LR represents a well-established therapy for HCC on cirrhosis. It remains one of the fundamentals in the multidisciplinary approach to this tumor and should be considered as the first option for patients with preserved hepatic function and limited disease. Today, LR should offer a surgical death rate of less than 1.5%, a 5-year survival rate of approximately 50%, and a 5-year tumor-free survival rate of 28% when performed in specialized centers.

RFA has still to be confirmed as an alternative to surgery for potentially-resectable HCCs.

Older donors are a growing part of the total donor pool but no definite consensus exists on the limit of age for their acceptance. From November 1998 to January 2003, in a retrospective case-control multicenter study, we compared the outcome of 30 orthotopic liver transplantations (OLTs) with octogenarian donors and of 60 chronologically correlated OLTs performed with donors <40 years. The percentage of refusal was greater among older than younger donors (48.2 vs. 14.3%; p < 0.001). Cold ischemia was significantly shorter in the older than younger groups. Recipients with hepatocarcinoma and older age received octogenarian grafts more frequently. No differences were seen in post-operative complications and 6-month graft and patient survival. However, longterm survival was lower in patients transplanted with octogenarian donors (p = = 0.04). Interestingly, the mortality related to hepatitis C recurrence was greater in patients with octogenarian donors. Accordingly, the long-term survival of HCV-positive patients who received older grafts was lower than those receiving younger grafts (p = = 0.05). Octogenarian livers can be used safely but a careful donor evaluation and a short cold ischemia are required to prevent additional risk factors. However, hepatitis C recurrence is associated with a greater mortality in patients who received octogenarian grafts raising concerns whether to allocate these livers to HCV-positive recipients.

The aim of this study was to evaluate the incidence, radiographic appearance, time of onset, outcome and risk factors of non-infectious and infectious pulmonary complications following liver transplantation. Chest X-ray features of 300 consecutive patients who had undergone 333 liver transplants over an 11-year period were analysed: the type of pulmonary complication, the infecting pathogens and the mean time of their occurrence are described. The main risk factors for lung infections were quantified through univariate and multivariate statistical analysis. Non-infectious pulmonary abnormalities (atelectasis and/or pleural effusion: 86.7%) and pulmonary oedema (44.7%) appeared during the first postoperative week. Infectious pneumonia was observed in 13.7%, with a mortality of 36.6%. Bacterial and viral pneumonia made up the bulk of infections (63.4 and 29.3%, respectively) followed by fungal infiltrates (24.4 %). A fairly good correlation between radiological chest X-ray pattern, time of onset and the cultured microorganisms has been observed in all cases. In multivariate analysis, persistent non-infectious abnormalities and pulmonary oedema were identified as the major independent predictors of posttransplant pneumonia, followed by prolonged assisted mechanical ventilation and traditional caval anastomosis. A "pneumonia-risk score" was calculated: low-risk score ( < 2.25) predicts 2.7% of probability of the onset of infections compared with 28.7% of high-risk (> 3.30) population. The "pneumonia-risk score" identifies a specific group of patients in whom closer radiographic monitoring is recommended. In addition, a highly significant correlation (p < 0.001) was observed between pneumonia-risk score and the expected survival, thus confirming pulmonary infections as a major cause of death in OLT recipients.

H epatocellular carcinoma (HCC) is a frequent finding in patients with chronic liver disease listed for liver transplantation (LT). Tumor recurrence after transplantation involves an ominous prognosis and strict selection criteria of transplant candidates on the basis of tumor features developed to minimize its incidence, among which the most widely adopted are the so-called Milan criteria. 1 Although it is known that the pharmacologic immunosuppression required after transplantation can accelerate tumor growth, the possible influence of different immunosuppressive schedules on HCC recurrence after LT had been poorly investigated until recently. 2,3 In a previous report, we demonstrated a close relationship between the amount of cyclosporine (CsA), one of the most widely adopted immunosuppressant drugs, administered during the first postoperative year and tumor recurrence in patients who underwent LT for HCC. 4 The aim of the current study was (1) to further investigate the possible relationship between the type and the degree of immunosuppression as expressed by exposure to the main immunosuppressant drug and tumor recurrence in patients transplanted for HCC and (2) to identify possible strategies to avoid tumor recurrence.The influence of different schedules of immunosuppression and many clinical, pathologic, and histologic factors on HCC recurrence also were investigated with univariate and multivariate analysis.Abbreviations: HCC, hepatocellular carcinoma; LT, liver transplantation; CsA, cyclosporine; AUC, area under the curve; AFP, alpha-fetoprotein; ROC, receiver operating characteristic; pT, pathologic tumor staging; OR, odds ratio; 95% CI, 95% confidence interval.From the

