sst PanArab Congress of Liver Transplantation
Abstracts
2006
A STUDY OF RISK FACTORS OF SPONTANEOUS BACTERIAL
PERITONITIS IN UPPER EGYPT
Osman A.M, Shehata M,Zaki S, Rashed H, Rashad A.
Presenting author: Shehata M
Background: Spontaneous bacterial peritonitis (SBP) is a common and
potentially fatal complications in cirrhotic patients. Its prevalence ranged
from 8-27% with mortality rate from 48- 57%. Many risk factors were
reported to predispose to SBP like severity of liver disease,
gastrointestinal hemorrhage ascitic fluid protein and previous SBP
episodes. Aim of Study: To estimate the prevalence of SBP in cirrhotic
patients in our ocality and to evaluate the frequency of different risk
factors for its development. Patients and Methods: One hundred cirrhotic
patients with ascites were selected, their ages ranged from 30 to 72 years.
Diagnosis of liver cirrhosis was based upon clinical,ultrasonographicand
laboratory investigations. Routine laboratory investigations like complete
blood count, liver function tests and assessment of kidney functions were
done. Ascitic fluid study (proteins and cells) and ascitic fluid culture were
done for all cases Results: 13 patients (10 males ,3 females) were
diagnosed to have SBP. Two patients had classical SBP and their culture
were positive for Kellebsiella and Escherichia coli species. Ten patients
had culture negative neutrocytic ascites(CNNA),and one had
monomicrobial non-neutrocytic bacterascites (MNBA) with culture positive
for E.Coli. Fever, abdominal pain and tenderness were the most prevalent
symptoms and signs in cirrhotic group with SBP.The total leucocytic
count, percentage of neutrophils and total biliuribin were higher in patients
with SBP than in patients with sterile ascites. As regards ascitic fluid
study, total ascitic fluid proteins was lower in SBP group .Regarding
ultrasonographic findings, internal ascitic fluid internal echoes and
adhesions were significantly more detected in this group. Conclusion: The
prevalence of SBP was 13% in our locality. Low ascitic fluid proteins is the
most detected significant risk factor for development of SBP in cirrhotic
patients.
MESOT
–
PAAG
–
PAAS
16
sst PanArab Congress of Liver Transplantation
Abstracts
2006
ACCURACY OF TWO DIFFERENT METHODS IN ESTIMATING THE RIGHT
GRAFT VOLUME FOR ADULT-TO-ADULT LIVING DONOR LIVER
TRANSPLANTATION
Hatem Khalaf, Yusuf Al Kadhi, Mohamed Shoukri, Mohamed Neimatallah,
Hamad Al-Bahili, Mohamed Al-Sofayan, Mohamed Al-Saghier, Yasser ElSheikh, Ahmed Helmy, Ayman Abdo, Mohamed Al-Sebayel
Department of liver transplantation and Hepatobiliary-Pancreatic Surgery,
King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
Presenting author: Hatem Khalaf
Introduction: Accurate estimation of graft volume is proven to be crucial in
avoiding small-for-size syndrome and graft failure following adult-to-adult living
donor liver transplantation (AALDLT). Herein, we evaluate the accuracy of two
different methods in preoperative assessment of right graft volume in AALDLT.
Method: Between Jan 2003 and Dec 2005, 27 AALDLTs were performed at our
institute. The right graft volume and percentage were both preoperatively
calculated in all donors using CT scan dedicated software (Tissue Volume Revision
V1.0.12H developed by General Electric). The right graft volume was preoperatively
estimated using two different methods; the first was the radiological volume (RV)
given by CT scan, and the second was a calculated volume (CV) = percentage % of
the right graft (given by CT scan) x standard liver volume (calculated by Makuuchi
formula [Volume (mL) = 706.2 x Body Surface Area (m2) + 2.4]). Both methods were
subsequently compared to the actual volume (AV) measured during the surgery.
The Graft Recipient Weight Ratio (GRWR) was also calculated using all three
volumes (RV, CV, and AV). Lins 1989 concordance correlation coefficient (CCC)
was used to measure the agreement between AV and RV as well as between the AV
and CV. This was repeated using the GRWR measurements. Results: The CCC
between AV and RV was ρc1=0.39; while the CCC between AV and CV was
ρc2=0.42. The CCC between the GRWR using AV and the GRWR using RV was
ρc1=0.60; while the CCC between the GRWR using AV and the GRWR using CV
was ρc2=0.76. According to the benchmark levels set by Landis and Kock in 1977,
an agreement between 0.21 & 0.40 is considered fair, between 0.41 & 0.60 is
moderate and between 0.61 & 0.80 is substantial. Accordingly, the CV correlates
better with AV when compared with RV (moderate agreement with CV versus fair
agreement with RV). This better correlation becomes even more apparent when
using the GRWR (substantial agreement with CV versus moderate agreement with
RV) Conclusions: In our experience, the use of CV has shown a good correlation
with AV. Therefore, using CV in conjunction with RV might be of value in a more
accurate estimation of right graft volume for AALDLT
MESOT
–
PAAG
–
PAAS
17
sst PanArab Congress of Liver Transplantation
Abstracts
2006
ADULT TO ADULT LIVE DONOR LIVER TRANSPLANTATION: DONOR
MORBIDITY IN THE KING ABDULAZIZ MEDICAL CITY EXPERIENCE
OHali WA, Abduldayem H, Abdullah KO, Issa S, Abdulkareem A
Department of Hepatobiliary Sciences and Transplantation King Abdulaziz
Medical City, Riyadh Saudi Arabia
Presenting author: OHali WA
The ongoing organ shortage from deceased donors has created the need
for living donor liver transplantation (LDLT). Donor safety concerns remain
a crucial issue in all LDLT programs. We report our experience with donor
complications in our first 26 donors for adult to adult LDLT between Nov.
2000 and Jul. 2005. All hepatectomies were right lobectomies without the
middle hepatic vein. There were 4 females and 22 males. The age range
was 19-39 years with a mean of 26.8 years. The follow up ranges from 6-62
months. No donor deaths occurred. Complications were graded according
to Clavien’s classification. There were 6(23%) Clavien grade 1
complications and 4(15%) Clavien grade 2 complications. The overall
complication rate was 38%. All donors are well and have returned to
normal activities. We conclude that adult to adult live liver donation can be
done safely. Our experience with donor complications is comparable with
reports of other centers.
MESOT
–
PAAG
–
PAAS
18
sst PanArab Congress of Liver Transplantation
Abstracts
2006
BILIARY COMPLICATIONS FOLLOWING CADAVERIC VERSUS LIVING
DONOR LIVER TRANSPLANTATION: KFSH&RC EXPERIENCE
Hatem Khalaf, Hamad Al-Suhaibani, Hamad Al-Bahili, Mohamed AlSofayan, Mohamed Al-Saghier, Yasser El-Sheikh, Ahmed Helmy, Ayman
Abdo, Mohamed Al-Sebayel.
King Faisal Specialist Hospital and Research Center
Presenting author: Hatem Khalaf
Introduction: Biliary tract complications continue to account for much of the
morbidity seen after both cadaveric liver transplantation (CLT) and living donor
liver transplantation (LDLT). Hereby we report our experience with biliary
complications at King Faisal Specialist Hospital and Research Center (KFSH&RC),
Riyadh, Saudi Arabia. Patients & Method: Between April 2001 and December 2005,
a total of 81 LTs were performed at KFSH&RC (47 CLTs and 34 LDLTs). Duct-toduct anastomosis without stenting was used in 40 CLT recipients and in 26 LDLT
recipients. Roux-en-Y hepaticojejunostomy without stenting was used in 7 CLT
recipients and in 8 LDLTs recipients. Five LDLT recipients were excluded from the
statistical analysis due to early death. Chi-Square Test was used for Statistical
analysis. Results: Overall male/female ratio was 41/40 and the adult/pediatric ratio
was 71/10. In the CLT group, 2 out of 47 recipients (4.3%) suffered from biliary
strictures; one was managed by ERCP and stenting, while the other necessitated
surgical reconstruction. In the LDLT group, 5 out 29 patients who survived (17.2%)
had serious biliary problems; 1 patient responded to percutaneous dilatation, 2
patients underwent successful surgical reconstruction, 1 patient died as a result of
serious biliary complication, and finally 1 patient failed both conservative and
surgical management and was found to have late hepatic artery thrombosis, he
was listed for re-transplantation. The incidence of biliary complications was
significantly higher in the LDLT group compared to the CLT group (P-value <0.05).
The overall survival rate in the CLD group was (91.5%) after a median follow-up of
571 days (range, 38-1661 days); none of the mortalities in the CLT group was
attributed to biliary complications. On the other hand, the overall survival rate in
the LDLT group was (85.3%) after a median follow-up of 439 days (range, 15-1116
days); only one of the mortalities in the LDLT group was a result of serious biliary
complication. Conclusions: In our experience, the incidence of biliary
complications was significantly higher in the LDLT group compared to the CLT
group. Moreover, biliary complications following LDLT were much more extensive
and difficult to treat when compared with those following CLT.
MESOT
–
PAAG
–
PAAS
19
sst PanArab Congress of Liver Transplantation
Abstracts
2006
BRAIN STEM POTENTIALS IN LIVER TRANSPLANTED CHILDREN
Magd Kotp, Adel Ryad, Hoda Abdelrahman, Hatem Saafan ,Hisham
Abdelkader, Ahmed darwish and Alaa Hamza
Pediatric liver Transplantation unit, Wady Elneel Hospital, Cairo, Egypt
Presenting author:
Magd Kotb
MESOT
–
PAAG
–
PAAS
20
sst PanArab Congress of Liver Transplantation
Abstracts
2006
CADAVERIC DONATION FOR LIVER TRANSPLANTATION: 5 YEARS
EXPERIENCE AT KFSH&RC, RIYADH, SAUDI ARABIA
Al-Sebayel M, Khalaf H, Al Bahili H, Al-Sofayan M, and Al-Saghier M
Department of liver transplantation and Hepatobiliary-Pancreatic Surgery,
King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
Presenting author: Mohammed Al Sebayel MD
Introduction: Successful cadaveric organ transplant programs require the
availability of adequate number of good quality donors. In this paper we are
reporting our experience with cadaveric organ donation as it pertain to liver
transplantation at King Faisal Specialist Hospital and Research Center
(KFSH&RC) emphasizing the number and quality of organs offered. Method:
All donors referred to KFSH&RC from January 2001until December 2005 were
reviewed retrospectively. Demographic, clinical and biochemical parameters
were evaluated and donor acceptance rate was calculated. Donors were
stratified according to the number of risk factors including; ICU stay more than
3 days, high inotropic support (more than 15 ug dopamine or the use of more
than one agent), AST more than 150 IU, serum sodium above 155 mmol/l and
bilirubin above 35 umol. Result: The number of donor offers was 159. Age
ranged from 2 years to 69 years, with an average of 34.5. Male to Female ratio
was 6 to 1. The cause of death was Road Traffic Accident (RTA) in 73 (46%),
Cerebro-Vascular Accident (CVA) in 48 (30%), Fall from Height in 19 (12%),
Brain Tumor in 10 (6.5%) and 9 (5.5%) from others causes. Prolonged ICU stay
was found in 113 donors (71%), significant inotropic support in 93 (58%),
elevated AST in 50 (31%), elevated sodium in 44 (28%) and high bilirubin in 21
(13%). Out of 159 donors, only 9 donors (5.7%) had no risk factors, 42 (26.4%)
had one risk factor, 64 (40.3%) had two risk factors, 33 (20.7%) had three risk
factors, 9 (5.7%) had four risk factors, and 2 (1.2%) had all five risk factors. Out
of 159 donors, 60 were accepted for liver donation and harvested. Out of these,
16 were rejected based on liver pathology and only 44 (28% of total) were
used. The outcome of the graft was excellent with only one incidence of
primary non function. Conclusion: The number of marginal donor in the
Kingdom is high. Effort should be directed towards the improvement of the
logistic of donation as well as the medical care of the donor in order to utilize
the maximum number of good quality livers in trying to alleviate the organ
shortage in the Kingdom of Saudi Arabia.
MESOT
–
PAAG
–
PAAS
21
sst PanArab Congress of Liver Transplantation
Abstracts
2006
COMBINED LIVING DONOR LIVER AND KIDNEY TRANSPLANTATION FOR
HYPEROXALURIA: KFSH&RC EXPERIENCE
Hamad Al Bahili, Mohammed Al Saghier, Hatem Khalaf, Mohammad Al
Sofayan, Khalid Al Shaibani , Ali Al Malaq, Samhar Al Akash, Riaz ahmad ,
Mohammed Al Sebayel
KING FAISAL SPECIALIST HOSPITAL & RESEARCH CENTER
Presenting author: Hamad Al Bahili
Background: Primary hyperoxaluria type I (PH1) is a rare metabolic
disorder which is caused by a deficiency of the liver perioxisomal enzyme
alanine glyoxalate aminotransferase (AGT) which catalyzes the conversion
of glyoxalate to glycine. The disease leads to systemic oxalosis and renal
failure. Combined liver and kidney transplantation is the definitive
treatment. Objective: To report our experience with three pediatric patients
with PH1 who underwent combined living related liver and kidney
transplantation from single donors , either sequential or simultaneous .
Cases: Two patients with PH1 underwent liver transplantation followed by
kidney transplantation few months later. Upon waiting for kidney
transplantation the first patient developed post transplantation
lymphoproliferative disorder (PTLD) three months post transplantation.
