abstracts of the joint congress

SCIENTIFIC PROCEEDINGS Joint Congress on liver Transplantation

The International Liver Transplantation Society and

liver Intensive Care Group Europe

London, United Kingdom September 27-30,1995

Abstracts are reproduced exactly as they were submitted except in certain instances where changes were made to comply with Congress regulations. Scientific, grammatical, or typographical inaccuracies have not been corrected.

Donor/Graft

S U C C C S I F U L hI.I.OTRIINSYI-\NThTION OF WAKH A N O X I C LLVERS TilE ROLE OF TOTAL

AUCNlNe NUCI.EOIlDE (TAN) SYNTllESIS I H CRAFT VIA6ILI IY IN LIVER HOMOGRAFI RECIPIENTS PREDICTIVE VALUE OF PREOPERATIVE PLASMA NOREPINEPHRINE CONCENTRATIONS

N.P, R M A ~ a ~ r e L e s , M I. L C L C C . N J m e n e i . F J T e n d i l l o . A H ~ s c l r r . J L. ~ , R e y " o l d ~ S . L u r a D . N o r p a a r O M . B e l a n i K . P a y n e W Depa~mentsolAne~thesiology. C a ~ c i l l r r . O I i v a r e r B~prrLmentrl S U L ~ E L - ~ CLLnisa Puerca de l i i erro n a d i i d . Sparn Universilqel NewMexoo. Albuquerque, NM67131 and UniverLityol Minnesota. Minneapolis. MN 55455

. . hepat ic funcl lqn follovrnq reperfusLon as reqards the rate of PNF and I P r .

Plasma noreplnephiine COnCenlratiOn [NEI and mean sonic pressure have been rep~nW as the two the be81 predictors Dl S Y N w e I lor palientz with liver Cirrhosis [Llach J el al J Hepal01 3 (Suppl 1) 56. ,9661 The purpose 01 lhir study was 10 evaluate the value 01 INEI as a ptedclor 01 opsrsl8ve monalMy lotlowmg traanrplanfatlon 01 lhver reclplentn The PreOperahVB plasma norepinephrine Concenlrahon [NE] was

(abdominal surgery) and 19 consecu11~e supine liver homogratt reaplenls 16 adullr (44r-3 years [mean+-SEl. primary bittary CirrhosL (1). s~ler0~i0g~h~lang111~ (31. hepat#t#s C (6). lulmlnant hepalo failure (3). Other 13). median ChildS-TYrCOlle-Pqh score = 12. range 7-14) and 3 children (1.3+-I years. ertrahepatlc blllary alresia (2). lulminanl hepatic lallure (1). median Chllds-TYrwlle.PUgh score i 12. range 7-13). iNEl In controls was 225r-51 Wiml. range 14-475 pqlml. Ten 01 16 adults had elevated lNEl llG67+-449 pqIml. p 4 01 unpaired T-lest) as did 1 chlld (38w pgiml. tulmmanl hepallc la,lure) lNEl coirelaled strongly with the Chdd-Turmlle.PUgh (CTPI score (CTP %ore = 6.7 + 0.001[NEI) Five 01 19 recipients (26%) dled within 30 days porloperatively. 4 01 them within 72 hours with [NEl < 25MJ pglml were alive a130 days. but 4 01 5 (60%) who died had [NEl > 2500 pgiml (Pearson's Chi square 7 4, p < 0 007. ~enahaly 60%. ~peclllclty 66% po~ilive and negative predictive values were 67 and 92% rerpectivelq) Thus. because [NEI r e l l e ~ l ~ Ihe sevmtq ot decompensalian m end-atage liver C8sease. 815 preoperative value identities a Subsel 01 liver recipienls wlth hlgh pOSl0perall"e morlallly

measured w L c . ssnslilvlty = 20 pgimi. ,nterassay men4cm 01 ~ a m ~ n = 10%) ,n 12 COnwr

I 4 01 19 recipienll (7454.)

.. .. . .... -.... .... - 11.

.. . *... ,-..a

.... - ,. .,... 1.1 .. .. . .I 1 .. .O -.

Donor/ Graft 41 1

FILTER BLEEDING TIME REVISITED DURlNO ORTHOTOPIC LIVER TRANSPLAKTATION? m. w.-t..ru of hihcriology. Msyo Clinic. Rocker . MN. USA

CAN IT PREDICT TRANSFUSION REQUIREMBNTS

41 2 Donor / Graft

Cerebral oxygen saturation during liver transplantation CIus Skak. Ellen Ejlcrwn and Nirlr H Sechcr Depanment of ANenhena. I(lgihoipitalet. Unrverrrty of Copenhagen. Denmark

Tlsnrplssacmn of tk lwer is arronated w l h vast changer m the cir~~.aiion and oAen uiih a large blood IOII. hence 11 ran be dificull to maintain a uficient central b . d vol~me to aicenam oxygen delivery to V I I ~ organs Also rrgulalion of cerebral p c r f u ~ o n may be compromised on paticntl w t h end stage l i v n disease (I Hepaml 1995, 21 000-000) Wtin I ~ U ) X ~ Z N ~ Doppler 11 has been dcmonrtrated that flow vrloc8ty ~n the mlddle cerebral anery 81 mantamed d u h g the mnhcpaus ph.se of the operatm. and nits dunng reperfusion of the grsflas anerml crrbonatoxyde tension (PaCO,) nses. when wlumc therapy IS guided to mnum P m u m s l venous oxygen sat~rmon ano a conitant lo decreasing thoracic almncal impedance (Clm Phyiiol I 5 119.130. 1995) We evrlvrted ifnear infrared rprctrophoromctri dnrmincd cerebral oqgcn saturatoon (NlR) changer m proponion to PaC0,dunng lbcr t rmrp la~ruan. *hen the same method t i used to control :he central b l w d volume We repon iilucs from 52 liver lranrplantaiionr and related changer !n PaCO, In 17 ofthe patients the m m a l pgdar VC~OUI ~ t u r a u o n was ascr i rd In the anhcpat c phsc of the opnaion PaC0,aecrcarcd fiom 4 88 ( 3 32-6 80) to 4 67 (3 80.6 51) kPa (median. ranget and NIR decreased 6om 10 2 (SO 8-94 0) 10 69 5 (48 0.91 5) 7. (pco 05) Conumcly. PaCO, incroarcd to 5 10 (4 39-1 05) kPa aod NlR to 71 1 (51 1.94 0) h dunng repcrfurion (p<O 05) T h e p y h r oxygen saturation decreased horn 71 0 ( 5 5 5.92 0) to 65 5(16 0.94 0) % 10 Ihc nnhepattc pllrrr and mueased to 77 0 (50 5-94 0) % 81 repcrfurion (p<o 05) The results mdtcarc rhat ccrcbral oxygenation was mainiamd tnioughoul the opn~ t ion and thai 11 vanes ~n proponion IU Ihc anmal carbandioxyde tension

Donor/Graft 41 3

BLOOU GLUCOSE ClVWGES DURING LIVER TRANSPIANTATION MJ Baokaiiil. A. Blinn. I?J l'ralaggan. PR. Wajon. VL. tiarrlson. AGR Sheil Australian Naliond Liver Transplantation Unit Departments of Anaesthesia and Surgery. University of Sydney. Sydney. Australia

Clypcrglycaciim was a constant feature before revascularisation. except in some fnlmtnanl i q m i c failurrs mere was a rise lrcference range 4 0.4.3 mmol/l) on rcvascui~arIsation then n slow fall to neax the prcrevascuiarisation level. Somcllnlcs lhyp?giycaeolia leading l o glucose lherapy occured towards the cnd of thc opcrnlton This t l ~ l not meau p r i ~ ~ x y non-function of the h e r gralt. external factors which appenr to be rclaled to hyperglycaernia are the glucose in bank blood t r r r l t~cr l by washirip). timing of thc steroids. !he glucose in mtravcnous fluids Including fluld uscd for Uienno-dilution cardiac output measurements atid possibly the voluiiics of blood products given. I lyperglycacmm IS ii usual rlunc~g liver 1r.msplantatmn It may be detrimental with rased intracranial pressure. Less than half the rises are related to vascularisation of the new liver The rest me exogenous. iiypoglycaemla may occur 12WhI cither iicfore or after rcvascularisation

414 Donor/ Graft

OXYGEN DELIVERY AM) CONSUMPTION DURING LIVER TRANSPUNTATION: EFIXCI'OF D I C H W R O A C m A T E (DCA).

R.E.. S.T. Robiwn. Dept. of Amthc.sioiogy. Oregon HdUl Science Univ. d VAMC, h d d . OR. 97201.

EFFECTS OF CAVAL CLAMPING AND UNCLAMPlNG ON PLASMA NOREPINEPHRINE CONCENTRATION IN LiVER RECiPlENTS OPERATED WITH AND WITHOUT VENO-VENOUS BYPASS ESUILU, Reynolds S. Lvla D. Nargaard M. BeIan8 K. Payne W. Depanmenls 01 Aneslhesblogy. UnlverSlty 01 New M~XICO, Albuquerque, NM 67131 and Universily 01 Minnesota. Mmneapahs. MN 55445

HYPOTENSION AT UNCLAMPING : INTRAOFERATIVE PREDICTIVE FACTORS:

Donor/Graft 41 5

PlGCY BACK W I M TEMWRARY WRTOCAVAL ANASTOMOSIS OR LIVER TRANSPLANTATION WITH VENOVENOUS BYPASS 1 HEMODYNAMICS, BIOLCCY. HEMOSTASIS. GRAIT FUNCTION &%& C Frep, N. Slo~ba . Ph Ocqusdml. F..611m. K. 8oudcma'

Drpnmnl 01 AnRlhelia and Trmrpbnal~on'. Univcncly Hoipiral Havlcplsre 67098 Slnsbourg C d r r , France

WIN PERCUTANEOUS I S FRENCH CANNULAE FOR VENO-VENOUS BYPASS AND RAPID VOLUME INFUSION I N LlVER TRANSPLANT nciscen 1 . 0 . . H . D . . oorje s . . 8 . n . . c r i d P r B . A . . n . 0 . . ~ e p a r t m e n ~ of

Anesthesiology. U n i v e r s l i y of Ulch lgan Medical Center

use of v e n o - v e n ~ u ~ bypass (VVB) is rourine d u r i n g a d u l t orrhotopic l i v e r cransplaeraTlon (OLT) I n many cenrers In the USA. downs have heen performed i n r r a o p e r a r t v e l y t o place t h e saphenous veln outflow l imb and the a i l l l a r y v e i n raturn l lmb of t h e VVB. cannulacions ace c l o s e d r u r g l c a l l y . s e p a r a t e l y through TWO 8 . 1 in troducer shcarhs.

for several reamn$- (I) TO o b v i a t e the TWO surgical cur-downs and t h e i r c o w l l - cartons (2) t o shorten overall r u r g l c a l t h e . (11 as il route r o admlnlster blood p;oducis from che rapid I n f u s i o n system ( R . 1 . S . ) together v l t l i (4) che blood t o and from che V Y B .

In t h e USA. Tradiclonally. surgical C U ~ - ~ O W ~ E Ihdve been performed inrraopera- f l v e l y te cannulace the a x i l l a r y v e i n and the raphenous v e l n for this purPOSe. A t decannulorion there c a n n u l a t l o n s are closed s u r g i c a l l y .

I n forty OLTs, percuraneoilr cannulat ion has r e s u l t e d in 1 s i g n i f i c a n t reduct ion in the surgical t i n e (berueen 10 and 60 m i o s l w i thour increase in a n e l t h e t i c rlne o c increase In complications and w i t h a reduct ion of the surgical campllearlonr O C car-downs ( b l e e d l n g . Lymph l e a k s , nerve damage). The r i g h t L n f e m a l jugular I S French cannu lae e a s i l y accosmod~res flow from both the R . 1 . S . (up to 1 L / m l # i ) and the VVB ( u p t o 3-4LIm~n). Our surgeons a r e pleased w i t h t h i s p r a c r l c e and encourage l c s use, and our p a r i e n r s are h a p p i e r .

T r a d i r l o n a l l y . surgical Cut-

A t decannulntion these Blood products have t r a d i t i o n a l l y been glven

Recenrly we h a v e placed these large cannulae pcrcuran~ously p c e o p e r a c l v e l y

U s e of V P I ~ - Y ~ O O Y S bypass ( V V B I 1s rouflne d u r i n g adul t 0I.T in many cenrerS

Preserv*~ton of mferior vena cavaIPIvcI mainLains t h e haemodynamics during the anhepatic phase. but does not relieve porLdl lhypertens~on produced. The aim of our Study was to asses3 the value of combining W0 and P I V C I n prevent ing porLai I L ~ E L S and C~osular hypoper fur ion. mehod.: A f t e r IRE consent. 20 LT patienis l h a l f of Calculated sample g l z e l were randomly assigned LO one of L h l D qroupr: W. where W B was Inst iCuLed e a r l y a t diSseCCLOn. Dc. no W B were used Prlmilry study variables linLramu~osa1 pH-pH&. card iac Index-Ci. 0 2 ~xCracLlOn-02Ex end IdcLaLe-LacI were dezerained a l t e r anacrrheric ~ n d u ~ t i o n . d u r i n g hepatectomyl r l i . at anhepaLiciTll and after re~erfus~anlT3l. Resu1t.1 There were no di f ferences between g r o ~ p ~ in relacion with demogiaphic p r o f i l e . Same percentage of p a t i e n t s w i t h portal hypertension w e r e d l3Lr ibured ~n both 9rDYps. Values are expressed as meanrSD.

T1 -.I TI

PERCUTANEOUS CANNULATION FOR VENOVENOUS BYPASS IS T H E PREFERRED TECHNIQUE FOR LIVER TRANSPLANTATION. &.oEhlp, Mcrion RM. Campkll DA. Sawyer RG. Bromberg JS. Turcauc JG Dspl of Surgsly, University of Michigm

Cannulae wew successfully placed prculannc&rly m 8bof there 92 prlicnir (93%). the remainder hud 0-n s u r c i d technique. Wc reviewed the medical records of the D ~ ~ I F ~ I S ihnl had V V B usmz

cokpltcarions. <honer o ~ m u v s lime. and less cold ischemia.

Donor / Graft 41 7

PRESERVATION OF THE RECIPIENT'S VENA CAVA I N ORTHOTOPIC L IVER TRANSPLANTATION FXGon2dler. J C GarCia-VatdeCaSas, L Gmnde. J L Pacheco. E.Cugat. J Fvster. A M-Lacy. P.Tsur6. M A L6pez-Boado. A Rimola. J Visa Liver Transplant Unit Hosptal Clinr. Barcebna. S p a n

ASSESSMENT OF RlCllT VENTRICULAR BUNCTION DURING ORTHOTOPIC L l M R TRANSPLANTATION

J W F m m n . R M h c d . S H R u u l l FclUTnlarr DCpmrOmcm O f ANIIIMICI and I ~ I C R I I I S Cam and TIE Llvrr Urn1 Queen EllmbeUl HOSpsW, Bmmnghm

A sudden tall m Iy~temlC vaSCcylar tone ha$ been reported to play a causative role 8" the hemOdynamlc changes totlowing gralt repellusion dunng liver Iransplanlatlon. The purpose 01 this sludy was to compare systemr and pulmonary VaXuIaI tone changes m recipients tranrplanted with and withoul bypass. Hemodynamic protiles - HR (bpm). MAP (mmHg). PADP (mmHg), Ct(L-mul-l -m.2). SVRI and PVRl tdvnes-rec cm-5.m-21. were measured OrcalC~latBd at stead" slate 5 minutes before and 10

ro;; sh&y dunng the anhepalie phase Only m group I1 SVRl in Groups I. 11. 111 was. respectively 1238t-22. 2308+-105. t347r~t05. PVRl was. 79+-8. 1201-16.95 +-t9. p < 0.OI repeated measures ANOVA. Wilh graft lepelluslon SVRl and PVRl lell Only In Group It I0 values (967 +. 64.67 +-11, respectively. p < 0 01) not 51qndLanlly ditterenl than the posl-repellunon values lound ~n grow l(769- 61. 65+-8). Group Ill (983+~150.90*-201. or group 1115 Own baselhe values In addtbon. due lo ellher collateral ponocaval tlow (n children or veno-venous bypass m adults. PADP and CI were hlgher In Groups I and 111 dunng the anhepallc phase PADP m Groups I. It, 111. respectaely. were: t4r-I, 9+-1. t4+-1 CI ~n Groups I, 11. 111 werw 6r.0 5.3r.O.t. 5.-0 3 (p<O 01. unpaired T-test) Thus. the data show

418 Donor/Graft

~epcrfuslon of lhc donor orgall during orthotopic lwer lransplanlatlon (OLT) is associated wlih variable d s p c s or acute cardiovascular depression. and variable expression of storage i#yury. NeuiropLil-ciidotl,cliuln lmleracliw is one component of rcpcrfurion injury tn experimenwl LT. T o eraminc wlicllier fneusophil activation. irlggcrcd by inlcraetion with lwcr graft mdothclium. could fcaiurc iri the cliiiical smug. muiropliil surface c i p r ~ r r ~ o n or the adherton m~lecuks CDI Ib and L-wlecliii, and circulaiitig levels of the neutropbil granuleconstituent elaslase. and Vou Willebrand factor I V W F ) as a markcr of endollielial damage were measured in 18 patienis undergoing OLT. Wllolc cilralcd b l d was oblained pre-reperfuscot1 and at I. I5 and 30 ~ ~ I I I U I ~ S aftcr rcperfurton and slaiiicd using ailtl-CDI l b and anli-L-selecliv aNibdier for FACS analysis. Elaslarc a 1 4 VWI' were imeasiirud by BLiSA. Vuriilg sampling inwall rurfacc C D I Ib exprcrscon iucreaied mid imcm L-selecu~! CX~WCS~IOII dccrciied 31 I . I5 and 30 ~mtnulei. a patterti typical of ncuaophil activdon. At 10 miiiulcs. C V I l b erpressm was 501 iM) wilS and L-sclecliv crprerrion 784+52 will compared willi prc-reperliirioii 1467iS6 aiid 810-t38 rerpeclweiy: paired I-test p<O.Ol for boll0. Elaslaw levels iiicrenscd rigiiilicaiiily (341 f281 8ngIwl prc-repcrfurioii 10 584i376 11g/m1 a1 10 niiiwes: p<O.MwI). V W P levels were abnormally lhigh a1 llie beginning of the study 1429-t 190 IU) a id remaiiied so a1 3U imiiiules [115-t104 IU). Our resulls indicate llial neulropliil actwalloil is an early f m a r c fullowiiig rcpcrfusioii of llie donor Iwer. while syrteniic evidence ofcsdall~cl$l damage appesrs 10 prcccdc rcpcrfusiou. and may in01 be llic sole trigger for neulropliil acIIYation

OBJECTIVE. Various authors believethat hypotenrlon. a feature Of the PRS. is triggered by the sudden increase in cardiac preload on r e p e r t u ~ l ~ n and involves the meChanOreCeptor d l e x af the left ventnds. We aim to study lhm hypothesis. METHODS. We studied 56 OLT patients divided Info: group A In-321, ~at ienfs in whom revancularozafion was performed tn the traditional manner. 8.e rupraheplic vena cava, intrshepllc Y.C. and portal vein: and group B ln=241. patients in whom revascuIar~zat~on was performed on the suprahepatrc vena c a m and portal Vein but delayed tor some moments on the inIrahepatic v.C. The technique of save1 preservation was not used. WE pertormed a hemodynamic proble. immediately belore and during repsrfuwm Slatirlicr: Student's t lest. Signhsance: p t0 .05 . RESULTS: The incidence of PRS was 33% I" group A and 60% 4" WOUp B. The decreare I ~ h ~ ~ r t ~ ~ t e w ~ r r l m l l a r I n b o l h g r a u D s l l 3 % v J 11%). alwalmeanatterlalprerrure136% vs 42%). However. there were indeed rignifisanf diiferences between the groups when comparing cardiac filling ureslure. which was considerably higher m group A: mean puimonary alterldl pressure$ were 53% vs 4%: central venous pressure 62% vs 9%: and pulmonary caplllary wedge PleSSYrB 56% vs 16% CONCLUSION Thechange ~nrevarculanrarian. when leading allthe flow throughthe portal vein. delays cardiac filling and shows that the sudden increase !n preload does not inciease the incidence of PRS: rather the opposite. Conrequentlv. hypotension would be caused bv the sudden vasodilation and IS connecled with reperfurion tnduced hepallc hyperemla

POSTREPERFUSION SYNDROME IPRSI. ITS CONSEQUENCES. V., XSabaCC, S. NoguLIs, L. Garcia. I. Camprubf, J. Figueras. E. Jaurrieta. Anaesthesia Department. Clutat Sanitaria i Universitaria de Bellvitge. Barcelona.

The aim of this Study was to determine which intraoperative events joint with PRS and its consequence on postoperative outcome. Methods: After I R B . perioperative notes from 93 patients who underwent liver transplantation during 1993-4 were reviewed. Oxygenation and metabolic data, neohepatic and postoperative blood requirements. major intraaperative events and bad Outcome variables were analyzed. x 2 and t-test were used. pc .05 was considered significant. Results: PRS was noticed in nine patients (1011. PRS was associaced with haemodynamic events (arrhythmias 33% and pulmonary oedema 11%). potassiumhigher than 5 . 5 m o l / L (33%1 and pHc7.25 144%1. COagUlatlOn profile was worse during neohepatic phase as defined by PT>1.5 ratlo 156).I. fibrinogenc2g/L (56%) and platelet count~so.O00/mm3 167\! Transfusion requirements were higher in the PRS group lneohepatlc RC'P 19t13 vs 7tB units; total hospital RC'P 46t24 YS 18tl3 UnltS). During the postoperative period these patients suffered more SUTgeTY for bleeding 1331 vs 5 % ) . prolonged mechanical ventilation during more than 5 days 1 6 7 1 YS 2 2 1 1 . infections I181 YS 4 1 % ) and number of tracheostamy procedures 1225 vs 2 \ 1 .

consecluences ao bevond the initial decrease in arterial Dressure and Conclusions: The postreperfusion syndrome IS a complex entity whose

- 1

should be treated energetically

POSTREPERFUSION SYNDROME IPRSI. PREDICTIVE FACTORS. L ~BxQL&. A.Sabat6. S. NoguOs. L . Garcla. I. Camprubi. J. Figueras. E. Jaurrleta. Anaesthesia Department. Ciutat Sanitaria i Unlversitaria de Bellvitge. Barcelona.

The objective of this Study was to detect preoperative and intraoperative PRS predictors.

