retrieved from donation after circulatory death (DCD) donors has continued to rise in recent years. The functional superiority of DCD organs is achieved when the lungs are perfused with cold perfusion and livers with normothermic regional perfusion (NRP). Thus, a precise surgical technique is required to combine thoracic and abdominal organ procurement. The technique used at our center consists of a rapid laparotomy and middle sternotomy, then the abdominal aorta (Ao) and abdominal inferior vena cava (VC) are cannulated and the descending thoracic Ao is cross-clamped. NRP is started at that point. As a variation of previously described techniques, the thoracic vena cava is not initially clamped in order to improve the return of blood volume to the NRP circuit. The pulmonary artery is cannulated to flush the lungs and the left atrial appendage is opened for drainage. After 120 minutes, NRP perfusion is stopped and the organs are flushed with cold preservation solution. In 2016, 3 livers and 6 lungs were harvested at our center using the technique described. After a minimum follow-up of 1 year, no evidence of biliary complications was observed. The combined procurement of lungs after room temperature perfusion and liver after NRP without initial clamping of the thoracic VC is feasible, with excellent function post-transplantation., (Copyright © 2018 Elsevier Inc. All rights reserved.)

We aimed to evaluate the safety and efficacy of low doses of anti-T-lymphocyte globulin (ATG)-based immunosuppression in preserving renal function and preventing liver rejection in liver transplant (LT) recipients with pretransplant renal dysfunction. We designed a prospective single-center cohort study analyzing patients with pre-LT renal dysfunction defined as eGFR<60 mL/min/1.73m 2 , who underwent induction therapy with ATG ( ATG group, n=20) . This group was compared with a similar retrospective cohort treated with basiliximab ( BAS group, n=20 ). An economic analysis between both induction therapies was also undertaken. In the ATG group, 45% and 50% of patients had recovered their renal function without acute cellular rejection (ACR) episodes at day 7 and 1 month after LT, respectively, versus 40% and 55% of patients in the BAS group (p=1). Renal function improved in both groups over time and no differences between groups were observed regarding one-year eGRF and one-year probability of ACR. Cost per patient of the ATG course was 403€ (r: 126-756) versus 2,524€ of the basiliximab course (p=0.001). In conclusion, induction with low dose of ATG or basiliximab in patients with pretransplant renal dysfunction is a good strategy for preserving posttransplant renal function; however the use of low-dose ATG resulted in a substantial reduction in drug costs. This trail is registered with ClinicalTrials.gov number: NCT01453218.

This brief report presents the results of 20 adult and pediatric patients treated with the use of biodegradable SX-Ella biliary stents placed by means of a transhepatic approach for the treatment of benign biliary strictures after liver transplantation. Stent insertions were always feasible (100%), and only 1 case of acute pancreatitis was observed (5%). The overall clinical success rate of the procedure, including anastomotic and nonanastomotic strictures, was 75%, and was higher in the anastomotic stricture group (81.25%) than in the nonanastomotic stricture group (50%)., (Copyright © 2018 SIR. Published by Elsevier Inc. All rights reserved.)

BACKGROUND The characteristics of liver donors have changed over the last decade owing to the shortage of organs and high mortality on the waiting list, leading to wider use of extended-criteria donors, including older donors. The aim of this study was to evaluate the effect of matching donor-recipient age on morbidity at 1 year post-transplant and on long-term patient and graft survival. MATERIAL AND METHODS Retrospective study from a prospectively-obtained database including adult patients who had received a primary liver transplant (LT) from whole graft of brain-dead donors. Recipients were divided into 2 age groups: <60 years and ≥60 years. Both groups were sub-divided according to donor age (younger than 60 years and 60 years or older). A propensity score analysis was performed to further adjust for baseline differences between recipients and donors. RESULTS We analyzed 642 patients who had LT performed between January 2000 and December 2013. No differences were observed in 1-year morbidity (hospital stay, rejection, surgical complications, and retransplant) between groups. Although patient and graft survival was significantly impaired in the older donor/older recipient group on Kaplan-Meier analysis (p=0.004), the propensity score analysis showed that donor age ≥60 years did not increase the risk of death for recipients aged ≥60 (HR1.40, p 0.074) and <60 years (HR 1.47, p 0.070). CONCLUSIONS Older donor age did not negatively affect survival regardless of recipient age, and comparable outcomes were achieved without an increased rate of complications.

