Longterm outcomes of auxiliary partial orthotopic liver transplantation in preadolescent children with fulminant hepatic failure

Abstract

By preserving part of the native liver, auxiliary partial orthotopic liver transplantation (APOLT) provides the advantage of potential immunosuppression (ISP) withdrawal if the native liver recovers but has had limited acceptance, especially in the United States, due to technical complications and low rates of native liver regeneration. No previous study has evaluated APOLT specifically for preadolescent children with fulminant hepatic failure (FHF). This population might benefit especially based on greater capacity for liver regeneration. Data from 13 preadolescent children who underwent APOLT were compared to 13 matched controls who underwent orthotopic liver transplantation (OLT) for FHF from 1996 to 2013. There were no significant differences in patient demographics or survival between the 2 groups. However, all surviving OLT recipients (10/13) remain on ISP, while all but 1 surviving APOLT recipient (12/13) showed native liver regeneration, and the first 10 recipients (76.9%) are currently off ISP with 2 additional patients currently weaning. In our experience, APOLT produced excellent survival and high rates of native liver regeneration in preadolescent children with FHF. This represents the largest series to date to report such outcomes. Liberating these children from lifelong ISP without the downside of increased surgical morbidity makes APOLT an attractive alternative. In conclusion, we therefore propose that, with the availability of technical expertise and with the technical modifications above, APOLT for FHF should be strongly considered for preteenage children with FHF.

Current status of auxiliary partial orthotopic liver transplantation for acute liver failure

“…A,B). An iliac vein interposition graft can be used to prevent portal vein narrowing . Problems in arterial discrepancy are common in pediatric APOLT as the left hepatic artery of the graft (usually an adult donor) is larger compared to the pediatric left hepatic artery.…”

“…(24) A recent report of APOLT for ALF in 13 preadolescent children with 100% survival and with 10 children completely off immunosuppression again strengthens the argument for using APOLT in this setting. (25)…”

Right lobe liver transplantation in patient with fulminant form of the Wilson’s disease from AB0-incompatible relative donor

“…При проведении трансплантации печени от по-смертного донора по поводу фульминантной пече-ночной недостаточности летальность, по разным данным, достигает 25,4-38,1% [7,8], среди реци-пиентов трансплантатов печени от прижизненного донора летальность значительно ниже и составля-ет 9% [9]. В исследовании Wainer et al сравнили группы пациентов, которым выполнена трансплан-тация целой печени от посмертного донора по по-воду фульминантной печеночной недостаточности, и группы реципиентов, которым была произведена трансплантация фрагмента печени от прижизнен-ного донора.…”

“…В исследовании Wainer et al сравнили группы пациентов, которым выполнена трансплан-тация целой печени от посмертного донора по по-воду фульминантной печеночной недостаточности, и группы реципиентов, которым была произведена трансплантация фрагмента печени от прижизнен-ного донора. Среди причин, приведших к острой печеночной недостаточности, указывается аутоим-мунный гепатит, гепатотоксичность азитромицина, гепатит А и идиопатическая фульминантная пече-ночная недостаточность, при этом выживаемость трансплантатов в первой группе составила 84,6%, а во второй 92,3% [8]. Кроме того, до 25% пациентов с острой печеночной недостаточностью умирают в листе ожидания трупной печени, так и не дождав-шись трансплантации [10,11].…”

Auxiliary Partial Orthotopic Liver Transplantation for Selected Noncirrhotic Metabolic Liver Disease

“…Despite several purported advantages, it is not widely accepted by the transplant community due to the technical complexity of the procedure, higher risk of technical complications, and concern of longterm graft atrophy due to portal steal . APOLT has a wider acceptance in acute liver failure (ALF), where it acts as a bridge to native liver regeneration, with a possibility of becoming immunosuppression free …”