Methods: After IRE. perioperative notes from 93 patients who underwent liver transplantation during 1993-4 were reviewed. 12 preoperative a n d 12 incraoperacive variables were analyzed using a linear regression. i n those significant variables a step-vise method were applied. pr.05 was considered significant.

Results: Nine patients llOI1 Showed PRS. Those patLents with PRS had significantly higher IMOS IIIIIV score I 5 6 % vs 1311. preoperative lower plasma sodium l134t4 vs 138i5 mol/LI and higher ~lasma mtassium 1 4 . 8 t 0 . 7 vs' 4.3+0.6 mmoll~l. Intraoveratively. huring Cepatectomy and-at anhepatic phase, those patienis with PRS had more episodes of diuresis under 50 cc/h 1621 vs 30%) and pH under 7 . 2 5 111% vs 1 % ~ . Cold ischemia was significatively longer in patients with PRS 111.5+3 vs 8.Bi 3 hoursl.

Conclusions: Those patients who develop PRS are in a worse preoperative condition, their intraoperative management IS more difficult. In those patients an effort to reduce cold ischemia must be made

Donor/Graft 419

POSTREPERFUSION SYNOROME IN LIVER TRANSPLANTATION: CORRELATION BETWEEN HEMODVNAMIC AN0 METABOLIC CHANGES. EA!2XL4. J OIAZ. P PARRILIA. JL ViDAL. RF CONTRERAS. MA RODRIGUEZ. PL TORNEL. R ROBLES. P RAMIREZ. FS BUENO. P MARTINEZ Llva Tmn$danl UII. Uruver.iity Hosmfai 'V. Arrixaca.. Mum$. SPAIN.

OBJECTIVE: If has been proposed that the decrease in arterial pressure and heart rate tn the fir¶ few minutes of the graft reperfurion are due to the grall releasing various metabohtes and hypothermia. Our aim war lo investigate whether such changes are Coiielated to one other. METHODS: We studied 33 coniecuwe ~ a t i e n f s undcrooino orfhotODiC liver rranrolantatlon. . .

*.*hod.: Dirlerence* in R rime. I l lpha mq ls , m ld -~ ,d -~ lpnm.d -m l heween narive and heparinane rls.nno.cops.IL,USrlon rep r fus ron in B cases of OLT wexe compared wi th those hrreen nariue and p'ormine in I 4 cases of OLT. i~suit.: an r.prrfusion, a i l of R C ~ rreaeed w i t h heFrin.se .hewed more improved data rather ehan n a t i v e one i n R . I I I D D ~ and MA. But.in orotanins *reared bload. R

- - . Blood sampler were Obtatned to determine potassium IKI at following times: at the end of anhepatis phase lberslinel and 30 SBC. 90 rec and 5 min alter star1 of reperfurlon. Heart rate IHRI. mean mer ia i pressure IMAPI and temperature IT1 were recorded at each time. Srafirficr: multivariate linear regression anaiysm Ip <0.051. RESUL 1.9 HR = -O.SHR,+5.3K,-5.5dK+12 6dT+42.9 lr=0.93: p=O.Oll

MAP - -0.7MAP--2.3K--2.1dK+8.4dF46.7 lr=O.68: p=O.371 . . . . .. . . . .. .. . . treated u i b

. .... . . ../".. I_. I.""-"*in." " *..*

CIRCULATING W H I N E OXIOASE PND NEWROPHIL ACTIVATION DURING HUMAN UMR TRANSPLIWTATION

Eero. Nina Under. Kari Rabia. Annikki Sarnerto. Helkki MBkisalo. Krister HdckerStedl. Stuw Anderrson Children's Hosplal and Fourth Ueparlment 01 Surgery. University of Hstankl. Helsinki. Finland

Oxygen free radicals. generated by xanlhine 01aas0 and aclivaled leukocytes. are tnwlved in reperlurion injury in experimental liver transplantation. In nme patients undergoing liver Iranrplanlalion. we studied Plasma mncenlralions of clrculalln~ xanlhine oxidase 1x0) by ELSA (n-8). purine melaboliles hypaxanthine (HXI. xanlhlne (XI. and ",ale (UR) by HPLC ("-6). lactolerrin (LF) by ELISA. and mabndialdehyde (MDA) fluoromslrically up lo 48 h p~toperatively. Preoperalively. low concentrations (5-12 nglml) of XO were detecled in pulmonary anery (PA) in only three patients. XO increased (pc0.05) a1181 reperlvalon and peaked alter hspafis allery declamping (14-465 oglml). Alter warming the liver with portal blood. caw1 ellluenl (warted) conlained 22.801 nglml of XO. Atler pnal vein dedamping. XO conc~nlral~ons were higher In hepatic than p r t a l Yein (pc0.05). indicating hepalic origin 01 circulating XO. HX and X in PA (praoperalively HX: 0.6-2.1 IimoW. X: 0-0.41 wmolil) peaked (both pc0.05) alter portal vein declamping IHX:48.2-108.7 pmolll. X: 8.7-22.3 pmoUIJ. At thal Isme highs, ~~ncenlratvmr 01 both HX and X occurred ~n hepatic than pnal vein (both pc0.05). indicating wash-Out of HX and X accumulaled during ischemia. No changer occurred in UR. LF (preoperatively 73.7.334.1 nplml) increased in PA (p<0.05) alter repeilu~ion peaking aflsi hepatic artery declamping (274.5. 1467.9 nglml). indicaling nsutrophil aclivation during reperfusion. LF mn~enlraU~ns were similar in portal and hepalic veins. No rignilicant changes were obsewsd in MUA. We conclude that reperlurion during clinical liver tran~plantalion is associated with hepatic liberation 01 clrculalioQ xanlhine oxidase and inlrava~cular neutrophil activation but not rignilicant lipid peroxidation.

420 Donor/Graft

HAEMODYNAMIC STATE DURING ORTOTOPIC LIVER TRANSPLAMATION COLT): ISORURANE VERSUS Pnornm ANAESWIESIA

F A l c h d u C. Pdlllm. P. Fchrrro. C Omd. F. Inacn le . M.L Bccni. A Mmfio. S. VCWUIIFX. G.P Ciruii

PREUCnVE VALUE OF GASTRIC MUCOSlL pKYEASUREYENT IN UVER TRANSPUMAllON MadfUJK. ZwIIeYIIg JH. V a w w R. GI-. ARJ. Slmll MJH U Y W T n N p b n I Gmvp Gmnlngsn. Udvsrrlly Hospltal Gmnlwn. the Nalherlards

INTRAOPERATIVE USE OF CONTINUOUS ARTERIOVENOUS HEMOFILTRATION (CAVH) IN ORTHOTOPIC LIVER TRANSPLANTATION (OLT)

Abderalem k*, Pageour GP".. Navarro F". Sowhe 0'. Robles G'. Fabre JM", Domergue***, Colron P*. Service d'AnertheSie Reaoimatmn'. d'nepatologie"' e t de chirurgie digestive'*. Hopital S t E l d Montpellrer. France.

Patients undergoing OLT often have multisystem diseases involving impairment of renal function. CAVH 15 simple technique for removing excess fluid during the tnnrplmt procedure when renal function is deficient. The aim of thw retrospective study was to evaluate the prono~fic of this patients. Method We perfatmed 140 OLT between march 1989 and dec 1994. 13 PattentP received intrroperative CAVH because of $evere preoperative ohgomuria in spite Of diuretics infusion (group A). NO heparine was added to the system a t any time. OLT were performed for Fulmmnt hepmc failure (FHF) (3). cirhosis with major hepatorenal syndmm (HRI (3). graft primary dysfunctton or hyperacute rejection (PO) (5). and combined liver- kodney tranrphntation (LK) (2) Control group ( 8 ) war represented by 36 patients who were transplanted for FHF (4). end stage cirrhorir l!7), re-OLT (14) and LK (1). In tho$ group "One patients had severe preoperative oligoanuria. We assessed mortality rate (after 1 yrl, CAVH duration and comphcition. inlrroperative hemofillrate removed Results: the mortality rate in group A was 38 94 VB 33 pb in 8 (NS). In group A median Operating time war 11 hours. transfusion requ8rement : I 3 2 6 packed red blood cell and 23 2 15 fresh frozen prrsma tranrfused. Mean CAVH time war 7.2 2 5 days and lntra Operatlve ult raf~l l r~te quantlty removed was 7.7 2 3.6 liters NO complication were associated wlth the use of CAVH. Conclusion: DeSplle 01 dilference between two groups (the select,on of patients was biased against CAVH because renal disease was more ienous on group A) no difference was found on mortality and M) complratbn were assmated. CAVH IS I simple technique that can be used by anesthestolog8St during the intraoperative period. These prelimmry rewlts ale encouraging and suggest the need for further EIinICaI mwrtlgatlon.

THE DELETERIOUS EFFECT OF INCREASED WARM ISCHSHIA I N OLT J Figueras, A Sabata. A Rafacas, J Sabregat, J Torras, E Jaurr~eta. CSU B e l l v i t g e . U n i v e r s i t y o f Barcelona. Spain.

The aim o f t h i s s t u d y was t o i d e n t i f y s u r g r c a l i n t r s a p e r a t i v e r i s k f a c t o r s a s s o c i a t e d w i t h p o s t o p e r a t i v e Comp l i ca t i ons i n l i v e r t r a n s p l a n t a t i o n (OLT). Nine pre , and Ln t raOpera t lVe v a r i a b l e s were matched w i t h 5 p o s t OLT e v o l u t i v e v a r i a b l e s i n 93 consecu t i ve a d u l t OLT pe r fo rmed i n O u t u n i t , between 1993-4. C o l d i s chemia t i m e was 9.lt3.5 hours , w a r n i schemia 68226.2 m inu tes and t o t a l d u r a t i o n o f the procedure was 9.3~2.2 hours. In a m u l t i p l e s tepw ise r e g r e s s i o n model, extended c o l d ischemia. t ime was a s s o c i a t e d w i t h i n c r e a s e d plasma consumption IP-0.0027). P r o l o n g a t i o n o f warn i schemia t i m e was a s s o c i a t e d w i t h i nc reased p l a t e l e t consumption (prO.OoZ2) and comp l i ca ted p o r t a l w i n r e c o n s t r u c t i o n (p=o.oOoo). I" t h e p o s t o p e r a t i v e e v o l u t i o n

vascu lar throinbosis (p=0.0002), acu te cellular r e j e c t i o n (p=o.oooo) and r n f e c t m n (p=o.o32). P ro longed t o t a l o p e r a t i v e t ime was a s s o c l a t a d w i t h i nc reased plasma consumption (p=O.OOOO) and m o r e ARoS ~ p i o . 0 0 0 ) . I nc reased Opera t i ve Limes probab le r e f l e c t s I n t r a o p e r a t i v e t e c h n i c a l problems b u t t h e cellular necrosis super imposed b y t h e extended warm i schemia p robab ly can also f avou r a c u ~ e cellular r e j e c t i o n and i n f e c t i o n .

extended warn8 i s chemia was associated w l t h more reopRrat iOnS f o r

Donor/Graft 42 1

Fla 2

URGENT REVASCUL4RIZ*TION OF LIVER ALLOGRAFT WITH EARLY HEPATIC ARTERY THROMBOSIS 0. V i n n ~ M 0.. C.V Smnh.M 0, H. Furdawlr.bl.D., 1,. Fung.M 0 .Vh.D. Pblllburgh Trrnlplrnl I~sLIIuLE. University 01 Pittsburgh. S c h d of hlcdcrinr. Ocpw!mc:nl 01 Surgmy. Pilbburgh. Pennqlrmia. USA.

I I Fig I

_ -

422 Paediatric Transplantation

INTRACRANIAL PRESSURE [ICP] MONITORING IN CHILDREN WITH FULMINANT LIVER FAILURE [FLF].

CJaxhkx. P Ourand. P Derremme. A Rousset, D Devccar. D&panemenr de Pkdiatne. Unite de Smns Intcnnfs. Hbpitrl de BICETRE. 94275. France.

Elevated ICP is a major complication of FLF. ICP is routinely monitored tn adults with FLF. Experience in children is limited. w since 1990, 4 0 children with FLF were evaluated for orthotopic liver transplantation (OLT). The indications for ICP monitoring were patients with grade 111 or IV hepatic encephalopathy and the absence o f contraindications for OLT. Coagulation disorders were corrected prior t o the insertion of an extradural fiberoptic catheter (Camino Lab. San Oiego). IC hypertension was defined by an ICP > 25 mmHg during > 5 min. Cerebral perfusion pressure was recorded simultaneously. Buulrs; ICP was monitored In 14 patients (mean = 6 yr). 8 were in grade 111 and 6 in grade IV hepatlc encephalopathy. Causes of FLF were undetermined (n-9). virus-induced FLF (n= 3). and mircellaneous (n=2). IC hypertension was noted in 10 children. In 6 of them ICP peaked above 40 mmHg. 2 children died awaiting a graft and 12 underwent LT. Among them, 7 died after LT. ~oncluslon. ' ' children with FLF and grade 111 or IV hepatlc encephalopathy may present IC hypertension. This complication should be considered prior to OLT. The prognosis value of ICP monitoring seems t o be limited but the number of Datients in this serles is limned.

ORTHOTOPIC LIVER TRANSPLANTATION [OLT] FOR TOXIN- INDUCED FULMINANT LIVER FAILURE [FLF] IN CHILDREN.

A Chouchana. C Lanchier, P Ourand. P Desremme. A Rausser, 0 Devcctor. Depanemenr de Pkdiame. UnK6 de Soms Intensifs. Hbpm de BICETRE. 94275. France.

Toxin and drugs are one of the main causes of FLF m children. We report our experience. since 1985. 63 children (mean : 5 . 5 yr) with FLF were evaluated for OLT. Drug-induced FLF and toxin-induced FLF were found in 9 of them (1 4.2%) [amanita phalloides n=2. halothane n=2, sodium valproate n-2, acetaminophen. salazopyrine. indometacin one case each]. Children with hepatic encephalopathy. factor V level below 25 % and the absence of contraindications were considered as candidates for OLT. ~~JLSL on admission all patients but one presented with hepatic encephaloparhy. bilirubtne : 134+187 wnol/l. ALT : 4648?5828 UIII. prothrombin time :1 8?7 %. factor V:l 7t10%. 4 children had contraindications for OLT (preexisting neurological disability, abdominal infection. multiple organ failure). All of them died. 2 children had no indication for OLT: all are alive. Three children were transplanted. two of them died, ~onclusion: in our series, toxin and drug-induced FLF represent the second identlfied cause of FLF in children. The prognosis 1s severe with an overall mortality = 66.6 %. The indications for OLT are limited by frequent contraindications.

ORTHOTOPIC LIVER TRANSPLANTATION lOLTl FOR FULMINANT . . WILSON'S DISEASE IN CHILDREN

N Aiadjid. U~G!!SL D Debray. P Dunnd. 0 Soubrane. 0 Dev~ctor. Dkpanement de Pedncne. Unite de Soinr lntenrlfr e l 8hhpsrologie pediarnque. HOpical de BICETRE. 94275. France.

We report 5 children evaluated for fulminant Wilson's disease. L&~.Ixz since 1985. 63 children (mean5.5 yr) with fulminant liver failure (FLF) were evaluated for OLT. Wilson's disease accounts for 8 % of the cases (n=5). on admission al l children (mean : 10 yrs) presented with grade 3 hepatic encephalopathy [HE], hepatomegaly and jaundice. The interval between jaundice and HE was 8 d (2-16 days). A Kayser-Flercher ring was present in 4. Laboratory features were as following: ALT 8932406. IU/L. total bilirubin: 1 0 6 9 e 2 3 4 vmol/l. factor V: 20?4 % of the normal, Creatininemia: 250?50 mmol/l, ceruloplasmin: 00.7?00.4 g/l. Hemolytic anemia was noted in all cases. Plasmapheresis were performed in all children prior to OLT: no improvement of HE and liver function tests were noted. All patients were registred on the emergency list of OLT. One died awaiting a graft, one died immediatly after OLT (brain herniation 7) . one died lately (severe neurological sequelae). Two patients are surviving. one after retransplantion for hepatic artery thrombosis. Unclusion; Wilson's disease may mimick fulminant hepatitis. Plasmapheresis does not modify the clinical course. The success of OLT ~n this situation is limited.

ORTHOTOPIC LIVER TRANSPLANTATION [OLT] FOR SEVERE LIVER FAILURE [SLF] IN INFANTS YOUNGER THAN 1 YEAR OF AGE.

LDhiri. D. Debray, C Lanchm. C Chardor. 0 Devictor. Departemem de Pedmtrie. umte de Sam lntenrifs el d'Hepatologle Pediatnque. H6pital de BICETRE. 94275. France.

Severe liver failure [SLF] is a rare but severe condition in infants. We report our experience. euiulll: SLF was defined as liver insufficiency with hepatic encephaloparhy and a decrease in the level of factor V t o below 28 %. Between 1984 and 1995. 29 infants (mean : 4 mo) were admitted for SLF (neonates excluded). Main causes were metabolic disorders (41.3%) (tyrosinemia n=S. hemochromatosis n=2. Reye's syndrome n=2. other n-3). virus-induced FLF (20.6%) and hematologic diseases (13.7%). In 4 cases, the causes remained undetermined. EcuIts OLT was contraindicated in 12 cases because of multiple organ failure (n=lO). or underlying disease. All of them died within 6 days after admission. 7 patients had no indications for OLT. all but one are alive. (1 of them was transplanted later for tyrosinemia and 1 died lately (virus Induced-SLF). Among the 10 infants who underwent emergency OLT. 6 are alive and 4 died because of primary non function of the graft. Canclusian. SLF in infants admitted before their first birthday is a severe condition with an overall mortality rate reaching 60?6 Inherited metabolic disorders are the first cause of SLF at this age. Contraindications for OLT are frequent because of underlying disease or multiple organ failure.

FULMINANT LIVER FAILURE [FLF] IN CHILDREN : REPORT OF 63 CASES EVALUATED FOR ORTHOTOPIC LIVER TRANSPLANTATION

unite de Soms IntenlifS, de chtrurge. dh~patalogce Pednmque. Hbpital de BICETRE. 94275. Fr.

We report our results with orthotoplc liver transplantation [OLT] in children with FLF. eatkntz between Dec 1987 and July 1995. 63 children (mean : 5.5 yr) with FLF were evaluated for OLT. The main causes were viral hepatitis (30.1 %) and toxin-induced FLF (14.2%). In 21 children (33.3%). the cause of FLF remained undetermined. Children were considered as candidates for OLT only i f hepatic encephalopathy was associated with a decrease in the level of factor V to below 25 %. Kcsults 12 children had no indications for OLT : all recovered. OLT was contraindicated in 7: all died. In 3 of these 7 children. contraindications included irreversible brain damage at the time of admission. 44 children were considered as candidates, 3 died awaiting a graft. 1 recovered spontaneously. 4 0 underwent OLT. Among them. 25 survived (62.5 %) but 2 had serious neurologic sequelae. Mortality rates in children with toxin-induced FLF. virus-induced FLF. and undertermined causes were respectively 66 %. 22 % and 30 %. Lxuluka emergency OLT is an effective treatment for children wlth FLF. However the prognosis is still serious especially in patlents with toxin induced fulmtnant liver failure.

D. Debrry. C Lanchw. B Dou~let. C Chardat. 0 D e v s t ~ . Depanement de P4diarne.

Paediatric Transplantation 423

PLASMA EXCHANGES IN 1 1 CHILDREN WITH FULMINANT LIVER FAILURE AWAITING ORTHOTOPIC LIVER TRANSPLANTATION

U&LI, P Ourand. C Lanchfer. P Desremme. A R O I I S P ~ ~ . 0 Devicror DCpanemenc de Pediarrie UmrC de S a m Incenrif~. H6pital de BICETRE. 94275. France

The potential benefits of plasma exchanges in patients with fulmmant liver failure [FLF] are t o correct coagulation disorders prior t o liver transplantation [OLT] and to protect the brain by removing hypothetical products implicated in hepatic encephalopathy. We report our experience in 1 1 children (mean : 6.9 yr) w the causes of FLF were virus-induced FLF n=2. Wilson's disease n=2. toxin-induced FLF n=l and undetermined n=6. Plasma exchanges were performed with a venovenous technique using a double lumen catheter. a pump Hospal BSM 22. (Hospal, Edaon. New Jersey USA) and a high performance membrane (Plasmacure. Kawasumi lab. Tokyo, Japan). the correction of coagulation disorders was obtained in 10 cases. No improvement of hepatic encephalopathy was observed. Severe complications occurred in 2 patients (cardiac arrest/hypocalcemia and hypovolemic shock/bleedtng) 10 children underwent OLT within 1 day after plasma exchanges. 6 patients are alive after OLT. Five died post OLT because of surgical complications. Lmdumn. ' these data suggest that plasma exchanges do not modify the course of hepatic encephalopathy However, thls lnvasive technlque may be interesting t o correct coagulation. disorders before liver transplantation.

M. Gundlash. B. Nachtwey. M Malag6. E. Slum'. M Burdelski'. X Rqllen. C E B d i c h Abt. lur Allgememchmngm. Kinderkhmk.. Universitaukrankenhaus Eppendoti. Hamburg. Germany

MINIMAL PRESERVATION-REPERFUSION INJURY IPRll IN LIVING RELATED LIVER TRANSPLANTATION ILRLTI -ACCURATE EVALUATION BY GLUTATHION S-TRANSFERASES tGSTl H Egawa. w. K Taoaka. Y Inomata. S Uomoto. K Saromura. T Kwchi. M Kawarhima. Y Vamaoka. Second Dept. of Surgery. Kvolo Unlversilv Harpitat. Kyoto. Japan.

MINIMAL PRESERVATION-REPERFUSION INJURY IN LlViNG RELATED LIVER TRANSPLANTATION (LRLTI - ACCURATE EVALUATION BY GLUTATHIONE S- TRANSFERASES (GST). H. Egawa. H., K Tanaka. Y. Inomafa. S. Uemolo. K. Salomura. T. Kiuchi. M. Kawarhima. Y. Yamsoka. Second Dept. of Surgery, Kyoto Univerrily Hospillll, Kyolo, Japan.

