Liver transplantation in Romania: present and future. Center of General Surgery and Liver Transplantation Fundeni Clinical Institute BUCHAREST ROMANIA Liver transplantation in Romania: present and future. Irinel Popescu, MD, FACS, FEBS Professor of Surgery

INTRODUCTION Possible solutions Liver transplantation (LT) has become an established treatment for end-stage liver disease, with more than 20.000 procedure annualy worldwide. The request for LT continues to increase while the donor pool size remains inadequate. Kim WR, Stock PG, Smith JM, Heimbach JK, Skeans MA, Edwards EB, et al. OPTN/SRTR 2011 annual data report: liver. Am J Transplant 2013;13(suppl 1):73-102.

WHO Mortality Database 2000-2002 EPIDEMIOLOGICAL DATA Death rates per 100,000 population from liver cirrhosis in European countries; WHO Mortality Database 2000-2002

Prevalence (%) of liver diseases in Europe

Inter-country comparison of the number of deaths per year; WHO, 2008

DONOR POOL SIZE ORGAN DONATION GLOBALLY Source: Global Observatory on Donation & Transplantation (WHO/ONT)

Deceased donation rates per million population Source: 2014 Transplant Newsletter (2013 data)

About 75-80% of donors provide a liver for LT. The rates of organ donation varies due to social, cultural or legal factors: 30 organ donor per million in Spain – highest in Europe, 20 in US, 16 in UK, <10 in New Zealand, <6 in Romania. About 75-80% of donors provide a liver for LT.

WAITING LIST The liver transplantation waiting list has grown continuously over the past decade in the context of a profound organ shortage Increased mortality rate on the WL Prolonged time on the WL Lack of emergency LT supply In US – ~10 000 new pts added each year on the WL, with ~15000 still on the WL by the end of the given year. Thuluvath PJ et al. Am J Transplant 2010; 10: 1003–1019; Busuttil RW, Tanaka K. Liver Transplant 2003; 9: 651–663; Rodrigue JR. American Journal of Transplantation 2011; 11: 1705–1711 Organ Procurement and Transplantation Network. Liver Transplantation Waiting List. 2000-2011.

By the end of 2013: 6700 pts on WL in EU (508,000,000 population)  13.2 / 1,000,000 454 pts on WL in Romania (19,960,000 population)  22.7 / 1,000,000 Necessity to significantly increase the overall number of LTs

Waiting List in Romania

Overall mortality on waiting list Fundeni Clinical Institute 2004- Dec. 2011 2012 – June 2016 N=856 pts N=919 pts Median overall survival -30.84 months 1-yr mortality rate - 31.4% 3-yr mortality rate - 54.1% 5-yr mortality rate - 63.5% – not reached – 4.4% - 13.9% - 23.6% Gheorghe L, Iacob S…..Popescu I, J Gastrointestin Liver Dis 2014 Gheorghe L, Iacob S, Popescu I (not published data)

Waiting time until LT Median waiting time OI – 19 months AII – 37.5 months BIII – 23.8 months ABIV – 28.4 months

LIVER TRANSPLANTATION Liver transplants per million population Source: 2014 Transplant Newsletter (2013 data)

First LT (15th of April 2015) 46-yr old man, HBV cirrhosis (MELD 19) Whole liver LT (April 2000) - 33-yr old compatible donor Alive at 16 yrs after LT 17.05.2015

Stages of development Early stage of development Low-volume center (up to 20 pts/yr) 2000 – 2006 Group 1: 96 pts Intermediate stage Mid-volume center (20 to 50 pts/yr) 2007 – 2010 Group 2: 148 pts Advanced stage High-volume center (over 50 pts/yr) 2011 – 2016 Group 3: pts

M/F ratio: / ; mean age 45 yrs (median 50, range 7 mo - 68 yrs) April 2000 – September 2016 LT in pts ( re-LT) Performed in Romania M/F ratio: / ; mean age 45 yrs (median 50, range 7 mo - 68 yrs) LT/year 122 96 73 Center of General Surgery and Liver Transplantation - Fundeni Clinical Institute, Bucharest Center of General Surgery and Liver Transplantation - Clinical Hospital “Sf. Maria’’, Bucharest

Indications for LT

Indications in adults ( LTs Retx)

Indications in children ( LTs Retx)

Type of LT

Organ procurement in Romania Deceased donor LT Organ procurement in Romania No of Donors

