Search

Background Liver transplantation is the most suitable treatment option available for end-stage liver disease. However, some patients require retransplantation, despite medical advances that have led to improved survival. We aimed to compile a definitive, nationwide resource of liver retransplantation data in Japan, seeking to identify the predictors of patient survival posttransplantation. Methods Questionnaires were sent to 32 institutions that had conducted 281 retransplantations before 2015. Results Among the 265 patients included in this study (142 pediatric cases), the average age at primary transplantation was 23 years, and retransplantation was performed after an average of 1468 days. The main indication for retransplantation was graft rejection (95 patients). Living-donor liver transplantation accounted for 94.7% of primary transplantations and 73.2% of retransplantations. Patient survival at 1, 3, or 5 years did not differ by type of transplantation but was better for pediatric (70.8%, 68.3%, and 60.1%, respectively) than for adult (57.2%, 50.4%, and 45.2%, respectively) recipients (P = 0.0003). Small-for-size syndrome, retransplantation within 365 days, and inpatient status at retransplantation were significant predictors of poor survival in pediatric cases. Retransplantation within 365 days and conditions warranting retransplantation were significant predictors of poor survival in adult patients. Conclusions In Japan, where >70% of retransplantations are performed using living donors, the indications and timing are different from those in previous reports from other countries, while maintaining comparable survival rates. Considering technical challenges, graft failure within 365 days should be thoroughly restricted to justify the use of living donor.

Background. Recurrence of hepatitis C viremia after orthotopic liver transplantation (OLT) is nearly universal, leading to variable outcome from no to severe recurrent disease. In the present study, the prognostic relevance of hepatitis C virus (HCV) genotypes and viremia for the development and severity of graft hepatitis was investigated. Methods. A total of 79 patients with chronic hepatitis C who could be followed for 1 to 78 months (mean: 30 months) after OLT were included in this study. HCV RNA concentrations were measured before OLT, 1 month after OLT, as well as in the long-term follow-up after OLT in 54 of the 79 patients. Results. Graft hepatitis could be documented in 40 of the 79 patients (51%), and 7 of them (9%) progressed to liver cirrhosis. More severe forms of graft hepatitis predominated in patients with subtype 1b infection, and all seven patients with progression to liver cirrhosis had subtype 1b (P5NS). Neither the pretransplant nor the posttransplant HCV RNA levels were significantly associated with the occurrence of graft hepatitis. However, there was a trend of more severe recurrent disease in subtype 1b-infected patients with high level viremia in the early course after OLT. Conclusions. Pretransplant HCV virological markers are not helpful to predict the outcome after OLT. However, it should be further investigated whether estimation of HCV genotype and viremia levels very early after OLT, i.e., within the first weeks, may be a better approach to recognize high-risk patients. Orthotopic liver transplantation (OLT*) has become a wellestablished treatment for end-stage liver diseases with excellent results for short-term survival, with a 30-day mortality of 3% at our center. The recurrence of the liver disease is now one of the most important problems in liver transplantation. Patients chronically infected with hepatitis C virus (HCV) before OLT will suffer graft reinfection in nearly all cases, and graft hepatitis of mild to moderate activity will occur in about 50 ‐70% (1‐5). However, in some patients, HCV reinfection induces a progressive disease leading to graft failure even within 1 year (6, 7). The mechanisms responsible for these different outcomes are still unclear. HCV genotype and hepatitis C viremia may influence the clinical course. In particular, an association between genotype 1b and manifestation of severe recurrent hepatitis C could be observed, and it was suggested that genotype 1b may play a major role in this respect (8, 9). Furthermore, the relevance of the hepatitis C viremia level for the development of graft hepatitis has also been discussed, but it seems that the evaluation of the preOLT HCV RNA concentration is of little help in this respect (10 ‐12).

For adult patients with end-stage liver disease, living-donor liver transplantation (LDLT) of right-lobe grafts with or without the middle hepatic vein (MHV) has been increasingly used in recent years. We investigated the role of the MHV in donor remnant liver regeneration after right-lobe LDLT, which has not been described in previous studies. A total of eight living donors were included in this study of right-lobe LDLT. Four donors underwent right lobectomy (without MHV), and the remaining four underwent extended right lobectomy (with MHV). Regeneration of the donor remnant liver was assessed by volumetric computed tomography studies before and 90 days after LDLT. Comparison between the right-lobe and extended right-lobe donors did not show a clear-cut difference in the net increase of remnant liver volume at 3 months. However, the mean volume increase of the medial segment at the 90th postoperative day was 7% in the extended right-lobe donors and 61% in the right-lobe donors, showing a lower value in the remnant livers without MHV. The MHV plays a specific role in remnant liver regeneration of right-lobe living donors. We expect that this knowledge will contribute to securing a margin of safety in right-lobe LDLT.

Rapid graft dysfunction caused by hepatitis C virus (HCV) reinfection, although uncommon, is a disastrous complication in liver transplant patients. Finding an effective therapy for this subgroup of patients with severe recurrent HCV is a priority.We describe a successful rescue of a 46-year-old man with recurrent hepatitis C (HCV genotype 1b) using long-term interferon (IFN) and ribavirin. The patient had a very aggressive type of posttransplantation HCV infection, as judged by biochemical and histologic findings.Despite high pretreatment values of serum alanine aminotransferase (ALT; peak value of 901 IU/L) and HCV-RNA (2.3 x 10(6) copies/ml), the combination therapy with IFN and ribavirin produced a rapid normalization of the serum ALT values, accompanied by the clearance of serum HCV-RNA. Although HCV-RNA reappeared in the serum at 3 months, the patient had continued ALT normalization and histological improvement with follow-up of over 26 months to date after the initiation of the combination therapy.This observation suggests that IFN in combination with ribavirin may offer an effective therapeutic option for liver transplant patients with severe recurrent hepatitis C.

The minimum graft volume still remains unclear in reduced-size liver transplantation (RLT). This study reports the improved survival of canine RLT using a quarter graft with the aid of a portahepatic vein shunt (PHVS). In beagles, the donor liver was reduced to the right lateral and caudate lobes (quarter graft) with or without provision of PHVS, and transplanted orthotopically in the recipient. The PHVS was established by an end-to-end anastomosis of the portal vein branch and the hepatic vein in the resected left lateral lobe. Liver chemistries including arterial blood ketone body ratio (AKBR) were serially measured during and after surgery. All seven animals with PHVS survived more than 3 days (mean +/- SD; 5.3 +/- 1.7 days), whereas all six without PHVS died within 3 days (1.8 +/- 0.8 days, P < 0.01). Portal vein pressures immediately after recirculation in animals with and without PHVS were 8.5 +/- 1.2 mmHg and 16.9 +/- 3.1 mmHg, respectively (P < 0.01). Regardless of the presence or absence of PHVS, AKBR dropped to a level lower than 0.7 during the anhepatic period and returned promptly to above 1.0 as early as 30 min after recirculation. Thereafter, the AKBR values in animals with PHVS remained higher than 1.0, whereas those in animals without PHVS showed a progressive decrease, showing a statistically significant difference between the two groups after 12 hr (P < 0.05). Graft function, as assessed by AKBR, was well correlated with survival and other liver chemistries. These results indicate that, in an extreme RLT, portal hypertension is a risk factor predisposing to graft failure, most likely by increasing microvascular injury after recirculation.