Hepatological aspects of liver transplantation – a 10 year personal experience Dr. Milen Vassilev, Lozenets Hospital Here I report my experience as transplant hepatologist in the first national liver transplant program in Lozenets Hospital (LH), which I joined in 2003. My first patient received living related donor graft, transplanted by a joint team with University Clinic Essen in early 2004. Later in 2004 a series of living donor pediatric transplants were done by the same team in LH. The first cadaveric donor liver transplant was done mid 2005 by the LH team of prof. L. Spassov. Between 2004 and 2014 I have screened 160 liver cirrhosis patients. Ninety five of them were rejected and 65 were listed. Of the 65 listed 29 were transplanted, 31 died on the list, before an organ became available. For this period the National Transplant Agency allocated 23.43% of the available organs to LH (bit.ly/1BxPm6s). Leading causes for listing of cirrhosis patients were viral hepatitis B, C and delta (~60%), alcohol (~23%), autoimmune and cholestatic liver diseases (~12%). Six patients with acute liver failure were referred to LH, 2 pediatric and 4 adult, for 2 of the adults an organ became available and transplanted. The two pediatric patients received grafts from their parents (data not shown). The group of non-listed patients had significantly higher age and significantly lower Child-Pugh and MELD scores. The overall survival rate after the first year was 74%; for the chronic diseases patients – 80%. Main reasons for graft and patient loss of the seven patients were infections in 3, primary graft disfunction-1, massive bleading-1 fibrocholestatic hepatitis -1. Immunosuppression was based on calcineurin inhibitors, combined with mycofenolate. We adopted strategy with early corticosteroid withdrawal and calcineurin exposure minimization. The rate of the typical early biliary and vascular complications we observed was lower as compared to the rates reported by other groups, while bleeding and infections were higher. The most common late complications were chronic rejection 24%, disease recurrence 28%, and metabolic syndrome 28%. There was one case of severe chronic kidney diseases (CKD), requiring hemodialysis; about 30% of the patients developed CKD grade 1 or 2. Viral recurrence for HBV was inconsequential due to the antiviral therapy. All HCV patients got re-infected; in one, eradication was achieved with peg-interferon-ribavirin therapy. All autoimmune disease patients had disease recurrence after average of 3.5 years post-transplant, which was asymptomatic and did not require medication change. The long term results of the LH liver transplant program are excellent. There was no loss of patients or grafts after the first year, which I consider my contribution, with all transplanted patients currently employed full time. Two healthy babies were born to two transplanted men.

1. 6 b A TA P C K A X E N ATO f A C T P O E H T E A O A O T 14 fl t.2014- KH. 1CTP.19
XENATONOTN'-IHI4 ACNEKTI4 HA TPAHCNNAHTALII4f, HA LIEPEH trPOE
- 10 roAuHn nnqEH onuT
Bacune9, M
Kruuuka no Bompewuu 6oaecmu, Soanuua Aoseneu, Meguuuncku Qakyamem,
CoQuucku yuuBepcumem,,CBemu Kauueum Oxpugcku".
flupBunm mpaHcnnaHmupaH naqueHm Ha SonHuua
AoseHeq (5A) 6eLue ugeHmuQuqupaH om veu B kpan
Ha 2003 eoguHa u 6eure mpaHcnnamupaH B yHu8epcu-memckama
knuuuka B ap. EceH om ekun c yqacmuemo
Ha nekapu om EA. ToBa nocmaBu Halranomo Ha cbmpyg-uuqecmBo
nite>kgy ekunume u npeHoc Ha 3HaHufl ,,know
how". flo-kucuo B kpar na 2004 eoguHa 6nxa uaBup-ureHu
cepue om mpaHcn^aHmaLluu Ha geua c BpogeHa
ampe3un Ha >knotrHume nbmuu-la om >kuB goHop, a npe3
2005 aoguHa u nupBama opmomonHa mpaHcnnaHmauue
ua 6tnaapcku nauueHm c mepMuHanna vepnogpo6Ha
HegocmambqHocm.
Uenma Ha Hacmonulemo npoyvBaHe 6e ga ce
npegcma8u u aHanu3upa xenamono?uttHus acnekm Ha
nupBama ycneurHa npo?paMa 3a mpaHcnnaHmauus 3a
vepeH gpo6 B Ernaapun Ha 6asa co6cm8eHu gaHHu.
Mqmepuan u Memogu:
Cto6utaBam ce pe3y mamume om ckpuHuHaoBa-ma
npoepaMa, npe>kuBneuocmma Ha 6onuume BknloqeHu
B HaquoHanHama Aucma Ha Lrakau-lume u paHHume, u
krcru pesynmamu om opmomonHama vepnogpo6Ha
mpaHcnnaHmaquF npu BuspacmHu nauueHmu, koumo nuq-
Ho cbM xapakmepueupan u nogan sa vepHogpo6Ha mpaHc-nnaHmaque.
