| Abstract|| |
Over the last decade, orthotopic liver transplantation (OLT) has become an established therapy for end-stage liver disease of various etiologies. The early experience with orthotopic liver transplantation in the Kingdom was in 1990 in the Military Hospital when a man with sclerosing cholangitis received a new liver successfully. Intensive effort was done at King Faisal Specialist Hospital and Research Center (KFSH & RC) to start liver transplantation and that was achieved in March 1994 when a man with an end-stage liver failure secondary to hepatitis C was transplanted successfully. Since then, forty four (44) more liver transplantations were done at KFSH & RC. The age of the patients transplanted ranged from 9-65 years old; there were more males than females, (26 males, 15 females). The waiting time until transplantation was up to one year. All patients received a combination of cyclosporin and prednisolone as an induction therapy ± Azathioprime. The majority of patients developed minor complications like wound infection and acute mild cellular rejection. In the second year, 3 out of 18 patients also developed primary nonfunction. Also in the first year, the majority of the patients developed primary dysfunction; however, this decreased significantly in the second year. The majority of the patients who were transplanted for hepatitis C had mild recurrence. None of them lost their livers because of recurrence of hepatitis C. Several patients developed biliary complications including bile leak and stricture at duct-to-duct anastomosis.
Keywords: Liver transplantation, Saudi Arabia, Liver failure.
|How to cite this article:|
Rezeig M, Nezamuddin N, Abdulkarim A, Pruet T, Ali A, Ahmed R, Al Quaiz M, Shabib S. Orthotopic Liver Transplantation at King Faisal Specialist Hospital and Research Center: 1994-1995. Saudi J Kidney Dis Transpl 1996;7:182-4
|How to cite this URL:|
Rezeig M, Nezamuddin N, Abdulkarim A, Pruet T, Ali A, Ahmed R, Al Quaiz M, Shabib S. Orthotopic Liver Transplantation at King Faisal Specialist Hospital and Research Center: 1994-1995. Saudi J Kidney Dis Transpl [serial online] 1996 [cited 2020 Mar 28];7:182-4. Available from: http://www.sjkdt.org/text.asp?1996/7/2/182/39524
| Introduction|| |
The first successful OLT to be performed in a human was by Thomas Starzl in 1963. The introduction of cyclosporine in 1979 improved the results of liver transplantation enormously from 30% to 80% and decreased the rate of complications. There are now, at least 104 liver transplant centers in Europe and over 90 in the United States performing more than 6,000 liver transplantations every year. By end of 1994, over 40,000 liver transplantations have been performed. OLT is now a well established method of treatment for end-stage liver disease as well as certain metabolic conditions and congenital abnormalities (e.g. biliary atresia).
Currently, patients with chronic liver disease due to HBsAg are not considered for transplantation at King Faisal Specialist Hospital and Research Center (KFSH & RC) and other institutions as aggressive recurrence of the disease occurs that results in failure of the transplanted liver. Similarly, patients with hepatocellular carcinoma, which unfortunately is common in Kingdom of Saudi Arabia (KSA) are not good candidates for ortho-topic liver transplantation (OLT) due to high rates of recurrence and mortality, hepatitis C viral (HCV) infection, while it recurs after transplantation, follows an indolent slow progression and transplantation therefore, is not contraindicated. Autoimmune liver damage is another indication for transplantations but is rare in KSA. Similarly, primary Biliary Cirrhosis and primary sclerosing cholangites are good indications for transplantation but again are rare in KSA.
Liver disease is prevalent in the Kingdom of Saudi Arabia. The prevalence of HCV and HBsAg is 2-4% and 9% respectively , . Wilson's disease is also prevalent  . It is estimated that 200 patients will require liver transplantation every year. In 1992, 52 patients went to USA for liver transplantation (with a cost of SR 1,000,000 to 4,000,000 per transplant, in addition to the social hardship). It was therefore, decided to offer liver transplantation within the Kingdom at an international standard. With governmental support and in the presence of existing excellent infrastructure at KFSH & RC, the liver transplant program commenced in March 1994, when the first transplant of a Saudi patient with end-stage liver disease was carried out.
| Patients|| |
Over the last 2 years 45 OLT were performed in 41 patients. The indications are shown in [Table - 1]. There were 26 males and 15 females. The age of the patients ranged between 9-65 years and 8 were below 15 years of age. The waiting time for transplantation ranged between few days to one year. All patients received a combination of cyclosporin and prednisolone as an induction therapy ± Azathioprime.
