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This retrospective study was conducted to examine the development and current status of pediatric liver transplantation (LT) in western China. Clinical, demographic, morbidity, and mortality data were collected to analyze. It included 260 consecutive pediatric LTs performed at three centers in western China between January 2000 and May 2019. Kaplan-Meier graft survival rates at 1, 3, 5, and 10 years were 82.1%, 77.2%, 76.6%, and 76.6%, respectively; corresponding patient survival rates were 84.7%, 80.7%, 80.0%, and 80.0%, respectively. More patients underwent living donor liver transplantation (LDLT; n = 188 (73.4%)) than deceased-donor liver transplantation (DDLT; n = 68 (26.6%)). Survival was better after LDLT (91.5%, 86.6%, and 80.6% at 1, 3, and 5 years, respectively) than after DDLT (80.9%, 72.4%, and 63.9%, respectively; P < .05). Biliary atresia was the leading LT indication (n = 141 (55.1%)), followed by metabolic disease (n = 36 (14.1%)), which was associated with the best recipient survival (88.5% at 5 years). The transplant era and graft-to-recipient body weight ratio (GRWR) also significantly predicted overall survival. Survival rates at 5 years were worst in 2000-2005 (54.5%) and best for GRWRs of 0.8%-4% (80.4%). The development of pediatric LT in western China began slowly, but the quantity and quality of pediatric LT has progressed in recent years. This procedure is now a promising and reliable treatment for children with end-stage liver disease in western China.

How much difference there is between hepatic resection (HR) combined with intraoperative radiofrequency ablation (RFA) and living donor liver transplantation (LDLT) in treatment of multifocal hepatocellular carcinomas (HCCs) remains unclear. This study compared outcomes for patients with multifocal HCCs meeting the University of California San Francisco (UCSF) criteria treated by LDLT or HR + RFA. A total of 126 consecutive Child–Pugh A patients with multifocal HCCs meeting the UCSF criteria, who underwent LDLT (n = 51) or HR + RFA (n = 75), were included. Propensity score (PS) matching was performed to adjust for baseline differences. Overall survival (OS) and recurrence-free survival (RFS) were calculated, and subgroup, multivariate and nomogram analyses were performed. LDLT provided significantly better OS and RFS than did HR + RFA before and after PS matching and reduced the dropout rate on waiting list, but HR + RFA was more convenient, less invasive and less cost. Patients with all lesions located in the same lobe had better OS and RFS than those located in the different lobes after HR + RFA. Multivariate and nomogram analyses revealed that HR + RFA, alpha-fetoprotein ≥ 400 ng/mL, the major tumour size > 3 cm and microvascular invasion were independent predictors of poor prognosis. For Child–Pugh A patients with multiple HCCs meeting the UCSF criteria, LDLT may offer significantly better long-term results than did HR + RFA, and HR + RFA may still be considered as an acceptable curative therapy for those without considering transplantation or as a bridge treatment for a patient, with a plan for transplantation in the future.

Background Given the shortage of suitable liver grafts for liver transplantation, proper use of hepatitis B core antibody-positive livers might be a possible way to enlarge the donor pool and to save patients with end-stage liver diseases. However, the safety of hepatitis B virus core antibody positive (HBcAb+) donors has been controversial. Initial studies were mainly conducted overseas with relatively small numbers of HBcAb+ liver recipients, and there are few relevant reports in the population of mainland China. We hypothesized that the safety of HBcAb+ liver grafts is not suboptimal. Aim To evaluate the safety of using hepatitis B virus (HBV) core antibody-positive donors for liver transplantation in Chinese patients. Methods We conducted a retrospective study enrolling 1071 patients who underwent liver transplantation consecutively from 2005 to 2016 at West China Hospital Liver Transplantation Center. Given the imbalance in several baseline variables, propensity score matching was used, and the outcomes of all recipients were reviewed in this study. Results In the whole population, 230 patients received HBcAb+ and 841 patients received HBcAb negative (HBcAb-) liver grafts. The 1-, 3- and 5-year survival rates in patients and grafts between the two groups were similar (patient survival: 85.8% vs 87.2%, 77.4% vs 81.1%, 72.4% vs 76.7%, log-rank test, P = 0.16; graft survival: 83.2% vs 83.6%, 73.8% vs 75.9%, 70.8% vs 74.4%, log-rank test, P = 0.19). After propensity score matching, 210 pairs of patients were generated. The corresponding 1-, 3- and 5-year patient and graft survival rates showed no significant differences. Further studies illustrated that the post-transplant major complication rates and liver function recovery after surgery were also similar. In addition, multivariate regression analysis in the original cohort and propensity score-matched Cox analysis demonstrated that receiving HBcAb+ liver grafts was not a significant risk factor for long-term survival. These findings were consistent in both HBV surface antigen-positive (HBsAg+) and HBsAg negative (HBsAg-) patients.Newly diagnosed HBV infection had a relatively higher incidence in HBsAg- patients with HBcAb+ liver grafts (13.23%), in which HBV naive recipients suffered most (31.82%), although this difference did not affect patient and graft survival (P = 0.50 and P = 0.49, respectively). Recipients with a high HBV surface antibody (anti-HBs) titer (more than 100 IU/L) before transplantation and antiviral prophylaxis with nucleos(t)ide antiviral agents post-operation, such as nucleos(t)ide antiviral agents, had lower de novo HBV infection risks. Conclusion HBcAb+ liver grafts do not affect the long-term outcome of the recipients. Combined with proper postoperative antiviral prophylaxis, utilization of HBcAb+ grafts is rational and feasible.

Many studies have confirmed that serum total cholesterol (sTC) concentrations were associated with underlying liver damage and the synthesis capacity of liver. However, the role of postoperative sTC level on evaluating graft function and predicting survival of recipients who underwent liver transplantation has not been discussed.Clinical data of 231 living donor liver transplantation recipients from May 2003 to January 2015 were retrospectively collected. Patients were stratified into the low sTC group (sTC1.42 mmol/L, 57 recipients) and high sTC group (sTC =1.42 mmol/L, 174 recipients) according the sTC level on postoperative day 3 based on receiver-operating characteristic curve analysis. The clinical characteristics and postoperative short- and long-term outcomes were compared between the two groups.Recipients with sTC1.42 mmol/L experienced more severe preoperative disease conditions, a higher incidence of postoperative early allograft dysfunction (38.6% vs 10.3%, P0.001), 90-day mortality (28.1% vs 10.9%, P=0.002) and severe complications (29.8% vs 17.2%, P=0.041) compared to recipients with sTC =1.42 mmol/L. The multivariate analysis demonstrated that sTC1.42 mmol/L had a 4.08-fold (95% CI: 1.83-9.11, P=0.001) and 2.72-fold (95% CI: 1.23-6.00, P=0.013) greater risk of developing allograft dysfunction and 90-day mortality, and patients with sTC1.42 mmol/L had poorer overall recipient and graft survival rates at 1-, 3-, and 5-year than those with sTC =1.42 mmol/L (67%, 61% and 61% vs 83%, 71% and 69%, P=0.025; 65%, 59% and 59% vs 81%, 68% and 66%, P=0.026, respectively). Cox multivariate analysis showed that sTC1.42 mmol/L was an independent predicting factor for total recipient survival (HR=2.043; 95% CI: 1.173-3.560; P=0.012) and graft survival (HR=1.905; 95% CI: 1.115-3.255; P=0.018).sTC1.42 mmol/L on postoperative day 3 was an independent risk factor of postoperative early allograft dysfunction, 90-day mortality, recipient and graft survival, which can be used as a marker for predicting postoperative short- and long-term outcomes.