The second patient required more frequent dialysis, five per week, to
manage his end stage renal disease . The third patient underwent
simultaneous living related liver and kidney transplantation from the same
donor. The donor and recipient had uneventful postoperative course with
good graft function. Conclusion: Combined pediatric living related liver
and kidney transplantation for PH1 is associated with excellent outcome.
Simultaneous transplantation from the same donor is possible and may
offer advantages to lower morbidity associated with extended dialysis ,
may reduced the morbidity of otherwise two procedures for both recipient
and donor, as well as reduction of the overall costs .
MESOT
–
PAAG
–
PAAS
22
sst PanArab Congress of Liver Transplantation
Abstracts
2006
DIAB M, STATINS AND CIRRHOTIC CARDIOMYOPATHY IN LIVER
TRANSPLANTATION
Abdel-Khalek Hamed
Consultant Gastroenterology and Diabetes Military Academy
Presenting author: Abdel-Khalek Hamed
The Era of liver transplantation is much growing . The medical problems
surrounding this issue are many. Most important are : 1- Post transplant
diabet.m among patients with HCV. 2- Management of dyslipidemia that
occurs with immune suppressive drugs post transplant. 3- The recent
issue of cardiac dysfunction occurring with liver transplantation(cirrhotic
cardiomypaty).
MESOT
–
PAAG
–
PAAS
23
sst PanArab Congress of Liver Transplantation
Abstracts
2006
EARLY POST RIGHT LOBE LIVING RELATED LIVER TRANSPLANT
VENOUS OUTLET OBSTRUCTION TREATED WITH BALLOON DILATATION
FOLLOWED BY SEVERE ARDS: CASE REPORT
Mohammed Al Saghier, MBBS, FACP, FRCSC, Ayman Abdo, MD, FRCPC,
Mohammad Al Sofayan, MBBS, FRCSC, FACS, Monther Kabbani, MBBS,
FRCSC, Ahmed Al Jedaie, PharmD, Hatem Khalaf, MBBCh, MSc, MD,
Mohammed Al Sebayel, MBBS, FRCS(Glas.), Ahmed Salem, PhD, Hamad Al
Bahili, MD, Yasser El-Sheikh, MBBCh, MSc, FRCSI, MD
Department of Liver Transplantation & Hepatobiliary-Pancreatic Surgery,
King Faisal Specialist Hospital & Research Center, Riyadh, KSA
Presenting author: Mohammed Al Saghier, MBBS, FACP, FRCSC
Background: Right lobe liver transplantation contributed to shortening the
waiting list of transplant programs and help patients on countries with
severe shortage of deceased donors. We are reporting a case of post
living related liver transplant venous outlet obstruction early in the
postoperative course This 45-year-old gentleman with hepatitis C and B
went for living related with right lobe transplant. Second week post
transplant, he developed large volume of ascites required paracentesis
followed by renal impairments. Ultrasound Doppler revealed monophasic
wave at the right hepatic vein caval anastomosis. The patient went for
caval venogram followed by gradual balloon dilatation of hepatic vein
caval anastomosis. On the third dilatation session, the patient did very
well and the Doppler waves became biphasic wave. Venogram revealed
complete patency of the anastomosis. On the same day after dilatation, the
patient has significant changes of gas exchange required high oxygen
requirement and prolonged the ICU admission. Conclusion: Venous outlet
obstruction post living related liver transplant is a possible complication.
Early balloon dilatation is a successful treatment. Attention should be paid
to the size of ascites and the parasenthesis volume when doing balloon
dilatation to avoid possible pulmonary complication.
MESOT
–
PAAG
–
PAAS
24
sst PanArab Congress of Liver Transplantation
Abstracts
2006
ETHICAL DILEMMAS IN LIVER TRANSPLANTATION
Hatem Khalaf
King Faisal Specialist Hospital and Research Center
Presenting author: Hatem Khalaf
Ethics is one of the most significant aspects of liver transplantation, there
are too many questions raised yet their answers are among the least well
defined. Before the introduction of live-liver donation, the ethical concerns
were mainly related to patient selection, organ allocation and methods to
alleviate organ shortage; for example should alcoholics be given a liver?
Should age be a determinant of candidacy? Should the sickest patient be
given preference? Who should be given a “marginal” liver? Is it acceptable
to use organs from the executed prisoners? Is it okay to give incentives to
the donor’s family aiming to alleviate organ shortage? Those entire
questions were heavily debated and the answers remain very subjective to
different circumstances. With the recent introduction of live donor liver
transplantation (LDLT), the ethical dilemmas became even more
complicated and much harder to resolve. LDLT was once labeled as the
“NECESSARY EVIL” because of the so many ethical debates that it has
generated; is it ethical to ask a person to donate part of his liver to save
the life of a loved one? Can the donor truly give informed consent under
such circumstances? Would it not be considered as “EMOTIONAL
BLACKMAIL”? Is it ethical to subject a healthy person to a major operation
with a potential morbidity and mortality to save the life of another? Should
we allow un-related donation whether directed or undirected? Should we
allow donation for money (i.e. altruism versus materialism)? Again all
those question remain unanswered. One other ethical dilemma is
economics; should economic factors dictate who will or will not be
transplanted? Who should absorb the high costs of this expensive
procedure? Should it be confined to those who can afford it? Should a few
patients benefit from liver transplantation when many others patients
cannot be treated of common diseases due to the lack of resources?
These are complex, interrelated questions that are easier to ask than to
answer. These decisions will require much thought and discussion and
will generate great debate but ultimately must be made by both individuals
and society as a whole.
MESOT
–
PAAG
–
PAAS
25
sst PanArab Congress of Liver Transplantation
2006
Abstracts
EXPERIENCE WITH LIVER TRANSPLANTATION
SPECIALIST HOSPITAL AND RESEARCH CENTER
AT
KING
FAISAL
Mohamed Al-Sebayel, Hatem Khalaf, Mohamed Al-Sofayan, Hamad AlBahili, Ayman Abdo, Ahmed Al-Jedai, Mohamed Al-Sagheir, Ahmed Helmy,
Yasser El-Sheikh, Hamad Al-Suhaibani , Hisham Negmi, Riyaz Ahmed,
Foad Hashem, Ali Al-Malaq, Mohamed Al-Omari
King Faisal Specialist Hospital and Research Center
Presenting author: Prof Mohamed Al-Sebayel
Introduction: The liver transplant (LT) program at King Faisal Specialist
Hospital and Research Center (KFSH&RC) has been performing both deceased
donor LT (DDLT) and living-donor LT (LDLT). Herein we present the center’s
recent experience in both procedures. Patients & Method: Between April 2001
Feburary 2006, 86 LT procedures were performed (50 DDLTs and 36 LDLTs) in
83 patients (3 re-transplants). The first 2 LDLTs were performed with the help
of an overseas team from Hong Kong; while all the remaining cases were
performed by the local team with no outside assistance. Results: The overall
male/female ratio was 42/41, adult/pediatric ratio was 73/10, and median age 43
years (range, 5-63 years) In the DDLT group; and after a median follow-up
period of 580 days (range, 8-1691), the overall patient and graft survival rates
was 92%. Deaths were due to primary non-function, central pontine
myelinolysis , and recurrent HCV infection in 2 patients. In the LDLT group;
and after a median follow-up period of 442 days (range, 7-1136, the overall
patient and graft survival rates were 86% and 78% respectively. Graft failure
and deaths were due to hepatic artery thrombosis, biliary complication,
uncontrollable bleeding, portal vein thrombosis in 2 cases, and small-for-sizesyndrome in 3 patients. Three patients were successfully re-transplanted
using cadaveric organs. Graft survival was significantly inferior in the LDLT
group compared with the DDLT group, 78% vs. 92% respectively (p-value
<0.05), however, there was no significant difference in patient survival between
the two groups. Biliary complications were significantly higher in the LDLT
group compared with the DDLT group, 21.2% vs. 4% respectively ( p-value
<0.05). Donor’s morbidity included; alopecia areata in two patients, incisional
hernia, wound dehiscence, biloma, and sever liver dysfunction. No donor
mortality encountered in our program Conclusions: Both DDLT and LDLT are
being successfully performed at KFSH&RC with good outcomes. Our early
experience indicates poorer graft survival and higher rate of biliary
complications in the LDLT group
MESOT
–
PAAG
–
PAAS
26
sst PanArab Congress of Liver Transplantation
Abstracts
2006
FOCAL AND SEGMENTAL GLOMERULOSCLEROSIS (FSGS) IS THE
COMMONEST GLOMERULAR LESION IN ORTHOTOPIC LIVER
TRANSPLANTATION (OLTX) RECIPIENTS ON TACROLIMUS. EARLY
CONVERSION TO CYCLOSPORINE (CSA) IN THIS SETTING DELAY THE
PROGRESSION OF THE GLOMERULAR LESION
Ali Al Lehbi, Q Nadri, S Suhail, O Alfurayh, H Al Ashgar, M Khuroo
Section of Nephrology, Department of Medicine, King Faisal Specialist
Hospital & Research Center
Presenting author: Ali Al Lehbi
BACKGROUND: Tacrolimus monotherapy or in combination with steroid in
OLTx is the standard practice. It has proven superior in preventing acute
rejection and improves graft and patients survival. Tacrolimus toxicity and
acute tubular necrosis are the commonest causes of renal impairment in
OLTx. We are reporting here and for the first time in the literature
supported by histopathology the presence of FSGS in a group of OLTx
patients treated with tacrolimus as the cause of proteinuria and renal
impairment. Furthermore, we evaluated the effect of conversion from
Tacrolimus to Cyclosporine in some patients in view of the well-known
role of the treatment of FSGS. METHOD: 15 patients who underwent OLTx
secondary to various etiologies (table) and developed renal impairment
with proteinuria were studied clinically as well as histopathologically.
Thirteen patients were treated with Tacrolimus and two were on
Cyclosporine. Four out of the 13 patients were converted to CsA at a dose
of 2mg/Kg in 2 divided doses, aiming trough level of 150ng/ml. Remission
or partial remission of FSGS was defined as reduction of total urine
protein excretion (UPE) of less than 0.5mg/d and less than 1.5gm/d
subsequently with stable renal function. All patients were on ACEI.
RESULTS: Of 15 patients, five females and 10 males with age ranging
between 6-70 years, HCV was positive in seven, HBV in one, combine
HCV/HBV in three, cryptogenic in two, oxalosis one, and shistosomiasis in
one patient. In 5/15 patients, two presented with advanced renal failure and
three with mild renal insufficiency and proteinuria were not biopsied. Out
of the other 10 biopsied patients, two patients histopathologically were
found to have diabetic nephropathy and the other eight had FSGS. In 4/8
patients with documented FSGS were converted from Tacrolimus to CsA.
MESOT
–
PAAG
–
PAAS
27
sst PanArab Congress of Liver Transplantation
Abstracts
2006
Continued...
Three out of these four patients responded with either improvement or
stabilization of renal function and complete or partial remission of
proteinuria with a follow up period of 4 years. The fourth patient (15) had
malignant course of FSGS leading to ESRD in 9 months. The other
unconverted four patients three progressed to ESRD, and one (1) was not
converted to CsA secondary to advanced interstitial fibrosis and sclerosis.
CONCLUSION: FSGS probably is the commonest underlying glomerular
lesion in OLTx recipients (regardless of the primary etiology of liver
disease). Tacrolimus may have a role in the genesis of FSGS in OLTx
recipients. Early conversion from Tacrolimus to Cyclosporine in OLTx
recipients with proteinuria and mild renal impairment delay the
progression and achieve remission of the glomerular lesion.
MESOT
–
PAAG
–
PAAS
28
sst PanArab Congress of Liver Transplantation
Abstracts
2006
HEPATITIS C RECURRENCE IN LIVING DONOR LIVER TRANSPLANTATION
VERSUS DECEASED DONOR LIVER TRANSPLANTATION: PRELIMINARY
DATA IN GENOTYPE 4
Mohammed Al Sebayel, MD, Hatem Khalaf, MD, Hamad Al Bahili, MD,
Ayman Abdo, MD, Ahmed Helmy, MD, Mohammad Al Sofayan, MD,
Mohammed Al Saghier, MD, Yasser El-Sheikh, MD
Department of Liver Transplantation & Hepatobiliary-Pancreatic Surgery
King Faisal Specialist Hospital & Research Center, Riyadh, KSa
Presenting author: Mohammed Al Sebayel, MD, MBBS, FRCS(Glas.)
Introduction: Difference in the incidence of hepatitis C recurrence
following Living Donor Liver Transplantation (LDLT) compared with
Deceased Liver Transplantation (DDLT) has been controversial. We hereby
report our experience with predominantly Hepatitis C genotype 4
recurrence in these two types of liver transplant. Patient and Method: From
January 2001 till December 2005, a total number of 33 patients were
transplanted for hepatitis C (14 DLT and 19 LDLT). All patients were
followed with liver enzymes. Liver biopsies, viral load and genotype were
done as clinically indicated. Data were reviewed retrospectively. Statistical
analysis for ALT and Viral load was done using t-test, Histology and
Genotype and Graft loss using Pearson Chi-Square and patient survival
using Log Rank. Result: Below are the demographic data of the two
cohorts: LDLT (N: 14) DDLT(N: 19) Mean Age 48 52 Sex Ratio: (M/F) 4.3/1
3/1 Follow up (days) Range 79-738 77-1659 Follow up (days) Mean 425 739
Below are clinical data: LDLT (N: 14) DDLT (N:19) P Value ALT(IU) Range
26-681 40-1445 0.284 Mean 249 374 0.284 Viral Load (Mean,copies/ml) 7.6 x
10000000 1.5 x 100000000 0.179 Viral Load (Below 3200,copies/ml)
1(patient) 2(patients) 0.179 Genotype 4 7/11 (63%) 11/15 (73%) 0.597
Histology (stage 2 and above) 2/7 (29%) 5/14 (36%) 0.743 Patient Survival
79% 84% > 0.5 Graft loss due to recurrence 0(0%) 2 (11%) 0.089
Conclusion: The above preliminary data indicates that hepatitis c
recurrence in living donor liver transplantation is not worse than that of
deceased liver transplantation. Larger cohorts of patients are needed to
confirm this conclusion.