Use of extended criteria donors (ECD) – 346 donors (52.7%) Whole liver LT ( LTs) Use of extended criteria donors (ECD) – 346 donors (52.7%) Donor-related features: Age > 65 yrs BMI> 30 kg/m2 31 pts 21 pts Factors related to ICU: ICU stay and ventilation support > 7 days Hypotension and inotropic support (≥2 pressors at any time, high-dose dopamine or epinephrine) Resuscitated cardiac arrest 41 pts 116 pts 88 pts Liver steatosis: Macrosteatosis (>30% but ≤60%) 54 pts Biochemical imbalances: Hypernatremia (peak serum Na >165 mEq/L) Liver disfunction (AST/ALT>3X; BT>3mg/dl) 29 pts 108 pts Cold ischemia time > 12 hours 1 Viral infections: Positive serology for HBV hepatitis AgHBs (+) AgHbc (+) Positive serology for HCV hepatitis 7 pts 4 pts 3 pts 1 pt Sepsis-related factors: Sepsis with positive blood culture Meningitis Malignancy risk factors: History of extrahepatic malignancy Non-heart beating donors Spitzer AL, Lao OB, Dick AA, Bakthavatsalam R, Halldorson JB, Yeh MM, et al. The biopsied donor liver: incorporating macrosteatosis into high-risk donor assessment. Liver Transpl 2010; 16: 874-884. Jiménez-Castro1 MB, Elias-Miró1 M, Peralta C. Expanding the Donor Pool in Liver Transplantation: Influence of Ischemia-Reperfusion. In: Organ Donation and Organ Donors. Nova Science Publishers, Inc. ISBN: 978-1-62618-853-2, 2013

Hypothermic oxygenated perfusion of marginal grafts with LiverAssist device ↓ the ischemia-reperfusion injuries of the graft ↓ the risk of postoperative primary non-function or dysfunction ↓ the risk of postoperative complications Dutkowski P, Odermatt B, Heinrich T, et al. Hypothermic oscillating liver perfusion stimulates ATP synthesis prior to transplantation. J Surg Res 1998; 80(2):365-72. Dutkowski P, Schonfeld S, Heinrich T, et al. Reduced oxidative stress during acellular reperfusion of the rat liver after hypothermic oscillating perfusion. Transplantation 1999; 68(1):44-50.

First case with LiverAssist in Romania Donor - 22-yr old female with polytrauma after car incident (including liver hematoma in segment 7). Marginal graft: resuscitated cardiac arrest, high doses of noradrenaline (1 microg/kgc/min the first 12 hours, followed by 0.5 microg/kgc/min until prelevation) associated in the last 24 hours with adrenaline (1 microg/kgc/min), hypernatremia (172 mEq/L).

Recipient - a 64-yr old male with HCC outside Milan Criteria (2 nodules – one of 5cm with previous TACE, and one of 2cm) on liver cirrhosis. The postoperative course was uneventful, with normal liver function. Discharged in POD 14 Regular follow-up at 6 months

Other sources for liver grafts 12 pts (1.8%) Methanol-poisoned donor 4 pts Liver graft trauma 5 pts Benign tumors in liver graft 2 pts Takayasu’s syndrome in donor 1 pt Zota V, Popescu I, Ciurea S, Copaciu E, Predescu O, Costandache F, Turcu R, Herlea V, Tulbure D. Successful use of the liver of a methanol-poisoned, brain-dead organ donor. Transpl Int. 2003 Jun;16(6):444-6.

POD 19: Complete resolution of haematoma. Liver graft trauma Liver graft hematoma 51-year old recipient; transplanted for HCC on VHC cirrhosis. POD 19: Complete resolution of haematoma. POD 5: Haematoma in S7 of liver graft.

Liver graft laceration Donor: 19-yr old woman, Politrauma after car accident (head and abdominal injuries – spleen rupture, right kidney hematoma and liver laceration in S6-7); Operated for abdominal trauma (splenectomy, hemostasis for liver laceration); Cause of death severe head trauma; Atypical resection of the hepatic laceration on back table; In situ hemostasis of the cut surface. Recipient: 53-yr old male Alcoholic cirrhosis, MELD 11 Follow-up: alive and well at 4 months.

Benign tumors in liver graft Donor: 23-yr old female, severe head trauma graft with adenoma S5-6 (resected on back-table). Recipient: 41-yr old male Alcoholic cirrhosis, MELD 21. Follow-up: alive and well at 12 months.

Particular cases of whole organ LT 39-yr old man Polycystic liver disease - highly symptomatic due to liver volume (23,200 cm3), whith severe physical and social handicaps LT in April 2011 Currently alive, with no complications.