// Chuan Li 1 , Jia-Ye Liu 1 , Wei Peng 1 , Tian-Fu Wen 1 , Lu-Nan Yan 1 , Jia-Yin Yang 1 , Bo Li 1 , Wen-Tao Wang 1 and Ming-Qing Xu 1 1 Department of Liver Surgery & Liver Transplantation, West China Hospital of Sichuan University, Chengdu, China Correspondence to: Tian- Fu Wen, email: // Keywords : liver transplantation, liver resection, hepatocellular carcinoma, outcomes, recurrence Received : November 14, 2016 Accepted : August 06, 2017 Published : September 02, 2017 Abstract The aim of this study was to compare the outcomes of patients with multiple hepatocellular carcinoma (HCCs) after liver resection (LR) versus liver transplantation (LT). Patients who had multiple HCCs without macrovascular invasion and who underwent LT or LR between 2007 and 2013 were reviewed. A propensity score matching model was used to adjust baseline differences between the two groups. A total of 204 patients were selected for the current study, including 137 LR patients and 67 LT patients. During follow-up, 100 patients experienced recurrence, and 78 patients died. The 5-year recurrence-free survival rate was 71.1% for the LT group and 31.1% for the LR group (P

Background Biliary reconstruction in ex vivo liver resection followed by autotransplantation (ERAT) for end-stage hepatic alveolar echinococcosis (HAE) remains the most challenging step, we present our experience with this complex procedure. Methods A retrospective data analysis of 55 patients with end-stage HAE underwent ERAT, the biliary reconstruction techniques and short- and long-term outcomes were discussed. Results All autografts were derived from the left lateral section after extensive ex vivo liver resection, multiple bile ducts were observed in 52 (94.5%) patients, and forty-four (80.0%) cases required ductoplasty. Biliary reconstruction was achieved with duct-to-duct anastomosis in 32 (58.2%) patients, Roux-en-Y hepaticojejunostomy (RYHJ) in 14 (25.5%) patients, and a combination of the two methods in 9 (16.4%) patients. Twenty (36.4%) patients had multiple anastomoses. Biliary leakage occurred in 8 (14.5%) patients postoperatively. Three (5.5%) patients died of liver failure, cerebral hemorrhage and intraabdominal bleeding. During a median of 31 months followed-up time, 3 (5.5%) patients developed anastomotic stricture, 1 of whom was treated by repeat RYHJ, while the others were managed with stenting. Conclusions With a well-designed plan and precise anastomosis, complex biliary reconstruction in ERAT can be performed with few biliary complications by a professional team.

Aim To investigate the impact of circadian rhythms on the outcomes of liver transplantation on patients suffering from hepatocellular carcinoma (HCC). Methods We retrospectively reviewed data of patients who underwent liver transplantation from 2012 to 2017 in our center. Based on the begin time of transplantation, these patients were separated into 2 groups: day group and night group. The intraoperative and postoperative clinical variables were analyzed to find out the impact of the circadian rhythms. Multivariate analysis was performed to examine strength associations between the begin time of operation and surgical outcomes. Results A total of 147 patients were included in this study: 102 patients in the day group and 45 patients in the night group. Compared with the day group, patients in the night group had higher incidence of intraoperative massive hemorrhage (11.1% vs 2.0%, P = .048), more intraoperative blood loss (2168.00 ± 2324.20 mL vs 1405.88 ± 1037.69 mL, P = .040), and more requirement of red blood cells (RBC) suspension (8.59 ± 7.11 u vs 6.37 ± 5.78 u, P = .048). In addition, total operation time in the night group was longer than that in the day group (8.90 ± 1.65 hours vs 8.26 ± 1.69 hours, P = .034), as well as the cold ischemia time (9.35 ± 5.03 hours vs 7.21 ± 3.93 hours, P = .014). Furthermore, the night group had higher incidence of other intraoperative complications (13.3% vs 2.9%, P = .038), postoperative abdominal infection (20.0% vs 6.9%, P = .038), and more hospital cost (37,357.96 ± 6779.96 dollars vs 33,551.75 ± 11,683.38 dollars, P = .045). Moreover, patients in the night group needed longer time to restore hepatic function to normal (21.77 ± 10.91 days vs 17.54 ± 10.80 days, P = .033). Multivariate analysis showed that begin time of operation was the independent risk factor of longer operation time, more blood loss during operation, higher incidence of massive hemorrhage and other intraoperative complications, longer time for restoration of hepatic function to normal, higher incidence of abdominal infection at the early stage after transplantation, and more hospital cost (all P value ≤ .05). Conclusion Liver transplantation performed at night was associated with higher incidence of intraoperative and early postoperative complications, as well as higher hospital cost. And these worsened outcomes all could be explained by the influence that circadian rhythms had on patients or medical workers.

BACKGROUND Albumin-Bilirubin (ALBI) grade has been evaluated as an objective method to assess liver function and predict postoperative complications, particularly after hepatectomy in patients with hepatocellular carcinoma (HCC). However, ALBI grade was rarely used in evaluation in living donor liver transplantation (LDLT). MATERIAL AND METHODS Between March 2005 and November 2015, 272 consecutive patients undergoing right-lobe LDLT were enrolled in this study. According to the ALBI score used to evaluate recipients preoperatively, those patients were divided into 3 grades (I, II, and III). Demographic findings and the post-operative complication rates were collected and compared among groups. RESULTS The proportions of massive blood cell transfusions were different among those 3 grades (p

