Objective To investigate the short-term acute rejection incidence of the recipients under the steroid-free immunosuppressive therapy after liver transplantation. Methods This retrospective study included 186 patients who were divided into two groups by random number table.The patients in no steroid group (the study group, n =94) received tacrolimus (Tac) with mycophemolate mofetil (MMF) or cyclosporine with MMF,and those in the steroid group (the control group,n =92) received the aforementioned immunosuppressive therapy combined with steroids.The acute rejection incidence was analyzed during six months post-transplantation.Results There was no significant difference in the gender,age,indication for transplantation,Child-Pugh score,MELD score,operating time,bleeding and transfusion volume during the operation,warm ischemia time and cold ischemia time between the two groups (P＞0.05).Liver biopsy was done on 9 cases of each group.The acute rejection incidence had no significant difference between the study group and the control group (5/94 vs 4/92,5.3％ vs 4.4％,P＞0.05).Conclusion The steroid-free immunosuppressive therapy after liver transplantation did not increase the short term acute rejection incidence.

Objective To evaluate liver biopsy for the diagnosis in liver transplant patients with suspected acute rejection. Methods From Oct. 2004 to Apr. 2005, liver biopsies were performed 53 times in 39 transplant cases. Results Based on Banff schema for grading liver allograft rejection, laboratory abnormalities and result of treatment, acute rejection was diagnosed on 16 episodes, preservation injury in 12, bile duct strictures in 9, drug-induced injury in 11, chronic rejection in 3 and acute hepatic failure in 2. Conclusions Hepatocyte ballooning with necrosis features preservation injury. Drug-induced injury commonly has a combination of hepatocyte denaturalization with mild portal inflammation. Histologic features of early bile duct strictures in liver biopsy show prominent bile ductular proliferation and the canalicular cholestasis with mild hepatocyte damage which help to exclude acute rejection.

Objective To characterize the clinical course of biliary complications after right lobe living donor liver transplantation (RL-LDLT) and to identify the independent risk factors for biliary strictures.Methods 105 consecutive RL-LDLT recipients operated from April 2007 to April 2010 were followed up. The clinical and operative data were reviewed. The biliary complications and independent risk factors of biliary stricture were studied.Results The median follow-up duration was 49.5 months ranging from 562 to 1675 days.A total of 40 patients (38.1 ％) experienced 11 bile leak episodes (10.4％ ) and 37 (35.2％) biliary stricture episodes after transplantation.Bile leaks occurred at a median time of 9 days ranging from 4 to 54 days after transplantation.For biliary strictures,the occurring time was delayed and scattered wide with a median of 7.6 months ranging from 12 to 790 days after transplantation. Moreover, the biliary stricture incidence in the first year after transplantation was significantly higher than later.The independent risk factors for biliary strictures were CMV infection,bile leaks and bile duct size (≤3 mm).Conclusion The independent risk factors for biliary strictures after RL-LDLT were CMV infection,bile leaks and bile duct size (≤3mm).In order to avoid biliary complications,careful preoperative evaluations are necessary. The dissection of bile ducts should be meticulous to protect its blood supply.CMV infection should be prevented after transplantation.Close surveillance of biliary complications should be given to RL-LDLT recipients during the first year after transplantation.