Background: Despite now being an infrequent complication in liver transplantation (LT) recipients, acute liver failure is still associated with high mortality., Case Report: Here we report a case of acute liver failure 11 months after AB0-compatible LT in a hepatitis C-positive 50-year-old male recipient caused by late antibody-mediated rejection (AMR). De novo donor-specific antibodies appeared later in a previously negative donor-recipient crossmatch, leading to a rapid deterioration of liver function., Conclusions: We highlight the importance of an accurate diagnosis and an early therapeutic intervention. The analysis of this case brings novel and generalizable insights to the differential diagnosis of acute liver failure after LT., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: To identify prognostic factors after hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT)., Methods: We retrospectively reviewed the combined experience at Toronto General Hospital and Hospital Vall d'Hebron managing HCC recurrence after LT (n = 121) between 2000 and 2012. We analyzed prognostic factors by uni- and multi-variate analysis. Median follow-up from LT was 29.5 (range 2-129.4) months. Median follow-up from HCC recurrence was 12.2 (range 0.1-112.5) months., Results: At recurrence, 31.4 % were treated with curative-intent treatments (surgery or ablation), 42.1 % received palliative treatment, and 26.4 % received best supportive care. The 1-, 3-, and 5-year survivals, respectively, after HCC recurrence were 75, 60, and 31 %, vs. 60, 19, and 12 %, vs. 52, 4, and 5 % (p < 0.001). By multivariate analysis, not being amenable to a curative-intent treatment [hazard ratio (HR) 4.7, 95 % confidence interval (CI) 2.7-8.3, p < 0.001], α-fetoprotein of ≥100 ng/mL at the time of HCC recurrence (HR 2.1, 95 % CI 1.3-2.3, p = 0.002) and early recurrence (<12 months) after LT (HR 1.6, 95 % CI 1.1-2.5, p = 0.03) were found to be poor prognosis factors. A prognostic score was devised on the basis of these three independent variables. Patients were divided into three groups, as follows: good prognosis, 0 points (n = 22); moderate prognosis, 1 or 2 points (n = 84); and poor prognosis, 3 points (n = 15). The 1-, 3-, and 5-year actuarial survival for each group was 91, 50, and 50 %, vs. 52, 7, and 2 %, vs. 13, 0, and 0 %, respectively (p < 0.001)., Conclusions: Patients with HCC recurrence after transplant amenable to curative-intent treatments can experience significant long-term survival (~50 % at 5 years), so aggressive management should be offered. Poor prognosis factors after recurrence are not being amenable to a curative-intent treatment, α-fetoprotein of ≥100 ng/mL, and early (<1 year) recurrence after LT.

Background: Liver transplantation (LT) is the treatment of choice for chronic and acute liver failure; however, the status of long-term survivors and allograft function is not well known., Aim: To evaluate the clinical outcome and allograft function of survivors 20 years post-LT, cause of death during the same period and risk factors of mortality., Methods: A retrospective study was conducted from prospective, longitudinal data collected at a single center of adult LT recipients surviving 20 years. A comparative sub-analysis was made with patients who were not alive 20 years post-transplantation to identify the causes of death and risk factors of mortality., Results: Between 1988 and 1994, 132 patients received 151 deceased-donors LT and 28 (21%) survived more than 20 years. Regarding liver function in this group, medians of AST, ALT and total bilirubin at 20 years post-LT were 33 IU/L (13-135 IU/L), 27 (11-152 IU/L) and 0.6 mg/dL (0.3-1.1 mg/dL). Renal dysfunction was observed in 40% of patients and median eGFR among 20-year survivors was 64 mL/min/1.73 m(2) (6-144 mL/min/1.73 m(2)). Sixty-one percent of 20-year survivors had arterial hypertension, 43% dyslipidemia, 25% de novo tumors and 21% diabetes mellitus. Infections were the main cause of death during the 1st year post-transplant (32%) and between the 1st and 5th year post-transplant (25%). After 5th year from transplant, hepatitis C recurrence (22%) became the first cause of death. Factors having an impact on long-term patient survival were HCC indication (p = 0.049), pre-transplant renal dysfunction (p = 0.043) and long warm ischemia time (p = 0.016); furthermore, post-transplant factors were diabetes mellitus (p = 0.001) and liver dysfunction (p = 0.05) at 1 year., Conclusion: Our results showed the effect of immunosuppression used during decades on long-term outcome in our LT patients in terms of morbidity (arterial hypertension, diabetes mellitus, dyslipidemia and renal dysfunction) and mortality (infections and hepatitis C recurrence).

