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Donation after brain death followed by circulatory death (DBCD) is a unique practice in China. The aim of this study was to define the pathologic characteristics of DBCD liver allografts in a porcine model. Fifteen male pigs (25-30 kg) were allocated randomly into donation after brain death (DBD), donation after circulatory death (DCD) and DBCD groups. Brain death was induced by augmenting intracranial pressure. Circulatory death was induced by withdrawal of life support in DBCD group and by venous injection of 40 mL 10% potassium chloride in DCD group. The donor livers were perfused in situ and kept in cold storage for 4 h. Liver tissue and common bile duct samples were collected for hematoxylin and eosin staining, TUNEL testing and electron microscopic examination. Spot necrosis was found in hepatic parenchyma of DBD and DBCD groups, while a large area of necrosis was shown in DCD group. The apoptosis rate of hepatocytes in DBD [(0.56±0.30)%] and DBCD [(0.50 ± 0.11)%] groups was much lower than that in DCD group [(3.78±0.33)%] (P<0.05). And there was no significant difference between DBD group and DBCD group (P>0.05)). The structures of bile duct were intact in both DBD and DBCD groups, while the biliary epithelium was totally damaged in DCD group. Under electron microscope, the DBD hepatocytes were characterized by intact cell membrane, well-organized endoplasmic reticulum, mild mitochondria edema and abundant glycogens. Broken cell membrane, mild inflammatory cell infiltration and sinusoidal epithelium edema, as well as reduced glycogen volume, were found in the DBCD hepatocytes. The DCD hepatocytes had more profound cell organelle injury and much less glycogen storage. In conclusion, the preservation injury of DBCD liver allografts is much less severe than that of un-controlled DCD, but more severe than that of DBD liver allografts under electron microscope, which might reflect post-transplant liver function to some extent.

Background: In addition to suprahepatic vena cava anastomosis in two-cuff rat liver transplantation, recipient portal vein revascularization is one of the most difficult procedures that must be performed, especially for beginners., Materials and Methods: A total of 43 cases of liver transplantation were performed. Rats in Group 1 and Group 2 were subjected to transplant procedures that used the conventional and portal venoplasty techniques, respectively. The portal vein anastomosis duration, anhepatic phase length, portal vein surgical complications, and 1 wk post-transplant survival rates were recorded for each group., Results: The portal revascularization duration was statistically significantly less for Group 2 versus Group 1 (1.50 ± 0.61 min and 4.32 ± 0.67 min, respectively, P < 0.05). The anhepatic phase length of Groups 1 and 2 were 21.79 ± 1.27 min and 18.55 ± 1.47 min, respectively (P < 0.05). No significant differences between the groups were observed in relation to either portal vein surgery complications or 1-week survival rates., Conclusions: The recipient portal venoplasty and cuff insertion technique is a safe and fast alternative surgical option for portal revascularization in two-cuff rat liver transplantations performed by a single trainee., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: This aims to evaluate the effects of lamivudine (LAM) and entecavir (ETV) in preventing hepatitis B virus (HBV) re-infection after liver transplantation (LT)., Methods: A retrospective matched case-control method was used in this study. From June 2005 to May 2007, the patients who received LAM (100 mg qd) or ETV (0.5 mg qd) were chosen. The LAM and ETV groups were matched using a 3:1 ratio based on the factors, such as age, gender, LAM or ETV antiviral duration, primary disease, and HBV DNA levels at the initiation of antiviral therapy. Data on serum HBV markers, HBV DNA, and cumulative recurrence were collected., Results: Two hundred and fifty-two patients were enrolled. The average duration of follow-up was 38.5 and 41.2 months (LAM and ETV groups) (p>0.05). Duration of pre-operative antiviral therapy was 30.3 and 25.8 d (LAM and ETV groups) (p>0.05). The HBV DNA level decreased from 3.89×10(6) to 5.31×10(5) copies/mL before LT in the LAM group, and decreased from 8.74×10(6) to 5.49×10(4) copies/mL in the ETV group (p<0.05). Eighteen patients in LAM group developed HBV re-infection and 0 in ETV group., Conclusion: ETV is superior to LAM for preventing HBV re-infection following LT., (© 2011 John Wiley & Sons A/S.)

Objective: To compare early and late orthotopic liver retransplantation (re-OLT) for patients with poor graft function after primary transplantation at our center and sum up our clinical experience in re-OLT., Methods: The clinical data of 36 re-OLTs from January 2004 to July 2009 were analyzed retrospectively, consisting of the first group with 17 cases of early re-OLT and the second group with 19 cases of late re-OLT. The average ages were (45 ± 13) years and (48 ± 10) years, and the time intervals were (49 ± 54) days and (514 ± 342) days in early re-OLT group and late re-OLT group, respectively., Results: Biliary tract complications were the main indications for early re-OLT and late re-OLT. Other common indications were vascular complications in early re-OLT and recurrence of primary diseases in late re-OLT. No significant differences were found between the groups with regard to the volume of bleeding during operation, cold ischemia time, operative duration and perioperative mortality except the MELD score. Outcome was fatal for 8 patients in early re-OLT and 10 patients in late re-OLT. Three deaths were due to severe sepsis-related disease, 3 deaths due to multiple organ failure in early re-OLT and 4 deaths due to severe sepsis-related disease, 3 deaths due to recurrence of HCC in late re-OLT. One and 2-year actuarial survival rates after re-OLT were 52.9% and 41.2%, respectively, for patients in early re-OLT, and 63.2% and 52.6%, respectively, for patients in late re-OLT. No significant differences were found regarding survival rates between the two groups (P > 0.05)., Conclusions: The similar clinical results can be achieved in early and late re-OLT. Proper indications and optimal operation timing, experienced surgical procedures and effective perioperative anti-infection strategy contribute to the improvement of the overall survival rate of the patients after re-OLT.

