Difference between revisions of "Liver transplantation"

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(Techniques)
Line 184: Line 184:
  
 
===Results===
 
===Results===
* Prognosis is quite good.
+
* [[Prognosis]] is quite good:
 
** 1-year survival is 83%  
 
** 1-year survival is 83%  
 
** 5-year survival is 76%  
 
** 5-year survival is 76%  
 
** 10-year survival is 66%
 
** 10-year survival is 66%
* Majority of deaths happen during the first three months after transplantation.
+
* Majority of deaths happen during the first three months after [[Organ transplant|transplantation]].
  
 
===Living donor transplantation===
 
===Living donor transplantation===
* ''Living donor liver transplantation'' (LDLT) has emerged in recent decades as a critical [[Surgery|surgical]] option for patients with end stage liver disease, such as [[cirrhosis]] and/or [[hepatocellular carcinoma]] often attributable to one or more of the following: long-term [[Alcoholism|alcohol]] abuse, long-term untreated [[Hepatitis C]] infection, long-term untreated [[Hepatitis B]] infection.
+
* ''Living donor liver transplantation'' (LDLT) has emerged in recent decades as a critical [[Surgery|surgical]] option for patients with end stage liver disease, such as [[cirrhosis]] and/or [[hepatocellular carcinoma]] often attributable to one or more of the following:
* The concept of LDLT is based on (1) the remarkable regenerative capacities of the human liver and (2) the widespread shortage of [[cadaver]]ic livers for patients awaiting [[Organ transplant|transplant]]. In LDLT, a piece of healthy liver is surgically removed from a living person and transplanted into a recipient, immediately after the recipient’s diseased liver has been entirely removed.   
+
** Long-term [[Alcoholism|alcohol]] abuse
* Historically, LDLT began as a means for parents of children with severe liver disease to donate a portion of their healthy liver to replace their child's entire damaged liver.  
+
** Long-term untreated [[Hepatitis C]] infection  
* The first report of successful LDLT was by Dr. [[Silvano Raia]] at the Universidade de São Paulo (USP) Medical School in 1986.  
+
** Long-term untreated [[Hepatitis B]] infection  
* Surgeons eventually realized that adult-to-adult LDLT was also possible, and now the practice is common in a few reputable medical institutes.  
+
* The concept of LDLT is based on:
* It is considered more technically demanding than even standard, cadaveric donor liver transplantation, and also poses the ethical problems underlying the indication of a major surgical operation ([[hepatectomy]]) on a healthy human being.
+
** Remarkable regenerative capacities of the human [[liver]] 
 +
** Widespread shortage of [[cadaver]]ic livers for patients awaiting [[Organ transplant|transplant]]
 +
* In LDLT, a piece of healthy [[liver]] is surgically removed from a living person and transplanted into a recipient, immediately after the recipient’s diseased [[liver]] has been entirely removed.   
 +
* Historically, LDLT was used as a means for parents of children with severe [[liver]] disease to donate a portion of their healthy [[liver]] to replace the damaged [[liver]] of their children.  
 +
* In 1986, the first successful LDLT was performed at the Universidade de São Paulo (USP) Medical School, by Dr. [[Silvano Raia]].  
 +
* More technically demanding than standard, cadaveric donor liver transplantation  
 +
* Has faced several [[Ethics committee (disambiguation)|ethical]] problems
 
===Complications of Liver Transplantation===
 
===Complications of Liver Transplantation===
 
* Complications that may develop in [[Organ transplant|transplant]] recipients include the following:<ref name="pmid9546022">{{cite journal |vauthors=Savitsky EA, Uner AB, Votey SR |title=Evaluation of orthotopic liver transplant recipients presenting to the emergency department |journal=Ann Emerg Med |volume=31 |issue=4 |pages=507–17 |year=1998 |pmid=9546022 |doi= |url=}}</ref>  
 
* Complications that may develop in [[Organ transplant|transplant]] recipients include the following:<ref name="pmid9546022">{{cite journal |vauthors=Savitsky EA, Uner AB, Votey SR |title=Evaluation of orthotopic liver transplant recipients presenting to the emergency department |journal=Ann Emerg Med |volume=31 |issue=4 |pages=507–17 |year=1998 |pmid=9546022 |doi= |url=}}</ref>  
Line 247: Line 253:
  
