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Expert consensus on liver transplantation perioperative evaluation and rehabilitation for acute-on-chronic liver failure

Organ Transplantation.2022;13(5):543-. doi:10.3969/j.issn.1674-7445.2022.05.001

Acute-on-chronic liver failure (ACLF) can be cured by liver transplantation; however, perioperative complications still affect posttransplant outcomes. In recent years, early rehabilitation for critical illness, liver disease, and surgery have significantly improved organ reserve function, surgery tolerance, and postoperative quality of life. They could also be applied in the perioperative period of liver transplantation in patients with ACLF. Therefore, the Transplantation Immunology Committee of Branch of Organ Transplantation Physician of Chinese Medical Doctor Association, the Organ Transplant Rehabilitation Committee of China Association Rehabilitation Medicine, and the Branch of Organ Transplantation Physician of Guangdong Medical Doctor Association conducted a comprehensive review of rehabilitation in end-stage liver disease, critical illness and surgical patients by summarizing current evidence and best clinical practices and proposed a practice consensus on evaluation of cardiopulmonary and physical function, rehabilitation or physiotherapies, as well as the safety concerns in perioperative liver transplant recipients. It will be a valuable resource for hepatologists, transplant surgeons, and intensivists as they care for ACLF patients during transplantation.

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Diagnosis and treatment of vascular complications after liver transplantation in adults

Jiabin ZHANG ; Guangming LI

Organ Transplantation.2022;13(5):555-. doi:10.3969/j.issn.1674-7445.2022.05.002

As an efficacious treatment for end-stage liver diseases and primary malignant liver tumors, liver transplantation has been widely applied worldwide, and gradually receives widespread recognition from patients. With the development of organ transplant technique, vascular complications have rarely occurred after adult liver transplantation. However, vascular complications, such as postoperative thrombosis and anastomotic stenosis, are still common in the recipients undergoing living donor liver transplantation and split liver transplantation. Inappropriate treatment may lead to the loss of grafts and death of recipients. The authors have been engaged in liver transplantation for many years, witnessing persistent development of diagnostic and therapeutic technologies for vascular complications after liver transplantation. In this article, current status and development trend of diagnosis and treatment of different vascular complications were illustrated from the etiology, clinical manifestations, diagnosis and treatment of hepatic artery complications, portal vein complications, inferior vena cava and hepatic vein complications, aiming to further improve the survival rate of grafts and recipients and provide reference for promoting the development of clinical liver transplantation.

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Discussion on the indications and timing of targeted therapy and immunotherapy before and after liver transplantation for hepatocellular carcinoma

Keyue LI ; Guowei WEI ; Tao LI ; Chunlin WANG ; Keli TANG ; Yi ZHANG ; Yan LIU

Organ Transplantation.2022;13(5):561-. doi:10.3969/j.issn.1674-7445.2022.05.003

Liver transplantation is one of the main treatments of early hepatocellular carcinoma (HCC). The recurrence of HCC after liver transplantation severely affects the long-term survival rate of the recipients. Targeted therapy and immunotherapy play a critical role in HCC downstaging, preventing disease progression, reducing recurrence rate, prolonging the survival and improving the quality of life. However, no consensus has been reached on the application of targeted therapy and immunotherapy in recipients undergoing liver transplantation for HCC, including indications, timing and dosage. In this article, clinical research progresses on the indications and timing of targeted therapy and immunotherapy before and after liver transplantation for HCC were reviewed, aiming to provide reference for prolonging the survival of recipients after liver transplantation for HCC.

