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Abstract

  1. Top of page
  2. Abstract
  3. Patients and Methodology
  4. Results
  5. Discussion
  6. References

Hepatitis C virus (HCV) recurs in nearly all patients after liver transplantation. This recurrence is associated with progressive fibrosis and graft loss. It remains unclear whether the natural course of HCV recurrence is altered in patients who undergo living donor liver transplantation (LDLT). We conducted a prospective, controlled trial using protocol liver biopsies to evaluate the histologic outcome of recurrent HCV in 23 patients who underwent LDLT and 53 patients who underwent transplantation with a deceased donor liver (DDLT) during the same period of time. Patients who did not survive at least 6 months after transplantation or who had hepatocellular carcinoma or any other coexistent liver disease were excluded from analysis. All patients underwent protocol liver biopsy at 6 months and at 12 months and at yearly intervals thereafter. The mean age, sex, racial distribution, and serum HCV RNA and the percentage of patients with genotype 1 were similar in the 2 groups of patients. The model for end-stage liver disease score at the time of transplantation was slightly lower in patients who underwent LDLT, but this difference was not significant. The distribution of immunosuppression agents used, the mean doses of calcineurin agents, the use of mycophenolate mofetil, and the dose and tapering schedule for prednisone were similar in both groups of patients. The mean duration of follow-up was 40 months. No significant difference in either graft or patient survival or the percentage of patients who developed acute rejection was noted in the 2 groups of patients. At 48 months, graft and patient survival were 82% and 82% and 75% and 79% for patients who underwent DDLT and LDLT, respectively. The degree of hepatic inflammation increased stepwise over 3 years but was not significantly different in the 2 patient groups. In contrast, the mean fibrosis score and the percentage of patients with fibrosis increased stepwise after DDLT but appeared to plateau 12 months after LDLT. At 36 months, fibrosis was present in 78% of DDLT patients, and mean fibrosis score was 1.9, compared with 59% with fibrosis and a mean score of .9 after LDLT. In conclusion, these data strongly suggest that fibrosis progression from recurrent HCV is not more severe in patients after LDLT. (Liver Transpl 2004;10:1248–1255.)

Approximately 40% of all persons undergoing liver transplantation have either decompensated cirrhosis or hepatocellular carcinoma related to chronic hepatitis C virus (HCV) infection.1, 2 Chronic HCV is, therefore, the most common indication for liver transplantation. Unfortunately, virtually all of these patients develop recurrence of HCV infection.1, 2 Although disease recurrence is relatively mild or slowly progressive in the majority of these patients, many others develop progressive injury to their liver allograft.3, 4 Cirrhosis secondary to recurrent HCV develops in approximately 25–33% of patients within 5 years of undergoing liver transplantation.3–5 Hepatic decompensation appears to develop in approximately 50% of these patients after just 1 to 2 additional years, and this event is associated with a 50% mortality within less than 1 year.6 Rapidly progressive cholestatic hepatitis leading to liver failure and death appears to occur within the first 1 to 2 years after liver transplantation in about 1–5% of patients with recurrent HCV.1, 2, 7, 8 It is therefore not surprising that the long-term survival of patients with chronic HCV is somewhat lower than that observed for patients who undergo liver transplantation for other indications.9

Given the shortage of deceased donor organs available for patients in need of liver transplantation, an increasing number of patients have chosen to undergo liver transplantation with a living donor.10, 11 Chronic HCV is the most common indication for living donor liver transplantation (LDLT); as the HCV epidemic continues to evolve, an increasing number of patients with chronic HCV will no doubt choose this option.12 Knowing that the outcomes associated with LDLT in patients with HCV are similar to those achieved in persons undergoing deceased donor liver transplantation (DDLT) is critically important for patients who are faced with this decision. It is therefore of great concern that some preliminary reports have suggested that recurrence of HCV might be more severe in patients after LDLT compared with DDLT.13–15 Unfortunately, these reports are the result of uncontrolled retrospective analyses, which in most cases failed to perform protocol liver biopsies in all patients to assess the degree of histologic injury secondary to recurrent HCV. The current study is a prospective, controlled evaluation in which protocol liver biopsies were used to document histologic progression over a 3-year period in patients who underwent LDLT and DDLT at our center.

