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Four-year experience with liver transplantation in Saudi Arabia
Four-Year Experience With Liver Transplantation in Saudi Arabia M. Al Sebayel, C. Ramirez, A.T. Kizilisik, G. Geldhof, T.J. Bhatti, and A. Abdullah
T
HE INITIAL experience with liver transplantation in developing countries such as Saudi Arabia has been encouraging, as reported previously.1 We summarize the progress of the liver transplant program at King Fahad National Guard Hospital in Riyadh, Saudi Arabia, with particular emphasis placed on the difficulties and limitations which continue to face the program 4 years after its inception. RESULTS
The liver transplant program at the King Fahad National Guard Hospital in Riyadh, Saudi Arabia, was launched in January 1994. Up to November 1997, a total of 84 procedures have been performed on 77 patients. Table 1 shows the demographics of transplanted patients. Table 2 shows the indications for transplantation in our population. Hepatitis C virus (HCV) infection continues to be the leading cause of liver disease. We continue to use the standard surgical technique with utilization of venovenous bypass in more than 80% of the cases.2 The piggyback technique was used in nine cases and biliary anastomosis was performed with either Roux-en-Y or duct-to-duct anastomosis. The T-tube has not been utilized in the last 2.5 years of the program. Immunosuppression was standardized to FK 506, steroids being discontinued 3 months following transplant. Of the 16 patients who died, 2 died after the first year. Table 3 details the causes of death in these patients. Table 4 outlines the technical complications in 84 transplant procedures. We continue to have a low rejection rate of 31%. All the cases responded to steroids without resorting to monoclonal antibody treatment. The leading cause of death was infectious complications. Primary nonfunction occurred in Table 1. Age and Sex of 77 Patients Transplanted at King Fahad National Guard Hospital Riyadh, Saudi Arabia Age
Male
Female
Total
0 –10 11–20 21–30 31– 40 41–50 51– 60 .61 Total
3 5 1 8 12 17 10 56
— 4 2 2 7 6
3 9 3 10 19 23 10 77
21
Table 2. Indications for Liver Transplantation in 77 Patients Indications
No. (%)
HCV cirrhosis HCV 1 HCC HBV cirrhosis Primary sclerosing cholangitis* Autoimmune hepatitis Primary biliary cirrhosis Wilson’s disease Familial cholestasis Hemochromatosis 1 HCC Schistosomiasis Alcoholic cirrhosis Cryptogenic cirrhosis† Total
39 (50.6) 10 (13) 3 (3.9) 4 (5.2) 3 (3.9) 2 (2.6) 5 (6.5) 5 (6.5) 1 (1.3) 2 (2.6) 1 (1.3) 2 (2.6) 77 (100)
Abbreviations: HCC, hepatocellular carcinoma. *One with incidental cholangiocarcinoma. † One with HCC.
one patient only. However, severe dysfunction with an alanine transaminase level (ALT) of greater than 3000 occurred in 27% of the patients. DISCUSSION
Since our initial report showing the results of liver transplantation, the program continues to have a 1-year survival rate above 75%.1 However, the annual number of transplants has not increased over the past 4 years, mainly due to the continuing problem of organ shortage. The main indication for transplantation continues to be HCV-related liver disease. Like others,3 we found a high recurrence rate of 85% in our recipients of whom only two patients lost their grafts. The problem with donors in the Kingdom of Saudi Arabia is not only the organ shortage but also the marginal quality in the organs offered. This is related to poor donor management in the intensive care units (ICUs) of peripheral hospitals as well as to the logistical difficulty in obtainFrom the Department of Hepatobiliary Sciences, King Fahad National Guard Hospital, Riyadh, Kingdom of Saudi Arabia. Supported by Hikma Pharmaceutical Company. Address reprint requests to Dr M. Al Sebayel, Chairman, Department of Hepatobiliary Sciences, King Fahad National Guard Hospital, PO Box 22490, Riyadh 11426, Kingdom of Saudi Arabia.