Objective To investigate the clinical effects of surgical intervention for end-stage hepatic alveolar echinococcosis (HAE). Methods We conducted a retrospectively study included 561 end-stage HAE patients between 2004 and 2016. The demographic characteristics, clinical data, and follow-up outcomes were collected and analysed. Kaplan-Meier curves were used for the overall survival (OS) and disease progression-free survival (PFS) analyses. COX multivariable regression analysis was carried out to identify risk factors. Result A total of 122 patients received surgical intervention were included, 55 cases underwent two-stage hepatectomy (group A, n=55), 21 cases underwent liver transplantation (group B, n=21), and 46 cases underwent non-radical reduction hepatectomy (groupC, n=46). The perioperative morbidity and mortality of liver transplantation group were significantly higher than other groups (47.6% and 14.3%). In group A, the 5- and 10-year OS rates were both 94.12%, and the 5- and 10-year PFS rates were both 91.18%. In group B, the 5- and 10-year OS rates were both 94.44%, and the 5- and 10-year PFS rates were both 94.44%. In group C, the 5- and 10-year OS rates were both 74.05%, and the 5- and 10-year PFS rates were both 54.58%. The rate of favorable prognosis in radical surgical treatment groups were much better than that in non-radical resection group ( P 0.001). Multivariate analysis indicated that diaphragm invasion ( P =0.021), neighbouring organs invasion ( P =0.027) and radical surgical treatment ( P =0.003) were the independent risk factors for OS. Multiple hepatic lobes invasion ( P =0.019), hepatic portal invasion ( P P =0.010) and radical surgical treatment ( P Conclusion Surgical intervention is effective and feasible for end-stage HAE. Patients received the radical operation treatment have better prognosis than those underwent palliative reduction resection.

The adoption of laparoscopic techniques for living donor major hepatectomy has been controversial issue. The aim of this study is to present the preliminary experience of laparoscopic right hepatectomy in China. All the donors receiving right hepatectomy for adult-to-adult living donor liver transplantation (LDLT) were divided into three groups: pure laparoscopic right hepatectomy (PLRH) group, hand-assisted right hepatectomy (HARH) group and open right hepatectomy (ORH) group. We compared the perioperative data and surgical outcomes of donors and recipients among three groups. From November 2001 to May 2017, 295 donors have received right hepatectomy for LDLT in our center. Among them, 7 donors received PLRH, 26 donors received HARH and 262 donors received ORH. The operation time of PLRH group (509.3 ± 98.9 min) was longer than that of the HARH group (451.6 ± 89.7 min) and the ORH group (418.4 ± 81.1 min, p = 0.003). The blood loss was the least in the PLRH group (378.6 ± 177.1 mL), compared with that in the HARH group (617.3 ± 240.4 mL) and that in the ORH group (798.6 ± 483.7 mL, p = 0.0013). The postoperative hospital stay was shorter in the PLRH group (7, 7–10 days) than that in the HATH group (8.5, 7.5–12 days) and ORH group (11, 9–14 days; p = 0.001). Only one donor had pleural effusion (Grade I) and another one experienced pulmonary infection (Grade II). One recipient (14.3%) in the PLRH group occurred hepatic venous stenosis. Laparoscopic approaches for right hepatectomy contribute to less blood loss, better cosmetic satisfaction, less severe complications, and faster rehabilitation. PLRH is a safe and feasible procedure, which must be performed in highly specialized centers with expertise of both LDLT and laparoscopic hepatectomy, and requires a hybrid-to-pure stepwise development.

Ex vivo liver resection combined with autotransplantation is a recently introduced approach to cure end‐stage hepatic alveolar echinococcosis (HAE), which is considered unresectable by conventional radical resection due to echinococcal dissemination into the crucial intrahepatic conduits and adjacent structures. This article aims discuss the manipulation details and propose reasonable indications for this promising technique. All patients successfully underwent liver autotransplantation with no intraoperative mortality. The median weight of the autografts was 636 g (360‐1300 g), the median operation time was 12.5 hours (9.4‐19.5 hours), and the median anhepatic phase was 309 minutes (180‐ 460 minutes). Intraoperative blood loss averaged 1800 mL (1200‐6000 mL). Postoperative complications occurred in 13 patients during hospitalization; 5 patients experienced postoperative complications classified as Clavien‐Dindo grade III or higher, and 2 patients died of intraabdominal bleeding and acute cerebral hemorrhage, respectively. Twenty‐nine patients were followed for a median of 14.0 months (3‐42 months), and no HAE recurrence was detected. The technique requires neither an organ donor nor any postoperative immunosuppressant, and the success of the treatment relies on meticulous preoperative assessments and precise surgical manipulation., This article discusses the details of ex vivo liver resection and autotransplantation in the treatment of end‐stage hepatic alveolar echinococcosis, including the feasibility, indications, preparation, technical innovations, and postoperative outcomes. See the video online at http://amjtransplant.com/videos.

To investigate the association between tacrolimus (TAC) blood concentration and the risk of post-transplantation diabetes mellitus (PTDM) development after living donor liver transplantation (LDLT).This study reviewed the clinical data of 158 adult LDLT recipients. A cut-off of mean trough concentration of TAC (cTAC) value at the sixth month postoperatively was identified using a receptor operating characteristic curve. Other clinical complications rates were compared between different cTAC groups.Thirty-four (21.5%) recipients developed PTDM during follow-up period. Recipients with PTDM suffered lower 1-, 5- and 10-year overall survival rates (85.2%, 64.9%, and 55.6% vs 92.4%, 81.4%, and 79.1%, p 0.05) and allograft survival rates (87.9%, 76.9%, and 65.9% vs 94.1%, 88.5%, and 86.0%, p 0.05) than those without PTDM. The best cut-off value of mean cTAC was 5.9 ng/mL. Recipients with higher cTAC (5.9 ng/mL) were more likely to develop hyperlipidemia (39.6% vs 21.9%, p 0.05), cardio-cerebral events (7.5% vs1.0%, p 0.05), and infections (37.7% vs19.0%, p 0.05) than recipients exposed to low cTAC (≤5.9 ng/mL). However, the two groups showed no difference in the incidence of acute and chronic rejection.Higher mean cTAC at the sixth month postoperatively is related to increased risk of PTDM in LDLT recipients.

BACKGROUND AND AIM The inclusion criteria for liver transplantation (LT) in hepatocellular carcinoma (HCC) are being expanded, and the Hangzhou criteria are the most accepted criteria in China. The aim of our study was to evaluate the Hangzhou criteria for LT in HCC with respect to the Milan criteria. METHODS We retrospectively collected data of 298 cases of LT in HCC in our center from August 2000 to December 2010, and then divided these patients into three groups according to the tumor characteristics: the Milan criteria group (n=97), the Hangzhou criteria group (n=172), and the out of Hangzhou criteria group (n=126). We compared the baseline characteristics and outcome of these three groups of patients. RESULTS Baseline patient characteristics showed no significant difference among the three groups, except for younger age in the out of Hangzhou group (P

Despite advances in immunosuppressive drugs, long-term success of liver transplantation is still limited by the development of chronic liver allograft dysfunction. Although the exact pathogenesis of chronic liver allograft dysfunction remains to be established, there is strong evidence that chemokines are involved in organ damage induced by inflammatory and immune responses after liver surgery. Chemokines are a group of low-molecular-weight molecules whose function includes angiogenesis, haematopoiesis, mitogenesis, organ fibrogenesis, tumour growth and metastasis, and participating in the development of the immune system and in inflammatory and immune responses. The purpose of this review is to collect all the research that has been done so far concerning chemokines and the pathogenesis of chronic liver allograft dysfunction and helpfully, to pave the way for designing therapeutic strategies and pharmaceutical agents to ameliorate chronic allograft dysfunction after liver transplantation.

