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Coronavirus disease 2019 has resulted in significant morbidities and mortalities in nearly all parts ofthe world. There remain major concerns about management, timing, and safety of liver transplant in patients who have recovered from COVID-19. We aimed to study the clinical course and outcomes of patients with liver cirrhosis who recovered from COVID-19 and underwent liver transplant from deceased donors.A retrospective study was conducted on liver transplant recipients who underwent liver transplant from April 1, 2020, to January 30, 2021. We evaluated all recipients of liver transplantfrom deceased donors during this period in the COVID-19 pandemic.There were 14 patients with decompensated liver cirrhosis who had recovered from COVID-19 as documented by reverse transcription-polymerase chain reaction test for SARS-CoV-2. Mean duration from COVID-19 to transplant surgery was 56.14 ± 29.96 days. Mortality occurred in 3 patients, and of whom 2 had been hospitalized and received medications for COVID-19 before transplant. Five patients had positive reverse transcription-polymerase chain reaction results for SARS-CoV-2 after liver transplant.This is a large reported series of patients with liver cirrhosis who have received liver transplant after recovery from COVID-19. We provided evidence that liver transplant from deceased donors should be considered in patients recovered from COVID-19, especially in those with deterioration of clinical status.

Peritoneal adhesion formation is a challenging postoperative complication. We aim to evaluate the effect of orally administered sirolimus, prednisolone, and their combination to prevent this entity.Eighty female albino underwent intraperitoneal injection of 3 mL of 10% sterile talc solution to induce peritoneal adhesion, and were subsequently and randomly divided into four groups (each n = 20); including a control group; 1 mg/kg oral prednisolone daily in the morning; 0.1 mg/kg oral sirolimus daily; and a combination group which received both drugs, with the same dosage. On the 29th day, abdominal cavities were explored, and classification was done based on Nair classification.All rats were healthy on the 29th day, in which exploration was performed. The rats in the control group had extensive intra-abdominal adhesions, while 17 (85%) rats in the control group had substantial adhesion; however, the prednisolone, sirolimus, and combination group had lesser adhesion formation. Also, 14 (70%) rats of prednisolone group, 13 (65%) of sirolimus group, and 16 (80%) of combination group had insubstantial adhesion. The decrease in the grade of peritoneal adhesion bands was highly significant in the combination group (P 0.001).The combination of sirolimus and prednisolone was effective for preventing peritoneal adhesions in rats.

Liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) are used for diagnosis of liver fibrosis and steatosis. This study aimed to noninvasively evaluate hepatic steatosis and fibrosis in liver transplant recipients using CAP and LSM and the impact on survival of patients.In a prospective study, adult liver transplant recipients were included. CAP and LSM obtained during transient elastography (TE) were used for assessment of hepatic steatosis and fibrosis. Patients were followed during 4 years for mortality as the main outcome after liver transplantation.From 296 patients, 24.7% and 25% of liver transplant recipients had liver steatosis and fibrosis in CAP and LSM, respectively. In multivariable Cox regression analysis, etiology of liver disease (NASH versus non-NASH) (HR: 3.125; 95% CI: 1.594-6.134;CAP and LS measurement during TE are useful methods for diagnosis of hepatic steatosis and fibrosis in liver transplant recipients. LS measurement might predict long-term survival of patients.

Objectives: Liver transplant recipients are more susceptible to vancomycin-resistant enterococci colonization than healthy individuals. We investigated the prevalence of vancomycin-resistant enterococci colonization and its effect on the outcomes of liver transplant recipients. Materials and Methods: Patients who had undergone primary liver transplant at the Shiraz Organ Transplant Center from 2015 to 2017 were enrolled in this study. Demographic characteristics, laboratory test results, duration of stay in the intensive care unit, total duration of hospital stay, and clinical outcome data were extracted from the Shiraz Organ Transplant Center database. Posttransplant outcomes such as graft rejection, mortality, hospital stay, and kidney function tests were included for the first 90 days after transplant. Results: A total of 753 liver transplant recipients (470 males and 283 females) were included in this study. Vancomycin-resistant enterococci colonization was identified in 51 patients (6.8%) after transplant at the time of intensive care unit admission. Our study found no significant difference between outcomes for patients with vancomycin-resistant enterococci colonization and outcomes for patients without colonization, including graft rejection, mortality, hospital stay, and kidney function tests. Conclusions: Our study revealed that asymptomatic vancomycin-resistant enterococci colonization in liver transplant patients has no adverse effect on the duration of posttransplant hospital stay, early mortality rate, graft rejection rate, or kidney function compared with noncolonized patients.