The effect of orthotopic liver transplantation (OLT) on the systemic and splanchnic hemodynamic alterations of cirrhosis is still largely unknown. The aim of this study was to prospectively investigate the long-term changes induced by OLT on several hemodynamic parameters. In 28 patients undergoing OLT for cirrhosis, the following parameters were measured before surgery and subsequently at 6-month intervals (mean follow-up period, 17 months): cardiac index, mean arterial pressure (MAP), heart rate, total peripheral resistance (TPR), portal vein flow velocity and flow volume, spleen size, and Doppler ultrasound resistance or pulsatility indexes (RI or PI) in the: 1) interlobular renal, 2) superior mesenteric, 3) splenic, and 4) hepatic arteries. The same parameters were measured in 10 healthy controls. After OLT, cardiac index and heart rate significantly decreased (P F .01), while MAP and TPR increased (P F .001), so that any significant difference from controls disappeared. Renal RI progressively decreased, achieving a significant reduction (P F .05) to normal values at the 12th month of follow-up. Portal flow velocity and hepatic and splenic RI returned to values not significantly different from controls. Portal flow volume increased over normal values after OLT (P F .001), and SMA PI, lower than normal before OLT, did not show any statistically significant increase thereafter. Spleen size decreased significantly, but persisted to be larger than in controls. In conclusion, systemic, renal, and most, but interestingly not all, splanchnic circulatory alterations of cirrhosis are restored to normal after OLT. (HEPATOLOGY 1999;30:58-64.)Advanced cirrhosis is accompanied by a peculiar hemodynamic derangement, which has been traditionally included in the hyperkinetic circulatory syndromes. 1,2 This derangement is characterized by high cardiac output, low total peripheral resistance (TPR), mild tachycardia, and low/normal blood pressure, and by various alterations in the peripheral circulation. 2 Among the latter, the most important are those occurring in the renal and splanchnic vascular beds.There is evidence that elevated portal resistance and liver failure are responsible for triggering the circulatory alterations of cirrhosis. 2,3 However, while it is accepted that orthotopic liver transplantation (OLT) restores normal portal resistance and pressure and liver function, 4 conflicting data have been reported about the corresponding modification of the hyperkinetic circulation 5 : some authors found a persistence of elevated cardiac output, 6,7 whereas others found a decrease to normal values. 4,8 No definite explanation accounting for such discrepancy has been proposed until now. Thus, it is still unclear whether or not the cardiac hyperkinetic circulation persists after OLT.The renal circulation of cirrhotic patients is characterized by an arteriolar vasoconstriction, which is especially intense in ascitic patients. 9,10 The two most likely mechanisms inducing renal vasoconstriction in cirrhosis are hypothesized ...

Chronic hepatitis C represents a major clinical problem after liver transplantation, but factors influencing the recurrent disease have not been well characterized. We analyzed the clinical records of all the patients transplanted for hepatitis C virus (HW-related liver disease in our Center between 1991 and 1997. Eighty consecutive HCV-positive (+) patients (60 men, ages 28 to 64) survived more than 1 month after transplantation and were followed for a median of 45 months. Diagnosis of recurrent chronic hepatitis C was made in 38 patients (47.5%), of whom 22 had moderate/severe chronic hepatitis. Decompensated cirrhosis occurred in six patients (7.5%).N o difference in patient survival was found between patients with and without hepatitis C recurrence. N o association was found between recurrent hepatitis C and presumed risk factors. The method of tapering off corticosteroids was significantly associated with both hepatitis C recurrence and the severity of hepatitis. In patients receiving a higher daily prednisone dose, 12 months after transplantation, the proportion of recurrent hepatitis C was The aim of our study was to evaluate the clinical records of all patients who underwent transplantation in our single center during the last decade to outline the features of recurrent hepatitis C and, possibly, to identi!+ the risk factors eventually associated with the more severe forms of this disease. 35 Patients and Methods Patient PopulationBetween January, 1991 and December, 1997, 25 1 adult patients underwent OLT at the Department of Surgery and Transplantation, University of Bologna, ofwhom 97 received liver graft for end-stage liver disease secondary to HCV infection. Of these patients, 12 with a concomitant hepatitis B virus (HBV) infection, one with de novo HBV infection after OLT, and four who died within 30 days after surgery were excluded from the analysis. Therefore, our study population included 80 consecutive patients (60 men and 20 women, ages ranging from 28 to 64 years), who underwent transplatation for HCV-related liver disease, who survived more than 1 month after OLT, with well-established HCV infection (anti-HCV and HCV-RNA positivity by polymerase chain reaction) before and after after liver transplant, Clinical and laboratory data were available for the complete series of patients at the time of transplantation and subsequently.

Liver transplantation with preservation of the recipient vena cava (the "piggy-back" technique) has been proposed as an alternative to the traditional method. We performed a randomized study on 39 cirrhotic patients, 20 who underwent the piggy-back technique (group 1) and 19 the traditional method using venovenous bypass (group 2) to evaluate the feasibility and true advantages of the piggy-back technique compared to the traditional method. Two patients were switched to the conventional technique due to the presence of a caudate lobe embracing the vena cava in one patient and a caval lesion in the other. Statistically significant differences between the two groups were only found for the warm ischemia time (48.5 +/- 13 min for piggy-back vs 60 +/- 12 min for the conventional method) and for renal failure (zero cases in group 1 vs four cases in group 2). We therefore believe that liver transplantation with the piggy-back technique can easily be performed in almost all cases, and that only a few, specific situations, such as a very enlarged caudate lobe, do not justify its routine use.