Background: Compensated cirrhotic patients with single hepatocellular carcinoma (HCC) ≤5 cm may benefit from both liver resection (LR) and liver transplantation (LT); however, the better 10-year actuarial survival of the two treatments remains unclear. We aimed to assess the long-term outcome of cirrhotic patients with single HCC ≤5 cm treated either with LR or LT on an intention-to-treat basis., Methods: A total of 217 cirrhotic patients with single HCC ≤5 cm were evaluated at our department: 95 were treated with LR (LR group), and 122 were included on the waiting list for LT (LT group). Patients in the LR group were divided into very early HCC (tumor size ≤2 cm) and early HCC (tumor size >2 cm). Median follow-up was 5.3 (range 0.1-18) years., Results: Tumor recurrence was 72 % in the LR group versus 16 % in the LT group (p < 0.001). 1-, 5-, and 10-year cumulative risk of recurrence was 18, 69, and 83 % in the LR group versus 4, 18, and 20 % in the LT group (p < 0.001). Ten-year actuarial survival was 33 % in the LR group versus 49 % in the LT group (p = 0.002). At HCC recurrence, 27.3 % were included on the waiting list for salvage transplantation (very early HCC group) versus 15.1 % (early HCC group) (p = 0.2). After salvage transplantation, HCC recurrence was 0 % (very early HCC group) versus 40 % (early HCC group) (p = 0.2). No significant differences were observed in 1-, 5-, and 10-year actuarial survival between the very early HCC group and the LT group (95, 55, and 50 % vs. 82, 62, and 50 %)., Conclusions: LR should be the treatment of choice for cirrhotic patients with very early HCC.

Background: The aim of this study was to analyze the evolution of biliary complications over 20 years among adult patients undergoing liver transplantation (OLT) at our institution., Patients and Methods: Between 1985 and 2007, we performed 1000 OLT in 789 adults and 211 children. To ascertain the evolution of biliary complications among adult OLT from October 1988 to September 2007, we compared the first 100 to with the last 200 adult OLT., Results: Duct-to-duct was the most common biliary anastomosis performed in both periods (1st; 89% and 2nd; 94%; P = NS). However, a T-tube was used more frequently in the first period (1st; 46% vs 2nd; 6.6%; P < .001). The remaining cases underwent a hepaticojejunostomy (1st; 11% vs 2nd; 7.6%). Biliary complications were more frequent in the first period (1st; 20% vs 2nd; 9%; P < .01). In the first period, the use of a T-tube caused 32% of complications, all of them being bile leaks; but there were none in the second period. Arterial thrombosis or strictures were related to biliary complications in 10% and 33.3% among the first and second periods, respectively. The severity of complications according to the Clavien classification was similar in both periods: IIIa, 15% versus 33.3%; IIIb, 55% versus 55.5%; and IV, 15% versus 11.1%, respectively (P = NS)., Conclusion: The biliary complication rate among adult patients post-OLT decreased over 20 years at our institution, probably owing to the abandonment of the routine use of a T-tube as well as to advances in immunosuppressive protocols, organ preservation, and preoperative patient management., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: The aim of this study was to ascertain the outcome of liver transplantation (LT) due to hepatocellular carcinoma (HCC) in patients who had undergone previous liver resection (LR) for HCC., Methods: A case-control study (1:2) was designed to compare patients who underwent LT due to HCC recurrence with a previous LR for HCC (study group) with those who underwent LT for primary HCC but without previous LR (control group)., Results: From January 1990 to December 2007, a total of 303 cirrhotic patients with primary HCC were evaluated for surgery. Primary LT was performed in 191 and LR in 100. When HCC recurrence was diagnosed after LR (69/100), 17 of the 69 (25%) patients underwent LT (study group). The median follow-up was 70 months (12.7-203.0 months). Disease-free survivals at 1, 3, and 5 years in the study group versus the control group were 86%, 68%, 58% vs. 97%, 93%, 89%, respectively (p < 0.04). The 1-, 3-, and 5-year actuarial patient survivals in the study group versus the control group were 59%, 52%, 52% vs. 85%, 76%, 65%, respectively (p = NS). Patients of the study group were divided into two groups according to the time to recurrence after LR: group 1 was <1 year, and group 2 was >1 year. Recurrence after LT was 75% in group 1 vs. 15.4% in group 2 (p < 0.03). The 1-, 3-, and 5-year actuarial patient survivals were 25%, 0%, 0% in group 1 and 69%, 69%, 69% in group 2, p < 0.02)., Conclusions: Liver transplantation can be safely performed after a previous LR for HCC. Patients with recurrence during the first year after hepatectomy have a poor prognosis after LT.