© 1998 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
0041-1345/98/$19.00 PII S0041-1345(98)01012-4
Transplantation Proceedings, 30, 3245–3246 (1998)
3245
3246
AL SEBAYEL, RAMIREZ, KIZILISIK ET AL Table 3. Causes of Death in 16 Patients Primary Causes of Death
No. of Patients
Sepsis Vascular complications Primary non function Intraoperative hemorrhage Hemorrhage following liver biopsy Myocardial infarction Pulmonary hypertension Mediastinitis Chronic rejection CVA
5 3 1 1 1 1 1 1 1 1
ing consent. These problems lead to a prolonged ICU stay and attendant deterioration in the graft quality.
Table 4. Technical Complications in 84 Liver Transplant Procedures Complications
No. (%)
Vascular complications HAT (5) HAT 1 PVT (1) HAS (2) PVT (2) SVCS (2) Biliary leak Intestinal perforation Total
12 (14.3)
2 (2.4) 1 (1.2) 15 (17.9)
Abbreviations: HAT, hepatic artery thrombosis; PVT, portal venous thrombosis; HAS, hepatic artery stenosis; SVCS, suprahepatic vena caval stenosis.
culties will continue to be a major obstacle to the progress of the transplant program.
CONCLUSION
The liver transplant program at King Fahad National Guard Hospital in Riyadh, Saudi Arabia, has been successful over the past 4 years. Seventy-seven patients have been transplanted with a success rate well above 75%. The difficulty facing the program remains the shortage of organs and the quality of the organs retrieved. Unfortunately, since our report 2 years ago, there has been no improvement in these two areas. A more concentrated and aggressive approach must be employed by agencies involved in the transplant service in the Kingdom. Otherwise, these diffi-
ACKNOWLEDGMENTS We express our appreciation to Ms Carol Wiebe for her expert assistance in the preparation of this manuscript.
REFERENCES 1. Al Sebayel M, Kizilisik AT, Ramirez CB, et al: Transplant Proc 29:2870, 1997 2. Shaw BWJ, Martin DJ, Marquez JM, et al: Ann Surg 200:524, 1994 3. Gane EJ, Portmann BC, Naumov NV, et al: N Engl J Med 334:815, 1996
T
HE INITIAL experience with liver transplantation in developing countries such as Saudi Arabia has been encouraging, as reported previously.1 We summarize the progress of the liver transplant program at King Fahad National Guard Hospital in Riyadh, Saudi Arabia, with particular emphasis placed on the difficulties and limitations which continue to face the program 4 years after its inception. RESULTS
The liver transplant program at the King Fahad National Guard Hospital in Riyadh, Saudi Arabia, was launched in January 1994. Up to November 1997, a total of 84 procedures have been performed on 77 patients. Table 1 shows the demographics of transplanted patients. Table 2 shows the indications for transplantation in our population. Hepatitis C virus (HCV) infection continues to be the leading cause of liver disease. We continue to use the standard surgical technique with utilization of venovenous bypass in more than 80% of the cases.2 The piggyback technique was used in nine cases and biliary anastomosis was performed with either Roux-en-Y or duct-to-duct anastomosis. The T-tube has not been utilized in the last 2.5 years of the program. Immunosuppression was standardized to FK 506, steroids being discontinued 3 months following transplant. Of the 16 patients who died, 2 died after the first year. Table 3 details the causes of death in these patients. Table 4 outlines the technical complications in 84 transplant procedures. We continue to have a low rejection rate of 31%. All the cases responded to steroids without resorting to monoclonal antibody treatment. The leading cause of death was infectious complications. Primary nonfunction occurred in Table 1. Age and Sex of 77 Patients Transplanted at King Fahad National Guard Hospital Riyadh, Saudi Arabia Age
Male
Female
Total
0 –10 11–20 21–30 31– 40 41–50 51– 60 .61 Total
3 5 1 8 12 17 10 56
— 4 2 2 7 6
3 9 3 10 19 23 10 77
21
Table 2. Indications for Liver Transplantation in 77 Patients Indications
No. (%)
HCV cirrhosis HCV 1 HCC HBV cirrhosis Primary sclerosing cholangitis* Autoimmune hepatitis Primary biliary cirrhosis Wilson’s disease Familial cholestasis Hemochromatosis 1 HCC Schistosomiasis Alcoholic cirrhosis Cryptogenic cirrhosis† Total
39 (50.6) 10 (13) 3 (3.9) 4 (5.2) 3 (3.9) 2 (2.6) 5 (6.5) 5 (6.5) 1 (1.3) 2 (2.6) 1 (1.3) 2 (2.6) 77 (100)
Abbreviations: HCC, hepatocellular carcinoma. *One with incidental cholangiocarcinoma. † One with HCC.