Objectives: To find out the risk factors predicting long-term survival, and to explore the measures for further improving the survival outcome of whom underwent liver transplantation (LT) for benign end-stage liver disease., Methods: The common causes of late death after LT and risk factors were retrospectively analyzed in 221 consecutive patients, who underwent LT from October 2003 to June 2007 and survived more than one year. Twenty-six potential risk factors were assessed by the Kaplan-Meier method, and those variables found to be univariately significant at P < 0.10 were entered into a backward step down Cox proportional hazard regression analysis to screen the independent risk factors influencing the recipient's long-term survival., Results: There were 28 recipients died one year later after LT during the follow-up period. The major causes of late mortality were related to infectious complications 5.0% (11/221), biliary complications 3.6% (8/221) and HBV recurrence/reinfection 1.4% (3/221). After Cox proportional hazard regression analysis, 5 covariables finally retained in the formula were: age (RR = 2.325, P = 0.009), ABO blood group (RR = 2.206, P = 0.015), cold ischemia time (RR = 3.001, P = 0.000), post-infection region (RR = 1.665, P = 0.007) and biliary complications (RR = 2.655, P = 0.004)., Conclusion: Age (≥ 60 years), ABO blood group (incompatible), cold ischemia time (> 12 h), infectious complications (lung infection) and biliary complications (diffuse biliary stricture) significantly impact patient's survival time.

Hepatic artery stenosis (HAS) is a common complication in liver transplant patients. Conventional angiography remains the gold standard for diagnosis. Recently, contrast-enhanced ultrasound (CEUS) has begun providing real-time angiographic-like images of vessels and allowing the accurate diagnosis of arterial diseases such as hepatic artery thrombosis. The purpose of this study was to evaluate the efficacy of CEUS in depicting HAS after liver transplantation. Forty-seven liver transplant recipients underwent CEUS examinations with the intravenous injection of microbubble contrast agents. The reference standard was conventional angiography for 15 patients and computed tomographic angiography for 32 patients. The presence, degree, location, and type of HAS were evaluated. For the detection of HAS by CEUS, the following was found: an accuracy of 91.5% (43/47), a sensitivity of 92.3% (36/39), a specificity of 87.5% (7/8), a positive predictive value of 97.3% (36/37), and a negative predictive value of 70% (7/10). CEUS corrected false-positive findings on color Doppler ultrasound in 7 of 47 cases (14.9%). The accuracy of CEUS in identifying the location and type of HAS was 92.3% (36/39) and 84.6% (33/39), respectively. CEUS is a useful noninvasive technique for the detection of HAS in liver transplant patients because it provides comprehensive information, including the presence, location, degree, and type. A positive CEUS finding suggests angiography as the next step rather than a computed tomography scan and may thereby alter the clinical imaging algorithm., ((c) 2010 AASLD.)

There has been a gradual increase in the number of patients with end-stage alcoholic liver disease (ALD) undergoing liver transplantation (LT) in mainland China. However, few studies have focused on the post-transplant outcomes of this population. The aim of this study was to evaluate the efficacy of LT in patients with ALD, mainly focusing on survival rates, complications, and alcohol recidivism. The results were retrospectively analyzed from 20 patients, who underwent LT for ALD from December 2003 to September 2007 at Liver Transplant Center of Third Affiliated Hospital of Sun Yat-sen University. The 1-, 2-, and 3-year survival rates of the ALD group and non-ALD group were 90.0, 80.0, 80.0% and 90.3, 84.7, 79.8%, respectively. There was no significant difference in 1-, 2-, and 3-year survival rates between these two groups (P=.909). No significant difference was observed in complications such as pulmonary infection (50.0 vs. 31.9%, P=.137), biliary complications (15.0 vs. 27.4%, P=.297), hepatic arterial complications (10.0 vs. 6.9%, P=.641), and rejection (15.0 vs. 8.1%, P=.394) after LT between the ALD group and non-ALD group. There was only one person who resumed mild, intermittent drinking after LT. End-stage ALD is a good indication for LT, with similar results in non-ALD patients. The major cause of death in ALD patients after LT was infectious complications. More attention is needed for the prophylaxis of infectious complications after LT., (2010 Elsevier Inc. All rights reserved.)

Objective: To observe the effect of artificial liver support system (ALSS) after liver transplantation on the survival rate of severe hepatitis patients., Methods: Patients with severe hepatitis with model for end stage liver disease (MELD) score above 35 were divided into two groups according to whether pre-transplantation ALSS was instituted (n=23) or not (n=41). Evaluation was performed on the day when the patient entered into the waiting list and 1 day pre-transplantation. Survival rates and survival curves were estimated with Kaplan-Meier method. Log-Rank test for trends was used when comparing curves., Results: There was no significant difference between two groups when comparing the parameters including prothrombin time, fibrinogen, total bilirubin, blood ammonia, creatinine, MELD score on the day of entering into the waiting list (all P>0.05). After the therapy of ALSS, the parameters of ALSS group were significantly improved comparing to those of the control group (all P<0.01). MELD score of ALSS group on the day pre-transplant was decreased significantly comparing to that on the day entering into the waiting list (37.6+/-2.0 vs. 41.4+/-2.2, P<0.01), with the difference in MELD score (DeltaMELD) of -3.8. MELD score of control group on the day entering into the waiting list and 1 day pre-transplant was 40.6+/-1.7 and 41.0+/-1.6 respectively, with DeltaMELD of +0.4 ( P>0.05). The blood loss and operation time in ALSS group was significantly less than the control group [(4 070.0+/-688.1) ml vs. (4 905.9+/-1 142.1) ml, (9.4+/-1.1) hours vs. (10.5+/-1.0) hours, P<0.05 and P<0.01). Thirty days and 1 year survival rate of ALSS group was 91% and 82%, and that of control group was 76% and 59% respectively (P=0.044)., Conclusion: ALSS can improve the survival rate of patients with severe hepatitis undergoing liver transplantation through ameliorating physiological status, lessening blood loss during operation and operation time.