Objective: To report a severe interaction between simvastatin and rapamycin resulting in rhabdomyolysis and acute renal failure in a liver transplant patient., Background: A 56-year-old man with hepatitis C virus cirrhosis (Child B) was diagnosed with hepatocellular carcinoma and underwent liver transplantation in April 2007. He was immunosuppressed with tacrolimus (FK) and mycophenolate mofetil (MMF). Postoperative complications were arterial hypertension and renal insufficiency. In June 2007, liver dysfunction was detected and acute rejection was diagnosed by biopsy. He received three 500-mg boluses of methylprednisolone and FK levels were maintained between 10 and 12 ng/mL. Laboratory values revealed persistent rejection and MMF was stopped with initiation of rapamicin. One month later, hyperlipidemia appeared as a consequence of rapamicin therapy; simvastatin was administered. In August 2007, the patient was readmitted due to severe muscule pain and the inability to ambulate. Laboratory values were: total bilirubin 16 mg/dL, serum creatinine 4.3 mg/dL, and total creatine kinase (CK) 42,124 U/L. With the suspicion of rhabdomyolysis, leading to worsening of his basal renal insufficiency, rapamycin and tacrolimus were stopped. Hemodialysis was initiated owing to renal failure and hyperkalemia. Some hours later, the patient developed ventricular fibrillation and respiratory failure and succumbed., Discussion: Calcineurin inhibitors (CNI), corticosteroids, and mammalian target of rapamycin (m-TOR) inhibitors are associated with adverse dyslipidemic effects. To reduce the overall cardiovascular risk in these patients, lipid-lowering drugs, especially 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, have been widely used. CNI and m-TOR inhibitors, as well as most statins, are metabolized by cytochrome P450 (CYP)3A4; thus, pharmacokinetic interactions between these drugs are possible. Previous reports have indicated an increased risk of rhabdomyolysis in the presence of concomitant drugs that inhibit simvastatin metabolism., Conclusions: Concomitant administration of statin therapy and drugs that inhibit cytochrome P450 (CYP)3A4 increased the risk of rhabdomyolysis in a patient suffering liver and renal dysfunction.