BknloLreHume B nucmama Ha qakaulume
nauueHmu ca uscnegBaHu om MeH u mpaHcnnaHmupaHu B
5A, ocBeu eguH BUB BMA u gBarva B l-eprvraHun. Tyk cuo6-
utaBanlt caMo naqueHmu ga koumo a3 cbM 6un omaoBopeH
3a uenun npoqec om uHgur.lupaHemo Ha vepHogpo6Hama
mpaHcnnaHmaquc, apu)kume B paHHun nocm-mpaHcnnaH-mauuoHeH
nepuog u npogrrukumenHomo Ha6nlogeuue B
krcHun cneg-mpaHcnAaHmauuoHeH nepuog.
flpegmpaHcnnaHmaLluoHHama oueHka unu ckpu-
HUH?a Ha 6onHume sa Bknloq8aHe B HauuosanHama nucma
Ha qakaulume ce usBupulBatue cuanacHo mulecmByBa-ulume
prkoBogcmBa[9, 13].
B ckpuHuHaa 6nxa BknloqBaHu nauueHmu om qqna-ma
cmpaHa. Tlngukauun sa Bknlo,r8aHe B ckpuHuHea 6eue
Hanuque Ha guaeHocmuLlupaHa Llupo3a na vepHun gpo6,
nocmaBeHa B gpyao neqe6uo aaBegeuue u Haco.reHu kuvl
6onHuuama 3a npegmpaHcnAaHmauuoHHa ou{eska, kakmo
u nauueHmu Ha 6onHuqama. 3a nepuoga om cenmevBpu
2003 go Haqa^omo ua 2Q14 ?oguHu 6nxa u:cnegBauu
o6uro 160 6onuu, om koumo B cnucuka Ha qakautume
6sxa Bknloqeuu 65 (Qua. 1).
Cpegnama Btspacm ua omxBupneHume naqueHmu
6eue 52.99+ 12.60 2., cpegHun Child-Pugh ckop 6eLue
8.4t2.45, a cpegHunm MELD ckop 15.9619.56. Emuono-euqHama
cmpykmypa Ha ma3u apyna 6onHu e.nokasaHa B
ma6nuua 1. Kakmo ce Bu>kga ocHoBHume npuiruHu sa X93
B epynama Ha He BknloqeHume ca ankoxonHo vepHogpo6-
Ho yBpe>kgaue u xpoHuqHume BupycHu xenamumu B u C.
OqeHkama Ha goHopckun opeaH 3a ?ogHocm cma-
BaLue Bus ocHoBa Ha uHcmpyMeHmanHu na6opamopHu
uscnegBauun, kamo okoHqamenHomo peureHue 3a u3non3-
Basemo Ha op?aHa ce Bguuauue om mpaHcnAaHmaquoH-Hue
xupype. 3a nepuoga om 2003 go kpan Ha 2013 a Ha
6A 6nxa npegocmaBeuu okono egHa vemBtpm (23.43ok)
om HanuvHume goHopu Quaypa 2.(qumama cauma Ha
1/AA) C me3u opzaHu 6rxa usBupueHu om ekuna na npoQ.
A.CnacoB 1 split-liver mpaHcnnaHmaqun u 25 opmomon-
Hu qepHogpo6Hu mpaHcnnaHmaquu. OcmaHanume 6nxa
usBrpuJeHu BrB BMA -1 u B Eceu - 2 (split-liver u adult
living related).
CpegHama Buspacm Ha nauueHmume BknloLreHu
B cnucuka Ha qakaulume 6er.ue 44,69t 11.73, cpegHun
Child-Pugh ckop 6eue 10J!2.47, a cpegHunm MELD
T{HBH .21
i
i TpaHcnnaHTt{paHH
2g*
t
NOqHHATH. /
qaHaqH - 5
TI !4CTBA H H
65
cKpHHHpaH|'4
150 DoL** - oTXBbpneHH 31
95
*2 ca mpaHcn^aHmupaHu B YE Ecen, 1 BuB BMA; .. Dol=Death on the List - 3a?uHanu B o.rak8aFte Ha opeaH.
