Mehrotra Siddharth, Mehta Naimish, Rao Prashantha S, Lalwani Shailendra, Mangla Vivek, Nundy Samiran
Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India.
Indian J Gastroenterol. 2018 Jan;37(1):25-30. doi: 10.1007/s12664-017-0812-y. Epub 2018 Feb 17.
Acute liver failure (ALF) is an indication for emergency liver transplantation (LT). Although centers performing only deceased donor liver transplants (DDLT) have shown improved outcomes in this situation, they still have relatively long waiting lists. An alternative would be living donor liver transplantation (LDLT), which has shown equivalent outcomes in the elective situation but there is limited evidence of its results in ALF.
The purpose of this study was to assess the outcomes in patients with ALF undergoing emergency LDLT in our center in Delhi, India.
We prospectively collected data on 479 patients who underwent LT in our hospital between January 2009 and December 2015 to evaluate the outcomes of those with ALF. The ALF patients were listed for transplantation after they met the Kings' College criteria and rapid evaluation was done following a protocol consisting of three phases. Patients with grade III/IV encephalopathy were put on mechanical ventilation. Data regarding their postoperative course, morbidity, and mortality were analyzed.
Thirty-six (7.5%) out of the 479 patients underwent emergency LT for ALF. Their mean age was 27.5 years (range 4-59 years) and the male to female ratio of 2:3. Preoperative intubation was required in 15 of 25 patients who had encephalopathy. Wilson's disease was the most common cause of ALF in children while in adults, it was acute viral hepatitis. The time interval between listing and transplantation was a mean of 36 ± 12.4 h. The mean graft to recipient weight ratio (GRWR) was 1.06 ± 0.3. The recipients were extubated postoperatively after a mean period of 2.6 days and their mean ICU stay was 6.3 days. Postoperative infection was the most common complication and required upgradation of antifungal and antibiotic treatments. Neurological complications occurred in five patients. Thirty-one of 36 (86.1%) patients survived and progressive cerebral edema and sepsis were the most common causes of mortality. Patients who died had higher model for end-stage liver disease scores, longer cold ischemia time (CIT), and higher grades of encephalopathy (though 80% patients with encephalopathy survived). There was no donor mortality. At long-term follow up of a median of 56 months, 29 (80.5%) of 36 patients were still alive.
In our experience, LDLT is an alternative procedure to DDLT in patients with ALF and is associated with good outcomes even in patients with high grades of encephalopathy.
急性肝衰竭（ALF）是紧急肝移植（LT）的指征。尽管仅开展尸体供肝肝移植（DDLT）的中心在这种情况下已显示出改善的预后，但它们的等待名单仍然相对较长。另一种选择是活体供肝肝移植（LDLT），其在择期情况下已显示出相当的预后，但关于其在ALF中的结果的证据有限。
本研究的目的是评估在印度德里我们中心接受紧急LDLT的ALF患者的预后。
我们前瞻性收集了2009年1月至2015年12月期间在我院接受LT的479例患者的数据，以评估ALF患者的预后。ALF患者在符合国王学院标准后被列入移植名单，并按照包括三个阶段的方案进行快速评估。III/IV级脑病患者接受机械通气。分析了他们的术后病程、发病率和死亡率数据。
479例患者中有36例（7.5%）因ALF接受了紧急LT。他们的平均年龄为27.5岁（范围4 - 59岁），男女比例为2:3。25例脑病患者中有15例术前需要插管。威尔逊病是儿童ALF最常见的原因，而在成人中，是急性病毒性肝炎。列入名单至移植的时间间隔平均为36±12.4小时。平均移植物与受体重量比（GRWR）为1.06±0.3。受体术后平均2.6天后拔管，平均ICU住院时间为6.3天。术后感染是最常见的并发症，需要升级抗真菌和抗生素治疗。5例患者出现神经并发症。36例患者中有31例（86.1%）存活，进行性脑水肿和脓毒症是最常见的死亡原因。死亡患者的终末期肝病模型评分更高、冷缺血时间（CIT）更长、脑病分级更高（尽管80%的脑病患者存活）。没有供体死亡。在中位56个月的长期随访中，36例患者中有29例（80.5%）仍然存活。
根据我们的经验，LDLT是ALF患者替代DDLT的一种手术方法，即使在高分级脑病患者中也与良好的预后相关。
