International Journal of Organ Transplantation Medicine
Volume:4 Issue: 4, Autumn 2013

Live-donor liver transplantation (LDLT) is a valuable option for patients with hepatocellular carcinoma (HCC) as compared with deceased-donor liver transplantation (DDLT); the tumor could be eradicated early. Herein, we reviewed the outcome of adult patients with HCC who underwent LDLT from 1990 to 2009 in the USA, as reported to United Network for Organ Sharing. Compared to DDLT (n=5858), patients who underwent LDLT for HCC (n=170) were more likely to be female (43.8% vs 23.8%), younger (mean age 48.6 vs 54.9 years) and have more tumors outside Milan criteria (30.7% vs 13.6%). However, the recipients of LDLT for HCC had a significantly shorter mean wait time before transplantation (173 vs 219 days; p=0.04). The overall allograft and patient survival were not different, though more patients in LDLT group were outside Milan criteria. Since implementation of the MELD exception for HCC, DDLT for HCC has increased form 337 (2.3%) cases in 2002 to 1142 (18.7%) in 2009 (p<0.001). However, LDLT for HCC has remained stable from 16 (5.7%) in 2002 to 14 (9.2%) in 2009 (p=0.1). Regions 1, 5 and 9 had the highest rate of LDLT for HCC compared to other regions. LDLT can achieve the same long-term outcomes compared to DDLT in patients with HCC. The current MELD prioritization for HCC reduces the necessity of LDLT for HCC except in areas with severe organ shortage.

Chronic renal failure and hemodialysis affect many ECG parameters which can affect cardiac repolarization. To investigate the change in ventricular repolarization before and after kidney transplantation in children. A total of 45 children with end-stage renal disease, 45 children at least 6 months after successful renal transplantation, and 45 normal age-matched subjects were enrolled into this study. A 12-lead ECG was recorded in the 3 groups. QT dispersion, QTc dispersion, and T peak to T end (TPE) dispersion were measured. In the patients before and after renal transplantation and the normal children, respectively, the mean±SD QT dispersion was 0.083±0.033, 0.056±0.029, and 0.033±0.016 (p<0.01); the mean±SD QTc dispersion was 0.104±0.038, 0.066±0.033, and 0.039±0.020 (p<0.01); the mean±SD TPE interval dispersion was 0.060±0.021, 0.045±0.021, and 0.034±0.019 (p<0.01). There was a significant correlation between left intra-ventricular diastolic diameter and QT dispersion, QTc dispersion, and TPE dispersion. The systolic velocity of the mitral valve also correlated with TPE dispersion (r=0.44, p=0.01). In children with chronic renal failure, indices of ventricular repolarization improve after transplantation, though they still remain longer than the normal values.

Due to the loss of autonomic nervous system, precise control of the hemodynamic status in dead brain potential donors presents a clinical dilemma. In these patients, due to head trauma and cerebral edema, fluids administration is restricted. Moreover, the decreased central venous pressure may put the viability of the organs at risk. To investigate hemodynamic factors affecting the suitability of the donated heart and kidney for transplantation. Data were retrospectively collected from the maintained databases of all dead-brain donors (DBDs) admitted to our organ procurement unit (OPU) ICU between 1999 and 2008. In this study, laboratory variables in addition to demographic data were collected. The time between donor entrance to the DBD ICU and organ procurement, vital signs, hourly urine output, amount of IV fluid administered, and the dosage of vasopressor and desmopressin were recorded. The end-point of the study was organ suitability for organ retrieval. A total of 132 dead brain donors were studied. The mean±SD age of the donors was 26.3±12.2 years. The main cause of brain death was multiple trauma (53%). The organ retrieval rate was 82.6% for the kidney, 59.8% for the liver, and 53% for the heart. 83 (63%) and 106 (80.3%) donors had suitable hearts and kidneys, respectively. 66 cases did not receive desmopressin (50.4%) at all. The mean±SD dose of desmopressin the donors received was 7±1 μg. There was a significant association between the suitability of these two organs for transplantation and the dosage of the administered desmopressin and volume of IV solution the donors received. Fluid therapy and administration of desmopressin can improve the number and quality of retrieved organs from dead brain donors.

Background/ We designed a clinical trial on a group of live-donor renal transplantation (LDRT) patients subjected to pre-transplant stem cell transplantation (SCT) to minimize immunosuppression to low-dose steroid monotherapy. LDRT patients subjected to pretransplant SCT who had stable graft function for ≥2 years and serum creatinine (SCr) <2 mg/dL were recruited. Patients with diabetes, hepatitis C/B, rejections, or unwilling to participate, were excluded. They had been subjected to non-myeloablative conditioning of total lymphoid irradiation (TLI)/bortezomib and cyclophosphamide, rabbit-antithymocyte globulin (r-ATG) and rituximab with SCT. The maintenance immunosuppression consisted of calcineurin inhibitors (CNI) and/or anti-proliferative agents and prednisone. Donor-specific antibodies (DSA) and peripheral T-regulatory cells (CD127low/–/4+/25high) (p-Tregs) were studied before and after withdrawal of major immunosuppressants; graft biopsy was taken after 100 days of withdrawal in willing patients. Rejections were planned to be treated by anti-rejection therapy followed by rescue immunosuppression. All immunosuppression but prednisone, 5–10 mg/day has been successfully withdrawn for a mean of 2.2 years in 76 patients with a mean age of 31.4 years and a mean donor-recipient HLA match of 2.9. The mean SCr of 1.4 mg/dL and p-Tregs of 3.5% was remained stable after withdrawal; DSA status was negative in 35.5% and positive in 47.4% patients. Protocol biopsies in all 10 patients who gave the consent were unremarkable. Stable graft function in LDRT on low-dose steroid monotherapy using pre-transplant SCT under non-myeloablative conditioning with generation of p-Tregs can be achieved successfully and safely.

Extensive ureteral stricture (EUS) after renal transplantation (RTx) is an important urological complication that adversely affects the longterm function of the allograft and therefore the morbidity and mortality of the recipients. We conducted this study to determine the prevalence of the EUS in RTx recipients and its impact on the patient and graft survival. We assessed retrospectively, 1450 patients who underwent renal transplantation by a fixed surgical team between December 1991 and December 2009 at Emam Reza Hospital, Mashhad University of Medical Science, Mashhad, Iran. EUS was diagnosed in 13 (1.1%) patients including 8 (61.5%) male. The mean±SD age of patients at the time of surgery was 33.6±13.7 years; the length of follow-up was 77.9±63.5 months; and the ischemic time was 126.5±114.1 min. Mostly, EUS was noticed in recipients of transplants with more than one artery (p<0.05) and of cadaveric donors with more than 4 hour ischemic time (p<0.001). In follow-up, after ureteropyelostomy (7 cases), ipsilateral pyelopyloplasty (4 cases) and contralateral pyelopyeloplasty (2 cases), no evidence of ureteral stricture recurrence, graft loss or death was observed. We concluded that the incidence of EUS, as a urologic complication after RTx is very low. The advanced techniques of RTx that preserve the ureteric blood supply and the better procedures for ureteral reconstruction have improved the survival rate of patient and graft.

Cutaneous metastasis of cholangiocarcinoma is extremely rare. It can be seen at distant locations or at the site of biliary drainage. To the best of our knowledge less than 30 cases have so far been reported in the English literature. This event should be considered in every skin lesion in a patient with cholangiocarcinoma and be treated promptly by resection and chemotherapy to increase the patient’s survival. Herein, we report our experience with two patients with cholangiocarcinoma and cutaneous metastasis at the site of biliary drainage.