Background: Only a few reviews of small case series and individual case reports including a relatively small number of adult patients undergoing liver transplantation for hepatopulmonary syndrome (HPS) are available, and there has been no prospective evaluation of the long-term outcome of HPS patients after orthotopic liver transplantation (OLT). The aim of this study was to determine the frequency of HPS in OLT patients with chronic end-stage liver-disease, and the short-term and long-term postoperative outcome of HPS patients after OLT., Methods: This prospective study included 31 HPS and 30 control, non-HPS patients. The preoperative conditions were similar between the two groups. Twenty-six of 31 HPS patients and all of the non-HPS patients underwent OLT. Standardized methods, such as arterial blood gas at room air and 99m-technetium macroaggregated albumin ((99m)Tc MAA) lung and brain perfusion scanning were performed for the diagnosis of HPS. Patients were followed after OLT., Results: The incidence of HPS in OLT patients was 9.3% (26/279). Hypoxemia in HPS was obviously improved with a normalized shunt of (99m)Tc MAA in the lungs after OLT. The immediate postoperative survival rate (within 28 days after OLT) of HPS was 76.9% (20/26). The one year survival was 61.5% (16/26) and four-year survival was 57.7% (15/26); much higher than HPS patients without OLT (0). But high postoperative morbidity and mortality were observed in HPS patients whose death occurred within 3 months of OLT due to complications summarized in this study., Conclusions: Liver transplantation was an effective treatment for HPS. But the postoperative mortality rate following OLT in HPS patients was still much higher than that of patients without HPS.

Little information is available about the risk factors and means to improve the survival rate of acute leukemia in a rare but often fatal complication after liver transplantation (LT). We report the development of AML-M2 in one of the 764 patients who underwent liver transplantation at our center, and review the literature on similar cases. The patient, a 42-year-old man who developed acute leukemia 38 months after liver transplantation, was successfully treated with chemotherapy and has subsequently been in remission. With appropriate adjustment of immunosuppressive agents, he was able to safely benefit from chemotherapy. Only 16 patients with acute leukemia after liver transplantation have been reported, and the mortality rate is extraordinarily high (52.94%, 9/17). More cases of acute leukemia will emerge as the rate of survival after liver transplantation increases. The patient's chromosomal mutation profile, the choice of immunosuppressive agent, and infection by hepatitis virus may be the risk factors for the development of acute leukemia after LT. Our experience suggests that clinicians should adjust the immunosuppressive agents according to the immunosuppressive state of the patient and explore the option of reducing or stopping the medication as long as liver function remains stable. These measures could help reduce the high mortality rate among these patients.

Objective: To observe the effect of orthotopic liver transplantation (OLT) on hepatopulmonary syndrome (HPS) and investigate risk factors predicting the prognosis of OLT., Methods: Twenty-six cases of HPS and 30 cases of non-HPS were analyzed treated from April 2004 to January 2006. Survival rates after OLT were compared and risk factors predicting the prognosis of OLT in HPS were researched by univariant and COX analysis., Results: The 28 days survival rate in HPS after OLT was 76.9% (20/26), half a year survival rate and one year survival rate were both 61.5% (16/26). Whereas the one year survival rate of patients without HPS was 100%(P < 0.05). By univariant analysis, shunt of (99)Tc(m)-labeled macro-aggregated albumin in lungs, PaO2 and PaO2/FiO2 in room air before operation were relative to the prognosis of peri-operative period and half a year outcome after OLT in HPS (P < 0.05). Shunt of (99)Tc(m)-labeled macro-aggregated albumin in lungs (OR = 1.182, P = 0.001), and mechanical ventilation time (OR = 1.003, P = 0.053) after OLT were independent risk factors predicting the prognosis of OLT in HPS by COX analysis. Shunt of (99)Tc(m)-labeled macro-aggregated albumin in lungs > or = 28.4%, or PaO2 < or = 56 mm Hg (1 mm Hg = 0.133 kPa) before OLT predicted the poor outcome of OLT in HPS. The sensitivity were 83.3% and 85.0% respectively, and the specificity were 95.0% and 83.3% respectively., Conclusions: OLT is an effective treatment for HPS.Shunt of (99)Tc(m)-labeled macro-aggregated albumin in lungs before OLT and mechanical ventilation time after OLT were independent risk factors for the prognosis of OLT in HPS.

Objective: To evaluate the efficacy and timing of re-transplantation for hepatic artery complications after orthotopic liver transplantation., Methods: Between December 2003 and December 2006, the clinical data of 13 patients diagnosed as hepatic artery complications after liver transplantation were retrospectively analyzed., Results: There were no significant difference in duration of operation and anhepatic phase between the initial transplantation and the second transplantation (P = 0.291, P = 0.312). However, intra-operative blood loss [(3.1 +/- 1.1) L vs. (1.5 +/- 0.9) L, P = 0.005] and intensive care unit stays [(4.3 +/- 1.8) d vs. (3.2 +/- 2.5) d, P = 0.015] were significantly increased in the re-transplant patients. No perioperative mortality occurred. The postoperative mortality of liver re-transplantation was 38.5% (5/13) including acute renal failure in two patients, severe infection in two and heart infarction in one. The other 8 patients were followed from 6 months to 51 months, with a median survival time of 22.5 months., Conclusions: Liver re-transplantation is the only viable option for patients with irreversible graft dysfunction secondary to hepatic artery complications after liver transplantation. Proper indication and optimum time of re-transplantation, reasonable individual immunosuppression regime and effective perioperative care program contribute to the increase of the survival rate of the patients performed liver re-transplantation.

Objective: To evaluate the long-term survival rates of the adults with benign end-stage liver disease (BELD) after liver transplantation (LT) and the causes of death., Methods: The common causes of late death (after more than 1 year) after LT were retrospectively analyzed in 203 consecutive patients with BELD who underwent LT from Oct. 2003 to May.2006., Results: The 1, 2 and 3-year survival rates were 88.7%, 85.5%, and 81.2% respectively. The 2-year and 3-year survival rates of the patients with HBV-related liver disease were 88.4% and 84.5% respectively, not significantly different from those of patients with non-HBV-related liver disease (75.6% and 64.0% respectively, P = 0.144). 165 recipients survived for more than 1 year and 21 recipients died during the period between 12 and 48 months after LT with a mean of (22.7 +/- 6.6) months. The common causes of late death included related to infectious complications (4.8%, 8/165), biliary tract complications (3.6%, 6/165), HBV re-infection (1.8%, 3/165), chronic rejection (1.2%, 2/165), renal functional lesion (0.6%, 1/165), and hepatic arterial complication (0.6%1/165)., Conclusion: Satisfactory long-term survival can be achieved in most adult recipients with BELD after LT and the major causes that influence the long-term survival are infectious complications, biliary tract complications, and HBV re-infection. Prevention of these complications, rational use of immunosuppressant, and regular follow-up are essential to improve long-term survival.

