Search

The article discusses the risk of delirium following liver transplant (LT) to increase the possibility of morbidity and mortality months after posttransplant.

The article discusses the essential of careful preoperative planning and expectation of possible problems for safe and effective management of complex portal vein thrombosis (PVT) intraoperatively.

Background: Chronic antibody injury is a serious threat to allograft outcomes and is therefore the center of active research. In the continuum of allograft rejection, the development of antibodies plays a critical role. In recent years, an increased recognition of molecular and histologic changes has provided a better understanding of antibody-mediated rejection (AMR), as well as potential therapeutic interventions. However, several pathways are still unknown, which accounts for the lack of efficacy of some of the currently available agents that are used to treat rejection., Methods: We review the current diagnostic criteria for AMR; AMR paradigms; and desensitization, treatment, and prevention strategies., Results: Chronic antibody-mediated endothelial injury results in transplant glomerulopathy, manifested as glomerular basement membrane duplication, double contouring, or splitting. Clinical manifestations of AMR include proteinuria and a rise in serum creatinine. Current strategies for the treatment of AMR include antibody depletion with plasmapheresis (PLEX), immunoadsorption (IA), immunomodulation with intravenous immunoglobulin (IVIG), and T cell- or B cell-depleting agents. Some treatment benefits have been found in using PLEX and IA, and some small nonrandomized trials have identified some benefits in using rituximab and the proteasome inhibitor-based therapy bortezomib. More recent histologic follow-ups of patients treated with bortezomib have not shown significant benefits in terms of allograft outcomes. Furthermore, no specific treatment approaches have been approved by the US Food and Drug Administration. Other agents used for more difficult rejections include bortezomib and eculizumab (an anti-C5 monoclonal antibody)., Conclusion: AMR is a fascinating field with ample opportunities for research and progress in the future. Despite the use of advanced techniques for the detection of human leukocyte antigen (HLA) or non-HLA donor-specific antibodies, alloimmune response remains an important barrier for successful long-term allograft function. Treatment of AMR with currently available therapies has produced a variety of results, some of them suboptimal, precluding the development of standardized protocols. New therapies are promising, but randomized controlled trials are needed to find surrogate markers and improve the efficacy of therapy.

Background: Biliary complications remain a significant problem following liver transplantation. Several surgical options can be used to deal with a significant size mismatch between the donor and recipient bile ducts during the biliary anastomosis. We compared biliary transposition to recipient biliary ductoplasty in cadaveric liver transplant., Methods: A total of 33 reconstructions were performed from January 1, 2005 to December 31, 2013. In the biliary transposition group (n=23), 5 reconstructions were performed using an internal stent (5 or 8 French pediatric feeding tube), and 18 were performed without. Of the 10 biliary ductoplasties, 2 were performed with a stent. All patients were managed with standard immunosuppression and ursodiol. Follow-up ranged from 2 months to 5 years., Results: No patients in the biliary transposition group required reoperation; 1 patient had an internal stent removed for recurrent unexplained leukocytosis, and 2 patients required endoscopic retrograde cholangiography and stent placement for evidence of stricture. Three anastomotic leaks occurred in the biliary ductoplasty group, and 2 patients in the biliary ductoplasty group required reoperation for biliary complications., Conclusion: Our results indicate that biliary reconstruction can be performed with either biliary transposition or biliary ductoplasty. These techniques are particularly useful when a significant mismatch in diameter exists between the donor and recipient bile ducts.

Obesity is on the rise worldwide. As a result, unprecedented rates of patients are presenting with end stage liver disease in the setting of non-alcoholic fatty liver disease (NAFLD) and are requiring liver transplantation. There are significant concerns that the risk factors associated with obesity and the metabolic syndrome might have a detrimental effect on the long term outcomes following liver transplantation. In general, short term patient and graft outcomes for both obese and morbidly obese patients are comparable with that of non-obese patients, however, several studies report an increase in peri-operative morbidity and increased length of stay. Continued studies documenting the long-term outcomes from liver transplantation are needed to further examine the risk of recurrent disease (NAFLD) and also further define the role risk factors such cardiovascular disease might play long term. Effective weight reduction in the post liver transplant setting may mitigate the risks associated with the metabolic syndrome long-term.