Primary hyperoxaluria type 1 is an autosomal recessive disorder that causes overproduction and urinary excretion of oxalate. Liver transplant has been suggested as a treatment for primary hyperoxaluria type 1 since the defective enzyme is expressed in the liver. This study aimed to investigate results of combined liver and kidney, sequential, and preemptive livertransplantin patients with primary hyperoxaluria type 1.In this cohort study, we followed patients with primary hyperoxaluria type 1 who underwent liver transplant at our centerin Shiraz, Iran. Clinical and laboratory data of patients were gathered, and major outcomes, including renal failure after liver transplant, rejection, and mortality were recorded. Survival of patients was analyzed by the Kaplan-Meier method.Our study included 24 patients. There were 16 male (66.6%) and 8 female (33.33%) patients. Thirteen patients were in the pediatric age group (age18 y), and 11 patients were adults (age ≥ 18 y). Thirteen patients underwent sequential transplant, 8 patients underwent combined liver and kidney transplant, and 3 patients underwent preemptive transplant. All patients received organs from deceased donors. There were no statistically significant differences in mortality, rejection, and hemodialysis after transplant between those with sequential transplant and those with combined liver and kidney transplant (P.05).Liver transplant can be considered a treatment for patients with primary hyperoxaluria type 1. Combined liver and kidney transplant and preemptive liver transplant could be proper options for these patients.

Background: Liver transplantation (LT) is the definitive treatment for patients with advanced liver failure. Bacterial infections are common consequences of organ transplantation resulting from immune suppression and prolonged hospitalization. Methods: This retrospective cohort study examined the records of all liver transplant pediatrics under 18 years of age in Abu-Ali Sina hospital, Shiraz, Fars province, Iran, from April 2019 to February 2020. Demographic, laboratory, and clinical data were extracted along with the administered therapeutic approach for the patient. Results: Of 80 enrolled patients, 52 were male, and 28 were female, with a median age of 60 months. An incidence of 67.9% of bacterial infections was recorded. Gram-negative and Gram-positive pathogens accounted for 64.06% and 35.93% of infections, respectively. Surgical site infections were the most common ones. The length of ICU stay, hospitalization, mechanical ventilation duration, and re-hospitalization were significantly higher in the infected group than in non-infected pediatrics (P-value < 0.05). Multivariate regression analysis showed that the only risk factor for bacterial infections after LT was the length of ICU stay. The mortality rate was 22%, which was significantly higher among the infection group (P = 0.008). Conclusions: A high rate of bacterial infections and an increasing prevalence of nosocomial and antibiotic-resistant pathogens were detected in the early period after LT.

OBJECTIVES Liver transplant is the most effective treatment modality for patients with end-stage liver disease, metabolic disorders, hepatic malignancy, and acute liver failure. When a graft fails after primary liver transplant, retransplant of the liver remains the only option. Here, we report the past 12-year experience of the Shiraz Transplant Center regarding liver retransplant. MATERIALS AND METHODS This is a retrospective cohort study of a 12-year period (2004-2015) of the Shiraz Center in Iran. RESULTS Of the 3107 patients who had a liver transplant during the study period, 58 retransplants were performed (1.86%) in 57 patients. The leading cause of retransplant was primary nonfunction in 24 patients (41.4% of retransplant cases and 0.77% of all liver transplant cases). The second leading cause of retransplant was vascular complications in 25 patients (23 with hepatic artery thrombosis and 2 with portal vein thrombosis), accounting for 43.1% of retransplant cases and 0.80% of all liver transplant cases. In addition, 5 patients (8.6%) had retransplant for rejection, which accounted for 0.16% of all liver transplant cases. Four patients with retransplant (6.9%) had recurrence of primary disease, which accounted for 0.12% of all liver transplant cases. Most liver retransplants occurred early (≤ 30 days after primary transplant) at the Shiraz Transplant Center. Five-year survival rate after retransplant was 35%, and retransplant for hepatic artery thrombosis was more common in children. CONCLUSIONS Because most patients required retransplants in the early period after primary transplant, the decision for retransplant must be considered carefully with full multidisciplinary evaluation and only in skilled hands. Retransplant in subgroups of patients with little chance of a successful outcome should be avoided.