Chronic liver allograft dysfunction (CLAD) remains the most common cause of patient morbidity and allograft loss in liver transplant patients. However, the pathogenesis of CLAD has not been completely elucidated. By establishing rat CLAD models, in this study, we identified the informative CLAD-associated genes using isobaric tags for relative and absolute quantification (iTRAQ) proteomics analysis and validated these results in recipient rat liver allografts. CXCL4, CXCR3, EGFR, JAK2, STAT3, and Collagen IV were associated with CLAD pathogenesis. We validated that CXCL4 is upstream of these informative genes in the isolated hepatic stellate cells (HSC). Blocking CXCL4 protects against CLAD by reducing liver fibrosis. Therefore, our results indicated that therapeutic approaches that neutralize CXCL4, a newly identified target of fibrosis, may represent a novel strategy for preventing and treating CLAD after liver transplantation.

Here, we report a case of severe immune thrombocytopenia that occurred after orthotopic liver transplant. On day 16 after transplant, the patient was readmitted to our hospital with a platelet count of 0 cells/mL, with the count remaining at a low level of 1000 to 10 000 cells/mL for 46 days. A diagnosis was made, after exclusion of other causes, of thrombocytopenia. Platelet blood transfusion and high-dose prednisone (1mg/kg/d) combined with intravenous immunoglobulin (0.5g/kg/d) were administered with no improvement. After additional treatments, which included altered use of immunosuppressive agents, changing adefovir to lamivudine and continuous steroid therapy, the patient was discharged with a platelet count of 55 000 cells/mL. Both liver and renal functions generally stayed well during hospitalization. The patient was discharged uneventfully and achieved remission during 10-month follow-up after discharge.

Background The number of living donor liver transplantations performed has increased rapidly in many Eastern transplant centres. However, the impact of the transplant centres’ experience and learning on the transplant outcomes are not well established. Aim of the study was to evaluate the learning curve for living donor liver transplantation in our centre. Methods Data from 156 recipients and 156 donors who underwent surgery were reviewed. Intraoperative data and postoperative outcomes of both donors and recipients were retrospectively analysed. Recipients and donors were divided into three groups that consisted of 52 consecutive cases each. Results Surgical duration and intraoperative blood loss during donor surgery were decreased significantly between the earlier and the more recent cases (423 ± 39 vs. 400 ± 44 min and 959 ± 523 vs. 731 ± 278 mL, respectively; P

The balanced application of a model for the estimate of outcomes of liver transplantation, in concert with assessment of disease severity, would not only improve transplant outcomes and maximize patient benefit from transplantation, but also facilitate informed decision making by patients and their relatives when considering transplantation. So far, however, linear discriminating methods have failed to attain sufficient power to predict post-transplant prognosis. Therefore, our aim was to develop a cancer-specific prognostic model by a nonlinear methodology based on pretransplant characteristics.With data collected retrospectively from 290 liver transplant recipients with HCC from February 1999 to August 2009, a multilayer perceptron (MLP) neural network was constructed to predict mortality risk after transplantation. Its predictive performances at posttransplant 1-, 2-, and 5-year intervals were evaluated using a receiver operating characteristic curve.By the forward stepwise selection in MLP network, donor age, donor body mass index, recipient hemoglobin, serum concentrations of total bilirubin, alkaline phosphatase, creatinine, aspartate aminotransferase, international normalized ratio of prothrombin time, and Na(+); alpha fetoprotein categorization, total diameter, number of tumor lesions, presence of imaging macrovascular invasion, and lobe distribution of the tumor were identified to be the optimal input features. The MLP, employing 24 inputs and 7 hidden neurons, yielded c-statistics of 0.909 (P.001) in the 1-year, 0.888 (P.001), in the 2-year, and 0.845 (P.001) in the 5-year prediction.Post-transplant prognosis is a multidimensional, nonlinear problem, and the specific MLP can achieve high accuracy in the prediction of posttransplant mortality risk for HCC recipients. The pattern recognition methodologies like MLP hold promise for solving outcome prediction after liver transplantation.

OBJECTIVES: To identify the factors influencing blood loss and secondary blood transfusion and to investigate the outcomes of patients who underwent a massive blood transfusion (MBT) following living donor liver transplantation (LDLT). METHODS: Patients who underwent primary adult-to-adult right hepatic lobe LDLT were included in the study, and were divided into the MBT group [≥ 6 red blood cell (RBC) units in 24 h] and the non-massive blood transfusion (NMBT) group ( 2 units and ≤ 2 units. Hemoglobin

We sought to identify the risk factors associated with the early mortality after a living-donor liver transplant.Two hundred eighteen patients were recruited in this study. Potential risk factors were analyzed using univariate and multivariate analyses. A C statistic equivalent to the area under the receiver operating characteristic curve was used to assess the ability of the model to predict mortality risk during the first 3 months after a living-donor liver transplant.Twenty-six recipients died within the first 3 months after a living-donor liver transplant. On a multivariate analysis, intraoperative allogeneic red blood cell transfusion and the preoperative creatinine levels were independently associated with early postoperative mortality. A prognostic model was proposed in this study (early mortality risk score = 0.107 × intraoperative allogeneic red blood cells transfusion [U] + 0.005 × preoperative creatinine concentration [μmol/L]). Three-month survival rates of patients with high and low scores were 69.8% and 95.5% (P.001).Transfusion of intraoperative allogeneic red blood cell and preoperative creatinine levels are associated with the early mortality after living-donor liver transplant. A model to predict early mortality after a living-donor liver transplant based on these risk factors was proposed in this study.

Chronic liver allograft dysfunction is the leading cause of patient morbidity and late allograft loss after liver transplantation. The pathogenesis of chronic liver allograft dysfunction remains unknown. Recent studies have demonstrated that CXCL4 and its variant CXCL4L1 are involved in organ damage induced through inflammatory and immune responses throughout all stages of liver transplantation. CXCL4 and CXCL4L1 are low-molecular-weight proteins that have been implicated in hematopoiesis, angiostasis, organ fibrogenesis, mitogenesis, tumor growth and metastasis. The purpose of this review is to discuss the current status and future developments of research into the roles of CXCL4 and CXCL4L1 in the pathogenesis of chronic liver allograft dysfunction. The potential utilization of CXCL4 and CXCL4L1 as therapeutic targets for chronic liver allograft dysfunction will also be discussed.