Patients and Methodology

  1. Top of page
  2. Abstract
  3. Patients and Methodology
  4. Results
  5. Discussion
  6. References

Patient Population

The study population consisted of 23 patients who underwent LDLT and 53 who underwent DDLT during the same period for decompensated cirrhosis secondary to chronic HCV. To be included in this study, patients had to have survived at least 6 months after transplantation and to have had detectable HCV RNA in serum by a polymerase chain reaction assay both before and after the transplant. Patients known to have hepatocellular carcinoma before transplantation or found to have cancer within the liver explant were excluded. Patients also were excluded if they were coinfected with either hepatitis B virus or human immunodeficiency virus or found to have any other coexistent liver disease based on serologic evaluation before liver transplantation or on review of explant liver pathology.

After transplantation, values for serum liver chemistries, renal function, complete blood count, and blood levels of immunosuppressive medications were evaluated at routine intervals. Over time, the frequency of monitoring was reduced to once every 3 months. The frequency of monitoring was similar for patients undergoing LDLT and DDLT. Serum HCV RNA was measured by the COBAS Amplicor polymerase chain reaction assay (Roche Molecular Systems, Branchberg, NJ). The lower and upper limits of this assay as reported by our laboratory were 50 and 800,000 IU/ml, respectively. Samples that tested greater than 800,000 IU/ml were not diluted and reanalyzed. It is the general practice of our liver transplant program not to treat recurrent HCV with interferon or peginterferon with or without ribavirin until patients develop bridging fibrosis. None of the patients in this study received interferon therapy during the first 24 months after liver transplantation. Two patients in the LDLT group and 5 in the DDLT group began treatment for chronic HCV after their 24-month biopsies. These patients were retained within the cohort for calculation of graft and patient survival. However, because the natural history of recurrent HCV may have been altered by therapy, no additional histologic data from these patients were included in the data analysis.

Immunosuppression

Immunosuppression consisted of either cyclosporine (Neoral) or tacrolimus (prograf) along with mycophenolate mofetil (MMF) and high-dose corticosteroids. The dose of cyclosporine or tacrolimus was adjusted as required to maintain constant therapeutic blood levels. The dose of corticosteroids was gradually reduced over several weeks and converted to oral prednisone at a maintenance dose of 10 mg/day. If no episodes of acute rejection occurred, prednisone was subsequently tapered and discontinued after the 6-month liver biopsy. MMF was not used in patients with severe neutropenia at the time of transplant. The dose was maintained between 500 and 1500 mg/day, as tolerated by white blood count, and was discontinued if neutropenia developed. Patients who developed significant renal insufficiency, defined as a serum creatinine of greater than 2.0 mg/dl, were converted from a calcineurin to rapamycin. The target blood level for cyclosporine, tacrolimus, and rapamycin; the target dosages for MMF and prednisone; and the time course by which prednisone was tapered and subsequently discontinued were identical for patients who underwent LDLT and DDLT.

The diagnosis of acute rejection was based solely on histologic documentation as previously described.16 Mild-to-moderate allograft rejection was treated with bolus doses of corticosteroids followed by a gradual taper to a prednisone maintenance dose of 10 mg/day and an increase in the dose of calcineurin or rapamycin to maintain a higher blood level. Moderate-to-severe rejection was treated with several doses of thymoglobulin and an increase in the dose of calcineurin, MMF, and prednisone, as tolerated. Some patients who developed rejection were switched to the alternative calcineurin or rapamycin. Patients were not treated for allograft rejection in the absence of histologic confirmation.

Evaluation of Liver Histology

All patients underwent protocol liver biopsies at 6 and 12 months after liver transplantation and at 12 month intervals thereafter. Additional liver biopsies were performed as needed to investigate the etiology of acute elevations in serum liver aminotransferases. A liver biopsy demonstrating typical changes of acute allograft rejection was required for this diagnosis. If a biopsy to evaluate abnormal liver chemistries was performed within 2 months of the scheduled protocol biopsy, and this biopsy demonstrated findings other than acute rejection, this specimen was used and the biopsy for protocol was not repeated. All liver biopsies were evaluated by 1 or both pathologists (MJC and ASM) and scored for HCV severity according to the histologic activity index of Knodell et al.17 Biopsies that contained evidence of acute rejection, those that were inconsistent with recurrent HCV, and those with insufficient sample were not scored for this study.