Budd-Chiari syndrome, with complete thrombosis of retrohepatic IVC. 24-yr old man Budd-Chiari syndrome, with complete thrombosis of retrohepatic IVC. Idiopathic thrombophilia. Thrombosis of hepatocaval confluence Thrombosis of retrohepatic IVC.

Cavo-caval anastomosis (inferior). LT in April 2014 Currently alive with no complications. Cavo-atrial anastomosis (superior). Cavo-caval anastomosis (inferior).

Split liver LT (10 procedures) Needs donors with normal liver anatomy and no risk factors for compromised graft function; Currently Split LT accounts for ~ 5% of total LTs, but ~20% of donors are potential candidates → they have to be properly identified; Comparable survival results after in-situ split LT with those for conventional LT; ↑incidence of biliary and vascular complications. deLemos AS, Vagefi PA. Expanding the Donor Pool in Liver Transplantation: Extended Criteria Donors. Clinical Liver Disease, Vol 2, No 4, 2013, 156-159. Goss JA, Yersiz H, Shackleton CR, et al.:In situ splitting of the cadaveric liver for transplantation. Transplantation 1997, 64:871–877. Rogiers X, Malago M, Gawad K, et al. In situ splitting of cadaveric livers. Ann Surg 1996, 224:331–341. Vagefi PA, Parekh J, Ascher NL, Roberts JP, Freise CE. Outcomes with split liver transplantation in 106 recipients: the University of California, San Francisco, experience from 1993 to 2010. Arch Surg 2011;146:1052-1059

SURGICAL TECHNIQUE

SURGICAL TECHNIQUE Drawbacks: Lengthy procedure with prolonged cold ischemic time; Increased inflammatory response on reperfusion; Poor function of the graft; EX-VIVO SURGICAL TECHNIQUE Prolonged procurement time; More experienced surgeon. IN-SITU

Split Liver Procedures 10 Split LTs – 20 recipients * 1 Split LT – Domino LT (adult) Adult + child Adult + adult Adult + child Adult * + child Adult + child Adult + child Adult + child

Adult-child split LT Donor: 38-yr old male, severe head trauma in car crash. Recipient 1: 21-yr old male; Cryptogenic cirrhosis; Extended right lobe LT (1350ml). Recipient 2: 9-yr old female; Cryptogenic cirrhosis; Left lateral section LT (350ml). Follow-up: No complications at 10 months.

Adult-adult split LT Donor: 21-yr old male, severe head trauma in car crash. Recipient 1: 18-yr old male; Acute liver failure (Wilson’s disease); Right lobe LT (890ml). Recipient 2: 24-yr old female; Cryptogenic cirrhosis; Left lobe LT (496ml). Follow-up: No complications at 44 months.

Domino LT (1 LT) Recipient & Marginal donor Marginal recipient Donor with hereditary metabolic disease: familial amyloidotic polyneuropathy; familial hypercholesterolemia. Marginal recipient (i.e. with cirrhosis + HCC) Donor A 21-year-old female patient, diagnosed with FHC when she was 7 years old, was referred to the Fundeni Clinical Institute in April 2001 and placed on the waiting list for liver transplantation. On admission, the patient exhibited xanthomas on the buttocks, elbows, and knees, and xanthelasmas. The cardiac investigation revealed coronary atherosclerosis with stenosis of the right coronary artery at its origin, congenital bicuspid aortic valve, aortic regurgitation, and aortic stenosis. Coronary artery dilatation was not considered necessary at that time. Her serum cholesterol was 500 mg/dL with simvastatin treatment (Zocor; Merck and Co., Inc., Whitehouse Station, NJ); without treatment it had reached 800 mg/dL. Her LDL cholesterol and triglyceride levels were 286 mg/dL and 84 mg/dL, respectively. The family history indicated hereditary disease. The mother, 46 years old, had serum cholesterol and triglyceride levels of 372 mg/dL and 408 mg/dL, respectively; the father, 48 years old, had serum cholesterol and triglyceride levels of 400 mg/dL and 160 mg/dL, respectively. Both parents had high blood pressure and mild systemic atherosclerosis. The 24-year-old sister of the patient was apparently in good health. Popescu I, Simionescu M, Tulbure D, Sima A, Catana C, Niculescu L, Hancu N, Gheorghe L, Mihaila M, Ciurea S, Vidu V. Homozygous familial hypercholesterolemia: specific indication for domino liver transplantation. Transplantation. 2003 Nov 15;76(9):1345-50 Popescu I, Habib N, Dima S, Hancu N, Gheorghe L, Iacob S, Mihaila M, Dorobantu B, Matei E, Botea F. Domino liver transplantation using a graft from a donor with familial hypercholesterolemia: seven-yr follow-up. Clin Transplant. 2009 Aug-Sep;23(4):565-70. Popescu I, Dima SO. Domino liver transplantation: how far can we push the paradigm? Liver Transpl. 2012 Jan;18(1):22-8. Liu C, Niu DM, Loong CC, Hsia CY, Tsou MY, Tsai HL, Wei C . Domino liver graft from a patient with homozygous familial hypercholesterolemia Pediatr Transplant. 2010 May;14(3):E30-3.

