大西 康晴

BACKGROUND: Graft inflow modulation (GIM) during adult-to-adult living donor liver transplantation (LDLT) is a common strategy to avoid small-for-size syndrome, and some transplant surgeons attempt small size graft strategy with frequent GIM procedures, which are mostly performed by splenectomy, in LDLT. However, splenectomy can cause serious complications such as portal vein thrombosis and overwhelming postsplenectomy infection. METHODS: Forty-eight adult-to-adult LDLT recipients were enrolled in this study and retrospectively reviewed. We applied the graft selection criteria, which routinely fulfill graft-to-recipient weight ratio ≥ 0.8%, and consider GIM as a backup strategy for high portal venous pressure (PVP). RESULTS: In our current strategy of LDLT, splenectomy was performed mostly due to hepatitis C and splenic arterial aneurysms, but splenectomy for GIM was intended to only one patient (2.1%). The final PVP values ≤ 20 mmHg were achieved in all recipients, and no significant difference was observed in patient survival or postoperative clinical course based on whether splenectomy was performed or not. However, 6 of 18 patients with splenectomy (33.3%) developed postsplenectomy portal vein thrombosis (PVT), while none of the 30 patients without splenectomy developed PVT after LDLT. Splenectomy was identified as a risk factor of PVT in this study (P < 0.001). Our study revealed that a lower final PVP could be risk factor of postsplenectomy PVT. CONCLUSIONS: Using sufficient size grafts was one of the direct solutions to control PVP, and allowed GIM to be reserved as a backup procedure. Splenectomy should be avoided as much as possible during LDLT because splenectomy was found to be a definite risk factor of PVT. In splenectomy cases with a lower final PVP, a close follow-up is required for early detection and treatment of PVT.

Early relaparotomy of adult recipients after living donor liver transplantation (LDLT) is significantly associated with poor prognosis. However, there are few reports focusing on pediatric recipients after LDLT. The aim of this study is to clarify the causes and outcomes of early relaparotomy after pediatric LDLT. A total of 265 pediatric recipients (272 LDLTs) transplanted from May 2001 to October 2015 were retrospectively analyzed. Early relaparotomy was defined as surgical intervention performed within 3 months after LDLT. Early relaparotomy was performed 49 times for 33 recipients (12.5%). The recipient and graft survival rates in the early relaparotomy group were significantly lower than those in the nonearly relaparotomy group, respectively (75.0% and 63.6% versus 96.6% and 95.8%; both P < 0.001). Left lateral segment grafts were used significantly more frequently in the nonrelaparotomy group (P = 0.01). According to the multivariate analysis, the preoperative Pediatric End-Stage Liver Disease (PELD)/Model for End-Stage Liver Disease (MELD) score of the early relaparotomy group was significantly higher than that of the nonearly relaparotomy group (13.7 versus 6.3; P = 0.04). According to the receiver operating characteristic curve, the preoperative PELD/MELD score cutoff point was 17.2. Early relaparotomy due to infectious causes led to significantly poorer graft survival than that due to noninfectious causes (P = 0.04). In conclusion, the recipient and graft survival rates of the early relaparotomy group were significantly lower than those of the nonearly relaparotomy group. A high preoperative PELD/MELD score was a risk factor for early relaparotomy. In particular, early relaparotomy due to infection showed a poor prognosis.

BACKGROUND: We present a retrospective analysis of our experience with pediatric liver transplantation (LT), focusing on the long-term outcome of percutaneous transhepatic biliary drainage (PTBD) for post-transplant biliary strictures. METHODS: Fifty-three PTBDs were performed for 41 pediatric recipients with biliary strictures. The median ages at LT and PTBD were 1.4 and 4.4 years, respectively. The median observation period was 10.6 years. RESULTS: Post-transplant biliary strictures comprised anastomotic stricture (AS) in 28 cases, nonanastomotic stricture (NAS) in 12, anastomotic obstruction (AO) in 8, and nonanastomotic obstruction (NAO) in 5. The success rate of PTBD was 90.6%, and the 15-year primary patency rate of PTBD was 52.6%. The recurrence rate of biliary strictures after PTBD was 18.8% (9/48), and among the four NAS cases with recurrence, two underwent re-LT. The biliary obstruction rate was 27.1% (13/48). Among the eight cases with AO, five underwent the rendezvous method and three underwent surgical re-anastomosis. Among the five cases with NAO, one underwent re-LT. The recipient survival rate of PTBD treatment was 100%. CONCLUSIONS: The graft prognosis of AS by PTBD treatment is good and AO is curable by the rendezvous method and surgical re-anastomosis. However, the graft prognosis of NAS and NAO is poor.