 
==== Acute and chronic graft rejection ====
 
==== Acute and chronic graft rejection ====
Acute graft rejection:<ref name="pmid9546022">{{cite journal |vauthors=Savitsky EA, Uner AB, Votey SR |title=Evaluation of orthotopic liver transplant recipients presenting to the emergency department |journal=Ann Emerg Med |volume=31 |issue=4 |pages=507–17 |year=1998 |pmid=9546022 |doi= |url=}}</ref>
+
[[Acute (medicine)|Acute]] [[graft]] [[Transplant rejection|rejection]]:<ref name="pmid9546022">{{cite journal |vauthors=Savitsky EA, Uner AB, Votey SR |title=Evaluation of orthotopic liver transplant recipients presenting to the emergency department |journal=Ann Emerg Med |volume=31 |issue=4 |pages=507–17 |year=1998 |pmid=9546022 |doi= |url=}}</ref>
 
* Occurrence: roughly 20-70 percent patients
 
* Occurrence: roughly 20-70 percent patients
 
* Timing: 1-2 weeks post- transplantation
 
* Timing: 1-2 weeks post- transplantation
* Outcome: Graft dysfunction
+
* Outcome: [[Graft]] dysfunction
 
* Clinical presentation:  
 
* Clinical presentation:  
** Jaundice
+
** [[Jaundice]]
** Fever  
+
** [[Fever]]
** Liver tenderness
+
** Liver [[tenderness]]
** Eosinophilia
+
** [[Eosinophilia]]
 
* Laboratory evidence:  
 
* Laboratory evidence:  
** Abnormal liver function tests
+
** Abnormal [[liver function tests]]
** Elevated Bilirubin  
+
** Elevated [[Bilirubin]]
** Elevated alkaline phosphatase levels  
+
** Elevated [[alkaline phosphatase]] levels  
 
** Elevation of hepatocellular enzymes:  
 
** Elevation of hepatocellular enzymes:  
*** Alanine aminotransferase (ALT)  
+
*** [[Alanine transaminase|Alanine aminotransferase]] ([[Alanine transaminase|ALT]])  
*** Aspartate aminotransferase (AST)  
+
*** [[Aspartate transaminase|Aspartate aminotransferase]] ([[Aspartate transaminase|AST]])  
* Treatment of acute rejection:  
+
* Treatment of [[Acute (medicine)|acute]] [[Transplant rejection|rejection]]:  
** High-dose steroids:
+
** High-dose [[Steroid|steroids]]:
*** Prednisolone 200 mg  
+
*** [[Prednisolone]] 200 mg  
*** Methylprednisolone 1 g for 3 days)  
+
*** [[Methylprednisolone]] 1 g for 3 days)  
*** High-dose steroid bolus followed by a rapid taper over 1 week
+
*** High-dose [[steroid]] bolus followed by a rapid taper over 1 week
  
 
* Alternative therapies include:  
 
* Alternative therapies include:  
** Antibody treatments:
+
** [[Antibody]] treatments:
*** Monoclonal therapy (OKT3 )
+
*** [[Monoclonal antibodies|Monoclonal]] therapy (OKT3 )
*** Antithymocyte globulin
+
*** Antithymocyte [[globulin]]
Chronic graft rejection:   
+
[[Chronic (medical)|Chronic]] [[graft]] [[Transplant rejection|rejection]]:   
* Occurence: 5% of patients  
+
* Occurence: 5% of [[Patient|patients]]
* Main cause of late stage graft failure  
+
* Main cause of late stage [[graft]] failure  
* Features of chronic graft rejection include:  
+
* Features of [[Chronic (medical)|chronic]] [[Transplant rejection|graft rejection]] include:  
** Gradual obliteration of small bile ducts  
+
** Gradual obliteration of small [[Bile duct|bile ducts]]
 
** Microvascular changes  
 
** Microvascular changes  
 
* Symptoms:  
 
* Symptoms:  
** Jaundice  
+
** [[Jaundice]]
** Pruritu
+
** [[Itch|Pruritus]]
 
* Laboratory investigations:  
 
* Laboratory investigations:  
** Elevated serum alkaline phosphatase  
+
** Elevated serum [[alkaline phosphatase]]
** Elevated bilirubin levels  
+
** Elevated [[bilirubin]] levels  
* Gold standard diagnostic modality: Liver biopsy
+
* Gold standard diagnostic modality: [[Liver biopsy]]
  