Domino LT (combined with Split LT) Adult with familial Hypercholesterolemia Child with glycogenosis split HCC on cirrhosis domino 1 Deceased Donor – 3 LTs Popescu I, Simionescu M, Tulbure D, Sima A, Catana C, Niculescu L, Hancu N, Gheorghe L, Mihaila M, Ciurea S, Vidu V. Homozygous familial hypercholesterolemia: specific indication for domino liver transplantation. Transplantation. 2003 Nov 15;76(9):1345-50 Popescu I, Habib N, Dima S, Hancu N, Gheorghe L, Iacob S, Mihaila M, Dorobantu B, Matei E, Botea F. Domino liver transplantation using a graft from a donor with familial hypercholesterolemia: seven-yr follow-up. Clin Transplant. 2009 Aug-Sep;23(4):565-70. Popescu I, Dima SO. Domino liver transplantation: how far can we push the paradigm? Liver Transpl. 2012 Jan;18(1):22-8.

Living donor LT One of the most remarkable steps in the field of LT. Unique source of grafts because the liver is directed to only one specified candidate, with no the need for an allocation system; For pediatric patients – main source of donors For adults – good indication in selected cases. Schiano T.D., Kim-Schluger L., Gondolesi G., Miller C.M. Adult living donor liver transplantation: the hepatologist’s perspective. Hepatology 2001;33(1):3-9. Middleton P., Duffield M., Lynch S., Padbury R.T., House T., Stanton P., et al. Living donor liver transplantation-Adult donor outcomes: A systematic review. Liver Transplantation 2005;12(1):24-30

128 in 126 pts 2 pts

LDLT – 128 procedures in 126 pts ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )

Advantages: Disadvantages: can be performed on an elective basis, with optimal timing and no waiting time for the recipient; graft in excellent condition (preselected graft, healthy donor); short ischemic time; extended indications (i.e. HCC beyond Milan criteria). Disadvantages: mortality in donors, even though <1%; higher rate of vascular (5-15%) and biliary (10-30%) complications for both donor and recipient; risk of small-for-size syndrome. Schiano T.D., Kim-Schluger L., Gondolesi G., Miller C.M. Adult living donor liver transplantation: the hepatologist’s perspective. Hepatology 2001;33(1):3-9. Middleton P., Duffield M., Lynch S., Padbury R.T., House T., Stanton P., et al. Living donor liver transplantation-Adult donor outcomes: A systematic review. Liver Transplantation 2005;12(1):24-30

Surgical technique RHV MHV RIGHT HEMILIVER LDLT with MHV RHV+MHV IVC

RIGHT HEMILIVER LDLT without MHV with venous reconstruction

Dual LDLT (2 LTs) Dual graft LDLT proved to be an efficient method to increase the pool donor, avoiding in the same time small-for-size grafts. Since the first case was published in 2001 by Lee SG et al, to date a total of 243 cases are reported worldwide. 2 indications for dual graft LDLT: when 2 donors are rejected for RL donation (due to anatomical variations of the liver hilum or insufficient remnant liver volume), but they can donate their left lobe or left lateral section for dual graft LDLT; when a right lobe graft is available but considered insufficient (as volume or have significant liver steatosis), is supplemented with a left lobe or a left lateral section from a second donor. Lee SG, Hwang S, Park KM, et al. An adult-to-adult living donor liver transplant using dual left lobe grafts. Surgery 2001;129:647-50. Lee SG, Hwang S, Park KM, et al. Seventeen adult-to-adult living donor liver transplantations using dual grafts. Transplant Proc 2001;33:3461-3. Lee SG. Living-donor liver transplantation in adults . Br Med Bull. 2010;94:33-48.

