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Abstract: Liver transplantation may be performed using extended criteria donor grafts (ECDg). The characteristics of ECDg include age >60 years, long intensive care unit (ICU) stay, history of malignancy or steatosis. Grafts are often discarded due to steatosis, which can be macrovesicular (MaS) or microvesicular (MiS). MaS is the variety most frequently involved with unfavorable outcomes due to primary nonfunction (PNF) or primary dysfunction (PDF). As of January 2000, all livers referred to our institution were considered potentially transplantable. Steatosis was defined as the presence of fat droplets in more than 5% of hepatocytes. We observed 35 steatotic grafts. Grafts were stratified according to MaS and MiS as follows: low steatosis (5%–15%), mild steatosis (16%–30%), moderate steatosis (31%–60%), or severe steatosis (>60%). Fifteen grafts with moderate (n = 2) or severe (n = 13) MaS were discarded. Twenty grafts were harvested: 18 of them were transplanted at our institution, the remaining 2, discarded by our donor team, were transplanted by other Italian centers. Low MaS was detected in 10 grafts (50%), mild MaS in 4 (20%), and moderate MaS in 2 (10%). Low MiS was detected in 8 grafts (40%), mild MiS in 5 (25%), and moderate MiS in 1 (5%). Steatotic grafts were transplanted only into recipients with model for end-stage liver disease (MELD) scores <27. The 6-month graft survival was 80%; the PNF rate was 10%; and the PDF rate was 15%. The careful use of ECDg with low to moderate steatosis is possible if particular care is taken to avoid additional risk factors related to the recipient. [Copyright &y& Elsevier]

Abstract: The indications for liver transplantation among patients with post-hepatitis B virus (HBV)-related cirrhosis have changed over the past 35 years. We reviewed the long-term results of 47 patients treated with liver transplantation for HBV-related cirrhosis. Patients were classified into 3 groups according to the perioperative regimen. In the initial experience, no immunoprophylaxis was adopted (no-IP; n = 5). From 1988–1996, an immunoprophylaxis scheme was adopted (HBIg; n = 16). From 1997–2007, we adopted the combination of lamivudine and HBIg (LAM-HBIg; n = 26). We calculated the prevalence of serological reinfection and patient survival at 1 to 20 years, using the 3 regimens. The recurrence rate was 75% in the group of untreated patients; 30% in the HBIg group; and 9% in the LAM-HBIg group. The overall survival was 67% at 5 years, and 64% at 10 and 20 years. The long-term survival for each of the 3 therapeutic approaches, namely, for the patients who did not receive any treatment, for the HBIg group, and for the LAM-HBIg group, were 20%, 50%, and 84%, respectively. We suggest to use the LAM-HBIg combination. [Copyright &y& Elsevier]

Abstract: In liver transplantation the identification of risk factors and the risk quantification for each single case represent a field of great interest. There are donor-related and recipient-related risk factors. Donor risk index (DRI) was retrospectively calculated in 223 liver transplant cases. We did not include patients with preoperative diagnosis of hepatocarcinoma and retransplants. The cases were stratified into two classes according to the DRI (low risk, DRI < 1.7, and high risk, DRI ≥ 1.7). A new index, namely the organ patient index (OPI) was calculated adding the Model for End-stage Liver Disease (MELD) score to the DRI. Patients were stratified into two classes according to the OPI (low risk, OPI ≤ 2.85, and high risk, OPI > 2.85). The cases with low DRI (n = 144) showed better survival than the cases with high DRI (n = 82; P < .02). The cases with low OPI (n = 173) showed better survival than cases with high OPI (n = 50; P < .01). The OPI predicted outcomes better than DRI, increasing the gap in the long-term graft survival between the low- and the high-risk class. The inclusion of the MELD in the new index allowed better prediction of graft survival. [Copyright &y& Elsevier]