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Diagnosis and treatment of common biliary complications after orthotopic liver transplantation in adults

Xinwen HU ; Ting LI

Organ Transplantation.2022;13(5):569-. doi:10.3969/j.issn.1674-7445.2022.05.004

Liver transplantation has become an effective treatment for end-stage liver diseases. With rapid development of surgical techniques, donor selection, organ preservation and transportation, immunosuppressants and perioperative management, the overall incidence of complications after liver transplantation has been significantly decreased, whereas the incidence of biliary complications remains relatively high. At present, biliary complications after liver transplantation are still an important cause of graft failure. Nevertheless, the pathogenesis, diagnosis and treatment of biliary complications remain controversial, which are also research hotspots in the field of organ transplantation in recent years. In this article, new breakthrough and research progress upon biliary complications after orthotopic liver transplantation in adults were reviewed, aiming to provide theoretical basis for resolving biliary complications-related clinical issues.

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Perioperative management of split liver transplantation

Chuan LI ; Yanhua LAI

Organ Transplantation.2022;13(5):577-. doi:10.3969/j.issn.1674-7445.2022.05.005

In the context of shortage of donor livers, split liver transplantation has achieved the goal of "one donor liver for two recipients", which effectively alleviates the shortage of donor livers and has promising development prospect. With the advancement of liver transplant techniques, split liver transplantation may yield clinical prognosis equivalent to total liver transplantation. However, perioperative management of split liver transplantation still encounters multiple challenges, with demanding techniques requirement and high-risk postoperative complications. Besides, there is a possibility of dividing one high-quality donor liver into two marginal donor livers, which will affect the development of liver transplantation. In this article, perioperative management of split liver transplantation was discussed from the perspectives of preoperative evaluation, recipient management and postoperative complication management, aiming to provide reference for promoting the development of split liver transplantation and enhancing clinical prognosis of recipients after split liver transplantation.

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Recurrence of IgA nephropathy after kidney transplantation

Yinsheng ZHANG ; Xingtong PENG ; Tingkai YANG ; Jiali XING ; Jin WEN ; Zhigang JI

Organ Transplantation.2022;13(5):583-. doi:10.3969/j.issn.1674-7445.2022.05.006

IgA nephropathy (IgAN) is one of the common primary glomerulonephritis, which is also an important risk factor for end-stage renal disease. Kidney transplantation is the optimal treatment for end-stage renal disease induced by IgAN, whereas there is still a risk of recurrence of IgAN after kidney transplantation. At present, research progress upon IgAN recurrence after kidney transplantation is relatively lacking. The pathogenesis of IgAN recurrence remains elusive, and its pathological manifestations are not specific. The diagnosis of IgAN recurrence still depends on renal biopsy. Besides, no effective prevention and treatment are available for recurrent IgAN. In this article, research progress on IgAN recurrence after kidney transplantation was illustrated from the perspectives of pathogenesis, diagnosis, risk factors and treatment, aiming to provide reference for clinical prevention and treatment of IgAN recurrence after kidney transplantation and improve clinical prognosis of kidney transplant recipients.

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Research progress on the role of STING signal pathway in ischemia-reperfusion injury

Haoran HU ; Jian XU ; Haoming ZHOU

Organ Transplantation.2022;13(5):591-. doi:10.3969/j.issn.1674-7445.2022.05.007

Ischemia-reperfusion injury (IRI) is a pathophysiological process, which widely exists in organ transplantation and surgery. IRI is mainly manifested with hypoxia injury of organs or tissues during the ischemia period, which could be further aggravated after reperfusion. Ischemia-reperfusion induces tissue cell injury, releases damage-associated molecular pattern and further activates multiple immune cells via pattern recognition receptor, leading to aseptic inflammation and aggravating tissue injury. Cyclic guanosine monophosphate-adenosine monophosphate synthase (cGAS), as a critical member of pattern recognition receptor, could activate the stimulator of interferon genes (STING) signal pathway and play an important regulatory role in innate immune response. At present, increasing evidences have shown that cGAS-STING signal pathway plays a significant role in organ IRI. In this article, STING signaling pathway, its role and mechanism in IRI of different organs were reviewed, aiming to provide novel ideas for clinical interventions.