OBJECTIVE: To assess the impact of LRLT on PRI. we p r ~ ~ p ~ l i ~ e l y studied the clinical C O U ~ E ~ S 01 41 pediatric patients measuring GST, recenlly reponed as a sensitive and rpci l ic marker of ihepatic parenchymal injury. excluded 15 patienls undergoing Iaparolomy wllhin 41 dayo after LRLT lrom 56 patient3 (5 month-old lo 17 years) undergoing primary LRLT between September 1993 and October 1994. Serum level of GST was delemined using Hepkit I Biolrin inl. Ireland I . RESULTS: All donors (age : 21 to 46) had normal liver function. Cold and Warm

ischsemic lime (WIT1 was 134+85 ImeenfSDl mi". and 48f1 1 mi". IntraopBratlve blood transfusion WBE 36 lo 819 ml/kg (median : 103 ml/kgl. The peak vsluef of ALT, AST. and GST were 55 lo 669 IUIL. 66 10 765 IUIL, and 30 to 2 4 7 nglml (normal :C 5 ng/ml). rerpeclweiy. The WIT rignificenlly co-related with the peak GST. GST returned to normal range signilicantly (pc0.05) esilier (mean: 3 2 days) than ALT 16.4 days) end AST 110.3 days). CONCLUSION: 1 .I LRLT prerumably contributes to Ihe minimal graft injury wliich was significantly effected by WIT. 2.1 The GST demonrtraled that the grafb recovered from PRI far 3 days after LRLT. 3.) GST could be a useful parameter for pastoperative management after liver Imnsplenl~l~on.

METHODS: To assess PRI. we

LIVING WNOR VERSUS CADAVER WNOR UVERTAANSFlbNTATlON OUTCOME ANU RESOURCE unLunoN IN PEDIATRIC RECIPIENTS

R Shacklelo , KM Ollholl. 0 Junm, S McD~annld. P Manm, A Shaked. A Mailield. A Pakr&, J MdtMk k K lmagawa ?.4 Kinkhablala S Ruhch. P Seu M *men1 J VPI as and RW BuSulll. olnrlon t;ver rmnwsplami oepanmem o i s u m , "cu &M ol ~ e ~ r i r e

424

GPT(LR) 71+11 6 9 4 9 S8+05 GPTICad) 362+204 406r23 I 284+168

Paediatric Transplantation

4 8 4 4 41+11 45+20 5 1 + 2 5 276+269 IS2s13.2 226130.6 158+200

INFECTIOUS COhlPLlCATlONS FOLLOWING LIVING RELATEU L lVEH TRANSPLANTATION

U., R CnnrrLor. X. Kogicn. hl. Uunlrlrki. Dept Pediatrics. Univerrity Horpilal Eppmdorf. Hamburg. Gemany

Due lo the rhonagr of pun-manew organs. no1 all chrldren woth exnd-stage hver diseare in need for liver !ran$plantation (LTX) can be tranrplanted. lading to monality an the waiting hst By means of living related liver transplantation (LRLTX). monaliiy rale on the woiing list can be reduced Tlx ohjectibc of this retrospective study was 10 delermine wlrther performing LTX electively reducer lhe raw of infectious complications following LRLTX From OEtobn 1991-Janualy 1995.42 LRLTX were performed in 42 children ( age 5 months- I3 years. weight range 5 6-38 5 kg (5PA.clOkg)) 1iiirnu1101~1pl)~eill~ll i n c l ~ d e ~ cyclosporine and predarone. FK 506 b a s used in 3 patients for aeroid-rerinani-rcj~i,~" episodes Following LTX. lliere wcrc 7 I significant episodes of bacterial infcctm m 35 children (81%). mainly caused by C ~ I ~ ~ ~ X O C L I ( 1 796). slspylococci (20%) and E coli (I 5%) The most common forms of bacterial mfti lan were repsir (n=31). cliolangitis (n=S) and perilonitis ("=a) 21 patients (50%) had nt lean1 one clinically significant epmde ofvra l infection. CMV being most common (16%) 12 pallenis had at least one epmdc of cliniCally relevmi fungal infection (15%) SuMval mle w81 69%. 6 deaths were associated w t h fungal infeciion occuring in severely malnourished rhildrcii wlli prmour history of recurrenl infections and antibiotic therapy Conrlurionr lnfecrious complications are a major cause of morbidity and monality followmg LRLTX In our population the m e of infectious complications followrlng LRLTX IS

not lower than followng LIS usmg a pa-monem organ llx broader use of FK 506 or a modified scheme of K I L U ~ ~ C bowel deconiaminatlon mlght he able to lower the rate of infectious complrmionr in !he fulurc

PIS 5 1 Y e w PIS < 1 Year N Pt. Surv % G r a f t Surv ?& N Pt. Surv X Graft S u r v %

Al l Pts 123 79 6 5 8 4 9 0 8 3 Seornen!s 6 8 7 6 56 69 94' 901

GLUTAMIC-PYRUVIC TRANSAMINASE (GPT) AND a-GLUTATHI0NE-S- TRANSFERASE IoGST) AS MARKERS OF CYTOLYSIS A€TER LIVING-RELATED AND REDUCED-SIZE CADAVERIC LIVER TRANSPLANTATION (OLT). R Rcding. P.Wa1lcin.a~. D.Moulin. S.Clcmen~ ESokal. J de Ville dc Goyct. J .9 Oiic (SI-Luc University Clinics. Brussels).

The enzyme UGST 1 1 ii more sensible m ~ i k e r of hcpatocellular damage than aminotnnsferaw~. k a u x of the I0-fold higher cylosul~c conccniration and \hortc~ scmm half-Me of Ihc former. WE rcpon il compdraiive study of early posl-OLT monilormg (day? 1-7) of aGST and GPT .tfler 14 pediatric livmp-rclaed ILR n=8) or reduccd~size crdilvciic (Cad n=6) hepec nllagrafts. Mean (SD) 101d ischemic I I I ~ C ~ (T IT minutes) were 175 134) and 651 (183) m the LR and Cad groups. rc<pecuvely Serum aGST Icvels were determined using an ELlSA (Biotnn 1~11.. Dublin, Ireland)

No early (<7 days) graft IOSSES were cncotimered. Mcon+SD GPT m d aGST IcveIs for LR and Cad group- are erprcs~cd as multiple oflhc upper l lmll ofthe norm31 values:

Paediatric Transplantation 42 5

Nephrotoxicity Melabolic disorders lacidoscs. hvoehaliemial

PEOIATRIC PRINAUY ORTHOTOPIC LIVER TRANSPUNTATION UNDER TACROLMUS e , Jain A , Todo 5 . Green M . Fung JJ, Jrbbour N . Srerzl TE. P i ~ c s b u c e l i

CONVERSION OF PEDIATRIC LIVER ALLOGRAFT RECIPIENTS FROM CYCLOSPORINE TO FK506: ANALYSIS OF CLINICAL EFFICACY.

&$antation 1 n r L ~ L u i e . Pircrburgh. PA.

Beneflt of Tacrollmur ~n c l l n l c r l r runrplnniac lon have heen described Present srudy exanlner the ~ u c c o i n e of 195 sonsecuLive prmary o i c b o r o p i c liver

performed between OcCulier 1989 co December 1991. mean age 4.96f5 21, (med ian 2 7 1 years. ( ~ 1 year-56, 62.?7. >215-1?. >5112-17. >12-321. These were 112 boys and 8 3 glrlr: mean follow-up was 44(range 16 to 66) months. Results are shown I n cable b e l o r .

suruiu.1 eat1enc 0 ) Craft

T. 1111 mg/dl AST U/L RLT U/L AlkPO. U/L GGTP U/L BUN mg/dl C r e a t mg/dl 1""""".3*"ppreSSlO" Tacrollmur dose m / d l 0 14 0 26 0 25 0 13 Tecro. level ng/mk+* 0 82 0 83 0 SG 0 56

U J B E A Y , E.JACOUEMIN. V.FURL4N. M.FABRE. 0.BERNARD. Department 01 Pediatric

FK506 IS a new immunosuppressive agent. used m the rescue 01 ,electing liver allograft rmpientr lading conventional immunosuppressvan. The a m 01 ths w r k was to evaluate the eflicacy 01 conversion lrom cyclospo~~ne.steroid immunosuppression to FK506 10 ped#atr#c liver albgraft recipients. eauearZ: Between November 1992 and December 1994. 16 children (mean age 6.9 years) were convened lrom cyctosponne 10 FK506 tor Slermd reswant acute lelectlon PAR: n-7L early stage Chronic reiectron (ie.bile duct damage and bile duct lops

Hepatolow. Pharmacobgy and Pathology. BiStre Hospilal. France

eranrplanc.clonr i n prl l iacr ic pOp"lacio"(r~ecl8 Y'I) fro," .1 LL"g1e L"rt,t"C*en

1 year 2 years 1 yerrr 4 y e a r s 5 years 82 16 84 78 84 79 8 1 8 1

L O 0 7 0 6

76 52 66 52

2bir 5 1

67 0 8 0 7

67 61 79 96

181 106 3 2 6 286 49 3 8 19 16 0 6 ;: '' 18 18 85

0 6 0 1 0 6 0 8

0 1 7 0 b 8 92

86 8 1 limited I0 leSS than 25% 01 the Inads) (E-CR. n-6) 0, later Sage ChrOnfC retectlOn (btle duct IOSS In mOfe than SO?'* 01 the tnadJ)(L.CR: "-3). m: FK506 was adminiliered Orally Llver/Rsnal function 1 nonrh 6 nonrh 1 y e a r 2 y e a r 1 year initially at a mean dose of 0.22 mgkgday, adjusted to the Clinral response and the monlloring of the patlenl'r whole blood trough levels (IMX aoalyser. ABBOTT). 10 be maintained between 10 and 20 Wml. Respanre to FK506 therapy was monitored bmhemicatly. W At the lime of FK506 onv version. al l chtldren but 2 had increased serum levels 01 total bilirubin (range 34.395 uM). all had increased ALT (range 57-784 IUil) and GGT (range 235-2307 IUII) activilies. Aner 6 mo to 3.5 years 01 FK506 therapy. liver 1uncli00 IePIs are normal ~n 8 C h l O e n and have improved 8" 9' serum lolal bilirubin 8s normal In all children but I, ALT ZCtlvlty has dBCreaSed slgnlcantly ~n 6 (range 50-87 IUIII and 1s normal #n 12. GGT actrvily

11 bcchem8cal response to FK506 conversm was observed rn 71.5% 15/71 of RAR. ~n 37 5% Hypercenr ion 0) 15 8 9 5 (3/8) 01 E-CR and m none 01 the children (013) wilh L-CR. One patient ,with L-CR railed to rerpond to FK506 and dled (11 Sept~C shock and liver ladwe. Overall pate01 and gram sury~val rates are 94.44'. at this writing. LmxImu~ ' FK506 allows 8mprovement in virtually all patients and especially 8" those wtth RAR. luggesllng that convemon to FK506 should be

has decreased rqnibcantly #n 9 (range 52.197 IUII). and is normal in 6 children. Full Freedom Of srenosir 0) 8 1 811 9 1 93

benefit of lacralimur LI? p e d i l l r i c popu l .? t i on is ever? nore I m p u l . r c i o n (1, terns o f / p i l l i rnr s u r v i v n l . g r a f t s i i r v i v a l and

Crrft l o s s due t o .?cute o c c h r o n i c rejecLion has been (*' Plasma trough exrrernely rare

kWl1 Toxicity p r o f i l e of the drug will he dischissed

consdered as soon as acute reiection does not respond to Ltel0,ds.

9 (757.1 1 116%) 7 1681.1 0

CONVERSION FROI CYCLQSPORINE TO TACROLIIUS 1 N PEDIATRIC LIVER TRANSPUWT R E C I P I E m s . BLuul. Jeln A. Todo 5 . fung JJ. Green K. Jnbbovr N. S L a r ~ 1 TE PiCcrburgh Tran=planration I n s ~ i C u r e , PiLLsburgh. PA.

I month 1 year 2 years 1 years 4 years 82 0 1 4 . 6 Pmfienc survlv.1 0) 9 1 . 2 81.2 8 4 6 8) 1

Cr.ft .urviv.1 0) 81.2 81.6 80 .7 76 9

I week 4 weeks 25 weeks 50 r e e k s 0 . 7 70

1 3

0 7 87

0 7 Llucr/Yidney function* Pre

9 1 116 1 1 207 1111 ng/dl

305 149 289 166 AST U/L

298 ALT U/L

79 17 17 16 0 8 0.8 0 8 0 8

2 1 0.8

27 CGTP U/L BUN mg/dl CreaC n&/dl

0 . 7 61 60 120

(*median valuer)

841 of the ch i l d ren who w e r e on Prednirone are currently completely o f f Prednirone 58% of the parlencs who regulred anclhyperrensive medlcationr are complete ly o f f t he i r antihypertensive medications Causes of death. graft f a i l u r e and adverse events v l l l be discussed. Above data ouillnes t h e b e n e f i c l a l e f f e c t s of Tacrolilnvr In acute and c h r o n i c refection of pediatric LTx r e c l p l e n i r

~xpnimrnlh ~ ~ 1 0 6 a, ~~lrnuy~mmunoluppr~ll lvc ihcnpy p d m S tl-r rranrplsnmion ADVERSE EFFECTS OF FK506 AFTER LIVERIRANSPLANTATION IN CHILDREN. V.FURLAN. E.JACC!UEMIN. t. VINCENT. 0 BERNARD. Department of Pediatric &Q!m!!S Barnet C. Varpar J. Arne01 M. Bvrullil R.

Hgatobgy. Pharmacology and Pathology. BicStre Hosp~tal. F m c s D e 2 a I m n t O t Pedatncsm surpery, U.I"B(YtY a( Cdllwul. lo%engeleJ

FK506 UaS used as rescue therapy in 16 pediatrc liver transplant recipients with steroid ieSlStant acute relectlon Or chronic releclmn. The a m 01 I hs work war to evaluate the adverse elfecls 01 FK506 8mmunorupprerrmn. 1 2 chlldien were converted tiom CIA to FK between Nov 9 2 and Sepl 93. FK was given orally initially at a mean dose 01 0.27mgkgd. adiusted I0 whole blood trough levels (IMX). mean 15.4 ngml The mean 4 monlh-cumulated dose 01 FK was 36.5mgikglchild. FK war diswnlinued 8" 2 children because 01 lymphoproliletalive diseases. Which Occurred 4 months alter FK conversion. w: 6 children were convened ID FK506 between Sepi 93 and Dec 9 4 FK w a ~ g w n at I mean dose 01 0.IJmdkaId. adlurled 10 Irouah Ieveli. mean 12.3noIml. The mean 4 month-cumulated dose 01

idverse eftects are dare-d&odenl 2) the whole blood trough tevds 01 FK should bemamtamed below l5ngml 31 the 4 months cumulated doles 01 FK506 should not exceed 20mgkg. In these CIICUmStanCBI. a reductton 10 the long term prevalence 01 ride effects 85 expected while maintaining ad~quate 8mmunosuppreroan.


INCREASED INTRACELLULAR CALCIUM AS A POSSIBLE MECHANISM FOR TACROLIMUS RELATED CARDIAC TOXICITY I N PAEDlATRlC TRANSPLANT RECIPIENTS.

ABD-1 PEDIATRIC LIVER TRANSPIANTATION A USEFUL MODALITY W S Andre-. J Sommerauer. J Roden. P Moore. C Conhn Divlrurn of Pedlalrlc Surgery, Deptof PedmlnCI. Unlverwlq 01 Texas Southwestern Medical Center. Dallas. Texas

ABO incompaoble lwer kmrplanlaDon (ABO-I) ?s freqvenlly used when an ABD dentcat or campat8ble organ S YMNdllable and Ihe PI S In CrlbEsl condilion However. because Of increased donor demands. we developed a PrOIoCDl for Ihs use of ABO-I graffr

All Shlldren who received ABO-1 followed a P(mllal pr010501. ImmunolupPrFSYan conysled of quadruple t h c r s p l ~ an mk17.10 days of an anlilymphocVte prepsralmn. cyclorporine. prednbne and azathioptine In 3 pabenk. cyclospome was replaced wlh tacrolimus PlOrpeEWe double volume plasma ershange (PE) war InnbNed when lhs ABO-I hler was rl 4 and was slopped anel the ABO-1 Yler had Ilabllzed for 7 day- Sc4enecW#!ywas no1 perlormed on any pabent From March 1988 I0 Oslober 1994,120 children received 129 LT and 24 (23%) of h e recmed 28 ABO-I g r a b The other 96 PIS are mcluded as a Sonlrol group The ABO-I gmvpnCluded 1 2 m a l e r a n d l 2 f e m ~ l ~ ~ h ~ ~ age013 9tSOyrr[9<1yr.land a lo l loW-up0f246~07yrs A1 LT. the UNOS llrbngs were 17 (71%) ~ t a t w IV. 5 rh lva 111 and 4 dabs I1 The donor lo mupien1 blood fype mat& M m 14 A-0, 4 8-0.3A-8.3 84.. I AB-A and 1 AB-B 77% of pts reselved whole organ graflr PE was requiredm92%dlheptr The Pup1 war7(1-17)andlhe p0sf-opdayf~rsomplallng PE war11 (1-451

The IF A W pl and gran SYNIY~I. were not s~gndcanuy dtRerenl fmm the sonuoi group (67% and 59% w R2%and77%~~arwereIhe3yrsu~vsl~(67%and59%~77%~nd73%) ThsincldenceofreLTwsr highermlh ABO-I (23%d% P- 003). but ieLTsumal was hoherwith ABO-I (80% M 25%) Gran lass andlor pt death was hredly rebled 10 lhe ABO-1 m only 33% of the cases Vascular COmpLcabOnS weie JigniAcanlly higher mlh ABO-I (hepatic arlely Ihrombasis- I 1 5 % ~ 2 1 % parfal vein thrombonr- 3 8%vrO%). bUI bhary somphcel~ons were smlar (I5 4%=9 3%) The inudence of rejecPan mth ABD-1 was 57 7% and 92% 01 these responded lo sIero1dl alone The hmptalrlayforlheABO-IwosIOt3~days(medlan24) The 1 y r S ~ N i V a l OlUNOS slalur IV pbwas no1 wrrened by either ABO-I (76% ABO-1 vs 73% control) or by reslpenl blood We

SPnous relemon occurred m only 2 patents and Caused gran loss In I A804 IP an mHec1NB lechnlque for erpandmg the donor pool m chddren

Wilh lhrd prolocDl. ABO-1 LT can be sccompllshed mfh an acceplabls paUBnl and graR I U W S I

I N T R A O P E R A T I V E VS PREOI'ERATIVE DOUBLE V O L U M E E X C H A N G E TRANSFUSION IN P E D l A T U l C L I V E R TRANSPLANTATION ACROSS ADO BLOOD G R O U P BARRIERS. Q L k k A Pula. P Tnn. KC Belmi. Deyutmcm of Anenheralogy, Mmnmmlu. MinneUIO -55451 U.S.A.


LIVER TKANSPLAWATION IN PATIENTS LESS THAN 5 KC OF WEIGHT

Lkpanmrnlr dSuryvry and I ' d m i m , Univenilnl Krnnkmhaus Eppedurf, Hamburg X I<u~wm, F. 5 1 u m V Whe, R Kuhlenodl, M Uurdebko and C E Dnr l rh

S i m Ihe mutine use of mduced size grans liver trnnrplantalion (LTX) has bnn pwlble in a smaller pdialrir. ptqdiliun. Children wiha body weight less lhan 10 kg. b v r ken conridcred 1 high riskpopulation. Scnme ciala exisl on palints kss than 5 kg. From October 'YI 10 hlny '95 91 pedinlric LTX have been performed at the Univenital Kmnkcnhavs EpFpmdorf in Hamhua. 46 (50.5%) were I r r lhan 10 kg and 7 (7.7%) were *u lhan 5 kg. In Ihe* Ik idiraliun fur LTX was biliaty atmia (n=3), neombl hepalills (n.3) and neonatal hemochnrmnlosis (n=l) . All patielus mceived a Id1 hlernl (segmmlr 2 + 3) onhoto ic gmn. In 3 uw a living r e h d lram lanblion w a s r f o r y d . 2 palients were dnsrilie8as UNOS 1 (High Urgency), I as UN& land one as NOS 4 51nged abdominal clorum wilh GoeTex palch was required in 5 ptima Two plalienls mLvivcd AKJ immpalibk gmhs. No aeulc vaxcylar or bib duct ~ompli~'ationr ovcurred. One paliea required p ~ ~ l l a l grnn rewdiuns ant1 lives IUW wilh only one liver segmenl a d deselopJ chmnic uholac%ilir. The peculiir immunolopir. iiiln and ptaluperalive -1s of thr nunagenicnl of lhis populntinn are dixuud. Short term wsu11s are very g d . All pnlienlr are aliw except one who died wnilinp lor rc'l'x'hor chmniu mjrcliun a1 12 months. Gnrwlh FUIYE~ and devclupmrnl are salidactory cxcepl in Ihr pilien1 wilh chnrnic vhular@tir wilh mean follow-up 19 months (1-38). Owan sire maluh duus mil fulluw standard ruler. There mlghl be an immunulogic ndvnnla~c graflinp. pl i rnls in yww .I e LTX inchildren Ieslhan 5 g i r technically demanding bulrrrtninly lenribkand indicaled.

P a l vein complications after liver transplantation lor biiiary a t rda C Chardot. JM Hemn , B Duqumm. 0 de D n q . C Lmnchkr, D l4aba.D RrknM. F OlUNlln. J V & y n

Analy%is d portal w i n m p l i u l i o n s (WC) alter liw Mnsplanta(ion (LT) IM biliry atnria (BA). PafkmW and methods: Rslmspe*iwJ W d y d Vn, chuU d 96 children aubmltlsd lo LT ( 1 1 4 ~ ~ ) r o r BAhOm i nmm- h u l f s : t 9 W C o m r m d i n l 7 r e d ~ n * , ( 1 7 . 7 % ) o l 2 5 g ~ ~ . ~ w a m 1 6 V m m b o s * (PT) and 3 stemsir (PS). Filleen early PVC occured beween day 0 and day 17 (median lime = day 2) and wem all diagnosed by means ol rouLina DOppler aorography. FWr delayed PVC ware m W i 4 m 24 months a m LT because ol penillem spknomekdy wim anemia t moalena. No Isolated PVC rerulled In impairemanl of praH IunctiOn. Contrarily early PT a d a l e d wilh mil U m m b a l s led m g r a f l e in 2 cases. M u l W andlor repeeled bowel PmfMaIims Ylo*red 3 early PT. Fa# slemss M hrombosis ol IVC or lwpalic wins were demonswaled In lhe cwne ol 3 early and I delayed PVC. Emergency UmmbectDmy was done in 8 Caws d d y PT and was SuoxssIuI h 5 Cases. Three children underwanl a d i u y p o n o s ~ k thunl (SuaeSSfId in 2). Three PS w e cured eilher by s u m or balloon dilaPLion. Four Children dled. partly due lo PT mmpliunions in 3 cases. 3 are aliw vilh portal hypsrtension (PHTI and 10 -1 PHT. T h r e b p r actuarial survival is 82% in PVC casas and 83% in olher cases. Risk hdors in lhis series are young age a1 LT and small dam- d portal vein (I test p = 0.027 and 0.006 respe*iwly). CmcIudom: In our expenence. PVC are hequenl aller LT IM BA. Whl in W g palienls with narruu portal win. Emergency lhrombecPDmy is mwmmmd& in case ol early PT in order lo a W -re morbidity. Furhermne. delayed shunl pmcsdues may be jeopardized by asscclated -I obslruccOns.

w m s * + M 78NmYGCU. -94 2 7 5 L E I V I E I U N ~ E . F-


INTERNAL HERNIA AND VOLWLUS OF SMALL BOWEL FOLLOWING LIVER TRANSPLANTATION

Pittsburgh Transplant Institute, 3601 Flfth Avenue. Pittsburgh PA 15213, USA.