Background: The number of robotic operations performed with the da Vinci Surgical System has increased during the past decade. This system allows for greater maneuverability and control than hand-assisted laparoscopic procedures, resulting in less tissue manipulation and irritation., Methods: We retrospectively analyzed the results of 100 consecutive robotic-assisted laparoscopic donor nephrectomies and compared them to our most recent 20 hand-assisted laparoscopic donor nephrectomies., Results: Between May 2008 and June 2012, 120 laparoscopic donor nephrectomies were performed at Ochsner Clinic Foundation. Of those, 100 live kidney donors underwent robotic-assisted laparoscopic donor nephrectomies. Surgical time and hospital length of stay improved after the first 20 patients receiving robotic-assisted laparoscopic nephrectomies, which was considered the learning curve. Sixty percent of patients who underwent robotic-assisted laparoscopic donor nephrectomies were released on postoperative day 1 compared to 45% of patients who underwent hand-assisted laparoscopic techniques., Conclusion: In our experience, robotic-assisted laparoscopic donor nephrectomy resulted in decreased postoperative length of stay that decreased the global cost of the procedure and allowed our institution to admit more patients.

Background: In 2005, the results published by the Scientific Registry of Transplant Recipients showed that Ochsner Clinic Foundation's patient and graft survival rates were statistically lower than expected, and the United Network for Organ Sharing Membership and Professional Standards Committee placed our center under peer review., Methods: In response, patient outcomes prior to August 2005 were carefully reviewed in a transparent fashion and protocols were written to standardize treatments. We renewed the focus on patient-related outcomes and regulatory adherence and empowered frontline staff to express their views, allowing for real teamwork to develop. Multiple changes were implemented in the everyday running of the program. A quality assurance and performance improvement plan (QAPI) was initiated to improve outcomes., Results: In 2012, the Ochsner liver transplant program became the largest liver transplant program in the United States by volume and in 2013 was awarded the prestigious CareChex award, acknowledging it as the number one program in terms of quality of care and outcomes for liver transplantation., Conclusion: The methodical application of this QAPI program achieved a remarkable transformation of the Ochsner liver transplant program and exemplifies what is possible with strong teamwork from dedicated and talented staff.

Background: Tumor necrosis factor-α (TNF-α) is a potent proinflammatory cytokine involved in a variety of disease pathologies, including ischemia/reperfusion (I/R) injuries in transplantation. The interaction of TNF-α with its cognate receptor TNF receptor I (TNFRI) results in the activation of signal transduction pathways that regulate either cell survival or cell death. Hepatocytes express TNFRI and respond to TNF-α released by resident Kupffer cells as well as leukocytes that migrate to the liver during I/R injury. Upon binding TNF-α, the hepatocyte proliferates or undergoes apoptosis or necroptosis. The decision by the cell to commit to one path or the other is not understood. The damaged tissue exhibits cell death and hemorrhaging from the influx of immune mediators. TNF-α inhibitors ameliorate the injury in animal models, suggesting that lowering (but not eliminating) TNF-α levels shifts the balance of TNF-α toward its beneficial functions., Methods: We review TNF-α signal transduction pathways and the role of TNF-α in liver I/R injury., Conclusions: Because TNF-α plays an important role in hepatocyte proliferation, complete inhibition of TNF-α is not desirable in treating liver I/R injury. The strategy for developing pharmacological therapies may be the identification of specific intermediates in the TNF-α/TNFR1 signal transduction pathway and directed targeting of proapoptotic and pronecroptotic events.

