Chapter 82: Liver Retransplantation

INTRODUCTION

• The only chance of survival for patients transplanted with irreversible graft failure is liver retransplantation (LRT). Regardless of the time of onset of graft failure, either during the early (30 days) or in the late posttransplant periods, LRT often remains a challenge for transplant surgeons, transplant centers, and health systems worldwide.

• LRT provides the benefit for survival of patients with graft failure despite related inherent ethical issues and logistical, economic, and social costs. Therefore, developing and establishing better selection policies are crucial.^1,2

INCIDENCE

• Over the past decade, the incidence of LRT decreased below 10% worldwide, accounting currently for approximately 5% to 7% in adult patients transplanted in the United States and Europe.^3,4 Between 2011 and 2013, 9% of pediatric liver transplants performed in the United States were LRT.⁵

INDICATIONS OF EARLY LRT

Early LRT is defined as repeated LT performed in a period of time ≤30 days after primary liver transplant (PLT). Together, primary nonfunction (PNF) of the liver graft and vascular complications, including hepatic artery thrombosis (HAT) and portal vein thrombosis (PVT), are the leading causes for early LRT in at least 50% of recipients.^6–13

INDICATIONS OF LATE LRT

• The main reported causes leading to late LRT are recurrent disease in 5.5% to 25%^9,14 and biliary complications in 11% to 16%.^14,15

  • The recurrence of autoimmune liver disease, viral hepatitis, especially hepatitis C virus (HCV) infection, recurrence of tumor disease, and biliary complications, are the main causes of irreversible graft failure and are leading indications for late LRT.^1-13

  • In an analysis based on the United Network for Organ Sharing (UNOS) database (1996–2005), chronic rejection and recurrent hepatitis were indications for approximate 26% and 28% of LRT after 1 year of PLT, respectively.¹⁶

LATE SURGICAL COMPLICATIONS

• Biliary:

• Late HAT and PVT

TECHNICAL SURGICAL ASPECTS IN RETRANSPLANTATION

• LRT is a surgical challenge that should be assumed by experienced surgeons at high-volume centers, where the chances of success could be amplified and the inherent technical difficulties anticipated. The time when retransplantation should be done has very important logistical and surgical implications.

• HAT during the first few weeks, PNF, and early allograft dysfunction (EAD) place the recipient in a state of emergency and medical severity (UNOS status A1, a Model for End-Stage Liver Disease [MELD] score exception of 40 is given in the waiting list (Table 82-1). Despite the delicate clinical condition of the recipient, early LRT has the advantage of fewer adhesions, allowing comfortable and safe vascular control. If graft failure persists beyond the first week, serious complications such as sepsis and multiorgan failure may be present at the time of LRT indication.

• For the preoperative logistical planning it is essential to differentiate between ...