MESOT
–
PAAG
–
PAAS
29
sst PanArab Congress of Liver Transplantation
Abstracts
2006
HIGH PREVALENCE OF OSTEOPENIA/OSTEOPOROSIS IN CIRRHOSIS
PATIENTS AWAITING LIVER TRANSPLANTATION
A. Helmy, A. Abdo, H. Al-Bahili, H. Khalaf, M. Al-Sofayan, M. Al-Saghier, M
Al-Sebayel.
Department of Liver Transplantation, Hepatobiliary and Pancreatic
Surgery, King Faisal Specialist Hospital & Research Center
(KFSH&RC),Riyadh, Saudi Arabia.
Presenting author: Ahmed Helmy
Background/Aim: Osteoporosis is an important complication in patients with
chronic liver disease. The goals of this study were to determine the bone
mineral density (BMD) among pre-transplant cirrhotic patients, and its relation
to disease etiology and severity as measured by the MELD and Child Scores.
Subjects/Methods: BMD of the lumbar vertebrae (LBMD) and femoral neck
(FBMD) were obtained in 70 consecutive cirrhotic patients awaiting liver
transplantation, (39 females & 31 males; Mean±SEM age 45.1±1.9 years).
Cirrhosis was post-hepatitic in 31 (58.5%) patients, and was Child grade B in
49 and C in 21 patients. Descriptive and inferential statistics were used to
compare the BMD among various groups. Results: Osteopenia and/or
osteoporosis were detected in 55 patients (78.6%). Lumbar osteopenia and
osteoporosis were detected in 31(44.3.9%) and 13(18.6%) patients,
respectively. Also, femoral osteopenia and osteoporosis were detected in
31(47.1%) and 4(5.7%) patients, respectively. FBMD correlated positively with
LBMD (r=0.57; p<0.001), and both correlated negatively with age (r=-0.4;
p<0.01). The mean FBMD and LBMD in males and females were similar
(p>0.05). Disease severity was significantly higher in the post-hepatitic group
(p<0.01). The mean±SEM FBMD and LBMD (in g/cm2) were significantly lower
in post-hepatitic patients than those with non-viral etiology (See table).
Etiology LBMD T-score* Z-score** FBMD T-score* Z-score** Viral 0.9±0.02 1.5±0.19 -1.7±0.21 0.8±0.02 -1.0±0.15 -1.2±0.16 Non-viral 1.0±0.03 -1.0±0.31 1.1±0.33 0.9±0.03 -0.6±0.29 -0.6±0.29 P value <0.046 0.123 0.155 <0.004 0.161
0.059 Conclusions: Low BMD is very common in pre-transplant cirrhotic
patients irrespective of gender. The lower BMD in patients with viral etiology is
mostly related to their higher disease severity. These findings necessitate
early detection, proper treatment, no post-transplant steroid induction to avoid
fractures.* T-score is the standard deviation from age- and sex-matched
controls. ** Z-score is the standard deviation from young adult control.
MESOT
–
PAAG
–
PAAS
30
sst PanArab Congress of Liver Transplantation
Abstracts
2006
IMAGING TECHNIQUES IN PREOPERATIVE EVALUATION OF LIVING
DONOR FOR LIVER TRANSPLANTATION
Presenting author: Adel El-Badrawy
Imaging techniques in preoperative evaluation of living donor for liver
transplantation. By Dr.: Adel El-Badrawy Radiology Department, Faculty of
Medicine, Mansoura University. Abstract Aim of the work: Detection the
value of non invasive imaging techniques as CT and MRI in evaluation of
potential donor for liver transplantation as regards parenchymal
evaluation and vascular mapping as well as biliary anatomy. Patients and
methods: This study included 15 patients. There were 5 females and 10
males with a mean age of 37.9 years (age range, 22-50 years). The study
was carried out in Department of Diagnostic Radiology, Mansoura
University. Imaging was performed as part of preoperative work up for
potential adult right lobe liver transplantation. Different imaging
techniques were used in this study; ultrasonography and Doppler study of
the hepatic veins and portal vein. Also, multiphasic spiral CT with 3D
rendering techniques, and MR imaging including MRCP, MRA. Results:
Thirteen potential donors were excluded on radiological basis. More than
one exclusion criteria was found in one patient. These findings included
fatty infiltration in 5 cases, insufficient left liver lobe volume in 2 cases,
portal vein anomaly in 3 cases, inferior right hepatic veins in 2 cases,
accessory hepatic veins in 2 cases, biliary tree anomalies reported to be
contraindication to transplantation were detected in three cases. Celiac
artery stenosis was detected in one case & incidental discovered rib mass
in one patient.. Conclusion: Preoperative evaluation of the potential donor
must focusing on conditions that would place the donor at increased risk
of complications and reveal any condition that would adversely affect graft
function. Donor wellbeing must always be the primary consideration. CT &
MRI are mandatory imaging techniques in preoperative evaluation of living
donor for liver transplantation. CT is better than MRI in evaluation of fatty
liver and hepatic volume. CT is equal to MRI in evaluation of vascular
mapping, in view of low cost of CT and its more availability, it is
considered superior to MRI. CT better evaluates other abdominal organs
than MRI. Bile ducts anatomy is only evaluated with MRCP.
MESOT
–
PAAG
–
PAAS
31
sst PanArab Congress of Liver Transplantation
Abstracts
2006
IMPACT OF PROPHYLACTIC ALPROSTADIL TREATMENT ON PATIENTS
OUTCOME AFTER LIVER TRANSPLANTATION
Yehia H. Khater M.D., Sahar S. Badawy M.D., Hala F. Hamed M.D., Ahmed
M. Mukhter M.D. Department of Anesthesia and Surgical Intensive Care,
Faculty of Medicine, Cairo university, Egypt.
Presenting author: Dr. Sahar badawy
Introduction: The prophylactic application of prostaglandin E1 (PGE1 )
after liver transplantation has several potential therapeutic effects
including cytoprotection against hepatic ischemia reperfusion injury,
improvement of hepatic bile flow, vasodilatation, inhibition of platelet
aggregation and promoting hepatic regeneration after liver transplantation.
The aim of this retrospective analysis study was to evaluate the effect of
prophylactic application of alprostadil, which is a selective PG E1, on
patients after liver transplantation. Methods : A retrospective analysis was
done on all recipients of liver transplantation in Wadi El Neel hospital
between 2001 and 2005. Pediatric patients, patients who required
inotropes postoperative, and those who died during the first five days after
transplantation were excluded from the study. Patients were divided into
two groups. Group alprostadil included patients who received alprostadil
infusion (0.5 mg/day by continuous infusion for five days), and the non
alprostadil group which included those patients who did not receive
alprostadil infusion. The two groups were compared, as regard the liver
function, including serum aspartate transaminase (AST), alanine
transaminase (ALT), bilirubin, prothrombin time and coagulation Factors
V, renal function tests including serum creatinine and creatinine clearance,
number of patients who needed dialysis and antihypertensive medications,
mean pulmonary and systemic blood pressure, length of stay in the
intensive care unit (LOS), and the 30 day mortality rate. Results : 87 adult
patients were transplanted in Wadi El Neel hospital from 2001 to 2005. 36
patients were excluded from the study (9 died during the first five days
after transplantation, and 27 patients required inotropes postoperative). 51
patients were included in the study 16 in the alprostadil group and 35 in
the other group. In the first postoperative week, there was a significant
reduction in serum AST and ALT in the alprostadil group (100.5+/54.3,
MESOT
–
PAAG
–
PAAS
32
sst PanArab Congress of Liver Transplantation
Abstracts
2006
Continued...
146+/ 45.5) U/L compared to the non alprostadil group (183+/79.4, 229+/
72.2) U/L , there was an increase in the prothrombin time and the
coagulation Factor V in the alprostadil group compared to the non
alprostadil group but this rise was not statistically significant. The serum
bilirubin levels were similar in both groups. After the first postoperative
week the results of the liver function tests were similar in both groups. The
mean pulmonary and systemic blood pressure values were similar in both
groups, but the number of patients in the alprostadil group who needed
antihypertensive medications was lower than in the other group. Although
there was a significant reduction in the LOS in the alprostadil group (7.5+/2.3 ) compared to the other group (16+/4.1), there was no significant
difference in the mortality rate between both groups. The renal function
tests and the number of patients who needed dialysis were similar in both
groups. Conclusion : The prophylactic application of alprostadil after liver
transplantation improves the liver function in the early postoperative
period and decreases the length of stay in the ICU , but its long term effect
on the liver function and the patients outcome warrant further assessment.
Key words : liver transplantation. prostaglandin E1, alprostadil, patients
outcome.
MESOT
–
PAAG
–
PAAS
33
sst PanArab Congress of Liver Transplantation
Abstracts
2006
INCIDENCE OF DE NOVO HYPERTENSION IN PATIENTS UNDERGOING
LIVING DONOR LIVER TRANSPLANTATION AND ITS RELATION TO THE
TYPE OF IMMUNOSUPPRESSION
wael safwat, rasha refaie, medhat abdel aal, ayman omar, amr talaat, alaa
fayez, mahmoud el meteiny, ibrahim mostafa.
liver transplantation unit - wadi al neel hospital
Presenting author: Wael Safwat
LDLT FOR HCC IN EGYPT
Mohamed Fathy, Alaa Fayez Hamza, Amr Abdelaa, Hatem Saafan,
Mahmoud Bahaa, Mohamed Abdel-Razek, Ibrahim Mostafa, Sahar Badawy,
Ahmed Mokhtar, Maged Salah, Medhat Abdelaal and Mahmoud El-Meteini
Presenting author: Mohamed Fathy
MESOT
–
PAAG
–
PAAS
34
sst PanArab Congress of Liver Transplantation
Abstracts
2006
LIVING DONOR LIVER TRANSPLANTATION, NATIONAL LIVER INSTITUTE
EXPERIENCE
Ibrahim Marawan
National Liver Institute, Egypt
Presenting author: Ibrahim Marawan
Liver transplantation is a well-established treatment for end stage liver
diseases. Living donor liver transplantation started in Egypt in the National
Liver Institute in 1991. The first successful trial was in a child, however,
this program didn’t continue for many reasons. In 28th of April 2003, the
program was revived in collaboration with Kyoto University, Japan first by
doing pediatric cases then, followed by doing adult cases. However, the
program faced many difficulties including financial coverage of the cases
and difficulties in availability of suitable donors, social and traditional
concepts and the surgical difficulties in some cases. By the end of
February 2006, twenty-seven cases were done (15 pediatric and 12 adults).
The perioperative mortality was 8/27 (29.6%); 6-month survival 19/27
(70.3%) and 1 year survival is 15/27 (55.5%). Postoperative complications
included; internal hemorrhage in 1 case, bile leak in 3 cases, portal vein
thrombosis in 3 cases, late hepatic artery thrombosis in 1 case, hepatic
vein stenosis in 2 cases, burst abdomen in 1 case. Donor complications
included bile leak in 3 cases, mild chest infection, minimal wound infection
in some cases.
