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Living donor liver transplantation for fulminant hepatic failure
Living Donor Liver Transplantation for Fulminant Hepatic Failure Y. Sugawara, J. Kaneko, H. Imamura, M. Minagawa, N. Kokudo, and M. Makuuchi
L
IVING DONOR LIVER transplantation (LDLT) is now widely performed for chronic end-stage liver disease. LDLT for fulminant hepatic failure (FHF)1 is aggressively performed in areas where transplantation from brain-dead donors is rare. This report concerns a single center’s experience with 11 FHF cases.
MATERIALS AND METHODS Between January 1996 and May 2002, 172 patients underwent 174 living related liver transplantation (LRLT) procedures, including two retransplants, at the University of Tokyo. Of these 172 patients, nine adults and two children had indications of FHF. The patients’ families gave informed consent for all treatment modalities. The study was approved by the Ethics Committee of the University of Tokyo. FHF was defined as acute hepatocellular necrosis complicated by the development of hepatic encephalopathy within 8 weeks of the onset of jaundice. Encephalopathy was graded from 1 to 4 in accordance with the Bernuau criteria.2 The patients ranged from 8 to 64 years of age and there were six males and five females. Causes of FHF were non-A, non-B hepatitis in six patients, hepatitis B in three, Wilson’s disease in one, and autoimmune hepatitis in one. The encephalopathy grade2 was I in two patients, II in three, III in four, and IV in two. The duration between the onset and development of encephalopathy ranged from 6 to 35 days. The donors consisted of four children, four siblings, two parents, and one spouse. Donor hepatectomy and the recipient’s operation were performed as described previously.3,4 The basic immunosuppression regimen consisted of tacrolimus and steroids as described previously.5
RESULTS Donors
The most common procedure was right liver resection (n ⫽ 4), followed by left liver with (n ⫽ 3) or without (n ⫽ 3) caudate lobe resection and right lateral sectorectomy (n ⫽ 1). The average blood loss was 593 ⫾ 377 g. No blood transfusion was performed. On average, the operation lasted 511 ⫾ 90 minutes. One donor had bile juice leakage from the dissection plane of the liver and underwent reoperation for drainage 7 days after the initial operation. The postoperative course of the other donors was uneventful. The average hospital stay was 15 ⫾ 2 days. All of the donors returned to their normal daily lives.
Recipients
The average graft weight was 484 ⫾ 100 g, which corresponded to 45 ⫾ 8% of the recipients’ standard liver volume. On average, the operation lasted 814 ⫾ 124 minutes. Blood loss was 5925 ⫾ 1820 g, corresponding to 65 ⫾ 40 g per kg of body weight. Two patients experienced acute rejection, which was successfully treated with steroid pulse therapy. In another patient, the graft function deteriorated for unknown reasons, and the patient was retransplanted 46 days after the operation. None of the patients experienced vascular or biliary complications. The postoperative hospital stay among the patients was 58 ⫾ 27 days. All of the patients survived the operation and are now doing well, with an average follow-up period of 22 months. DISCUSSION
All the patients in our series survived the LDLT. The favorable results are consistent with a previous report. The Shinshu group in Japan reported the first successful case.6 They performed LDLT for FHF in 14 patients until 1999 with 93% patient survival.7 The Hong Kong group8 reported that a 22-year-old man received a small graft corresponding to 25% of his standard liver volume and survived LDLT. They also described 14 of 16 patients who received right liver graft and survived the operation.9 LDLT is still not a common treatment for FHF in Japan, and the number of patients with FHF who underwent LDLT is quite limited.8 The possible bias at referral cannot be ruled out. The satisfactory results, however, indicate LDLT as a treatment option for FHF. ACKNOWLEDGMENT This work was supported by a grant-in-aid for scientific research from the Ministry of Education, Culture, Sports, Science and Technology of Japan, Public Trust Fund for the Promotion of Surgery, Welfide Medical Research Foundation, Mitsui Life Social From the Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan. Address reprint requests to Y. Sugawara, MD, Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Japan. E-mail: [email protected]
© 2002 by Elsevier Science Inc. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/02/$–see front matter PII S0041-1345(02)03609-6
Transplantation Proceedings, 34, 3287–3288 (2002)
3287
3288 Welfare Foundation, and a grant-in-aid for research on human genome, tissue engineering, food biotechnology, health sciences research grants, Ministry of Health, Labor and Welfare of Japan.
REFERENCES 1. Marcos A, Ham JM, Fisher RA, et al: Transplantation 69:2202, 2000 2. Bernuau J, Rueff B, Benhamou JP: Semin Liver Dis 6:97, 1986 3. Sugawara Y, Makuuchi M: J Hepatobiliary Pancreat Surg 6:245, 1999
SUGAWARA, KANEKO, IMAMURA ET AL 4. Sugawara Y, Makuuchi M, Takayama T, et al: Liver Transpl 8:58, 2002 5. Sugawara Y, Makuuchi M, Kaneko J, et al: Clin Transplant 16:102, 2002 6. Matsunami H, Makuuchi M, Kawasaki S, et al: Lancet 340:1411, 1992 7. Miwa S, Hashikura Y, Mita A, et al: Hepatology 30:1521, 1999 8. Lo CM, Fan ST, Chan JK, et al: Transplantation 62:696, 1996 9. Liu CL, Fan ST, Lo CM, et al: Br J Surg 89:317, 2002
L
IVING DONOR LIVER transplantation (LDLT) is now widely performed for chronic end-stage liver disease. LDLT for fulminant hepatic failure (FHF)1 is aggressively performed in areas where transplantation from brain-dead donors is rare. This report concerns a single center’s experience with 11 FHF cases.