BACKGROUND: Intracranial and pulmonary vascular anomalies are well-known complications and causes of mortality in AGS; however, visceral artery anomalies are less commonly recognized. Herein, we present a retrospective analysis of our experience with pediatric LDLT that focuses on the current problems with and treatments for visceral artery anomalies in AGS after LDLT. METHODS: Between May 2001 and December 2017, 294 LDLTs were performed for 285 pediatric recipients. Of these, 13 LDLTs (4.4%) for 12 AGS patients were performed. We classified the visceral artery anomalies into aneurysms and stenosis. RESULTS: The overall incidence of visceral aneurysm was 2 of 12 recipients (16.7%) and included a SMA aneurysm in one patient and an IPDA aneurysm with a subsequent SPA aneurysm in one patient; the ages of the diagnosis of visceral aneurysm were 16.3, 21.1, and 21.7 y, respectively. An endovascular treatment was performed for a progressive IPDA saccular aneurysm (12.0 × 14.5 × 15.0 mm). The overall incidence of visceral artery stenosis was 7 of 12 recipients (58.3%) and the median age at the diagnosis of visceral artery stenosis was 15.5 y (range 1.7-22.9 y). All 3 AGS patients with RA stenosis suffered from renal dysfunction (eGFR of 51, 78, and 51 mL/min/1.73m2 ). CONCLUSION: The morbidity of visceral artery anomalies is not negligible. The performance of periodic imaging examinations is necessary, even for infants, because it is difficult to detect visceral vascular anomalies in the infant stage.

BACKGROUND: Serial monitoring of Epstein-Barr virus (EBV) reveals that certain pediatric liver transplant (LT) recipients exhibit high EBV loads for long periods. We investigated the incidence and risk factors of chronic high EBV (CHEBV) loads (continuous EBV DNA >10 000 IU/mL of whole blood for ≥6 months) and long-term outcomes. METHODS: This single center, retrospective observational study investigated pediatric LT recipients who survived ≥6 months. We quantitated EBV DNA weekly during hospitalization and subsequently every 4 or 6 weeks at the outpatient clinic. Tacrolimus was maintained at a low trough level (<3 ng/mL, EBV DNA load >5000 IU/mL). RESULTS: Thirty-one of 77 LT recipients developed CHEBV. Univariate analysis revealed that age <2 years and body weight <10 kg upon LT, operation time <700 minutes, warm ischemia time (WIT) >35 minutes, graft-to-recipient weight ratio (GRWR) >2.7%, and preoperative EBV seronegativity were significantly associated with the development of CHEBV loads. Multivariate analysis identified significant associations of CHEBV with WIT >35 minutes, GRWR >2.7%, and preoperative seronegative. None of the recipients developed post-transplantation lymphoproliferative disorder. Survival rates of patients with and without CHEBV loads were not significantly different. CONCLUSIONS: A significant number of pediatric LT recipients developed CHEBV loads. Long WIT, high GRWR, and preoperative EBV seronegativity were significantly associated with the development of CHEBV loads. Although the long-term outcomes of patients with or without CHEBV loads were not significantly different, further studies of more subjects are warranted.

We herein report a case of lung metastases with unusual radiological appearances that mimicked those of chronic airway infection, causing diagnostic difficulty. A 60-year-old woman who underwent liver transplantation from a living donor was incidentally diagnosed with bile duct adenocarcinoma after a histopathological analysis of her explanted liver. Six months later, chest computed tomography (CT) revealed bilateral bronchogenic dissemination that had gradually worsened, suggesting chronic airway infection. A biopsy with bronchoscopy from a mass lesion beyond a segmental bronchus revealed adenocarcinoma identical to that of her bile duct adenocarcinoma, leading to the diagnosis of multiple lung metastases from bile duct adenocarcinoma.