A. Rhanna, 8 . ~evnan, J. &yes, J. F U ~ , s . Todo. T.E. starzi

Internal herniation with volvulus of the small intestine is an Uncommon and potentially fatal complication after liver transplantation. We present here four cases where herniation occurred around the Roux-y-loop used for the billary reconstruction. One patient died due to intestinal and liver allograft necrosis, and another lost almost the entire small intestine and has undergone successful intestinal transplantation. TWO patients survived fallowing surgery which involved reduction Of the hernia and Closure Of the meSentPIIC defect. Clinical diagnostic implications emphasize early diagnosis and appropriate operative intervention. Clinical sum mar^ O r Datients with internal hernia follovinq OrthotoDis Liver TransDlantation

onset time Svmotoms QKtGQIg

12F Bil. atresia 10 years abd.pain sb resect. cured 14F Ala91lles 2 years vomiting hernia cured

12F A-1 at def. 13 days abd. pain sb resect. died reduction

38F Crypt. ~ 1 r rh. 19 months abd. parn hernia cured reduct ion

INTERVENTIONAL RADIOLOGY FOR COMPLICATIONS AFTEA LIVER TRANSPLANTATION IN CHILDREN L. D b ne I Kenemans" E Robberedl.. v. Verstraelen B de Hempunne" M Kunnen &% 01 VaSCulX a i d InterYenIlOnal RadlOlogy Pa;dmtrlc Gaslroenteiblcg and AbdOminal surgery. unit 01 ~wer ~ransp~antation , University ~orp;tat. ~e Pinieiaan 18s. ~ m t . Llgium

Overview 01 md!callons. lethnques and WtCOme m mlervenlmnal proCedures On children *,,a. trim=dnnlillim, nl t h P !,"a,

conclusion^ , lnlervenlioiial radiology m children lor CWnpliCaIionS BIler lhei transplantation is IechnicaUy leasble. wim low mmplicaDM rate and g o d outCane

B O W E L PERFORATION AFTER PAEDlATHlC LIVER TRANSPLANTATION H. Vilca MelendeG V. Vougar. P Muteran. A. Baker". G Mieh-Vergani". M Rela. K Williams'. ND Heaton, A Mowat" Liver Transplant Surgical Service, lnslitule of Liver Studter', Depanrnent o f Child Health", Kmg'n College Horpilpl. London.

The incidence of bowel perforalion following onhoropic liver tranrplantation (OLT) his been investigaled in 159 consecutive p i d i l r i c liver recipients Nine patientr (5 6%) had bowel perfamtion post-trmrplant (6 female. median age 4 years. range 0 6-12). The ncfiology of their liver di- was biliary atresia in 7. acute hepatic failure from Non A-Nan B hepatitis in one and Langsrhans' cell hisliosytosrr (LCH) in one All received sadaveric gnnr trcepl one who msived a living related graA The medan cold iwhaemin time was 13.5 hours (range 5 to 17) All received Cyclorparin A. Steroids and Amhioprine. except for one convened 10 FKSM for intractable ncule rejection The small b o d was involved an all cmcs and 2 patients had additional perforations of the large bowel. The child w lh LCH developed lymphoproliferalive disease involving smell bowel. which perforated afler turnour regwsion following withdrawal of FK506 and increaxd steroid therapy. In 8 patients the perforation w a oversewn and one had resection and primary anmtomoliis T h m underwen1 ilmitomy (2 81 second laparotomy) S m n plisnts (77%) reperforated and underwent second laparalomy All the palimts arc alive and well Conclusion The incidence of bowel perforation rRer paedialric OLT in this series was 5 6% Previous K-8 ponoenterostomy for biliary atrclia may be a risk factor. possibly 8s a resull of ndhaions and unrecognised diathermy injury. The nrk of reperforalion with rimplc ovnlewng is significant


DMLOPMENTALAND PHYSICAl GROWTH STATUS OF PEDIATRIC LIVER TRANSPLANTATION PATIENTS AT LEAST 5 YEARS AFTER SURGERY Mane Bannister. Sunila M Slewan. Belly D Kennard. Marparsla Bsnrar, Waller S Andrews. and Paul E Moore Children's Medcal Canlor Of LXII~I. 1935 Mole, SI . Dallas. Texas 75235. All"

PEUIOPERATIVE MORTALITY AkTER PEDIATRIC LIVER TRANSPLANTATION K..NaUO. C NgYycn. D. UIEbc. W Paw. H. Shw. K. Uelmnl LW-cnrr or Anulhendogy. Surgw wld Rdiauic GuUocnlerolqy. Un~nnnyof Mmncsu. Mmncapalir. MN SYJS. u S A


RETRANSPLANTATION RATE I N 200 PAEDIATRIC L I V E R TRANSPLANTS - THE BIRMINGHAM EXPERIENCE OA Achillem, D Talbot. DF Mirza, BK Gunson, JW Freeman, P McMaster, *DA Kelly, AD Maser. JAC Buckels Liver Unit, Queen Elizabeth Hospital and 'Liver Unit Children's Hospital . Bitmingharn. UK

Retransplantation is the treatment o f choice for liver transplant recipients with irreversible graft failure. Of 200 paediatiic liver transplants in our institutlon. 78.59 were far chronic disease and 21.5% were for fulminant hepatic failure (121 reduced size grafts and 79 whole grafts). The number of the reduced size grafts increased from 51 for the first 100 grafis to 70 for the second 100 grafts 32 (21 reduced and 11 whale praftsyout o f 200 liver transplants were regrafts due to vascular complications (79) . chronic rejection (6%) and primary non.iunction (3%). Retransplants had a significantly worse survival than primaly grafts (47% vs 7 4 8 one year actuarial survival, p<O 05). Patients who were regrafted had a poorer survival than those receiving one grafi (60% vs 88.9%. p<0.05). The incidence of graft failure and regrafting regarding the first 100 and the second 100 liver grafts divpped for the whole livergrafts h m 28% to 3% and for the reduced size fiom 29% to 9%. There was B significant difference in complications rates between the two periods (25% YS 7% p<0.05) with vascular complications dropping irom 10% to 4 8 , ehmnie rejection from 9% to 38 and primary "on-function Rom 6% to 0% The improved results are due to advances in surgical techniques, patient selection, graft preservation and refinements in immunosuppiession.

59 90 10 81

c 91 8ZC OL1 CS 19 60 6 76

(6 90 11 0

61 62 LLZ 602 95 99 6.0 (62 6;69

6.9 LO

ZI 0 81

LO2 527. 91 29 6'0 9',9

or

z;5L

1'8 L.0

CI 0 LI 1C

C1Z L9 C6 60 6.69 9;6L

r*,L

EL 60

(1.0 22 zr 607 172 C9 C8 8.0 6 LL 9'18

432

O W , 68 54 IN. 4 4 % .

lmmunobiology

1 5 % 76 5% 79.1%

A TWO-YEAR FOLLOW-UP OF LIVER TRANSPLANT PATIENTS FROM THE U.S. MULTICENTER TRIAL COMPARING FK506 AND CYCLOSPORINE Ronald W. &$ullil. MD. PhD. Liver Transplant Program. UCLA School of Medicine, Lor Angeles. CA. for the U.S. Multicenter FK506 Liver Study Group

This presents Ihe 2-year efficacy and safety results from an ongoing 5-year follow-up of an open-label, comparative study of FK506 and cyclosporine- based immunosuppression. Dala from Ihe 1-year comparative study (N Engl J Med. 1994) were combined wflh the additional 1-year follow-up data. The primary endpoints were 2-year palient and grafl SuNiVal. and a secondary endpoint was %year freedom from rejection. Complele 2-year data on survival and reieclion were obtained from all 529 patients originally randomized. and safety data were available for 204 FK5064reated and 157 cyclosporine-treated patients who entered the long-term follow-up During Ihe second year post transplant, there were trends toward decreased palient mortality and graft loss with FK506. Two-year patient suwival was 86.2% for FK506 and 81.6% for cyclosporine (p = 0.18). and 2-year graft survival was 79.8% for FK506 and 74.1% forcyclosponne (p = 0.17). The percenl of patients free from rejection was 28% for FK506 and 24% for cyclosponne. The Overall incidence 01 new adverse events during the second year was 0.6% with FK506 and 1.2% with cyclosporine At ?-years. lymphoma was found In 2 pallents in each gmup Serum creatinine at 2 years was 1 SO f 0.4 and 1.52 and cyclosporine groups. respectively. These results indicate that the efficacy and safety of FK506 are maintained during long-term immunasuppresslon for primary liver transplants.

0.04 mg/dL In the FK506

Tr,.le 62

ADULT P R I W Y LIVER TWSPLANTRTION UNDER TACROLIMUS MORE THAN FIVE Y W S ACTUAL FOLWY-UP. W. Pun& J J , Ilamad I . Todo S . Reyer J . Reycr J. Jnbbour N. Krnmer D . Cr.nav1lla A. Rnke la J . Mrrrll W . IvrCruki S . Str r r l TE. P l r r s b u r g h T m r i r p l m r a c l o n Insriruce. P l r r s b u r g h , PA,

67 7% 6 5 % 1 6 % 8 0 6 % 885%

FK506 I n pr lnary o r ~ h o c o p i c l i v e r ~ranrp l=nr .~ l .n (OLTx l a t 1 year has shown improved p a t i e n i s and g r a f t survival w i t h less episodes of rejectlm. Little Is k n o w PbauC i i r benefILs i n long c e m I n order to study t h e long term e f f e c i s . we chore the Y ~ E f l r r L conresuiive 1 2 1 OLTx reclplenrr berueen A Y ~ U S L 1989 and February 1990. d o h n v r cornplaced n c r u ~ l follow-up of nore Lhnn 5 years There were 68 n0lc.i rnd 51 female The maan f o l l o w - u p per iod w a s G 6 ( r a n g ~ G2 to 1 0 ) months. The o~ccome 1hm been summarized n Lhe cable be low.

Craft rurvlvll 8 2 6 1 18 5 % 76 9% 72 I\ 68 6) L i v e r funcrion

B l l l r v b l n SCOT SCPT Tacro l imur (mg/kg /d) . l S 12 Tacro. l eve l (ng /mLl * * .I6 .73

Freedom from steroids 69s 10%

0 1 5 16 18 41 18

0 1 4 0.60 0.11 0 6 9 16 56 11 5 2

1 0 01 1 5 0 s

08

61% 69%

Ir6 'r0

6 4 , T " " ' ? / l "

1 6 40 12 08

1 6 'I 21 0%

1 6 50 29

1 6 1 6 .l"__.-, creat (mean1 H y p e r k s l e n l o ( % I 5 4 56

n y p e r f e n s l o n ( 8 ) 21 2 4 PTLD (coroll 41 0% 0 %

ORAL TACROLIMUS lFK5061 THERAPY IN THE IMMEDIATE POSTOPERATIVE PERIOD ELIMINATES THE NEED FOR INTRAVENOUS ADMINISTRATION FOLLOWING LIVER TRANSPLANTATION k l e r N E U H A W . Paul McMASTER'. Roy CALNE'. Rudolf PICHLMAYR'. Roper WILLIAMS'

FKSOCRESCUE . TREATMENT O f C l l O l C E FOR A C U T E STEROID-RESISTANT EFFECTS OF CONCOMITANT DRUGS ON THE PHAKMACOKINETICS RWECTION AFTER LIVER TRANSPLANTATION

K.-P., A R. Mucllcr. M Zyluwski. 51. Luhrr-k'. H Keck. W.O. Bcobcm. 1I.P Lfrnmcm, P. Ncuh;lu\. D E l ~ l I l l l ~ l l d 01 Surg~iy awl Pakhulugy', Rudolf Vimhuw Clinic, Hvmhuldi University of Bcrlin,

AND NEPHROTOXICITY OF FK506 IN SOLID ORGAN RECIPIENTS; V.FURLAN. N. CAZALI. L.PERELL0. D-DEBRAY. E.IACQUEMIN. A.M.TABURET. D c p m e n l of Clincal Phirmacy and Pediatrics. Bidire Hospital. Paris. Fnncc.

Immunobiology 433

INDUCTION IMMUNOSUPPRESSION IN LIVER TRANSPLANTATION: MALG YS A E A M w. KW Schoonaver. JM Launn. Khl Paync. R Dclcoic. Dcpanmmrr of Mcdicine and Surgery. University of Kansas Medical Center, Kansas 0 1 y . Kansas.

In Onhotopic liver mnsplanlation (OLT). induction irnrnunaruppression (IND) has bcen sddcd 10 cyclasponnc and steroids i n an effon to decrwrc the incidence of rejection. Such matmsni though may increase the incidence of infections. To dcicrminc $he cffcctivcnesr and cornplicatlons of I N 0 and to compare the two agents. Minnesota Anti-Lyrnphablan Globulin (MALG) and An& Tliyrnwyie Globulin (ATGAM) (UPJOHN). 82 OLTs from February 1990 through June 1994 were rwicwcd: 43 were done in the MALG en and 39 under ATGAM Three patients in each group were excluded due to invaopcrativc dcath (4) or other IND agents (2). Thc ages. the sex dirmbution. and the eiialogicr of the liver disease were simlar in the IWO groups. The adequacy of IND was judged b! the absolute lymphocylc count. with a mgci of 100-2M xi03 cc l l~ /p l . MALG oamnts received an ~VCKIEC of 1.3 e m dnilv over 1.3 davr: whereas. ATGAM rccinientr receivd

I ~ N O S U F I R F S S I V E PROPERTIES OF A 97 kUA PROTEIN ISOIATEU FROM TliE VENUM 08 BITIS ARIETANS

WLSceamao. H JeruiinKs. P Lukey. SC Robson. R Kirsch and 6 Sherhard nRCNCI Liver Research Centre. University of Caw Town. Observatory

I n t e g r i r receptors expressed on t h e c e l l surface are e s 3 e n t i a l for c e l l - c e l l i n t e r a c t i o n and c e l l adhesion t o e x t r a c e l l u l a r matr ix . I n t e g r i n s a l s o play an i m w r t a n t role i n cell a c t i v a t i o n phenomena. These receFtOrS cornwise a superfamily o f h e t e m d m e r i c trmammbrans glycoproteins which c o n s i s t of two "oncovalently aSsociated ~1 a d 0 s u b m i t s . The p p t i d e sequence RGO e x i s t i n g In e x t r a c e l l u l a r matr ix p r o t e i n s f ibronect in . laminin and col lagen hair been elucidated as the ligauid f o r i n t e g r i n receptors of t h e 01 and 03 famil ie=. Recently low molecolar weight RGC-containing c y s t e i n o r i c h wptidel l known as d m i n t e g r i n s . have been i s o l a t e d from the venom of var ious v i w r s . r r c t i d e a bind with high affinity t o i n t e g r i n s on t h e surface of P l a t e l e t s and

These

*p < 0 05 by Chi2 In !he iablc above. no consislent advantage of eilhcr agcnr was found. Additmnally. the ~ y p c of infecrion and the incidence did no1 differ krwccn l c two groups. Examining all patients together. of (how %,ho xcewcd 7 days of either agent. 63% were rejection-free VCISUS 43% of those wiih Ies? ihcrapy (KS) The 1 yr actuarial S U I V ~ Y ~ of those paiicnis rejection-ficc was S(wa bug 9 3 2 for those with icjccuon (NS). In conclusion, both ATGAM and MALG have very stmil.vicffecttvcncrr

o t h e r cells. YIP?^ Bitis .?r-lrtrns that binds LO fibrinogen. Berides inhibiting p l a t e l e t a g g r e g a t i m inis. IC.ln:l~ln) tI1m protein peeessez imnnlnomodulatory p r o w ? t i e s . Dose depiideiit i d l i b i t i o n of himan PBnC proliferation i n reswnse t o mitogen iPWA. ICsn=2@0t f l I . ant igen I t e t a n u s toroid. ICso-5Onnl and al loant igen a t i m o l a t i w i I C ~ o r 2 0 O t d l l was observed. r e s p n d i n p t o a n t i e e n .itogen o r a l l o m t i g e n s ~n t h e presence of the 97 kDA p ~ ~ t ~ i n . revealed t h i s protein t o i n h i b i t the expression of a c t i v a t i o n markers lnchtding C t W . l l.-2R arid nHC-class 11. t h a t occilr.5 during P M C s t m u l a t i o n . the ab6ence cf this i.roteir>. These r e s u l t s suggests t h a t t h i s ncsei r P O t P i n

cotlld be a p , l e n t i a i I ~ W ~ O S I I ~ ~ P B S S ~ V B agent following i d e n t i f i c a t l o n o f the

We have & s o l a t e d a novel peotein (97 kDA) from the v e n ~ e o f the

Phenotypic a n a l y s i s of the cells

PROSPECTIVE. MULTICENTER STUDY COMPARING TWO IMMUNOSUPPRESSIVE REGIMES IN LIVER TWSPLANTATION AN ANTI-INTERLEUKIN-2 RECEPTOR MONOCLONAL ANTtBODY-BASED REGIME VERSUS A CYCLOSPORINE-BASED REGIME &&!lWb V Cuervar-Mons. G Clemenle. J Quiroga. H AWreu. J Manaell. M Navas, J Calleja. R Bailarer. J VIS HorPUal Clmlc 8 Provmclat. Barcelona. Clinica Puma de Hierro. Madnd. Hmptal Gregono Marandn. Madrid. Clinica unmnlana. Pamplona: Spaln.

The admmislratm 01 monmlonal enlrbodiei to the mterleukin-2 recepta (anti-IUR) m comh(nat8M with standard immunosuppressve drugs has been reponed lo reduce the incideme of rewmn ~n Ihver transplantallon WlhOut lncreariog the Incidence 01 adverse events TO asserr Ihe real potency 01 alO.IL2R I" there patlenlr. we pedorrned a comparative study aimed at mvest#gatmg the ellicacy and ralety 01 an anll- IUR-bared regime (anti IUR. steroids and azalhloppnne during the f i l l 10 pOst~lat lvB days. fOllDVed by a tnpb standard therapy imcludmg 11~014s. mathiopnne and cyclorponne. Grwp I. 38 palleMS) versus a cydorponne based reglme (tnple standard lherapy lrom the 1st postoperallw day. Gmup 11. 42 Pal4eLSl BolhgrOUpS had similar clinical and IaDorafo~ data at mcl~sion Dunng fhetirsf 10 pasfoperalive days. blood CDZL lymphocyte (cells expressing w m c e I U R ) count was. lwer I" Group I than m Group It paliens (48r79 YE. 104-1 121mm3 on day 10, p=O WOI). thus ruggerling an adequate sfleclol anWL2R I" Group I PllenfS Newnheless. 8n 5ple 01 this tacl. reledion occurred more trequenlw 8" Group I than Jn Group I1 palenls 84% YJ 54%. p=O W4 (dkagnonr 01 releclion 6-3 VE 7 ~ 3 days aner transplan0 NO dillerencer were Observed Delveen the fuo groups m relation to the incidence 01 rferoid-re+lstanl reiecllon and In0

pallent required retransplanlalion becaus~ 01 inlraclable reteclion The incidence 01 renal lallum during the lilsl 10 days was lower 8n Gro\ip I than in Group It pallenlr (21% VI 52%. p d 0381. this dillererice was paflimlarly marked tn patients with pre-transplant renal dyslunnion (33% YE 90%. p=O 0351 During follow up (423 monlhs to date). pallent and gran SYNIV~I and the modence 01 5811005 adverse event3 were Onlllrlr 8n the Wo groups We mnclude that aob-IUR can not be considered as a malor ImmUnOSYplXelEIVe a'JBn1 bn l w r transplantation. but. rimeanti IUR-based regmes are aidoCMled I0 a IOwerrlOk 01 renal llnPalrlllFnt than standard reglmes lnClUdlny cydoaponne. the admlnlstratlon olanll-IUR based reglnler during lhe Wrty porloperatiw period may be ~selut m patienls with pretranrplanl renal dyrluncl~on

'Ihe m o f thm s t c d y was (1) to &te& t h e w r e s s i o n of adhesion nolerules ICIYI-1 and VCNI-I on W i n vim under m m l and i n f l m t o r y &ti- (as sim- l a t e d by m VIW s t i r m l a t i a n with m - a 1 and (21 to determine the e f f e c t of a n t i - ICIIM-1 and anti-KAY-1 & on in v i m i m e respwses to a l l c g e n e i c W us- t h e h e p a t o y y t e - s p q e mtnx a l l q a f t d l (HC-%I . C57BL/6 (861 (H2? e r e m l ~ t e d with "?-a 13ugl I." ; HC e r e M s t e d 24 hyLTs l a t e r by Ln S l t U mllagenase d i g e s t i o n and prmll d e n s i t y g r a d i e n t p u r i f i c a t i o n . m - a u p t q u l a t e d expressran of ICPM-1 and mc class I on HC ht not W-1 or WC class I1 by ?xCS and I-- h i s t a h e m i s c r y . % t e a r i n g 2 x 10' 86 HC e r e grafted into C3H (H2'1 b t S . Wts receive3 rat 1 9 . a n t i - I M - 1 . or a n t i - W - 1 & 1400 ugl i n t r a p r l t o n e a l l y daily for 10 days. Host cells m f i l t r a t m n g HC-% e r e &sted on day 12 and tested f o r tile develqmznt of al l -c i f lc cyT0t-c T cells bf 'ICY r e l e a s e assay agalnst dnwr v c i f i c l!zL-H2'I or thud party targets IP815-H2? a t =rim efEeCtOr to taTget 1E:T) ratios

a H BG 100.1 50:l 1O:l 5:1 100:1 I* iS3tm CG"trol 1 6 . 6 74.4 70 3 6 5 . 6 29.0 mt1-VrS-1 6 51.6 52.4 39.7 22.2 26.5

iGost IH2'1 Donor(H2Q) P815 (H2?