15-year old female with acute liver failure due to Wilson’s disease First case of dual LDLT in Romania. 2nd Donor 19-year old female (sister) right hemiliver GV/SLV = 40.9% GRWR = 0.76 1st Donor 38-year old female (mother) left lateral section GV/SLV =15.5% GRWR = 0.33 Recipient 15-year old female with acute liver failure due to Wilson’s disease Combined GV/SLV = 56.4% GRWR = 1.10 Botea F, Braşoveanu V, Constantinescu A, Ionescu M, Matei E, Popescu I. Living donor liver transplantation with dual grafts -- a case report. Chirurgia (Bucur). 2013 Jul-Aug;108(4):547-52

2nd Donor 1st Donor Recipient Intraoperative image of the preparation for porto-portal anastomosis of the left graft. The iliac vein graft reconstructing the venous drainage from V5 & V8 can be seen on the cut surface of the right graft. Intraoperative image during hepatocaval anastomosis for the left lateral section graft, with the right lobe graft in place and re-vascularized. 2nd Donor 1st Donor Recipient Botea F, Braşoveanu V, Constantinescu A, Ionescu M, Matei E, Popescu I. Living donor liver transplantation with dual grafts -- a case report. Chirurgia (Bucur). 2013 Jul-Aug;108(4):547-52

36 months follow-up: no complications in recipient & donors. Postoperative CT scan (POD 6): patent grafts. 36 months follow-up: no complications in recipient & donors. Botea F, Braşoveanu V, Constantinescu A, Ionescu M, Matei E, Popescu I. Living donor liver transplantation with dual grafts -- a case report. Chirurgia (Bucur). 2013 Jul-Aug;108(4):547-52

Postoperative results Postoperative mortality rate: 7.8% ; Retransplantation rate: 4.4% ; Major postoperative complication rate: 42.6% . Retransplantation 21 after DDLT 13 after LDLT Graft-related postoperative complications: Biliary - 11% Arterial - 17.6% Portal - 2.4% Venous - 0.7%

Retransplantation (34 pts, 4.4%) CAUSE FOR RETRANSPLANTATION Pts % Immediate ReLT primary non-function 7 0.9 hyperacute rejection 1 0.1 hepatic artery thrombosis 14 1.8 portal vein thrombosis small-for-size syndrome 2 0.3 Late ReLT HCV recurrence 5 0.6 chronic rejection 3 0.4 Primary cholangiosclerosis recurrence

Retransplantation TYPE OF RETRANSPLANTATION Primary LT Deceased LT (21 pts: 20 WLT & 1 reduced LT) LDLT (13 pts: 12 LDLT & 1 dual LT) ReLT Whole LT (18 pts) Split LT (2 pts) LDLT (1 pt) Whole LT (8 pts) Reduced LT (3 pts)

Long-term results Overall long-term survival 1-yr 88.8% 3-yr 82.5%

Program objectives Reduction of WL drop-out rate (due to mortality and morbidity) by shortening the time on WL Providing the liver grafts for urgent liver transplantation: Acute liver failure Emergency re-transplantation Proper recipient selection to obtain best results after transplantation

Solutions Increasing the number of the deceased donors (brain-dead and non heart-beating donors) Extended criteria for organ acceptance (marginal grafts) Increasing the number of surgical variant LT procedures in experienced center: Living donor liver transplantation Technical variant grafts: Split liver transplantation Dual graft liver transplantation Domino liver transplantation Opening new LT centers “Sfanta Maria” Hospital in Bucharest “Sfantul Spiridon” Hospital in Iasi

Increasing the number of the deceased donors Increase the donor pool by: Optimizing the laws for organ donation Improving the LT program Education of medical professionals and the public Increasing the consent rate Improving the donor hospital efficiency Regional motivation for increasing the donor rate by opening regional LT center – “Sfantul Spiridon” Hospital in Iasi

CONCLUSIONS Implementation of proper measures to increase the number of the deceased donors are mandatory to extend the donor pool. The use of extended criteria is an efficient method to extend the donor pool, with good recipient survival rates. Surgical variant LT procedures (LDLT, Split LT, Dual LDLT, and Domino LT are good methods to increase the number of LTs. Proper donor-recipient matching is the key for the optimal use of marginal and surgical variant grafts.

Multidisciplinarity is the main feature of a LT program, that involves many disciplines like surgery, imaging, endoscopy, interventional radiology, microbiology, pathology, psychology, etc. The new regional transplant centers (“Sf Maria Hospital” -Bucharest, and “Sf Spiridon Hospital” – Iasi) may be the key to increase donation rate and the overall number of LTs. Opening the new LT programs was justified when the main program (at “Fundeni” Institute) has reached its limits. Using the LiverAssist device to improve marginal grafts will insure better results in such LTs New challenges are to be faced in order to maintain and to further develop this program, in the context of political and economical crisis.