The aim of this study was to assess whether the use of a temporary portocaval shunt (PCS) with inferior vena caval (IVC) preservation during orthotopic liver transplant procedures (OLT) in cirrhotic patients had any advantage. This work evaluated a group of cirrhotic patients who underwent liver-transplant between 1999 and 2006 with a temporary portocaval anastomosis and IVC preservation (PC group, n = 356) versus an historical group (no-PC group, n = 45) with only IVC preservation. We excluded cases of fulminant hepatitis, retransplants, portal vein thrombosis, or prior surgical portosystemic shunts. In both groups, graft reperfusion was achieved by simultaneous arterial and venous revascularization. Donor, recipient, and surgical characteristics were similar in both groups. The PCS group displayed significantly higher portovenous flow (PVF) than the no-PCS group (773 +/- 402 mL/min vs 555 +/- 379 mL/min, P = .004). We studied two subgroups: high PVF subgroup A (>800 mL/min; mean 1099 +/- 261 mL/min) and a low PVF subgroup B (<800 mL/min; mean 433 +/- 423 mL/min). In the high flow group (subgroup A) with PCS, a smaller number of blood units were required and better renal function was exhibited at the third postoperatory day. In contrast, no differences were observed among subgroup B between patients with or without PCS. The use of PCS with IVC preservation during the OLT enhanced the hemodynamic recipient status requiring a smaller number of blood units and displaying better renal function.

Liver transplantation (LT) for hepatitis C virus (HCV)-associated cirrhosis in human immunodeficiency virus (HIV)-infected patients was compared with non-HIV patients. Nine patients with HIV-HCV coinfection were compared with patients transplanted before and after each HIV patient (control group). Immunosuppression consisted in tacrolimus with steroids or mycophenolate mofetil. Acute cellular rejection and three-year actuarial patient survival were respectively 44% and 87.5% in HIV group and 22% and 93.7% in the control group (P=NS). Acute hepatitis C virus occurred earlier (2.3 vs. 4.3 months) and was more cholestatic (mean bilirubin: 10.8 vs. 1.6 mg/dL) in the HIV group. Eight (100%) HIV and nine (64.3%) control patients received antiviral treatment with pegylated interferon and ribavirin. One patient (11.1%) of the control group and one patient (20%) of the HIV group presented a sustained virologic response (P=NS). Short- to midterm results of LT in HIV-HCV co-infected patients were excellent and similar to non-HIV patients.

The aim was to study the advantages of the use of a temporary portacaval shunt (PCS) with inferior vena cava (IVC) preservation during the piggyback technique for the anhepatic phase of orthotopic liver transplantation (OLT) performed in cirrhotic patients. Two groups of cirrhotic patients who underwent OLT with piggyback technique were compared; one with a PCS (n = 57) and the other, without PCS (n = 54). Patients with fulminant hepatitis, retransplantation, portal thrombosis, and previous portosystemic shunts were excluded. In both groups graft reperfusion was achieved by simultaneous arterial and venous revascularization. Donor, recipient, and surgical characteristics were similar in both groups. The PCS group had a significantly higher portal venous flow (PVF) than the no-PCS group (773 +/- 402 mL/min vs 555 +/- 379 mL/min, P = .004). Therefore, two subgroups were studied; the high PVF subgroup A (>800 mL/min), mean 1099 +/- 261 mL/min, and the low PVF subgroup B (<800 mL/min), mean 433 +/- 423 mL/min. Subgroup A, who were treated with PCS, required fewer blood transfusions and displayed better postoperative renal function; whereas, no differences were observed among subgroup B patients with versus without PCS. In conclusion, the use of a temporary PCS with piggyback technique during OLT in cirrhotics has advantages in patients who still maintain a high portal venous flow.

Auxiliary liver transplantation for patients with fulminant hepatic failure supports the patient's failing liver for a period of time until the native liver (NL) has recovered and immunosuppression can be withdrawn. Auxiliary heterotopic liver transplantation (AHLT) with portal vein arterialization (PVA) has several advantages over auxiliary orthotopic liver transplantation: NL resection is not required, and the hepatic hilum is left untouched; thus, the chances of liver regeneration are optimal. The successful application of emergency AHLT with PVA in a young patient who developed toxic fulminant hepatic failure caused by tuberculostatic drugs is described. Two and one-half months after the procedure, the NL had completely regenerated; the graft was removed, and immunosuppression was suspended.

