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Advances in liver transplantation allocation systems

World Journal of Gastroenterology 2016年第10期22卷 2922-2930页

作者： michael l schilsky Maryam Moini Departments of Medicine (Digestive Diseases) and Surgery (Transplantation and Immunology) Yale University Medical Center Gastroenterohepatology Research Center Shiraz University of Medical Sciences

With the growing number of patients in need of liver transplantation, there is a need for adopting new and modifying existing allocation policies that prioritize patients for liver transplantation. Policy should ensure fair allocation that is reproducible and strongly predictive of best pre and post transplant outcomes while taking into account the natural history of the potential recipients liver disease and its complications. There is wide acceptance for allocation policies based on urgency in which the sickest patients on the waiting list with the highest risk of mortality receive priority. Model for end-stage liver disease and Child-Turcotte-Pugh scoring system, the two most universally applicable systems are used in urgencybased prioritization. However, other factors must be considered to achieve optimal allocation. Factors affecting pre-transplant patient survival and the quality of the donor organ also affect outcome. The optimal system should have allocation prioritization that accounts for both urgency and transplant outcome. We reviewed past and current liver allocation systems with the aim of generating further discussion about improvement of current policies.

关键词： liver Transplantation Allocation Model for end-stage liver disease

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De-novo hepatocellular carcinoma after pediatric living donor liver transplantation

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World Journal of Hepatology 2017年第36期9卷 1361-1366页

作者： Samuel Torres-landa Armando Salim Munoz-Abraham Brett E Fortune Ananta Gurung Jeffrey Pollak Sukru H Emre Manuel I Rodriguez-Davalos michael l schilsky Department of Gastrointestinal Surgery Hospital of the University of Pennsylvania Department of Surgery Yale University School of Medicine Division of Gastroenterology and Hepatology Weill Cornell Medicine Department of Pathology Royal Columbian Hospital Department of Radiology and Biomedical Imaging Yale University School of Medicine Division of Digestive Diseases and Transplant and Immunology Department of Medicine and Surgery Yale University School of Medicine

De-novo malignancies carry an incidence ranging between 3%-26% after transplant and account for the second highest cause of post-transplant mortality behind cardiovascular disease. While the majority of de-novo malignancies after transplant usually consist of skin cancers, there has been an increasing rate of solid tumor cancers over the last 15 years. Although, recurrence of hepatocellular carcinoma(HCC) is well understood among patients transplanted for HCC, there are increasing reports of de-novo HCC in those transplanted for a non-HCC indication. The proposed pathophysiology for these cases has been mainly connected to the presence of advanced graft fibrosis or cirrhosis and always associated with the presence of hepatitis B or C virus. We report the first known case of de-novo HCC in a recipient, 14 years after a pediatric living related donor liver transplantation for end-stage liver disease due to biliary atresia without the presence of hepatitis B or C virus before and after transplant. We present this case report to increase the awareness of this phenomenon and address on the utility for screening and surveillance of hepatocellular carcinoma among these individuals. One recommendation is to use similar guidelines for screening, diagnosis, and treatment for HCC as those used for primary HCC in the pre-transplant patient, focusing on those recipients who have advanced fibrosis in the allograft, regardless of etiology.

关键词： liver transplantation De-novo hepatocellular carcinoma living donor liver transplantation Biliary atresia

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Review on immunosuppression in liver transplantation

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World Journal of Hepatology 2015年第10期7卷 1355-1368页

作者： Maryam Moini michael l schilsky Eric M Tichy Gastroenterohepatology Research Center Shiraz University of Medical SciencesNemazee Hospital Departments of Medicine (Digestive Diseases) and Surgery (Transplantation and Immunology) Yale University Medical Center Department of Pharmacy Yale-New Haven Hospital

The optimal level of immunosuppression in solid organ transplantation,in particular for the liver,is a delicate balance between the benefit of preventing rejection and the adverse side effects of immunosuppression. There is uncertainty about when this level is achieved in any individual recipient. Immunosuppression regimens vary between individual centers and changes with time asnew agents and data are available. Presently concerns about the adverse side effects of calcineurin inhibitor,the main class of immunosuppressive agents used in liver transplantation(lT),has led to consideration of the use of antibody induction therapies for patients at higher risk of developing adverse side effects. The longevity of the transplanted organ is potentially improved by better management of rejection episodes and special consideration for tailoring of immunosuppression to the individual with viral hepatitis C,hepatocellular carcinoma or pregnancy. This review provides an overview of the current strategies for post lT immunosuppression and discusses modifications to consider for special patient populations.

关键词： liver transplantation Immunosuppression Immunosuppression induction Immunosuppressionmaintenance

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Host factors are dominant in the development of post-liver transplant non-alcoholic steatohepatitis

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World Journal of Hepatology 2016年第15期8卷 659-664页

作者： Salih Boga Armando Salim Munoz-Abraham Manuel I Rodriguez-Davalos Sukru H Emre Dhanpat Jain michael l schilsky Division of Digestive Diseases Section of Transplantation and Immunology Department of Medicine and Surgery Yale University School of Medicine Department of Surgery Section of Transplantation and Immunology Yale-New Haven Transplantation Center Yale University School of Medicine Department of Pathology Yale University School of Medicine

Non-alcoholic fatty liver disease(NAFlD) is a recognized problem in patients after orthotopic liver transplantation and may lead to recurrent graft injury. As the increased demand for liver allografts fail to match the available supply of donor organs, split liver transplantation(SlT) has emerged as an important technique to increase the supply of liver grafts. SlT allows two transplants to occur from one donor organ, and provides a unique model for observing the pathogenesis of NAFlD with respect to the role of recipient environmental and genetic factors. Here we report on two recipients of a SlT from the same deceased donor where only one developed non-alcoholic steatohepatitis(NASH), suggesting that host factors are critical for the development of NASH.

关键词： liver Split graft Steatohepatitis Host factors Transplant

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