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Comprehensive minimally invasive treatment for biliary anastomotic stenosis after orthotopic liver transplantation: a single center analysis of 60 cases

Wenjie TIAN ; Dinghui DONG ; Jie HAO ; Jie TAO ; Xue YANG ; Min TIAN ; Xuemin LIU ; Bo WANG ; Hao SUN ; Yi LYU ; Yu LI

Organ Transplantation.2022;13(5):597-. doi:10.3969/j.issn.1674-7445.2022.05.008

Objective To evaluate the clinical efficacy of endoscopic retrograde cholangiopancreatography (ERCP)-based comprehensive minimally invasive treatment for biliary anastomotic stenosis (BAS) after liver transplantation. Methods Clinical data of 60 BAS recipients after liver transplantation were retrospectively analyzed, 54 male and 6 female, aged (48±10) years. ERCP was initially carried out. If it succeeded, plastic or metallic stents were placed into the biliary tract. If it failed, percutaneous transhepatic cholangial drainage (PTCD) or single-operator cholangioscopy (SpyGlass) was adopted to pass through the stenosis. If all these procedures failed, magnetic anastomosis or other special methods were delivered. The incidence and treatment of BAS after liver transplantation were summarized. The efficacy, stent removal and recurrence were observed. Results The median time of incidence of BAS after liver transplantation was 8 (4, 13) months. Within postoperative 1 year, 1-2 years and over 2 years, 39, 16 and 5 recipients were diagnosed with BAS, respectively. All 60 BAS recipients after liver transplantation were successfully treated, including 56 cases initially receiving ERCP, and 41 completing BAS treatment, with a success rate of 73%. The failure of guide wire was the main cause of ERCP failure. The success rates of PTCD, SpyGlass and magnetic anastomosis were 5/9, 5/7 and 7/8, respectively. Two recipients were successfully treated by percutaneous choledochoscope-assisted blunt guide wire technique and stent placement in the biliary and duodenal fistula. After 3 (3, 4) cycles of ERCP and 13 (8, 18) months of stent indwelling, 38 recipients reached the stent removal criteria, including 25 plastic stents and 13 metallic stents. The indwelling time of plastic stents was longer than that of metallic stents (P < 0.05). Six cases suffered from stenosis recurrence at 12 (8, 33) months after stent removal, and the recurrence rate was 16%. Six patients were treated with ERCP, and 5 of them did not recur after the stents were successfully removed. Multivariate analysis showed that delayed diagnosis of stenosis and frequent ERCP before stent removal were the independent risk factors for BAS recurrence (both P < 0.05). Conclusions ERCP-based comprehensive minimally invasive treatment may improve the success rate of BAS treatment after liver transplantation and yield satisfactory long-term efficacy. Delayed diagnosis of BAS and high frequent ERCP required for stent removal are the independent risk factors for BAS recurrence.

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Liver transplantation for acute liver failure in children: 8-year experience in a single center

