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{{CMG}}; {{AE}} {{MAD}}
{{CMG}}; {{AE}} {{MAD}}
{{Liver transplantation}}
{{Liver transplantation}}


==Overview==
==Overview==
Prognosis is good. One-year [[survival rates]] are 83%, 5-year survival is 76% and 10-year survival is 66%. Mortality rates in donors are 0.2% in the USA and vary from 0.1 to 1.0% worldwide. The risk associated with left-lobe donation may be lower than that with right-lobe donation. Recurrence varies according to the cause; [[hepatitis B virus]] is the commonest cause of recurrence followed by [[hepatitis C]]  virus. Recurrence of [[Hepatitis B virus|HBV]] after liver transplantation can be prevented by administering [[hepatitis B]] [[immune globulin]] at the time of transplantation. There is no established role for [[Prophylaxis|prophylactic]] or therapy following transplantation in [[HCV]]. Combination therapy for [[HCV]] may be [[Peginterferon Beta-1a|peginterferon]] or standard interferon and [[ribavirin]], monotherapy may be [[Peginterferon Beta-1a|peginterferon]], standard [[Interferon|interferon,]] or [[ribavirin]], and anti-HCV [[immune globulin]].
==Liver transplantation prognosis==
==Liver transplantation prognosis==
* Prognosis is good. One-year [[survival rates]] are 83%, 5-year survival is 76% and 10-year survival is 66%.<ref name="pmid18505689">{{cite journal| author=Ghobrial RM, Freise CE, Trotter JF, Tong L, Ojo AO, Fair JH et al.| title=Donor morbidity after living donation for liver transplantation. | journal=Gastroenterology | year= 2008 | volume= 135 | issue= 2 | pages= 468-76 | pmid=18505689 | doi=10.1053/j.gastro.2008.04.018 | pmc=3731061 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18505689  }}</ref>
* Majority of deaths happen during the first three months after transplantation.
* Mortality rates in donors are 0.2% in the USA and vary from 0.1 to 1.0% worldwide.
* The risk associated with left-lobe donation may be lower than that with right-lobe donation.
* The incidence of complications in the donor varies from 9 to 67%.
* The modified Clavien classification is commonly used to describe donor morbidity:<ref name="pmid11932469">{{cite journal| author=Surman OS| title=The ethics of partial-liver donation. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 14 | pages= 1038 | pmid=11932469 | doi=10.1056/NEJM200204043461402 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11932469  }}</ref>
**Grade I—a complication that is not life-threatening and does not require a therapeutic invasive intervention.
**Grade II—a complication that is potentially life-threatening and that requires the use of drug therapy or foreign blood units.
**Grade III—a complication that is potentially life-threatening and that requires a therapeutic invasive intervention.
**Grade IV—a complication with residual or lasting disability or which leads to death.<ref name="pmid15201680">{{cite journal| author=Salvalaggio PR, Baker TB, Koffron AJ, Fryer JP, Clark L, Superina RA et al.| title=Comparative analysis of live liver donation risk using a comprehensive grading system for severity. | journal=Transplantation | year= 2004 | volume= 77 | issue= 11 | pages= 1765-7 | pmid=15201680 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15201680  }}</ref>


Living-donor recipients have been noted to have a higher incidence of surgical complications post-transplant compared with whole-liver recipients.
== Recurrence ==
 
Early data suggested that outcomes (graft survival) might be inferior to those in whole-liver transplants, especially if the patients were matched for severity of liver disease [39].


Partial grafts have smaller vessels, more complicated biliary reconstructions, and a cut surface, all of which make for
==== Hepatitis B virus ====
a technically more challenging procedure and a higher incidence of surgical complications.  
* Recurrence of [[Hepatitis B virus|HBV]] after liver transplantation can be prevented by administering [[hepatitis B]] [[immune globulin]] at the time of transplantation and at regular intervals thereafter in combination with [[antivirals]] such as [[tenofovir]] or [[entecavir]].  