INSTRUCTION: Organ transplantation from a brain death donor on mechanical circulatory support is rare. We report a case in which a brain death donor, supported by a left ventricular assist device (LVAD), unexpectedly displayed significant congestive fibrosis of the liver. PRESENTATION OF CASE: The potential organ donor was diagnosed 23 years previously as having dilated-phase of hypertrophic cardiomyopathy. He had undergone implantation of an LVAD as a bridge to heart transplantation. Laboratory tests and imaging studies performed during the follow-up for his cardiac disease and donor evaluation confirmed that he was suitable for donation of liver. During organ procurement, special attention was paid to preserving LVAD and its device's drive lines and the exposure of the surgical fields was restricted by those devices. Thoracotomy and laparotomy were performed, and the aorta and inferior vena cava were encircled successfully. The gross appearance of liver, however, suggested significant fibrosis. Therefore, the decision was made not to use this liver. Subsequent trichrome-stained permanent sections revealed advanced fibrosis (stage F3-4). DISCUSSION: As previously reported, organ procurement from donors with LVAD was thought to be demanding procedure because of the limited exposure of surgical field. In addition, it would be difficult to predict severe liver fibrosis in patients with an LVAD without a pathological examination. CONCLUSION: Donors with mechanical circulatory support systems can be candidate to expand the donor pool, but technical difficulty should be expected owing limited exposure during the donor operation. For liver transplantation, subclinical advanced liver fibrosis should be noted.

BACKGROUND Around 20-30% of patients who undergo liver transplantation (LT) for alcoholic liver disease (ALD) will resume heavy drinking after LT. It is crucial to control post-transplant relapse of alcohol use, because alcoholic recidivism has been shown to have a negative impact on post-transplant compliance and long-term outcomes of LT recipients. However, there is currently no specific, effective psychiatric intervention for preventing additional alcohol consumption in clinical practice. CASE REPORT We present 3 patients who underwent LT for ALD at Nagoya University Hospital who were followed up for prolonged periods (7.2, 8.8, and 11.3 years, respectively), and review the psychiatric interventions employed to address critical situations. Additional alcohol consumption was noted in Case 1, but prompt collaborative care led to stable abstinence. In Case 2, marked anger and irritation were exacerbated as a result of work, but the anger was controlled by anger management. Case 3 abused a minor tranquilizer, but limit-setting resulted in adequate medical adherence. CONCLUSIONS Transplant teams need to provide comprehensive treatment for alcoholic recidivism to improve long-term health after LT for ALD.

BACKGROUND We reported a strategy of thrombophilia testing-guided venous thromboembolic events (VTE) prophylaxis for living donors of liver transplantation in 2011. The aim of the present study was to evaluate the safety and efficacy of this protocol for VTE prophylaxis. MATERIAL AND METHODS Thrombophilia testing, including protein S (PS), protein C (PC), antithrombin (AT) III, and anti-phospholipid antibody (APLA), was performed in 306 living donor candidates between July 2005 and June 2016. Donors who met any of the criteria of PS <60%, PC <64%, AT-III <70%, and positive APLA were classified into the borderline group and received continuous venous infusion of heparin immediately after surgery, in addition to use of elastic stockings and intermittent pneumatic compression (IPC) until patients were ambulatory. Other donors who were classified into the normal group used elastic stockings and IPC with no anticoagulants. The efficacy and safety endpoints were VTE occurrence and bleeding events, respectively. RESULTS PS was considerably decreased in 3 candidates and PC was considerably reduced in 1 candidate, and they were excluded for high risk of VTE. Seventeen candidates in the borderline group and 137 in the normal group underwent donor surgery. One donor in the borderline group developed a wound hematoma. Postoperative complications were similar between the 2 groups. None of the donors in either group developed VTE. CONCLUSIONS Thrombophilia testing-guided VTE prophylaxis is safe and may contribute to reduced VTE risk in donors, although further investigations are warranted to assess the necessity of thrombophilia testing prior to surgery among living donors.

