RESEARCH – April 2019

20-years of liver transplantation in Estonia

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Liver transplantation (LT) is a generally accepted treatment for adults with end-stage liver disease and for children with congenital liver diseases worldwide. Excellent postoperative results, particularly those related to the introduction of LT, are obscured by accompanying infections, complications and rejection-affected morbidity and mortality. The aim of this study was to present an overview about indications for LT, infections, complications and rejections, focusing on the introduction and progress of LT and related morbidity, mortality and outcomes. The data of 84 consecutive LT patients who had undergone surgery within 20 years at our institution were grouped under two 10- year periods: introduction of LT from 1999 to 2009, with 8 transplantations, and implementation of LT from 2009 to 2018, with 80 transplantations. When in the first period the main indication for LT was cholestatic disease, then in the second period it was hepatocellular cancer (HCC) due to post hepatitis-C (HCV) cirrhosis. In the second period we reduced immmunosuppressionrelated bacterial infections,, using more effective antibacterial prophylaxis, to 30% versus 100% in the first period. Fungal infection was accompanying in 7% of patients with bacterial infection. After the death of two cytomegalovirus (CMV) R+ serostatus recipients due to CMV pneumonia in the first period we introduced anti-CMV prophylaxis for all CMV R+ serostatus recipients, who had received a graft from CMV R+ serostatus donors, in the second period. Although we failed to significantly reduce the 32% occurrence of biliary complications and the 18% occurrence of vascular complications, we succeeded in avoiding extrahepatic complications with markedly reduced operation time in the second period. In our study with triple immunosuppressive regime, histopathologically confirmed acute liver rejection was observed in only 8% of LT recipients. In only one patient did acute rejection not respond to medrol impulse therapy or anti-thymocyte globulin therapy and this patient required retransplantation. Further reduction in the present 9% early posttransplant mortality, mostly due to primary nonfunction and coagulopathy, and in the present 17% late posttransplant mortality, mostly due to malignances and recurrences, still needs attention. The achieved one-year 81% and five -year 73% patient survival rate with excellent quality of life in the development of LT allow to continue LT in Estonia.