one patient only. However, severe dysfunction with an alanine transaminase level (ALT) of greater than 3000 occurred in 27% of the patients. DISCUSSION
Since our initial report showing the results of liver transplantation, the program continues to have a 1-year survival rate above 75%.1 However, the annual number of transplants has not increased over the past 4 years, mainly due to the continuing problem of organ shortage. The main indication for transplantation continues to be HCV-related liver disease. Like others,3 we found a high recurrence rate of 85% in our recipients of whom only two patients lost their grafts. The problem with donors in the Kingdom of Saudi Arabia is not only the organ shortage but also the marginal quality in the organs offered. This is related to poor donor management in the intensive care units (ICUs) of peripheral hospitals as well as to the logistical difficulty in obtainFrom the Department of Hepatobiliary Sciences, King Fahad National Guard Hospital, Riyadh, Kingdom of Saudi Arabia. Supported by Hikma Pharmaceutical Company. Address reprint requests to Dr M. Al Sebayel, Chairman, Department of Hepatobiliary Sciences, King Fahad National Guard Hospital, PO Box 22490, Riyadh 11426, Kingdom of Saudi Arabia.
© 1998 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
0041-1345/98/$19.00 PII S0041-1345(98)01012-4
Transplantation Proceedings, 30, 3245–3246 (1998)
3245
3246
AL SEBAYEL, RAMIREZ, KIZILISIK ET AL Table 3. Causes of Death in 16 Patients Primary Causes of Death
No. of Patients
Sepsis Vascular complications Primary non function Intraoperative hemorrhage Hemorrhage following liver biopsy Myocardial infarction Pulmonary hypertension Mediastinitis Chronic rejection CVA
5 3 1 1 1 1 1 1 1 1
ing consent. These problems lead to a prolonged ICU stay and attendant deterioration in the graft quality.
Table 4. Technical Complications in 84 Liver Transplant Procedures Complications
No. (%)
Vascular complications HAT (5) HAT 1 PVT (1) HAS (2) PVT (2) SVCS (2) Biliary leak Intestinal perforation Total
12 (14.3)
2 (2.4) 1 (1.2) 15 (17.9)
Abbreviations: HAT, hepatic artery thrombosis; PVT, portal venous thrombosis; HAS, hepatic artery stenosis; SVCS, suprahepatic vena caval stenosis.
culties will continue to be a major obstacle to the progress of the transplant program.
CONCLUSION
The liver transplant program at King Fahad National Guard Hospital in Riyadh, Saudi Arabia, has been successful over the past 4 years. Seventy-seven patients have been transplanted with a success rate well above 75%. The difficulty facing the program remains the shortage of organs and the quality of the organs retrieved. Unfortunately, since our report 2 years ago, there has been no improvement in these two areas. A more concentrated and aggressive approach must be employed by agencies involved in the transplant service in the Kingdom. Otherwise, these diffi-
ACKNOWLEDGMENTS We express our appreciation to Ms Carol Wiebe for her expert assistance in the preparation of this manuscript.
REFERENCES 1. Al Sebayel M, Kizilisik AT, Ramirez CB, et al: Transplant Proc 29:2870, 1997 2. Shaw BWJ, Martin DJ, Marquez JM, et al: Ann Surg 200:524, 1994 3. Gane EJ, Portmann BC, Naumov NV, et al: N Engl J Med 334:815, 1996