The purpose of this study was to identify the incidence, outcomes, and risk factors of postoperative abdominal bleeding after living-donor liver transplant.Adult patients who had living-donor liver transplant between 2001 and 2013 were evaluated. Preoperative and intraoperative variables of transplant recipients were analyzed retrospectively with univariate analysis. Cox proportional hazards regression model was used to identify independent factors for postoperative bleeding.There were 241 living-donor liver transplant recipients included in the study. Postoperative abdominal bleeding was observed in 12 recipients (5%). The 3-month cumulative survival was significantly lower in recipients who had postoperative bleeding (survival, 8 patients [67%]) than recipients who did not have postoperative bleeding (survival, 204 patients [89%]; P = .009). Univariate analysis showed that preoperative albumin level, Child-Pugh class, and intraoperative blood loss were risk factors for postoperative bleeding. In multivariate analysis, intraoperative blood loss and Child-Pugh status were significant risk factors for postoperative bleeding.Living-donor liver transplant recipients who had postoperative bleeding had a poor outcome. Postoperative bleeding was associated with higher intraoperative blood loss and Child-Pugh class.

To detect whether the up-to-seven should be used as inclusion criteria for liver transplantation for hepatocellular carcinoma.Between April 2002 and July 2008, 220 hepatocellular carcinoma (HCC) patients who were diagnosed with HCC and underwent liver transplantation (LT) at our liver transplantation center were included. These patients were divided into three groups according to the characteristics of their tumors (tumor diameter, tumor number): the Milan criteria group (Group 1), the in up-to-seven group (Group 2) and the out up-to-seven group (Group 3). Then, we compared long-term survival and tumor recurrence of these three groups.The baseline characteristics of transplant recipients were comparable among these three groups, except for the type of liver graft (deceased donor liver transplant or live donor liver transplantation). There were also no significant differences in the pre-operative α-fetoprotein level. The 1-, 3-, and 5-year overall survival and tumor-free survival rate for the Milan criteria group were 94.8%, 91.4%, 89.7% and 91.4%, 86.2%, and 86.2% respectively; in the up-to-seven criteria group, these rates were 87.8%, 77.8%, and 76.6% and 85.6%, 75.6%, and 75.6% respectively (P0.05). However, the advanced HCC patients' (in the group out of up-to-seven criteria) overall and tumor-free survival rates were much lower, at 75%, 53.3%, and 50% and 65.8%, 42.5%, and 41.7%, respectively (P0.01).Considering that patients in the up-to-seven criteria group exhibited a considerable but lower survival rate compared with the Milan criteria group, the up-to-seven criteria should be used carefully and selectively.

AIM: To validate the “Metroticket” predictor using a large cohort of liver transplantation (LT) patients with hepatocellular carcinoma (HCC) in China. METHODS: In total, 230 cases of LT for HCC treatment at our center, from July 2000 to August 2008, were included in the present study. The predicted 1-, 3- and 5-year post-LT survival rates were calculated using the Metroticket model (http://89.96.76.14/metroticket/calculator/). The predicted and observed long-term survival rates were then compared and analyzed. RESULTS: The predicted survival rates for all 230 cases, as calculated by the Metroticket model, were 64.7% and 56.2% at 3 and 5 years, respectively, and the observed survival rates for these patients were 71.3% and 57.8%, respectively. For the 23 cases with macrovascular invasion, the predicted 5-year survival rate was 43.5%, whereas the observed 5-year survival rate was only 8.7%. For the 42 cases with microvascular invasion but an absence of macrovascular invasion, the predicted 5-year survival rate was 44.9%, and the observed 5-year survival rate was 50%. For the remaining 165 patients without any vascular invasion, the predicted 5-year survival rate was 65.8%, and the observed 5-year survival rate was 66.7%. CONCLUSION: The Metroticket model can be used to accurately predict survival in HCC-related LT cases with an absence of macrovascular invasion.

Some patients with portal hypertension due to hepatitis B cirrhosis who were suitable for periesophagogastric devascularization with splenectomy (PDS) also met the indications of liver transplantation (LT), the study compared the effect of PDS and LT, and of PDS followed by LT when required.Patients with portal hypertension due to hepatitis B cirrhosis were analyzed. Patients were organized into PDS or LT groups, and PDS followed by LT.The PDS group suffered from lower incidence of severe postoperative complications (p=0.007) and perioperative death (p=0.015) than group LT. The 1-, 3- and 5-year survival rates of the PDS and LT groups were 99.3%, 98.1% and 89.0%, and 91.1%, 85.4% and 79.0%, respectively (p=0.04). There were no significant differences in severe postoperative complications (p=1.000) or perioperative mortality (p=1.000) between the PDS followed by LT and the LT groups, and their 1-, 3- and 5-year survival rates were 91.2%, 82.1% and 82.1%, and 91.1%, 85.4% and 79.0%, respectively (p=0.694).For patients with portal hypertension due to hepatitis B cirrhosis, when they satisfy the indications for both PDS and LT, we appeal to perform PDS as bridging therapy for final liver transplantation.

AIM: To evaluate the relationship between donor safety and remnant liver volume in right lobe living donor liver transplantation (LDLT). METHODS: From July 2001 to January 2009, our liver transplant centers carried out 197 LDLTs. The clinical data from 151 cases of adult right lobe living donors (not including the middle hepatic vein) were analyzed. The conditions of the three groups of donors were well matched in terms of the studied parameters. The donors’ preoperative data, intraoperative and postoperative data were calculated for the three groups: Group 1 remnant liver volume (RLV) 40%. Comparisons included the different remnant liver volumes on postoperative liver function recovery and the impact of systemic conditions. Correlations between remnant liver volume and post-operative complications were also analyzed. RESULTS: The donors’ anthroposomatology data, operation time, and preoperative donor blood test indicators were calculated for the three groups. No significant differences were observed between the donors’ gender, age, height, weight, and operation time. According to the Chengdu standard liver volume formula, the total liver volume of group 1 was 1072.88 ± 131.06 mL, group 2 was 1043.84 ± 97.11 mL, and group 3 was 1065.33 ± 136.02 mL. The three groups showed no statistically significant differences. When the volume of the remnant liver was less than 35% of the total liver volume, the volume of the remnant had a significant effect on the recovery of liver function and intensive care unit time. In addition, the occurrence of complications was closely related to the remnant liver volume. When the volume of the remnant liver was more than 35% of the total liver volume, the remnant volume change had no significant effect on donor recovery. CONCLUSION: To ensure donor safety, the remnant liver volume should be greater than the standard liver volume (35%) in right lobe living donor liver transplantation.