Statistical Analysis

Values were reported as mean ± standard error. The significance between mean values was assessed by Student t test, Mann–Whitney rank sum test, or the Kruskal–Wallis one way analysis of variance on ranks, as appropriate. The χ2 test was used to determine whether the frequency of observations between groups was significant. Patient and graft survival were calculated according to the Kaplan–Meier method. A P value of less than .05 was considered significant.

Results

  1. Top of page
  2. Abstract
  3. Patients and Methodology
  4. Results
  5. Discussion
  6. References

Patient Characteristics

The mean age of the patients population was 47 years, 82% were male, and 76% were White (Table 1). No significant differences existed between the 2 patient groups. In 34% of patients, alcohol was believed to have contributed to the need for liver transplantation. This was significantly higher (P < .02) in the patients who underwent DDLT. The mean duration of follow-up ranged from 14–66 months.

Table 1. Clinical and Laboratory Features of the Patients at the Time of Transplantation
 DDLTLDLTP
  • Abbreviations: DDLT, deceased donor liver transplant; LDLT, living donor liver transplant; MELD, model for end-stage liver disease; HCV, hepatitis C virus; NS, not significant.

  • Values are given as mean ± standard error.

  • Values in parenthesis represent range.

Number of patients5323 
Age (yr)47.8 ± 0.847.6 ± 2.0NS
Male45 (87%)17 (74%)NS
White38 (73%)20 (87%)NS
Alcohol contributed to cirrhosis23 (43%)3 (13%)0.02
Follow-up (months)39.9 ± 2.1 (14–66)41.3 ± 2.9 (9–60)NS
Bilirubin (mg/dL)4.9 ± 1.03.1 ± 0.5NS
Pro-time (s)15.3 ± 0.513.9 ± 0.60.04
Albumin (g/dL)2.7 ± 0.12.7 ± 0.1NS
Serum creatinine (mg/dL)1.3 ± 0.21.0 ± 0.1NS
MELD score16.2 ± 1.013.5 ± 1.1NS
HCV genotype 1 (%)9188NS
Log HCV RNA (copies/mL)5.25 ± 0.115.25 ± 0.17NS
Donor age (yr)40.8 ± 2.3 (13–73)38.2 ± 1.7 (23–55)NS

Liver function tests at the time of liver transplantation were slightly more abnormal in patients who underwent DDLT. However, these differences were not significant except for the prothrombin time (P = .04) (Table 1). The mean model for end-stage liver disease score and serum creatinine were slightly higher in patients who underwent DDLT, but these differences were not significant. The mean serum level of HCV RNA was similar in the 2 groups of patients, and 90% were infected with HCV genotype 1. Mean donor age was significantly lower (P < .001) in patients who underwent LDLT compared with DDLT.

Immunosuppression, Acute Rejection, and Cytomegalovirus Infection

The percentage of patients treated with the various immunosuppressive agents used at our center was similar in those who underwent LDLT and DDLT (Table 2). The mean blood levels achieved for each of the calcineurin inhibitors and rapamycin used was also similar in the 2 groups of patients. Acute cellular rejection occurred in 21% of patients who underwent DDLT, including 2 patients with severe rejection treated with thymoglobulin. Of the patients who underwent LDLT, 14% developed acute rejection. None of these cases was graded as severe. The incidence and severity of rejection in the 2 groups was not significantly different. In addition, no significant difference was observed in the incidence of cytomegalovirus infection: 16% and 13% in patients who underwent DDLT and LDLT respectively.

Table 2. Immunosuppression Used After Liver Transplantation
 DDLTLDDLTP
  • Abbreviations: DDLT, deceased donor liver transplant; LDLT, living donor liver transplant.

  • *

    Values represent the number (and percentage) of patients in each group treated with the various immunosuppressive agents. All patients received more than 1 agent. Also provided is the mean ± standard error serum level for each immunosuppressive agent. This was calculated by averaging all blood levels obtained for each patient taking that particular immunosuppressive agent throughout the entire follow-up period.