Background: The main therapeutic treatments for hepatic artery complications after orthotopic liver transplantation (OLT) include thrombolysis, percutaneous transluminal angioplasty, stent placement, and liver retransplantation. The prognosis of hepatic artery complications after OLT is not only related to the type, extent, and timing but also closely associated with the selection and timing of the therapeutic methods. However, there is no consensus of opinion regarding the treatment of these complications. The aim of this study was to determine optimal treatment for hepatic artery complications after OLT., Methods: The clinical data of 25 patients diagnosed with hepatic artery thrombosis (HAT) and hepatic artery stenosis (HAS) between October 2003 and March 2007 were retrospectively reviewed. Treatments included liver retransplantation and interventions which contain thrombolysis, percutaneous transluminal angioplasty and stent placement., Results: Among five patients with HAT, 3 were treated with thrombolysis. One recovered, one died after thrombolysis and another one died of multi-organ failure after retransplantation because of recurrent HAT. The remaining 2 patients underwent successful retransplantation and have survived after that. Among 12 patients presented with HAS within 1 month postoperatively, 2 patients underwent retransplantation due to irreversible liver failure and another 10 patients were treated with interventions. The liver function failed to improve in 3 patients and retransplantations were performed in 4 patients after stent placement because of ischemic cholangitis. Among 6 patients undergoing liver retransplantations, two died of intracranial hemorrhage and infection respectively. Eight patients presented with HAS after 1 month postoperatively, 5 patients were treated with interventional management and recovered after stent placement. Among another 3 patients presented with HAS, 2 patients' liver function was stable and one patient received late liver retransplantation due to ischemic bile duct lesion., Conclusions: Individualized therapeutic regimens should be adopted in treating hepatic artery complications after OLT, according to postoperative periods, types and whether ischemic bile duct lesion exists or not. Liver retransplantation is the best treatment for patients with hepatic artery thrombosis. Interventional treatments of late HAS without irreversible liver failure or bile duct ischemia are appropriate, whereas retransplantation is recommended for early HAS.

Background: Orthotopic liver retransplantation (re-OLT) is the only effective therapy for irreversible failure of a liver graft. Early and late graft failure gives way to two different clinical conditions that should be discussed separately. This study was designed to compare early and late re-OLT for patients with poor graft function after primary transplantation at our center and sum up our clinical experience in re-OLT., Methods: The clinical data of 31 re-OLTs at our center from January 2004 to February 2007 were analyzed retrospectively, consisting of the first group with 14 cases of early re-OLT and the second group with 17 cases of late re-OLT., Results: Biliary tract complications were the main indications for early re-OLT (57.1%) and late re-OLT (52.9%). Other common indications were vascular complications in early re-OLT and recurrence of primary diseases in late re-OLT. No significant differences were found between the groups with regard to the volume of bleeding during operation, cold ischemia time, operative duration, and perioperative mortality; except for the model of end-stage liver disease (MELD) score. Outcome was fatal for 7 patients in early re-OLT and 9 patients in late re-OLT. Two deaths were due to multiple organ failure with 3 deaths due to severe sepsis-related disease in early re-OLT, and 4 deaths were due to severe sepsis-related disease with 3 deaths due to recurrence of hepatocellular carcinoma (HCC) in late re-OLT. One and 2-year actuarial survival rates after re-OLT were 55.2% and 36.9%, respectively, for patients in early re-OLT, and 65.1% and 52% respectively, for patients in late re-OLT. No significant differences were found regarding survival rates between the two groups., Conclusions: Similar clinical results can be achieved in early and late re-OLT. Proper indications and optimal operation timing, adequate preoperative preparation, experienced surgical procedures, and effective perioperative anti-infection strategy contribute to the improvement of overall survival rates of patients after re-OLT.

Objective: To evaluate the prophylactic efficacy of adefovir dipivoxil (ADV) for post-transplant recurrence of hepatitis B virus (HBV) with lamivudine-resistant YMDD mutation in liver recipients., Methods: From March 2004 to May 2006, 20 patients with chronic hepatitis B associated with YMDD mutant HBV prior to liver transplantation received treatment with ADV and additional intramuscular hepatitis B immunoglobulin (HBIG) for prevention of post-transplant graft reinfection. The liver function, serum HBsAg, anti-HBs (HBIG), HBeAg, anti-HBc, anti-HBe, HBV DNA and creatinine were examined in all the patients before and after the transplantation., Results: The median follow-up duration of these patients after the transplantation was 33.5 months. Nineteen patients survived and one patient died of recurrent hepatocellular carcinoma. There was significant difference in YMDD mutation rate between the patients with HBV-DNA over 10(6) copies/ml and those with HBV-DNA less than 10(6) copies/ml (12.4% vs 2.5%, P < 0.05). HBV-DNA was undetectable at 4 weeks after the transplantation in 95.0% of the patients (19/20) and at 6 months in one case. No recurrence of hepatitis B was detected by long-term regular testing of HBsAg, HBeAg and HBV-DNA. Serum creatinine increased in 1 case 1 year after the use of ADV., Conclusion: ADV offers protection against recurrence of HBV with YMDD mutation after liver transplantation with only mild nephrotoxicity, but renal function monitoring during the use of ADV is still necessary.

Objective: To compare the efficiency and safety of itraconazole oral solution with those of fluconazole to prevent invasive fungal infections (IFI) in postoperative patients receiving orthotopic liver transplantation (OLT)., Methods: In a randomized, controlled, open trial, 60 patients receiving OLT were randomized into itraconazole treatment group (n = 30) and fluconazole treatment group (n = 30). The patients in itraconazole treatment group were given itraconazole oral solution in a dose of 20 ml once a day for 15 days and the patients in the fluconazole treatment group were given fluconazole in a dose of 150 mg once a day also for 15 days. The incidences of fungal infections after liver transplantation and the resistance to drugs were recorded., Results: There were three patients in the itraconazole treatment group getting IFI; the infection rate was 10.0%. One patient had confirmed diagnosis and two other patients were diagnosed clinically. In the fluconazole treatment group there were 10 patients getting IFI, the infection rate was 33.3%. Two patients had confirmed diagnosis, six patients were diagnosed clinically and the remaining two were diagnosed tentatively. There was a significant difference between the two groups (P < 0.05)., Conclusion: Compared with fluconazole, itraconazole oral solution is more effective in the treatment of invasive fungal infections in postoperative patients receiving OLT.