434 lmmunobiology

DIAGNOSIS OP muunocisnm c*RImI INPELTIONS IN uyw ~ S P M R B C I P I ~ USING POLWERASK a U I N WCIION (Pa) ON =IJM AND SPVTIJM. mu1 I(. J i n u . Ronald 5. Pilo. Chao-Uung Lie-. Dcnsrtments of Surgecry. Parhalogy and laboratory Medicine. Indianapelio, IN, USA.

(Pc). is asraeiaced with serious infections In recipients of orthotopic liver transplanracion (OLT). Traditionally, the diagnosis of PneunOeYltitis earinii pneumonia (PCP) l o made by morphological demonstration of PC in broneheoalvcolar lavage (BAL), or transbronchial biopsies. which require bronehoncopy. Furthermore. the morphological techniques for the diagnosis of PC are not sensi t ive and specific. Ye describe an a ~ ~ u r i t t less invasiva method, for diagnosis of PCP by detection of PC DNA from sera and'sputum by the PC-ITS-PCR. which uses nested PCR to amplify the infernal tr*nrerihed spa~ers (ITS) Qf the rRNA ~ e n e r of P.e.rinll.

Ye tested serum m d rputvm specimens of 2 OLT rcciplcnfs by this method. Second liver transplant , developed Interstilid pneumonilis 1 nrh

1ar.r BAL VBS negative for . r ' n " , however, serum for PC-ITS-FCR YaE stron;ly positive. Anfl-PCP cre%%k initialed, BAL was later positive for Pc. Presented 3 yrs after oLT with Interstitial pneumenitls. Bronchorcopy was avoided. diagnosis of PCP by serum PC-ITS-FCR was positive, and therapy commenced.

&mn.tration of PC DNA in serum or q u t m offers a "on-invarive method for the diagnosis of anti-rcP therapy. Results are available vithin 8 hours. This is the first rerun PCR method which has rufficienr sensitivity and specificity as a diagnostic method for PC infections.

Acute Liver Failure 435

FFRCUTANOUS LlVEll l l lOr5I IN rATIENTS WITI I ACmk LIVLI' ~r\lLURL~RIOI(TOTRINSFL~NT*TION Ironicnil 11. Mlkirulo 11. Ll3kinrn J. I IZkcrrbdt K I V I)cp;lrtnic~~t of Suracry. Ilrlrinki University CcnlmI Ilorpilal. Ilclnnki. FINLAND

ASSESSMENT OF COAGULATION FACTOR V LEVELS AS A PROGNOSTIC INDICATOR IN PARACETAMOL-INDUCED FULMINANT IlEPATlC FAILURE.

S Irumi, PC Langley, A.UUis, J Wendon, JRD Pcernnn,bueo, RD Hughe and Roger Williams. lnilitule of Liver Studies. Kine's Colleee k h m l of Medicine and Dentistry. London . -

Coagulation laclor V ieveli ~ r e suggested by the Paris group 10 be h e belt prognostic indicalor for lulminant heplic failure (FHFJ caused by viral hepatitis. but it is unclear i f this il valid lor olher aetiologier. In this study w have measured factor V lev&, on admission. in 88 patients wilh FHF due to paracerno1 overdose. h i c n t r had severely reduced levels (median 0.06 ulml. r a n ~ e 0.016.70) compvsd to ~ontro l subjects (median 0.92 ulml. range 0.61-1.09; n = 2 0 p<O.Ool) and levell w f e significantly lower in thox patients who did not surviv~ (median 0.03 ulml. range 0.01-0.27; n=35) compua to hose who did (median 0.10 ulml. range 0.02-0.70; n=46 p<O.Wl). mere WL( no clear cut-off cvei of fxtw V which %paraced palientl who survived from thox who did not. Serial Sdbl of20 patltitnlr showed lh l in tho% who rurvlvsd f x i m V kvela incrcrrsd aitec the Rrll day and I1WUy.i remained higher han in lhox who did not survive (median 0.36 ulml range 0.07-0.97 compared Lo 0.09 ulml range 0.044 84 on day 3).

On predictive M~IYIII a positive predictive value (the momliiy in those predcfcd lo die) of 0.4' and 0.57 was calculated for factor V <0.20 ulml and factor V <O. 10 vlml respecttvely. whereas fo h e King's progmstic criteria baYd on pH and a combination of INR. renal failure and enaphalopah) the value was 0 92. Predictive accuracy was 0.56 and 0.65 lor laclor V lwei <0.20 ulml and <O. l i ulml compared to 0.83 lor the King's criteria. In a small group (n= 17) o l patients with FHF from other aeiiolome~ oredcuve ~ U ~ S C C Y was 0 77 lor factor v <0.20 was 0.71 compared to 0.88 using

SEVERE NEUROLOGICAL SEOUELAE AFTER LIVER TRANSPLANTATION FOR FULMINANT

Ph. ICHAI. Q-WUEL. Ph CHEMOUILLY. F SALIBA. D AZOULAY H BISMUTH Hepalobliary Surgery and Liver TranSplaolal~n Center. Paul OrOUIIe HoIP#IuI. 94800 VilleluI. France

HEPATITIS ROLE OF mE PRETRANSPUNT CONDITION

1994. 152 palrnls (PIS) &we beon'lramulanted lor FH The SYNIY~I rate was 75 7.11 bm monlh and 68% st one year Fnlleen pls (9.6X)dmd tmm brain death during or imrnedialely attar the Iranrplalation pocedYle m relalon wlh the pmlansplanl inlracranial hypenenron. Seven plr (4 67.1. who rvwlved more than 1 month. devehped severe neurobglcal requelae and were studled There wew 2 lemale and 5 male. mean age 29 y e a s (range 13.52) The cause 01 Ihe hepahtis was HEY (3). HAV (1). drug indused (1) and unkwwn (2) The mean delay hetween on~elot encephalopalhy and LT was 4 4 days (enremer: 1.7 days) Prior 10 transcianlalum all the 7 01% were on enceohsloaalhv rtaae I V and all were in deeD mma BOW slam

SULTS AN0 PROCNO5TIC FACTORS IN PATIENTS WITH ACVTE HEPATTIC FNLURE UNDERGOING i h o m w t.ivmTR*Nsm*KIATtoN

ADMISSION SERUM Gc-GLOBULIN LEVELS IN FULMINANT HEPATIC FAILURE: PREDICTIVE VALUE OF OUTCOME. FV Schirtdt. S Bondesen, I Petersen. KP Oalhoff, P 011. N Tygstrup. Oept Hepatology A- 2101, Rlgshospitalet. University of Copenhagen. Copenhagen. Denmark.

Objsctiva; Gc-globulin scavengesactin released from damaged hepatocytes in acute liver disease. The aim of the studv was to evaluate the predictive value of Serum Gc-globulin In relation to survivallnonrurvlval 8" fulminant hepatic failure IFHFI. compared to the well-established King's College criteria IKCCI. Patients andmethodr: In 82 FHF oatients not treated with liver t ran~~ lan ta t i on admission levels o f i e r u m Gc-globulin and complex ratio with monomeric actih were determined. Resulls: Gc-globulin was reduced in 51 nons~rvivors. compared to 3 1 S U ~ Y ~ Y O ~ S

IP<O.OOl I. whereas complex ratio did not differ significantly Gc-globulin was significantly lower in the "on-acetaminophen group In = 591. compared to the acelami- nophen group IP<O.Ol ) . A Serum Gc-glabulln cutoff level of 100 mgll war used to predict outcome and estimate predictive value of positive test IPVPl or negatwe test IPVNI:

PVP PVN Gc: non-ACM: 79% 60% Gc: ACM: 100 % 45% KCC: "on-ACM' 69% 57% KCC: ACM: 58% 36%

Conclusions: In this study a serum Gc-globulln cutoff value of 100 mgll has a predictive value of outcome within the same range as the KCC. Serum Go-globulin gives an estimate of the outcome already on admisslo". Liver transplantation should be considered in FHF patients with Gc-globulin less than 100 mgll.

436 Acute Liver Failure

MANAGEMENT OF PATIENTS WITH FULMINANT OR SUBFULMINANT LIVER FAILURE (FSLF) WITHOUT INTRA-CRANIAL PRESSURE MONITORING (ICPM): A YEAR PROSPECTIVE mm ~. . . . . ._ . J., F. Durand. P. Werner'. A. SaUY.net*. 5. Erlmger. J.P. nenhamou. J. Belghlti*. SeNlces d'H+ppatologne. de 'Chtrurgie Dcgestive. e l INSERM U24; H d p ~ a l Beaupn. Clichy. France.

Although no controlled trial demonstrated a rqnlflcant benefot of ICPM. t h e htgh risk procedure (P C~rrent ly extensively used in Patients wtth FSLF prior to and durmg emergency lber transplantation (ELT). The aim of our prospectwe study m pat& With FSLF 4.1 to evaluate the efficacy and the safety of the management with no lnd8catmn of ELT before clmcal encephalopathy. no sedatwe drugs. no fresh frozen plasma. no p ~ ~ p e ~ a t ~ e central venous Catheter and no ICPM.

From 1991 10 May 1995, I 3 2 pat!entr with an acute liver dnrease (paracetamol overdose ~n 22 patients) and factor V (FV)<SO% Of normal were rdmmed to our liver unit. Prothrombin ram (PT) was 4 0 % of normal 4n all, and lower than FV on 81%. of them. ELT was lndtcilted m the only Patients with confurion or coma and ether FVdO% (age<30) or FV<SWC (age.30). Among the 69 Patlentr who did not develop Confusion or coma. 2 (2.8 %)died O f septic shock. Among the 63 patients who developed confusion or coma, 8 (7 on mechanical v e n t l s t m and 6 w t h ~ h n c a l symptoms of increased mtra-c?mal pressure) wnh FV and PT raising above 30% wtfhin 2 days recovered ( 5 patients lhsted. 2 refuralr of liver graft. 2 patientz comatose for 7 days). 11 ( 1 7%) died with decerebration p m r to ELT. 44 were transplanted (al l with full prerervatian of porfal and caval flow% 9 with auxiliary liver tranrplantatlon) with a 82% 3-month survtval rate (2 fatal neurological ~ o m p l i ~ a t i o n ~ , 3% of the 63 pat8ents with ConfuIm or coma).

We conclude that. m pat~ents wlth an acute hver dlreare and PT<50%. (a) emergency LT should not be decided when ~linical encephalopathy IS absent: (b) when COnfUIiDn 0, Coma 1s present 111

pat8cnt~ not gwen fresh frozen plasma and not managed wtth ICPM. rapid raising of PT above 30% herald3 recovery. LT with full preservation of portal and C a d flows may be performed In 80% of patients With a 82% 3-month IUrVival rate. and fatal neurologlcal COmpllCatlOns Occur In 20% Of patients Thus, ICPM which IS dangerous IS unnecessary m 80% Of the patients with FSFLF.

lmpmven cerebral oxygen metabolism after high-volume plasmapheresis in patients with fdminant hepatic failure

FS. BA Hanren'. E Ejierscn'. NH Sechcr'. 10 C l e m a e n I. N Tygsuup' & O M Knudsen'. DepMwnts of Hepatology'. Annathuia', dr Neurology'. Ripsharpitdet. D m u k .

Ohirni*o: The effw of high-volume plumrpheraii on hepatic cncephalopathy. cerebral h i d flow (CBF) and cerebral metabolic rile for oxygen (CMROJ w u i n v ~ ~ t i g ~ t e d in patients with fvlminrnt hepatic failure (FHF). Methods: Twelve C D N ~ C U ~ ~ V C patients (8 remalcs. median age 34 (range 19.51) yr) MIC rtvdiod bcforedzf ler high-valumsplumrphetcsir with I0-16Lfrwhfrmmpluma.whilePiCO,.ndbody temperature were mrinllincd at 30 (23 - 34) mmHg a d 37 6 (36.6-38.4)'C. rsrpectiucly. Blwd smpla fmm the internal jugular vein d a radial incry allowed d c v l v i o n of the cerebral merio. YCIWKIUS oxygen difference (AVDO) d oxygen emaction (AVDO, divided by uterirl oxygen content). 7hc CBF w u dciermined by I "'Xenon c l e ~ ~ l n ~ e mcthod in eight patients uul CMRO, C a l c ~ l i t e d u AVD02t ima COF. Cerebral perfusion p " ~ s w e (CPP) w u detcrmined as the difference between mean merial and ruhdural prarurrr ~n eight paticnlr R s u l U High-volume plumrphemis w u initiated 22 (6168) h aRer development of hepatic encephrloprthy and eleven patients were in grade 4 encephaloprthy. Following high-volume plasmipheruir the grade af encephalopathy improved in four palieiiu. The CBF increased from a median of 31 (rmgc 16861 lo 45 (18-97) ml IOOg' mi".' and u oxygen exlr~iclion remained unchanged(32(94l)us. 29(1-39) R).CMRO,increasedfcom 1.24(096-1.82)m 1.86(1.00-2.07) ml IWg' mi"' (P < 0.05). 'The CPP inerured from 62 (19.71) to 92 (50-105) mmHg (P < 0.01). wherw the ilmcranial preiurc remained unchanged (19 (3-45) "3. I I (5-31) mmllg). Cnnclurlun: Although the clmicrl itm~ did no1 improve in dl patients. bath O F and CMRO, increased aRrr high-volume pl;lrmrpheresi,. The alwiaiion of hran oxygen m~tabol i~m by high- vnlvme plumaphereris may reflect panid f ~ m o ~ a l of neuroinhibilory plama factors.

Auxiliary liver I l ~ l l L D l a ~ l ~ l l O n iALTI. 4 e placeinem of healthy liver t#swe somewhere in the body while leaving the native lhver u, bs fheoreftcally attracwe for palmnfs wtth Irublacule liver lailure IALFI became recovery 01 the own liver remains possible. unlike after orlhotopnc llver franSplantation IOLTI. However. after the f i r i t ALT lor drug-induced ALF m 1980 a few ALT'S were performed wi lh poor i e i ~ l r s until tn 1989 the first patient wi th ALP was Iuccel~l i i l ly iransplented by heterofopoc grafting lollowed by l~l l recovery of her own livei wilh dirconwwatton 01 m m m O i w P r e s E ~ o n (Lancet 1990.1 11 561. Since then seveial centers m EWOW and some cn the USA included the use of ALT m their armamentarium lor treatirig patients wi th ALF We collected the European experience with ALT wi th ALF.

RESULTS In the DellOd 1986-June 1994 37 ALT'I wece perlormsd m 34 patmnfs with ALF 111 12 E ~ o p e . ~ Centers Overall patient S u r ~ ~ v a l after a mean follow-UP 01 16 monlho r I 59%. w v d . 3 1 $0 !lie results 01 OLT. lor the same indication In 13120 s ~ r v ~ v o r s rsCovBry 01 the patients own l iver lead I0 discontinuation 01 the 1inmunos~ppre3iwe medication ReSuII3 alter ~ r l l i ~ l ~ p i ~ ALT were belter than aker the hetemtopic procedure

CONCLUSIONS 111 the collected ex11etience with ALT for lsublacufe Ih~er failure t f was demonrtrared ihilt chis lech!iiqim offers the maprilv 01 patients a lile free of rmmunorup- pesr ive drugs with 8 chance 01 surv~val that 84 similar l o that of OLT Orthotopic ALT may have some physiologrc advantages over helerofopic ALT Criteria 10 predlcl the probdbilitv of recovery 01 the native liver at the isme 01 frani~laniation are not well defined and need further study, preferably ~n a ~nulcicenter study

Acute Liver Failure 437

438 Perioperative Management

SUCCESSFUL USE OF OLDER DONORS (>SO carso) FOR LIVER TRANSPLANTATION.

Nauasa. J Visa. Liver Transplant Unit. Hospilal Clinic. University 01 Barcelona. Barcelona. Spain.

IUPICT o? DONOR ACE ON CRAFT OmCOne A m E R LIVLR TRANSPUNTATION.

8. de H.mpLinn. - DcPL. of Sur9.r~. Vniver.ity Homp1C.l Ohencl B - l q i u m . LGcande. FX Gonzdler. JC Garcia-Valdecasas. YFusler. AM Lacy. C Ramos. A Rimola. M , P. Pat ty" , ". R...., I. It*rr.m.n,, J. Decruy.n..r., 1. PraeC.

6 2 . 6

2 6 . 5 1 0 . 5 1

( 2 6 . 1 1

( 2 7 . 4 1

RISK FACmRS OF ri\RI.I WIRTALITY MI) GRAFT LOSS AITFR OLT. J.FIGUERAS, J.BUSWETS. L.GWDE. E.J,\Wll:TA, J . P C R L Z - F E ~ I R O A . J.NIK. C.MhRGARIT. P.LOI'EZ. J.VA2QUEL. D.CASAN0VA. M.BEHNARW1S. F.DE VICENTE. P.PARRILLA.

SHOULD WE ACCEPT INFERIOR RESULTS FOR HEPATIC RETRANSPIANTATION 7

Oepanmenl of Surgery. Univerritv 0fAlbena HOipitelD, Edmonton. Cmada.

Hepatic retrsnrplantalion IreOLTxl has been generally asoci8te.d with poorer WICOW lhan

V.G. bin, 0. L. Signlet and N.M. Knaeman

primary traanrplanllion. and if has bacn argued lhar reOLTx may be an inapprwriale use of ~ c l r c t l organ msowce We herein repon our 5 year experience with 16 retrmrplants (25% psdiatricl d a fo ld of 137 liver IranlDlanfS performed In Our inshfution lreOLTX rate Of 12%l. IndiCBtionl for reOLTx in this series Were DrLmsry non4unClion 112Sbl. hepahc artery thiOmbOSislrt.nOiii I I 2C) . ~or ta l vein IhrOmboIts 112%l I1 after iSlel transplanletion1 mute relaction 16%). Chronic re)eclion 125%). recurrent heDBhfis C 113%). and other 120%)

01 19 referrals Considered lor reOLTx 2 PBfients were decllned IEhroniC rejection from non- compliance, and recurrent hepatitis B carhorh in the absence of enactlve treatment). One PBUent

with fulminanf acute rejection was lisfed hut dled Whtlst awaiting frSnrplantSfiOn Survival tollowmg reOLTx was 94% with I median follow-up of 22 mon~hr. Compared wifh an

overall Iuwv~vaI of 87% for 111 liver flanSDl8nlS Ins!

Penoperative Management 439

COSI OF LI\'ER 1KANSPLANrAlION IN Ah UNIVERSITY HOSPII'AL IN BRAZIL Diwmon ofGastrointenma1 Surqev, Oemnment o f Surccw. Federal Universitv of Parma. . . . . . Brml Coclho, J C , Wkderkehr. J C . Lacerda. M A . Campor. A C L , Zeni Neta, C , Matias. J E F Campor. G M

The cost of 25 liver trmrplantatwn done in 24 patients at the Hospital dc Clinicas of the Federal Univasitv of Parana wiu determined The aye of the patients varied from 6 6 to 56 years Sir patienlr \rere youn~er than 14 years hive patients died during hospitalinion Retransplantation was perfamed In Onlv one patient The totsl cost aflivsr Lranglantnion vaned. depending on the occurrence afcompl!cauon. length of horpitaltration. and the amount of blood products lranrhsed The length of hospitalmuon vaned from 2 10 86 days. wth L mean of 29 days

bli"im"m M..m"m Me"" ?I> 945 I") 11 7'0,III 21.175 1m

I2.38U ,JZ 4.911 US h825" 9.781 5" 2 724 10

2.68U UO I 2 " W 14.48U uu 5.5 d 6.01 I IIU I.yU791 615 13 2.527 15 I.U9% 55 21775 '35 50 277 l i

~ o i ~ ~ ~ n r t r-

ICUlrmm Cllrrgcr 1.120 i Y M 033 B Y OD I

B l a a d t ~ l o n b 0 l O n . xu16

M I I c ~ ~ I OR fm

The mean IOIJI cost for lher procurement was USS 5.139 44 The total EOSIS vaned TOTAL 14.176.11 X7J6711 ,l.WL.IS

from USS 27.400 87 10 USS 83.550 85. r i lh an axmeape ofUSS 42,721 I 19 The mast

ONE YEAR EXPERIENCE WITH A LIVER ASSESSMENT SCORING SYSTEMISSI DESIGNED TO FACILITATE ORGAN SHARING

CURREm STATUS OF ORTHOTnPIC LIVER T~SPlANTATIOll AT GRIXTE SWIJR HOSPITAL

-.I RsLky Hinrs MIIS? luhn A h m r l Howard M NAthm US.) Slphcn E Smolinrki

llcrovrccl md Serviccr Adtiiin , )Delhwr.c Valley Trmsplml Pm~rml

CrM. D Kahn. Am Hi l l a r . SC Robiron. L Hichell. P Gordon. M James. RE Kirsch. and .I Terblanche IIRCNIX Liver Research Centre. University of Care Tom, Observatory

Since October 1988 50 adul ts and ?1 chi ldren with endatage l i ve r disease have undergone 55 o r tho twlc l i v e r t ransplants . in the adu l t s included p a t n e c m t i c c l r rhosie(11): b i l i a r y cirrhosio(7); 0-1- antitrYFBm deficiency(?) : &add ch ia r i syndromsll): Hae~ansiosndothel~oma(1): Haemochmmataslslli: Primary hufemxalur ia l l ) : a lcohol ic c i r rhosis i r i ) : fulminant l ~ v e r iall,,rel: ~. reds transFlan~s have been F e r f a ~ e d In ad,,lts Yeln thrombosis. 1 actire re ject ion and 1 chronic diictowenic reject ion! . Postarerat ive morbidity iriclrided acute and chronic re ject ion, delayed g ra f t fonction, renal f a i lu re a d b i l i z r v s t r i r t i i r ea . tlaa~ar Infectmns included RN h e w t i t i s . 6YatemlC fun& infecr icns ilnd m l i a r y TB. 20 adul ts are a l ive 3 months to 7 yeara Pst transplant . haemarrhage 124 hoirs!; oesophageal ulceratxan and Amgaemia (10 days) ; re tmrer i t rvleal haemcrrhage (10 days): lmoontrolleo acute ce l lu ln r ieJectlDn (10 days and 2 ueeksl: chronic ductofaenzc reJectim 16 months); cerebrovascular accident ( 0 months): chronic doctapaenic rejection v l th a s p r g i l l i i s and nocardla1 respiratory infect ion (13 monthsl: Kapos3.s sa~coma (11 months) and Fneumococcal pneimonla 13 Y ~ R T S ) Although or thotopic liver t ransplantatmn is an establ ished form of treatment. I t is st i l l considered local ly as a l a s t r e so r t , and w t l e n t s are referred l a t e I" the cmirse of t h e i r disease. Despite l imited resources. an ac t ive liver t r ansp la i t a t i cn pr~grdmme has been establ ished. increased general wbl1c and medical avareness a i liver t ransplantat ion 15 reqwred and careful se1ect:cn of ratients in B coimtry wlth 11slted resources 1s extremely Important.