Ouaypa 1. l4scnegBaxu Auua 3a Bkn]oqBaHe B Hauuona,ruun cnuctk Ha qakaulume

2. 20 cTP. KH. 1 - f.2014 6 b A TA P C K A X E N ATO TA C T P O E H T E A O A O T l/1 F
ckop 18.9719.16. EmuonoauvHama cmpykmypa Ha ma3u
apyna 6onHu e nokagaua B ma6nuua 1. Kakmo ce Bu>kga
ocuoBHume npuLtuHu sa X93 ca omxo8o ankoxonHo vep-
Hogpo6Ho yBpe>kgaHe u xpoHuqHume BupycHu xenamumu
B u C. ,Qenum Ha xenamum B e no-Bucok, mu[ kamo myk
ca BknloqeHu u gBavra nauueHmu c ocmpa uepHogpo6Ha
HegocmambqHocm c HBV emuonoauR. XonecmamuqHume
vepuogpo6Hu yBperkgaHun - nupBuvHa 6unuapna qupo-ea,
nrpBuveH cknepo:upau1 xonaH?um - ce Hape>kgam
Ha cnegBaulo Mecmo, cnegBaHu om xenamoueny apHun
kapuuHow.
Kakmo ce Bukga om ma6nuua 1 emuonoaullHama
cmpykmypa Ha mpaHcnnaHmupaHume 6onHu e cxogHa
c ma3u B apynama Ha HeBknloqeHume B cnucrka Ha
qakauume. Oo.roBHume pasnuku kacacm Buspacmma
u me>kecmma Ha LrepHogpo6Homo sa6oncBaHe. flaLlu-eHmume
BknloqeHu B cnucuka Ha qakaulume ca c no-
Hucka Buspacm u no-me>kko vepr.rogpo6no sa6oncBaHe,
B cpaBxeuue c ?pynama ua omxBrpneHume, npeL{eHeHo
no Child-Pugh u MELD ckop, kamo u36poeHume pasnuku
ca cmamucmuqecku 3Ha'.{uMu (ma6nuua 1). B epynama
Ha ankoxonHo vepuogpo6Ho yBpe>kgaue okono 40% ca
anti-HBcAg(+) u BeponmHo cmaBa gyMa 3a kovr6uHupaHo
y8pe>kgaHe om MuHaAa HBV un$ekLlus u ankoxon.
3a mosu nepuog krl 6onnuqama 6nxa HacoqeHu
6 6onnu c ocmpa vepr-rogpo6Ha Hegocmambr.{Hocm, om
mRx 6cxa mpaHcnnaHmupaHu gBavra BrepacmHu nauu-eHmu
c QnynauHamHa xenamum B BupycHa uHQekuuc
gua?HocmuqupaHu u npeBegeru om gpy?u 6onHuqu.
EguHunm naqueHm 3a?uHa om Mo3bqeH omok, a gpyeunm
om npeHeceHa om goHopa uHQekqun, u gBaMama noBeqe
om 30 gHu cneg mpaHcnnamauuqma.
TpynHh AoNopr npeAroxeHu Ha 60rH{qa .tlo3ereq or }lAT
H * s- &
Ouaypa 2. flpegno>kenu na 5A goHopu om l4gnrnuumelHama
aeeHuue no mpaHcn^aHmaqun. http://bit.ly/1BxPm6s
Re.s"yl.Tel,t"s;
He pasnonaaaM c gaHHu sa npe>kuBneuocmma B
epynama Ha He Bknlo.teHume B cnucuka Ha vakaulume,
mb0 kamo me He ce npocnegnBaHu om MeH cneg cecuffma
Ha ckpuHupaHe sa BknloL{BaHe B cnucuka Ha qakaulume.
O6ulama npe>kuBneuocm Ha mpaHcnAaHmupaHu-me
B 5A, kamo myk He ca BknloqeHu mpaHcn^aHmupaHu
om gpyeu ekunu B gpyzu 6onHuuu naqueHmu,3a qnnama
?pyna mpaHcnnaHmupaHu, BknloqumenHo me3u c ocmpa
vepHogpo6r-ra HegocmambqHocm e 74o/o cn€et nrpBama
eoguHa. HRnaa cmamucmuLtecku gocmoBepHa pasnuka B
npe>kuBneuocmma Ha 6onuume c MELD > 15 u MELD <
15, rrrakap mesu MELD < 15 ga uMam oqeBuguo no-go6pa
npe>kuBneuocm. flpe>kuBnuocmma Ha 6onHume c xpo-
HuLrHu r.{epHogpo6Hu aa6onnBauun cneg nupBama eoguHa
e 80%. Hal-gunaama npe>kuBnevrocm e 3830 gHu, kamo
Bcu.rku mpaHcnnaHmupaHu nauueHmu cneg nupBama
?oguHa pa6omnm Ha nbneH pa6omeH geH.
Ta6nuua 1. Emuonoaun, ckop na Child- Pugh u MELD B mpancnnaHmupaHama apyna 6onHu.
