移植技術と研究

Aim: Liver transplantations (LT) have proven to be a successful treatment for many tumors of the liver. The goal of this study was to evaluate the outcomes of liver transplantations in patients with primary liver tumors with a focus on rarer malignancies. Methods: The UNOS database catalogues all adult patients who underwent LT for a primary liver tumor from 1992-2008. Of the 73, 231 liver transplantations, 5,682 patients with liver tumors were identified and categorized by indication for LT: hepatocellular carcinoma (HCC, n=5272), hepatic epithelioid hemangioendothelioma (HEH, n=85), cholangiocarcinoma (n=249), sarcomas (n= 11) and combined HCC-Cholangiocarcinomas (HCC-CC, n=12). Survivals were calculated using Kaplan-Meier and log rank tests. Results: 5,629 patients received LT for solid liver tumors. HCC patients and their allografts survived longer than those transplanted for cholangiocarcinomas (p=0.001, 0.002) or for HCC-CC (p=0.025, 0.004). Overall survival rates of HCC patients were 86.4%, 71.3%, and 61.2% at 1, 3 and 5 years, respectively. Cholangiocarcinoma patients had survival rates of 79.7%, 60.3% and 45.5% at 1-, 3- and 5-years from transplant. HCC-CC patients had the worst overall survival of 72.9%, 39.1% and 39.1% at 1, 3 and 5 years. Allograft survival in HCC-CC patients was comparatively low, averaging 65.6%, 35.2% and 0% at 1-, 3- and 5-years. HEH patients and their allografts survived the longest with overall survival of 83.9%, 77.8% and 73.5% at 1, 3 and 5 years, respectively, and allograft survival at 76.8%, 69.8% and 64.3%. Conclusion: Our data reveals overall survival was significantly better in HEH patients when compared to HCC, cholangiocarcinoma and HCC-CC patients after LT. In fact, HCC-CC patients fared the worst, both in patient and allograft survival, as compared to HCC and HEH. Results of cholangiocarcinoma patients show worse survival after LT compared to HCC and HEH, though recent evidence suggests adjuvant therapy will change outcomes for the future. Our findings suggest transplantation for HCC-CC may not be sufficient treatment. Other forms of adjuvant and neoadjuvant therapy may be indicated, warranting further research.

Background: Solid-organ transplant recipients (OTRs) have an increased risk of developing nonmelanoma skin cancer.

Objective: This study explored the longitudinal history of sun exposure in OTRs from a few months after transplantation to two-three years later.

Methods: OTRs, who previously completed a telephone survey in 2007 to 2009 were re-surveyed in summer 2011 about their skin cancer history and habits of sun exposure. The two sets of data were compared to assess change in sun exposure.

Results: OTRs were enrolled (baseline) a mean of 8 months (range of 6 to 17.0 months) after transplantation. The interval between enrollment and the follow-up survey was a mean of 14 months (range of 2 to 21.8 months).

Duration of self-reported weekday and weekend exposure increased from a mean of 2.05 hrs at baseline to a mean of 2.52 hours at follow-up. The mean difference in weekday exposure was 0.31 hrs (range -5.25 to 5.05 hrs) (t-test, p= 0.02, rank sum test, p =0.017) and in weekend exposure was 0.47 hrs (range-5.25 to 0.05) (t-test, p = 0.0007, rank sum test, = =0.004). Kidney transplant recipients increased the duration of weekday and weekend exposure significantly more than liver transplant recipients. (p=0.05) The number of sunburns experienced at baseline and follow-up remained consistent (p=0.58) with about 13% experiencing 1-5 sunburns each year.

Conclusion: OTRs did not limit outdoor sun exposure or experience fewer sunburns in the 14 months after their transplant. Research is needed to ascertain the impact of educational programs on skin protection behaviors.

Background: Laparoscopic donor nephrectomy represents a significant source of allografts to patients with endstage renal disease. Given the increasing wait-list and limited number of deceased donors, utilization of the right kidney is necessary to maximize the donor pool.

Materials: We retrospectively reviewed 122 right-sided kidney donors; 73 hand-assisted laparoscopic donor nephrectomies (R-HAL-DN), 36 standard laparoscopic donor nephrectomies (R-LAP-DN), and 13 laparoendoscopic single site donor nephrectomies (R-LESS-DN). We compared these groups to matched left donors and each other, analyzing various parameters including operative times, warm ischemia time (WIT), estimated blood loss (EBL), incision length, length of stay (LOS), convalescence data and complications.

Results: Right and left donors demonstrated no difference in analysis parameters in all 3 procurement techniques. When comparing all right donors total operative time and allograft extraction time were lowest in the R-LAP-DN group (p=0.003 & p=0.04, respectively). The R-LESS-DN group had the lowest EBL (p=0.06) and shortest incision length (p<0.0001). The LOS was shortest in the R-LAP-DN group (p=0.03). WIT, donor convalescence, and recipient allograft function were similar in all 3 groups.

Conclusion: Our data demonstrates the safety and reproducibility of procuring the right kidney. Donor safety and allograft function have continued through evolution of the technique.

Introduction: The human T cell lymphoma virus was screened for previously in organ donors secondary to concern for progressive disease in an immunocompromised host. However, due to the low prevalence of the virus, a shortage of suitable allografts, and the lack of a time effective test, this practice has been abandoned in the United States. The human T cell lymphoma virus type I may cause progression to several diseases, including human T cell lymphoma virus associated myelopathy, and adult T cell lymphoma/l eukemia. Moreover, there is an overall lack of data relating to the safety profile in the medical literature with use of human T cell lymphoma virus positive allografts.

Aim: To determine the safety of human T cell lymphoma virus positive allografts in orthotopic liver transplantation.

Materials and Methods: Our database was queried for recipients of known human T cell lymphoma virus positive allografts at time of transplantation. We present one patient case report followed by a review of the medical literature.

Results: The patient was transplanted secondary to cirrhosis due to alcohol and hepatitis C virus infection with hepatocellular carcinoma. When a suitable allograft became available, the patient was advised that it was human T cell lymphoma virus type I positive. The risks and benefits were discussed thoroughly with the patient and he elected to proceed with the operation. His operation and post operative course were unremarkable. He continues to do well during on follow up of over 777 day s, and currently he has no symptoms of any human T cell lymphoma virus associated disease. Review of the medical literature demonstrates few reports on human T cell lymphoma virus related complications after orthotopic liver transplantation; however, the re are theories that immunosuppresion may cause progressive disease in these patients.

Conclusions: Human T cell lymphoma virus type I positive donors can be life saving sources of allografts. Our center supports the use of these allografts in patients that otherwise continue to be on the waiting list.