The aim of this study was to compare the long-term effect of tacrolimus and cyclosporine therapies on serum cholesterol levels in liver transplant recipients. We retrospectively studied 127 consecutive adult liver transplant recipients who survived for at least 1 year after transplantation. Basal immunosuppression consisted of cyclosporine plus prednisone in 100 patients and tacrolimus plus prednisone in 27 patients. Hypercholesterolemia was defined as a fasting serum cholesterol level greater than 220 mg/dL. Mean follow-up was 39 months. No statistical significance was found between cyclosporine- and tacrolimus-treated patients regarding age, sex, diagnosis, and previous cholesterol levels; both groups were similar. Significantly more tacrolimus-treated patients were steroid free in the first and second year of follow-up (tacrolimus, 37% and 63%; cyclosporine, 13% and 32%, respectively; P <.01). In the third year of follow-up, this difference was not significant (77% v 56%). The overall incidence of hypercholesterolemia was 34.6% (44 patients). At the end of the study, hypercholesterolemia was found in 24 of 51 and 14 of 70 patients with and without steroids, respectively (P <.002). Also, mean cholesterol levels were 224 +/- 70 and 191 +/- 48 mg/dL before and after steroid withdrawal, respectively, P <.001. Hypercholesterolemia was found in 43.7% of the patients during cyclosporine plus prednisone therapy compared with 46.1% of the patients during tacrolimus plus prednisone therapy (P <.9). Greater mean cholesterol levels were found in the cyclosporine group, particularly in the second and third years of follow-up (P <.01). Hypercholesterolemia was found in 22% of the patients during cyclosporine monotherapy compared with 15% during tacrolimus monotherapy (P <.5). No differences were found in mean cholesterol levels during follow-up when both monotherapy groups were compared. In conclusion, a lower incidence of hypercholesterolemia was achieved in tacrolimus-treated patients, mainly when steroids were still part of the immunosuppressive treatment.

Two patients with previous distal splenorenal shunts (DSRSs) performed 6 years earlier underwent liver transplantation (LT). A preoperative selective mesenteric artery angiogram showed collateral veins draining mesenteric venous flow into the shunt. Intraoperative flow measurements were performed to assess the steal of portal venous flow by the shunt and determine the need for shunt occlusion. Portal vein, hepatic artery, and shunt flows were measured by ultrasound transit-time flow probes in the native liver and after graft implantation with and without temporary shunt occlusion. Hemodynamic studies showed that long-standing DSRSs are high-flow shunts that steal portal flow. After graft implantation, DSRS flows remained high. Occlusion of the shunts produced an increase in portal vein flow at an amount similar to those of splenorenal shunt. Thus, the flow measurements showed persistent steal by the shunts after graft implantation and, therefore, the DSRSs were occluded but splenectomy was not performed. We conclude that the decision to occlude a DSRS should be based on the demonstration of steal of portal flow by the shunt and reversibility once the shunt is occluded. Splenectomy is not required when the DSRS is occluded.

Biliary complications (BC) are the usual presentation of late hepatic artery thrombosis (HAT) of the liver graft. Our aim was to study the clinical features and outcome of BC secondary to HAT compared to BC which occurred in liver transplant (LT) patients with patent vessels. We present a retrospective study of 224 LTs performed in 204 patients between 1988 and 1996. The mean recipient x s age was 51 years. A choledochocholedochostomy without T-tube was used as biliary reconstruction in most cases (67%); in 12%, a choledochojejunostomy was performed. An iliac conduit was necessary in 15% of cases and back-table arterial reconstruction was performed in 10% of cases of anatomic variants in graft arteries. Different donor, recipient and intraoperative variables, as well as treatment and outcome. were studied in the two groups of patients presenting BC with or without HAT. BC occurred in 38 cases (17%) whereas HAT was diagnosed in 11 cases (4.9%). Therefore, 23% of BC encountered after LT were secondary to HAT. Nine cases of late HAT manifested as BC, septicaemia (88%) and hepatic bilomas (8 cases). Percutaneous or surgical drainage of hepatic bilomas was performed in all cases, followed by retransplantation in six cases (66%). BC secondary to HAT appeared later than the rest of BC. Donor age was the only significant predisposing factor found in our study. Graft survival is significantly reduced as most patients needed retransplantation. In conclusion, BC secondary to HAT presented later in livers from older donors in the form of biliary sepsis and hepatic biloma. Retransplantation was ultimately required in most cases and graft survival was significantly diminished.