Background The scarcity of grafts available necessitates a system that considers expected posttransplant survival, in addition to pretransplant mortality as estimated by the MELD. So far, however, conventional linear techniques have failed to achieve sufficient accuracy in posttransplant outcome prediction. In this study, we aim to develop a pretransplant predictive model for liver recipients' survival with benign end-stage liver diseases (BESLD) by a nonlinear method based on pretransplant characteristics, and compare its performance with a BESLD-specific prognostic model (MELD) and a general-illness severity model (the sequential organ failure assessment score, or SOFA score). Methodology/Principal Findings With retrospectively collected data on 360 recipients receiving deceased-donor transplantation for BESLD between February 1999 and August 2009 in the west China hospital of Sichuan university, we developed a multi-layer perceptron (MLP) network to predict one-year and two-year survival probability after transplantation. The performances of the MLP, SOFA, and MELD were assessed by measuring both calibration ability and discriminative power, with Hosmer-Lemeshow test and receiver operating characteristic analysis, respectively. By the forward stepwise selection, donor age and BMI; serum concentration of HB, Crea, ALB, TB, ALT, INR, Na+; presence of pretransplant diabetes; dialysis prior to transplantation, and microbiologically proven sepsis were identified to be the optimal input features. The MLP, employing 18 input neurons and 12 hidden neurons, yielded high predictive accuracy, with c-statistic of 0.91 (P

AIM: To investigate the effect of zinc finger protein A20 on chronic liver allograft dysfunction in rats. METHODS: Allogeneic liver transplantation from DA rats to Lewis rats was performed. Chronic liver allograft dysfunction was induced in the rats by administering low-dose tacrolimus at postoperative day (POD) 5. Hepatic overexpression of A20 was achieved by recombinant adenovirus (rAd.)-mediated gene transfer administered intravenously every 10 d starting from POD 10. The recipient rats were injected with physiological saline, rAdEasy-A20 (1 × 109 pfu/30 g weight) or rAdEasy (1 × 109 pfu/30 g weight) every 10 d through the tail vein for 3 mo starting from POD 10. Liver tissue samples were harvested on POD 30 and POD 60. RESULTS: Liver-transplanted rats treated with only tacrolimus showed chronic allograft dysfunction with severe hepatic fibrosis. A20 overexpression ameliorated the effects on liver function, attenuated liver allograft fibrosis and prolonged the survival of the recipient rats. Treatment with A20 suppressed hepatic protein production of tumor growth factor (TGF)-β1, interleukin-1β, caspase-8, CD40, CD40L, intercellular adhesion molecule-1, vascular cell adhesion molecule-1 and E-selectin. A20 treatment suppressed liver cell apoptosis and inhibited nuclear factor-κB activation of Kupffer cells (KCs), liver sinusoidal endothelial cells (LSECs) and hepatic stellate cells (HSCs), and it subsequently decreased cytokine mRNA expression in KCs and LSECs and reduced the production of TGF-β1 in HSCs. CONCLUSION: A20 might prevent chronic liver allograft dysfunction by re-establishing functional homeostasis of KCs, LSECs and HSCs.

Background/Aims The number of people undergoing living donor liver transplantation (LDLT) has increased rapidly in many transplant centres. Patients considering LDLT need to know whether LDLT is riskier than deceased donor liver transplantation (DDLT). The aim of this study was to compare the outcomes of patients undergoing LDLT versus DDLT. Methods A total of 349 patients with benign liver diseases were recruited from 2005 to 2011 for this study. LDLT was performed in 128 patients, and DDLT was performed in 221 patients. Pre- and intra-operative variables for the two groups were compared. Statistically analysed post-operative outcomes include the postoperative incidence of complication, biliary and vascular complication, hepatitis B virus (HBV) recurrence, long-term survival rate and outcomes of emergency transplantation. Results The waiting times were 22.10±15.31 days for the patients undergoing LDLT versus 35.81±29.18 days for the patients undergoing DDLT. The cold ischemia time (CIT) was 119.34±19.75 minutes for the LDLT group and 346±154.18 for DDLT group. LDLT group had higher intraoperative blood loss, but red blood cell (RBC) transfusion was not different. Similar ≥ Clavien III complications, vascular complications, hepatitis B virus (HBV) recurrence and long-term survival rates were noted. LDLT patients suffered a higher incidence of biliary complications in the early postoperative days. However, during the long-term follow-up period, biliary complication rates were similar between the two groups. The long-term survival rate of patients undergoing emergency transplantation was lower than of patients undergoing elective transplantation. However, no significant difference was observed between emergency LDLT and emergency DDLT. Conclusions Patients undergoing LDLT achieved similar outcomes to patients undergoing DDLT. Although LDLT patients may suffer a higher incidence of early biliary complications, the total biliary complication rate was similar during the long-term follow-up period.

To summarize our experience in adult-to-infant living donor liver transplantation (A-ILDLT) and to analyze the efficacy and complications of A-ILDLT.The clinical data, surgical strategies and complications of 28 adult donors and infantile recipients who underwent A-ILDLT from April 2006 to December 2009 were retrospectively analyzed. These 28 patients (14 boys and 14 girls) aged from 80 days to 11.5 months with body weights of 3.08 to 10.3 kg at the time of operation . They suffered from biliary atresia with decompensated cirrhosis. The living donors were 15 mothers, 9 fathers, 3 grandma and 1 elder brother with ABO compatible with the infantile recipients. 27 Donor organs were the left lateral lobe grafts (segment II, III) and 1 graft was segment II. All patients were followed up for 5 to 24 months.These grafts were orthotopically transplanted into the infantile recipients. The average length of stay was 9.3 days for the donor group without any complications. Postoperative immunosuppression included prednisone, Cyclosporin and mycophenolate mofetil (MMF). A total of 24 postoperative complications occurred in 20 recipients, including 5 vascular complications, 4 bleeding, 7 pneumonia, 2 bowel obstruction, 4 intestinal perforation and 3 rejection. Three recipients died of hepatic arterial thrombosis (HAT). The perioperative mortality rate of recipients was 10.7% (3/28) and the survival rate was 89.3% in peroperative period. One died of stricture of hepatic vein and 1 of accidental asphyxia during follow-up term. At present, 23 cases are still alive.A-ILDLT has become an effective method to infants with end-stage liver disease. The postoperative vascular complication is the predominant cause of death.