Abstract: Determination of cardiac output (CO) is crucial for perioperative monitoring of orthotopic liver transplant (OLT) recipients. A pulmonary artery catheter (PAC) has always been considered the “gold standard” of hemodynamic monitoring. The aim of this study was to evaluate the suitability of a transesophageal echo-Doppler device (ED) as a minimally invasive device to measure CO in OLT. ED was compared with the standard PAC technique taking into account the disease severity of OLT recipients as defined by the model for end-stage liver disease (MELD) score. We enrolled 42 cirrhotic patients scheduled for OLT 3 thermodilution CO measurements were taken by a PAC and the most recent ED measurement (COED) was also recorded. Paired measurements of CO were performed at standard times, unless there were additional clinical needs. Recipients were stratified into 3 groups according to MELD score: MELD score ≤15 (14 patients); MELD score between 16 and 28 (17 patients); and MELD score ≥29 (11 patients). We performed 495 paired measurements of CO. Mean bias was 0.34 ± 0.9 L/min and limits of agreement were −1.46 and 2.14 L/min. In patients with MELD score <15, the bias was 0.12 ± 0.55. The ED results were not interchangeable with PAC, because of the large limits of agreement. However, in cirrhotic patients with MELD scores <15, the precision of the new method was similar to that of PAC; therefore, in this subset of patients, it may represent a reliable alternative to PAC. [Copyright &y& Elsevier]

Abstract: In recent studies, nonstandard donors and high Model for End-stage Liver Disease (MELD) values have been indicated as risk factors for both graft survival and patient survival. A recent debate concerns which donor and recipient match guarantees the best results in terms of early and late survival. To emphasize the role of the donor–recipient match, we have reported herein a complex case of a patient who changed his preoperative risk status, being transplanted three times using donors of different risk levels. At each transplant, the patient moved to a higher MELD class: first transplant MELD = 22; second transplant MELD = 37; third transplant MELD = 38. Only at the third transplant did the patient recover. Besides the liver, almost all his organs (kidneys, heart, lungs) recovered in a few weeks, as well. Unfortunately, severe cortical and subcortical brain damage remained a crucial limiting impairment, leading to death 5 months later, due to pulmonary infection, yet with a perfectly working liver. We underlined the role of donor factors to predict the outcome after liver transplantation in the MELD era. [Copyright &y& Elsevier]

Abstract: Various artificial liver support systems are currently used in patients with decompensated chronic liver disease or acute liver failure as a bridge to recovery or to orthotopic liver transplantation (OLT). Between June 2004 and September 2006, 9 subjects were treated with plasma exchange (PE) for acute decompensation on chronic liver disease or chronic decompensation in end-stage liver disease. All of them were awaiting OLT or were listed at the moment of decompensation. Grade II to III hepatic encephalopathy (HE) was present in 4 patients, significant renal dysfunction in 3 patients, and ascites in 6 patients. Baseline serum total bilirubin was 35.1 ± 11.2 mg/dL (mean value ± SD). The patients underwent a mean of 12.1 2-hour exchanges over 1 to 8 weeks. The 3 who recovered were alive after a mean follow-up of 22.7 ± 10.3 months. There were 3 patients who underwent transplantation and 3 who died due to liver failure during treatment. Only subjects with acute decompensation and without HE or significant renal dysfunction survived without OLT. PE did not significantly modify the grade of HE or the renal function. PE seemed to be a safe, long-term, effective therapeutic option for acute decompensation among subjects with chronic liver disease without brain or renal dysfunction. [Copyright &y& Elsevier]

Abstract: Candidates for liver transplantation with AB blood group remain on the waiting list for shorter times than candidates with O blood group. To investigate the reasons of this phenomenon, we analyzed data concerning deceased donors, liver transplant candidates, and liver first transplants performed in the United States during the period 2003 to 2004. The percentage of deceased donors with blood group O was higher than that of candidates on the waiting list with the identical blood group (P < .05). On the other hand, for blood groups A, B, and AB an opposite situation was observed: the percentages of deceased donors were significantly lower compared to those candidates with the identical blood group (A blood group, P < .05; B and AB blood groups, P < .001). When the number of grafts from deceased donors was compared with the number of those effectively transplanted, a negative difference for O blood group recipients was found (ie, transplanted livers < harvested livers) and a positive one for AB blood group (transplanted livers > harvested livers) were found. Since disease progression and causes of acute liver failure, including primary nonfunction and hepatic artery thrombosis leading to retransplantation were similar among the various blood groups, we concluded that the shorter waiting time for AB patients in the pre-MELD era was due to the use of compatible livers to the detriment of group O recipients. [Copyright &y& Elsevier]