Brspacm ,;l"j;"' MELD ckop Emuonoaun
^ BknloqeHu B 4o.69" 10.11 19.g5r :il:ff# 11.7s. 2,47" s.2***
4 11 21 tc e
Tpancnnanmu- 40.861 10.611 20.43!
panu - o6qo 16.63* 2.66 10.84
z z 4 o 'I o e
Tpancnnanmu- 41.14! 10.191 17.71!
paxu - >kuBu 13.13 2.113 7.6**
0 3 8 1 0
Tpancnnanmu- 40t 11.81 28.57!
paHU -noquHa^u 11.84 2.3 15.27**
z 0 1 0 0
OmxBopnenu 52,99112,6* 8,4!2,45* 15,9616,5--- 0 26 33 z 100 7 4 0
- P<0.0001;**P:0.0186; ***P=0.0069; lanti-HBclgG (+) - 5
Aeaeuga: ALF - ankoxo^Ha uupo3a Ha qepHuf, gpo6, HCC -
xenamoueny apen kapquuol, HCV - xpoHuqeH xenamum C,
HBV-xpouuvex xenamum B, HDV- xpoHuqeH xenamum genma,
NASH - xeankoxonex cmeamoxenamum, Cholest - xonecma-muqHo
qepHogpo6Ho ea6onnBaHe, AIH - aBmouvynex xpoHulreH
xenamu,.
;. -. -. -..1 " *. *. -,J i,i.:i
74
67 *r* * * J - - r * * L lL Li -l * * i
-. MELD < 15
*'- MELD > 15 r 3a qenara rpyna
0 365 1000 2000 3000 4000
,QH n cneg rpaHcnnaHT at 1IAAT a
51
(Il s
-FT
T
E
Oueypa 3. flpe>ku8neMocm 3a qfl^ama apyna, BknlovBa
u ocmpu u xpoHur{Hu vepHogpo6Hu ga6o^eBaHus

3. 6b A TA P C K A X E N AT O TA C T P O E H T E A O A O T U F f.2014-KH. 1CrP.21
B uvyuocynpecuBHama cmpame?un ce npugbp-
>kaxve ktu pe>kulu cnecmcBaulu ugnonsBaHemo Ha
kopmukocmepougu, kamo npu Bcuvku nauueHmu kopmu-kocmepougrm
6eue cnpnH B paukume Ha 6 ueceqa cneg
mpaHcnnaHmauunma, npu nauueHmume c xenamum C - B
nupBume 45-60 gHu. lzkuyHocynpecuema Hu ce 6a3upaue
ocHoBuo r-ra kanuHeBpuHoBu uxxu6umopu (ma6nuua 2)
u 6er-ue kou6unupana c rvukoQeHonam u no-pngko rvo-
HouMyHycynpecunc kanuuseBpuuoB uHxu6umop - 1 unu
caMo c kopmukocmepoug - 1 (npu nauuexm Ha guanusa).
Ta6nuua 2. L4rvryxocynpecopu usnonaaBHu 3a npoQunakmuka Ha
omxBupnnxemo na nnpucagkama.
TltvryHocynpecop 6po0 nauuexmu
Takponuuyc 1 1
Lluknocnopun 7
Takponuuyc (nponoHaupan) 2
MukoQexonam naoQemun 16
Cuponuuyc 2
EBeponuuyc 1
flaknuayrvra6 1
CmpaHuvHu eQekmu om uMyHocynpecuema 6flxa
Ha6nlogaBanu npu npakmuLrecku Bcuqku 6onHu u sano-
>kuxa HavanRBaHe ua go3ama unu 3aMFHa Ha uMyHocy-npecopa.
3avRHa Ha makpo^uMyc ce Hano>ku npu qemupu
naqueHmu nopagu, Aunca Ha agekBamHa uMyHycynpecun
- 2, nos8a Ha xunep6unupy6uHervrun-1 u HeBpomokcuvHu
cmpaHul{Hu eoekmu - 2. f'laqueHmume Ha cupo^uMyc
nokasaxa me>kku cmpaHuLtHu eQekmu c egHo cr6umue
Ha EBV uuQekqun u egHo r.ra me>kuk gepMamum nopagu
koemo 6eue cnpnH u^u 3aMeHeH c eBeponurvyc. OcHoB-Hume
cmpaHuvHu eQekmu, koumo Ha6nlogaBaxrve npu
makponuvyc 6nxa HeBpomokcuL{Hocm u HapyuaBaHe Ha
anlokosHus monepaHc, Ho 6es nosBa Ha uHcy uHo3a8ucuM
3axapeH gua6em, Brnpeku usnonsBaHucm om Hac an?o-pumbM
3a MuHuMu3upaHe Ha go3ama.
PaHHume ycnor(HeHun ca nocoqeHu B ma6nuqa 3.
flpa8u BnevamneHue omHocumenHo uuckama qecmoma
Ha >knrqHu u cbgoBu ycno)kHeHun.
Ta6nuqa 3. Paxnu ycno>l<Heuun cneg qepHogpo6xa mpaHcnnar-mauufl.
