Percutaneous Transhepatic Bile Duct Ablation with n-Butyl Cyanoacrylate in the Treatment of a Biliary Complication after Split Liver Transplantation

Biliary complications continue to be a major cause of morbidity after split-liver transplantation (SLT). In this report we describe an uncommon late biliary complication. One year after SLT the patient showed an intrahepatic bile dicy dilatation with severe cholangitis episodes. The segmentary bile duct of hepatic segment VI-VII draining in the left duct was unidentified and tied at the time of the in situ split-liver procedure. We perform a permanent obliteration of the dilated intrahepatic ducts by a percutaneous embolization using an n-butyl cyanoacrylate (NABC). The management of biliary complications after SLT requires a multidisciplinary approach. The use of NBCA in obliteration of a dilated bile duct seems to be a safe procedure with good results providing a less invasive option than hepatic resection and decreasing the morbidity associated with chronic external biliary drainage. Further studies are needed to determine whether this approach is effective and safe and whether it could reduce hospital stay and cost

Very Early Introduction of Everolimus in De Novo Liver Transplantation: Results of a Multicenter, Prospective, Randomized Trial

Abstract Early everolimus (EVR) introduction and tacrolimus (TAC) minimization after liver transplantation may represent a novel immunosuppressant approach. This phase 2, multicenter, randomized, open-label trial evaluated the safety and efficacy of early EVR initiation. Patients treated with corticosteroids, TAC, and basiliximab were randomized (2:1) to receive EVR (1.5 mg twice daily) on day 8 and to gradually minimize or withdraw TAC when EVR was stable at >5 ng/mL or to continue TAC at 6-12 ng/mL. The primary endpoint was the proportion of treated biopsy-proven acute rejection (tBPAR)-free patients at 3 months after transplant. As secondary endpoints, composite tBPAR plus graft/patient loss rate, renal function, TAC discontinuation rate, and adverse events were assessed. A total of 93 patients were treated with EVR, and 47 were controls. After 3 months from transplantation, 87.1% of patients with EVR and 95.7% of controls were tBPAR-free (P = 0.09); composite endpoint-free patients with EVR were 85% (versus 94%; P = 0.15). Also at 3 months, 37.6% patients were in monotherapy with EVR, and the tBPAR rate was 11.4%. Estimated glomerular filtration rate was significantly higher with EVR, as early as 2 weeks after randomization. In the study group, higher rates of dyslipidemia (15% versus 6.4%), wound complication (18.32% versus 0%), and incisional hernia (25.8% versus 6.4%) were observed, whereas neurological disorders were more frequent in the control group (13.9% versus 31.9%; P < 0.05). In conclusion, an early EVR introduction and TAC minimization may represent a suitable approach when immediate preservation of renal function is crucia

Prevalent use of Combined Prophylaxis of Hepatitis B after liver transplantation in Italy: Results of a national survey in a large cohort

BACKGROUND: Prophylaxis of hepatitis B after liver transplantation with antiviral(s) and immunoglobulins efficiently protect the majority of recipients; however recent experiences suggest a decline of HBsag-positive candidates and the use of hepatitis B immunoglobulin-free schedules. MetHoDs: this national survey evaluated the epidemiology and clinical results of hepatitis B prophylaxis among 10,365 liver transplants performed in 25 years in 13 italian centers. RESULTSː With a percentage of 22, 2260 procedures were performed in HBsAg-positive recipients and 714 out of 1080 anti-HBc-positive grafts were used in HBsag-negative recipients; a total of 2974 patients (29%) were considered at risk of hepatitis B after liver transplantation. similar rates (18% of HBsag-positive candidates and 15% of anti-HBc-positive grafts) were registered in the last collected year. combined prophylaxis with Hepatitis B immunoglobulins remained prevalent among centers and was effective in 96% of HBsag-positive recipients and in 94% of HBsag-negative recipi-ents of anti-HBc-positive grafts.CONCLUSIONS: Data from this survey confirm: the excellent results of combined prophylaxis; the past and persistent use of Hepatitis B immunoglobulin-on and only rare -off prophylactic regimens, in contrast with the newest reports; the increasing use of anti-HBc-positive grafts; the past and present high prevalence of HBsag-positive recipients, due to an increase in candidates with either hepatocellular carcinoma and Hepatitis Delta Virus coinfection in the last years

Optimization of Donor-Recipient match and identification of the futile match cutoff. A national italian study on liver transplantation.

Intentional matching of liver transplant donor-recipient risk factors, supported by D-MELD (donor age 7 biochemical MELD), could offer a new therapeutic strategy with effects on survival. As yet, an extensive stratification of cases according to the futile transplant principle using a continous quantitative parameter has not been performed. To stratify the prognosis according to donor-recipient match and assess the predictive role of D-MELD together with covariates, a database detailing 5946 liver transplants performed in 21 Italian Centers (2002\u20132009) was analyzed. Primary endpoint was to evaluate the prognostic power of D-MELD and covariates in terms of 3-year patient survival. The futile-transplant cutoff (life-expectancy <50% at 5 years) was investigated. The database was divided into a training and a validation set. The adequacy of fit for both sets was tested using Hosmer-Lemeshow and C-statistics. Cases were stratified in ten D-MELD deciles. Significant differences among D-MELD deciles allowed regrouping them in three D-MELD classes (A 1628). D-MELD classes were used for regression analyses. At 3 years, the odds ratio (OR) for death is 2.03 (95% CI 1.44\u20132.85) in D-MELD class C versus class B (reference). The OR is 0.40 (95% CI 0.24\u2013 0.66) in D-MELD class A versus class B. Other significant covariates were HCV status (OR = 1.42; 95% CI 1.11\u20131.81), HBV status (OR = 0.69; 95% CI 0.51\u20130.93), re-transplant status (OR = 1.82; 95% CI 1.16\u2013 2.67) and low-volume transplant Center (OR = 1.48; 95% CI 1.11\u2013 1.99). Results were confirmed by Cox regressions. The \u201cfutilematch cutoff\u201d was identified only in HCV patients (D-MELD=1750, p < 0.001).Assuming the same high D-MELD value, an organ from an elderly donor is likely to fail in an old recipient or in an HCV recipient but not in an HBV recipient. The identification of predictive factors (D-MELD class and covariates) and the introduction of the futile cutoff may lead to formulate new organ-allocation policies. The futile matches should be proibited by national allocation rules. Fatal allocation of high-risk organs to high-risk patients should be avoided. Organs from young donors should not be allocated to recipients with a low biochemical MELD without additional risk factors