Objective: To evaluate the efficacy of ABO-incompatible orthotopic liver transplantation (OLT) in treatment of liver failure., Methods: The clinical data of 66 cases of OLT, including 21 cases of ABO-incompatible OLT, for liver failure were retrospectively analyzed., Results: The 3-month, and 1-, 2-, and 3-year survival rates of the ABO-identical group were 84.2%, 77.4%, 67.6%, and 60.1%, respectively, while those of the ABO-incompatible group were 75.6%, 64.0%, 58.2%, and 58.2%, respectively. The mean survival time of the ABO-identical group was (806.0+/-70.0) d, not significantly different from that of the ABO-incompatible group (720.3+/-118.5 d, P=0.417). The acute rejection rate of the ABO-identical group was 8.9%, not significantly different from that of ABO-incompatible group (9.0%, P=0.253). The biliary tract complication rate and infection rate of the ABO-incompatible group were 76.2% and 28.6% respectively, both significantly higher than those of the ABO-identical group (48.9% and 8.9% respectively, P=0.037 and P=0.038). The major causes of death in the ABO-incompatible group were serious infection (5/21) and renal failure (4/21)., Conclusion: ABO-incompatible OLT is an acceptable option to cure liver failure in emergency. Intensive perioperative supervision is essential to improve the effect of ABO-incompatible OLT.

Objective: To study the clinical features, underlying mechanism and management of major neurological complications following liver transplantation., Methods: The data of 467 patients undergoing liver transplantation from Oct. 2003 to Sep. 2005 were retrospectively reviewed., Results: Neurological complications occurred in 91 (19.49%) cases. The most common neurological complications were encephalopathy (72 cases), followed by stroke (12 cases), seizure (4 cases), central pontine myelinolysis (3 cases), and central nervous system infections (2 cases). Five encephalopathy cases were treated with continuous renal replacement and 5 intracranial hemorrhage cases with neurosurgical intervention. The mortality related to neurological complications was 10.98% (12/91)., Conclusions: Neurological complications are common and potentially fatal following liver transplantation involving several factors. CsA and FK506 may play an important role in the onset of neurological complications, and stroke, especially intracranial hemorrhage, has a high mortality. Combined therapies and timely modulation of the immunosuppressive regimens may improve the patient's outcome.

Background: The most frequently used therapy for post-transplantation recurrence of hepatitis B virus (HBV) infection is lamivudine, but this drug is associated with a high resistance rate due to YMDD mutant. In preliminary reports, adefovir dipivoxil (ADV) has been shown to have activity against lamivudine-resistant strains of HBV. However, clinical experience in treatment of HBV infection after liver transplantation (LT) is still not entirely clear. This study was aimed to evaluate the prophylactic efficacy of ADV plus hepatitis B immunoglobulin (HBIG) in patients with YMDD mutant before LT., Methods: From March 2004 to March 2006, 16 patients with chronic hepatitis B had lamivudine-resistant YMDD mutants detected prior to liver transplantation and received treatment with ADV plus additional intramuscular HBIG after LT as prophylaxis against graft reinfection. Tests for liver function, serum HBsAg, anti-HBs (HBIG), HBeAg, anti-HBc, anti-HBe, HBV-DNA, and creatinine were assessed pre- or post-liver transplantation., Results: The median follow-up of these patients post-liver transplantation was 19.4 months. Fifteen patients survived and one patient died of recurrence of hepatocellular carcinoma (HCC). There was significant difference (10.98% vs. 2.26%, P < 0.05) in YMDD mutant rate between the patients with HBV-DNA over 10(6) copies/ml and those with HBV-DNA less than 10(6) copies/ml. Fifteen patients (93.8%) had undetectable HBV-DNA at 4 weeks and 1 (6.3%) at 6 months after LT. No hepatitis B recurrence was detected by persistent testing of HBsAg, HBeAg, and HBV-DNA and no increase of serum creatinine level associated with ADV was observed in any of the patients., Conclusion: ADV combined with intramuscular HBIG can effectively prevent patients with pre-transplantation YMDD mutant from HBV recurrence after LT.

Objective: To investigate the anatomical variations of donor hepatic artery and explore the measures that can be taken to avoid accidental hepatic artery injury during graft procurement and reconstruction., Methods: The data of totally 843 consecutive patients undergoing orthotopic liver transplantation (OLT) during the period from April 2001 to July 2006 was reviewed in relation to anatomical variation of the donor hepatic arteries. The variations of the hepatic artery, the relationship between the anomalous hepatic artery and accidental injury of the hepatic artery were analyzed., Results: In the 843 cases of OLT, the total anatomical variation rate of the donor hepatic arteries was 20.4% (172/843). The common variations included replaced or accessory right hepatic arteries originated from superior mesenteric artery (6.67%, 57/843), replaced or accessory left hepatic arteries originated from the left gastric artery (6.41%, 54/843) or from the celiac trunk and gastro-duodenal artery (1.66%, 14/843), replaced or accessory right hepatic arteries originated from the celiac trunk, common hepatic artery and gastro-duodenal artery (1.54%,13/843), replaced or accessory right hepatic arteries and left hepatic arteries coexistence (0.83%, 7/843), variation of the common hepatic artery from the superior mesenteric artery (1.54%, 13/843) or from the abdominal aorta (0.95%, 8/843)., Conclusion: During graft procurement and reconstruction, accidental injury of the hepatic artery is more likely in the presence of hepatic arterial variation, which can be a common clinical entity. Acquaintance with hepatic arterial variation and maintenance of the integrity of the superior mesenteric artery and celiac trunk are key to reducing potential hepatic artery injuries.