Objective:To explore the clinicopathological characteristics, treatments and outcomes of posttransplant lymphoproliferative disorder(PTLD)in pediatric liver transplant recipients.Methods:From October 2016 to October 2021, retrospective data analysis was performed for 11 pediatric liver transplant recipients with PTLD. There were 5 males and 6 females with a diagnostic age of 1-8 years. Living donor liver transplantation(LDLT, n=9)and deceased donor liver transplantation(DDLT, n=2)were performed. All recipients received tacrolimus plus methylprednisolone. The major clinical manifestations included lymphadenopathy, splenomegaly, anemia, fever and digestive system symptoms(diarrhea, abdominal pain, ascites, hematochezia & intussusception, etc.). Laboratory tests hinted at hypoproteinemia, elevated transaminases and serum positivity of EBV-DNA. Positron emission tomography and computed tomography(PET-CT)revealed PTLD( n=9). Ten children were diagnosed by pathology, including lymphoid hyperplasia( n=3), plasmacytic hyperplasia PTLD( n=1), polymorphic PTLD( n=2), diffuse large B-cell lymphoma( n=2), infectious mononucleosis PTLD( n=1)and Burkitt lymphoma( n=1). Results:After a definite diagnosis of PTLD, tacrolimus was tapered or discontinued. And rituximab was prescribed. Two patients received chemotherapy(R-COP & R-CHOP)while 2 cases of local masses were operated. Up until February 2022, 10 cases survived and their conditions improved. One patient died of infection.Conclusions:PTLD is one of the most serious and fatal complications after liver transplantation in children. Clinical manifestations are diverse and an early diagnosis is difficult. The changes of EBV-DNA load should be closely monitored after liver transplantation. Imaging and pathological examinations may aid in an early diagnosis of PTLD. A treatment regimen based on immunosuppression reduction and rituximab improves the prognosis of PTLD in pediatric liver transplant recipients.

Inherited metabolic liver disease (IMLD) is a category of liver metabolic diseases caused by genetic disorders. The pathogenesis of IMLD is complex, which primarily comprises the accumulation of harmful metabolic substrates or products caused by specific enzyme defects and energy defects or abnormal deposition caused by abnormal metabolism of glucose, fat and other substances. In recent years, liver transplantation has played an increasingly critical role in the treatment of IMLD with the development of liver transplantation. At present, IMLD has become the second most important indication after biliary atresia in pediatric liver transplantation. Currently, IMLD patients receiving liver transplantation can be divided into two categories: the first category is IMLD complicated with liver disease; Category 2 patients have a normal liver structure but are deficient in related metabolic enzymes. It can not only replace the liver with abnormal structure and function, but also provide normal enzymes required for patients' metabolism, which may improve their quality of life and even save their lives. In this article, common feasible liver transplantation for IMLD, clinical prognosis and surgical procedures of liver transplantation for IMLD were reviewed, aiming to provide reference for liver transplantation for IMLD.

ObjectiveTo surnmarize the experience of tacrolimus or cyclosporine A-based immunosuppression after pediatric living-donor liver transplamation.Methods The clinical data of 30 children undergoing living-donor liver trarsplantation from October 2006 to January 2010 were analyzed retrospectively.In 30 patients,7 were given Tac-based immunosuppression (group A),10 given CsA-based immunosuppression (group B),and 13 switched from CsA to Tac for complications or adverse effects of drugs.Dosages and blood concentrations of immunosuppressants were recorded.Changes of liver and kidney functions were monitored.Incidence of rejection,infection and adverse effects of drugs were observed.ResultsIn the premise of the stable concentration and liver and kidney functions,the weight of children was increased by about 50％ and the per- kilogram dosage of CNIs was decreased significantly 1year postoperatively.There was no case of rejection in group A and 4 cases of rejection in group B(40％,4/10),and the original symptoms were gradually alleviated after the increased dosage in immunosuppressants.During the first 3 months,there was 1case of abdominal infection in group A (1/7) and 3 cases of lung infection in group B (3/10),and the original symptoms were gradually alleviated after anti-infective therapy.There was 1CMV lgM-positive case in group A (1/7) and 2 CMV IgM-positive cases in group B (2/10),and the original symptoms were gradually alleviated after using ganciclovir.The original symptoms of the 13 children switched from CsA to Tac were gradually alleviated.ConclusionThe two CNIs can be safely used in children undergoing pediatric livlng-donor liver transplantation.Both of them show the same effect in promoting the restoration of liver and kidney functions,but tacrolimus has more satisfactory effect in inhibiting the rejection and it has leas adverse effects.