1)s 1 I ~ ~ p m ~ ~ ~ m "f surgcfy. yric unlv S i h w ~ c d ~ ~ ~ ~ ~ . 2 ~ ~ ~ . ~ ~ ~ ~ doryrn T ~ ~ ~ ~ ~ ; , ~ , ~ w ~ . kicAtlh

As sharing "1 vholc or Ind2cations f o r l i ve r t ransplantat ion rmdicalolr or "1an uu"1zlY

-IS%) ~ h c ss rpp~lnl rCtr,,.PI~ilrc~y ~ rgrnr orrcrcd fur twan5p~nl~nlan In OnC OM In IWI n e data 13" convertsd inw SnS Iorntni. a d ihc U ~ I ~ L O I ~ E n n d y X d forcach IIVC~. b a w l on xporlr rmns indw8durI Iran.pld#l

ECn'err' All IIVLC? ~ 8 1 1 1 il i m r c L65 U C ~ E p w h i l r d I0 bs lm~pln l lcd . thaw 555 W C ~ C prddlrrsrl nor 3 0 b Irmsplmlcd.

Death I" the 10 adul t Fat ients ascribed t o massive Intra-orerat ive

440 Perioperative

C O M P L E M E N T ACTIVATION I N ORTHOTOPIC LIVER TRANSPLANTATION QA AchillwLG 'CJ Lloyd, * S Hubsher, !A Germenis, "A Williams, !C Dinas, J M Neubemer. JAC Buckels. *MT Drayson Liver U&. Queen E l i z n k h Hospital. Birmingham. UK *Dept. oflmmunolugyand "Depl ofPndtalogy. Univenityof Uirmingham. UK !&PI. o f Immunology. General Hospital o f Alhens. Greece

Plasma levelsaf mmplemcnt actimtion praducrs tC3d. CBadcsArg. CBbBbP & C5b-91 were menourcd tn serial samples wiihdrnwn from 30 patienrs lmcm age 47 G I 10 7 years. range 15.63 yenrol undergoing orrhotopie l i v w tmnsplnnlatton. The concentralton of a l l ~ O J I poramelers sl ioxsd B marked merense durmg the perioperarive period rcrurnmg w baseline levels within 24 hours aner tho open sttoti During the poslopcrative period a wtal o f 3 1 hiswlogicslly confirnicd a w i e graft rejection episodes were observed Elevnuon o f a b 9. C3bUbP and C3adesArg levels LO more than 160% baseline levels w w found ~n all 31 episodes. predicuri~ biopsy findings by 1-3 days. in 28 of llieni I n it total o f 439 piitiettt wmplc days. l rvc ls o f C6b.Y C3bllbP & C3"desAm arcuiiitcly Indicated D stntuc of no I.2JleCllOn foi 280 day>. R C ~ I V P iejec~icm ep isdv% for 93 days and t w o l t i n g rcjectiun for GG da,s Immunohiswlogy uf l t v w bwpws showed drpoaitiun of smvntcd CB ~onipoiieiit o f mmplement in ihe grafts during W J W ~ U , ~ opiwdea I t 1s mneluded that mea~urenicut ofmmplemont BC~IYULIOO products may be ptoved useful index L I I ihe monitoring lor hepnlic ollogran rejeclion atid that cornplcment may hove a si~nif iuui i t tole ~n rhc p ~ ~ h ~ g e n e ~ i s of I ejection phenomenon

Management

EARLY MARKERS OF PRIMARY MOMGRAFT FUMCTIOM IN ORTHOTOPIC LIVER TRAMSPLAMTATION lOLT1. w. F ACOSTA. P PARRILLA. PL TORNEL. RF CONTRERAS. I LORENZO. R ROBLES. P RAMIREZ. FS BUENO. P MARTINEZ. Liver Transplant Unit. University Ho~pital 'V. A r m a d Murcia. SPAIN.

OBJECTIVE: The delerminatcan of the primary nongraft function IPNGFI of OLT grafts has relied upon metabolic tests of the liver. which take several hours to evaluate. Our aim was to study the evolution 01 oxygen consumption and concentrations of glucose. ammonia and lactate as markers 01 early PNGF in OLT. METHODS. We studied 75 patients undergoing OLT. classified m two groups: group A ln=51. patient3 with PNGF and required retransplantation for the first 72 postoperative hours, whereas group 6 (n = 701, patients with adequate hepatic function. These parameters were measured at differents moments 01 preanhepattc. anhepatic and neohepatic phases. RESULTS In bath groups. glucose. ammonia and lactate levels increased pragresslvelv during preanhepatic and anhepatic phases. and decreased after reperfusion. Ths decreases during neohepatic phase m group A. were smaller than group 8. Patients In group A had lower anhepatc oxygen conwmption. and smaller increases during reperfusion than those in group 6. CONCLUSION The evolution of this parameters after reperfusion is due to the beginning of graft function. and in consequence. the ability to remove this metabolites may probably be associated wlth PNGF and provide information in the neohepatlc phase of procedure

RTFLLIENCE OF PRE-REPERFUSION PORTAL VENOUS BLOOD FLUSE ON THERAPEUTIC PUSMAPHERESIS IN LIVER TRANSPLANTATION FOR AWTIBOOY MEDIATED EARLY GFAFT FONCTION. ALLCGRAFT DYSFUNCTION

D F Mirza. BK Gunson. H Khalaf, S Russell. Sw Freeman. W,II,.m c. Gem ins. R o k n A. Frhcr. Dennis S. Cuhm. Luke Wolfa. Pam M. K~rnbll. Chnrlophcr M. L c h m . JAC Bucke l s . P MCMaSter. AD Mayer. John M. Hun. Marc P. Po-. D lpnnauofSurpcr / url Qnihulopy. Medrr.1 C o l l e ~ o f Virgro,.. &chmond. VA The Liver unit. Queen Elizabeth Hospital, Birmingham. UK.

H u n v v l l l r e ~ m ~ l ~ u u o n h r r b o n r r * x ~ ~ t d r i i h . n i n n u m l o g i o l l y p n v i l c p d ~ ~ l s . b u i i h m ~ s n b ~ ~ l l o r m w The use of portal blood to rinse the liver graft o€ University ?hem-n. l lmohia t~uc oflhir study w u (0 dr (cmm nfihrnpcvtic pl-phomsis VPP) would no-li_ bolh Of Wisconsin SolutionlWs1 UtiliSeE a physiological €hid. ptirnl uld gRR wwwd In dlognlu which w e ~ n d l r p m g anlibsly d i a t o d dysfwlion. We deftnod mltbsly removes acidotic mesenteric venous blood and has been reported d w o d dys6~uncdonu ~ l l - n d p f u s # ~ c q b ~ ~ ~ l , qnihdic Or Imnumlogic) ruai.id wlL a pdw Bscll to result in more stable haemadynarnic parameters during InC flw cytor.2tk smunvlsh IFCXM: - c b l shtn > 40). Fmm luly I. 1991 u) Janwry 28. 1591. 115 reperfusion. kaLb!aL From July 1993 to Peb 1995. 209 adult OLTS plirnu u n d e w l 122 liver m-lmU .I 0-r i~LiNLicm. url wire pmspzlirrly e v a l w t d for TPP. .nO 17 pstamU were studied prospectively. The W L was flushed Out with 500 m1s who undenrrnt U r n p v l i s plnnuphrmts 1- follou-up I4 nanlhl) were compml 80 98 nm-TPP pticnu 1- portal blood in 95 grafts IGroup 1) and with 1.0 L of 5t fo l lowp 20 m n l b l vl lh reg.& 80 purnt .nd dlognR ~w1v.l. Plrmuphrrr.~ - sonlinud MLII dlos"R dextrose a t 37OC in 114 grafts function w-Ld or FCXM bum neg.#iro (m r b t shift < 40). D.u - - 1 y d hy Chi-qurr. P a i d comparable for age. sex. median cold ( 7 6 3 vs . 738 minutes) and P k s e a l . or Wdroxa M k 1 0 1 w k m .ppmpri.k wilh p c 0 05 mnaideml smmtxcally ssmlsanl. Them w u no warm I 5 0 vs 49 minutes) ischaemia time. and proportion of d i f f r r r n c c b * w ~ T P P p l , c n ~ a n d t b o t h n p l i r m n L r a ; p # loage. EX. race, ~'~liologyorlivrrdlau. The emergency, urgent and routine cases.Resules : The median day 1 TPP p#tm#s %re aplifiuntlysicker at t ~ m oft-lanYli~n u dclcrmmed by Unitd Nnwrk of Organ Shmng and peak A S T [day 1 - 5 1 levels were Significantly elevated in the rulluwhencornprd l o ~ I I o l ~ r p l i r n u l 1 . 0 ~ 0 . 9 7 r ~ 2 . S S t 0 77; p=O.O162).%rr - n o d i f f m e mrLwn.l 5 ) dextrose group. 755(range 118-110901 Vs. 546(range 121- plimlwnir~lmTPPp~iml.somp.mlto.IIolhrplimnLL 1 2 m t b ( T P P r s h h e r s ; 94% vs86X.N.S.lmd 615oliujL lp=0.007. WilCoXOnl. and 10951159-11090) vs. 7441157- 14 manlhs (TPP YS Others. 94% YI/ 83%: N.S.). Thm w u no dtff-se m h-tmn.1 snn s~wiv.1 IR TPP p18mb 78701 iulL lp=O 008. Wilcoxonl. respectively. There was no sompml lomIIolhcipltcn(s~t I 2 m L s ( T P P u s O l h s ~ : 88% ~ ~ 8 0 % : N.S.).ndl4 nanths(TPPnOkn:Sll% difference in peak bilirubin. lowest day 1-5 PT levels, primary IS 78%; N S.). A1lazr.n h c t i o n tmpmmnll stgmfiunily owr t h COY= of TPP. Tho ~ m m .sp.rWe nonLunction 13 Y S . 1. p=0.251, median ITU Stay 13 days). total s m n o l ~ l a f e n x (ASTI level. md #he acIw.Ied pni.1 I h m m b l u l m urn (AFTTI nm (phmt AQlT Imlml inpatierit stay I14 days) and one month graft survival 1 8 9 t vs. AF'TTI signifiunlly d a d by Day 7 of TPP ( A n , Dsy 0 vs Day 7: p=O.W721 ( A m nun: DW 0 V I Oar 7: 8 8 t ) between the two groups. A median of 5 1 0 - 2 7 1 units blood p-O.CO17) Bdroutwufimprord hy Day 1 (p-O.022S)Uul Day 7 (p-0.00ll.fler miti.lionofTPP. Incarlwlm. were transfused 2" group 1 compared to 4 1 0 - 5 1 ) Units In group 2 ws have drmnvtnfod l l u f TPP for lhr lmfnal of mlibaly d i a l e d dlognn dyif~nslim M)mIIDLI DaLiCnluld

blood flush may be associated with less hepatocellular damage. without significant additional intraoperacive blood usage.

IGroup 2 1 . The two groups were

1n.s I . C o n ~ l ~ ~ i o n : These results Suggest that a pre-reperfusion .iiognn svniv.~.

Perioperative Management 441

m, Pikul S , Lowndes R, Ghant C, Grant D, Wall W , Asfar S. Departments of Anaesthesia, Nutrition. Internal Medicine and surgery, University Hospital. Program in Critical C a r e Medicine,

EEF reduces postoperative infections and is hypothesized to be due to modulation of ilmunologisal function. We therefore examined the erfects of early versus late enteral feeding following liver transplant (LTX) on the incidence or aariy rejection. kWhs2&: Thirty-three LTx patient. were randomized to receive either EEF via a naro-jejunal feeding tube within 8 hours of LTx or maintenance intravenous fluid until initiation of oral feeds (late oral feed - Lor) , usually on post-op day 3-5. Total number of days spent in I C U and hospital (HOSP) were also recorded. Rejection soisodar yare recorded within 30 dava from tine of LTx.

UniVerSitY Of Western Ontario, London, Ontario CANADA

U: C&p&ii~-tha EEF-[n=l5) -;i WF (n-18) groups, mean age (53i12 vs 52tll). ICU stay (12319 VL 12320). HOSP stay 122319 Ys 313311 and mortalitv rates 17% vs 1181 were not sisnifisant. Hovevir, the incidence of eariy rejection in the EEF group was 7 % compared to 44a in the Lor group (P-0.013. chi square). -: 1) EEF reduces the incidence of early rejection (30 days post LTx), hwever 21 the effects of EEF on long term rejection, and post-Op morbidity needs to be examined.

USkFULNESS OF BILE SALT AND BlLlhKY 1,tVID ANALYSIS IN TllC DIfFCRC\r141. THE SEOUENTIAL ACTIVATION OF ThE T nELPER CYTOWNES IN rlJMAh .VER DIAGNOSIS OF EARLY GRAFT DYSFUNCTIONS AFTEK L I V I X TR\ \SVLr\hTh I IOV A.-OGRAFTS IS BIPnASIC EARLY IL.2 N MPENDING AND LATE l L 4 IN OVERT ACLTE \CE.LJlARI w L O U W C ~ r IP.IW c G.WJI~. A A~JCI,,,O. I REJECTION A S , G 0110- 1 G e i i w r(F olio' w. Mmann. n l r d c 01 Patho wy' b DCP, 01 I.lwr Transplan1 U n l ~ Ocpt of S u r m ) & Dcpt of Pub1.c tlca.11t. for Vrrgaia Unwerwy. KO nc s~lpery-. LO v s n . ~ , of r(e,aeiocpp, f em any

hi ,\nSr .4 CLJ C~S. , .UU

U.lY

Prompt tdenfification of palienu wvlth "primary nan-function" (PNF) IS of cruucm imponance early aner IIW transplanlalion We invuligaled tine early postopcm~~ue changes m blood and bile chemistry in 16 I w r transplanted patimts. including 9 with normal graft funcuon. 3 WIIII init ial pmr function (IPF) and 4 with PNF. IVF was dcfined as one or imorc AST values ,1500 m U h L plul P prothrombin lime nbove 20 sec PNF as the failure of lhe yraR within the Arit week Total and individual bile $a111 (0s) were measured by rcvcrsc pliiue-III'LC 1IESLIWS Daily nleSJurmenIs of liver tssu. biliary BS and lipids during lhc lirst week after DLTx W E ~ E DAYS AF"I$.&Q!&

ALT(mU/ml) 639. 579' 241' 1206 1732 581 2151 2305 h 4 Pmthromb(sec) 187' 1 4 7 * 1 4 6 * 2 2 2 2 6 2 2 0 6 2 1 5 2 1 3 2 3 3 Bilirubin (mddl) 5 0. 6 8. 9 2. 6 9 16 I 19 3 8 1 I S 6 2 0 9 BillaryFJS(mM) 96+ 21 6+ 209+ 12 5+ 5 I 22 2+ 2 4 3 0 I 6 BiliaryGCA(n3M) 3 5; IDS+ I t O+ 4 2 + I 7 1531 07 I I 0 6 BileLesithin(mhl1 I I 2 9 3 0 0 7 C 2 0 I 7+ 3 I 2 7 J 2 Sipnilicantly dlllkerent from patients with IPF and PNF(1) or PNF(+) TONCLUSIONS: Analyrm of bdmy components afrer lwer trm~plilnt.ztiou t i ~niorc ilccwatu llm conventional Iwer tern in identifying patients with early graft dyrfmclion de\elopw! 1°F The bile of these patients 8s chnruclertzed by low tolill and tndwdusl bile d l s Inn ahnornlally llisll biliary lecilhin t on central ion. a likely imnrkcr of lher inembratie diiiissc

N O R M A L GRAFTS - IFF rn 1 3 1 3 5 1 3 5

GLUTATHIONE S-TRANSFERASE IN THE DIAGNOSIS OF ACUTE GRAFT REJECTION IN LIVER TRANSPLANT RECIFVENTS. 4UU. F ACOSTA. C CARRASCOSA. P MARTINEZ. PL TORNEL. RF CONTRERAS. R ROBLES. P RAMIREZ. FS BUENO. P PARRILLA Liver Tran~planr Unit U l v e r l ~ l y Holpilal 'V Amxxa- . MYICI~. SPAIN.

OIUECTIVE Dmonortr of acute rqectmn IS an mportant twue after hver transplantatton ILTI. The monttoring of COnYBntlOnal buxhemlcal liver function tests has been quertloned. The o.glutathions transferase IoGSTI has been proposed as the most iensmve speclflc marker of Ihvar function. Our a m w m 10 study lhe evoIulion 01 serum oGST levels durmg tho f m r P O S ~ ~ P ( I I B ~ I V ~ monlh and to arsarr its urslfulness as an earl" marker of acute , ~ ~ ~ ~.... graft rqsctmn I" LT. METHODS We studied I 8 patients undergoing LT. Daily, the serum levels of the COnvenUonal biochemical IIVW function tests were measured. We performed a longitudinal study and the results were normalized as B multiple of the upper Itmtt of the reference range IULRl for each parameter to bring covar8sle data onto a comparable scale. RESULTS. The oGST level returned 10 normal approxmately 5 dayr after procedure. FoYrleen of Ihs lwenlv relectlon epiLOdeE 170.0%1 were preceded by an increase ~n oGST level. w h c h ranged from 1.4 10 3.1 times bt9 ULR. At least e 39.0% increase was detected in 111 COnCenlratlon In the acute graft relectmn episodes. The increase in oGST occurred an average of 3.2 days before the diagnosis of re~ection. CONCLUSION The oGST as an early marker of acute allograft re,ecimn. presents two fundamental advantages: 11 reaches normal range more uu~sklv when patent evoIu1~00 8s adequate. and 11s level riser early on in the epiroder 01 relection. We Conclude that oGST may be an adequate biochemical marker for the early diagnosis 01 acute repctmn I" LT.

442 Penoperative Management

EOSINOI'IIILIC CATIONIC PROTEIN (ECP) IN ACUTE LIVER ALLOCRAlq REJECTION

W. Hughes V. loshi 0. IAlaander C. 2Calnc R Depti Chnical Biochmiiary. IMcdicinc and 2Surgcry. Addcnbrooke's Hospilal, Cambridge

Illood eosinophilia is Ihnughl 10 be the earliest marker of the mjecim proccu and ponal iract extnophil infillrnlion ii probably the -%I specific histological marker o f liver ccjmion ECP IS

a eytoloric subslance releswd by islivaled corinophils and may be panly rcrponriblc fur Ihc Ilepaiocellular datnagc associated with allogran rejection we. thed.,re. compared smm E r r concmlralion (ECP RIA. I*harmacia. Sweden) wilh ~lamnc minotransferare (ALT) in I s lever transplan1 mipienti 20 rejection episodes w e diagnowd b * w m days S and 97 (median IW) ECP was within the refercncc rangc following Iransplantalion for a median of 3 dtyr (95% C I I 5 lo ?I I lolh ECI' conccnlmtion and ALT aclivily increpsd by >So% beyond thc rdercnce range in 14/11) acute rejection eptsodas. an inweax in cilher leil occurred in 19/20 episodes The nx in ECP occurred significanlly earlier than the rise in ALT (P<OO5). the medm rise occunsg 3 0 days before the diagnosis of mjedon (95% C I I 5 10 4) CCP concentration fell lo within i t s reference range in 5/12 trsaied rejection episodes h$m therapy bcgnn (0 . rd earlier) and m 4 more cases was normal before complelion o f lrcatmenl In conira11. ifthe ALT actwily was raised. it r e m a i d so lhroughwl therapy

Surgical tramin and donor organ iwhaemia do not appear 10 influence xmni ECI' conc~n~ralions A rise 1~ ECI' is an early markrr of acute allogran rcjmlion and precedes biochemical evidence of hepaioeellular damagc The fall in ECI' pnor 10 lrealrnenl of rqenwn ruggertr lhat acute rejection may be =If-hmiting in some C ~ X I


ACCURACY ANV SIGNIFICANCE OF PRIGTRANSPLANT LIVER VOLUhlE MEASURED BY MACNLTIC RESONANCE IMAGING (hlRI) COMPAREU TO EXPLANT UISPLACEhIENr V 0 L U L I E S . S . H . . E.E,deLange. M.Sue. M J.Grffcy,R.C. Dickron. C. Drlrcull. W.K. Sleucnron. M.B. Ishitmi. C. McCullough. T.L. Pwctt. Dspts. Mdcine. Radiology. P i l h ~ l ~ g y and Surgery. Univerrily or Virginia. Chrrlottavillc. VA.

Liver vulume is anen measured in patients 6m) evalualed ior l iver traruplantaion (OLV. Liver volume n a y have prognoslic value and is vied to gauge h s size o i donor ocgmr. PURPOSE: We detcrmimd h e accuracy of MRI i n measuring liver ~olume md correlated h e volume with h e clinical swrrity u i l iver disease. hlETHODS: 19 adult pts under conlidsration for OLT were studied. Liver vol~ inr was measured at M R I by averaging h e crlculated liver volumes measured from coronal and ~rrn~verse bre;ihhuld T-1 weighted images. There results were compared to h e sxplanted lwrr volume measured by fluid displacement. Direare severity was clinically vrerred by h e Child-Pugh Class 10 pmenir were Child-?ugh (CP) chss AD and 9 werr class C. RESULTS The mean liver v ~ l ~ m e fur Child-Pugh AD by MRI was 1986 k 568 ce (lW2-2470 ec) wmpared LO 1433 5 379 EC

(540-1889 cc) in Cliild-Pagh Clsrr C b=O 02) Tlls percenlrgeof MRI liver volUme to body weigh1 was 2 5% i 0 7 fur CP AB versus 1.6% k 0 5 fur Child-Push C 1q=O 0091. The ~ ~ r r e l a t m n caeflicirnt fvr h l R l hvrr volume and h e explmt dirplx'ement volume was 0 90 CONCLUSIONS:

Lower l iver V D ~ U ~ F I rtprerred either 1s rbnolute values or percentages or body weight wrret*te to disease scveriiy IS mesurd by h e CIIrId-Pugh d a s

we cunc~vdr titat htni ufrrrr an ana tumlca~~y 3ccycilte or dFtermlnlng liver Vo~Yme in

USEOF ARTERIALCONDUITS INORTIIOTOPIC LIVERTRANSPLANTATION ( o m ELkkh~ F Nod&. M Re14 H V i l a Melendeq V Vaugas Roger Wclliamr. ND Heaton Liver Transplant Surgical Service. Innitute of Liver Studier. ffing'r College Hoipilal. London

Anmd conduits, using donor iliac Mery. rep-nt a reliable technique for grall rcvarulariwtion 8" OLT Indisttonr include retransplantalion. paediatric patients, poor inflow bom native mery nlhcr due to m a l l sire or to diseased hepatic or coeliac aneries, or for more complex pmcedurcs including reduced. split. livmg-mhted or auuliary liver mrplantr We reviewed 757 wn-twe OLT performed bnween 1989 and 1995 for fulminant or chronic liver di- Of thew, 218 ~onduits were connructed using donor iliac anery anartornosed to the infrarrnal mna The conduit was prepared and anas~anrased before the anhepatic phase in 86 OLT (39 5 %), d e r reprfurion in 120 (55 %), and a previous conduit was used in I 2 rctraniplmtr (5 5 %) The incidence of hepatic ancry thrombarir (HAT) for conduits was 4 I % (9/218), wmpared lo 4 % (2U539) for direct anerial ~ I M Y O ~ O U S Patients in the anend conduit group at risk for H A T insluded 66% (991159) ofthe children leis than 5 year ofage and 75 % (67189) ofall retranrplsntr and in panicular 25

Four conduit thromboses occurred within 4 days of OLT. 3 patients were retransplanted and one died awatmg a suitable organ Three patients $"&red anerial tlroniborir between I and 3 months afler OLT. 2 were retransplanted and one developed an abrccrr in the nght lobe and has been treated conwrvatively One patient originally transpianted for HCV had 2 episodes of anerial thrombonr. the first 2 monihr aflei retransplantstion for chronic rejmion, and the second, fatal. I year afler the tliird OLT. Anerial conduits provide an eITeclive and reliable method of revauulariration in paltents at higher risk of merial thrombosis, panicularly small children and retranrplaniation for lhepatlc ancry thromboar The aauarial %year patency for canduitr is 95 %and the incidence ofHAT is similar to that ofstandard OLT

caserregranedbecauSeofHAT.