Cyclosporine*18 (34%)3 (13%)NS
 level (ng/mL)277.2 ± 10.9220.2 ± 20.3NS
Tacrolimus32 (60%)19 (83%)NS
 level (ng/mL)10.1 ± 0.29.4 ± 0.2NS
Rapamycin7 (13%)5 (22%)NS
 level (ng/mL)16.2 ± 1.714.3 ± 1.9NS
Myconphenolate moefitil32 (60%)14 (61%)NS
Prednisone53 (100%)23 (100%)NS

Outcome After Liver Transplantation

Patient and graft survival after DDLT or LDLT are illustrated in Fig. 1. After 48 months of follow-up, graft survival was 82% in patients who underwent DDLT and 76% in patients who underwent LDLT. This difference was not significant (P = .46). Similarly, no significant difference in patient survival was observed—82% and 79% for patients who underwent DDLT and LDLT, respectively.

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Figure 1. Graft (A) and patient (B) survival in patients with recurrent hepatitis C virus (HCV). The solid line (—) represents the Kaplan–Meier survival for patients who received a deceased donor liver. The dashed line (- - -) represents patients who received a liver graft from a living donor. No significant differences in either graft or patient survival existed between the 2 groups of patients.

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The pattern of serum alanine aminotransferase (ALT) for patients who underwent DDLT and LDLT is illustrated in Fig. 2. Patients who underwent LDLT tended to have a higher mean value for serum ALT during the first 4 weeks after transplant compared with patients who underwent DDLT. At 2 weeks, these values were 162 IU/l and 105 IU/l; at 3 weeks, they were 123 IU/l and 80 IU/l for LDLT and DDLT respectively. However, the absolute values in each patient varied widely in both groups, and the differences in these mean values were not significant. About 8 weeks after transplantation, the mean values for serum ALT were similar; these remained similar throughout the follow-up period. Very similar trends were observed for serum aspartate aminotransferase and bilirubin (data not shown). No patients in either group developed the syndrome of rapidly progressive fibrosing cholestasis.

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Figure 2. Changes in serum alanine aminotransferase (ALT) over time after liver transplantation in patients who received a deceased donor (dark circles) or living donor (open circles) liver graft. Each point represents the mean value for all patients at a particular time point. Within the first 12 weeks after transplantation, the ALT value obtained closest to the time point ±2 weeks was used. Thereafter, the ALT value obtained closest to the time point ±2 months was used. Although serum ALT within the first 6 months after transplantation tended to be higher in patients who underwent LDLT, these differences were not significant.

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Liver Histology

The mean values for liver inflammation and fibrosis scores at various time intervals in patients who underwent DDLT or LDLT are illustrated in Fig. 3. The mean inflammation score 6 months after transplantation was 5.1; this increased to 5.9 at 12 months, 6.3 at 24 months, and 6.6 after 36 months. No significant differences in inflammation were present between patients who underwent DDLT and LDLT at any of these time points. The mean fibrosis score 6 months after transplantation was .25; this was similar in both groups. In patients who underwent DDLT, the fibrosis score increased stepwise to 1.2 at 12 months, 1.4 at 24 months, and 1.9 after 36 months. By contrast, the fibrosis score in patients who underwent LDLT appeared to plateau at a value of .9 between 12 and 36 months after transplantation. However, given the variability in fibrosis scores observed for individual patients, the mean differences in fibrosis scores observed for the 2 groups were not significantly different at any of these time points.

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Figure 3. Liver biopsy scores at various time intervals after liver transplantation in patients who underwent deceased donor liver transplant (DDLT) (solid bars) and living donor liver transplant (LDLT) (hatched bars). No significant difference in mean inflammation score (left) or fibrosis score (right) was present between the 2 patient groups.

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Fig. 4 illustrates the percentage of patients within each group who developed various stages of fibrosis. Of the patients who underwent DDLT, 13% developed portal fibrosis and 7% developed bridging fibrosis within just 6 months. These percentages increased stepwise, and after 36 months, 39% of patients had portal fibrosis and 39% had bridging fibrosis. Both patients who developed severe rejection and those who received thymoglobulin developed bridging fibrosis by Month 36. However, none of the patients who underwent DDLT developed cirrhosis after 3 years. Of the patients who underwent LDLT, 20% developed portal fibrosis within 6 months. After 12 months, 50% of patients had developed portal fibrosis and another 10% developed bridging fibrosis. However, over the next 2 years, the percentage of patients who underwent LDLT and developed fibrosis remained stable; the percentage found to have bridging fibrosis increased from 10% to only 12%. After 3 years, none of the patients who underwent LDLT had developed cirrhosis.