Background: Liver transplantation has improved patients' survival rates and quality of life (QoL). This study investigated the effect of liver transplantation and model for end-stage liver disease (MELD) score on patients' QoL at Shiraz Organ Transplantation Center. Materials and Methods: This perspective longitudinal study was conducted among 40 liver transplant candidates at Shiraz Organ Transplant Center. Inclusion criteria were patients who were 12 years or older, able to answer the questions and willingness to participate. If they had received multi-organ transplant and had mental or physical disabilities, we excluded them from the study. They were interviewed by the same researcher in the transplant clinic before transplantation, 1 and 6 months after transplantation. The participants completed the data collection form and Short Form-36 questionnaire via face-to-face interview. The data collecting form consist of demographic and medical information. Medical information was collected from Shiraz Organ Transplant Center. Results: Mean age of participants was 41.18 ± 14. By comparing QoL dimensions, a significant difference was found between before and after transplantation (P < 0.001), except in General Health dimension (P = 0.711). There was no statistically significant relationship between MELD score and QoL after liver transplantation (P > 0. 05). Conclusion: Liver transplantation improves patients' quality life with end-stage liver disease. MELD scores do not depict QoL after liver transplantation.

OBJECTIVES Estimation of liver fat among living donor candidates is necessary before living donor liver transplant. This study aimed to investigate the usefulness of the controlled attenuation parameter compared with liver biopsy for pretransplant estimation of hepatic steatosis in living liver donors. MATERIALS AND METHODS In this retrospective study, we included all individuals who underwent transient elastography with controlled attenuation parameter and ultrasonography-guided liver biopsy as a part of donor evaluations before living donor liver transplant. Clinical and laboratory data of living donor candidates were reviewed and collected. RESULTS Of 49 donor candidates included in this study, 21 (42.9%) had different degrees of hepatic macrosteatosis. Of the 21 donor candidates who had hepatic steatosis in liver biopsy, 13 individuals were diagnosed to have steatosis in transient elastography. Of the 28 donor candidates without hepatic steatosis in liver biopsy, 26 individuals showed no steatosis in transient elastography (odds ratio: 21.12; 95% CI, 3.91- 114.08; P < .001). Controlled attenuation parameter was useful in discriminating presence (P = .001) and grade of hepatic steatosis (P = .009) compared with liver biopsy with good sensitivity and specificity. CONCLUSIONS The controlled attenuation parameter is a noninvasive method for detection of hepatic steatosis in living donor candidates and can be used as an adjunct to liver biopsy for screening of living donor candidates before liver transplant.

Background: Hepatitis C is one of the most common causes of end-stage liver disease and liver transplant worldwide. In recent years, with the rapid advances in the treatment of hepatitis C by direct-acting antiviral drugs (DAAs), the clinical course of the disease as well as liver transplantation have had significant improvement. Also, DAAs have completely replaced interferon-based regimens in the treatment and prevention of HCV recurrence after liver transplant. Objectives: This is the first study that aimed to investigate the clinical course of liver transplantation in patients with hepatitis C in Iran. Methods: This retrospective study was conducted on patients with HCV liver transplantation within five years (2012 - 2017) with the age range of 18 to 65 years at Shiraz Organ Transplant Center. All demographic and clinical data were recorded. Pre-transplant viral load, disease recurrence, graft rejection, and mortality rate were the most important indices in this study. Results: Among 55 transplant patients, 49% had received hepatitis C treatment before liver transplantation and interferon-based regimens were more prevalent. Besides, HCV genotype 3, followed by genotype 1, was the most prevalent one. A liver biopsy was performed in patients with elevated liver enzyme levels. The numbers of patients with HCV recurrence at 2, 6, 12, and 24-month intervals were three, two, zero, and two patients, respectively. At these time intervals, eight, eight, one, and three cases of acute graft rejection were found, respectively. Eight patients died with a one-year survival rate of 85%. Sepsis and infectious complications were the most leading causes of death. Conclusions: This study is the first study of liver transplant patients with hepatitis C in Iran. In the five-year study period, rapid development was made in the treatment of HCV patients. It led to the introduction of DAAs, which replaced interferon-based therapies. The results of this study indicated the high success rate of liver transplantation in patients with hepatitis C in Iran. The results of this study could be used to compare the efficacy of DAAs in future research.

Objective We described our experiences on pediatric liver transplantation (LT) from the largest LT center in the world termed the Shiraz Transplant Center. Background After the first successful pediatric LT in 1967, pediatric LT has become the routine treatment for children with liver failure worldwide. Methods Data on a total of 1141 pediatric cases of LT were collected. Specifics on baseline and anthropometric characteristics, clinicopathology, prognosis of recipients of LT, and donor characteristics are reported. Results Mean age of patients was 7.83 ± 5.55 years old. Most common etiologies for LT were biliary atresia (15.9%), progressive familial intrahepatic cholestasis (13.4%), and Wilson's disease (13.3%), respectively.Whole organs, living donor grafts, and split grafts were used in 47.9%, 41%, and 11.1% of patients, respectively. In-hospital complications were seen among 34.7% of patients and the most common complications were infections (26.8%), bleeding (23.4%), and vascular complications (18%).Median (interquartile range) model for end stage liver disease score was 20 (15, 25). Main causes of death among patients were sepsis (35.2%), followed by post-transplantation lymphoproliferative diseases (10.5%), and primary nonfunction of liver (9%).Patient survival showed improvement over the years (1-year survival of 73.1%, 83.4%, and 84.4%, 2-year survival of 65.2%, 77.1%, and 78.7%, 5-year survival of 58.2%, 72%, and 77.8% for 1997-2007, 2007-2013, and 2013-2019, respectively; P Conclusions This is the largest single-center report on pediatric LT in literature which provides valuable experiences in pediatric LT.