Ycno>kHeHuq Epo0 ct6umun
lbpBuvna gucQynkqus na npucagkama 1
Ocmpo omxBrpnnue
Ocmpa CMV uH0ekuuc 2
Panna moovr6o3a Ha xenamannama Bena 0
Xnu.rHu vcno>kxexuq 0
Xupypauvecko kbpBeHe c npkga om
I
oeBusuc
KupBeue Halaeauto kprBonpenuBaue o
Cencuc c nosumuBHa xenaokynmypa 6
flHe8uoHuR 6
l-16uqxa undekuus
Paxxa knuHuqHo nponBeua CMV undekuun a
Pauua mpovr6o3a Ha xenamanrume Benu 0
PaHHa mporra6o3a Ha nopmanHama Bepa 0
flpuvuHume 3a cMbpm Ha nauueHmume ca no-coL{
eHu B ma6nuqa 4. Kakmo ce BDkga om ma6^uqa-om?
oBopHu 3a cMbpmma Ha noBeqe om nonoBuHama
mpaHcn^aHmupaHu.
Ta6nuqa 4. flpuvur.ru 3a cMbpmma npu mpaHcnnaHmupaHume
6onsucX93uOVH.
6oo0 X3L.l OqH
flpuvuna
f'bpBuvxa gucQynkuun xa apaQma
Cencuc
KrpBene (xupypauvecko)
L4nQekuun npeHeceHa om goHopa
Too sick lo transDlant
xenamum
11
22
1
111
'1 1
11
/cz
neeeHga: X93- xpoxuvuo veprogpo6no sa6onsBaFte; OVH ocmpa
vepuogpo6Ha HegocmambLrHocm
Krcxume ycno>kHeuun ca nocoqeHu B ma6nuqa 5 u Quaypa 4.
OcuoBeu gFA uMam xpoHuqHomo omxBapnnHe Ha npucagkama,
peuuguBrm na ocnoBuomo ga6onsBaHe (aBmouuyxxo u Bupyc-no)
u rvema6onumHume ycnot(HeHun.
Ta6nuua 5. Kucsu ycno>krenun cleg opmomonna vepuogpo6Ha
mpaHcnAaHmauun.
Vcno>kHeuus
5po0 cr6umun/
naqueHmu
XponuvHo omxBrpnnxe
Ou6poxonecmamuLreH xenamum 1
CmeHosa u moovr6oga na
qepHoqpo6Frama apmeouc. krcHa
'I
Kucna mporvr6o3a Ha nopmalHama Beta 1
XnrqFru ycno>kHeHun (cmenoau),
Hanaeaulu cmeHmuoaHe
0
PequguB Ha ocxoBnomo sa6onc8aHe,
aBmouvvHHo unu Buovcno
8
3axapex gua6em, uHcy uH gaBucul 0
Mema6onumeH cuHqooM
PeuHdekuun c xenamum C
Krcxa EBV undekuus 1
[enpecun
lpo6ouumoneruqHa nypnypa 1
Iucxugposa z
/lugupekmHa xunep6unupy6uHeMufl 4
.E[ucnunugeuun
Xunepypukeuun 8
Heonnaguu 0
Apmepuanxa xunepmoHuR a
PeuuguB ua ocHoBHomo 3a6onflBaHe Ha6nloga-
Baxue npu Bcuqku mpaHcnnaHmupaHu c aBmouvryuuu
3a6o rBaHun: aBmouMyHeH xenamum, nbpBuqHa 6unuapHa
uupo3a, npbBulreH ck^epo3upaul xonaHmum cpegHo 3,5
?oguHu c^eg mpaHcn^aHmauugma. Bcuqku nauueHmu c
xpoHuqeH xenamum c ce peuuQekmupaxa B pavkume ua
nbpBume mpu Meceqa. He Ha6nlogaBaxue kapmuHa ua
ocmbp xenamum. flpu eguH om nauueHmume ce nocmu?-
Ha epagukaqun c uoguQuuupaHo neqeHue c pu6aBupuH
u ne?u^upaH uHmepQepoH.
6u6pevHomo yBpe>kgaHe npu mpaHcnnaHmupa-
HUme nauueHmu e no-r{ecmo nopagu Ha^uquemo Ha
yBpe>kgaHe Ha 6r6pevrama QyHkqun npegu mpaHc-n^
aHmaqufima om vepHogpo6Hama Llupo3a u c^eg
mpaHcn^aHmaquflma nopagu HeQpomokcuvHun eQekm
ma ocHoBeH npo6neu ca 6akmepua^Hume uHoekquu, Ha kanuuHeBpuHoBume uHxu6umopu.

