Background:Although, ALTx for acute liver failure(ALF) has been described over 30yrs ago, utilization of operation has been limited. Benefit of operation is to provide bridge therapy for ALF patients(pt) whose native liver(NL) is expected to recover, with subsequent withdrawal of immunosuppression(ISP), avoiding ISP-related complications. However, procedure can be technically challenging requiring expertise and careful pt. selection.Methods:Two heterotopic ALTx were performed for ALF; both recipients(R) received DBD organ offers. On backtable, hepatic II/III segments were reduced. Grafts were implanted: suprahepatic (D)IVC end-to-side to (R)infrahepatic IVC, (D)portal vein end-to-side to (R)main portal vein using (D)iliac vein conduit, (D)celiac trunk via (D)iliac artery conduit to (R)infrarenal aorta, loop hepaticojejunostomy. Native liver(NL) and ALTx were followed with imaging/biopsies.Results:Case 1:41 yo female with ALF secondary to Tylenol overdose; AST/ALT 4137/1604U/L, INR 8.2, t.bilirubin 4.4mg/dL, ammonia 250umol/L, acetaminophen 46mg/L, AFP 16.8ug/L, normal flow in NL on US. Given reversible etiology and hemodynamic instability, ALTx was performed. NL biopsy at Tx: submassive necrosis. During first year, HIDA scans: marked improvement of radionucleotide uptake by NL(Figure 1A); interval CT 8Ms post-Tx: normal appearance of NL and ALTx; repeat NL biopsy: complete regeneration. IST was withdrawn 8Ms post-Tx; repeat CT 12Ms post-Tx: normal NL, fibrosed ALTx(Figure 1B).Case 2:7 yo boy with ALF of unknown etiology; AST/ALT 2500/2400U/L, INR 8, t.bilirubin 24mg/dL, AFP1500 ug/L; negative infectious, inconclusive auto-immune work-up, normal flow in NL on US. Given evidence of liver regeneration, ALTx was performed(Figure 2A). Post-ALTx: normalization of LFTs/INR, HIDA 0 and 1M post-ALTx- radionucleotide excretion by ALTx with minimal uptake by NL, interval CTs- growth of ALTx and decrease in size of NL. Pt. was continued on IST. Conclusion:In the setting of appropriate expertise and careful pt. selection, heterotopic ALTx is appropriate option that allows less extensive operation, bridge to recovery of NL and life, free of ISP-associated comorbidities.

CITATION INFORMATION: Kirchner V, Minja E, Chinnakotla S, Kandaswamy R, Payne W, Pruett T. Heterotopic Auxiliary Liver Transplantation(ALTx) – Revisited. Am J Transplant. 2017;17 (suppl 3).

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