Background: We aimed to evaluate the impact of COVID-19 outbreak on pediatric transplant outcomes and determine whether to continue pediatric transplant activity or not, and how policies intended our center has been effective in preventing COVID-19 among organ transplant recipients.Methods: We conducted a single-center, retrospective, cohort study of hospitalized pediatrics after organ transplantation at Shiraz transplant center since March to August 2020. All liver and kidney transplanted children were included the study and their laboratory and clinical related COVID-19 characteristics were followed up till 3 months after transplantation during hospitalization period and then weekly by the transplant committee.Results:Fifty-one patients underwent transplantation including 11 kidney and 40 liver recipients. The mean age of the pediatric cases was 6.72±5.47 years. A total of 11 patients died due to post-transplant complications, while none of the patients presented any sign or symptoms in favor of COVID-19 in the hospital course after transplantation. Six transplants including 2 kidney and 4 liver were canceled when positive PCR tests were detected in their donors before the surgery. In the three months of follow up, two patients presented with symptoms including high grade fever, malaise, rhinorrhea, and GI symptoms. Both patients had two negative PCR, and no radiologic or laboratory results regarding COVID-19 were also detected. One had positive influenza PCR, while the second one had a positive serologic test for EBV; CT, computed tomography Conclusion: transplant programs could continue their activities during the COVID-19 pandemic with specific case selection, accurate screening methods and following protective protocols.

Background Immunosuppressed patients, including individuals with organ transplantation, have been among susceptible groups with regard to COVID-19, on the other hand pediatric patients more commonly undergo a mild clinical course after acquiring COVID-19. To the best of the authors knowledge, to this date very little data exists on COVID-19 in a pediatric patient with liver transplantation. Case presentation We report a three year-old boy who had liver transplantation at 18 months old. He was admitted due to dyspnea with impression of acute respiratory distress syndrome and was then transferred to the intensive care unit. Chest X-ray at admission showed bilateral infiltration. Vancomycin, meropenem, azithromycin, voriconazole and co-trimoxazole were started from the first day of admission. On day 4 of admission, with suspicion of COVID-19, hydroxychloroquine, lopinavir/ritonavir and oseltamivir were added to the antibiotic regimen. PCR was positive for COVID-19. The patient developed multi-organ failure and died on day 6 of admission. Conclusions For pediatric patients with organ transplantations, extreme caution should be taken, to limit and prevent their contact with COVID-19 during the outbreak, as these patients are highly susceptible to severe forms of the disease.

BACKGROUND In this study, we report the epidemiology of COVID-19 among recipients of organ transplantation and evaluate associated factors with death. METHODS We screened 6969 patients who had organ transplantations in our center for COVID-19. Specific data on presentation, clinical course, treatment, and prognosis were acquired. RESULTS We found 85 patients (66 liver, 16 kidney, 2 kidney-pancreas, and 1 liver-kidney recipient) who acquired COVID-19. Most common symptoms included fever (48.2%), cough (41.2%), myalgia (41.2%), and fatigue (40%). Dyspnea developed in 33% of patients. Overall, one-third of patients had an oxygen saturation of below 90% on admission. Patients were hospitalized for a median (interquartile range) of 9 (5, 13.7) days and had a 33.9% intensive care unit admission rate. Overall, 17 patients (20%) died, which included 31.3% of patients with kidney transplantations and 18.2% of patients with liver transplantations. All 4 pediatric patients in our series died. In our univariate analysis among adults, rates of leukopenia (38.4% versus 13.2%; P = 0.04), low albumin levels (53.8% versus 10.2%; P = 0.001), and shorter duration between transplantation and COVID-19 (P = 0.02), were higher among patients who died. In our least absolute shrinkage and selection operator regression model, low albumin levels (OR, 4.48; 95% confidence interval, 1.16-17.27) were associated with higher risk of death. CONCLUSIONS This is the largest single-center report on abdominal transplantations and COVID-19. Liver and kidney transplant recipients have an increased risk of mortality compared with the general population due to COVID-19. More specifically, pediatric patients and those with low albumin levels are at higher risks of death due COVID-19.