AIM: To investigate factors, including psychosocial factors, associated with alcoholic use relapse after liver transplantation (LT) for alcoholic liver disease (ALD). METHODS: The clinical records of 102 patients with ALD who were referred to Nagoya University Hospital for LT between May 2003 and March 2015 were retrospectively evaluated. History of alcohol intake was obtained from their clinical records and scored according to the High-Risk Alcoholism Relapse scale, which includes duration of heavy drinking, types and amount of alcohol usually consumed, and previous inpatient treatment history for alcoholism. All patients were assessed for eligibility for LT according to comprehensive criteria, including Child-Pugh score, Model for End-Stage Liver Disease score, and psychosocial criteria. RESULTS: Of the 102 patients with ALD referred for LT, seven (6.9%) underwent LT. One (14.3%) of these seven patients returned to heavy drinking, but that patient was able to successfully quit drinking following an immediate intervention, consisting of psychotherapeutic education and supportive psychotherapy, by a psychiatrist. A comparison between the transplantation/registration (T/R) group, consisting of the seven patients who underwent LT and 10 patients listed for deceased donor LT, and 50 patients who did not undergo LT and were not listed for deceased donor LT (non-T/R group), showed statistically significant differences in duration of abstinence period (P < 0.01), duration of heavy drinking (P < 0.05), adherence to medical treatment (P < 0.01), and declaration of abstinence (P < 0.05). CONCLUSION: Patients with ALD referred for LT require comprehensive evaluation, including evaluation of psychosocial criteria, to prevent alcoholic recidivism.

Advanced liver cirrhosis is usually accompanied by portal hypertension. Long-term portal hypertension results in various vascular alterations. The systemic hemodynamic state in patients with cirrhosis is termed a hyperdynamic state. This peculiar hemodynamic state is characterized by an expanded blood volume, high cardiac output, and low total peripheral resistance. Vascular alterations do not disappear even long after liver transplantation (LT), and recipients with cirrhosis exhibit a persistent systemic hyperdynamic state even after LT. Stability of optimal systemic hemodynamics is indispensable for adequate portal venous flow (PVF) and successful LT, and reliable parameters for optimal systemic hemodynamics and adequate PVF are required. Even a subtle disorder in systemic hemodynamics is precisely indicated by the balance between cardiac output and blood volume. The indocyanine green (ICG) kinetics reflect the patient's functional hepatocytes and effective PVF, and PVF is a major determinant of the ICG elimination constant (kICG) in the well-preserved allograft. The kICG value is useful to set the optimal PVF during living-donor LT and to evaluate adequate PVF after LT. Perioperative management has a large influence on the postoperative course and outcome; therefore, key points and unexpected pitfalls for intensive management are herein summarized. Transplant physicians should fully understand the peculiar systemic hemodynamic behavior in LT recipients with cirrhosis and recognize the critical importance of PVF after LT.

BACKGROUND Hepatitis C recurrence is a serious matter after liver transplantation (LT). Approximately 10% of hepatitis C virus (HCV) positive recipients develop fibrosing cholestatic hepatitis (FCH). FCH rapidly results in graft loss. Currently, direct-acting antivirals (DAAs) are effective and safe for hepatitis C, even after LT. However, only a few cases of successfully treated FCH after LT have been reported. We present FCH in a complicated case with sepsis and portal flow obstruction after LT. CASE REPORT A 66-year-old man underwent cadaveric LT. Liver function disorders were observed from post-operative day (POD) 22. Sepsis repeated on POD 38, 74, and 101. Steroid pulse therapy was given from POD 40 to 54. The infectious focus was surgically removed on POD 89. Interventional radiology for portal venous obstruction was completed on POD 96. To make a real-time diagnosis and to investigate the graft condition, repeat liver needle biopsies (LNBs) were taken. Although there was a combined impact of sepsis, portal flow decrease, and recurrent hepatitis C on graft failure, it was interesting that recurrent hepatitis C was consistently detectable from the first LNB. HCV-ribonucleic acid increased on POD 68. Liver function disorders peaked on POD 71 and 72. Jaundice peaked on POD 82. DAA induction was regrettably delayed because of a reluctance to introduce DAAs under conditions of graft dysfunction. DAAs were administered after hospital discharge. CONCLUSIONS A real-time and precise diagnosis based on histopathological examination and viral measurement is important for FCH treatment. Well-considered therapy with DAAs should be aggressively introduced for potentially fatal FCH after LT.