 
==== Infection ====
 
==== Infection ====
* <1 month : Common conditions developing in patients in the early posttransplant period include intra-abdominal infections such as:
+
* <1 month : Common conditions developing in [[Patient|patients]] in the early posttransplant period include intra-[[Abdomen|abdominal]] [[Infection|infections]] such as:
** Cholangitis
+
** [[Cholangitis]]
** Liver abcess
+
** [[Liver abscess]]
** Abdominal abcess
+
** [[Abscess|Abdominal abscess]]
  
* 1-6 months: Infections commonly occur due to:
+
* 1-6 months: [[Infection|Infections]] commonly occur due to:
** Viruses  
+
** [[Virus|Viruses]]
** Opportunistic organisms
+
** Opportunistic [[Organism|organisms]]
  
* After the first 6 months, risk of infection in transplant patients is equal to that of the population.
+
* After the first 6 months, risk of [[infection]] in transplant patients is equal to that of the population.
  
* Infection is primarily nosocomial. Common organisms responsible for causing infection post-transplant are as follows:   
+
* [[Infection]] is primarily [[Nosocomial infection|nosocomial]]. Common [[Organism|organisms]] responsible for causing [[infection]] post-transplant are as follows:   
** Bacterial (most common):  
+
** [[Bacteria|Bacterial]] (most common):  
*** Enterococci  
+
*** [[Enterococcus|Enterococci]]
*** Staphylococci  
+
*** [[Staphylococcus aureus|Staphylococci]]
 
*** Gram-negative aerobes  
 
*** Gram-negative aerobes  
*** Anaerobes  
+
*** [[Anaerobic organism|Anaerobes]]
** Fungal: Candida (75% of fungal infections)   
+
** Fungal: [[Candidiasis|Candida]] (75% of fungal infections)   
 
** Presenting symptoms:  
 
** Presenting symptoms:  
*** Fever  
+
*** [[Fever]]
*** Abdominal pain   
+
*** [[Abdominal pain]]  
*** Jaundice  
+
*** [[Jaundice]]
  
 
* Laboratory investigations:  
 
* Laboratory investigations:  
 
** Complete blood count (CBC)  
 
** Complete blood count (CBC)  
 
** Serum chemistries   
 
** Serum chemistries   
** Liver function tests  
+
** [[Liver function tests]]
 
** Coagulation panel   
 
** Coagulation panel   
** Urinalysis  
+
** [[Urine|Urinalysis]]
** Urine culture   
+
** [[Urine culture]]  
** Blood culture   
+
** [[Blood culture]]  
 
* Imaging:   
 
* Imaging:   
 
** Abdominal radiographs   
 
** Abdominal radiographs   
** Chest radiographs   
+
** [[Chest X-ray|Chest radiographs]]  
 
** Computed tomography (CT)  
 
** Computed tomography (CT)  
 
** Abdominal ultrasonography  
 
** Abdominal ultrasonography  

Revision as of 13:59, 15 January 2018


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:


Overview

Liver transplantation or hepatic transplantation is the replacement of a diseased liver with a healthy liver allograft. The most commonly used technique is orthotopic transplantation, in which the native liver is removed and the donor organ is placed in the same anatomic location as the original liver. Liver transplantation nowadays is a well accepted treatment option for end-stage liver disease and acute liver failure.