THE SIGNIFICANCE OF EARLY POST.TRANEPLANT TRANSAUINASE ELEVATION IN LIVER TRANSPLANTATION CR, P Martin. J Mdmek. 1 Slothers. KM Ollholl, OK Imagawa. M Kmkhabwala. S Rudch. P Seu. S McDtarmld. 11 Geldstein. A Shaked and RW BUIULBI. &panmen1 01 Swgery. UCU Schwlol Medmne

Qlamy~ To determine the impact el early part.lransplan1 lranrammare elevation. a$ I nllectlon 01 Iwhemia- preie~allon-reped~~~on intuly (IPRI). on patienl IYRIVII. gialt wwival and grall lunclian in Ihe inlermedJale term m llVBl Iransplantalc" MEIbm3 We renewed 213 conse~ullve patienlr who received their lirit liver allogiall belween 111193 and 12131193 The eitenl 01 IPRl war assessed by Ihe peak value 01 aspanale ammotranslerase (ASTmax) ohsewed within Ihe 1 1 ~ 1 72 hours pasl.transplanl Recipient$ were grouped by ASTmu a$ l o l b ~ ~ : Group I, ASTmax 5 600 iUIL, (N i 46). Group 2. ASTmilii > 6w s 2000 iUIL. (N = 97) and. Gmup 3. ASTmax > 2wo 5 MW IUR. IN = 50) and Group 4. ASTmai > 5000 IUIL. (N 17) Groups were comparable with respect to age, UNOS status (30% $talus 4) and diagnostic case mix Dell were analyzed via unrvaiidte and multlvariale methods. W The incidence 01 pnmar/ gmlt no"-luncl~on (PNF) was ngntlicanlly correlated with the extent 01 lPRl (0%. 4%. 10% and 41% tor groups 1 lo 4 rerpectively. P<OOOOI) bul this impact was conlined to the rerpeclive lalei 01 ntrin~plantali~n as early palient I U N ~ Y ~ ~ was unatlecled. One-year s u ~ i v a l 01 patlanlr whose grafts manilelled extreme IPRl (group 4) Was rlgnlllcanlly tnlenol to rpclplentr ~n the three other groups (77%. 71%. 73% and 52% respectsely. P=rlO3] TbS increased monality was canlined to patients who never achleved dischaige tiom their initial horpitalizalion Wlth no rignlllcanl dlllelenceS between groups being deleeted in h e IUwivaI 01 those patlenls who were discharged (84% 80%. 85% and 81% respectively. PzNS). While OVeRll one-year grall IUwlVal was strongly correlated w l h the extent 01 lPRl (77% 67%. 62% and 41% rerpeclwely. P=O.OOI). this carrelation war ilbeliihed when SUNIWI 01 gritti not 1011 lo PNF was examined (77% 70%. 69% and 70% rerpecttvely. P=NSl Sle w ~ e cox regression analysis conlirmed Ihe independent s i ~ ~ ~ i a l i o n belween ASTmax and oveiall paltent and gra! s~wival There were no r~gml8canl dlllerences observed belween groups 10 Ihe biOChemiCat functlOn Of 128

f?" 'oi lo':d."~;~~~~~:Nivai B inllwnced by IPRI only when /t 8% exlreme (ASTmax > 5000 iUI1) provided $%%?gmll l~ncl80n are used in coniuncti~n wilh lrdniamma~e values 10 assess Ihe need lor prompt relransplanlation 2) shorl-term grall I U ~ Y ~ Y P ~ IS proport8onal lo Ihe extenl 01 lPRl but gratlr lhal are "01 I h t to PNF have equivalenl one-year s~wival irrespective 01 the magnllude 01 lPRl 3) 40% of graltr wllh ASTmax > 5000 IUL are lost lo PNF bul Ihe same proponlon also provide long-term lunc180n and 4) pml.6monlh bmhemical IUnCllOn 01 surviving gralls I$ independen1 01 ASTmax


culuim OF LIVE4 1T IN ISPuwIs am FOSIT~VE m cnmnw awss mm. U\, Rp Pelletier, M. ~ e n r y , GL E ? q a d w r , FA cavies, m F-. -t of SJFler/. 1 1 ~ Chi0 S ta t e Universrty.

?he u t i l i t y of flow n/rmtric a- m t c h i q IFPI] in liw transplantation is urcertain. Wa retraspfft ively r e v i d au exprierre in 52 l i ve r recipients w i t h W t i w l m t o x i c -5 m e . sequential quadruple Lmrvmuppression was usd. Patients were divided in to 2 -ps. Group I consisted of 19 recipients with a p i t i v e frn d group 11 SoNistgl of 33 patients w i t h a negative frn. me gmup WI mt s t a t i s t i c a l l y different i n rqa'ds to q. -, r i sk , or hep c. we carpared early g ra f t furrt ion 4r irrid- of pr- mn-furrtion, hepatic artery t A r m b x h 3 m. g r a f t survival, d r e t r m l a n t a t i o n rate. we sly, DDmpared 12 nmth patient and w a f t survivals in b ~ t h -p.

a W f t YUV. 3/12 nas. 90190 89/78 0.20

f r n m l N = l a EWlm(PW2l % pt -. 3/12 nos. 93/93 89/81

pr- m-funs t ion "1%) 216%) 21101) 0.56 hep arter, thzmksis n o ) O l o t ) 4121)) 0.006 retr-lantation nltl 21621 512611 0.039 GtLGj&iOn ncri ' l i ( 3 6 % ) 0i42 ' t j 0.62 'Ihere is m differ- in patient or g r a f t swim1 or lonq ten0 gra f t function be- the two grarps. Il-ver. hepatic arter, thrcmbosis and re&-plantation are mre anmn in g r w p I. mnclurions: Illhere is m detrlnental effest of a pmi t ive frn on m a r t or patient survival. 2) lhe incidence of hepatic artery thmmtosis arcl retransplantation wag siqnificantly msd in rn p i t i v e patients. 3)For W p i t i v e recipients ye pr- that the mcst appmpriate action is either transplan- t a t ion m different irmurasuppression protom1 or of the g r a f t 111 a -5

net& negative recipient. Further data is needed t o d i m or refute this -1u51m and to study the mle of FGE1 i n these Cases.

hSSOCl&TfON BETWEEN POST TRANSPUNT LYWPHOPROLIFER*TIVE DISEASE ( P T W ) . EPSTEIN-BARR VIRUS (EBV) AND LYMPHOCYTE SUBSET CHANGES AFTER ORTHOTOPIC LIVER TRANSPUNTATION (OLT). m. PA S i d n e r . No Pescoviti. L L Luneng. SB Leapman and RS F l l o .

Department of Surgeiy. Indlaua U o l u School of Medic ine . 1 n d r a n a p o l i s . l N . USA

We inverrigaced rlie asrociaiion between PTLD, EBV, and lyinphocyre subset changes

cvclosnorlne. Imurnn. and steroids. Seven ~ a i i e n i r develooed PTLO 12 9 % ) . CYO in a rerrorpecrive r ! l a l y l i r of 240 OLT recipients Initial immunoruprerrion was

~. of which wer? discovered at autopsy for which lymphocyte ruhrer dacr was not available SIX had lnulrlple rejeccion episodes created u i rh steroid p u l s e s . c-0 were rroaied uiih OKT3. and t w o pedincric r e s i y i e n r s were switched to Fi(506 The Table shows EBV s t i i u ~ . ruhset analysis . organ involvemenr at tine of PTLD d

T h e r e was a ~ r l a n g rrrociaflon belvoen PTLD. jn Ivmohocyie subsets. EBV IGN = i t e r r were i i ~ f e levated PTLD generally 15

elevated EBV IgG f i r e r , and Changer

, . . characterized b\ 0 cell proli feration. however, Two patients showed elevation 2n peripheral acfi':afed T r e l l r ( C D I + . H U D R + ) ( 0 rhe ercluslon o f B cells data suggest chic >mon~:or~nr , lymphocyre suhserr may help 111 ~ c r e e n i n g OLT

There

rPCl"/en/F fm- r h l n n i r F"V , " f?c r , "n and P 1 1 "

ORIGIN AND 1UW"t ION OF hllCROClllhlERIC CELLS IN LIVER TRANSI'LANTATION I IRRADIATION SENSITIVITY

Surgery. Naliond Childrm'r

""OUT cell '"1g'"""n rmm IlX

I l l le cell, ,ha C 0 " l l l l Y I C l h g

Penoperative Management 445

surw~al 8n group 1 (anti HGV f) was 87 5 and 79 7. tn group 2 (anti HCV-I INS log rank IeLI j Liver Iun~Lion lest a1 12 months were 51m1lar slltouph values 01 AST and ACT were higher m group 1 (pc0 051 The number 01 biopses peerformed in group 1 (21) was higher than 8n group 2 (12) ( K O 05) A biopsy was never performed In 21 patienls an18 HCV - 13 palcents I" group 1 (40 ' lo) had hiSlologlCal chronic hepalilid and there war no one 10 group 2 (pc 0 05) These Oala did MI change a! two years Conclunion Prevalence 01 anis HCV m pahenlr with ALC IS dose lo 50% However allhovgh l,"er l"WllO" ,P ""palred m In15 type 01 pa1ients I, dDes "0, allecf Y l M Y a l at ,wo years


ALCOHOLISM RECURRENCE DOES NOT INFLUENCE THE CLINICAL OUTCOME OF PATIENTS TRANSPUNTED FOR A i c o n o i i c CIRRHOSIS

Length of sobriety Alcoholics UNOS IV'

56 6 1 4 1 16 5 4 7(r 74 78

4 nonth(n- l l1 62

86 1.6 months ( " - 2 1 ) 78 >6 months ("-,a&) 91 78 Jb a i

*In 16 pstiencs. letigth o F s o b r i e t y I S not known

Overall. alcoholic cirrhotics had better. Chough n o n - r ~ a ~ i s r i c a l l y s i g n i f i c a n t . s u r v i v a l . The varnt sucvlvill occurred in che UNOS I C ~ C Y S I V (old) alcoholic group with the PhoctesL length oC sobriety (Cl month). However. the severity O F status IV eL the time of tranrp11lnC 13 not Caten in to considerarlon Them w e 8 no difference In survival for thore who underwent r c h r b i l i c a l i o n Y S chose uho did noC (P-0 l(1. log rank L e s t ) . sll l iough rate of r e d i v i s i o n i r currercly i i ~ L known.


RECURRENCE OF HEPATITIS B VIRUS IHBV1 FOLLOWING ORTHOTOPIC LIVER TRANSPLANTATION IOLTI 15 NOT DUE TO MUTANT STRAINS OF HBV. j3LSmyd. OA Peterson. VA Luketic. EB Thompson. RA Fisher. ML Shillman. Hepatology Section and Divi~ion 01 Transplant Surgery. Medical College 01 Virginia. Richmond VA, USA,

The recent ure 01 hepatitis 0 immune globulin IHBlGl durtng and follow~ng OLT has dramatically decreased the rale of recurrent HBV lollowing OLT However. the reason why some pts mll develop recurrenl HBV despite this treatment 4s unknown One possibility 1s that recurrence ~ ~ E u I I s from the presence 01 mutant strains 0 1 HBV s gene which are ellher present prior to or develop following OLT and which ere not ellecfively neutralized bv the HBlG P ~ C D W ~ ~ ~ O ~ S currentlv available. PATIENTS: A total 01 10 pts with HBV rAg f + I have undergone OLT BI our 1nst6tution during the pai t 2.5 years. Their mean age at the tlme 01 OLT was 44.8 years: 7 were male. 8 were Caucasm and 1 was onenfal. 1 pt underwent OLT for acute fulmmanf HBV 9 ~ 1 s had chronic HBV and 1 had bolh HBV and HCV. 7 DIS were HBVeAg I + I. 3 HBVeAb I + 1, 6716 had delectable level5 01 HBV-DNA I +I m serum HBlG PROTOCOL: All pamnts recelved HBlG 100 mi IV during the anhepatic phase followed by 5 ml IV daily lor 7 days. HBrAb titers were then measured at 2-6 week intervals and IlBlG 15 mil was administered Y I ~ the IM route whenever sAb t m r s declined below 200 lUIni1 to mainlain levels > 1W m1Uh Reappearance of HBsAg was treated with daily and lncrearlng darer of HBIG. HBV ANALYSIS: The DNA sequence 01 the HEW S gene Was determined by auloiiiat8c DNA sequencing. RESULTS: 3 pts had recurrence of HBVrAg. This developed a1 I. 4 and G wkr tollowing OLT and was characterized by dmppearance 01 HBrAb and rapidly increasing HBY DNA t#te(s despite daily and increasiiig dosing of HBlG This treatment war subsequently dlrconlinucd ~n these pts Prior to OLT all 3 pts had chronx HBV and were HBVeAg I + I and DNA I + 1 All 3 pis were HBV subtype ADW2 lthe wild type nucleolide rcuuencel. CONCLUSION: Recurrence of HBV despite long term HBlG therapy occurred rn 30% Of PIS: Were HBeAg end DNA I + 1 at the lime of OLT. Recurrence does not appear to rewl l from mutant ZtralnE 01 the HBV I gene which are present either pr80r to or develop lallow#ng OLT.

CLINICAL COURSE AFTER LIVER TRANSPLANTATION IN PATIENTS WITH HBV PRECORE MUTANT INFECTION M,m&xE Koskinas J. Kalirl G. Lams A, Tzakou A. Hadriyannis S. Academic Department 01 Medicine, Hippokiation General Hospital, Athens. Greece.

Recurrence 01 HBV inle~tion In the liver gran occurs less lrequenlly in the absence 01 HBeAg and HBVDNA In the Serum than an their presence. However, a high rate of graft reinlection and bad

atlribuled 10 precare HBV mutants Fifteen HBV inlected pabents negatwe lor serum HBeAg and HEWDNA by mOleCUlar hybndizalion. harboring precore HBV mulanls, 12 w m cirrhosts and 3 with lulmmant hepalm LFHFI. were lallowed up lor a median 29 months (range I 6-724 mo) alter success1uI orthotopic liver lransplanlatian (OLq All paltents received HBlg post-transplant to maintain serum anti.HBr level3 > IW iufml. In FHF no HBV recurrence war ObSewed at a median time of 37 mo Five HBeAg(-) pat lent^ with CirrhoStS were also positive lor HDV; only one developed reinfection 31.5 monlhs post-OLT In 5 01 7 patients with HBeAg(-) Cirrhosis uncomplicated by HDV or HCV, the gran was reinlected at a median 5.8 mo (3.5-13 5 mo) post surgery. Serum IgM ant#- HBc titers and aminOtranrlelare IevelS remained relatively low and dld not Correlate wllh the HBV- DNA levels. Liver hwdogy at the time 01 reinfection revealed mild degree 01 lobular and ponal inflammation in all paltents Follow-up liver biopsy, performed m 4 out of 6 reinlected patients at a median 18 mo post graft remfectm did no1 Show signiiicant histological progression (Irom HA1 index 2 to 4) except lor one patrenl who developed ftbrosmg choleslallc hepa1811s (FCH). Canclurinns I t Reinfection of the oraft occurs freauentlv ~n HBeAal-1 Clrrholif due to OreCole HBV

pragnosls have been recenlly reporled on HBeAg(-) and HDV.DNA(.) pattents and has been

relnlectlon raie IS v e r q k w 2) h e r changes ~n th8S Subset 01 patients are usually characlerized by mild ~nflammalion and slight progression 01 t#brOS#S, whereas FCH appears to occur less frequently.


SUCCESSFUL RETWANSPLANTAIION FOR SEVERE POST-TRANSPLANT HEPkTITIZ B V l R U S IHBV) INEECTlON I N TllE PRlMAlY ALLOGRAFT. I s h l t a n l . M . . HCGory. H.. Dickson, K . . Calduell. 5 . . McCullough. C . . Slevcnsoa . W . . Roberts. J.*, Ascher. N.*, Wrlghc. T... Lake, J.., and Prueil. T. Deparimenr~ of Sucger~lMedic lne. U n i v e r s i t y 01 Vlrglnia , C h d r l o t L e s u i l l c . VA *Oepdrtnenc~ of Surgery/Mediclne. U n l v e r s l i y of Calllornla a t San Franclsco. San Franclrco. C A .

The OuCcome 01 parlenta relransplrnred l o c 11BV-Induced Liver l a l l u r e In rhe prlmary aL lOgra lC lhas been poor u l t h hlgh rates o f l lAV r e l n l e c r l a n and r a p l d l y pcogressive dlsense 10 t h e second graft. I l e p a L l L l ~ B lnmuoe g l o b u l i n (HBIg) h a s been S Y C C ~ I S -

f u l in delay ing o r prevenr lng HBV relnlecrlon in parlenrs rranoplsnred lor chronlc HBV-Induced c l r r h o s i a . Using am aggresilve HBl8 regimen, CYO centers retransplanted 7 paflenrs ( p t s l a l r e r they deve loped post-crsnoplanl H I V i n t h e prlmary a l l o - 8Cal t . HBV r e i o l e c l l o n occurred a mean of 10.3 w s following the first lransplanr (range 2-26 morl. Retransplantarion was performed I mean oi 29.1 OF (range I - 5 7 mOS) lolloulng the ClrsC C r a n ~ p l a t l i and a mean of 19.0 mos (range 1-44 m o r l following the diagnosis of HBV. A t rerransplanrarlon. 617 p c i were HBsAg (+)/anrl-HBn(-l/ HBeAg (+l/HDV ~ - l / l l B V D N A (+) by YCR; I p i was IlBeAg ( - I I H B V DNA (-1. I n 4 p r s . HHV DNA quantltaclve immunoblor assays were performed. ( 4 . 2 - 9 0 . 0 0 0 p g l m l ) l l l s r o l o g y showed chron lc acrlve h e p a l l c i s and cirrhosis w i t h tmnunohlslochemlcal sralns 3trongly IIBoAg (+llHBcAb ( + I . A l l p t s r e c e i v e d HBIg a t r e r recranilplanr t o l n d e f l n i - c e l y nainCsls seri im a n c l - l l B r 1 5 0 0 I U I L . A l l 7 p t s a r e a l i v e fvlloulng Che second rransplanr. Six p l r ( 8 6 2 ) are RBsAg (-1IHBY DNA (-1 by lmmonoblof assay w i t 1 1 l i v e r b l o p s l e s normel and I a n u n o l ~ l r f o c I ~ e n l c a I s t a i n s l o r HBcAb ( -1IHBrAp (-1. Mean 10llOV up 1s 2 4 . 2 (range I - 4 7 ~ o s ) . one p~ ( 1 4 2 ) 1has developed recurcsnr RBV 9 mas a l t e r the second Cransp l snt . but Is c l l n i c . l l l y s t a b l e uiLhvuL progrers lvr l i v e r In- j u r y . Ye concli lde that patients who develop post-transplant h e p a t l t l r B I n the p r l - msry a l l o p r r f t can underpo refransplantatiun w i t h eggiesslve HEIS 1mmunopropllYl~xls a n d remain f r e e 01 l l B v inleciion. The f a i l u r e ln m e p a r l e n t underscores the need l o r other eflecitue adiuncl iur anti-HRV therapy.

GENOTVPE AND OUANTITATIVE PCR PREDICT OUTCOME OF LIVER TWNSPUNTATION IN HEPATITIS C +VE PATIENTS.