Background: Liver transplantation (LT) is the only curative therapy for acute and chronic end-stage liver disease in pediatrics. Nevertheless, bacterial infection post-transplant account for one of the most significant causes of mortality which requires attention, along with appropriate antibacterial treatment. Therefor this study was designed to provide a multifaceted overview of bacterial infections during a one-year experience in the biggest pediatrics LT center in Iran.Methods: In this retrospective cohort study, records from all liver transplant pediatrics in Abu-Ali Sina hospital, Shiraz, Fars, Iran from April 2019 to February 2020 were assessed. Demographic, laboratory, and clinical data were extracted along with the administered therapeutic approach for the patient.Results: an incidence of 67.9% bacterial infection rate was observed, in which more than 64.06% of isolated pathogens were Gram-negative and 35.93% were gram-positive. The most isolated pathogens were E. coli sp. and pseudomonas sp. for gram negative, and enterococci and staph sp. for gram positive. Our study demonstrated that Intra-abdominal Surgical Site Infections (24.24%) was the most common site of infections in post LT pediatrics. According to the results of the sensitivity-resistance pattern of isolated pathogens, 24.39% of isolated gram-negative bacteria were Extensively drug resistant (XDR). Also, 30.43% of gram-positive bacteria were Vancomycin-resistant enterococci (VRE) and 8.69% of them were methicillin-resistant staphylococcus aureus (MRSA). Furthermore, multivariate regression analysis showed that the only risk factor for bacterial infections after LT is the length of stay in the ICU. The mortality rate in our study was 22%, which was significantly higher among the infection group (P = 0.008). Also, it was found that patients receiving colistin had a significantly shorter in length of stay in the ICU and hospital than those who did not receive colistin. There is no any significant difference between piperacillin-tazobactm versus meropenem as empirical treatment regarding clinical outcomes.Conclusion: a high rate of bacterial infection was detected among hospitalized pediatrics in the early period after LT. High antibacterial resistance of bacteria isolated from LT pediatrics is alarming. Furthermore, Replacement of piperacillin-tazobactam instead of carbapenems in empirical treatment should be considered.

Our data about pathogenesis of hepatic steatosis after liver transplantation is scarce. This study aimed to investigate the association between serum adipokines and insulin resistance with hepatic steatosis in liver transplant recipients. We investigated the association between insulin resistance, serum adiponectin, insulin, and leptin with hepatic steatosis in a cohort of liver transplant recipients. Homeostatic model assessment of insulin resistance 2 (HOMA 2-IR) was used for estimation of insulin resistance. Hepatic steatosis was determined using ultrasound and controlled attenuation parameter (CAP). A total of 178 patients were included. 79 patients (44.4%) had hepatic steatosis. Serum adiponectin (OR: 0.912; 95% CI 0.869–0.957; P

Reducing graft thickness is essential to prevent large-for-size graft problems in pediatric living donor liver transplantation (LDLT). However, long-term outcomes of LDLT using reduced-thickness left lateral segment (LLS) grafts are unclear. In 89 patients who underwent LDLT using reduced LLS grafts between 2005 and 2017, short-term and long-term outcomes were compared between a nonanatomically reduced LLS (NAR-LLS) graft group and a reduced-thickness LLS graft group. Estimated blood loss was lower and abdominal skin closure was less needed in the recipient operation in the reduced-thickness LLS graft group. Postoperatively, portal vein (PV) flow was significantly decreased in the NAR-LLS graft group, and there was shorter intensive care unit (ICU) stay and fewer postoperative complications, especially bacteremia, in the reduced-thickness LLS graft group. Graft survival at 1 and 3 years after LDLT using reduced-thickness LLS grafts was 95.2% and 92.4%, respectively, which was significantly better than for NAR-LLS grafts. Multivariate analysis revealed that fulminant liver failure, hepatofugal PV flow before LDLT, and NAR-LLS graft were associated with poor graft survival. In conclusion, LDLT using reduced-thickness LLS grafts is a safe and feasible option with better short- and long-term outcomes in comparison with NAR-LLS grafts.