Liver Transplantation

History

  • In the 1960s, Thomas Starzl used dogs as the first animals for research on liver transplantation in Boston and Chicago.
  • In 1963, the first liver transplant in humans was attempted by a surgical team led by Dr. Thomas Starzl[1] of Denver, Colorado, United States.
  • Dr. Starzl performed several additional transplants over the next few years before the first short-term success was achieved in 1967 with the first one-year survival post-transplantation.
  • In 1970, the regimen for immunosuppressive therapy following transplant was introduced, but azathioprine and steroids did not improve survival rates of patients.
  • In the 1980s, with the introduction of cyclosporine by Sir Roy Calne, there was an improvement in rejection rates.
  • In 1983, liver transplantation was no longer an experimental modality, but a clinically acceptable form of therapy for both adult and pediatric patients with appropriate indications.
  • In 1986, the introduction of monoclonal antibodies such as muromonab-CD3 [OKT3] further contributed to improvement of quality of immunosuppressive therapy used in patients, with significant decline in rejection rates.
  • In 1988, University of Wisconsin (UW) solution was developed, which ensured a smooth surgery and longer preservation period.
  • In 1992, the concept of xenotransplantation and cloning techniques were introduced by Starzl.
  • In 1999, approximately 5000 procedures were carried out, in contrast to 100 which had been performed a decade earlier.
  • Recently, the introduction of newer immunosuppressive agents such as IL-2 receptor blockers and tacrolimus, have drastically increased patient survival rates to 1 and 5-year rates of approximately 85 and 70 percent respectively.[2]
  • Liver transplantation is now performed at over one hundred centers in the USA, as well as numerous centers in Europe and elsewhere. One year patient survival is 85-90%, and outcomes continue to improve, although liver transplantation remains a formidable procedure with frequent complications.
  • Unfortunately, the supply of liver allografts from non-living donors is far short of the number of potential recipients, a reality that has spurred the development of living donor liver transplantation.
  • In December 2016, 147,128 liver transplants were performed in the US as compared to 7217 in 1998 based on data from the United Organ Sharing (UNOS) network.

Indications

Contraindications

Absolute contraindications: [3]

Relative contraindications:[3][4][5][6][7][8][9][10][11][12][13]

Pretransplant evaluation

Techniques

Orthotopic Liver Transplantation

Immunosuppressive management

Results

  • Prognosis is quite good:
    • 1-year survival is 83%
    • 5-year survival is 76%
    • 10-year survival is 66%
  • Majority of deaths happen during the first three months after transplantation.

Living donor transplantation

  • Living donor liver transplantation (LDLT) has emerged in recent decades as a critical surgical option for patients with end stage liver disease, such as cirrhosis and/or hepatocellular carcinoma often attributable to one or more of the following:
  • The concept of LDLT is based on:
    • Remarkable regenerative capacities of the human liver
    • Widespread shortage of cadaveric livers for patients awaiting transplant
  • In LDLT, a piece of healthy liver is surgically removed from a living person and transplanted into a recipient, immediately after the recipient’s diseased liver has been entirely removed.
  • Historically, LDLT was used as a means for parents of children with severe liver disease to donate a portion of their healthy liver to replace the damaged liver of their children.
  • In 1986, the first successful LDLT was performed at the Universidade de São Paulo (USP) Medical School, by Dr. Silvano Raia.
  • More technically demanding than standard, cadaveric donor liver transplantation
  • Has faced several ethical problems

Complications of Liver Transplantation

  • Immediate postoperative complications of liver transplantation include:
  • The most common causes of death in liver transplant patients are as follows:
  • To monitor the patient for complications, the following investigations are used:

Laboratory investigations

Imaging studies

Acute and chronic graft rejection

Acute graft rejection:[19]

Chronic graft rejection:

Infection

  • After the first 6 months, risk of infection in transplant patients is equal to that of the population.
  • Treatment of infection:
    • Antimicrobials prescribed for nonimmunosuppressed patients

Cytomegalovirus (CMV)

  • Most common viral infection (affects 25-85% patients)
  • Occurrence: Between posttransplant months 1 and 3
  • Infection may be:
    • Primary
    • Reactivated
  • Clinical presentation:
    • Fevers
    • Malaise
    • Arthralgias
  • Laboratory investigations:
    • Atypical lymphocytes
    • Thrombocytopenia
    • Mildly elevated transaminase levels
  • Imaging findings:
    • CXR: CMV pneumonitis patients may have bilateral infiltrates on CXR
  • Serology:Indirect immunofluorescence testing method
  • Treatment: Ganciclovir intravenously for 2-4 weeks

Pneumocystis carinii pneumonia (PCP)

  • May occur along with CMV infection or alone
  • Diagnosis:Bronchoalveolar biopsy
  • Treatment: Trimethoprim-sulfamethoxazole

Other less common organisms causing infection include:

  • Fungi (especially Candida species)
  • Herpes simplex
  • Herpes zoster
  • Toxoplasma
  • Hepatitis C virus (HCV)
  • Hepatitis B infection
  • Malignancy:
    • In transplant patients, malignancy is the second leading cause of late mortality.
    • Common malignancies occuring patients after transplantation include:
      • Lymphomas
      • Squamous cell carcinoma : SCC of skin is the most common malignancy that occurs pos-tranplantation
      • Posttransplant lymphoproliferative disorder