PURPOSE: Development of renal dysfunction, including acute kidney injury (AKI) and chronic kidney disease (CKD), after liver transplantation (LT) remains a critical issue adversely affecting patient survival in both the short and long term. Previous reports have suggested that inflammatory and antiinflammatory cytokines and their functionally relevant gene polymorphisms may play critical roles in the development of AKI and CKD. However, the involvement of these cytokines and their gene polymorphisms in renal deterioration following LT remains unclear. METHODS: We examined 62 recipients who underwent LT at Nagoya University between 2004 and 2009 and who had survived for at least 1 year. The following gene polymorphisms in recipients were analyzed: tumor necrosis factor-A (TNFA) T-1031C, interleukin-2 (IL2) T-330G, IL10 C-819T, IL13 C-1111T, transforming growth factor-B (TGFB) T29C, and IL4 T-33C. RESULTS: Thirteen patients (21 %) developed AKI within 4 weeks after LT. Of the investigated gene polymorphisms, the IL4 -33 T/T genotype was significantly associated with higher incidence of AKI compared with the other two genotypes [hazard ratio (HR) = 5.48, 95 % confidence interval (CI) 1.18-25.52, p = 0.03]. On the other hand, 16 patients (26 %) had developed CKD at median follow-up of 9.2 years after LT. We showed the lack of association between investigated gene polymorphisms in recipients and CKD development. CONCLUSIONS: The IL4 -33 T/T genotype might be a risk factor for AKI in LT, and this might contribute to earlier withdrawal of immunosuppressive agents to minimize renal toxicity. In contrast, none of the investigated cytokine gene polymorphisms were associated with CKD.

BACKGROUND Prolonged-release tacrolimus (Tac QD) is widely used in organ transplantation. However, the conversion from twice-daily tacrolimus (Tac BID) to Tac QD in Japan is usually done in stable patients months or years after liver transplantation. The aim of this study was to assess the early conversion of Tac QD during liver transplant hospital stay. MATERIAL AND METHODS Eighteen liver transplants (excluding pediatric) were performed during 2014-2015. All cases except 2 early-expired patients were enrolled. Our standard immunosuppression is oral Tac BID and steroid taper, and we add mycophenolate mofetil if indicated. Conversion criteria from Tac BID to Tac QD were: 1) relatively stable liver function with stable trough level by oral Tac BID, and 2) good general condition (no or well-controlled complications). We did not fix the exact conversion date because each patient's recovery was different. Dose conversion rate from Tac BID to Tac QD was set at 1:1. RESULTS The median number of conversion days after liver transplant was 27 days. Sixty-two percent of patients were converted within 4 weeks after liver transplant, and 56% were discharged from the hospital within 2 weeks after conversion. The comparison of the last week of Tac BID and the first week of Tac QD revealed that the mean tacrolimus trough level declined by 30.4%, resulting in the 26.2% tacrolimus dose increase during the first 2 weeks after conversion. Adverse events after conversion were limited, and all patients show normal liver function to date. CONCLUSIONS Early Tac QD conversion is safe and feasible, but its long-term effects need further investigation.

BACKGROUND: Cytomegalovirus (CMV) remains a major cause of morbidity and mortality for liver transplant recipients. Although the CMV pp65 antigenemia (AG) assay has been widely used to monitor patients for CMV infection after liver transplantation, real-time PCR is becoming the standard procedure. The World Health Organization (WHO) International Reference Standard for CMV quantification has become available to standardize values diagnostic of CMV infection. MATERIAL AND METHODS: Our in-house real-time PCR assay was standardized using the WHO standard reagents. Levels of CMV DNA in 1339 blood samples obtained from 190 liver transplant recipients were quantified and expressed in international units, and results were then compared with those of the CMV pp65 AG assay performed on the same blood samples. Correlation was assessed and receiver operating characteristic curves were analyzed to determine the optimal cut-off value for CMV DNA (IU/mL) PCR results. RESULTS: Significant correlation was found between results of the 2 assay methods (p<0.001, r=0.715); a PCR result of ≥288 IU/mL predicted a positive result by the CMV AG assay (1 positive cells/150 000 leukocytes) with a sensitivity of 67.4% and specificity of 94.8%. CONCLUSIONS: To the best of our knowledge, this is the first report to compare CMV AG and real-time PCR (calibrated to the WHO standard) results in a large number of recipients after liver transplantation. Use of this technique may provide useful information for the management of CMV infection.