4. 22 CrP. KH. 1 - f.2014 B b A TA P C K A X E N AT O TA C T P O E H T E A O A O T T F
Ha6nlogaBaxMe caMo eguH enu3og Ha me)kko
6t6pevno y8pe>kgane goBeno go xeMogua^u3a npu na-
UueHm c xpoHuqHa xenamum B BupycHa uHQekquc, npu
koumo na6nlogaBaxMe ugqesBaHe ua HBsAg, crnpoBoge-
Ho me>kuk MeMpaHo3eH ?AoMepy oHeQpum u 6t6pevHa
HegocmambqHocm (CDK - 5). B 6nuao egHa mpema om
naqueHmume na6nlogaBave xpoHurrHo yBpe>kgane Ha
6u6pequme (CDK - Chronic kidney disease) om ntpBa u
Bmopa cmeneH.
Ouaypa 4. XpoHuuHo 6t6pevno sa6onsBaHe c^eg mpaHcnAaH-mauue
Ha vepeH gpo6
Aeaerga: CDK - Chronic kidney disease, xpoHuqHo sa6onsBaFte
na 616pequme
.0o ceaa uMa gBe pogeHu :gpaBu geua Ha Mb)ke
c mpaHcn^aHmupaH vepeH gpo6.
Bcuqku mpaHcnnaHmupaHu ca ce BtpHanu Ha
pa6oma B parvkume ua8-12 M c^eg mpaHcn^aHmaquema
Ha nbneH pa6omen gen.
O6ct>kgaHe:
OcHoBHume emuonoauLtHa npuLtuHu 3a pa3Bumue
Ha qepHogpo6Ha HegocmambLtHocm, goBena go qep-
Hogpo6Ha mpaHcn^aHmauun B Hauama apyna e HBV,
ankoxonuo yBpe>kgaHe Ha r{epHun gpo6, xonecmamuqHu
a8mouMyHHu sa6onnBauun u xenamum C. l-1pu ?pynama
c ankoxonHu yBpe>kHauun BeponmHo yLtacmue uMa u Mu-
Hana uHQekquf, c xenamumHun B Bupyc. Tesu, aageHo c
ocmpama vepHogpo6na HegocmambqHocm ca u ocHoB-Hume
npuquHu 3a mpaHcnnaHmaqufl B EBpona[1, 3, 4,
61. Pasnukama B xapakmepucmukume Ha Bknloqenume B
cnucbka Ha vakauqume 6onHu u megu, koumo He ca Bk^lo-qeHu
e BUB Btapacmma u uHgekcume 3a vepHogpo6Ho
y8pe>kgaHe Child-Pugh u MELD.
9ecmomama Ha 6unuapHume 3a6onflBaHuc B
aHanu3upaHama epyna 6onsu e no-sucka cbo6uaBaHume
B numepamypama gaHHu[2], BeponmHo nopagu u3non3-
Bauama xupypauvecka mexHuka[8, 10]. 9ecmomama Ha
crgoBume ycno>kHeuun, na mporvr6osama Ha apmepun
xenamuka Hucka u e cxogHa Ha cu6oulaBaHama B nu-mepamypama[
12].
llaulueumume nonyL{u^u split-liver (2) unu living
donor mpaHcnnaHmauue (gecHu gnnoBe - 1 ) He nokasaxa
pa3nuL{Ha qecmoma u xapakmepucmuku Ha ycno>kueuu-flma.
Peaynmamume om mpaHcnAaHmaL^(uflma Ha nauu-eHmu
c xpoHuqeH xenamum B u C nokasaxa MHoeo go6pu
pe3y mamu, Beponmuo nopagu usnnagBaHume Memogu
sa npoQunakmuka Ha peuuQekqunma c xenamum B [3]
XonecmamuqHu qepHogpo6Hu sa6onnBaFtun ca
munuqHa uugukauun sa vepuogpo6Ha mpaHcnnaHmaqun B
EBpona c MHo?o go6rp pe:ynmam, Ho u Bucoka Ltecmoma
ua pequguBupaHe Ha ocHoBHomo sa6oncBaFte [11]. flpu
ankoxonuume vepnogpo6Hu sa6onnBaHus, nogo6Ho Ha pe-
3y mamume B EBpona ce Ha6nloga8am MHo?o go6pu pe-
3y mamu [4]. flBavama naqueHmu c ocmpa vepHogpo6Ha
Hegocmambquocm, koumo 6nxa mpaHcnnaHmupaHu 3aeu-
Haxa, koemo omeoBapn Ha omHocumenHo no-BucoKama
cMbpmHocm B cpaBueHue c mpaHcnnaHmauunma npu
xpoHuLrHume vepHogpo6Hu sa6onnBanun [6].
t/HQekuuume ca ocsoBeH npo6nervr cneg qepHo-gpo6Ha
mpaHcnnaHmaqun 3a Bcuqku mpaHcnnaHma-tluoHHu
ueHmpo8e [7], BknlovumenHo u me3u npeHeceHu
om goHopa [5]. B naLuama apyna 6akmepuuanHume unu
BupycHu uHQekuuu ca omeoBopHu 3a cMbpmma sa no8eqe
om nonoBusama om 3a?uHaAume cneg mpaHcnnaHmaquff.