Objective: To investigate the practical value of endoscopic retrograde cholangiography (ERC) in biliary complications after liver transplantation., Methods: The data of 71 biliary complications after liver transplantation were analyzed retrospectively. All patients were diagnosed and treated by ERC in our center from October 2003 to March 2006. The biliary complications included 52 cases of biliary stricture, 6 biliary leakage and 13 biliary stone., Results: The diagnostic rate of ERC for biliary stricture, leakage and stone was 98.1% (51/52), 100% (6/6) and 100% (13/13), respectively. The cure rate of interventional therapy through therapeutic ERC for anastomotic, extrahepatic, hilar, intrahepatic and diffuse biliary stricture was 66.7% (4/6), 66.7% (10/15), 0 (0/7), 0 (0/2) and 0 (0/21), respectively. And that for biliary leakage, common bile duct and intrahepatic bile duct stone was 66.7% (4/6), 77.8% (7/9) and 0 (0/4), respectively., Conclusions: ERC is effective for diagnosis of biliary complications after liver transplantation. The effect of interventional therapy through ERC varies with the type of biliary complications. Only part of biliary complications (anastomotic stricture, extrahepatic biliary stricture, gently and moderate biliary leakage, common bile duct stone) can be cured by interventional therapy through ERC.

Background: There has been increasing interest in the research into cytomegalovirus (CMV) pneumonia after liver transplantation (LT). This study was undertaken to investigate the immunomodulatory therapy of CMV pneumonia after LT., Methods: Six patients with CMV pneumonia after LT from October 2003 to November 2005 were analyzed retrospectively. They were diagnosed according to clinical manifestations, chest X-ray findings and pathogenic changes and given comprehensive therapy including mainly immunomodulation therapy and anti-viral medication. At the early stage of CMV pneumonia, the dose of immunosuppressive agents was decreased or ceased, instead replaced by immunoenhancement therapy. During recovery period from CMV pneumonia, the dose of immunosuppressive agents was given again or enhanced, and immunoenhancement therapy was ceased. The liver function of the patients was monitored closely during the treatment., Results: In this series, five patients were survived and one died. The liver function of the six patients remained normal during the treatment, and no episode of acute rejection took place., Conclusions: Poor immunity is the pathogenic basis of CMV pneumonia after LT. At early stage of CMV pneumonia, the immunity of the patients should be enhanced, and during the recovery period from CMV pneumonia, immunosuppressants should be given again but immunoenhancement therapy ceased. Individualized immunomodulatory therapy is essential to the treatment of CMV pneumonia after LT.

Objective: To find out the epidemiology of bacteria infection after orthotopic liver transplantation (OLT)., Method: Postoperative bacteria infection of 451 OLT cases were retrospectively analyzed., Result: Bacteria infection were detected in 239 OLT cases, and the infection rate was 52.9%. Sum up to 304 bacilli lines were separated from all above cases. Among them, the detectable Gram-positive bacilli (G(+)) accounted for 59.9% (182/304), while Gram-negative bacilli (G(-)) accounted for 40.2% (122/304). The impressionable organ were respiratory tract and bile duct, which occupying 81.5% (248/304) and 15.1% (46/304) among all infective cases respectively. The main infected strain were G(+) bacteria in respiratory tract, account for 65.3%; while G(-) bacteria were mainly in bile duct, account for 60.9%. There was significant difference between each other (P = 0.018)., Conclusions: The bacteria infection rate was high after OLT, and the main infected strain was the G(+) bacteria. Most fo them were the opportunistic pathogenic bacteria and the antibiotic multi-resistant bacteria. The bacteria category was significantly related to the infected tissue, according to which we could adopt corresponding antibacterial approach.

Objective: To explore the treatment and appropriate management of invasive aspergillosis infection following orthotopic liver transplantation., Methods: The clinical data of 576 cases who underwent orthotopic liver transplantation consecutively between January 2000 and January 2005 were analyzed retrospectively., Results: The prevalence of invasive aspergillosis infection was 1.74 (9/576), included 8 cases with pulmonary aspergillosis and 1 case with cerebral aspergillosis. The interval between transplantation and diagnosis were from 10 days to 2 months. Persistent or discontinuous low fever maybe the main clinical presentation after operation. Liposomal amphotericin B (AmBisome) is the mainly treatment for invasive aspergillosis infections, 5 patients were cured and 2 patients developed multi-organ aspergillosis infection died., Conclusions: The clinical features of invasive aspergillosis infection following orthotopic liver transplantation were un-typical presentations in the early stage and easy to disseminate. Appropriate modification of immunosuppression therapy and early, high dose and long-term application of antifungal treatment is effective and safe to cure the disease.

Objective: To investigate the treatment strategy of early acute lung injury (ALI) after liver transplantation., Methods: 18 patients complicated with ALI after liver transplantation were given comprehensive therapies and two minutes of recruitment maneuver (RM) to open previously collapsed lung units and then lung protective ventilatory strategy within 3 hours of hypoxemia. The inspiratory pressure was 25 cm H2O and PEEP 17 cm H2O. Optimal PEEP were maintained after RM to stabilize lung volume., Results: The PaO(2), SaO(2) and PaO(2)/FiO(2) of all 18 patients were improved greatly. RM was effective in 17 patients except one case of severe pulmonary infection, whose PaO(2)/FiO(2) was only improved by 40%. PaO(2), SaO(2) and PaO(2)/FiO(2) were increased by 68 mm Hg, 9.5%, and 104.7% respectively. And the improved oxygenation can be maintained 2 - 24 hours. The effective rate of RM was 94.4%. All 18 patients were weaned and extubated successfully with the survival rate of 100%. RM was well tolerated without complications., Conclusion: ALI post liver transplantation should be diagnosed and treated in early stage. RM combined with lung protective ventilatory strategy is a safe and effective treatment for early ALI after liver transplantation.

Objective: To evaluate the effect of perioperative HLA antibody changes on acute allograft rejection in cadaveric liver transplantation., Methods: Totally 134 patients received modified piggyback liver transplantation and enzyme-linked immunosorbent assay was performed for HLA antibody detection before and the 1, 7, 14 and 30 days after operation. B ultrasound-guided liver biopsy was employed for diagnosis of acute allograft rejection, and the perioperative changes of HLA antibodies were evaluated for their effect on allograft acute rejection., Results: Of the 44 recipients with preoperative positivity for HLA antibodies, acute rejection occurred in 56.8% of the patients, as compared with 25.9% in those negative for HLA antibody (P=0.001). The patients who became positive for HLA antibody postoperatively had a rate of acute rejection of 60%, which was significantly higher than that in those persistently negative for HLA antibody (18.6%, P=0.003)., Conclusion: HLA antibody positivity before transplantation may contribute to acute rejection episode in liver transplantation, and persistent posttransplant HLA antibody positivity is closely associated with the occurrence of acute rejection.