MESOT
–
PAAG
–
PAAS
35
sst PanArab Congress of Liver Transplantation
Abstracts
2006
MANAGEMENT AND OUTCOME OF PORTAL VEIN THROMBOSIS DURING
ORTHOTOPIC OF LIVER TRANSPLANTATION
Khalid ABDULLAH, Hesham ABDELDAYEM, Wael O’HALI, Hussein
OSMAN, Samir ISSA, Ossama NAFEA, Abdulmajeed ABDULKAREEM
Presenting author: Khalid ABDULLAH,
Background: Portal vein thrombosis (PVT) has been seen as an obstacle
to orthotopic liver transplantation (OLT), but current data suggest that
favorable results may be achieved in this group of patients. Aim: The aim
of this study is to analyze the incidence, management, and outcome of
patients with PVT undergoing OLT . Patients and methods: Between March
2002 and January 2006, 39 cases of OLT were performed at the Liver
Transplant Center, King Abdul Aziz Medical City. Data concerning
preoperative
diagnosis,
extension,
intraoperative
management,
postoperative course and outcome of patients with PVT were
retrospectively studied. Operative time and length of stay in the intensive
care unit and patient and graft survival rates were compared with cases
without PVT Results: Portal vein thrombosis was present in 8 patients
(20.5%). While five cases were diagnosed incidentally at the time of
surgery, only three cases were diagnosed preoperatively. PVT was partial
in 5 cases and complete in 3 cases. Portal flow was reestablished by
venous thrombendvenectomy in 5 cases, jump graft in 2 cases and
thrombectomy followed by retransplantation in one case. In our series
patient and graft survival rates in cases of PVT were not compromised
when compared with cases patent portal. Conclusion: liver transplantation
can be safely performed in the presence of portal vein thrombosis
MESOT
–
PAAG
–
PAAS
36
sst PanArab Congress of Liver Transplantation
Abstracts
2006
MANAGEMENT OF COMPLICATIONS OF CIRRHOSIS IN PATIENTS
AWAITING LIVER TRANSPLANTATION
King Abdulaziz Medical City, National Guard Health Affairs
Presenting author: BANDAR AL KNAWY, MD, FRCPC
Ascites, hepatorenal syndrome (HRS), hepatic encephalopathy (HE),
spontaneous bacterial peritonitis (SBP), gastroesophageal variceal
bleeding and/or hepatocellular carcinoma are complications of liver
cirrhosis had a grim prognosis without orthotopic liver transplantation
(OLT). The goals of pre-transplant care include the appropriate
management of decompensated liver disease with interventions such as
diuretics for ascites, antibiotic prophylaxis against SBP, the use of betablockers or banding for the primary or secondary prophylaxis of variceal
bleeding, endoscopic variceal banding plus vasoconstrictors for active
variceal bleeding, use of oral synthetic disaccharides such as lactulose to
prevent recurrences of hepatic encephalopathy, therapeutic paracentesis
with albumin for refractory ascites and vasoconstrictors with albumin for
HRS. As the demand for OLT increases, patients with advanced cirrhosis
will end up spending a longer time waiting in the list with an increased risk
of developing further decompensation and dying. Rather than prioritizing
candidates for OLT based primarily on waitlist times, as was the case
under the former allocation system, the Model for End-Stage Liver Disease
(MELD) went into effect February 27, 2002. The new system prioritizes
candidates for OLT based on the severity of the underlying liver disease.
MELD is a mathematical model based on log-transformation of three
objective variables, bilirubin, creatinine and INR. Use of MELD guarantees
that the most ill patients are transplanted first within an organ distribution
area and has reduced pre-transplant mortality without adversely affecting
post-transplant survival. With waiting list mortality exceeding posttransplant survival in many programs, pre-transplant medical management
has become of paramount importance and has increased the role of
community and academic gastroenterologists and hepatologist. The aim of
this presentation is to delineate the care of patients who await LT. It will
focus on clinical issues that do not require hospitalization, with an
emphasis on preventive medicine as well as disease specific measures
that can maximize the survival of candidates prior to LT.
MESOT
–
PAAG
–
PAAS
37
sst PanArab Congress of Liver Transplantation
Abstracts
2006
MARKEDLY INCREASED SERUM CA19-9 IN AUTOIMMUNE HEPATITIS
DESPITE ABSENCE OF MALIGNANCY; WITH COMPLETE
NORMALIZATION AFTER LIVER TRANSPLANTATION
Yasser M. El Sheikh, Walid A Mourad, Hatem A.Khalaf, Hamad Al Bahili,
Mohammed AL Omari, Ayman Abdo, Ahmed Helmy, Mohammed Al
Saghier, Mohammad Al Sofayan, Mohammed Al Sebayel
King Faisal Specialist Hospital & Research Center
Presenting author: Yasser El-Sheikh
Background: CA19-9 is a carbohydrate antigen that is usually elevated and
specific for pancreateco-biliary adenocarcinomas. Levels beyond 200 U/ml
are usually indicative of malignant conditions. We report three cases of
autoimmune hepatitis with markedly elevated serum CA19-9 levels and
were not associated with malignancy. Materials and Methods: Three cases
of autoimmune hepatitis with marked evelvation of CA19-9 serum levels
underwent cadaveric liver transplantation for end-stage liver disease.
Routine post-operative follow up included CA19-9 serum level
assessment. Results: We report two female and one male patient (21, 35
and 28 years respectively). Peak pre-transplant serum CA19-9 levels were
2800, 819 and 217 U/ml respectively. Pre-transplant work up ruled out
malignancy. Histopathologic examinationn of the explanted livers
excluded malignancy, and showed extensive bile ductular proliferation
leading to bile duct nodules measuring up to 2 cm. Immunohistochemical
stains for CA19-9 showed intense membranous uptake in all bile ductules.
Proliferative indices using Ki-67 antibody showed surprisingly low levels
of proliferation (< 1%). All three cases showed normalization of serum
CA19-9 levels within the first three months post-transplant. Conclusion: In
autoimmune hepatitis CA19-9 can show extremely high levels of serum
and tissue expression in absence of malignancy due to over-expression at
the individual cellular level.
MESOT
–
PAAG
–
PAAS
38
sst PanArab Congress of Liver Transplantation
Abstracts
2006
MORPHOLOGIC EVIDENCE OF CHOLESTATSIS IN BIOPSIES FROM LIVER
ALLOGRAFTS: FREQUENCY AND ASSOCIATED FINDINGS
Mohammad Alomari, M.D.*, Hatem Khalaf, M.D.+, Mohammed Al Sebayel,
M.D.+, Abdelghani Tbakhi, M.D.* and Walid Mourad, M.D.*
Departments of *Pathology and +Liver Transplantation/HepatobiliaryPancreatic Surgery, King Faisal Specialist Hospital and Research Centre
Presenting author: Mohammad Alomari
Background:
Cholestasis
is
a
common
feature
of
hepatic
dysfunction/injury in liver allografts. The etiological differential diagnosis
is broad and includes different possibilities such as graft rejection,
infection, recurrence of primary disease, biliary obstruction, etc. Materials
and methods: A total of 98 liver biopsies from 50 patients with hepatic
transplant were reviewed. Pertinent clinical data were also obtained. These
biopsies were examined for the presence of morphologic evidence of bile
retention (the presence of bile pigment in the cytoplasm of hepatocytes,
canaliculi and bile ductules/ducts). In addition, the presence or absence of
ductular proliferation and other associated histological findings (e.g.,
rejection, recurrent disease) were also evaluated. Results: Morphologic
evidence of cholestasis was seen in 45 out of 98 biopsies (46%). All of
these showed hepatocellular/hepatocanalicular cholestasis. Bile ductular
proliferation was identified in 18 of the 45 biopsies with cholestsis (40%).
Overall, acute cellular rejection was the most frequent diagnosis (13
cases). Other histologic findings included recurrent hepatitis, preservation
injury and chronic rejection. Ten (10) of the 18 biopsies with ductular
proliferation (55%) were obtained from 6 patients who were found clinically
to have biliary complications (biliary stricture or leak). More than one
etiology was suspected in 6 biopsies (e.g., recurrent hepatitis with
associated features suggestive of impaired biliary flow). No
histopathologic explanation was found in 4 biopsies. Conclusion:
Morphologic evidence of cholestasis is common in biopsies from liver
allografts. Acute cellular rejection is the most frequent etiology noted.
Careful evaluation of the biliary tree is recommended in case the
cholestasis is associated with bile ductular proliferation.
MESOT
–
PAAG
–
PAAS
39
sst PanArab Congress of Liver Transplantation
Abstracts
2006
PATTERNS OF CHOLESTASIS IN SAUDI CHILDREN; BIOCHEMICAL AND
MOLECULAR APPROACH
Sami Wali
Riyadh Armed Forces Hospital, Pediatric Gastroenterology
Presenting author: Dr. Sami Wali
The Riyadh armed forces hospital started living related liver transplant
program in 1998. Since then, we evaluated more than 450 children with
various liver disorders. The consanguinity rate was more than 70 % in this
population. We classified our patients depending on simple biochemical
data that are based on molecular physiology of the various familial
disorders. Progressive familial intrahepatic cholestasis was one of the
most common disorders detected in the gulf area. We present our
experience and approach to the various familial liver disorders that are
seen in our unit since the beginning of the program.
MESOT
–
PAAG
–
PAAS
40
sst PanArab Congress of Liver Transplantation
Abstracts
2006
PEDIATRIC LIVER TRANSPLANTATION A 16 YEAR FOLLOW-UP OF 52
PATIENTS
Shabib SM, MD, Nazer H.MD, Mehaideb A.MD, Banamie M MD,
King Faisal Specialist Hospital & Research Centre
Presenting author: Souheil M. Shabib
Introduction :Liver Transplant (LT) a life saving measure for patients with
end stage liver disease Aim :To review our experience in infants and
children post LT and analyze graft survival, rejection rate, complications,
and outcome. Methods: Charts of children underwent LT between 19892005 were reviewed. Data collected retrospectively and subjected to
statistical analysis. Results : 52 children 25M(48%), 22F(42%) underwent
cadaveric LT and 5pts(10%) (3M, 2F). received living related LT. Age
range1-13yrs Mean (4±7yrs) [30pts(57%) <4yrs, 21pts(40%) between 510yrs and 1pt 12 yrs. Patients were transplanted in 13 centers:USA(36)
Europe,(6),
Egypt(2)
and
Saudi
Arabia(6).
Indications:Biliary
atresia/hypoplasia 15pts(29%), Neonatal hepatitis 8pts(15%), glycogen
storage disease7pts(13%), cryptogenic cirrhosis5ptts(10%), autoimmune
hepatitis 5 pts(10%) Wilson’s disease 6pts(11%), primary oxalosis 2pts,
Byler’s disease 2pts, fulminant hepatic failure 1 pt, hepato-cellular
carcinoma 1pt. Immunesuppression: Tacrolimus used in 43pts(83%) and
Cyclosporine 9(17%)pts. Rejection, 49 episodes encountered, 17pts(33%)
in the Ist 6m. 7pts(13%) in the 2nd 6m. and 12pts(23%) 2nd year. Acute
rejection detected up to 8yrs after transplant. 3pts(6%) developed chronic
rejection. Complications:- biliary 14pts(30%), renal 13pts(25%), CMV
11pts(21%), 3 out of 4 pts with EBV developed Lymph proliferative
Disorder, Common bile duct stricture 2 pts. Puematosis carnii 2 pts(4%),
7pts (13%) required re-transplant and 4pts(8%) died. Follow up:37
survivals (71%) > 9yrs Conclusions : Outcome of infants and children with
LT remains comparable to other transplant centers world-wide. With the
scariness of cadaveric livers, national liver transplant centers should
consolidate their effort on living related transplant (LRT) for infants and
young children to meet the needs in Saudi Arabia.
MESOT
–
PAAG
–
PAAS
41
sst PanArab Congress of Liver Transplantation
Abstracts
2006
POST TRANSPLANT DIABETES MELLITUS & HYPERLIPEDEMIA:
EFFECTS OF HCV AND CALCINEURIN INHIBITORS
Rasha O Refaie, MD1, Wael Safwat, MD1, Medhat Abdelaal, MD1,Amr Talaat
MD ,Ayman Omar MD,mahmoud ElmeteiniMD and Ibraheem Mustafa, MD1
1Hepatology & liver Transplantation, Wady Elneel Hospital, Cairo, Egypt.
Presenting author: Rasha Refaie
Post Transplant Diabetes Mellitus (PTDM) is a serious complication of
Liver Transplantation, it increases the susceptibility to infection and
cardiovascular complications leading to diminished long-term & graft
survival. Up to one third of patients with chronic hepatitis C virus (HCV)
develop type 2 diabetes mellitus (DM), this prevalence is much higher than
that observed in patients with other chronic liver diseases. HCV infection,
Calcineurin inhibitors (CNI) & methyl-prednisolone boluses were found to
be independent risk factors for the development of (PTDM). The authors
tried to establish the effects of HCV and the type of CNI on the
development of PTDM. In Wady Elneel hospital Cairo Egypt 56 adults were
followed up for more than one year after living related liver transplantation.
Two parameters were assessed the presence HCV and the type of CNI
used (either Tacrolimus (TAC) or cyclosporine (CsA). Fifty patients were
HCV +ve and 6 were other pathologies, 16 patients (32%) of the HCV group
were IDDM before transplantation. 18 Patients were on CsA based immune
suppression and 38 were on TAC. All patients were on steroids which were
tapered over one month. 3 patients developed new onset diabetes mellitus
(NODM) (7.5%), these patients were all from the HCV group with an
incidence of (8.8%). The 3 patients were on TAC based immune
suppression. None of the non HCV developed NODM, also none of the CsA
group developed NODM. The 16 patients with pre-transplant DM needed
higher doses of insulin for better glycemic control in the post-transplant
period. In conclusion HCV and TAC are positively related to the
development of NODM, they are also related to poor glycemic control in
the post-transplant period. The relation between both factors and NODM
needs further investigations
MESOT
–
PAAG
–
PAAS
42
sst PanArab Congress of Liver Transplantation
Abstracts
2006
PROSTAGLANDIN E1 (ALPROSTADIL) INFUSION FOR POSTOPERATIVE
ICU MANAGEMENT OF POOR GRAFT FUNCTION AFTER LIVER
TRANSPLANTATION
W. Mahmood MD, L. Al-Jaroudi MD, H. Khalaf MD, M. Al-Sebayel MD
Section of Critical Care Medicine1, Department of Medicine1 Department of
liver Transplant and Hepatobiliary surgery King Faisal Specialist Hospital
& Research Center, Riyadh, Saudi Arabia
Presenting author: Wafeeq Mahmood, MD, FRCPC
Prostaglandin E1 (Alprostadil) Infusion for Postoperative ICU Management
of Poor Graft Function after liver transplantation W. Mahmood(1) MD, L. AlJaroudi(1) MD, H. Khalaf(2) MD, M. Al-Sebayel(2) MD Section of Critical
Care Medicine(1), Department of Medicine1 & Department of liver
Transplant and Hepatobiliary surgery(2) King Faisal Specialist Hospital &
Research Center, Riyadh, Saudi Arabia Background: Grafts with initial
poor function (IPF) are well recognized problems after liver transplantation
(LT). Although there is lack of agreement on the definition of IPF,
Strasberg et al. used the definition AST > 1500 IU/L, PT > 20 seconds
during the first postoperative week. Prostacyclin (Prostaglandin)
administration has been shown to reduce hepatocellular ischemic
reperfusion injury (IRI) after liver transplantation. In addition, donor
pretreatment with Prostacylin before organ retrieval has also been shown
to reduce IRI. However, the role of Prostaglandin E1 (Alprostadil) infusion
in the postoperative management of IPF is unclear. Objective: To evaluate
the efficacy and safety of Prostaglandin infusion in the postoperative
intensive care unit (ICU) management of IPF after liver transplantation
Methods: All adult patients admitted to our tertiary care medical-surgical
ICU (MSICU) after liver transplantation and received Prostaglandin E1
(Alprostadil) infusion for IPF were evaluated and had data collected.