Maluf et al. and Fan et al. reported that despite smaller graft
==== Hepatitis C virus ====
size and higher technical complexity, the graft and patient survival rates of patients with right-liverLDLTare not different from those of patients receiving whole-graft DDLT [40,41].
* There is no established role for prophylactic or therapy following transplantation.<ref name="pmid4976215">{{cite journal| author=Smith B| title=Segmental liver transplantation from a living donor. | journal=J Pediatr Surg | year= 1969 | volume= 4 | issue= 1 | pages= 126-32 | pmid=4976215 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4976215  }}</ref>
* No effective [[immunoglobulin]] [[prophylaxis]] exists for [[HCV]].
* Treatment is initiated within six weeks of the transplantation. Theapy may be combined or monotherapy.  
* Combination therapy may be [[Peginterferon Beta-1a|peginterferon]] or standard interferon and [[ribavirin]], monotherapy may be [[Peginterferon Beta-1a|peginterferon]], standard [[Interferon|interferon,]] or [[ribavirin]], and anti-HCV [[immune globulin]].
* '''Direct-acting [[antiviral]] agents''' 
**[[Sofosbuvir]] is an NS5B nucleotide analog used for the treatment of [[HCV]].<ref name="pmid25304641">{{cite journal| author=Charlton M, Gane E, Manns MP, Brown RS, Curry MP, Kwo PY et al.| title=Sofosbuvir and ribavirin for treatment of compensated recurrent hepatitis C virus infection after liver transplantation. | journal=Gastroenterology | year= 2015 | volume= 148 | issue= 1 | pages= 108-17 | pmid=25304641 | doi=10.1053/j.gastro.2014.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25304641  }}</ref>
**Treatment resulted in persistently undetectable [[HCV]] ribonucleic acid ([[RNA]]) 12 weeks after stopping treatment.
**[[Sofosbuvir]] is usually now given in combination with one of several additional direct-acting antivirals.<ref name="pmid23593993">{{cite journal| author=Fontana RJ, Hughes EA, Bifano M, Appelman H, Dimitrova D, Hindes R et al.| title=Sofosbuvir and daclatasvir combination therapy in a liver transplant recipient with severe recurrent cholestatic hepatitis C. | journal=Am J Transplant | year= 2013 | volume= 13 | issue= 6 | pages= 1601-5 | pmid=23593993 | doi=10.1111/ajt.12209 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23593993  }}</ref>


The only difference is a higher incidence of biliary complications in the LDLT patients (25.8 versus 7.1%) [40].
==== Hepatocellular Carcinoma ====
* [[Resection]] remains the standard with which alternative treatment methods must be compared.
==== Alcoholic liver disease ====
* Patient survival rates following liver transplantation for [[alcoholic liver disease]] are similar to rates following transplantation for non-alcohol related diagnoses.
* Five-year patient and graft [[survival rates]] 72 and 66 percent.
* Five-year survival without liver transplantation is 23 percent.


Most centers have reported a 15–46% incidence of biliary complications, including early bile leaks, after transplant, and a 15–20% incidence of late biliary strictures.  
==== Primary biliary cirrhosis ====
* A precise estimate of the recurrence rate is uncertain.<ref name="pmid11124816">{{cite journal| author=Liermann Garcia RF, Evangelista Garcia C, McMaster P, Neuberger J| title=Transplantation for primary biliary cirrhosis: retrospective analysis of 400 patients in a single center. | journal=Hepatology | year= 2001 | volume= 33 | issue= 1 | pages= 22-7 | pmid=11124816 | doi=10.1053/jhep.2001.20894 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11124816  }}</ref>
* Methods to prevent recurrence may include [[immunosuppression]] using [[cyclosporine]] rather than [[tacrolimus]] and giving [[ursodeoxycholic acid]] (UDCA) following liver transplantation.  


These figures are significantly higher than are generally
==== Primary sclerosing cholangitis (PSC) ====
reported for whole-liver recipients (9–15%) [40]. The possible factors associated with an increased risk of postoperative biliary complications include having multiple bile ducts to reconstruct and an inadequate arterial perfusion in patients with a high preoperative MELD score [42,43].
* Recurrent PSC following liver transplantation in 14 to 20 percent of patients.<ref name="pmid8045496">{{cite journal| author=Harrison RF, Davies MH, Neuberger JM, Hubscher SG| title=Fibrous and obliterative cholangitis in liver allografts: evidence of recurrent primary sclerosing cholangitis? | journal=Hepatology | year= 1994 | volume= 20 | issue= 2 | pages= 356-61 | pmid=8045496 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8045496  }}</ref>
* Risk factors for recurrence include age, sex mismatch, male sex, presence of an intact colon after transplantation, [[cytomegalovirus]] infection, recurrent acute cellular rejection, [[steroid]]-resistant cellular rejection, use of [[OKT3]].


With advances in microsurgical techniques, the incidence of vascular complications such as hepatic artery thrombosis has decreased and is now not significantly different from that in deceased-liver transplants [44–47].
==References==
Certain subgroups of recipients may do worse after living-donor transplants. Critically ill adult recipients with advanced liver failure, high MELD scores, and numerous secondary complications have generally been reported to have worse outcomes with this procedure. Such recipients have minimal
{{Reflist|2}}
functional reserve and are probably ill equipped to manage the lower hepatocyte mass and the higher complication rate associated with partial transplants. However, in parts of the world where DDLTs are uncommon, living donors have been used for critically ill patients, with good results [40].

Latest revision as of 16:42, 19 December 2017


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]

Liver trasnsplantation Microchapters

Home

Patient Information

Overview

Historical Perspective

Indications

Pre-surgical management

Choice of donor

Epidemiology and Demographics

Techniques

Complications

Acute rejection

Immune therapy

Post-surgical infection

Prognosis

Overview

Prognosis is good. One-year survival rates are 83%, 5-year survival is 76% and 10-year survival is 66%. Mortality rates in donors are 0.2% in the USA and vary from 0.1 to 1.0% worldwide. The risk associated with left-lobe donation may be lower than that with right-lobe donation. Recurrence varies according to the cause; hepatitis B virus is the commonest cause of recurrence followed by hepatitis C virus. Recurrence of HBV after liver transplantation can be prevented by administering hepatitis B immune globulin at the time of transplantation. There is no established role for prophylactic or therapy following transplantation in HCV. Combination therapy for HCV may be peginterferon or standard interferon and ribavirin, monotherapy may be peginterferon, standard interferon, or ribavirin, and anti-HCV immune globulin.