Hepatitis C recurrence continues to present a major challenge in liver transplantation (LT). Approximately 10% of hepatitis C virus (HCV)-positive recipients will develop fibrosing cholestatic hepatitis (FCH) after LT. FCH is clinically characterized as marked jaundice with cholestatic hepatic dysfunction and high titers of viremia. Pathologically, FCH manifests as marked hepatocyte swelling, cholestasis, periportal peritrabecular fibrosis and only mild inflammation. This progressive form usually involves acute liver failure, and rapidly results in graft loss. A real-time and precise diagnosis based on histopathological examination and viral measurement is indispensable for the adequate treatment of FCH. Typical pathological findings of FCH are shown. Currently, carefully selected combinations of direct-acting antivirals (DAAs) offer the potential for highly effective and safe regimens for hepatitis C, both in the pre-and post-transplant settings. Here, we review FCH caused by HCV in LT recipients, and current strategies for sustained virological responses after LT. Only a few cases of successfully treated FCH C after LT by DAAs have been reported. The diagnostic findings and therapeutic dilemma are discussed based on a literature review.

INSTRUCTION: Inferior vena cava (IVC) thrombosis can be a life-threatening complication after liver transplantation (LT). Although this complication is usually related to technical problems associated with vascular anastomosis, we report a case of IVC thrombosis which developed from a ligated large mesenteric-caval shunt. PRESENTATION OF CASE: A 35-year-old man underwent LT from a brain-dead donor for primary sclerosing cholangitis. Enhanced computed tomography (CT) before LT showed a huge collateral vessel of the inferior mesenteric vein (IMV) draining into the infra-renal IVC directly. To obtain sufficient portal vein (PV) flow, the dilated IMV collateral was ligated. A routine Doppler ultrasound study on post-operative day 1 showed thrombus inside the infra-hepatic IVC. Enhanced CT showed that this thrombus originated from a ligated collateral vessel of the IMV and extended into the IVC. He was hemodynamically stable and liver function was consistently stable. The size of IVC thrombus slowly reduced and he is currently in good condition without any symptoms. DISCUSSION: To obtain adequate PV flow, ligation of a major PSS at the time of LT has been suggested. However, where it should be occluded has not been discussed. We should occlude a mesenteric-caval shunt not only at the upper side, but at the IVC side, based on findings from the current case. CONCLUSION: To obtain appropriate PV flow toward a liver graft, occlusion of portosystemic shunts during LT is recommended. However, the position of ligation should be carefully considered to avoid extension of thrombus to major vessels.

UNLABELLED: Despite of recent development of imaging modalities, congenital intrahepatic portosystemic shunt (IPSS) is rarely diagnosed. Therefore, living donor liver transplantation using a liver graft with IPSS has not been previously published. MATERIALS AND METHODS: We report a 28-year-old male patient with end-stage liver disease secondary to Wilson disease. His 26-year-old brother was a potential living donor, who had an IPSS of 25 mm in diameter at segment 6 as shown by computed tomography. Liver function tests were normal, and blood ammonia concentration was in the upper limit of normal. RESULTS: Living donor liver transplantation was uneventfully performed. After surgery, a recipient liver function tests showed a quick recovery, and serum ammonia levels were consistently normal. Although thrombosis inside the IPSS was confirmed by computed tomography on postoperative day 21, this thrombosis disappeared at 3 months posttransplant with anticoagulants. Currently (12 months posttransplant), the patient has fully recovered, and the IPSS is still the same size. CONCLUSIONS: Based on our experience, liver allografts with IPSS can be accepted as potential liver allografts.

Background: Liver transplantation recipients are at high risk for severe complications due to infections because of being treated with immunosuppressive drugs that affect the immune system. Vaccination for liver transplantation candidates is generally recommended before surgery, but the opportunities for vaccination prior to transplantation in pediatric candidates are often limited by severe disease conditions.Methods: The participants in this study comprised 39 pediatric recipients of living donor liver transplantation performed between 2005 and 2013. Criteria for administering live-attenuated (measles, rubella, mumps, and varicella) and inactivated (hepatitis B, pertussis, and Japanese encephalitis) vaccines were as follows; (1) >1 year after transplantation; (2) no use of systemic steroids to treat acute rejection within the last 6 months; (3) serum trough concentration of tacrolimus <5 ng/mL; (4) no severe immunosuppression according to blood examinations; and (5) provision of written informed consent. Median age at transplantation was 17 months, and median period from transplantation to the beginning of immunization was 18 months.Results: Seroprotection rates for measles, rubella, mumps, varicella, hepatitis B, pertussis, and Japanese encephalitis after post-transplant immunization were 44% (11/25), 70% (19/27), 48% (12/25), 32% (6/19), 83% (19/23), 87% (13/15), and 88% (7/8), respectively. Seroprotection rates for measles, rubella, mumps, and varicella after second vaccination for recipients with primary vaccine failure after first vaccination were 100% (8/8), 50% (1/2), 71% (5/7), and 50% (5/10), respectively. While four recipients contracted mumps and eight contracted varicella before immunization, one recipient developed varicella after immunization. No serious systemic adverse events were observed in vaccinated recipients.Conclusions: Seroprotection rates for measles, mumps, and varicella appeared low in children after the first post-transplantation vaccination. Immunizations with four live-attenuated and three inactivated vaccines were safe and effective for pediatric liver transplantation recipients who were not severely immunosuppressed. (C) 2015 Published by Elsevier Ltd.

