Feasible Isolated Liver Transplantation for a Cirrhotic Patient on Chronic Hemodialysis
The recipient was a 63-year-old Japanese male who had been suffering from hepatitis C cirrhosis since the age of 37 years. He had undergone endoscopic variceal ligation for esophageal varices at the age of 58 years. His liver function had gradually become decompensated and he had developed hepatic encephalopathy 5 months before admission. He had had cryptogenic chronic nephritis from the age of 19 years and started hemodialysis at the age of 60 years. He had no other complications such as diabetes, hypertension or hemodialysis-related complications. His height was 159 cm and his weight was 53 kg before hemodialysis and 51 kg after hemodialysis. His Child-Pugh score was 10 (grade C) with a total bilirubin level of 0.9 mg/dl, an albumin level of 3.4 g/dl and a prothrombin time of 68% (international ratio 1.25). He was seropositive for hepatitis C virus (HCV) antibodies but seronegative for HCV RNA. The levels of blood urea nitrogen and creatinine were 61 and 9.01 mg/dl, respectively. His model for end-stage liver disease score was 22. A computed tomography scan revealed the presence of liver cirrhosis, splenomegaly and developed collateral vessels such as splenorenal shunt, recanalized paraumbilical vein and gastric varices. No definite hepatocellular carcinomas were detected (fig. ). The bilateral kidneys were very atrophic, which was consistent with irreversible renal failure (fig. ). In summary, he had decompensated hepatitis C cirrhosis without serum HCV RNA. He had non-diabetic renal failure after 3 years on hemodialysis. He showed good general function except for the liver and kidney failure. Therefore, the patient was expected to have a good prognosis after LDLT.\nThe donor was his healthy 58-year-old wife with identical blood type to the recipient. The right lobe graft was procured using a typical method described elsewhere [, , , , ]. The actual graft weight was 546 g, which accounted for 50.4% of the recipient's standard liver volume.\nIn the recipient, intraoperative continuous hemodiafiltration (CHDF) without water removal was started immediately via the right femoral vein after laparotomy. The CHDF provided a stable acid-base and electrolyte balance. A total hepatectomy and implantation were performed under stable hemodynamics using an extracorporeal veno-venous bypass. The V5, right inferior hepatic vein and right hepatic vein of the right lobe graft were reconstructed to have a co-orifice using the left internal jugular vein and explanted portal vein grafts of the recipient at the backtable according to our usual method [, ]. Operative time was 14 h 22 min. The anhepatic, cold ischemic and warm ischemic times were 140, 169 and 65 min, respectively. The blood loss was 2,000 g, for which 10 units of red cell concentrate, 10 units of fresh-frozen plasma and 30 units of platelet concentrate were transfused.\nThe postoperative courses of the recipient and the donor were uneventful. CHDF was continued until postoperative day 4, at which point CHDF was converted to hemodialysis. The amount of water removal was appropriately adjusted according to blood pressure, central venous pressure and body weight. The drained ascites was below 500 ml/day and all abdominal drains were removed by postoperative day 6 except for the biliary stents (table ). Other than the renal replacement therapy and dose modulation of renal excretory drugs such as acyclovir, the perioperative management of the recipient was typical, as previously described [, , , , ]. Immunosuppression was induced with intravenous methylprednisolone and then switched to oral prednisolone, cyclosporin A and mycophenolate mofetil. He left the intensive care unit on postoperative day 5 and was discharged on postoperative day 36 with good hepatic function.