Ying LIU ; Liying SUN ; Zhijun ZHU ; Lin WEI ; Wei QU ; Zhigui ZENG

Organ Transplantation.2022;13(5):605-. doi:10.3969/j.issn.1674-7445.2022.05.009

Objective To evaluate the efficacy of liver transplantation for acute liver failure (ALF) in children. Methods Clinical data of 15 children with ALF who underwent liver transplantation were collected and retrospectively analyzed. The proportion of ALF among children undergoing liver transplantation during the same period was calculated. The characteristics, postoperative complications and clinical prognosis of ALF children receiving liver transplantation were analyzed. Results In the same period, the proportion of ALF was 2.0% (15/743) among pediatric recipients undergoing liver transplantation. All 15 children had acute onset of ALF, and most of them were accompanied by fever, diarrhea and progressive yellowing of skin and sclera. Thirteen children were complicated with hepatic encephalopathy before operation (6 cases of stage Ⅳ hepatic encephalopathy), and two children were complicated with myelosuppression and granulocytopenia before liver transplantation. Ten children underwent living donor liver transplantation with relative donor liver, 4 received liver transplantation from donation after cardiac death (DCD), and 1 underwent Domino donor-auxiliary liver transplantation. Of 15 children, 12 recipients had the same blood type with their donors, 1 recipient had compatible blood type with the donor and 2 cases had different blood type with their donors. Among 15 children, 10 cases developed postoperative complications. Postoperative cerebral edema occurred in 5 cases, of whom 4 cases died of diffuse cerebral edema, and the remaining case was in a persistent vegetative state (eyes-open coma). Postoperative cytomegalovirus (CMV) infection was seen in 5 cases. Two children presented with aplastic anemia and survived after bone marrow transplantation, 1 case died of CMV hepatitis and viral encephalitis, and 2 cases died of diffuse brain edema. One child developed graft-versus-host disease (GVHD) after liver transplantation, and died of septic shock after bone marrow transplantation. Nine children survived and obtained favorable liver function during postoperative follow-up. Conclusions Liver transplantation is an efficacious treatment for ALF in children, which may enhance the survival rate. Brain edema is the main cause of death in ALF children following liver transplantation, and treatment such as lowering intracranial pressure, improving brain metabolism and blood purification should be actively performed. Liver transplantation should be promptly performed prior to the incidence of irreversible neurological damage in ALF children, which might prolong the survival and enhance long-term prognosis.

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Predictive values of ALBI and EZ-ALBI scores for early survival of recipients with liver failure after liver transplantation

Chengkai YANG ; Jiamian XU ; Huaxiang WANG ; Lizhi LYU ; Yi JIANG ; Aiping WU

Organ Transplantation.2022;13(5):611-. doi:10.3969/j.issn.1674-7445.2022.05.010

Objective To evaluate the predictive values of albumin-bilirubin (ALBI) and easy albumin-bilirubin (EZ-ALBI) scores for early survival (postoperative 3 months) of recipients with liver failure after liver transplantation. Methods Clinical data of 137 recipients diagnosed with liver failure and underwent liver transplantation were retrospectively analyzed. The optimal cut-off values of preoperative ALBI, EZ-ALBI and MELD scores to predict early survival of recipients with liver failure after liver transplantation were determined by the area under the receiver operating characteristic (ROC) curve. The risk factors of early death of recipients with liver failure after liver transplantation were identified by univariate and multivariate Cox regression analyses. The effects of different ALBI and EZ-ALBI levels upon early prognosis of recipients with liver failure after liver transplantation were analyzed. Results The optimal cut-off values of ALBI, EZ-ALBI and MELD scores were 0.21, -19.83 and 24.36, and the AUC was 0.706, 0.697 and 0.686, respectively. Univariate Cox regression analysis showed that preoperative alanine aminotransferase(ALT)≥50 U/L, aspartate aminotransferase(AST)≥60 U/L, ALBI score≥0.21 and EZ-ALBI score≥-19.83 were the risk factors for early postoperative death of recipients with liver failure after liver transplantation (all P < 0.05). Multivariate Cox regression analysis demonstrated that preoperative ALBI score≥0.21 was an independent risk factor for early postoperative death of recipients with liver failure after liver transplantation (P < 0.05). According to the optimal cut-off value of ALBI score, the early survival rates in the ALBI < 0.21 (n=46) and ALBI≥0.21(n=91) groups were 93.5% and 64.8%, and the difference was statistically significant (P < 0.05). According to the optimal cut-off value of EZ-ALBI score, the early survival rates in the EZ-ALBI < -19.83(n=60) and EZ-ALBI≥-19.83(n=77) groups were 88.3% and 63.6%, and the difference was statistically significant (P < 0.05). Conclusions Preoperative ALBI score is of high predictive value for early survival of recipients with liver failure after liver transplantation, which could be utilized as a reference parameter for selecting liver transplant recipients.

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