Liver transplantation (LT) has been widely accepted as the treatment of choice for end-stage liver diseases. Due to the scarcity of cadaveric donors, adult-to-adult living donor liver transplantation (LDLT) is advocated as a practical alternative to deceased donor liver transplantation (DDLT). However, some reports suggest that the long-term and recurrence-free survival rates of LDLT are poorer than those of DDLT for hepatocellular carcinoma (HCC). This study aimed to compare the long-term and recurrence-free survival rates of HCC between LDLT and DDLT.We retrospectively analyzed the clinical data of 150 patients with HCC from January 2005 to March 2009. Eleven patients who died of complications during the perioperative period were excluded. The remaining 139 eligible patients (101 DDLT and 38 LDLT) were regularly followed up to October 2009. The Chi-square test or Fisher's exact test were used to compare the characteristics of LDLT and DDLT. The long-term and recurrence-free survival curves of both groups were determined using the Kaplan-Meier method with comparisons performed using the log-rank test. One-way analysis of variance was performed to compare the waiting time of the two groups.Survival rates at 1, 2, 3, and 4 years for LDLT were 81%, 62%, 53%, and 45% and for DDLT were 86%, 60%, 50%, and 38%, respectively. The overall 1-, 2-, 3-, and 4-year recurrence-free rates for LDLT were 71%, 49%, 42%, and 38%, and for DDLT were 76%, 52%, 41%, and 37%, respectively. No significant differences were found by the log-rank test on both long-term and recurrence-free survival rates.The role of LDLT is reinforced by our study. It may expand the donor pool and achieve the same long-term and recurrence-free survival rates of DDLT.

Metastases from malignant melanoma to the liver are rare in China, and surgical resection may be of potential benefit. Liver transplantation for this disease has never been reported.We report a case of adult-to-adult living donor liver transplantation (A-A LDLT) for metastatic melanoma. With a surgical history of ocular melanoma, the recipient presented with emaciation from a large right hepatic mass which also probably had portal vein invasion. A-A LDLT was successfully performed and no postoperative complications were observed in either the donor or the recipient. Postoperative pathology confirmed the diagnosis of metastatic malignant melanoma; however no adjuvant chemotherapy was employed after transplantation. We also reviewed the literature on the surgical treatment of metastatic malignant melanoma to the liver and discussed the LDLT indications.Recurrence occurred 6 months after surgery and the patient died from recurrence of the disease 8 months post-transplant.Review of the literature suggested that only a small subset of selected patients may benefit from liver resection. Large metastatic disease in the liver potentially involving a major vessel, as in this case, should be contraindicated for liver transplantation.

Congestion of the right anterior segment may lead to graft dysfunction in right-lobe living donor liver transplantation (LDLT) without a middle hepatic vein (MHV) trunk. Selective reconstruction of MHV tributaries with the interposition of vascular grafts has been introduced to overcome this problem. However, there is still no consensus on the definite criteria of MHV reconstruction.LDLT patients were reviewed to evaluate the effects of MHV reconstruction. From March 2005 to September 2008 in our transplantation center, 120 consecutive LDLTs were performed using a right-lobe graft without a MHV. Excluding 11 patients, among the remainder, 73 (67%) had reconstructed MHV tributaries, and the others 36 (33%) did not. The values of liver functional index and liver graft regeneration ratio were compared between the two groups.There was a prolonged period of liver functional recovery in patients with small-for-size grafts and a graft-recipient weight ratio (GRWR)1.0%, and without MHV reconstruction. The ratio of liver regeneration 1 month post-operatively in reconstruction cases was 81%, versus 78% in patients without reconstruction (P=0.352), but among small-for-size grafts, there was a significant difference between the two groups (95% vs. 80%).Our study shows that reconstruction of MHV tributaries is not necessary in all patients, but is beneficial for patients with GRWR1.0%.

Seventh-day syndrome (7DS) is an early serious complication following liver transplantation with a high mortality because of its unknown etiopathogenesis. This study aimed to analyze the potential etiopathogenesis of 7DS.A retrospective analysis of 98 consecutive living donor liver transplants performed from 2001 to 2007 at our center revealed that 5 patients had suffered from 7DS; their age, MELD score, portal vein inflow and other parameters were compared with those of the other recipients.The 5 patients showed common features: (a) initial uneventful recovery, and a dramatic rise of serum liver enzyme levels 1 to 2 weeks later; (b) decreased inflow in the portal vein accompanied by augmentation of serum creatinine and urea nitrogen level; and (c) serial liver biopsy findings of apoptosis and ischemic necrosis of hepatocytes. Four of the 5 patients died. Age, waiting time to transplantation, MELD score, operation time, cold ischemic time, portal interceptive time and diameter of the portal vein were not significantly different between the 2 groups, but a difference was found in the flow rate of the portal vein (t=3.234, P0.001).The 5 patients suffered from a decreased portal vein inflow, ischemic liver necrosis, and renal failure. Hence, hypoperfusion of the liver graft was considered to be the etiopathogenesis of 7DS, for which, however sufficient evidence is lacking. More studies of 7DS are needed.

Because of the shortage of deceased donors with livers fit for transplantation, living donor liver transplantation (LDLT) is becoming an attractive alternative. Attention should be paid to the donors, especially to those of the right lobe. In this study, we evaluated the risks faced by donors of the right lobe for adult-to-adult LDLT.The perioperative data from 105 consecutive living donors of the right lobe performed in West China Hospital from January 2002 to December 2007 were retrospectively studied. Preoperative evaluation included CT, MRCP, and intraoperative cholangiography, showing liver volume, hepatic vasculature and the biliary system. The standard liver volume (SLV) and the ratio of left lobe volume to SLV were calculated. The right lobe grafts were obtained by transecting the liver on the right side of the middle hepatic vein without inflow vascular occlusion, using an ultrasonic dissector. After operation the donors were monitored in the Intensive Care Unit for about three days. Each donor was followed up for at least 6 months.There was no donor mortality. Major complications occurred in 14 donors (13.3%), of whom 3 received conservative treatment, 8 required invasive paracentesis, and 3 required further surgery. All donors were recovered well and resumed their previous occupations.Donors of the right lobe face low risks. The preoperative evaluation, especially evaluation of the volume of the remnant liver, should be exact. During the operation, the patency of the remnant hepatic vasculature and bile duct must be preserved, and the extent of injury to the remnant liver should be limited as much as possible. The detection and treatment of postoperative complications should be diligently performed.