Abstract: Two hundred seventy-six liver transplants were retrospectively reviewed to analyze 6-month graft survival in relation to the combination of donor quality (standard donor vs nonstandard donor) and risk related to the severity of recipient liver disease low-risk, ie, United Network for Organ Sharing [UNOS] status 3/2b; high-risk, ie, UNOS status 1/2a). The overall 6-month survival rate of 82% was stratified into 4 classes: (1) standard donor to low-risk recipient = 88%; (2) standard donor to high-risk recipient = 86%; (3) nonstandard donor to low-risk recipient = 84%; and (4) nonstandard donor to high-risk recipient = 67%. According to the observed graft survival in the 4 different classes, 2 simulations were performed: the “match simulation” (transplantation of all low-risk recipients using standard donors, and transplantation of all high-risk recipients using nonstandard donors), and the “mismatch simulation” (transplantation of all the high-risk patients using low-risk donors and transplantation of low-risk patients using high-risk donors). The 6-month survival rates, calculated using the match simulation, were 74% and using the mismatch simulation, 84%. The authors suggest that, in the era of marginal donors, the recipient should be selected in relation to the characteristics of the donor according to the mismatch model. [Copyright &y& Elsevier]

Abstract: Introduction: Hepatic artery stenosis (HAS) is an important complication after liver transplantation. However, studies are not conclusive in terms of definition, incidence, best treatment, and timing of intervention. The aim of this study was to evaluate the incidence of SSHA that occurred in a single center over the past 12 years, pointing out diagnostic and therapeutic strategies. Methods: The incidence of HAS was reviewed in 258 liver transplant recipients between January 1999 and December 2011. All patients underwent Doppler ultrasound (DUS) at fixed times. Multidetector computed tomographic angiography (MDCTA) was performed to confirm the DUS findings. Results: HAS occurred in 23 cases (9.3%). In all cases diagnosis was performed by DUS resulting in a sensitivity of 100% and a specificity of 99.6%. Based on DUS and MDCTA data integration, in 10 cases we adopted the “wait and see” strategy, whereas 13 patients underwent interventional radiology techniques. Conclusion: DUS monitoring is efficacious in the diagnosis of HAS after liver transplantation. Interventional radiology procedures are safe and efficacious. [Copyright &y& Elsevier]

Abstract: Liver dysfunction is an important cause of morbidity and mortality after orthotopic liver transplantation (OLT). The Molecular Adsorbent Recirculating System (MARS) is an albumin-based dialysis system designed to enhance the excretory function of a failing liver. MARS has been successfully used in patients affected by advanced liver disease and presenting with severe cholestasis. The aim of this study was to evaluate the safety and clinical efficacy of MARS in patients with liver dysfunction after OLT. Seven patients (primary nonfunction, 2 patients; graft dysfunction, 5 patients) fulfilled the inclusion criteria of serum bilirubin level >15 mg/dL and least 1 of the following clinical signs: hepatic encephalopathy (HE) ≥grade II, hepatorenal syndrome (HRS), and intractable pruritus. Graft and patient survival rates at 6 months were 42.8% and 57.1%, respectively. All patients tolerated MARS treatment, with no adverse event. In all patients, a decrease in serum bilirubin (P < .05), bile acids (P < .05), serum creatinine, and ammonia levels was observed after treatment with MARS. A considerable improvement of HE, as well as renal and synthetic liver functions, was observed in 4 of 5 patients with graft dysfunction, but not among those with primary nonfunction. The patients with intractable pruritus showed significant improvement of this symptom after MARS therapy. Thus, MARS is a safe, therapeutic option for the treatment of liver dysfunction after OLT. Further studies are necessary to confirm whether this treatment is able to improve both graft and patient survival. [Copyright &y& Elsevier]