Inclusion criteria were: adult patients with IPF after LT defined by AST >
1000 IU/L, PT > 20 seconds and rising serum lactate during the first
postoperative week. Alprostadil was administered by infusion at the rate of
20-40 µg/hr for a period of 5 to 7 days. Each chart was reviewed for the
indication and type of LT (cadaveric vs living donor liver transplant), risk
factors for IPF (graft, donor, recipient and surgical risk factors), liver
function tests (LFTs) before, during (at 24, 48, 72 hours and 7 days) and
after Alprostadil infusion, APACHE II score and outcomes.
MESOT
–
PAAG
–
PAAS
43
sst PanArab Congress of Liver Transplantation
Abstracts
2006
Continued...
The primary outcome measure was improvement (> 50 percent change) in
LFTs at day 7 of Alprostadil therapy. Secondary clinical outcomes
included the requirement for surgical intervention, renal replacement
therapy and mortality. Results: A total of 76 adult patients were admitted to
our MSICU after liver transplantation from April 2001 to January 2006. Six
patients (8%) received Alprostadil infusion postoperatively for IPF. All
patients were recipients of living donor liver transplant (LDLT) and had
APACHE II score > 20. In our case series, the most common risk factors for
IPF were small for size liver (5 patients), fatty liver (3 patients) and
prolonged warm ischemic time (2 patients). Three patients had more than
one risk factor. Three out of six patients (50%) with IPF showed significant
improvement in their LFTs at day 7 of Alprostadil infusion. Two patients
(33%) failed to respond to Alprostadil therapy and required emergency
cadaveric retransplantation. Both patients survived ICU stay and
discharged in stable conditions. All patients, except for one, survived ICU
and hospital stay. The cause of death was primary graft nonfunction
attributed to small for size liver and prolonged warm ischemic time. Two
out of six patients (33%) developed acute renal failure and required
continuous renal replacement therapy (CRRT). None of our patients
required discontinuation of Alprostadil infusion for adverse events. In one
patient, the rate of Alprostadil infusion was reduced by 50% because of
hemodynamic instability. Conclusion: Although Prostaglandin E1
(Alprostadil) administration is safe and well tolerated, further studies are
required to evaluate the efficacy of Prostaglandin infusion in the
management of patients with IPF after liver transplantation. Keywords:
Prostaglandin, liver transplantation, initial poor function
MESOT
–
PAAG
–
PAAS
44
sst PanArab Congress of Liver Transplantation
Abstracts
2006
PROTOCOL LIVER BIOPSY FOR MACROVESICULAR STEATOSIS IN THE
EVALUATION OF LIVING DONORS WITH NORMAL BODY MASS INDEX
Al Sebayel M, Al Bahili H, Al Omari M, Al Showly S and Saleh M
Department of liver transplantation and Hepatobiliary-Pancreatic Surgery,
King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
Presenting author: Mohammed Al Sebayel
Introduction: In liver transplantation, the presence of significant
macrovesicular steatosis in the donated liver can be detrimental to graft
function. Protocol biopsy as a prerequisite in the evaluation of living donor
for liver transplantation has been controversial. In our LDLT (living donor
liver transplant) program, we adopted liver biopsy for all potential donors.
We herby report our experience with the advantage of this approach in the
exclusion of donors with significant macrovesicular steatosis in the
setting of normal body mass index. Patients & Method: Between May 2001
and November 2005, 100 consecutive donors were evaluated for living
donor liver transplantation. Only donors with body mass index of less than
28 were included. Liver biopsy was done as the final procedure when all
other criteria for donation were met including detailed radiological
evaluation. All liver biopsies were evaluated by two independent
pathologists. Results: The overall male/female ratio was 3/1. The average
age was 26 years (range 18 – 42 years). There were no major complications
related to the procedures. Overall, 35 donors (35%) had macrovesicular
steatosis 10 donors (10%) had less than 5% macrovesicular steatosis,
eighteen (18%) had between 5-15% and seven above 15%, three of these
seven were above 25%. More than 10% steatosis was exclusion criteria in
our program. Such policy excluded 19 patients from being suitable for liver
donation. Conclusions: Significant macro vesicular steatosis was found in
25% of the donors with normal body mass index. Such finding will
influence the decision of accepting donors. We therefore recommend
protocol liver biopsies for all donors including those with normal body
mass index
MESOT
–
PAAG
–
PAAS
45
sst PanArab Congress of Liver Transplantation
Abstracts
2006
RETROSPECTIVE ANALYSIS OF THE CAUSES OF REJECTION OF
POTENTIAL DONORS FOR LIVING RELATED LIVER TRANSPLANTATION
Khalid Abdullah, FRCS, Hesham Abdeldayem, MD, Khaled Badah, ODA,
Badriyah Al-Somali, ODA and Abdulmajeed Abdulkareem, FRCS,FICS.
Presenting author: Khalid Abdullah
Background: A major prerequisite for living related liver transplantation
(LRLT) is to ensure both donor safety and optimal graft quality. Therefore,
excluding unsuitable donor candidates should be an important priority of
the transplant team. Purpose: is to analyze the criteria for exclusion of
potential living related liver donors. Patients and Methods: From
November 2000 to March 2005, 327 potential living related donors for 136
potential recipients for liver transplantation were screened and worked up
at the Liver Transplant Center, King Abdul Aziz Medical City. They were
evaluated in a stepwise manner including medical, physical, laboratory,
psychosocial, and imaging assessment Data regarding potential donors
was retrospectively reviewed. Reasons for rejection of disqualified donors
were analyzed. Results: Out of the 327 potential donors, 223 (68.2%) were
rejected at an early stage. One hundred and four cases (31.8 %) had CTvolumetry and/or MRCP. While 44 (42.3%, of those who had CT-volumetry
and/or MRCP) had their work up completed, 24 (23%) went for surgery.
Causes for donor rejection were classified as donor related factors
(inadequate volume, unsafe anatomy, abnormal liver function tests,
medical/psychiatric, fatty liver, etc.), n = 191 and recipient related factors
(too ill, died, received cadaveric transplant, etc.), n = 112. Conclusion: In
our as well as in most other centers experience, small proportion of
potential donors prove to be satisfactory candidates. Therefore, strict
attention to a stepwise evaluation process is of utmost importance to
disqualify unsuitable potential donors as early as possible during war
MESOT
–
PAAG
–
PAAS
46
sst PanArab Congress of Liver Transplantation
Abstracts
2006
RIGHT LOBE LIVING DONOR LIVER TRANSPLANTATION: SURGICAL
PITFALLS IN 112 CASES. WHERE DO WE STAND AFTER 7 YEARS?
A. Abdelaal, M. El-Meteini, A. Hamza, M Fathy, I. Mostapha, M. Adham, J.
Dumortier, P. Sagnard, O. Boillot.
Presenting author: Amr Abdelaal, MD.
Abstract: Objective: Reporting our experience concerning the
collaboration and transferral of biotechnology (knowledge) between 2
centres (France and Egypt) with the (realisation of) performance of 112
right lobe LDLT from December 1998 to May 2005. Patients & Methods:
From December 1998 to May 2005 we performed 112 cases using right lobe
graft. Our patients were 82 men and 30 women with median age of 48.7
years (range 18 – 66 years). Median age of the donors was 31.1 years
(range 18 – 57 years) with average BMI of 24.64 (range 18.7-31.25). The
main liver diseases were post-hepatitis C cirrhosis in 63 cases (56%),
alcoholic cirrhosis in 22 cases (18%), post-hepatitis B cirrhosis in 10 cases
(8.9%) and Budd Chiari Syndrome in 6 cases (5.3%). We followed the
standard protocols of assessment for donors and recipients and the
international recommendations in harvesting the right lobe and its
implantation but, we made our own modifications to adapt with the
anatomical variations and the surgical necessities. Results: We had 32
patients with HCC on top while 89 patients (79.4%) were classified as Child
C. MHV was harvested with the graft in 2 cases. The presence of vascular
and biliary anomalies were frequent with the presence of multiple HV, HA,
PV and bile duct in 25, 6, 15 and 59 cases respectively. Temporarily
portocaval shunt was done in 17 patients, 10 of them were at the beginning
of our series. None of the recipients had primary non-functioning of the
graft, while 32% had surgical postoperative complications treated either
surgically or radiologically. The one & three years patients’ survival rates
were 87.5% & 77.6% respectively. Conclusion: RLLDLT is one of the
modalities to decrease the mortality rate on the waiting list and it is of
crucial importance in countries, in which, cadaveric transplantation is not
yet feasible. Extended experience in liver resections is a prerequisite
before initiating an adult living-related program to decrease the effect of
learning curve. In addition, use of strict criteria for donor and recipient
selection may lessen the risk associated with living donor liver transplants
and thus further justify its use.
MESOT
–
PAAG
–
PAAS
47
sst PanArab Congress of Liver Transplantation
Abstracts
RISK OF PROGRESSION OF NEUROWILSON’S DISEASE
ORTHOTOPIC LIVER TRANSPLANTATION (OLT): CASE REPORT
2006
AFTER
Mohammed Al Saghier, MBBS, FACP, FRCSC, Ayman Abdo, MD, FRCPC,
Mohammad Al Sofayan, MBBS, FRCSC, FACS, Monther Kabbani, MBBS,
FRCSC, Ahmed Al Jedaie, PharmD, Hatem Khalaf, MBBCh, MSc, MD,
Mohammed Al Sebayel, MBBS, FRCS(Glas.), Ahmed Salem, PhD, Hamad Al
Bahili, MD, Yasser El-Sheikh, MBBCh, MSc, FRCSI, MD
Department of Liver Transplantation & Hepatobiliary-Pancreatic Surgery,
King Faisal Specialist Hospital & Research Center, Riyadh, KSA
Presenting author: Mohammed Al Saghier, MBBS, FACP, FRCSC
Background: Wilson’s patient with compensated liver disease and
progressive neurological symptoms suggested to be a good candidate for
OLT. This 35-year-old lady who presents with subacute fulminant failure
secondary to Wilson’s disease went for urgent cadaveric transplant. Pretransplantation neurological examination revealed involuntary fascial and
right upper limb movement. Post transplant, she was extubated with
neurological examination that no difference from the pre-operative
baseline exam. Third day, postoperative she went on deep unresponsive
coma (Glasgow Coma Scale of 4). Then gradually, her neurological status
start to improve that required a prolonged hospitalization. The patient
initial immunossupression was Tacrolimus® and her MRI revealed high
intensity signal in both basal ganglion. The patient’s maintenance
immunosuppression was Sirolimus® and MMF®. The patient was able to
get back to her baseline neurological function after six months of
physiotherapy. Conclusion: There is a high-risk of progression of
neurological Wilson’s symptoms to a severe form of the disease after OLT.
Correlation with MRI findings and neurological outcomes post transplant
is unknown. The role of Sirolimus® as a primary immunosuppression for
Neurowilson’s patient post liver transplantation to avoid Tacrolimus®
neurotoxicity might be beneficial
MESOT
–
PAAG
–
PAAS
48
sst PanArab Congress of Liver Transplantation
Abstracts
2006
SIGNIFICANCE OF CENTRILOBULAR NECROSIS IN LIVER ALLOGRAFT
BIOPSIES: CLINICAL PATHOLOGICAL CORRELATION
Muhammad Ashraf Ali, M, D., Abdulmajeed Abdulkareem, M.D., Walid E.
Khalbuss, M.D., Ph.D., Mohammad Afzal, M.D. Abdaal W. Khan, M.D., and
Bandar Knawy, M.D.
Department of Pathology & Laboratory Medicine, Department of
Hepatobillary Sciences and Department of Medicine. King Abdulaziz
Medical City , King Saud bin Abdulaziz University for Health Sciences,
College of Medicine, P.O. Box 22490, Riyadh 11426, Saudi Arabia
Presenting author: Muhammad Ashraf Ali, M, D.,
Introduction: Centrilobular necrosis (CLN) in liver allograft is not an
uncommon finding in liver biopsies and can be difficult to interpret
histologically. The goal of this study is to highlight the histological
features of CLN in liver allograft biopsies and study the clinical outcome in
different diagnostic groups. Method: Between January 2003 and December
2005, 131 liver allograft biopsies were submitted for evaluation and
diagnoses. Only biopsies taken more than 15 days after liver
transplantation were included in this study. Twenty-six biopsies from 24
patients reported with centrilobular necrosis (19.8%). The slides of 23
cases were available for review. Two pathologists who were unaware of
the clinical outcome of the patients evaluated theses cases. Cases were
evaluated for the presence of CLN, the grade of CLN (mild, moderate, and
severe as grade I, grade II, and grade III with or without bridging necrosis),
rejection, hepatitis, and biliary tract pathology (BTP). Then, biopsies were
categorized into rejection group, hepatitis group, vascular pathology
group, and BTP group. The clinical outcome of these patients was
evaluated independently by clinicians who were unaware of the biopsy
data, by reviewing the medical data and liver function tests (LFTs).