External Links


References

  1. STARZL T, MARCHIORO T, VONKAULLA K, HERMANN G, BRITTAIN R, WADDELL W. "HOMOTRANSPLANTATION OF THE LIVER IN HUMANS". Surg Gynecol Obstet. 117: 659–76. PMID 14100514. 
  2. Kanwal F, Dulai GS, Spiegel BM, Yee HF, Gralnek IM (2005). "A comparison of liver transplantation outcomes in the pre- vs. post-MELD eras". Aliment. Pharmacol. Ther. 21 (2): 169–77. PMID 15679767. doi:10.1111/j.1365-2036.2005.02321.x. 
  3. 3.0 3.1 Martin P, DiMartini A, Feng S, Brown R, Fallon M (2014). "Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation". Hepatology. 59 (3): 1144–65. PMID 24716201. 
  4. Mathurin P, Moreno C, Samuel D, Dumortier J, Salleron J, Durand F, Castel H, Duhamel A, Pageaux GP, Leroy V, Dharancy S, Louvet A, Boleslawski E, Lucidi V, Gustot T, Francoz C, Letoublon C, Castaing D, Belghiti J, Donckier V, Pruvot FR, Duclos-Vallée JC (2011). "Early liver transplantation for severe alcoholic hepatitis". N. Engl. J. Med. 365 (19): 1790–800. PMID 22070476. doi:10.1056/NEJMoa1105703. 
  5. Cooper C, Kanters S, Klein M, Chaudhury P, Marotta P, Wong P, Kneteman N, Mills EJ (2011). "Liver transplant outcomes in HIV-infected patients: a systematic review and meta-analysis with synthetic cohort". AIDS. 25 (6): 777–86. PMID 21412058. doi:10.1097/QAD.0b013e328344febb. 
  6. Mindikoglu AL, Regev A, Magder LS (2008). "Impact of human immunodeficiency virus on survival after liver transplantation: analysis of United Network for Organ Sharing database". Transplantation. 85 (3): 359–68. PMID 18301332. doi:10.1097/TP.0b013e3181605fda. 
  7. Terrault NA, Roland ME, Schiano T, Dove L, Wong MT, Poordad F, Ragni MV, Barin B, Simon D, Olthoff KM, Johnson L, Stosor V, Jayaweera D, Fung J, Sherman KE, Subramanian A, Millis JM, Slakey D, Berg CL, Carlson L, Ferrell L, Stablein DM, Odim J, Fox L, Stock PG (2012). "Outcomes of liver transplant recipients with hepatitis C and human immunodeficiency virus coinfection". Liver Transpl. 18 (6): 716–26. PMC 3358510Freely accessible. PMID 22328294. doi:10.1002/lt.23411. 
  8. Cross TJ, Antoniades CG, Muiesan P, Al-Chalabi T, Aluvihare V, Agarwal K, Portmann BC, Rela M, Heaton ND, O'Grady JG, Heneghan MA (2007). "Liver transplantation in patients over 60 and 65 years: an evaluation of long-term outcomes and survival". Liver Transpl. 13 (10): 1382–8. PMID 17902123. doi:10.1002/lt.21181. 
  9. Prachalias AA, Pozniak A, Taylor C, Srinivasan P, Muiesan P, Wendon J, Cramp M, Williams R, O'Grady J, Rela M, Heaton ND (2001). "Liver transplantation in adults coinfected with HIV". Transplantation. 72 (10): 1684–8. PMID 11726833. 
  10. Wreghitt T (2001). "Liver Transplantation in Adults Coinfected With HIV. Transplantation 2001; 72: 1684". Transplantation. 72 (10): 1594–5. PMID 11726816. 
  11. Stock P, Roland M, Carlson L, Freise C, Hirose R, Terrault N, Frassetto L, Coates T, Roberts J, Ascher N (2001). "Solid organ transplantation in HIV-positive patients". Transplant. Proc. 33 (7-8): 3646–8. PMID 11750549. 
  12. Stock PG, Roland ME, Carlson L, Freise CE, Roberts JP, Hirose R, Terrault NA, Frassetto LA, Palefsky JM, Tomlanovich SJ, Ascher NL (2003). "Kidney and liver transplantation in human immunodeficiency virus-infected patients: a pilot safety and efficacy study". Transplantation. 76 (2): 370–5. PMID 12883195. doi:10.1097/01.TP.0000075973.73064.A6. 