Objective: To investigate the risk factors and treatment of hepatitis B virus (HBV) reinfection after liver transplantation., Methods: Patients with HBV related end-stage liver disease underwent liver transplantation in our center, and received the combination of intramuscular hepatitis B virus immunoglobulin and oral lamivudine as prophylaxis for HBV reinfection. HBV reinfection cases were monitored after the transplantation., Results: HBsAg disappeared and HBsAb was detectable in 128 of total 130 patients. The median follow-up period was 12.2 months after transplantation. Eight patients developed HBV reinfection. The recurrence rate of HBV was 6.3%. The reinfection risks were 14.3% and 4.0% respectively among patients with serum HBeAg positive and negative before transplantation (P < 0.05). Among patients with serum HBsAg positive and negative at the first day after liver transplantation, the reinfection risks were 21.1% and 3.7% respectively (P < 0.05)., Conclusions: Combination of intramuscular HBIg and Lamivudine as prophylaxis of HBV reinfection is effective. HBeAg positive before liver transplantation and HBsAg positive at the first day after transplantation are risk factors of HBV reinfection.

Objective: To investigate the common reasons, prophylaxis and treatment of operation-correlated complications in orthotopic liver transplantation (OLT)., Methods: Six hundred and forty-seven patients who underwent OLT from Apr 1993 to Dec 2004 were enrolled and analyzed retrospectively., Results: There were totally 39 cases (6.0%, 39/647) of vascular complications including 23 cases (3.6%) of hepatic artery complications, 6 cases (0.9%) of portal vein complications and 10 cases (1.5%) of vena cava complications. All vena cava complications were occurred in the patients of non-cavaplasty. The success rate of stent placement in treatment of hepatic artery stenosis was 2/2; for patients with hepatic artery thrombosis, the success rate of retransplantation was 4/6, that of revasculation and balloon dilation were 3/7 and 2/7 respectively. Stent placement can treat both anastomotic strictures and venae cavae stricture with the cure rate of 3/3 and 10/10 respectively. There were 34 cases of biliary complications, in which 27 cases were in patients with T tube, and 7 cases in without T tube. The incidence of biliary leak and biliary infection was significantly different between these two groups., Conclusions: The modified piggyback (cavaplasty) technique could prevent the incidence of venae cavae complications effectively. Stent placement is an effective way to treat vascular stenosis. And retransplantation should be performed in early hepatic artery thrombosis. It is important to protect the blood supply of biliary system, and choledochostomy without T tube is the first choice for biliary reconstruction.

Objectives: To investigate the diagnosis and treatment of cytomegalovirus (CMV) pneumonia after liver transplantation., Methods: Five cases of CMV pneumonia after liver transplantation were analyzed retrospectively. CMV pneumonia was diagnosed according to its clinical manifestation, chest X-ray, and etiologic test. All 5 patients received comprehensive therapy based on anti-virus treatment and immunologic adjustment., Results: The clinical manifestation of CMV pneumonia after liver transplantation was nonspecific. Its main symptoms included fever, cough, dyspnea, tachycardia, fatigue, hypoxemia and neutropenia. The chest X-ray showed interstitial pneumonia. Sera CMV antigens or antibodies could be detected in the patients. Four patients were cured and 1 patient died., Conclusions: The clinical manifestation of CMV pneumonia was nonspecific. CMV pneumonia could be diagnosed according to its manifestations, chest X-ray and etiologic test. The comprehensive therapy based on anti-virus treatment and immunologic adjustment was effective for the disease.

Aim: To study the association between host immunity and hepatitis B virus (HBV) recurrence after liver transplantation., Methods: Peripheral blood mononuclear cells (PBMC) were isolated from 40 patients with hepatitis B and underwent orthotopic liver transplantation (OLT) before and 2, 4, 8 wk after surgery. After being cultured in vitro for 72 h, the levels of INF-gamma and TNF-alpha in culture supernatants were detected with ELISA. At the same time, the quantities of HBV DNA in serum and PBMCs were measured by real time PCR., Results: The levels of INF-gamma and TNF-alpha in PBMC culture supernatants decreased before and 2, 4 wk after surgery in turns (INF-gamma 155.52+/-72.32 ng/L vs 14.76+/-9.88 ng/L vs 13.22+/-10.35 ng/L, F = 6.946, P = 0.027 < 0.05; TNF-alpha 80.839+/-46.75 ng/L vs 18.59+/-17.29 ng/L vs 9.758+/-7.96 ng/L, F = 22.61, P = 0.0001 < 0.05). The levels of INF-gamma and TNF-alpha were higher in groups with phytohemagglutinin (PHA) than in those without PHA before surgery. However, the difference disappeared following OLT. Furthermore, INF-gamma and TNF-alpha could not be detected in most patients at wk 4 and none at wk 8 after OLT. The HBV detection rate and virus load in PBMC before and 2, 4 wk after surgery were fluctuated (HBV detected rate: 51.4%, 13.3%, 50% respectively; HBV DNA: 3.55+/-0.674 log10 copies/mL vs 3.00+/-0.329 log10 copies/mL vs 4.608+/-1.344 log10 copies/mL, F = 7.582, P = 0.002 < 0.05). HBV DNA in serum was 4.48+/-1.463 log10 copies/mL before surgery and <10(3) copies/mL after OLT except for one with 5.72 x 10(6) copies/mL 4 wk after OLT who was diagnosed as HBV recurrence. The levels of INF-gamma and TNF-alpha were lower in patients with a high HBV load than in those with a low HBV load (HBV DNA detected/undetected in PBMCs: IFN-gamma 138.08+/-72.44 ng/L vs 164.24+/-72.07 ng/L, t = 1.065, P = 0.297 > 0.05, TNF-alpha 80.75+/-47.30 ng/L vs 74.10+/-49.70 ng/L, t = 0.407, P = 0.686 > 0.05; HBV DNA positive/negative: IFN-gamma 136.77+/-70.04 ng/L vs 175.27+/-71.50 ng/L, t = 1.702, P = 0.097 > 0.05; TNF-alpha 75.37+/-43.02 ng/L vs 81.53+/-52.46 ng/L, t = 0.402, P = 0.690 > 0.05)., Conclusion: The yielding of INF-gamma and TNF-alpha from PBMCs is inhibited significantly by immunosuppressive agents following OLT with HBV load increased, indicating that the impaired immunity of host is associated with HBV recurrence after OLT.