Results: The 23 cases came from 15 male patients and 8 female patients.
The average age of the patients was 49 years (ranging from 25-62 years).
The majority of the cases were in rejection group (10 cases; 43%). There
were 5 cases of hepatitis, 4 cases of BTP, one case of vascular pathology
group, one case of BTP and hepatitis, one case of rejection and hepatitis,
and one case of rejection and vascular group. The majority of the cases
were of grade I CLN (15 cases, 65%). There were 5 case of grade II CLN,
MESOT
–
PAAG
–
PAAS
49
sst PanArab Congress of Liver Transplantation
Abstracts
2006
Continued...
2 cases of grade III CLN without bridging necrosis, and one case of grade
III CLN with bridging necrosis. Clinical outcome of 20 cases was available
for correlation with 18 cases (90%) showing significant clinical
improvement. Two cases, both of grade I CLN showed ductopenic
rejection, which required another liver transplant. Conclusion:
Centrilobular necrosis (CLN) is a common finding in liver allograft
biopsies. The majority of CLN cases were seen in association with acute
rejection and hepatitis. The presence of CLN in any grade does not
necessarily indicate poor prognosis
MESOT
–
PAAG
–
PAAS
50
sst PanArab Congress of Liver Transplantation
Abstracts
2006
SINGLE CENTER EXPERIENCE IN PEDIATRIC LIVER TRANSPLANTATION
Hatem Saafan, Mahmoud El-Meteini,Hisham Abdelkader, Ahmed Darwish,
Magd Kotp, Adel Ryad,Hoda Abdelrahman and Alaa Hamza
Pediatric liver Transplantation unit, Wady Elneel Hospital, Cairo, Egypt.
Presenting author: Hatem Saafan
MESOT
–
PAAG
–
PAAS
51
sst PanArab Congress of Liver Transplantation
Abstracts
2006
SPECTRUM OF CHILDHOOD LIVER DISEASES IN SAUDI ARABIA
Abdullah Al Zaben MD, FRCP(C ) Department of Pediatrics, Division of
Gastroenterology King Abdulaziz Medical City - Riyadh, KSA
Presenting author: Abullah Al-Zaben
PURPOSE: To study the different types of liver diseases in children who
had liver biopsy in a single center. METHODS: The case records of all
children between 1 week and 13 years of age referred with liver diseases
who had liver biopsy over a 10-year period between January 1994 –
December 2003 were reviewed. The diagnosis of the disease was based on
clinical, biochemical, radiological and histopathological evaluations.
RESULTS: Three hundred sixty children with primary liver diseases had
liver biopsy over the study period. Forty-two (11.7%) patients were
diagnosed with idiopathic neonatal hepatitis, the most common disease.
Forty-one patients (11.3%) had progressive familial intrahepatic
cholestasis type II and III. Biliary atresia accounted for 29 (8%), Glycogen
storage disease 7.5% and autoimmune hepatitis 5.8% of patients. Wilson
disease was rare and diagnosed in 5.2% of cases. Twenty-eight percent of
cases were not diagnosed. Inherited liver diseases comprised 45% of all
cases. Some diseases could be common but not represented well since
liver biopsy was not done such as congenital hepatic fibrosis.
CONCLUSIONS: Chronic familial fatal liver diseases are common.
Awareness and good health care is needed for childhood liver diseases.
Health education for side effects of consanguineous marriage should be
arranged and living related liver transplant program is highly needed
MESOT
–
PAAG
–
PAAS
52
sst PanArab Congress of Liver Transplantation
Abstracts
2006
SPLIT LIVER TRANSPLANTATION FOR HEPATOCELLULAR CARCINOMA
O.Omar, M.Malago, G.sotiropoulos, C. Broelsch
Department of General, Visceral and Transplantation Surgery, Essen
University Hospital
Presenting author: O. Omar
Objektive: Liver transplantation (LTx) is recognized as the treatment of
choice for small hepatocellular carcinomas (HCC) in patients with endstage liver failure. However, because of limited organ availability, not all
those who qualify can benefit from full-size LTx. Patients and Methods:
Over a 28-months period, we transplanted 6 deceased donor split liver
allografts in stable recipients with HCC and cirrhosis. Results: There were
5 men and one woman with a median age of 60 years. Median waiting time
to LTx was 82 days. Extended right split grafts (segments I, IV-VIII) were
transplanted in 5 patients. One patient received a right split graft. In situ
harvesting was performed in 4 instances and ex situ in the remaining 2.
Median cold ischemia time was 10 hours. Primary non function was not
observed. Median intensive care unit stay was 4 days. There were neither
vascular nor biliary complications. The postoperative course was
uneventful in half of the patients. Two patients were re-operated because
of an abscess caused by a liver necrosis in the marginal zone of segment
IV. One patient died for reasons unrelated to liver function or to the
surgical intervention. The remaining 5 patients are alive after a median
follow up of 20 months. Conclusions: Deceased donor split LTx
constitutes an additional option for patients with HCC and cirrhosis. The
potential risks of using “split livers” as well as the potential benefits of
transplanting patients unlikely to survive the waiting list period must be
evaluated on an individual basis
MESOT
–
PAAG
–
PAAS
53
sst PanArab Congress of Liver Transplantation
Abstracts
2006
SPONTANEOUS RECOVERY OF FULMINANT HEPATIC FAILURE DUE TO
PROPYL-THIO-URACIL IN AN 8 YEAR CHILD
Shabib SM, Al Dekhail W, Banemai M, Shanafey S, Khalaf H
Section of Gastroenterology and Hepatology, Department of Pediatrics,
King Faisal Specialist Hospital and Research Center
Presenting author: Dr Souheil Shabib
INTRODUCTION: Propyl-thio-uracil (PTU) is an Antithyroid Agent that has
been implicated as a rare cause of fulminant hepatic failure (FHF) in adults
with grave consequences. Few reports of PTU induced FHF in pediatric
population. We report an 8 year girl with PTU-induced FHF who recovered
without liver transplantation. CASE REPORT: An eight year old girl that
was placed on PTU for the treatment of hyperthyroidism. Who presented
two months with 3 days history of lethargy, jaundice and fluctuation of
level of consciousness. Clinically: grade III encephalopathy, jaundiced,
enlarged liver, and moderate ascites. Investigations on admission: WBC
43,000, HGB 134g/L, platelets 376,000, AST 118u/L, , ALT 161u/L, total
bilirubin 613umol/L, INR 1.5, albumin 21g/L, ammonia 175umol/L,
creatinine 44umol/L, blood sugar 5.3mg/dL. All viral markers were
negative. Serum copper, ceruloplasmin, and 24 hours urine for copper:
normal. Autoimmune markers: negative. Tandem MS and urine for
Succinyl acetone: unremarkable. US of the liver including Doppler were
normal. Liver biopsy was consistent with drug induced massive
hepatocytes necrosis, minimal inflammations and cholestasis. Although
liver transplant was considered,. PTU was discontinued and the patient
was given supportive treatment and the thyroid was controlled with
potassium iodine and Inderal. She was monitored closely with special
emphasis on keeping away medications that are metabolized in the liver.
By day 16 the clinical picture and the biochemical data indicated that
patient achieved complete recovery. CONCLUSION: This is one of few
reports that describe PTU induced FHF in a child. In this report, complete
recovery was achieved by conservative treatment and without resorting to
liver transplant. Children receiving PTU should be closely monitored for
early detection of hepatic toxicity.
MESOT
–
PAAG
–
PAAS
54
sst PanArab Congress of Liver Transplantation
Abstracts
2006
SUCCESSFUL LIVING RELATED DONOR KIDNEY TRANSPLANTATION
AFTER TREATMENT OF POST TRANSPLANT LYMPHOPROLIFERATIVE
DISORDER (PTLD) USING HUMANIZED ANTI-CD20 MONOCLONAL
ANTIBODY (RITUXIMAB)
Mohammed Al Saghier, MBBS, FACP, FRCSC, Ayman Abdo, MBBS, FRCPC,
Ibrahim Al Hassoun, MD, Khalid Hamawi, MD, Mohammad Al Sofayan, MBBS,
FRCSC, FACS, Samhar Al Akash, MBBS, FAAP, Abbas Al Abbad, MBBS, Khalid Al
Shaibani, MBBS, FRCS(Glas.), Khalid Abdul Al Meshari, MD, FACP, Mohammed Al
Sebayel, MBBS, FRCS(Glas.), Hatem Khalaf,MD, Ibrahim Al Ahmadi, MBBS, ABIS,
Ahmed Chaballout, MD, Hamad Al Bahili, MD, Yasser El-Sheikh, MD, FRCSI
Department of Liver Transplantation & Hepatobiliary-Pancreatic Surgery
King Faisal Specialist Hospital & Research Center, Riyadh, KSA
Presenting author: Mohammed Al Saghier, MBBS, FACP, FRCSC
Background: Post Transplant Lymphoproliferative Disorder (PTLD) could be life
threatening associated with high-rate of morbidity and mortality and significant
risk of graft lost. Using a new chemotherapy agent: Humanized anti-CD 20
monoclonal antibody (Rituximab) ® and utilizing the anti-proliferative properties of
Sirolimus® may provide an alternative treatment strategy to help changing the
outcome of this transplantation complication. An eleven-year-old female with end
stage renal disease secondary to type I primary hyperoxyluria presented 3 months
after receiving living related liver transplant with nasal congestion and sore throat.
Her maintenance immunosuppressive regimen consisted of Tacrolimus® and
Prednisone®. CT scan revealed large nasopharyngeal mass. Patient underwent
open biopsy and the pathological diagnosis was consistent with Epstein-Barr Virus
(EBV) positive B- cell polymorphic subtype lymphoma. Cytomegalovirus (CMV) and
EBV- polymerase chain reaction (PCR) were both negative by serology.
Tacrolimus® was stopped and Sirolimus® was started with a target level of 5-8
ng/L. Patient received 2 doses of Rituximab® 300 mg/m2 with complete remission
at seven months post treatment as evident by a follow up CT scan of the head and
neck and continued negative CMV, EBV-PCR. The patient subsequently underwent
living related kidney transplant from the same donor. Post kidney transplant
immunosuppressive regimen consisted of Tacrolimus® and Prednisone®. Patient
has normal functioning hepatic and renal allografts after one and two –years of
follow up respectively. No signs of PTLD recurrence. Conclusion: PTLD can be
treated effectively using Rituximab® with Sirolimus® based immunosuppressive
regimen. Sequential organ transplant after PTLD is possible after treatment. Larger
studies and longer follow up are needed to confirm those findings.
MESOT
–
PAAG
–
PAAS
55
sst PanArab Congress of Liver Transplantation
Abstracts
2006
SURVIVAL FOLLOWING CADAVERIC VS LIVING DONOR LIVER
TRANSPLANTATION: A SINGLE CENTER EXPERIENCE
Al-Sebayel M, Khalaf H, Al-Sofayan M, Al-Bahili H, Abdo A, Helmy A, AlSaghier M, El-Sheikh Y, Al-Suhaibani H, Negmi H, Hashem F, Al-Malaq A
Department of liver transplantation and Hepatobiliary-Pancreatic Surgery
(MBC 72) King Faisal Specialist Hospital and Research Center
Presenting author: Mohammed Al Sebayel
Abstract Introduction: The liver transplant (LT) program at King Faisal
Specialist Hospital and Research Center (KFSH&RC) re-started in April
2001 by a local team that has been performing both cadaveric LT (CLT)
and living-donor LT (LDLT). Herein we present the center’s recent
experience in both procedures. Patients & Method: Between April 2001 and
November 2005, 81 LT procedures were performed (47 CLTs and 34
LDLTs) in 78 patients (3 re-transplants). Log rank test was used for
statistical analysis. Results: The overall male/female ratio was 41/40,
adult/pediatric ratio was 71/10, and median age 43 years (range, 5-63
years) In the CLT group; and after a median follow-up period of 571 days
(range, 38-1661 days), the overall patient and graft survival rates was
91.5%. The 4 deaths after CLT were due to primary non-function in one
patient, central pontine myelinolysis in one patient, and recurrent HCV
infection in 2 patients. In the LDLT group; and after a median follow-up
period of 439 days (range, 15-1116 days), the overall patient and graft
survival rates were 85.3% and 76.5 % respectively. Graft failure and deaths
in the LDLT were due to portal vein thrombosis in two patients, hepatic
artery thrombosis in one patient, small for size in 3 patients, biliary
complication in one patient and uncontrollable bleeding in two patients.
Three patients were successfully re-transplanted using cadaveric organs.
Patient survival was not significantly different between the two groups,
however graft survival was significantly inferior in LDLT (p value<0.05)
Conclusions:. Survival in this group is expected to improve with better
patient and donor selection In Saudi Arabia; effort should be directed to
improving the numbers and quality of available cadaveric organs, however
and till then, LDLT may be the only way forward to save the increasing
number of patients on the waiting list.