Liver transplantation prognosis

  • Prognosis is good. One-year survival rates are 83%, 5-year survival is 76% and 10-year survival is 66%.[1]
  • Majority of deaths happen during the first three months after transplantation.
  • Mortality rates in donors are 0.2% in the USA and vary from 0.1 to 1.0% worldwide.
  • The risk associated with left-lobe donation may be lower than that with right-lobe donation.
  • The incidence of complications in the donor varies from 9 to 67%.
  • The modified Clavien classification is commonly used to describe donor morbidity:[2]
    • Grade I—a complication that is not life-threatening and does not require a therapeutic invasive intervention.
    • Grade II—a complication that is potentially life-threatening and that requires the use of drug therapy or foreign blood units.
    • Grade III—a complication that is potentially life-threatening and that requires a therapeutic invasive intervention.
    • Grade IV—a complication with residual or lasting disability or which leads to death.[3]

Recurrence

Hepatitis B virus

Hepatitis C virus

  • There is no established role for prophylactic or therapy following transplantation.[4]
  • No effective immunoglobulin prophylaxis exists for HCV.
  • Treatment is initiated within six weeks of the transplantation. Theapy may be combined or monotherapy.
  • Combination therapy may be peginterferon or standard interferon and ribavirin, monotherapy may be peginterferon, standard interferon, or ribavirin, and anti-HCV immune globulin.
  • Direct-acting antiviral agents 
    • Sofosbuvir is an NS5B nucleotide analog used for the treatment of HCV.[5]
    • Treatment resulted in persistently undetectable HCV ribonucleic acid (RNA) 12 weeks after stopping treatment.
    • Sofosbuvir is usually now given in combination with one of several additional direct-acting antivirals.[6]

Hepatocellular Carcinoma

  • Resection remains the standard with which alternative treatment methods must be compared.

Alcoholic liver disease

  • Patient survival rates following liver transplantation for alcoholic liver disease are similar to rates following transplantation for non-alcohol related diagnoses.
  • Five-year patient and graft survival rates 72 and 66 percent.
  • Five-year survival without liver transplantation is 23 percent.

Primary biliary cirrhosis

Primary sclerosing cholangitis (PSC)

  • Recurrent PSC following liver transplantation in 14 to 20 percent of patients.[8]
  • Risk factors for recurrence include age, sex mismatch, male sex, presence of an intact colon after transplantation, cytomegalovirus infection, recurrent acute cellular rejection, steroid-resistant cellular rejection, use of OKT3.

References

  1. ↑ Ghobrial RM, Freise CE, Trotter JF, Tong L, Ojo AO, Fair JH; et al. (2008). "Donor morbidity after living donation for liver transplantation". Gastroenterology. 135 (2): 468–76. doi:10.1053/j.gastro.2008.04.018. PMC 3731061. PMID 18505689.
  2. ↑ Surman OS (2002). "The ethics of partial-liver donation". N Engl J Med. 346 (14): 1038. doi:10.1056/NEJM200204043461402. PMID 11932469.
  3. ↑ Salvalaggio PR, Baker TB, Koffron AJ, Fryer JP, Clark L, Superina RA; et al. (2004). "Comparative analysis of live liver donation risk using a comprehensive grading system for severity". Transplantation. 77 (11): 1765–7. PMID 15201680.
  4. ↑ Smith B (1969). "Segmental liver transplantation from a living donor". J Pediatr Surg. 4 (1): 126–32. PMID 4976215.
  5. ↑ Charlton M, Gane E, Manns MP, Brown RS, Curry MP, Kwo PY; et al. (2015). "Sofosbuvir and ribavirin for treatment of compensated recurrent hepatitis C virus infection after liver transplantation". Gastroenterology. 148 (1): 108–17. doi:10.1053/j.gastro.2014.10.001. PMID 25304641.
  6. ↑ Fontana RJ, Hughes EA, Bifano M, Appelman H, Dimitrova D, Hindes R; et al. (2013). "Sofosbuvir and daclatasvir combination therapy in a liver transplant recipient with severe recurrent cholestatic hepatitis C." Am J Transplant. 13 (6): 1601–5. doi:10.1111/ajt.12209. PMID 23593993.
  7. ↑ Liermann Garcia RF, Evangelista Garcia C, McMaster P, Neuberger J (2001). "Transplantation for primary biliary cirrhosis: retrospective analysis of 400 patients in a single center". Hepatology. 33 (1): 22–7. doi:10.1053/jhep.2001.20894. PMID 11124816.
  8. ↑ Harrison RF, Davies MH, Neuberger JM, Hubscher SG (1994). "Fibrous and obliterative cholangitis in liver allografts: evidence of recurrent primary sclerosing cholangitis?". Hepatology. 20 (2): 356–61. PMID 8045496.
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