OBJECTIVES Nonalcoholic fatty liver disease is a rapidly growing disease and is hypothesized to become the most common cause of liver cirrhosis in the near future. This study aimed to investigate trends of nonalcoholic steatohepatitis as an indication for liver transplant in Iranian patients. MATERIALS AND METHODS Liver transplant data from all adult patients (age > 18 y) who had undergone liver transplant between 1993 and 2017 at the Shiraz Organ Transplant Center (Shiraz, Iran) were reviewed. Underlying liver diseases leading to liver transplant were stratified according to year of transplant, and trends of increase or decline were analyzed. Kaplan-Meier curves were used for analysis of posttransplant survival of patients with nonalcoholic steatohepatitis and patients with modified nonalcoholic steatohepatitis. RESULTS We evaluated 3184 liver transplant patients. Of these, 112 patients with biopsy-proven nonalcoholic steatohepatitis underwent liver transplant up to the end of 2017. Mean age of patients was 52.86 ± 9.01 years in those with nonalcoholic steatohepatitis and 51.73 ± 7.91 years in those with modified nonalcoholic steatohepatitis (P > .05).The prevalence of nonalcoholic steatohepatitis as an indication for liver transplant was 0.8% in 2011, 0.36% in 2012, 1.9% in 2013, 4.01% in 2014, 2.89% in 2015, 6.65% in 2016, and 9.97% in 2017. The prevalence of modified nonalcoholic steatohepatitis was 2.4% in 2011, 2.88% in 2012, 2.71% in 2013, 2% in 2014, 2.17% in 2015, 2.13% in 2016, and 2.28% in 2017. We found that nonalcoholic steatohepatitis as a cause of liver transplant increased significantly during recent years (P < .001). CONCLUSIONS Nonalcoholic steatohepatitis is a rapidly growing indication for liver transplant among Iranian patients. Health care providers should consider programs for prevention and early diagnosis of patients with nonalcoholic steatohepatitis for proper treatment.

The use of marginal kidneys or kidneys with pathologic problems (such as renal artery aneurysms in a living or deceased donor) is on the rise due to organ shortages and improvements in surgical techniques. When renal vascular abnormalities are detected during a transplant, it puts the surgeon in a difficult position to decide what to do with the organ. In this study, we report a case of a kidney from a deceased donor who had 2 renal artery saccular aneurysms, which we were able to use for transplant. The recipient was a 61-year-old male patient with diabetic nephropathy and significant comorbidities. Kidney transplant was performed successfully with a good outcome. Recent advancements in surgical techniques have allowed the use of kidneys with renal artery aneurysms for kidney transplant, thus helping to overcome shortages of transplantable organs.

Background The liver transplant recipients are often subjected to excessive therapy by immunosuppressive drugs which produce several complications. Consequently, the minimization or even withdrawal of immunosuppression in selected patients is an attractive alternative. We investigated the frequency and characteristics of these near (or prope from Latin) tolerance in liver transplant recipients in Shiraz Organ Transplant Center. Material and methods We reviewed the medical records of over 3800 adult liver transplant recipients to select a group treated with a low-dose tacrolimus monotherapy (n = 90) between 1994 and 2017 in our transplant center. The patients with the best liver function parameters were selected; then, the clinician arbitrarily decided to withdraw steroids first and then mycophenolate mofetil and maintain each patient on a low dose tacrolimus. We compared the characteristics of prope tolerant recipients on a low-dose tacrolimus with those on standard immunosuppression, namely full-dose tacrolimus plus steroids and mycophenolate mofetil (n = 233). Data were analyzed by t-test, chi-square test using SPSS software version 16. Results Out of over 3800 liver transplant patients, 90 (2.34%) recipients were treated with a minimum dose of tacrolimus monotherapy. These recipients were compared to a selected group of 233 (6.1%) recipients treated with full-dose tacrolimus plus steroids and mycophenolate mofetil. In a prope tolerant group, there were 55 males (61.1%) and 35 females (38.9%) recipients. Mean age at the time of transplant was 39.92 ± (SD = 13.40) years with an average time from the transplantation time to completed weaning from triple immunosuppression to low-dose monotherapy of 41.35 months (SD = 17.27). The most common etiology of liver disease among both groups was viral hepatitis. Conclusion The achievement of prope (almost) immune tolerance was possible only in some liver transplant recipients with a relatively low risk of rejection. Our analysis suggests that there is a difference in the underlying diseases and recipients' age and the number of rejections between the two groups.

AIM To investigate incidence and survival of post-transplant lymphoproliferative disorder (PTLD) patients after liver transplantation. METHODS A cross-sectional survey was conducted among patients who underwent liver transplantation at Shiraz Transplant Center (Shiraz, Iran) between August 2004 and March 2015. Clinical and laboratory data of patients were collected using a data gathering form. RESULTS There were 40 cases of PTLD in the pediatric age group and 13 cases in the adult group. The incidence of PTLD was 6.25% in pediatric patients and 1.18% in adult liver transplant recipients. The post-PTLD survival of patients at 6 mo was 75.1% ± 6%, at 1 year was 68.9% ± 6.5% and at 5 years was 39.2% ± 14.2%. Higher serum tacrolimus level was associated with lower post-PTLD survival in pediatric patients (OR = 1.07, 95%CI: 1.006-1.15, P = 0.032). A serum tacrolimus level over 11.1 ng/mL was predictive of post PTLD survival (sensitivity = 90%, specificity = 52%, area under the curve = 0.738, P = 0.035). CONCLUSION Incidence of PTLD in our liver transplant patients is comparable to other centers. Transplant physicians may consider adjustment of tacrolimus dose to maintain its serum level below this cutoff point.

