Many subjects with cryptogenic cirrhosis have underlying nonalcoholic steatohepatitis (NASH). The natural history of NASH-related cryptogenic cirrhosis after orthotopic liver transplantation (OLT) is not well defined. A primarily retrospective study of patients with the clinical histological phenotype of NASH-related cirrhosis undergoing OLT was performed. Data were compared with 2 sets of age-and weight-matched controls with (1) primary biliary cirrhosis or primary sclerosing cholangitis or (2) alcoholic liver disease. After OLT, all patients were managed by a standard immunosuppressive protocol. Liver biopsies were performed at 6 and 12 months after OLT and at 1-to 2-year intervals thereafter, as well as when liver enzyme levels were elevated enough to warrant diagnostic biopsy. Twenty-seven subjects with cryptogenic cirrhosis and a clinical histological phenotype of NASH and 3 patients with a long-standing diagnosis of NASH before OLT were included. The 30-day perioperative mortality was 1 in 30 patients. During a median follow-up of 3.5 ؎ 2.7 years, 2 additional patients died of sepsis. There was a timedependent increase in the risk for allograft steatosis that approached 100% by 5 years compared with only an approximately 25% incidence of steatosis in the control groups (P < .009, log-rank test). On multivariate analysis, only the cumulative steroid dose correlated with time to development of allograft steatosis. Three patients developed histological progression from hepatic steatosis to steatohepatitis. Of these, 1 patient developed progressive fibrosis. Four patients experienced at least 1 episode of acute cellular rejection; however, no patient developed chronic rejection or graft failure. In conclusion, nonalcoholic fatty liver disease occurs frequently after OLT in patients with the phenotype of NASH-related cirrhosis.

The limited donor organ supply has led to several bridging techniques to sustain patients with acute and subacute liver failure. We report here the prospective, controlled trial of transplanted isolated fresh and cryopreserved human hepatocytes as a bridge to orthotopic liver transplantation. Five hepatocyte transplant recipients with grade IV encephalopathy and multisystem organ failure and four patients of equal illness severity due to liver failure were studied. Medical therapy resulted in a significant (P<0.05), but not normal, fall in blood ammonia, and a significant (P<0.02) resolving biochemical marker of liver injury that did not improve cardiovascular or cerebral stability; this lead to death within 3 days in all control patients. The five hepatocyte-treated patients maintained normal cerebral perfusion and cardiac stability, with withdrawal of medical support for 2 to 10 days before orthotopic liver transplantation. Biochemical evidence of liver injury improved significantly (P=0.004) and blood ammonia levels decreased significantly (P=0.0005) to normal levels in the hepatocyte-treated patients. Three of five patients who successfully bridged to whole liver allograft transplant are alive, home, and normal with more than 20 months of follow-up. No infections or embolic or pulmonary complications resulted from intra-arterial splenic hepatocyte infusion. Specific antiprotease production in a patients with genetically deficient alpha-1-antitrypsin disease, and immunohistochemical and electron microscopic evidence of splenic "hepatization" are presented as evidence of the viability of hepatocyte splenic seeding. In conclusion, splenic transplantation of differentiated adult hepatocytes can control hyper-ammonemia, correct genetic defects in liver function, and bridge life to orthotopic liver transplantation in human liver failure.

MRI accurately determines right lobe mass. Most liver regeneration occurs in the 1st week after resection or transplantation, and the time course does not differ significantly in donors or recipients. The mass of the graft or remnant segment affects the duration of the regeneration process, with a smaller initial liver mass prolonging the course. Steatosis of <30% had no bearing on liver function or regeneration and, therefore, should not be an absolute criterion for exclusion of donors. A calculated graft to recipient body weight ratio of 0.8% is adequate for right lobe living donor liver transplantation.

The first adult-to-adult living donor liver transplant using the right hepatic lobe in the United States was performed only 2 years ago. Although initial reports were encouraging, continuous review of the results and appropriate modifications in patient management will be necessary to minimize donor risk and optimize recipient outcome. The results of 40 such transplantations were analyzed and are summarized. Recipients were listed for transplantation according to the usual criteria. Living donors were not considered for United Network for Organ Sharing status IIA patients after the initial 22 patients. Donor evaluation followed a rigid protocol. A graft-to-recipient body weight ratio of at least 0.8% was the minimum required throughout most of the study. The surgical procedures were similar, except the plane of transection was modified to better accommodate donor biliary anatomy, and uniform stenting of bile ducts was practiced after the first 10 transplants. Immunosuppression consisted of tacrolimus, mycophenolate mofetil, and a prednisone taper. The target tacrolimus level was decreased and mycophenolate was withdrawn more rapidly in the second half of the study because of the absence of acute cellular rejection. Donor morbidity has been limited to minor complications, and transplant recipient biliary complications decreased from 35% to 0%. Acute cellular rejection has not been observed despite less aggressive immunosuppression, and septic complications decreased dramatically. There have been no recipient deaths since these changes were instituted. Right lobectomy can be performed safely in the donor population. Recipient biliary complications can be minimized with stenting. Less aggressive immunosuppression is well tolerated and minimizes septic complications and attributable mortality. (Liver Transpl 2000;6:296-301.) L iver transplantation has evolved in response to the continued and worsening shortage of organs. Surgical techniques to safely resect viable grafts from living donors have been developed and have the potential to significantly reduce mortality for patients with acute and chronic liver disease. The pediatric population has already realized the benefit of living donors, but progress has been slower for adults. Right lobectomy is the only segmental resection that consistently yields a graft of appropriate size for adults, but it has been approached cautiously because of concern for the safety of the donor. It has only been within the last 2 years that centers in the United States have started to offer this option to their patients. The early reports were encouraging, and enthusiasm has grown as a result. The continued use of this technique must, however, be dependent on a very low incidence of donor complications and demonstrated efficacy in recipients.The results of the first 25 adult-to-adult living donor liver transplantations (LDLTs) using the right lobe (RL) performed at our institution were analyzed and previously reported. 1 Only minor complications occurred in donors, and recipient morbidi...

Anatomical variations of the right lobe can be accommodated without donor complications or complex reconstruction. Previous transplantation and TIPS do not significantly complicate right lobe transplantation. Microvascular arterial anastomosis is not necessary, and vascular complications should be infrequent. Biliary complications can be minimized with stenting.