INTRODUCTION: Hepatic hemangioma is one of the most common benign liver tumors. There are few published reports regarding liver transplantation using liver allografts with hemangioma. PRESENTATION OF CASE: A 45-year-old man was evaluated as a living donor for 19-year-old son with cirrhosis due to hepatic fibrosis. Preoperative investigations revealed 20 and 7mm hemangiomas, at segment 2 (S2) and 4 (S4) respectively. Considering the anatomical relation of S2 hemangioma and Glisson 2, liver graft was designed as left lobe excluded S2 hemangioma by partial resection. Estimated graft recipient weight ratio (GRWR) even after partial resection of hemangioma was reasonable. During the donor operation, a partial hepatic resection of S2 hemangioma was performed. Intraoperative pathologic findings revealed a cavernous hemangioma, and then, the left hepatic graft with the caudate lobe was harvested. Actual GRWR was 0.90%. Donor's postoperative course was uneventful. Recipient's post-operative course was almost uneventful. Postoperative computed tomography of the recipient showed the graft regeneration without increase or recurrence of hemangioma. DISCUSSION: Organ shortage is a major concern in the field of liver transplantation. A novel donor source with a further option is extremely crucial for a guarantee of liver transplantation. We experienced the first case of adult-to-adult living donor liver transplantation using liver allograft after the resection of hemangioma. CONCLUSION: We advocate that the use of liver allograft with hemangiomas in adult-to-adult LDLT settings can be remarkable strategy to reduce the problem of organ shortage without any unfavorable consequences in both living donor and recipient.

The combination of nucleos(t)ide analogues (NAs) and hepatitis B immune globulin has been established as safe and effective prophylaxis against hepatitis B virus (HBV) reactivation after liver transplantation (LT). However, the essential weak point of this regimen is its high cost. The hepatitis B (HB) vaccine is an attractive alternative that costs less, and it enables some patients to have sufficiently high hepatitis B surface antibody (HBsAb) titers. Almost no data exist on whether NAs can be stopped safely in such successfully vaccinated patients. We investigated the incidence of HB vaccine escape mutants in liver recipients who had sufficient HBsAb titers after LT and stopped NAs. Among 18 HBV carriers and 7 non-HBV patients who received grafts from hepatitis B core antibody-positive donors, 2 HBV carriers and 6 non-HBV patients who achieved HBsAb titers >100 IU/L for >3 months after posttransplant vaccination were weaned from NAs. For the patients who showed viremia, we analyzed amino acid sequences of the HB envelope protein, and we performed a statistical analysis for the factors associated with viremia. In 4 of the 8 patients who achieved sufficient HBsAb levels after vaccination and stopped NAs, HBV DNA appeared after a median of 12 months. A sequence analysis showed various amino acid mutations, including the a-determinant, in the HB envelope region. Frequent vaccination was shown to be a statistically significant risk factor for inducing viremia. In conclusion, although the HB vaccine is an effective substitute for prophylaxis against HBV reactivation in some patients after LT, frequent vaccination could be a risk factor for producing escape mutants. Our data demonstrate not only that caution must be exercised in stopping NAs in effectively vaccinated patients (especially in patients vaccinated frequently) but also that it is important to set stopping rules for vaccination in transplant patients.

The availability of a regional team may facilitate the organization and coordination of organ procurement. As a result, regional organ procurement has been reported to reduce costs, streamline logistics, and increase safety for the teams. We herein report a case of brain-dead donor liver transplantation with regional organ procurement. Because of the collaboration between the transplant team and the donor surgery team, the latter being was comprised of a liver transplant team in the local area of the donor hospital, a smooth brain-dead donor liver transplantation was successfully performed. Regional organ procurement is considered achievable in the future with the standardization of organ procurement by the establishment of an educational system for donor surgery.