OBJECTIVES Detection of hepatic steatosis in donors is an important step for selection of a suitable liver allograft in living-donor transplant. This study aimed to investigate the role of hepatic computed tomography volumetry as a noninvasive method for detection of hepatic steatosis in living liver donors. MATERIALS AND METHODS In a cross-sectional study, individuals who had undergone liver biopsy as a pretransplant checkup before living-donor liver transplant were included. The segmental liver volumes were measured by computed tomography scan with intravenous contrast enhancement. RESULTS Our study included 179 individuals. Mean total volume of the liver was 1705.2 ± 256.5 cm3 in those with steatohepatitis and 1419.4 ± 241.2 cm3 in those without steatohepatitis (P < .001). Higher total volume of the liver (odds ratio of 1.005; 95% confidence interval, 1.001-1.010; P = .012) and total liver volume-to-standard liver volume ratio (odds ratio of 1.090; 95% confidence interval, 1.021-1.163; P = .009) were independent predictors of steatohepatitis. A cutoff value of 1531 cm3 for total liver volume was a predictor of presence of steatohepatitis in liver biopsies of donors (sensitivity = 83%; specificity = 71%; area under the curve = 0.809; P < .001). CONCLUSIONS Computed tomography volumetry may be considered as an auxiliary noninvasive method for estimation of hepatic steatosis/steatohepatitis and may be used as a guide to select donor candidates for liver biopsy.

Objectives Survival after liver transplant depends on pretransplant, peritransplant, and posttransplant factors. Identifying effective factors for patient survival after transplant can help transplant centers make better decisions. Materials and methods Our study included 902 adults who received livers from deceased donors from March 2011 to March 2014 at the Shiraz Organ Transplant Center (Shiraz, Iran). In a 3-step feature selection method, effective features of 6-month survival were extracted by (1) F statistics, Pearson chi-square, and likelihood ratio chi-square and by (2) 5 machine-learning techniques. To evaluate the performance of the machine-learning techniques, Cox regression was applied to the data set. Evaluations were based on the area under the receiver operating characteristic curve and sensitivity of models. (3) We also constructed a model using all factors identified in the previous step. Results The model predicted survival based on 26 identified effective factors. In the following order, graft failure, Aspergillus infection, acute renal failure and vascular complications after transplant, as well as graft failure diagnosis interval, previous diabetes mellitus, Model for End-Stage Liver Disease score, donor inotropic support, units of packed cell received, and previous recipient dialysis, were found to be predictive factors in patient survival. The area under the receiver operating characteristic curve and model sensitivity were 0.90 and 0.81, respectively. Conclusions Data mining analyses can help identify effective features of patient survival after liver transplant and build models with equal or higher performance than Cox regression. The order of influential factors identified with the machine-learning model was close to clinical experiments.

Non-alcoholic fatty liver disease (NAFLD) is frequently seen among non-obese overweight individuals and lean subjects (those with normal body mass index). This study aimed to investigate prevalence and risk factors of biopsy proven NAFLD in a cluster of healthy non-obese and lean individuals.In a retrospective study, adult (18 years) apparently healthy individuals who had donated liver to pediatric patients between July 2012 and October 2018 were included. Non-obese and lean individuals were defined as BMI30kg/mTotally 310 patients were included. Seventy-six individuals (24.5%) had NAFL and 30 patients (9.67%) had non-alcoholic steatohepatitis (NASH) among non-obese population. In multivariate regression analysis, only higher BMI was marginally associated with NASH in non-obese compared to those without NASH (Odds ratio: 2.52, 95% CI: 0.097-6.54; P=0.05). Totally, 246 individuals were lean. 55 individuals (22.3%) had NAFL and 20 individuals (8.2%) had NASH in their liver biopsies. In univariate analysis, serum triglyceride, cholesterol, LDL, ALT, alkaline phosphatase and uric acid were associated with NAFL among lean individuals (P0.05). In regression analysis, serum uric acid was associated with NAFL (Odds ratio: 1.70, 95% CI: 1.18-2.45; P=0.004) and NASH in lean individuals (Odds ratio: 1.98, 95% CI: 1.27-3.10; P=0.003).NAFLD/NASH is prevalent even in a healthy lean population when evaluated by liver biopsy. Higher BMI and serum uric acid were two major risks of NAFLD/NASH in non-obese and lean individuals.

