We report the results of a large series of chain transplantations that were facilitated by a multicenter US database in which 57 centers pooled incompatible donor/recipient pairs. Chains, initiated by nondirected donors, were identified using a computer algorithm incorporating virtual cross-matches and potential to extend chains. The first 54 chains facilitated 272 kidney transplants (mean chain length = 5.0). Seven chains ended because potential donors became unavailable to donate after their recipient received a kidney; however, every recipient whose intended donor donated was transplanted. The remaining 47 chains were eventually closed by having the last donor donate to the waiting list. Of the 272 chain recipients 46% were ethnic minorities and 63% of grafts were shipped from other centers. The number of blood type O-patients receiving a transplant (n = 90) was greater than the number of blood type O-non-directed donors (n = 32) initiating chains. We have 1-year follow up on the first 100 transplants. The mean 1-year creatinine of the first 100 transplants from this series was 1.3 mg/dL. Chain transplantation enables many recipients with immunologically incompatible donors to be transplanted with high quality grafts.

Four cases of patients in whom graft vs. host disease developed after liver transplantation are described. The clinical course of each patient was similar with fever, pancytopenia, diarrhea and a skin rash developing 1 or 2 mo after liver transplantation. The clinical diagnosis was made from skin or colon biopsy specimens. Liver dysfunction did not occur in the patients at the time of diagnosis. Extrahepatic donor DNA was identified in the three patients it was tested for. Three patients died from the complications of the disease primarily related to sepsis. The other patient recovered from the graft vs. host disease but died from lymphoproliferative disease.

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To evaluate the role of interventional radiologic procedures in the diagnosis and treatment of biliary complications in children after liver transplantation, the authors reviewed the cases of 58 pediatric patients who underwent transplantation over a 4-year period. In 21 patients suspected of having biliary complications, 31 diagnostic percutaneous transhepatic cholangiographic studies, 19 transhepatic biliary drainages, eight pressure-flow studies, five percutaneous drainages of abdominal fluid collections, 11 balloon dilations, and one basketing procedure were performed. Biliary complications were seen in 38% of allografts, with obstruction being more common than leakage. Complications were most frequent in patients with cholecystojejunostomy reconstructions. Only two children had biliary complications that were thought to be related to arterial compromise. No significant intervention was required in 17% of complications. Percutaneous techniques were associated with a low frequency of significant complications (6%). The authors conclude that interventional radiologic techniques can be used effectively in the evaluation and management of biliary complications in pediatric hepatic transplant recipients.

A distinct peliosis-like lesion arose in the liver allograft of a 51 year old man. This lesion was caused by necrotic, fat-laden hepatocytes that released fat globules into the sinusoids. These then became strikingly distended with cysts, thus mimicking peliosis hepatitis. It is suggested that this lesion be called lipopeliosis. and alanine aminotransferase (ALT) to 1002 IU/l (normal 9-50). Both enzymes returned to normal by the eighth postoperative day. Bilirubin rose to 50 mg/dl (normal 0 1-1 2) by day 10, but gradually decreased to 8-6 mg/dl by day 41. Alkaline phosphatase activities remained near normal for the first three weeks, but gradually rose over time to three times the normal concentration by day 41. Liver biopsy specimens were examined at four, 10, 18, 25 and 33 days after surgery. The patient had no evidence of rejection, hepatitis, opportunistic infection, or biliary obstruction or leak following transplantation. ResultsA biopsy specimen taken six days after transplantation showed large spaces in the centrilobular zone associated with hepatocyte ballooning and necrosis caused by preservation (ischaemic) injury.6 These spaces mimicked the cystic, blood-filled spaces seen in peliosis hepatis ( fig IA). Moderate fatty change of both macrovesicular and small droplet types was noted in centrilobular hepatocytes, but only a few foci of small fat droplets were present in periportal zones ( fig IA). Routine haematoxylin and eosin staining showed occasional flattened cells lining the cystic spaces; factor VIII and collagen type IV immunoperoxidase stains were positive along the lining of the spaces, confirming that they were sinusoids ( fig 1B). No blood was present in the spaces. Scattered neutrophils and mononuclear cells were also present in the centrilobular zone, and were associated with the necrosis and fat globules. The spaces were still present in the next two biopsy specimens taken 10 and 18 days after surgery, and a frozen section sample stained for neutral lipid by the oil red 0 technique showed fat globules within them (fig 1 C). Two more biopsy specimens taken 25 and 33 days after transplantation showed that the spaces were noticeably smaller, and Kupffer cells with foamy change were the most preva-