To identify prognostic factors of patients with hepatocellular carcinoma (HCC), who were treated by orthotopic liver transplantation (OLT).From January 2000 to October 2006, 165 patients with HCC underwent OLT. Various clinicopathological risk factors for actuarial and recurrence-free survival were identified using the Kaplan-Meier method with the log-rank test. The Cox proportional hazards model was used to identify independently predictive factors for actuarial and recurrence-free survival, which were used to propose new selection criteria. We compared the outcome of the subgroup patients meeting different criteria. Survival analysis was performed using the Kaplan-Meier method with the log-rank test.The median follow-up was 13.0 mo (2.8-69.5 mo). Overall, 1-, 2-, 3- and 5-year actuarial survival was 73.3%, 45.6%, 35.4% and 32.1%, respectively. One-, 2-, 3- and 5-year overall recurrence-free survival was 67.0%, 44.3%, 34.5% and 34.5%, respectively. In univariate analysis, number of tumors, total tumor size, lobar distribution, differentiation, macrovascular invasion, microvascular invasion, capsulation of the tumor, and lymph node metastasis were found to be associated significantly with actuarial and tumor-free survival. By means of using the multivariate Cox proportional hazards model, total tumor size and macrovascular invasion were found to be independent predictors of actuarial and tumor-free survival. When the selection criteria were expanded into the proposed criteria, there was no significant difference in 1-, 2-, 3- and 5-year actuarial and tumor-free survival of the 49 patients who met the proposed criteria (97.6%, 82.8%, 82.8% and 82.8%, and 90.7%, 82.8%, 68.8% and 68.8%, respectively) compared with that of patients who met the Milan or University of California, San Francisco (UCSF) criteria.Macrovascular invasion and total tumor diameter are the strongest prognostic factors. The proposed criteria do not adversely affect the outcome of liver transplantation for HCC, compared with the Milan or UCSF criteria.

Hepatic venous outflow stenosis is an uncommon but serious complication after right lobe living donor liver transplantation (LDLT). Failure to recognize and treat this complication early can result in graft failure and even death. The early diagnosis and management of hepatic venous outflow stenosis has become an important issue.We report a case with this complication treated by endovascular stent placement in the early period after right lobe LDLT and review related reports to explore the possible mechanism.A 44-year-old man with end-stage hepatitis B liver cirrhosis underwent right lobe LDLT. On postoperative day 13, his liver function deteriorated and he developed refractory ascites for maximal diuretic therapy. Hepatic venography showed a stenosis with an element of torsion of the venous drainage proximal to the anastomosis of the right hepatic venous orifice and inferior vena cava. The stenosis was successfully treated by insertion of an expandable metallic stent.The result demonstrates that stent placement for stenosis is safe and effective. We suspect that rapid hypertrophy of an asymmetric right lobe graft may result in hepatic venous outflow stenosis caused by twisting or external compression of the hepatic veins.

To investigate whether microproteinuria could be used as an early and sensitive indicator to detect calcineurin inhibitor (CNI)-related nephrotoxicity after liver transplantation.All liver transplant recipients with normal serum creatinine (SCr) and detectable microproteinuria at baseline were included in this study. The renal function was monitored by the blood clearance of (99m)Tc-diethylenetriaminepentaacetic acid every 6 mo. Microproteinuria, SCr and blood urea nitrogen (BUN) were measured at entry and at subsequent follow-up visits. The patients were divided into different groups according to the mean values of glomerular filtration rate (GFR) at the follow-up time points: Group 1, GFR decreased from baseline by 0%-10%; Group 2, GFR decreased from baseline by 11%-20%; Group 3, GFR decreased from baseline by 21%-40%; Group 4, GFR decreased from baseline by40% and/or SCr was increasing.A total of 143 patients were enrolled into this study (23 females and 120 males). The mean follow-up was 32 mo (range 16-36 mo). Downward trends in renal function over time were observed in the study groups. SCr and BUN increased significantly only in Group 4 patients (P0.001). beta2-microglobulin (beta2m) and alpha1-microglobulin (alpha1m) significantly increased with the subtle change of renal function in recipients who were exposed to CNI-based immunosuppression regimens. The reductions in GFR were closely correlated with elevated alpha1m (r(2) = -0.728, P0.001) and beta2m (r(2) = -0.787, P0.001).beta2m and alpha1m could be useful as early and sensitive indicators of CNI-induced nephrotoxicity.

Human CD8+CD28- T-suppressor (Ts) cells have been considered to indicate a reduced need for immunosuppression in pediatric liver-intestine transplant recipients and recipients of deceased heart-kidney transplants. However, in adult-to-adult living donor liver transplantation (A-A LDLT) little information is available and the clinical significance is still unknown.Flow cytometry was used to detect the population of CD8+CD28- Ts cells present in peripheral blood in A-A LDLT recipients (n=31), patients with end-stage liver disease (n=24) and healthy controls (n=19). Meanwhile, we tested the graft function and trough levels of immunosuppression in recipients. The clinical and follow-up data of 31 transplant recipients were analyzed.Compared with diseased controls (P=0.007) and healthy individuals (P=0.000), a notable expansion of CD8+CD28- Ts cells was found in recipients of A-A LDLT. This was associated with graft function, levels of immunosuppression and rejection episodes.To monitor the CD8+CD28- Ts cells levels is important to evaluate the immune state of recipients. Meanwhile, it is also important to promote expansion of CD8+CD28- Ts cells in recipients of A-A LDLT, not only to sustain good graft function and decrease the dosage of immunosuppressants, but also to reduce the occurrence of rejection.

Prophylactic strategies against hepatitis B virus (HBV) recurrence after liver transplantation (LT) are essential for patients with HBV-related disease. Before LT, lamivudine (LAM) was proposed to be down-graded from first- to second-line therapy. In contrast, adefovir dipivoxil (ADV) has been approved not only as first-line therapy but also as rescue therapy for patients with LAM resistance. Furthermore, combination of ADV and LAM may result in lower risk of ADV resistance than ADV monotherapy. Other new drugs such as entecavir, telbivudine and tenofovir, are probably candidates for the treatment of hepatitis-B-surface-antigen-positive patients awaiting LT. After LT, low-dose intramuscular hepatitis B immunoglobulin (HBIG), in combination with LAM, has been regarded as the most cost-effective regimen for the prevention of post-transplant HBV recurrence in recipients without pretransplant LAM resistance and rapidly accepted in many transplant centers. With the introduction of new antiviral drugs, new hepatitis B vaccine and its new adjuvants, post-transplant HBIG-free therapeutic regimens with new oral antiviral drug combinations or active HBV vaccination combined with adjuvants will be promising, particularly in those patients with low risk of HBV recurrence.

Intrahepatic cholangiocarcinoma (ICC) is a rare primary liver cancer with a global increasing trend in recent years. Symptoms tend to be vague and insidious in development, often are diagnosed at an advanced stage when only palliative approaches can be used with a median survival rate of months. Comparing with HCC, ICC tends to spread to lymph nodes early, and is rarely limited to the regional lymph nodes, with a frequent postoperative recurrence. Surgery is the only choice of curative therapy for ICC, but recently no consensus has been established for operation. Thus, more data from multiple centers and more cases are needed. Generally speaking, current adjunctive therapy cannot clearly improve survival. Further research is needed to find more effective radio- and chemotherapeutic regimens.