The aim of this study was to compare two different periods of tacrolimus rescue therapy for intractable rejection. From January 1992 to May 1996, 140 liver transplants (LTx) were performed in our hospital under cyclosporine A-based immunosuppression. Twenty-four (17.1%) patients were switched to tacrolimus because of chronic rejection, steroid-resistant rejection or cholestasic hepatitis C recurrence. Mean follow-up was 21 months (range 12-56 months). In the first period (January 1992-March 1994), conversion to tacrolimus was indicated later, after unsuccessful repeated rejection therapy. In the second period (April 1994-May 1996), conversion to tacrolimus was indicated early, immediately after unsuccessful rejection therapy or directly at the moment of diagnosis with no further treatment. Eleven of 54 LTx were treated with tacrolimus in period 1 (20.3%), and 13 of 86 LTx in period 2 (15.1%). Only 4 of 11 (36.6%) grafts converted were rescued during the first period, while 11 of 13 (84.6%) were rescued in the second (P < 0.03). Patients in the first period received more courses of steroids than those of the second (1.7 +/- 0.7 vs 0.9 +/- 0.7, P < 0.02). Furthermore, six patients received one or two courses of OKT3 in period 1 while only one received one course in period 2 (P < 0.03). Preconversion mean bilirubin levels of patients in the first period were higher than those in the second (15.9 +/- 7.3 mg/dl vs 9.7 +/- 5.8 mg/dl, P < 0.05). Preconversion mean bilirubin levels of 6.8 +/- 5.4 mg/dl and 21.8 +/- 18.5 mg/dl were observed in patients with successful and unsuccessful tacrolimus rescue therapy, respectively, independent of the treatment period (P < 0.05). Mortality rates were higher in the first period than in the second (82% versus 23%; P < 0.02). In conclusion, conversion to tacrolimus as rescue therapy for intractable rejection or cholestasic hepatitis C recurrence is an efficacious alternative, particularly when tacrolimus is initiated early.

A common stump of the three hepatic veins has always been used to fashion the upper vena cava anastomosis in 205 liver transplantations with the piggyback (PGB) technique performed in our Unit, to avoid outflow problems. The aim was to study the repercussion of lateral inferior vena cava (IVC) clamping on IVC flow and pressure as well as on systemic hemodynamics. We have studied 42 orthotopic liver transplantations performed with the PGB technique. Intraoperative IVC blood flow measurements by transit time ultrasonic volume flowmetry, IVC pressure, and systemic hemodynamics were taken before and after lateral IVC clamping. Graft outflow complications, stenosis or kinking of the upper vena cava anastomosis have not been found in any of the 205 PGB procedures. A significant decrease of IVC flow (23%) and cardiac output (12%) occurred after IVC clamping, whereas mean arterial and central venous pressures were not altered significantly, probably due to an increase (25%) of systemic vascular resistance. Only in one case was an almost total clamping of IVC needed. Venovenous bypass was not needed in any case. Renal perfusion pressure was adequate in all cases. We conclude that the use of a common stump of the three hepatic veins for upper vena cava anastomosis in the PGB technique is safe because any outflow problem of the graft is avoided and, at the same time, is well tolerated hemodynamically because most of the IVC flow is preserved.