Pe:ynmamume om mpaHcnAaHmauuoHHama
npo?paMa B EonHuua AoseHeu ca MHoeo go6pu, kamo
cMbpmHocmma u qecmomama ua ycno>kueHutma e cxog-
Ha c ma3u B gpyaume mpaHcnnaHmaquoHHu qeHm8ope
B EBpona. KrcHama npe>kuBnevocm, e usknloqumenHo
go6pa, kamo unva sa?uHan naqueHm cneg nupBama
?oguHa, koemo cvRmarvr sa cBou npuHoc ktv mpaHcnnau-maquoHHama
npo?paMa ua Sonuuqa AoseHeq.
HEPATOLOGICAL ASPECTS OF LIVER
TRANSPLANTATION - A 1O YEAR PERSONAL
EXPERIENCE
Dr. Milen Vassilev
lnternal Diseases Clinic, Lozenets Hospital, Department
of lnternal Dlseases, Medical Faculty, Sof ia University
Saint Kliment Ohridski
Here I report my experience as transplant
hepatologist in the first national liver transplant program
in Lozenets Hospital (LH), which I joined in 2003. My f irst
patient received living related donor graft, transplanted
by a joint team with University Clinic Essen in early
2004. Later in 2004 a series of living donor pediatric
transplants were done by the same team in LH. The first
cadaveric donor liver transplant was done mid 2005 by
the LH team of prof. L. Spassov. Between 2004 and 2014
I have screened 160 liver cirrhosis patients. Ninety f ive of
them were rejected and 65 were listed. Of the 65 listed
29 were transplanted, 31 died on the list, before an organ
became available. For this period the National Transplant
Agency allocated 23.43o/o of the available organs to LH
(bit.ly/l BxPmOs). Leading causes for listing of cirrhosis
patients were viral hepatitis B, C and delta (-60%), alcohol
(-2306, autoimmune and cholestatic liver diseases (-12%.
Six patients with acute liver failure were referred to LH, 2
pediatric and 4 adult, lor 2 of the adults an organ became
available and transplanted. The two pediatric patients
CKD - 5,

5. 5 b A TA P C K A X E N ATO TA C T P O E H T E A O A O T il F r.2014-KH.1 CTP.23
received grafts from their parents (data not shown). The
group of non-listed patients had significantly higher age
and signif icantly lower Child-Pugh and MELD scores. The
overall survival rate after the first year was 74%; for the
chronic diseases patients - 80o/o. Main reasons for graft
and patient loss of the seven patients were infections
in 3, primary graft disf unction-1 , massive bleading-1
f ibrocholestatic hepatitis -1. lmmunosuppression was based
on calcineurin inhibitors, combined with mycofenolate. We
adopted strategy with early corticosteroid withdrawal and
calcineurin exposure minimization. The rate of the typical
early biliary and vascular complications we observed was
lower as compared to the rates reported by other groups,
while bleeding and infections were higher. The most
common late complications were chronic rejeclion 24o/o,
disease recurrence 28o/o, and metabolic syndrome 28%.
There was one case of severe chronic kidney diseases
(CKD), requiring hemodialysis; about 30% of the patients
developed CKD grade 1 or 2. Viral recurrence for HBV
was inconsequential due to the antiviral therapy. All HCV
patients got re-infected; in one, eradication was achieved
with peg-interferon-ribavirin therapy. All autoimmune
disease patients had disease recurrence after average of
3.5 years post-transplant, which was asymptomatic and
did not require medication change. The long term results
of the LH liver transplant program are excellent. There
was no loss of patients or grafts after the f irst year, which
I consider my contribution, with all transplanted patients
currently employed f ull time. Two healthy babies were born
to two transolanted men.
KHuaonucl
1. Adam R, Karam V Delvart V O'Grady J, Mirza
D, Klempnauer J, Castaing D, Neuhaus B Jamieson N,
Salizzoni M, Pollard S, Lerut J, Paul A, Garcia-Valdecasas
JC, Rodriguez FS, Burroughs A. Evolution of indications
and results of liver transplantation in Europe. A report f rom
the European Liver Transplant Registry (ELTR). J.Hepatol.
2012;57:675-688
2. Buck DG, Zajko AB. Biliary complications after
orthotopic liver transplantation. TechVasc.lnterv.Radiol.