  13. Neff GW, Bonham A, Tzakis AG, Ragni M, Jayaweera D, Schiff ER, Shakil O, Fung JJ (2003). "Orthotopic liver transplantation in patients with human immunodeficiency virus and end-stage liver disease". Liver Transpl. 9 (3): 239–47. PMID 12619020. doi:10.1053/jlts.2003.50054. 
  14. Friend PJ (1997). "Liver transplantation". Transplant. Proc. 29 (6): 2716–8. PMID 9290801. 
  15. McCaughan GW, Koorey DJ (1997). "Liver transplantation". Aust N Z J Med. 27 (4): 371–8. PMID 9448876. 
  16. Middleton PF, Duffield M, Lynch SV, Padbury RT, House T, Stanton P, Verran D, Maddern G (2006). "Living donor liver transplantation--adult donor outcomes: a systematic review". Liver Transpl. 12 (1): 24–30. PMID 16498709. 
  17. Perry I, Neuberger J (2005). "Immunosuppression: towards a logical approach in liver transplantation". Clin. Exp. Immunol. 139 (1): 2–10. PMC 1809260Freely accessible. PMID 15606606. doi:10.1111/j.1365-2249.2005.02662.x. 
  18. Papadopoulos-Köhn A, Achterfeld A, Paul A, Canbay A, Timm J, Jochum C, Gerken G, Herzer K (2015). "Daily low-dose tacrolimus is a safe and effective immunosuppressive regimen during telaprevir-based triple therapy for hepatitis C virus recurrence after liver transplant". Transplantation. 99 (4): 841–7. PMID 25208324. doi:10.1097/TP.0000000000000399. 
  19. 19.0 19.1 Savitsky EA, Uner AB, Votey SR (1998). "Evaluation of orthotopic liver transplant recipients presenting to the emergency department". Ann Emerg Med. 31 (4): 507–17. PMID 9546022. 
  • Eghtesad B, Kadry Z, Fung J (2005). "Technical considerations in liver transplantation: what a hepatologist needs to know (and every surgeon should practice)". Liver Transpl. 11 (8): 861–71. PMID 16035067. 
  • Adam R, McMaster P, O'Grady JG, Castaing D, Klempnauer JL, Jamieson N, Neuhaus P, Lerut J, Salizzoni M, Pollard S, Muhlbacher F, Rogiers X, Garcia Valdecasas JC, Berenguer J, Jaeck D, Moreno Gonzalez E (2003). "Evolution of liver transplantation in Europe: report of the European Liver Transplant Registry". Liver Transpl. 9 (12): 1231–43. PMID 14625822. 
  • Reddy S, Zilvetti M, Brockmann J, McLaren A, Friend P (2004). "Liver transplantation from non-heart-beating donors: current status and future prospects". Liver Transpl. 10 (10): 1223–32. PMID 15376341. 
  • Tuttle-Newhall JE, Collins BH, Desai DM, Kuo PC, Heneghan MA (2005). "The current status of living donor liver transplantation". Curr Probl Surg. 42 (3): 144–83. PMID 15859440. 
  • Martinez OM, Rosen HR (2005). "Basic concepts in transplant immunology". Liver Transpl. 11 (4): 370–81. PMID 15776458. 
  • Krahn LE, DiMartini A (2005). "Psychiatric and psychosocial aspects of liver transplantation". Liver Transpl. 11 (10): 1157–68. PMID 16184540. 
  • Nadalin S, Malagò M, et al. Current trends in live liver donation. Transpl. Int. 2007;20:312-30.
  • Vohra V. Liver transplantation in India. Int Anesthesiol Clin. 2006;44:137-49.
  • Strong RW. Living-donor liver transplantation: an overview. J Hepatobiliary Pancreat Surg. 2006;13:370-7.
  • Fan ST. Live donor liver transplantation in adults. Transplantation. 2006;82:723-32.


bg:Чернодробна трансплантация de:Lebertransplantation it:Trapianto di fegato he:השתלת כבד nl:Levertransplantatie fi:Maksansiirto



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