MESOT
–
PAAG
–
PAAS
56
sst PanArab Congress of Liver Transplantation
Abstracts
2006
THE FIRST 100 LIVE LIVER DONORS IN EGYPT: A SINGLE CENTER
EXPERIENCE
Alaa F Hamza, MD FRCS1,Mahmoud S. El-Meteini, MD1, Mohamed Fathy,,
MD1, Amr Abdelaal, MD1, Hatem A Saafan, MD1, Ahmed Mokhtar, MD1,
Fawzya Abuelfetouh, MD1, Ibraeem Mustafa, MD1, Rasha O Refaie, MD1,
Sahar Badawy, MD1, Mohamed Shaker, MD1, Massimo Malago, MD2,
Christofer Brolesch, MD2 and Olivier Boillot, MD3.
1Liver Transplant Unit, Wady Elneel Hospital, Cairo, Egypt; 2Liver
Transplant Unit, Universitätsklinikum Essen, Essen, Germany and 3Liver
Transplant Unit, Hopital Eduard Heriot, Lyon, France
Presenting author: Alaa Hamza
Body: Aim: Outcome of live liver donation (LLD) for end-stage liver
disease (ESLD) patients is presented. Method: From October 2001 through
October 2005, following informed consent, 106 LLD were contemplated
with 6 being aborted. One hundred procedures were completed in 65
males and 35 females with median age 28.9 yrs. Body mass index was 28
and routine liver biopsy was done. Left liver grafts (LLG) (n=15) included
left lateral segment (n=10) or left liver (n=5). Middle hepatic vein (MHV)
inclusion divided right liver grafts (RLG) (n=85) into RLG+MHV (n=8) or
RLG-MHV (n=77). Per-operative cholangiogram and ultrasound MHV
mapping was performed. Parenchymal transaction proceeded using
harmonic scalpel. Results: Median operative time was 6.3 hrs while median
blood transfusion was 356 ml. The right bile ducts (RBD) were single,
double or triple in 35, 48 and 2 donor, respectively. In LLG donors, no
morbidity was recorded. In RLG group, bleeding and biliary leakage were
the main morbidity in 3 (3.5%) and 6 donors (7%), respectively. Reoperation was needed in 5 cases (5.8%), 3 for bleeding control and 2 for
biliary leakage. One case succumbed on D67 from prolonged sepsis
following uncontrolled biliary leakage. Median hospital stay was 11.7 days.
Conclusion: LLD is the only hope for ESLD patients in our country. Donor
mortality is un-acceptable but with growing experience this will be
abolished.
MESOT
–
PAAG
–
PAAS
57
sst PanArab Congress of Liver Transplantation
Abstracts
2006
THE OUTCOME OF HEPATITIS C RECURRENCE ON ARAB ETHNIC RACE:
POST LIVER TRANSPLANTATION WITH GENOTYPE 1 AND 4
Mohammed Al Saghier, MBBS, FACP, FRCSC, Ayman Abdo, MD, FRCPC,
Mohammad Al Sofayan, MBBS, FRCSC, FACS, Hatem Khalaf, MBBCh,
MSc, MD, Monther Kabbani, MBBS, FRCSC, Ahmed MongiJelassi, Hamad
Al Ashgar, MD, Mohammed Al Quaiz, MRCP, MD, Mohammed Al Sebayel,
MBBS, FRCS(Glas.), Hamad Al Bahili, MD, Yasser El-Sheikh, MBBCh, MSc,
FRCSI, MD, Ahmed Helmy, PhD
Department of Liver Transplantation & Hepatobiliary-Pancreatic Surgery,
King Faisal Specialist Hospital & Research Center, Riyadh, KSA
Presenting author: Mohammed Al Saghier, MBBS, FACP, FRCSC
Objective: Universally, recurrence of HCV is common after orthotopic liver
transplantation (OLT). There are no guidelines or concensus of the best
medical management of this condition in genotype 1 and 4 patients post
OLT. Methods: Reviewed 81 patients with HCV at time of transplantation.
Data was looking at negative predictive variables associated with
recurrence post OLT. These patients went for OLT between July 1988 &
May 2005. Results: The total numbers of patients transplanted for Hepatitis
C are 81 patients, with mean follow-up of 87 months (1 - 204 months).
Mean age is 61 (20-83) at time of follow up. 28 females & 46 males. 59
patients went for cadaveric transplant. Fourteen patients living related
liver transplant. Genotype 4 is seen in 65%, followed by genotype 1 (15).
5% of patients had mixed genotype 1 & 4. Significant recurrence happened
with 51 % of patients. 10% with fibrosing cholestatic recurrence four of
them died. The commonest immunosuppression was used in this cohort
was Tacrolimus in 58% of patients with recurrence. Cyclosporin based
therapy on 42% of recurrence patients. 81% of patients with recurrence
received INF based therapy if there is no contraindication. Conclusion: In
this cohort with the genotype 1 & 4 on patients of Arab ethnicity, severe
disease was lower. The preemptive therapy may be necessary on first year
with presence of high recurrence rate to control virus load especially with
potent immunosuppression. Further studies are needed to illustrate role of
selective management versus preemptive on first year OLT.
MESOT
–
PAAG
–
PAAS
58
sst PanArab Congress of Liver Transplantation
Abstracts
2006
THE ROLE OF RECOMBINANT FACTOR VII IN CONTROLLING THE
INTRAOPERATIVE BLOOD LOSS IN PATIENTS WITH SEVERE
COAGULOPATHY AND PORTAL HYPERTENSION DURING LIVING DONOR
LIVER TRANSPLANT SURGERY
Fawzia Aboul- Fetouh, Maged Salah, Ahmed Mokhtar, Ahmed Sharara,
Sahar Badawy, Alaa Hamza, Mahmoud El-Meteini
Presenting author: Fawzia Aboul Fetouh
The role of recombinant factor VII in controlling the intraoperative blood
loss in patients with severe coagulopathy and portal hypertension during
living donor liver transplant surgery. Objective: To investigate the effect of
recombinant factor VII on the intraoperative blood loss in patients with
portal hypertension and coagulopathy during liver transplant surgery.
Design: Prospective clinical study. Setting: University-affiliated teaching
hospital. Participants: Adult patients (n = 24) undergoing elective liver
transplant surgery from living donor selection criteria based to include
patients child C classification with portal hypertension ,high risk of
bleeding and in severe coagulopathy INR > 2 and platelet count less than
40.000 Interventions: Two groups of patients were compared (N = 12 for
each: The first group received 30 µg /kg recombinant FVII. Immediately
after induction of anesthesia giving as a bolus dose followed by
continuous infusion of 5 µg/kg/ h till the end of dissection phase The
second group used as a control group Measurements Assessment of
blood loss and the need or blood and blood products during operation
Assessment of the effect of r FVII on the coagulation profile Assessment
of the duration of surgery with respect to dissection time. Doppler
assessment of flow in the graft vesssels. Post operative blood loss. Post
operative coagulation profile assessement The results Will be presented
Conclusion The rVII proved to have an effective role in controlling the
intraoperative blood loss in liver transplant patient during the dissection
phase,with protective effect on the platelets function and coagulation
profile , with no postoperative effect on the blood flow of grafted liver .
MESOT
–
PAAG
–
PAAS
59
sst PanArab Congress of Liver Transplantation
Abstracts
2006
THE ROLE OF TRANSPLANT CLINICAL PHARMACIST IN THE CARE OF
TRANSPLANT PATIENTS
Ahmed Aljedai
Presenting author: Ahmed Aljedai
The burgeoning clinical discipline and growth of organ transplantation has
resulted in an expansion in the number of healthcare specialists to
support clinical care and research. Many studies have demonstrated the
impact of pharmacists on the care of ambulatory and hospitalized patients
including those who received solid organ transplant. The past 10 years
have seen a dramatic increase in the number of immunosuppressive
agents and other medications used in transplantation, resulting in more
complex medication regimens and greater potential for interactions,
adverse effects and increased costs. The clinical pharmacist’s
responsibilities are to review medication regimens; identify, resolve, and
prevent medication related problems; interview patients; answer drug
information questions; and make therapeutic recommendations. This short
presentation will try to focus on the role of the transplant clinical
pharmacist in the care of transplant patients.
MESOT
–
PAAG
–
PAAS
60
sst PanArab Congress of Liver Transplantation
Abstracts
2006
TOURISM FOR LIVER TRANSPLANTION IN CHINA: A SINGLE SAUDI
CENTER EXPERIENCE
Yasser M. El Sheikh, Ayman Abdo, Hatem Khalaf, Hamad Al Bahili, ,
Ahmed Helmy, Mohammed Neimatallah, Monther Kabbani, Mohammed Al
Saghier, Mohammad Al Sofayan, Mohammed Al Sebayel
Department of Liver Transplantation & Hepatobiliary-pancreatic Surgery,
King Faisal Specialist Hospital & Research Center
Presenting author: Mohammed Al-Saghier
Background: liver transplantation in the past few years became the best option
in the treatment of End Stage Liver Disease (ESLD). However, due to the donor
organ shortage, long waiting lists for cadaveric liver transplantation, and
limitations of Living Donor Liver Transplantation (LDLT), transplantation
tourism started to emerge in some countries which offered ESLD patients a
short waiting time for cadaveric liver transplantation. In our center, we are
currently following 17 patients who under went liver transplantation in China,
which compelled us to evaluate their outcome, in particular because of the
uncertainty about donor situation at the time of retrieval, specially the warm
ischemia time and the possibility of Non Heart Beating Donor (NHBD). Patients
and Methods: Retrospective data base review was done for 17 patients who
have been transplanted in China (3 centers), in the last 3 years (2003-2006), the
outcome evaluation of these post cadaveric liver transplantation patients
included patients survival, overall graft function and survival, post operative
complications specifically biliary and vascular problems. Results: A total of 17
patients were included in this study, with a mean age of 59.9 years (46-68
years), 14 males and 3 females, all were suffering from ESLD secondary to
different etiologies (HBV, HCV, HCC, cryptogenic liver cirrhosis, autoimmune
hepatitis), who under went cadaveric liver transplantation in China, the
mortality among them was 29%, biliary complications as high as 52.9%,
vascular complications 11.7%, and 41.1% of the patients showed no clinical or
laboratory evidence of preservation injuries. Conclusion: China liver
transplant has emerged as an alternative source of organs for many patients
across the Arab world. However, this pattern of ischemic organ injury and
biliary complications could be suggestive of Non Heart Beating Donation in
China. Moreover, the lack of transparency about donation and organ retrieval
protocol could be a major issue for Arab countries who will be faced with such
outcome.
MESOT
–
PAAG
–
PAAS
61
sst PanArab Congress of Liver Transplantation
Abstracts
2006
USE OF SMANCS FOR DOWENSTAGING OF HEPATOCELLULAR
CARCINOMA PRIOR TO LIVER TRANSPLANTATION
Khaled Greish 1, Emad El-Kady 2, M Abd El-Salam 2 , Ahmed El-Dory3 and
Hiroshi Maeda 1
1Kumamoto University, Japan 2 International Medical Center-Cairo 3 Ein
Shams University, Cairo
Presenting author: Khaled Greish
Many reports describe high incidence of HCC among Egyptian, one
describes 2 fold increases over the last 5 years. Orthotropic liver
transplantation (OLT) is one of the curative options for treatment of HCC,
However only fraction of patients can meet the criteria for OLT, mostly due
to large tumor size. SMANCS is a targeted polymer conjugated anticancer
agent that proved most effective against HCC (about 90 % response rate)
with least side effect. Use of SMANCS can provide a powerful mean for
dowenstaging of HCC in patients other wise not eligible for OLT. The drug
is especially valuable for patients with compromised liver functions (Child
B and C) due to HCV infection, as it possess very high safety profile when
properly used. The presentation includes review of the clinical results of
using SMANCS since 1994 in Japan
MESOT
–
PAAG
–
PAAS
62
sst PanArab Congress of Liver Transplantation
Abstracts
2006
THE BENEFITS OF CYCLOSPORINE IN TRANSPLANTATION
Gary A. Levy, MD, FRCP(C)
Director, Multi Organ Transplant Program, University Health Network,
University of Toronto
Presenting author: Gary A. Levy
The introduction of cyclosporine (CsA) was a major advance in
transplantation leading to a reduction in the incidence of allograft
rejection in renal transplant recipients and establishment of successful
heart, lung and liver transplant programs. The microemulsion formulation
of CsA, Neoral® (CsA-Me), provides better and more consistent drug
exposure than Sandimmune and use of 2 hour post dose sample (C 2)
measurements results in lower rates of rejection and toxicity. The
emergence of the (CNI) tacrolimus (Tac) has questioned the value of
continued use of CsA. Recent data suggest a superiority of CsA for
transplant recipients to optimize patients outcomes.
Cyclosporine and Diabetes Mellitus
New onset diabetes mellitus (NODM) is a major risk factor for
cardiovascular disease. A recent retrospective review found that
approximately 18% of patients receiving CsA-Me developed NODM over
the first 2 years post transplant compared to 30% of those receiving Tac.
Two multi centered liver studies similarly showed that the incidence of
NODM was significantly higher in patients receiving Tac than CsA-Me.
Preliminary data suggests that conversion from Tac to CsA-Me for
patients with NODM is associated with a marked improvement in glucose
metabolism and even reversal of diabetes. A recent meta analysis
examining the incidence of NODM during the past decade, demonstrates
that there is a significantly higher incidence of NODM in renal, liver, heart
and lung transplant patients receiving Tac than in those receiving CsAMe.
