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Goals: To assess the current practice patterns of liver transplant centres in Canada and the USA regarding transplant eligibility., Background: Liver transplantation is an evolving field and today remains the only life-sustaining treatment for end-stage liver disease. Issues of allocation and transplant eligibility are important factors in the ethical practice of medicine., Study: Questionnaires were mailed to liver transplant programme directors in Canada and the USA inquiring about current practices regarding recipient eligibility., Results: This study demonstrates that there is consensus in the use of other eligibility criteria, including non-compliance, social status, abstinence from alcohol and methadone and cocaine use. Interestingly, literature is lacking to support the use of these parameters as eligibility criteria with the exception of alcohol. There is a lack in consensus regarding marijuana use, human immunodeficiency virus status, ability to accept blood transfusions and prisoner status. The literature suggests that liver transplantation in select patients who refuse blood transfusions results in good outcomes., Conclusions: Important decisions regarding transplant eligibility still have to be made empirically in the absence of scientific literature about various social issues. While consensus among transplant programmes is useful, it is important that we continue to use the evidence in the literature to revise these eligibility criteria, keeping in mind ethical principles applied to the access and allocation of a scarce resource.

In an attempt to more completely define the histopathologic features of the portal vein hyperperfusion or small-for-size syndrome (PHP/SFSS), we strictly identified 5 PHP/SFSS cases among 39 (5/39; 13%) adult living donor liver transplants (ALDLT) completed between 11/01 and 09/03. Living donor segments consisting of 3 right lobes, 1 left lobe, and 1 left lateral segment, with a mean allograft-to-recipient weight ratio (GRWR) of 1.0 +/- 0.3 (range 0.6 to 1.4), were transplanted without complications, initially, into 6 relatively healthy 25 to 63-year-old recipients. However, all recipients developed otherwise unexplained jaundice, coagulopathy, and ascites within 5 days after transplantation. Examination of sequential posttransplant biopsies and 3 failed allografts with clinicopathologic correlation was used in an attempt to reconstruct the sequence of events. Early findings included: (1) portal hyperperfusion resulting in portal vein and periportal sinusoidal endothelial denudation and focal hemorrhage into the portal tract connective tissue, which dissected into the periportal hepatic parenchyma when severe; and (2) poor hepatic arterial flow and vasospasm, which in severe cases, led to functional dearterialization, ischemic cholangitis, and parenchymal infarcts. Late sequelae in grafts surviving the initial events included small portal vein branch thrombosis with occasional luminal obliteration or recanalization, nodular regenerative hyperplasia, and biliary strictures. These findings suggest that portal hyperperfusion, venous pathology, and the arterial buffer response importantly contribute to early and late clinical and histopathologic manifestations of the small-for-size syndrome.

Introduction: Living donor hepatectomies are technically challenging and we continue to modify our techniques to decrease morbidities. Patients and methods: We present our program experience with 114 living donor hepatectomies (95 right lobes, 3 left lobes, 16 left lateral segments) from 3/4/03 to 2/28/06 at the Starzl Transplantation Institute. A total of 208 potential donors were screened, resulting in 114 (54%) living donor hepatectomies and living donor liver transplants (98 adults, 16 pediatric recipients). Results: In all, 94 potential donors (46%) were declined for the following reasons: fatty livers (43), availability of a deceased donor liver (15), small liver volume (12), workup (6), biopsy consistent with fibrosis (4), polycystic liver disease (3), cardiovascular contraindications (2), mental illnesses (2), hepatitis B (2), and hepatic vascular/biliary anomalies (2). There was no donor mortality and the donor morbidity rate was 8.8%. Three (2.6%) donors had bile leak from cut liver edges with JP removed by 3 weeks (all managed conservatively). Other morbidities included 1 unit pRBC transfusion (2), pneumonia (1), incisional hernia (1), prolonged LFTs (1), deep venous thrombosis (1), and narcotic pscyhosis (1). The mean donor hospital stay was 7 days. Blood loss did not correlate with liver volume but correlated with technique of liver parenchymal dissection. With technique modifications (combination of Tissue Link, Erbe HELIX hydro-jet, endovascuar GIA stapler, and CUSA) during the last 70 right lobe hepatectomies, the mean estimated blood loss has dropped to about 250 mL, with no blood transfusion. Operative time for liver parenchymal dissection has also dropped from about 200 minutes to 90 minutes. Discussion: With intraoperative technical experience and refinements, previous surgical contraindications are decreasing. A higher percentage of potential living liver donors screened are allowed to donate, with decreasing morbidities. [ABSTRACT FROM AUTHOR]

Introduction: Alemtuzumab (Campath-1H) is a humanized anti-CD52 monoclonal antibody that results in prolonged depletion of T and other immune cells. Patients and methods: Alemtuzumab (30 mg IV x1) was used for induction in 45 consecutive right lobe adult-to-adult living donor liver transplants (RLALDLTs) from 6/10/03 to 9/20/05 at the Starzl Transplantation Institute. Maintenance immunosuppression was with steroid-free tacrolimus monotherapy, which was weaned when possible. The mean preoperative MELD score was 12.4 (6 to 25); mean follow-up was 18.6 + 8.6 months. Results: Our 1-year recipient and graft survival rates were 93.3% and 91.1%, and compare well to UNOS data (89.1%, 79.3%). The cumulative acute cellular rejection (ACR) incidence was 0% at 1 mos, 2.4% at 2 mos, 4.8% at 3 mos, 7.3% at 4 mos, 8.9% at 12 mos, and 11.1% at 18 mos. Preweaning ACR was 8.9% (n=4) and only 1 patient had post-weaning ACR. Weaning was attempted in 38% (n=17) of recipients. At follow-up, of the 39 living patients, 19 are maintained on daily tacrolimus monotherapy, 7 on qod tacrolimus monotherapy, and 7 on 3x/week tacrolimus monotherapy. The 18.6-mos recipient and graft survival rates were 88.9% and 86.7%. The mean total bilirubin of our survivors is 0.83 (+ 0.51). There were minimal infectious complications, with no incidence of tissue-invasive CMV disease, no PTLD, and no posttransplant insulin-dependent diabetes. Discussion: This study represents the largest series to date of RLALDLT recipients undergoing alemtuzumab induction and steroid-free tacrolimus monotherapy, and confirms the short-term safety and efficacy of this approach. [ABSTRACT FROM AUTHOR]