MATERIALS AND METHODS Between January 1996 and May 2002, 172 patients underwent 174 living related liver transplantation (LRLT) procedures, including two retransplants, at the University of Tokyo. Of these 172 patients, nine adults and two children had indications of FHF. The patients’ families gave informed consent for all treatment modalities. The study was approved by the Ethics Committee of the University of Tokyo. FHF was defined as acute hepatocellular necrosis complicated by the development of hepatic encephalopathy within 8 weeks of the onset of jaundice. Encephalopathy was graded from 1 to 4 in accordance with the Bernuau criteria.2 The patients ranged from 8 to 64 years of age and there were six males and five females. Causes of FHF were non-A, non-B hepatitis in six patients, hepatitis B in three, Wilson’s disease in one, and autoimmune hepatitis in one. The encephalopathy grade2 was I in two patients, II in three, III in four, and IV in two. The duration between the onset and development of encephalopathy ranged from 6 to 35 days. The donors consisted of four children, four siblings, two parents, and one spouse. Donor hepatectomy and the recipient’s operation were performed as described previously.3,4 The basic immunosuppression regimen consisted of tacrolimus and steroids as described previously.5
RESULTS Donors
The most common procedure was right liver resection (n ⫽ 4), followed by left liver with (n ⫽ 3) or without (n ⫽ 3) caudate lobe resection and right lateral sectorectomy (n ⫽ 1). The average blood loss was 593 ⫾ 377 g. No blood transfusion was performed. On average, the operation lasted 511 ⫾ 90 minutes. One donor had bile juice leakage from the dissection plane of the liver and underwent reoperation for drainage 7 days after the initial operation. The postoperative course of the other donors was uneventful. The average hospital stay was 15 ⫾ 2 days. All of the donors returned to their normal daily lives.
Recipients
The average graft weight was 484 ⫾ 100 g, which corresponded to 45 ⫾ 8% of the recipients’ standard liver volume. On average, the operation lasted 814 ⫾ 124 minutes. Blood loss was 5925 ⫾ 1820 g, corresponding to 65 ⫾ 40 g per kg of body weight. Two patients experienced acute rejection, which was successfully treated with steroid pulse therapy. In another patient, the graft function deteriorated for unknown reasons, and the patient was retransplanted 46 days after the operation. None of the patients experienced vascular or biliary complications. The postoperative hospital stay among the patients was 58 ⫾ 27 days. All of the patients survived the operation and are now doing well, with an average follow-up period of 22 months. DISCUSSION
All the patients in our series survived the LDLT. The favorable results are consistent with a previous report. The Shinshu group in Japan reported the first successful case.6 They performed LDLT for FHF in 14 patients until 1999 with 93% patient survival.7 The Hong Kong group8 reported that a 22-year-old man received a small graft corresponding to 25% of his standard liver volume and survived LDLT. They also described 14 of 16 patients who received right liver graft and survived the operation.9 LDLT is still not a common treatment for FHF in Japan, and the number of patients with FHF who underwent LDLT is quite limited.8 The possible bias at referral cannot be ruled out. The satisfactory results, however, indicate LDLT as a treatment option for FHF. ACKNOWLEDGMENT This work was supported by a grant-in-aid for scientific research from the Ministry of Education, Culture, Sports, Science and Technology of Japan, Public Trust Fund for the Promotion of Surgery, Welfide Medical Research Foundation, Mitsui Life Social From the Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan. Address reprint requests to Y. Sugawara, MD, Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Japan. E-mail: [email protected]
© 2002 by Elsevier Science Inc. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/02/$–see front matter PII S0041-1345(02)03609-6
Transplantation Proceedings, 34, 3287–3288 (2002)
3287
3288 Welfare Foundation, and a grant-in-aid for research on human genome, tissue engineering, food biotechnology, health sciences research grants, Ministry of Health, Labor and Welfare of Japan.
REFERENCES 1. Marcos A, Ham JM, Fisher RA, et al: Transplantation 69:2202, 2000 2. Bernuau J, Rueff B, Benhamou JP: Semin Liver Dis 6:97, 1986 3. Sugawara Y, Makuuchi M: J Hepatobiliary Pancreat Surg 6:245, 1999
SUGAWARA, KANEKO, IMAMURA ET AL 4. Sugawara Y, Makuuchi M, Takayama T, et al: Liver Transpl 8:58, 2002 5. Sugawara Y, Makuuchi M, Kaneko J, et al: Clin Transplant 16:102, 2002 6. Matsunami H, Makuuchi M, Kawasaki S, et al: Lancet 340:1411, 1992 7. Miwa S, Hashikura Y, Mita A, et al: Hepatology 30:1521, 1999 8. Lo CM, Fan ST, Chan JK, et al: Transplantation 62:696, 1996 9. Liu CL, Fan ST, Lo CM, et al: Br J Surg 89:317, 2002