| Results|| |
Experience in 1994
Twenty-three patients received OLT in 1994. Six of these developed primary nonfunction. All died because of unavailability of a liver for re-transplantation (except in one who had re-transplantation within 24 hours). Six percent of the remaining patients developed primary dysfunction (AST > 300 and PT>20). Of these, half remained in ICU for prolonged periods (> 3 months in some cases). About 10% of the patients had intraabdominal hemorrhage requiring re-exploration and transfusion. Three patients required ventilation for more than 2 weeks. One patient died from Central nervous System fungal infection. Sixty percent of the patients developed acute rejection which was reversible by steroids and/or muromonab OKT3 except in one case (who also did not respond to OKT3 and died of Sepsis). The overall survival rate for the 1994 group was 65% (15 out of 23).
Experience in 1995
Only 3 out of 18 patients had primary nonfunction and all died due to nonavailability of liver for re-transplantation. Out of the four patients listed as status IV and transplanted (two with Fulminant Wilson's Disease, one with Congenital Hepatic Fibrosis and one with Hepatitis B. Two died and two are still alive and well. Of the remaining 14 patients with status I & II, three died (two with primary non-function and one due to acute hepatic artery thrombosis).
Three patients developed biliary complications (two biliary leaks and one biliary structure). All were successfully corrected. Therefore, of the patients with status IV, the survival rate was 50% (two out of four). The survival rate for the patients with status I & II was 79% (11 out of 14). The overall survival rate for the whole group transplanted in 1995 was 73% (13 out of 18). During the follow-up of the entire group 80% of the 22 patients with HCV developed recurrence but this was mild and only two required therapy with interferon and none lost their grafts from recurrence of viral hepatitis. The overall survival rate for the entire group (1994-1995) was 68%.
| Discussion|| |
Over the last decade, OLT has become an established therapy for end stage liver disease of various etiologies. Early experience with OLT in the KSA was at the Military Hospital, when one of the patients with primary sclerosing cholangitis was transplanted in 1990. The intensive efforts at KFSH & RC to establish liver transplantation including the process of referral, evaluation, selection, discussion in the liver transplant committee, listing, transplantation, postoperative care, as well as dealing with complications proved to be successful.
The major problem which we faced, especially in the first year, was primary nonfunction of the transplanted livers which happened in over 25% of the cases. This was higher than expected internationally. Also, the rate of dysfunction was also elevated. This complication decreased significantly in 1995; however, frequency is still higher than expected internationally ,, .
The rate of the other complications was not higher than expected, and the results, especially in 1995, were similar to those published elsewhere. The KFSH & RC is proud of providing high quality care for the patients in Saudi Arabia. The infrastructure in our hospital is at an international level and it is revised annually and certified by international certifying bodies. This facilitated the success of liver transplantation.
The future of liver transplantation at KFSH & RC would be brighter with plans to introduce pediatric and live related liver transplantation as well as encourage clinical and basic research.
The success in establishing liver transplantation of KFSH & RC was made possible by so many dedicated personnel; secretarial, procurement and clinical coordinators, intensive care and operating room nurses, physicians, anesthetists, pathologists, nurses in the wards and outpatient clinics, in addition to a group of dedicated surgeons and hepatologists strongly interested to establish liver transplantation, besides a major support from all the administration in the hospital and computer department.
| Acknowledgements|| |
I thank Menchita Denosta Baluran and Barbara Miligan for their superb secretarial work and dedication to get things done.
| References|| |
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|3.||Awada A, Al-Rajeh S, Al Qrain A, Al Ghassab G. Wilson's disease in Saudi Arabian female patient. Rapid changes in cerebral x-ray computed tomography. Rev Neurol Paris 1990;146(4):306-7. |
|4.||Martinez IV, Iglesias J, Lloret J, Barat G, Boix J. Seven years' experience with hepatic transplantation in children. Cir Pediatr 1993;6(l):7-10. |
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|6.||Mirza DF, Goetzinger P, Fuegger R, Wamser P, Steininger R, Muehlbacher F. Orthotopic liver transplantation in the management of end stage liver disease: the University of Vienna experience. Indian J Gastroenterol 1991;10(3):92-5. |
Director of Liver Transplant Unit, P. O.ot3354, Riyadh 11211
[Table - 1]