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Figure 4. Percentage of patients with fibrosis in their liver allograft at various time intervals after deceased donor liver transplant (DDLT) or living donor liver transplant (LDLT). Solid bars represent portal fibrosis. Hatched bars represent bridging fibrosis. No patients in either group developed cirrhosis during the follow-up period. No significant difference in the percentage of patients who developed fibrosis existed between the 2 groups.

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Discussion

  1. Top of page
  2. Abstract
  3. Patients and Methodology
  4. Results
  5. Discussion
  6. References

The current study was an evaluation of the severity of recurrent HCV in patients after DDLT and LDLT. Protocol liver biopsies were performed at predefined intervals in both groups of patients, and more than 75% of the patients who survived in the 2 cohorts had liver histology evaluated to 36 months. Our results clearly demonstrate that histologic recurrence of HCV is not more severe in patients who underwent liver transplantation with a living donor as opposed to a deceased donor graft. Although inflammation scores increased stepwise between months 6 and 36, this was similar in both groups of patients. Mean fibrosis scores and the percentage of patients with either portal or bridging fibrosis increased stepwise between Months 6 and 36 after DDLT. In contrast, mean fibrosis scores and the percentage of patients with fibrosis increased between Months 6 and 12 but then remained relatively stable through Month 36 after LDLT. It is therefore apparent that recurrent HCV is not more severe in patients who underwent LDLT, at least for the first 4 years after the transplant.

The results of the current study are in general agreement with those recently reported in 2 other series.18, 19 In these 2 reports, the incidence and severity of recurrent HCV and both patient and graft survival were similar in patients who underwent LDLT and DDLT. In contrast, the results of the current study and these 2 recent reports are in sharp contrast with several small preliminary reports that implied that recurrent HCV might occur earlier and be more severe in patients who underwent LDLT.13–15 There are several possible explanations for these differences. Each of these preliminary reports was retrospective in nature, followed patients for only a brief period of time, used serum ALT as a surrogate for liver injury, and failed to perform protocol liver biopsies at periodic intervals to assess for histologic progression. Liver histology was assessed only in response to abnormalities in serum liver chemistries. Our group previously demonstrated that patients who underwent LDLT tended to have persistent elevations in serum aspartate aminotransferase, ALT, and bilirubin for several weeks or months as opposed to those who underwent DDLT in which the liver chemistries typically decline into the normal range rapidly after transplantation.20 Similar findings were observed in the current study (Fig. 2). In the report by Van Vlierberghe,19 serum bilirubin also was noted to remain elevated in LDLT recipients when compared with patients who underwent DDLT. As a result, performing liver biopsies sooner to investigate persistent abnormalities in liver chemistries in the LDLT cohort may have given the false impression that recurrence of HCV occurred earlier and was more severe than after transplantation with a deceased donor graft. Furthermore, no previous study has demonstrated that time to recurrence of HCV after liver transplantation is either meaningful or predicts fibrosis progression. These data point out the limitations of performing a retrospective analysis of uncontrolled data with a small sample size. A controlled trial using liver biopsies performed at regular intervals, as in the current trial, is a far more accurate method by which to compare histologic severity and fibrosis progression of recurrent HCV in 2 cohorts of patients.

