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Patient-reported outcomes are important to consider when the relative success of liver transplantation (LT) is being evaluated. Our primary objective was to examine the expectations for LT and the criteria for its success across 4 domains of functioning (pain, fatigue, emotional distress, and interference with daily activities) from the perspective of patients who were wait-listed for LT. One hundred four adult patients with a mean wait-list time of 16.5 ± 13 months completed a semistructured interview with a modified version of the Patient-Centered Outcomes Questionnaire (PCOQ). The patients reported moderate usual levels of pain, fatigue, emotional distress, and interference with daily activities (mean rating range = 3.8-6.2), and they attached great importance to improvements in these domains after LT (mean rating range = 7.3-8.0). Patients considered a mean reduction in pain of 33% to be a successful LT outcome. A reduction in fatigue of 56%, a reduction in emotional distress of 44%, and a reduction in interference with daily activities of 54% represented successful LT across these domains. Patients with more severe illness had higher expectations for fatigue (r = -0.30, P = 0.002) and interference with daily activities (r = -0.24, P = 0.015). Cluster and correlational analyses provided support for the validity of the PCOQ with LT patients. Our findings underscore the importance and value of using patient-centered assessments to better understand the ways in which patients prioritize LT outcomes and define transplantation success. Patient-centered assessments have the potential to facilitate provider-patient communication by helping patients to prioritize their goals for LT and make informed choices on the basis of those priorities., (Copyright © 2011 American Association for the Study of Liver Diseases.)

Hepatocyte proliferation early after liver resection is critical in restoring liver mass and preserving function as the liver regenerates. Carbon monoxide (CO) generated by heme oxygenase-1 (HO-1) strongly influences cellular proliferation and both HO-1 and CO are accepted hepatoprotective molecules. Mice lacking functional HO-1 were unable to mount an appropriate regenerative response following partial hepatectomy (PHTx) compared to wildtype controls. We therefore hypothesized that exogenous administration of CO at low, nontoxic concentrations would modulate hepatocyte (HC) proliferation and liver regeneration. Animals treated with a low concentration of CO 1 hour prior to 70% hepatectomy demonstrated enhanced expression of hepatocyte growth factor (HGF) in the liver compared to controls that correlated with a more rapid onset of HC proliferation as measured by phospho-histone3 staining, increased expression of cyclins D1 and E, phosphorylated retinoblastoma, and decreased expression of the mitotic inhibitor p21. PHTx also increased activation of the HGF receptor c-Met, which was detected more then 9 hours earlier in the livers of CO-treated mice. Blockade of c-Met resulted in abrogation of the CO effects on HC proliferation. Corresponding with increased HC proliferation, treatment with CO maintained liver function with normal prothrombin times versus a 2-fold prolongation in controls. In a lethal 85% PHTx, CO-treated mice showed a greater survival rate compared to controls. In vitro, CO increased HGF expression in hepatic stellate cells, but not HC, and when cocultured together led to increased HC proliferation. In summary, we demonstrate that administration of exogenous CO enhances rapid and early HC proliferation and, importantly, preserves function following PHTx. Taken together, CO may offer a viable therapeutic option to facilitate rapid recovery following PHTx., (Copyright © 2011 American Association for the Study of Liver Diseases.)

Objective: Evaluate recurrence and survival in patients who underwent intraoperative margin re-resection for colorectal cancer liver (CRC) metastases., Design: Retrospective analysis., Setting: University Hospital, Cincinnati, Ohio. Academic medical center., Participants: Cohort of 118 patients who underwent resection of CRC liver metastases between 1992 and 2004. All patients were divided into 3 groups: resection margin (MOR) less than 1 cm (n = 64), MOR greater than 1 cm (n = 33), and re-resection margin (re-MOR) greater than 1 cm (n = 21)., Results: Patients with a margin greater than 1 cm, when compared with re-MOR greater than 1 had decreased incidence of liver and distant recurrence (p < 0.05) as well as improved disease-free survival (39.2 vs 22.9 months, p = 0.023). Differences in overall survival (58.6 vs 44.2 months, p = 0.14) were not significant., Conclusion: Intraoperative re-resection is associated with an increased risk of local and distant recurrence, which may be a reflection of both inadequate surgery and underlying tumor biology.

With nearly two years of data available since the inception of the MELD and PELD allocation system, this article examines national OPTN/SRTR data to describe trends in waiting list composition, waiting list mortality, transplant rates, and patient and graft outcomes for liver transplantation. Following a 6% reduction in the size of the waiting list after MELD was implemented in 2002, the number of patients on the waiting list grew by 2% from 2002 to 2003, while the number of liver transplants increased by 6%. The overall death rate while on the liver waiting list has decreased from 225 deaths per 1,000 patient years in 1994 to 124 deaths in 2003. As with the waiting list death rates, post-transplant death rates have also decreased over the past decade. Unadjusted one-year patient survival was lower for older donor age groups (88% for donors aged 18-34, 87% for donors aged 35-49, 85% for donors aged 50-64); a similar trend was observed at three and five years following transplantation. Intestine transplantation is performed with slowly increasing frequency and success. Early graft losses and rejection rates have changed little since 1994, but rejection is easier to control and long-term survival is improving.

Progressive multifocal leukoencephalopathy (PML), a demyelinating disease of the brain caused by JC virus (JCV), occurs following transplantation and other conditions associated with immunosuppression. On magnetic resonance imaging (MRI), PML lesions typically appear as hyperintense signal on T2-weighted and FLAIR images located in the subcortical white matter, which are devoid of contrast enhancement or mass effect. The prognosis is poor, but unusual inflammatory forms of PML characterized by contrast enhancement have been associated with a cellular immune response against JCV and a better prognosis. The authors report an atypical presentation of PML with contrast-enhancing lesions and mass effect on the MRI in a liver transplant recipient,who had a progressive course and fatal outcome.

The most significant development in liver transplantation in the USA over the past year was the full implementation of the MELD- and PELD-based allocation policy in March 2002, which shifted emphasis from waiting time within broad medical urgency status to prioritization by risk of waiting list death. The implementation of this system has led to a decrease in pretransplant mortality without increasing post-transplant mortality, despite a higher severity of illness at the time of transplant. The trend over the last few years of rapidly increasing numbers of adult living donor liver transplants was reversed in 2002 by a decline of more than 30% in the number of these procedures. In 2002, a greater percentage of women received livers from living donors (43%) than deceased donors (34%), possibly because of size considerations. From 1993 to 2001, the waiting list increased more than sixfold, from 2902 patients to 18,047 patients. For the first time since 1993, the waiting list size decreased in 2002, dropping 6% to 16,974 candidates. The percentage of temporarily inactive liver candidates also increased from 2001, thus the net decrease in the active waiting list for 2002 was 12%. This may reflect a trend toward less pre-emptive listing practices under MELD. Intestine transplantation remains a low-volume procedure limited to a few transplant centers and is still accompanied by significant pre- and post-transplantation risks. As this procedure matures, its application may increase to include recipients at an earlier stage of their disease with better likelihood of success.