Objective: To investigate the effect of adjuvant individualized chemotherapy in prevention of tumor recurrence and improvement of patient survival after liver transplantation for hepatocellular carcinoma (HCC)., Methods: 21 HCC cases received orthotopic liver transplantation and treated with adjuvant individualized chemotherapy based on ATP tumor chemosensitivity assay (ex vivo) between April 2001 and January 2003 were retrospective reviewed, compared with 52 cases received orthotopic liver transplantation only. The cumulative and tumor-free survivals were compared between 2 groups., Results: The 1, 2 years overall survival rates were 92.31%, 73.85% for the individualized chemotherapy group and 92.06%, 63.93% for the non-chemotherapy group, the difference was not statistically significant. The 6, 12, 18, 24 months tumor-free survival rates were 90.00%, 80.00%, 80.00%, 60.00% and 67.31%, 51.92%, 40.03%, 37.81% respectively, the difference was statistically significant (P <0.05)., Conclusions: This study suggests that tumor recurrence decreases and tumor-free survival increases by adjuvant individualized chemotherapy after liver transplantation for HCC. The individualized protocol based on ATP-TCA may be effective for patients with HCC after liver transplantation.

Objective: To investigate etiology, diagnosis, treatment and prophylaxis of liver abscess after orthotopic liver transplantation (OLT)., Methods: Of 274 recipients of OLT from January 1993 to June 2003 in our transplant center, liver abscess were identified in 6 recipients (2.2%). The clinical presentation included fever, shiver, abdominal pain, jaundice, hepatic dysfunction, hypoalbuminemia, anemia, leukocytosis and neutrophilia. They were diagnosed mainly according to the clinical presentation and Ultrasonography or CT scan. The treatments included aspiration and drainage of abscess, removing bile sludge, antibiotics and supportive therapy., Results: Of 6 patients, 2 were cured, 3 refused liver retransplantation and 2 died of serious systemic infection. The cure rate was 33.3%., Conclusions: the etiology of liver abscess after OLT is complicated. The predisposing factors might be included hepatic artery thrombosis or stenosis, MP pulse therapy, cholangitis and biliary interventional therapy. Its prognosis seemed disappointing. Strong prophylactic measures should be recommended to reduce the liver abscess after OLT.

Objective: To evaluate the role of orthotopic liver transplantation (OLT) in treatment of hepatocellular carcinoma (HCC) and the selection of recipients., Methods: OLT was performed in 60 patients with HCC at Organ Transplantation Centre of the First Affiliated Hospital of Sun Yat-sen University between September 1993 and September 2002. Medical records were retrospectively analyzed with regard to the response to OLT and survival., Results: One-month, 1, 2, 3-year survival rate of 23 liver transplant performed from September 1993 to July 2002 were 73.9%, 60.9%, 43.5% and 29.0%, respectively. One-month, 1, 2-year survival rate of 37 liver transplant performed from August 2000 to September 2002 were 89.2%, 75.8% and 61.2%, respectively. One-month survival rate was significantly greater in the patients with a preoperative liver function of Child A or B than Child C (P < 0.05). One-month, 1, 2, 3-year survival rate of small HCC (single tumor 5 cm diameter, n = 41) were 84.2%, 76.6%, 65.6%, 65.6% and 82.9%, 63.1%, 46.7%, 37.4%, respectively. The median survival of large HCC was 18.0 months and mean survival of small HCC was 29.6 months, respectively. The recurrence rate of small HCC and large HCC were 15.8% and 27.7%, respectively. There was no significant difference between the cumulative survival of small HCC and large HCC. The quality of life of patients with long-term survival was good., Conclusions: HCC associated with cirrhosis can be effectively treated by OLT on condition that no extrahepatic spread and no vascular involvement. OLT is recommended for treatment of small HCC combined with liver cirrhosis, meanwhile, OLT performed in the partial large HCC still is reasonable at the present time.

Objective: To study the prevention, diagnosis and treatment of biliary complications after liver transplantation., Methods: One hundred and twenty-three recipients who had received liver transplantation between April 1993 and November 2001 were retrospectively reviewed., Results: Biliary complication was diagnosed by cholangiography in 11 patients. Nine patients were cured, 1 patient was improved and 1 patient died. The incidence for biliary complications was 8.9% (11/123), and the mortality was 0.8% (1/123). The incidence of biliary complications due to T tube was 4.2% (5/119). The incidence of biliary complications due to hepatic artery was 1.6% (2/123). In recipients with WIT > 3 min and CIT > 8 h, the incidence of biliary complications elevated significantly., Conclusions: The most important reason for biliary complications was preservative and ischemic injury. While repairing donor liver, damage to the blood supply system of donor liver bile ducts should be avoided. Meticulous T tube placement may reduce the incidence of biliary complications. Early cholangiography is helpful to diagnose biliary complications.

Aim: To analyze the relationship between hepatitis B virus (HBV) and hepatocellular carcinoma (HCC) recurrence in orthotopic liver transplantation (OLT) patients. Methods: 340 HBV patients with OLT were included in the study; among them were 148 patients with HBV-associated HCC. Results: HCC recurrence rates at 1, 3 and 5 years were 21, 29, and 46%, respectively. Exceeding Milan criteria (hazard ratio, HR = 12.35; 95% confidence interval, CI, 2.80-54.49; p = 0.001), HBV DNA level >5 log10 copies/ml before transplant (HR = 2.45; 95% CI 1.10-5.45; p = 0.03) and HBV recurrence (HR = 2.27; 95% CI 1.10-4.75; p = 0.03) were significant independent predictors of HCC recurrence. HBV DNA >5 log10 copies/ml before transplant (HR = 8.65; 95% CI 3.40-21.98; p < 0.001) and concomitance with HCC (HR = 2.79; 95% CI 1.33-5.87; p = 0.007) were predictors of HBV recurrence. Further stratified analysis showed that HBV recurrence was more prevalent in the HCC recurrence group (HR = 4.58; 95% CI 1.88-11.12; p = 0.001). Conclusions: There is a close relationship between HBV and HCC recurrence after transplant. High HBV DNA levels before transplant are associated with HCC recurrence after transplant. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]