Cyclosporine A and Hepatitis C Virus (HCV)
HCV is now the leading indication for liver transplantation. Watashi et al
have recently shown that a cellular peptidyl-prolyl cis-trans isomerase
(ppiase), cyclophillin B (CyPB) is critical for the replication of HCV. CyPB
was shown to interact with the HCV RNA polymerase (NS5B) to stimulate
its RNA binding activity. CsA-Me in contrast to Tac inhibits cyclophillin B
leading to inhibition of HCV replication.
MESOT
–
PAAG
–
PAAS
63
sst PanArab Congress of Liver Transplantation
Abstracts
2006
Ghobrial also previously reported a shorter time to HCV recurrence with
Tac and Duvoux and Metselaar have also suggested that the rate of liver
fibrosis is slower in HCV transplanted patients treated with CsA-Me. CsAMe has also been shown to inhibit collagen production by fibroblasts
more than Tac. These data may explain the report of Berenguer which
showed that Tac compared to CsA–Me was independently associated with
development of cirrhosis. In the LIS2T study, Tac treated HCV patients
had a higher incidence of death than CsA-Me treated patients (15%
versus 6%, p<0.05). Furthermore, at 1 year post transplant, HCV histologic
recurrence occurred sooner in Tac treated patients. As time to recurrence
is a predictor for severity of recurrence, this has important clinical
implications. Additional analyses of the LIS2T data set has shown that
Tac-treated patients had increased fibrosis, higher liver transaminase
levels (ALT), increased graft loss and need for re- transplantation that
patients treated with CsA-Me. In a single centre experience, patients on
CsA-Me in comparison to Tac also appear to have an increased sustained
virologic response to interferon/ribavirin.
Cyclosporine and Living Related Transplantation Living Donor liver
transplantation is an increasingly important treatment option for adult
patients with end stage liver disease. As part of the LIS2T study, 39
patients of the 495 patients enrolled were recipients of a living donor
transplant and received wither Neoral (23) or Tac (16) based
immunotherapy. By month 6 graft survival was 91% in Neoral versus 81%
in Tac treated patients and incidence of rejection was 17% in Neoral
versus 31% in Tac treated patients.
Conclusions: Despite attempts to substitute other agents for CNIs to
reduce toxicity and improve efficacy, both Tac and CsA remain
cornerstones of immunossuppression. Recent studies have shown that
both Tac and CsA-Me (Neoral) are similarly effective in preventing
rejection. The introduction measurement of C2 has improved outcomes for
patients taking Neoral. Recent data suggest that the use of Neoral has
significant advantages compared to Tac for patients at risk for diabetes
mellitus and for patients transplanted for HCV and is effective in living
donor liver transplantation.
MESOT
–
PAAG
–
PAAS
64
sst PanArab Congress of Liver Transplantation
Abstracts
2006
IMPACT OF IMMUNOSUPPRESSION ON RECURRENCE OF HEPATITIS C
GENOTYPE IV IN LIVING DONOR LIVER TRANSPLANTATION
(PROSPECTIVE STUDY)
Mostafa I.,Abd El All M.,Refaee R.,Safwat W.,Omar A.,Fayez A.,Meteni
M.,Abd El All A., Fathi M.,Dorry A., Monayeri M., Hamed H., Abd El Wahab S.
Liver Transplantation Unit Wady El Neel Hospital, Cairo, Egypt
INTRODUCTION
Hepatitis C virus (HCV) infection of the graft is universal. Many factors has
been studded in the recurrence of hepatitis as; Recipient age, BMI , HCVRNA before transplantation , HCV-RNA after transplantation , Donor age ,
Graft Size , type of immunosuppression.
Our Immunosuppression Protocol: Tacrolimus, Cyclosporin micro
emulsion, Mycophenolates , Corticosteroids which is tapered within first 3
months and Basiliximab as induction therapy in selected cases.
PURPOSE OF STUDY
Impact of tacrolimus versus Cyclosporin micro emulsion in hepatitis C
virus-infected living related liver transplant recipients on recurrent
hepatitis.
MATERIAL AND METHODS
Liver Transplantation started five years ago in several centers in Egypt
(more than 280 patients), In Wadi El Neel Hospital, Since October 2001; 107
patients underwent Living Donor Liver Transplantation 92 Adults and 15
Children. Mortality rate was: 32 patients (29.9%). Early Post Operative
Mortality (27 patients) was 26.4 %. Late Mortality (5 patients) was 4.7 %.
This Study was started on 57 HCV Recipient; they were classified into two
groups; Recurrent Group: 16 patients and Non Recurrent Group: 41
patients.
RESULTS
I. Recurrent Group:
Mean Recipient age 48.56 , Mean Recipient weight 78.44 , Mean Donor Age
29.38, Mean HCV-RNA before transplantation 250.56 ( X 103) , Mean HCVRNA after transplantation 880.5 ( X 103) , Mean Graft size 1.178 k.g.
II. Non Recurrent Group:
Mean Recipient age 47.94 , Mean Recipient weight 83.33 , Mean Donor Age
28.72 , Mean HCV-RNA before transplantation 238.83 ( X 103) , Mean HCVRNA after transplantation 492.11 ( X 103and Mean Graft size 1.108 k.g.
MESOT
–
PAAG
–
PAAS
65
sst PanArab Congress of Liver Transplantation
Abstracts
2006
Continued….
Immunosuppression:
For Recurrent Group; 56.3 % of patients were receiving Basiliximab as
induction of immunosuppression and 43.8% didn’t. While Non Recurrent
Group; only 9.8 % receives and 90.2 % didn’t ,with P value: 0.0002 Very
highly significant.
The Correlation between Tacrolimus & Cyclosporin micro emulsion and
the recurrence of HCV
Recurrent
Non Recurrent
Number of
Patients
12
25
%
32%
68%
Number of
Patients
4
16
%
20%
80%
* P value: 0.2469 Non Significant
CONCLUSION
The correlations were not significant between (patient's age, donor's age,
donor's relation, graft size, HCV-RNA before transplantation, type of
immunosuppressant) and occurrence of recurrence
Significant correlations were detected between (HCV-RNA after
transplantation, Basiliximab) and occurrence of recurrence
Tacrolimus is more associated with recurrence than Cyclosporin micro
emulsion however this association is not significant may be due to small
sample size
From This Study we recommend for patients with HCV genotype IV to start
immunosuppression
protocol
as
Cyclosporin
micro
emulsion,
Mycophenolates and
Basiliximab should be used as induction of
immunosuppression in selected cases.
MESOT
–
PAAG
–
PAAS
66
sst PanArab Congress of Liver Transplantation
Abstracts
2006
THE VALUE OF ULTRASOUND IN EVALUATION OF POTENTIAL LIVER
DONORS
Eman Rewisha
Department of Hepatology, National Liver Institute
Presenting author: Eman Rewisha
Donor evaluation for living donor liver transplantation passes through
several steps in a stepwise progress, including: clinical evaluation,
laboratory tests, psychological evaluation, non invasive investigation
including ultrasound, volumetric and vascular studies, and invasive
evaluation including liver biopsy. In this study we attempted to shift
ultrasound evaluation to an early stage as part of the clinical examination
to evaluate its role in selecting potential donors for further evaluation
studies, to assess whether this will have an impact on reducing
unnecessary utilization of resources in donor evaluation.
135 Potential donors who were of compatible blood group and normal
laboratory tests and negative for hepatitis B and C markers were evaluated
by ultrasound. 5 Had hepatomegaly (4%), 26 mild splenomegaly (19%), 49
had bright liver suggestive of moderate and severe steatosis (36%, all with
BMI 29-32), and 8 had moderate peri-portal fibrosis (PPF) (6%). Of the 47
cases who proceeded to liver biopsy, only 2 had steatosis >10% (4%). 14
of the 49 donor with bright liver on ultrasound managed to reduce more
than 10% of their weight over at least one month. Repeat ultrasound shoed
moderate or severe steatosis. They were biopsied as the only available
donors, and biopsy revealed steatosis more than 25%. 3 Other potential
donors were evaluated further after having an abnormal ultrasound
(echogenic liver and PPF), and they all showed hepatitic changes and
portal fibrosis.
CONCLUSION: Liver biopsy is the gold standard in donor evaluation.
However, we recommend moving ultrasound examination earlier before
lab studies, and excluding donors with ultrasound criteria of moderate or
severe steatosis, with echogenic liver or with PPF without proceeding to
liver biopsy.
MESOT
–
PAAG
–
PAAS
67
sst PanArab Congress of Liver Transplantation
Abstracts
2006
FACTORS LIMITING THE EXPANSION OF THE TRANSPLANT PROGRAM
IN EGYPT
Hassan Zaghla, Eman Rewisha, Hosam Taha, Tse Ling Fong*, Imam Waked
and Saleh M. Saleh
Department of Hepatology, National Liver Institute Menoufiya University &
University of Southern California *
Presenting author: Emam Waked
Living donor liver transplantation (LDLT) has become an option for
patients with end stage liver disease (ESLD) when cadaver transplantation
is not available. In Egypt, the current status does not permit cadaver
transplants, and LDLT is the only option for patients with ESLD.
Aim: The aim of this study was to evaluate possible transplant candidates
and their potential donors to study the prospect of LDLT in the setting of
high prevalence of HCV infection and schistosomiasis in the general
population, to estimate the possible future needs for LDLT.
Patients and Methods: 1000 Patients with ESLD (75.8% males, mean age
47.2 +/- 7.9 years, 90.9% due to HCV infection and 9.1% due to HBV) and
their apparently healthy family members were evaluated for possible LDLT.
Results: 257(25.7%) Patients did not agree for LDLT and 74.3% agreed.
Patient consent was significantly related to being male, the presence of
ascites, and the severity of liver disease as assessed by the MELD score
(all p<0.05). Of the 743 agreeing patients, 522 (70.3%) had 1091 of 1527
family members consenting for evaluation as potential donors (range 1-6
per patient, mean 2.09 family member), and 221 had all family members
(486 family members) refusing to be evaluated. Family consent was
significantly related to previous variceal bleeding, the severity of jaundice,
presence of ascites, and the severity of liver disease. 72 of the potential
donors were excluded because of hepatomegaly and/or splenomegaly on
initial clinical examination, and 523 were excluded because of
incompatible blood group. Of the 496 blood group compatible donors, 36%
had HCV antibodies (4% with schistosomiasis, 5% with fatty liver, 12% with
elevated ALT), 39% had schistosomiasis, 5% had HBsAg , and 3% had fatty
liver on ultrasound, CT. Only 80 family members (16% of the blood group
compatible donors) were successful donors for 53 patients (5.3% of the
patients or 7.1% of the consenting patients).
MESOT
–
PAAG
–
PAAS
68
sst PanArab Congress of Liver Transplantation
Abstracts
2006
Continued…
Conclusion: The potential for expanding the LDLT program in Egypt is low.
This is mainly due to the high prevalence of HCV and schistosomiasis in
apparently healthy family members who are the potential donors for
patients with ESLD. Whether patients with schistosomiasis can be donors
for LDLT is not known and they are currently excluded, and this has to be
studied in a trial to increase the potential donor pool.
ADVERSE EFFECTS OF SCHISTOSOMIASIS ON LIVER
TRANSPLANTATION
Om-Kolsom El-Haddad
Department of Hepatology, National Liver Institute
Presenting author: Om-Kolsom El-Haddad
A number
of
parasitic
infections
have
been
reported
in
immunocompromized individuals and in solid organ transplant recipients.
However, post liver transplantation schistosomiasis is thought to be
extremely rare. We report on a live-related liver transplant recipient who
has developed active schistosomal disease in his allograft.
MESOT
–
PAAG
–
PAAS
69
sst PanArab Congress of Liver Transplantation
Abstracts
2006
THE IMPACT OF THE PRIMARY LIVER DISEASE ON THE EARLY
OUTCOME OF LIVING RELATED LIVER TRANSPLANTATION
Hatem Konsowa, Ibrahim Marwan, Tarek Ibrahim, Taha Yassin
National Liver Institute
Presenting author: Hatem Konsowa
Living related liver transplantation was done for 14 pediatric cases with
end stage liver disease in National Liver Institute, from April 2003 to May
2005 . The primary liver disease in these patients was: 5 cases Biliary
atresia (BA) {37%}; 2 cases Byler,,s disease {14%} ; 3 cases Venous
outfollow obstruction (VOD) 21%} ; 2 cases congenital hepatic fibrosis
(CHF) {14%}; one case chronic hepatitis C (CHC) {7%} and one case
hepatoblastoma {7%}.
Morbidity was observed in 4 cases {28%} : Three pts had developed
ductopenic rejection ( two of them were associated with CMV infection) ;
one patient with biliary leak which managed by ERCP and one patient with
renal impairment and hypertension. Five deaths occurred {36%} ; one
patient with CHF (50%) , two patients with VOD (66.6%), one patient with
Byler's disease(50%), and one patients with chronic HCV infection {50%}
No deaths were encountered among BA cases.
In Conclusion : A part from venous outflow obstruction the primary liver
disease has no influence on the outcome of living related liver
transplantation . BA is not only the most common indication in LRLT in
pediatric but also have the best result after operation . CMV prophylaxis
should be started early in the postoperative time to avoid its role in
induction of rejection.
MESOT
–
PAAG
–
PAAS
70