Liver transplantation has become the best and most durable treatment for both acute and chronic liver disease. Over 1400 liver transplants have been performed at the Ochsner Clinic since the first successful transplant in 1987. Since its inception, the program has gone through several changes and advancements and has become one of the largest liver transplant programs in the United States. We have helped evolve steroid sparing immunosuppression and the use of extended criteria, donor organs. Establishment of criteria for the selection of recipients for re-transplantation has resulted in better than expected short and long-term results. Our center has faced the challenge of Hurricane Katrina and overcome it. We have improved steadily in both outcomes and transplants performed. The Ochnser Clinic Liver Transplant program will continue to improve access and outcomes for all patients with liver disease.

Hepatic ischemia/reperfusion (I/R) injury has a significant influence on the outcome of liver transplants. Inhibiting certain enzymatic reactions that occur during I/R injury may have a protective effect on the liver during transplantation. After reviewing the biochemical pathways involved in hepatic I/R injury, we describe a pharmacologic line of defense against this injury by means of the enzyme tissue inhibitor of metalloproteinase 3 (TIMP-3). Current results suggest that TIMP-3 will play a clinically relevant role in improving outcomes of liver transplants by reducing I/R injury to the donor liver.

Objective: Our objective was to quantitatively assess the value of early posttransplantation hepatic artery resistive indexes in predicting vascular and nonvascular complications in adult orthotopic liver transplant (OLT) patients., Materials and Methods: Between 1999 and 2001, 110 consecutive adults received grafts. Doppler sonographic graft evaluations measured main, right, and left resistive indexes within 24 to 48 hr after surgery (normal resistive index cutoff, 0.6). Clinical, operative, procedural, and radiologic reports were reviewed for vascular and biliary complications. Frequency, Student's t test, logistic, and regression statistical analyses were performed., Results: even patients (6.4%) had vascular complications, including two (1.8%) hepatic artery and two (1.8%) hepatic vein stenoses, one (0.9%) hepatic vein thrombosis, two (1.8%) portal vein thromboses, and one (0.9%) thrombosis and two (1.8%) stenoses of the inferior vena cava (IVC). In 19 patients (17.3%), biliary complications included anastomotic strictures and leaks 1 week to 18 months after transplantation. In 11 patients (10%), sonographically large hematomas required surgical evacuation. In grafts with vascular complications or large hematomas, the mean early posttransplant main, right, and left indexes were significantly lower (< or = 0.6) than without these complications (p < 0.01). In grafts with and without biliary complications, mean early posttransplant main, right, and left indexes did not differ significantly., Conclusion: In adult OLT patients, low early posttransplant hepatic artery resistive indexes were sensitive (100%) and specific (80%) predictors for vascular complications (e.g., hepatic artery, portal vein, hepatic vein, and IVC) but not for biliary complications. All patients with indexes less than 0.6 within 24-48 hr after surgery should be monitored closely for vascular complications.

Liver transplantation is now advocated for patients with early stage hepatocellular carcinoma (HCC) not amenable to surgical resection. In this article we review our experience with liver transplantation as treatment for patients with HCC and end-stage liver disease. Between April 1998 and May 2002, 36 patients with a diagnosis of HCC underwent liver transplantation at Ochsner Clinic Foundation. A retrospective analysis was performed examining pretransplant staging of disease, pathologic staging, disease recurrence, and patient survival. Cumulative 1- and 3-year patient survival rates are 80% and 61%, respectively. To date, none of our patients has developed evidence of recurrent cancer. Our data support liver transplantation as the treatment of choice for patients with unresectable early stage HCC.

We present a case of primary pulmonary mucormycosis infection in a renal transplant recipient diagnosed serendipitously by computed tomography scan. Treatment included discontinuation of immunosuppressive regimen, initiation of antifungal therapy with amphotericin B lipid complex, administration of granulocyte-macrophage colony stimulating factor, surgical excision of the involved lobe, and outpatient treatment with amphotericin B with dialysis. The patient ultimately required transplant nephrectomy as a result of immunosuppression discontinuation.