A curious finding in the study by Gaglio et al.18 was that 4 of 23 (17%) patients who underwent LDLT at that center developed what was thought to be severe cholestatic HCV; however, this was not observed in either the current study or in the series reported by Van Vlierberghe et al.19 Rapidly progressive cholestatic hepatitis has been reported to occur in 1–5% of patients after DDLT and appears to be associated with the use of high-dose immunosuppression for treatment of severe acute rejection within the first few months after liver transplantation, a very high rate of HCV replication, and very high levels of HCV RNA in serum.1, 2, 7, 8 Gaglio et al.18 hypothesized that the rapid regeneration of hepatocytes, which is known to occur within the first several weeks after LDLT,20, 21 may have enhanced HCV replication and may have contributed to severe cholestatic HCV. This hypothesis was based on several in vitro observations as follows: HCV appears to enter young and rapidly dividing hepatocytes more readily than older nonreplicating cells22; HCV enters cells at least in part through the low density lipoprotein (LDL) receptor23; the production of LDL receptor appears to be upregulated by hepatocyte growth factor24 and this and many other cytokines appear to stimulate hepatic regeneration.25 However, there are no data to suggest that the uptake of HCV into hepatocytes is enhanced after LDLT and that this even leads to a more severe form of recurrent HCV. In addition, none of the other factors typically associated with severe cholestatic HCV, including acute rejection, bolus doses of corticosteroids, or significantly higher levels of HCV RNA, were present in the LDLT cohort described by Gaglio et al.18 One factor that has been shown to contribute to severe cholestatic HCV is overimmunosuppression; a recent study has demonstrated that blood levels of calcineurin agents are higher in patients after LDLT given the same immunosuppression dosing as in patients undergoing DDLT.26 Alternatively, it is possible that the severe cholestasis observed in some patients after LDLT was not related to HCV but to some alternative process. Bile leak from the cut surface of the liver and a higher incidence of biliary tract complications is significantly more common after LDLT. This may lead to persistent and severe cholestasis in this setting.10, 11, 27–29 In addition, patients who receive a right lobe graft that is too small for the recipient develop a syndrome associated with severe cholestasis and graft failure;30, 31 this risk appears to be increased when patients enter transplantation when critically ill or clinically unstable.25 It therefore remains unclear whether severe cholestatic HCV is indeed more common in the setting of LDLT.

An intriguing observation in the current study was that patients who underwent LDLT had somewhat less fibrosis progression over 3 years compared with patients who underwent DDLT. This suggests that the long-term outcome from recurrent HCV might actually be more favorable in patients who choose and are able to undergo LDLT rather than wait for DDLT. One possible explanation for this could be the age of the donor liver. Increased donor age has recently been shown to be a risk factor for fibrosis progression and cirrhosis in patients with recurrent HCV.32–34 However, mean donor age was not significantly different in patients who underwent LDLT or DDLT in the current study (Table 1). Alternatively, rapid regeneration, as hypothesized by some to be detrimental, may actually reduce fibrosis progression following LDLT. Rapd regeneration associated with recovery from severe acute liver necrosis, whether the result of viral hepatitis A or B, drugs such as acetaminophen or CCl4, or after ischemia, is rarely associated with the development of fibrosis.35, 36 Although the cellular and molecular mechanisms involved in this process are not completely understood, stellate cells, cytokines, and interleukins appear to be important components of this process.37 Whether the reduced rate of fibrosis progression after LDLT as observed in the current study is the result of sampling variation, a real and important finding, or in some way related to LDLT will require additional studies, a larger cohort, and a longer follow-up. The adult-to-adult LDLT cohort study is a multicenter, National Institutes of Health–sponsored trial designed to compare the outcomes of LDLT to those achieved with DDLT. The results of this study are likely to significantly improve our understanding of recurrent HCV in the setting of both LDLT and DDLT. This study also will help determine if rare events following liver transplantation, such as severe cholestatic HCV, are indeed more common in patients who undergo LDLT.

As the number of patients added to the United Network for Organ Sharing liver transplant waiting list continues to grow and the waiting time to undergo DDLT increases, the mortality for patients on the waiting list has increased substantially.38 The use of LDLT has provided an important option for patients with decompensated cirrhosis or hepatocellular carcinoma awaiting liver transplantation. This option is particularly important for patients with chronic HCV who comprise the single largest group of patients awaiting liver transplantation.1, 2 Furthermore, as the epidemic of HCV continues to expand, the percentage of patients undergoing both DDLT and LDLT for end-stage liver disease secondary to chronic HCV is expected to increase.12 If HCV recurrence is more severe and graft failure is more common in patients who undergo LDLT, this procedure should be relatively contraindicated for patients with chronic HCV, as recently suggested.39 In contrast, the current study has clearly demonstrated that both graft and patient survival and the rate of fibrosis progression are not more severe after LDLT. Rather, fibrosis progression may occur at a slower pace than that observed in patients undergoing DDLT. This should be reassuring to the large numbers of patients with chronic HCV who will need to consider the option of LDLT in the future.

References

  1. Top of page
  2. Abstract
  3. Patients and Methodology
  4. Results
  5. Discussion
  6. References
  • 1
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    Marcos A, Fisher RA, Ham JM, Shiffman ML, Sanyal AJ, Luketic VA, et al. Liver regeneration and function in donor and recipient after right lobe adult to adult living donor liver transplantation. Transplantation. 2000; 69: 13751379.
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  • 33
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