Objective To observe the outcomes of living donor liver transplantation (LDLT) for children with biliary atresia (BA) and to summarize the clinical experiences. Methods Forty-four BA patients (26 boys and 18 girls) underwent LDLT between October 2006 and December 2010. Mean (SD) and median (range) age at operation was (12.1 ± 9.0) months and 9 (6-60) months,respectively. The 44 donors were lineal relatives to the consorted recipients. Their mean (SD) and median (range) age at operation was (32. 7 ± 8. 0) months and 31 (20～54) years, respectively. All donor graft types were the left lateral segments with compatible ABO blood groups. Clinical data,including pre-operative evaluations, surgical technique, postoperative management and outcomes in all donors and recipients were retrospectively analyzed. Results All donors were followed up for (17. 5 ± 13. 3) months. No donor mortality was encountered, with a minimal morbidity and no long-term sequelae. Nine out of 44 recipients died. Three patients died of portal vein thrombosis (PVT), one of hepatic artery thrombosis (HAT), two of biliary complications, one of surgical site infections, one of abdominal bleeding and one of pulmonary infection. The overall 1-year and 2-year cumulative survival rate in recipients was 81. 2% and 76. 1 %, respectively. No re-transplantation was done. Postoperative complications included PVT, HAT, biliary leakage and refluxing cholangitis, pulmonary infections,surgical site infections and acute rejection. Conclusion LDLT has been the effective treatment for pediatric recipients with BA and provides favorable prognosis. To improve prognosis of recipients, the key points are pre-operative evaluations, surgical technique, and postoperative management

Objective To summarize the screening Methods for human parvovirus (HPV) B19 infection after liver transplantation and analyze the related risk factors. Methods Clinical data of 86 recipients were retrospectively analyzed. According to the Results of next generation sequencing (NGS), all recipients were divided into the HPV B19 infection group and control group. Clinical characteristics, treatment regime and clinical prognosis of patients infected with HPV B19 were analyzed. The risk factors of HPV B19 infection were analyzed using univariate and multivariate Logistic regression model by forward LR step method. Results Nine of the 86 recipients developed fever and progressive anemia with unexplained reasons at approximately 2 weeks after liver transplantation. NGS detection demonstrated that HPV B19 was positive and they were diagnosed with pure red cell aplasia (PRCA) caused by HPV B19 infection. After intravenous immunoglobulins (IVIG) was given and the immunosuppressant therapy was adjusted, the hemoglobin levels in all patients were significantly increased. The Results of multivariate analysis revealed that low serum globulin level in peripheral blood at postoperative 7 d [odds ratio (OR) =0.749, P=0.040] and young age (OR=0.937, P=0.038) were the independent risk factors of HPV B19 infection after liver transplantation. Conclusions HPV B19 infection should be considered in relatively young patients with unexplained hemoglobin decline early after liver transplantation. NGS screening is an effective method for early diagnosis of HPV B19 infection. Low serum globulin level in peripheral blood at postoperative 7 d and young age may be independent risk factors of the incidence of HPV B19 infection.