One of the X chromosome-linked disorders is ornithine transcarbamylase deficiency in the urea cycle. This disorder results in increased ammonia and glutamine in the blood. Accumulation of these metabolites without treatment causes brain edema, which often progresses to coma and death. This study describes a 5-year-old girl with ornithine transcarbamylase deficiency who presented with hyperammonemic encephalopathy that was successfully treated with an orthotropic liver transplant. Recently, liver transplant has been introduced as an alternative treatment for patients with ornithine transcarbamylase deficiency.

FH is a genetic disorder characterized by an increase in serum LDL and total cholesterol values. The afflicted patients are at increased risk of premature atherosclerosis and myocardial infarction. Different treatment modalities are present, including pharmacological agents and surgical procedures. The most effective method of therapy in refractive cases is liver transplantation. Herein, we report our experience on 36 cases of patients with FH undergoing liver transplantation in our center, the main referral center of liver transplantation in Iran. The clinical findings, hospital courses, post-operative complications, and patient follow-up are also described.

Background: Hepatocellular carcinoma is a rare tumor in children, thus, there are not many studies regarding clinicopathologic findings of this tumor and no report regarding this tumor in this age group from Iran. Objectives: In this study, we tried to find out the clinicopathologic findings including outcome of hepatocellular carcinoma in the patients under the age of 18. Methods: During the last 10 years (2005 - 2016), we collected all hepatocellular carcinoma cases in the affiliated hospitals of Shiraz University of Medical Sciences (as the largest referral center in the South of Iran and the only center of pediatric liver transplantation in the whole country) from the archives of Pathology department. Next all clinical data were subsequently extracted from the patients’ hospital charts. Results: We collected 30 cases of hepatocellular carcinoma with the age range of 9 months to 18 years with no significant sex preference. All of the patients, except 3, showed abnormal levels of AFP. The most common underlying cause of liver tumorigenesis was type I tyrosinemia. Conclusions: Hepatocellular carcinoma in children is a rare tumor and is mostly secondary to an underlying liver disease, which is tyrosinemia in our center. Hepatitis B related hepatocellular carcinoma is rare in our country, which seems to be related to successful early neonatal vaccination against this viral disease. This tumor has a poor outcome in children and without liver transplantation, has a very short survival rate.

Introduction: Although patient and graft survival rate has increased in recent years, biliary complications after liver transplantation are associated with significant morbidity and mortality. Methods and Materials: We reviewed the database of 1930 patients who underwent deceased donor liver transplantation between 2000 and 2013. The patients had abnormal results in liver tests, as well as fever and jaundice. Abdominal sonography was performed, and if complication was identified, the patient underwent an interventional procedure by endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. If the complication was not resolved by the mentioned procedures, exploration of common bile duct and Roux-en-Y choledochojejunostomy or revision of Roux-en-Y choledochojejunostomy was done. Results: Our study group comprised 105 patients including 66 (63%) men and 39 (37.1%) women with a mean age of 36.7 ± 12.5 years (range: 15-66 years). Among 1930 patients, 105 (5.4%) cases presented with biliary complication after liver transplantation, of which 97 (5%) and 8 (0.4%) cases presented with biliary stricture and bile leak/biloma, respectively. Conclusion: In our study, most patients with biliary complications after liver transplantation responded to interventional procedures, with 37.1% requiring surgical exploration.

In some cases of liver transplant, standard hepatic artery reconstruction may be difficult or impossible due to inadequate flow of the recipient's hepatic artery, as a result of stenosis, intimal dissection, or anomalies of the hepatic artery. We compared splenic artery transposition with extra-anatomic jump graft as 2 alternative methods for hepatic artery reconstruction in these situations.We reviewed the files of 2135 liver transplant recipients from March 2011 to February 2016 at the Shiraz Transplant Center. Data of 93 patients with unusual hepatic artery reconstruction were analyzed to assess outcomes, morbidity, mortality, and pre- and posttransplant parameters (both clinical and paraclinical). Patients were divided into 2 groups: 17 with splenic artery transposition (splenic artery group) and 76 with extra-anatomic jump grafts (control group).There was only 1 occurrence (5.8%) of hepatic artery thrombosis in the splenic artery group causing extra-anatomic jump graft. However, in the control group, there were 4 occurrences (5.2%) of hepatic artery thrombosis, causing 1 revision of anastomosis and 3 retransplant procedures. No deaths due to hepatic artery complications were reported in the 2 groups. Three-year survival rate was 87.5% in the splenic artery group and 68.9% in the control group.Splenic artery transposition is an acceptable method for hepatic artery reconstruction in deceased-donor liver transplant procedures with no greater rates of complication or morbidity than extra-anatomic jump grafts. Less operation time and better exposure during surgery are advantages of this method.