Background/aims: The role of crossmatching in liver transplantation is controversial. The aim of this study was to investigate retrospectively the effect of sensitization and IgG lymphocytotoxic crossmatching on liver transplantation., Methods/results: Over 5 years, 20 of 243 (8.2%) first liver transplants were performed with a positive crossmatch and their outcome was compared with the remaining 223 performed with a negative crossmatch. Women had a higher incidence of positive crossmatch than men (p < 0.001). Significant differences in mean panel reactive antibody of 2.7% and 43.3% were found in negative and positive crossmatch patients, respectively (p < 0.001). Severe early rejection resulting in graft loss occurred in eight of 20 positive crossmatch patients, and only one of 223 negative crossmatch patients (p < 0.001). Five of the remaining positive crossmatch patients suffered several acute rejection episodes some months after liver transplantation. Two of 20 in the positive crossmatch group developed chronic rejection (10%) compared with ten of 223 negatives (4.4%) (N.S). Nine of 16 positive crossmatch female recipients suffered graft loss and seven died, representing 1-year graft and patient survival of 56% and 43%, respectively. Fifteen of 68 negative crossmatch female recipients presented graft loss and 12 died, accounting for 1-year patient and graft survival of 82% and 78% (p < 0.005), respectively. Five patients (20%) displayed positive crossmatch at the time of retransplantation, compared with 24 (10%) who were negative (N.S)., Conclusion: Our experience confirms the adverse impact of a positive crossmatch in liver transplantation, particularly in female recipients. Candidates with high panel reactive antibody are more likely to display a positive crossmatch, and therefore to develop early severe rejection and graft failure.

Several risk factors have been reported that may favour the development of chronic rejection. From October 1988 to December 1993, 97 liver transplants with survival of more than 3 months were included in the study. Fifty-two patients (54.1%) had chronic hepatitis C virus (HCV) infection before liver transplantation. Immunosuppression consisted of cyclosporine A and prednisone, whereas 14 patients received FK 506 and prednisone. Severe graft HCV reinfection was present in 32 patients (61.5%) after liver transplantation and chronic graft hepatitis C was found in 26 cases at the end of the study. Chronic rejection occurred in 8 of 97 allografts (8.25%); 5 presented chronic rejection and concomitant chronic graft hepatitis C. The incidence of chronic rejection in patients with HCV infection before liver transplantation (9.6%) did not differ when compared with the negative HCV patients (6.6%). However, when the 26 cases that developed graft dysfunction due to chronic hepatitis C after liver transplantation were considered, 5 presented chronic rejection, a significantly higher incidence than in the remaining patients (3 of 71) (Yates chi-square test: P < 0.05). In our experience, there appears to be a relationship between the development of chronic rejection and chronic hepatitis C in the graft after liver transplantation.

Of 91 liver transplants (LTX) performed from October 1988 to December 1992, 13 (14.2%) of the patients received a liver from a lymphocytotoxic-positive crossmatch (CM) donor. Severe early rejection resulting in graft floss occurred in seven positive CM patients. Three of the remaining positive CM patients suffered several rejection episodes leading to chronic rejection and FK 506 was required as rescue treatment. A significant difference in mean panel-reactive antibody (PRA) of 8.6% and 56.9% was found in negative and positive CM patients, respectively (P = 0.012). A higher mean PRA (67.7%) was found in positive CM patients with rejection compared with positive CM patients without rejection (PRA 38%). Overall graft and patient survival were 31.9% and 35% in positive CM patients compared with 57.0% and 61.9% in negative CM patients. These differences were statistically significant (P = 0.023). In our experience the risk of developing severe acute rejection with graft failure and chronic rejection is related to PRA > 60% and positive CM. We recommend that in patients with PRA > 60%, the result of CM should be awaited before proceeding to LTX.

Recipient hepatectomy with inferior vena cava (IVC) preservation, the piggy back (PGB) technique, was adopted as our routine option in the management of the anhepatic phase of orthotopic liver transplantation (OLT) to avoid the use of veno-venous bypass (VV-BP). In the last 5 years, 119 OLT in adult patients have been performed in our unit. In the first period (47 OLT), VV-BP was used in 59% of the cases and cross-clamping in the rest. In the second period, following the introduction of the PGB technique, 72 OLT were performed. VV-BP was used in 5.5% of the cases, PGB technique in 87.5% and cross-clamping in 6.9%. There was a significant reduction in the need for VV-BP in the second period. Operating time and blood transfusion were significantly greater in the VV-BP group. No PGB technique related complications were observed. In conclusion, the PGB technique reduced the need for VVBP with consequent savings in time, blood transfusion and the cost of OLT.