Objective:To explore the effect of pre-transplant immunotherapy on the prognosis of transplant recipients with hepatocellular carcinoma(HCC).Methods:From June 2018 to September 2021, retrospective analysis was conducted for clinical data of 19 HCC-liver transplant recipients receiving pre-transplant immunotherapy in affiliated Huashan Hospital of Fudan University. Pre-transplant immunotherapy regimen, adverse reactions, post-transplant acute rejection, tumor recurrence and metastasis and other complications were recorded. According to the preoperative tumor imaging and the changes of alpha-fetoprotein level, tumor change during recipient waiting period was judged by the mRECIST standard. According to whether or not there was partial tumor remission, they were divided into two groups of non-remission( n=13)and remission( n=6). Postoperative conditions of two groups were compared. Kaplan-Meier method was used for calculating the survival rate of recipients after transplantation and survival curve and Log-rank test utilized for comparing the recurrence-free and overall survival rates of recipients at 1 and 2 years post-operation. Results:A total of 19 liver transplant recipients received immunotherapy plus targeted and transcatheter arterial chemoembolization(TACE) before transplant. In non-remission group, tumor was stable( n=9)and progressive( n=4); 6 cases in remission group had tumor partial remission. Two recipients in non-remission group were pathologically confirmed by liver biopsy to have acute rejection(2/19, 10.5%)and both recovered after glucocorticoid + rATG and glucocorticoid therapy. In non-remission group, 2 patients died from septic shock post-operation. Among 3 patients of tumor recurrence and metastasis post-operation, 2 cases survived with tumor and 1 died after tumor recurrence and metastasis. In remission group( n=6), none had postoperative tumor recurrence and metastasis. The recurrence-free survival rates of non-remission group recipients at 1 and 2 years post-operation were 76.9% and 76.9% and recurrence-free survival rates in remission group were 100% and 100% respectively and inter-group difference in RFS was not statistically significant( χ2=1.468, P=0.226). The overall survival rates of recipients in non-remission group at 1 and 2 years post-operation were 76.9% and 76.9% respectively. And recipients in remission group were 100% and 100% respectively and no statistically significant inter-group difference existed in OS( χ2=1.292, P=0.256). Conclusions:Without a significantly higher risk of acute rejection after transplant, immunotherapy may be an effective option for bridging treatment before liver transplantation for HCC. And it remains necessary to expand the sample size for verifications and supports.

Objective:To explore the relationship between CD24 expression in preoperative peripheral blood as well as cancer tissue and clinical parameters and prognosis in patients with hepatocellular carcinoma (HCC) after liver transplantation (LT).Methods:From November 2018 to November 2019, clinical data were collected for 65 HCC patients and 41 patients with benign liver disease.The preoperative peripheral blood level of CD24 was detected by enzyme-linked immunosorbent assay (ELISA) and the expression of CD24 in cancerous foci and adjacent tissues examined by immunohistochemistry.Kaplan-Meier survival curves of differential CD24 expression were plotted and survival differences compared by Log-rank method.One-way ANOVA was utilized for examining the relationship between the expression level of CD24 and various clinicopathological parameters and multivariate Cox analysis for screening independent risk factors affecting patient prognosis.Results:The concentration of CD24 in preoperative peripheral blood (p-CD24) of HCC patients (6.51±2.33 μg/L) was significantly higher than that of patients with benign liver disease (4.10±0.91) μg/L, P<0.05.The positive rate of CD24 was obviously higher in cancerous tissues than that in adjacent tissues (87.7% vs. 4.6%, P<0.05). The peripheral blood level of CD24 was positively correlated with the expression intensity of CD24 in tumor tissues (t-CD24, r=0.570, P<0.001). The expression of CD24 (both in blood and cancer foci) was significantly correlated with preoperative level of gamma-glutamyl transferase (GGT), maximal tumor diameter, microvascular invasion, portal vein tumor thrombus, vessel carcinoma embolus and satellite focus ( P<0.05). The expression of CD24 in patients exceeding the Milan/UCSF criteria was higher than those fulfilling the criteria ( P<0.005). Patients with a higher expression of CD24 had worse overall survival and recurrence-free survival rates as compared to those a lower expression of CD24 ( P<0.05). Multivariate Cox analysis indicated that t-CD24 [OS: HR=3.661(1.005-13.333)], P=0.049; recurrence-free survival (RFS): [HR=4.331(1.887-9.942), P=0.001] and preoperative level of alpha fetoprotein (AFP) [OS: HR=4.900(1.590-15.097), P=0.006]; RFS: [HR=3.414(1.614-7.221), P=0.001] were independent risk factors for overall survival and recurrence-free survival in HCC patients undergoing LT. Conclusions:The preoperative peripheral blood level of CD24 in HCC patients undergoing LT indirectly reflects the expression of CD24 in cancerous tissues to a certain extent.And the expression of CD24 in cancerous tissue is one of the independent risk factors affecting OS and RFS of LT patients.