2008; 11:51-59
3. Burra P, Germani G, Adam R, Karam V Marzano
A, Lampertico B Salizzoni M, Filipponi F, Klempnauer JL,
Castaing D, Kilic M, Carlis LD, Neuhaus P, Yilmaz S, Paul A,
Pinna AD, Burroughs AK, Russo FP. Liver transplantation for
HBV-related cirrhosis in Europe: an ELTR study on evolution
and outcomes. J.Heoatol. 2013: 58:287-296
4. Burra P, Senzolo M, Adam R, Delvart V Karam
V Germani G, Neuberger J. Liver transplantation for
alcoholic liver disease in Europe: a study from the ELTR
(European Liver Transplant Registry). Am.JTransplant.
2010; 10:138148
5. Doucette KE, Al-Saif M, Kneteman N, Chui L,
Tyrrell GJ, Kumar D, Humar A. Donor-derived bacteremia
in liver transplant recipients despite antibiotic prophylaxis.
Am.JTransplant. 2013; 13:10801083
6. Germani G, Theocharidou E, Adam R, Karam
V Wendon J, O'Grady J, Burra B Senzolo M, Mirza D,
Castaing D, Klempnauer J, Pollard S, Paul A, Belghiti J,
Tsochatzis E, Burroughs AK. Liver transplantation for acute
liver failure in Europe: outcomes over 20 years from the
ELTR database. J.Hepatol. 2012: 57:288-296
7. Kim Sl. Bacterial infection after liver transolantation.
World J.Gastroenterol. 2014; 20:621 1 -6220
8. Kochhar G, Parungao JM, Hanouneh lA, Parsi
MA. Biliary complications following liver transplantation.
World J.Gastroenterol. 2013; 19:2841-2846
9. Murray KF, Carithers RL, Jr. AASLD practice
guidelines: Evaluation of the patient for liver transplantation.
Hepatology 2005; 41:1407 -1 432
10. Paes-Barbosa FC, Massarollo PC, Bernardo
WM, Ferreira FG, Barbosa FK, Raslan M, Szutan
LA. Systematic review and meta-analysis of biliary
reconstruction techniques in orthotopic deceased donor
liver transplantation. J.Hepatobiliary.Pancreat.Sci. 201 1 ;
18:525-536
11. Patkowski W Skalski M, Zieniewicz K, Nyckowski
P, Smoter P, Krawczyk M. Orthotopic liver transplantation
for cholestatic diseases. Hepatogastroenterology 2010;
57:605-610
12. Proposito D, Loinaz SC, Garcia G, l, Jimenez
C, Gonzalez B l, Gomez SB, De La Cruz J, M.oreno GE.
[Assessment of risk factors in the incidence bf hepatic
artery thrombosis in a consecutive series of 687 liver
transplantationsl. An n. ltal.Ch i r 200 1 ; 7 2:187 -205
13. Russo MW. Current concepts in the evaluation of
patients for liver transplantation. Expert.Bev.Gastroenterol.
Hepatol. 2007 ; 1:307-320
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flaHHume B masu cmamun ca cb6paHu om MeH u
cmamuema e HanucaHa u3unno om MeH. B Hes e Bno>keH
mpyga Ha ue^us ekun om EA. BrB Bpuaka c moBa myk
us6ponBana xopama ua koumo B oepouHa cmeneH ce gbn-
>ku ycnexa Ha npoapaMama. Bcuqku nauueHmu B moBa
npoyvBaHe ca 6u^u xocnumanu3upaHu BrB Bumpeuua
knuHuka Ha 5A, prkoBogeHa om gou. X.BacuneBa u B
guaaHocmukama u neeeHuemo uM ca yvacmBanu g-p
lOpykoBa u g-p l4opgaHoBa, kakmo u qenue ekun cuanacHo
mexHume cneuuanHocmu. 06pasHama guaeHocmuka e r-ra
g-p P.Kaneoucku u gou.X.BacuneBa. Bcuqku, nauueHmu
ca 6u^u mpaHcnnaHmupaHu om npoQ.g-p A. CnacoB u
ueaoBun ekun g-p fluue8, g-p MuxaunoBcku, g-p fopueB
u gpy?u. AHecmegucma u paHHomo nocm-mpaHcnAaHma-
UuoHHomo Ha6^logeHue e u38bptleHo om ekuna Ha g-p
a.MymaQoB. E-p ll>kaneBa u g-p O.l..lJanaMaHoB ca usBup-uru^
u koopguHaL{uRma c gpy?ume mpaHcn^aHmauuoHHu
ekunu u l4AT. Aa6opamopHume u xeMocma3eono?ut{Hume
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A.Cmanqe8a. AekapcmBeHomo MoHumopupaHe e geno
Ha npo$. CBuuapo8. BupyconoauvHume u3cnegBaHuc ca
u3BbpLuBaHu B na6opamopuume Ha g-p l-lBemaxcka, urvy-
HoAo?uLrHume B na6opamopufima Ha npo$. AnmrnkoBa.
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Ha YMEAA cB.t/1Bau Puncku nog prkoBogcmBomo Ha
nood. AumoHoB.