OcParlrnenl5 of Surpcry, Infertiom Direasear b Heoalology. Uniwoiiy 01 Albrta. Edmonton. Canada J.K. PRik~alf is, V G. Bain. D. 1. SIpIct and N.M. Knefemin

Recurrence of hepatitis C IHCV1 after bv8r transplanlaf#on IOLTxl IS of great oncei in. and the impact 01 ~~nmunOl i~pprCIs~on on the HCV uiral.hort relstionshcp 81 not clear. We herein study the inteiaclion 01 HCV genolype strain 1genl and level of HCV RNA expresion using q~anlitalive PCR IqPCRl to pretlicl the reveriry Of reeurrenl HCV porllranrplsnt. Of 137 OLTx performed m 121 recipient$ over 5 years I" our inslilUIion 19 116%1 re~ipienls were confirmed HCV +ve on PCR. 2 Of

whom SeroEOnvened aher OLTx. SUrYivalo1 HCV +we recipienlr was 84% [median follow-up 27 mmlhrl compared 10 8% for OLTx overall Ins). none 01 the deaths rerulling from HCV. There weie 2 IIOZI retrm~plants lor HCV Cirrhosis lgen 4a a< 10 months. and gen la at 84 monthrl. 2 HCV +ue pahenls became HCV PCR .ve 816 manlhr. and remain disease free

We found Ilgnif8Canl pobilivo ~ ~ r r e l a l i ~ n of 9PCR with degree 01 lranraminalaemia 1AST1 s3ll2 poitiraniplant ~n the absence of reieehon or olher compI~cat~on IR=0.76. 0~0.0011 Mean qPCR e ~ p r e ~ s ~ o n 8n reciprenlr with sggrsrrive HCV recwren~e w s greater I4 4 5 2 9 x ldcallierlmll than ~n those Wilh uncomplicated direare (8.431 2 x 10'1 qPCR titre5 fell from 1.3 10 1.2 x 1 f f in One

individual lrealed wilh nllvirin afler relranrplanlafion

We conclude that the severity of recurrent HCV alter OLTx correlaler wllh hlgh l l l r ~ HCV qPCR ant1 that gen01y"ei l a and 4a arc srsocialed wllh more rapid recurrence 01 urrhosls

SlGNlPlCANCE OF HEPATITIS C VIRUS (IICV) RNA LEVELS IN ORTHOTOPIC LIVER TRANSPLANT (0I.T) RECIPIENTS NKL3". JU Gm>r Jr. A A Cursurd. RH Wiener. JI Polcrucha. DH Persing. Mayo Clinic and Mayo Foundal~os. Rochcrler. MN. USA

s m m IIEPATITIS c RNA TITERS AFTER LIVLR TKAYSPLAYT IJO NOT CORRELATE WIT11 InlnlUNOSUPKESSlOV O K IlEPATlTlS

NEW Enilmd

,


RECURRENT HEPATITIS C IN HEPATIC ALLOGRAFTS PRESENTING AS CHOLESTATOHEPATITIS IMPORTANCE IN DIFFERENTIATING FROM REJECTION Mamarbeilia C. !%sQ!YE Oyloe VK. Cdonna JO' Transplant Center of Fairlax Horpdal, 33W Gallows Road. Fails Church. VA 22046, and Wallet Reed Army Medical Center('), 69M1 Georgia Avenue. N W , Washington, DC 20307

Recurrenl hepalilir C infection aner liver tranrplanlatlon usually lakes the form 01 elevated tranramcnarer This 8s b8oChem8Cally slmllar to natlve (non-transptanl) HCV In two cases of reactlvatton Of HCV I" lhVer allogralt recipentS. a predommantly choiertalic b#cchem#eal plclure Was noted. wllh PreSentatlon at 3 and 6 months port-transplant Biopsies showed mild portal inllltrales with virtual absence of eosmoph~ls and no bile duct damage Dramatic gamma-glutamyl transpeplidare (GGTP) elevation war the main enzymatic abnormalcty. ~n one tnstance reaching as high as 6265 IUlml Transamlnares were in the range of 3W-4W IU/ml Biiiary tract evaluation was negative in one inslance and revealed a mddly steml~c accessow right hepatic duct ~n the other Two other HCV-porilbve extrahepatic allogralt recipienlr (kidney and kidneylpancreas. rerpectlvety) developed a 5 m m r picture and GGTP rose dirproponionafely lo the lianraminares In these latler Cases. interferon was used successtuIIy with r e i ~ l ~ l i ~ n of the bioChem,cal abnOrmal8tes by RIBA-2 tesung and PCR

We Conclude that recurrent hepatitis C m hepmc allograflr may occarionaily present as a CholeStatOhepatII~c pcture as apposed ID the ClaSItCaf pcture of elevated transammares Recognition of lhls may help avad overzealous emplrlc anlirelection lherapy

HCV was confirmed all cases

450 Periooerative Manaeement

SURGICALCORREITION OF DlLlAHV COMPLICATIONS FOLLOWING ORTIIONIPIC LIVER TRANSPLANTATION (OW)

Y J ! u g & P . M k m C k d s m * . J Kanui*,H VkaMdadqMR&Rc.wWdhm'*.NDHoucn Liver Tmwph l Suryry. D q m n l a l of Kadiologj' and 11(stitulc of Livn Studia'.. Kmg'r College Hapilal. London SES YRS. UK

Biliary mmpllcalions remain a sipifisant CBUV of morbidity follouing OLT. We have remcwed patients undergoing mmd mcgq for biliq empl ianns aRer OLT lo upeu their long lm Outmme. 695 palimlr underwent 781 Ihm tnlupLnti wsr a 5 5 yean pnid and of t h e 30 (I 8 male. n m n wyc 13 y". ~ g e 2-59) underwent hep.tic~jqunolfany (H-J) or mirion of prsvious H-J I'm biliary complications which included awtomotic lfrinure (22). ~ P Y O W I C Id (6) and combined Id and nnnure (2) a1 B ma? o f 6 marnhr (mw 1.19) pon.OLT Mean pa19 mld ivhaemis Iiw wy 11.9 houn(mge.55-19). Pnmarybiliaryawtomoriiw~md-~~mdin ISandH-Jin IZpalisnts Of 30 paltau undqoiog Rau-sn-Y revisioq 9 paisnu ( 3 P 4 dnrrloped CompliCaIioN whch included shd@tir due 10 Rour Imp kinkins hepatic anmy u w i s and b i l i q lfnnure. x w pleural &ion vlbphmic abyss. d u o d d ulcn W i n g and shmnic rejntion in one paliml cnch Two patmls were fard 10 have hepalic meiy thrombosis (HAT) (I) I l fmsis (I) In the i d i a t e ponaperative pniod. whch vas mi diagmud prmperatiuely Three patienti had elevated livcr cmyne and radio!+A Evidmee of imrahepatic bile duct dihlation. but ng obnrunion and have been maMged w i h mtibiMic therapy Three pimtr (lG%) have Bed (mean follow up 21 mlk. range I - 65) Fmm fungal wpsk dler rrtrarupht for HAT. turnour mmnu: and lymphopmlifsralivc disease WJ is valuable for thc yrrgid co~rsdion of biliq complicalian~ nfla OLT PRopraliVc w*uP In these patimtr must include Doppla/ar&nphy mdia to exclude HAT

Perioperative Management 45 1

ROLE OF UREA SyMHEslS IN THE MZI'ABOLIC A L K A U X I S FOLLOWING LIVER TRANSPUhTATION.

R.E.. F. J h r . DW. of Arralhcsiology. Oregon H d t h Sciences Univ.. d VAMC, Podmd. OR; md Children's NuVilioo Research Ceniu. Houwn. TX.

Mcubolie dtdosis follows onhaopis liver ua~~ply l f l t ion. reaching a m ~ i m u m on the rscolul p o ~ t o ~ a t i v c day. I t h u b a n rvggc.ted that hepatic Y- synthesis. which U ) R I Y ~ ~ ( bicarbonate. plays M imponant mlc in a c i d k c hommsUSis. Urea synthesis In vilro Is slimulated by a bicarbmale challenge. On lhe other had. i m p r i d urea synthesis in chronic liverdiream may vlulerlie 1 metabolic dkdosuis mir study m u r e d urea rymhai i directly W dauminc iu mle in development ofmeuholic dkdosu after liver Irur~planUIion. MUk&: Following written IRB-rppmved informed ~)menl. 10 patienu usre sludied on the second p m p e r n i v r dry. using I Chr primed. mmum infusion of stable isowpie "N -urea. Blmd -pies w e laken -60. 120. 180 d 140 mi". Anerid pH. KO,. HCO,. [Crl. INH.1 [BUN] were Ukem fmm the m e p i c n u before a d after wrgeq. Ulu isowpic cnrichmenl was d r t e r m i d by GCIMS. and v r u rynthnis @a urea) ulmiated by irolopc dilution. StatistiEd wrnpYwN w u c by ANOVA. &&&: Pmlopwaiive pvienu exhibited 1 marbolie dlutosis with a concomitant I-fold incr-c in urea syntherir (Table). Q&sh: me E O I I ~ ~ ~ I N mnrbolis dkalosir md incrcp~ed urea 1unthc6is indicate that I ) Ute d k d m i i is MI caused by an irnpaimcnl of u r u synth&. and 1) the graft liver responds ID the metabolic dkdoris by augmenting YIU synthesis. thus incrrping bicuhunrte consumption md dusting the dkdoris. (Suppon: lnlemtiond Anesthesia Research Sociay)

7.%::$1- 42+1

3 1.1i0.4' 6.8+0.4:

39.5+6.3 1.3zO. I'

36+2 Art pH Art PCO, Art [HCO,] 22.7k1.0 Art Base EX -0 .8kO.4 Art [NH,) 65.427.3

0 . BfO. 0 1723 35+6'

Art (Crl Art [SLW] Ra urea (rrmollkslain)

4 . 2 5 2 0 . 5 0 13.42k2.61'


PROPOFOL STIMULATES THE HEPATIC CELL PROLlFERAllON AFlER PARTIAL HEPATECTOMY J.P Gong. A. Saler. 1. Lamboue. Laboratory of Dlpsnmental Surgery. Untvenlty of ~ouvain Medical SCIIooI. Brurreb. Belgium.

Pmpofol. an intravenous anesmeslc agent. IS -nUy used during W banrpbnbtion almough 11s metabdirm IS mainly hepauc. As prolonged administram might ba rsquimd. we e m i d a possible inlerterem mm SubseqWnl liva lunmms. In these e m r i m e . we u)nSidepM the pmliferalive response f a l h n g a partial hepalaiomy (PH) in rat P-foll% in 10% lml ip id sohlllon (Dipnvan. Zeneca) administered inbSvenaudy (0.4 mhr) durinp the 6 hours following me PH. iiiueared sigmficantiy me 3H-mymodine uptake into VH, DNA, a d a s ~ ~ l n d c x o f c e u p ~ f e n t l o n a I t e r a 1 0 % P H ~ ~ . 5 + 7 . 7 v s n u s 1 3 . 2 + 1 . 8 ~ ~ ~ l ~ g D ~ ~ : p ~ o . 0 i ) o r a 4m PH (102.7 f 11 5 v415 t 3 1 p c 0 W1) bul has na influam on norcoperaled rat Pan of this slmulahon IS due lo the vehlcle. Inh-aliwd (mi). whkh inmasesl #so me liver meemration afler a 40% PH (62.4 + 6 3; p < 0.05) bul an addnlw icdepndenl effad of Pmpofol u n be Observed mlh Ihb vehicle P I -11 0s wm Cremforwhid is mamve by I M f .

mis slimulation does no1 Ieem related lo a pmlonged sedation of the rat since 11 is not pmduced by the neudeplanalgtric H y p n m (Jansms Pban.) (35.1 + 6.1 NS). Pmpafol has been reponed lo depress P450 achwl!es. Oadalive phorpharylation and lipopemmdaljon. A rtimulamry effecl on cell pmbferation. related or no1 lo one of these mechanisms. can be an assel afler lim lransplanlali~n or hepatic resenion (living donor. for instance) but muld be mnridemd rmh caution aner tumor resemon

HaemOStaE15 In Prlnary Billary ClrrhosLS Durlnq OrthOtOplC Liver TranSplantatlon Compared to 'Other' llVeC dlsedse- Helen Seqal., Beverley J Hunt., S . Cottam., 0. Potter. Research Naenatoloqy Harefleld Hospital and Dept Anaesthetics Kinqs C O l - leqe Hospital. London.

Concern has been expressed over the incidence of graft fhromboals during OTthOtOpiC liver transplant (OLT) I" patients With prlaary biliary CITrhos1s (PBCl. It has been suggested that patients with PBC have a hypercoagulable State. The aim of this study was to compare haeaostatlc changes in PBC with other liver disease before and during OLT. Both groups had subnonbl mean levels of prekallikreln, factor XIIa. antlthroabln 111, plasnlnogen and alpha-2-antlplasnin. C1 esferase inhibitor in PBC Yois higher than the normal range mean [+I- SD) at 1.29(0.23) v 's 0.84(0.22)u/ml p<O.Ol). as was kallikrein inhibition 161(38) V ' s 108(151%, p<O.O1, but not in non PBC. Non PBC had lower median fibrinogen levels (138 v's 312 u/dl, pt0 .05 ) and shorter euqlobulin clot lysis tines (115 v 's 360 nins ~ 0 . 0 5 ) . tPh antigen levels did not differ between groups but Le?e higher than the normal range (p<O.O5) as were median thrombin anti thrombin COWlexeI (TAT). Durinq OLT there was a tendency for less hyperfibrinolysis In PBC with lover levels of D-diner. TAT levels in PBC Were hlqher 1" the anhepatic phase at 116 V'I 47 uy/l in non PBC ( p < 0 . 0 5 ) and tended to remain higher during and post OLT. In conc1Yslon PBC has hiqher levels of haemostatic factors and contact aCfl"atlO" inhibitors r e s u l t l n q in less Contact and fibrlnolytlc aCtlYatlOn durinq OLT: Th15 confirms that in PBC there 15 less derranqeaent of haemOStas1s durinq OLT maintalnlny the capacity to generate thrombin and therefore, pdfentlally, a more prothrombotic State.

MAXlhfAL EXERCISE TESTING IN PATIENTS AWAITING LIVER TRANSPLANTATION AND ITS IMPLICATION ON RELlABILIT'ATlON K. Slaklon. L Irving. M Mom33ey. P Angus. J Prcilo , R M Janss Liver Tnnsplml Uiiil Aurlin Reprlrtrlion hledcll Crnue Mclhournc AwdnJQ&


R I S K FACTORS OF POSTOPERATIVE BAD OUTCOME. THE ROLE O F THE ASSOCIATE ORGAN DYSFUNCTION. A . Saba&. C . Benito. C . Martin. M. KOD. C. BartolomC. a Dalmau. J. Fisueras. E . Jaurrieta. Anaesthesia Department. Clutat Sanitaria I Uni;erSitaria de Bellvitge. Barcelona

End-stage hepatic chronic disease 1s a multisystemic process. The lung. kidney and brain are the organs more frequently involved. Evidence Of Systemic disease may influence the Outcome. Methods: After IRB. 91 Consecutive LT 11993-4 Period1 were analyzed. The evidence of preoperative hepatopulmonary ( H P I . hepatorenal ( H R I . altered EEG. metabolic acidusIs. Child and UNOS ClaSSIfICatiOn were matched with che followings outcome parameters: blood requirements. malor pulmonary complications, relection. infective process. recransplancarion and death. A step-vise regression was used. Results: 2 0 % of patients had some degree of HP, 16 patlents were classified as WNOS class III+IV In three patients an HR Syndrome was detected. UNOS class 1s predictive for che need for mechanical ventilation for aore than 5 days lp=o.021. ARDS ip=O 0161 and tracheostomy (p=O.olll Preoperative metabolic acidosis and hepatopulmonary syndrome were also predictive f o r tracheostomy. p<O.OOl and p=O.OOl respectively.

We conclude that associate systemic disease represents a predictor of bad outcome. mainly for respiratory complications


A NEW MODEL OF OUTCOME OF LIVER CHOLESTATIC LIVER DISEASES.

TRANSPLANT IN PATIENTS WITH

E!u%M. Themeau TM. Pc12. JL. Benson J. MalmchoC M. Cripprn JS. Klinlmalm GB. Steers ", W.esner RH. Slan. TE Abu.ElmaQ0 K. Dickson ER Baylor University Medical Center. Dallas. TX. Lnivsrsily 01 P ttsDJgh PillsbLrgh. PA, Mayo Clime. Rocnestor. MN

Background: Ophm zabon 01 pat en1 Zelection and t.ming 01 onhotopfc liver transp.an1 (OLTJ IS now an imponanl lot-s 01 research because 01 the increasing d.spann/ DetWeOn demand an0 donor availabil ty Aims' It To deline preoperative variab,es lhal best predict morbid ty n pal enis undergoing OLT lor cnolestatc liver diseases 2) To develop mathemahca models Inat will help pat wl selecfion an0 liming Methods We Womd 415 PIS rrrth Prrmary biliary cirrhos 5 a n j PPmary sclerosing cholangilis who had OLT Oelween 1985 and 1994 a1 lhree centeis Baylor Un.veraly Meoica Cenler (BUMCJ. u n versily 01 P ItsoJrgh and Mayo Clmz Dala were lrom hlH Liver Tiansplanl Dalabase lo$ms (Ln vers l y 01 P llsbrrgh Mayo Cmmcl an0 5 m la! toms mapped lo hlH data loniis (BLMC) Meom IoIIow-up I me=l 2 y15 posl.OLT Preoperative YallaD es lor dnivaiiale and mull variale ana ys 5 were JhOS slalus asciles. encephalopalny. nrtMlOn. edema. renal larlure. alb~min. CIBal n ne. D C , I V ~ I " , INR ou~cames SIJO es intraoperat ve 010oo loss. days m an intonswe care J~II. malor comp icatlons n In0 Iirsl 30 days lrom 0 - T and alter 30 oays lrom OLT ReSUIIS Many preoperative lac!ors signilicanlly Predcled Ihe l m t three OJtcomes Only renal blue (oelineo as creahri ne > 2 rngoLl PreOlcIed camp cations grealcr I n w one m o m after OLT A malnemattcal mode based on age. renal la .NC. Childsclass and UhOS slalus. preoicleo bloou .ass. ICU aays and comp rat,ons m the I rs1 monln post OLT The scoru derived liom the model pred cled the s12e 01 Ine effect on each Outcome Conclusions The new oulcorne mode lor OLT m cno estalic we, d,seases Lt hies foul nomnvas ve var ab es readily avaoiable 10 the Pract c ng Pnysician

age. Kamolsny score. Cnllds c ass. Mayo .(- score.

LIVER TRANSPLANTATION FOR IIEPATOPORTAL SCLEROSIS P.H. Dernrrd. J. Ckrlc% [I h Owl. J. Sdric. CJkhkld. P. Dmulrc-S3ge. L ~ V W T l~n~p l r t i t Untl. CHU Dordwur: GREF. L;lhommic: dc Pdlologre. UniversttL' Bordcnui 2. Frmce

SEVERE BACERIAL INFECUONS (SBI) A F E R LIVER TRANSPLANTATION (LTx).

M . B m m . J.C.GarcL-Vuldecrur. R.Rull. L.Grmde. J.Fuslcr. A.M.Lacy. A.Rimola, M.Navasa. J.Viw.~epmmcnl of Surgcry. Liver Trmrplnnl Unii. Horpitrl Clinic. Omclona Spain.

Wc havc previously shown !hilt SBl in paticnir undergoing LTx continue 10 bc a major caux of morbidity (65%) and mondily. Berider we also showed i h i l SBI epirodcs were dircctly relaled 10 the incidence of prcopcniive cnccphalopaihy and massive blood mnsfusion. However. since llic migniiud of h c prwdurc has ken significantly reduced over Ihc last years we have rruospcelively evaluated the incidence of SBl rflcr LTz durine tho first 90 davr as well as the osrioarativc risk

CI.INICN OUTCOMF: OF AN0 RISK FACTORS FOK INVASIVF. FUNGAL lNF€CnONS FOLLOWING 405 FIRST U V h R TRANSI'I.ANTATIONS

IlStnp. KuSrll H WICIW. Hvvd A F b i n . Crlur V. hyr Mayo Clinrr. HOCIXSLI. hllnneaolr USA W ' d l . d D a ~ d Ponela. A W e w D U=lley. William S Ilarrnen. Jclfre) J I . a ~ ~ n . K c l k r . Duur M


LIVER TRANSPLANTATION AND CMV INFECllON U U I W K EXPERIENCE RESOLUTION OF PULMONARY SHUNTING AND GAS EXCHANGE ADNORMALITIES WST Soncllr DL. W. M ~ M i l l i n RW. Aullrrun DF. Cholun CF. McDonald JC. Dcparmsnl of Surgmy. L&w,iuu Swc Untrmhy M u l i d Center

LIVER TRANSPLANT L E 5 a u & . IJ PmLLo. L B Imng. RM. l m c ~ and P.W Angms. Lircr Trmwplml Unrl 2nd Rcwrnov Labonlw. AULK HOIPIWI. Mclboumc. AwmhAX4


AN OI~EN-I.AIIEI.EI) WJLTICENTEH IWXPECTIVE HANIKII)IIZEU CONIKOLLED 1 RIAI. 01' I~ROSTACI.ANUIN E USE IN I.1VF.R TRANSPIANTATION wIruy. L Bxkmm. k W Busulld. SO Kcllcy. I Robens. RM Goldnrm BS tlurberg. TA Gonur. CB KlliNmrlm

L I V E R TRANSPLANTATION AND CHEHOEHBOLIZATION FOR HEPATOCELLULAR CARCINOMA. J.Flmueraq, P . H o r e n 0 , C . V a l l s , C . B e n a s c o , J.Domln9UeZ. C.Sancho, R.Rdfecas. T . C a n a n o v a s . J.Fabregat, x.X101. J.TOrraS, E-JaUIrieta. C.S.U.Bsll~it98.Uni~er~ity of Barcelona. S p a l n . Ccmcr. Ddla. Texas

unirersq or crilrornla 0, LU? A ~ ~ ~ I E , . un,verstty or c a ~ a r n i r .I ~m ~rmccrco. mnd 8rylor univririiy m i r r i

L ~ v e r transplantation ( O L T ) for hepatocellular carclnama (HCCAl 1s controversial. Chernaenbolization (TAE) 1 s a palliative treatment for UnreSeCtable HCCA. The arm of thls study IS to analyze the reSU1tS of T I E and OLT in the treatment of localized HCCA. 24 HCCA In Cirrhotic patients were transplanted between 1991 and 1994, HCCA incidently discovered or the flbrolamellar variant and those a r l S l n 9 I" no" clrrhotic patrents were excluded of the study. TAE was carrlsd out with 5 0 mg of Adriamicine. 6-16 ml of L i p m d o l and the artery was embollzed with gelfaam particles, interval between TAE and OLT was 3 months. Fifteen patients were in Child Pugh"A" Status, 1 " B " and 2°C". N i n e t e e n p a t l m t s ( 8 6 % ) w e r e HCV + . In 10 cases the diameter Of the , I turnour was ,3cm and 6 patients had ) 3 nodes. TNH Status Was 4 T 9 T l . 5T3 and 1':p 6T all cases were PN&~'. I n 4 cases thyre was mlcroscopx vascular invasran while 3 HCCA Shoved maCI-OSCOPIC

(sl la) 1 -1 (rm

vascular invasran. T h r e e patients W e r e retransplanted due to PNF, recurrence of cirrhosis and artery thrOmbos1s. 1 11

I I I 917. I SIX I 96192% I 88178% PGE 983 I8 1 1125

("=la41

PANNICULITIS ASSOCIATED\VITII ALPI IA-ONLAMITRYSIN INDEflCIENCY(AlAT):R*PID RESOLUTION WIT11 B O W INTRAVENOUS AlAT LND LIVER TR*NSPL*NTATION. K. ORiordm. A. B h , D. Kwfrmvl. F S f y n and M. Abosulis.

abstracts of the joint congress

Documents