51
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Song JL, Yang J, Yan LN, Yang JY, Wen TF, Li B, Zeng Y, Wu H, Wang WT, Xu MQ, Chen ZY, Wei YG, Jiang L. A new index predicts early allograft dysfunction following living donor liver transplantation: A propensity score analysis. Dig Liver Dis 2017; 49:1225-1232. [PMID: 28750872 DOI: 10.1016/j.dld.2017.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 06/08/2017] [Accepted: 06/12/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVE/AIM The aim of this study was to identify a new index to predict early allograft dysfunction following living donor liver transplantation. METHODS The study enrolled 260 adult living donor liver transplantation recipients. Postoperative laboratory variables were assessed for their association with the prevalence of early allograft dysfunction using the inverse probability of treatment weighting and propensity-score matching (n=93 pairs) analysis. RESULTS Forty-seven recipients (18.1%) developed early allograft dysfunction. In multivariable analysis, the alanine aminotransferase and gamma-glutamyl transpeptidase levels on postoperative day 1 were independent predictors of early allograft dysfunction. The alanine aminotransferase to gamma-glutamyl transpeptidase ratio (AGR) was developed. All cases were divided into two groups (Group 1 [AGR≥8.47, n=103] and Group 2 [AGR<8.47, n=157]). AGR≥8.47 (OR 10.345, 95%CI 4.502-23.772, p<0.001), hepatorenal syndrome (OR 3.016, 95%CI 1.119-8.125, p=0.029), and graft to recipient weight ratio <0.8% (OR 2.155, 95%CI 1.004-4.624, p=0.049) were independent risk factors for early allograft dysfunction. The prevalence of early allograft dysfunction was higher in group 1 (after adjusting for inverse probability of treatment weighting [n=39; 37.9% vs n=8; 5.1%] and propensity-score matching [n=33; 35.5% vs n=2; 2.2%]) than that in group 2 (p<0.001). CONCLUSIONS The postoperative AGR is a practical index for predicting early allograft dysfunction after living donor liver transplantation.
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Affiliation(s)
- Jiu-Lin Song
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Jian Yang
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Lu-Nan Yan
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Jia-Yin Yang
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Tian-Fu Wen
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Bo Li
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Yong Zeng
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Hong Wu
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Wen-Tao Wang
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Ming-Qing Xu
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Zhe-Yu Chen
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Yong-Gang Wei
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Li Jiang
- Liver Transplantation Center, Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
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Effect of Prereperfusion Ephedrine on Postreperfusion Syndrome and Graft Function in Living Donor Liver Transplantation. Transplant Proc 2017; 49:1815-1819. [DOI: 10.1016/j.transproceed.2017.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/27/2017] [Accepted: 05/13/2017] [Indexed: 01/29/2023]
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Nakamura K, Kageyama S, Ke B, Fujii T, Sosa RA, Reed EF, Datta N, Zarrinpar A, Busuttil RW, Kupiec-Weglinski JW. Sirtuin 1 attenuates inflammation and hepatocellular damage in liver transplant ischemia/Reperfusion: From mouse to human. Liver Transpl 2017; 23:1282-1293. [PMID: 28719070 PMCID: PMC5705033 DOI: 10.1002/lt.24821] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/28/2017] [Accepted: 07/09/2017] [Indexed: 12/12/2022]
Abstract
Hepatic ischemia/reperfusion injury (IRI), an inevitable antigen-independent inflammation response in cadaveric liver transplantation, correlates with poor early graft function, rejection episodes, and contributes to donor organ shortage. Sirtuin 1 (SIRT1) is a histone deacetylase that may regulate inflammatory cell activity and manage liver function in IRI, though its functional role and clinical relevance remains to be elucidated. We investigated the efficacy of SIRT1 activation in a murine liver IRI model and verified the concept of putative SIRT1-mediated hepatoprotection in clinical liver transplantation. In the experimental arm, mice were subjected to 90 minutes of liver partial warm ischemia followed by 6 hours of reperfusion with or without adjunctive SIRT1 activation in vivo (resveratrol [Res]). In parallel, bone marrow-derived macrophage (BMDM) or spleen lymphocyte cultures were treated with Res. In the clinical arm, liver biopsies from 21 adult primary liver transplant patients (2 hours after reperfusion) were divided into "low" (n = 11) versus "high" (n = 10) SIRT1 expression groups, assessed by Western blots. Treatment with Res attenuated murine liver IRI while up-regulating SIRT1, suppressing leukocyte infiltration, and decreasing proinflammatory cytokine programs. SIRT1 silencing (small interfering RNA) in BMDM cultures enhanced inflammatory cytokine programs, whereas addition of Res decreased proinflammatory response in a SIRT1-dependent manner. In addition, Res decreased interferon γ production in liver-infiltrating and spleen lymphocyte cultures. Human liver transplants with high SIRT1 levels showed improved hepatocellular function and superior survival (P = 0.04), accompanied by lower proinflammatory cytokine profile. In conclusion, our translational study is the first to identify SIRT1 as a regulator of hepatocellular function in human liver transplant recipients under ischemia/reperfusion stress. By targeting innate and adaptive immune activation, manipulation of SIRT1 signaling should be considered as a novel means to combat inflammation in liver transplantation. Liver Transplantation 23 1282-1293 2017 AASLD.
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Affiliation(s)
- Kojiro Nakamura
- Dumont-UCLA Transplant Center, Department of Surgery, Division of Liver and Pancreas Transplantation, University of California, Los Angeles, Los Angeles, CA
| | - Shoichi Kageyama
- Dumont-UCLA Transplant Center, Department of Surgery, Division of Liver and Pancreas Transplantation, University of California, Los Angeles, Los Angeles, CA
| | - Bibo Ke
- Dumont-UCLA Transplant Center, Department of Surgery, Division of Liver and Pancreas Transplantation, University of California, Los Angeles, Los Angeles, CA
| | - Takehiro Fujii
- Dumont-UCLA Transplant Center, Department of Surgery, Division of Liver and Pancreas Transplantation, University of California, Los Angeles, Los Angeles, CA
| | - Rebecca A. Sosa
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA
| | - Elaine F. Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA
| | - Nakul Datta
- Dumont-UCLA Transplant Center, Department of Surgery, Division of Liver and Pancreas Transplantation, University of California, Los Angeles, Los Angeles, CA
| | - Ali Zarrinpar
- Dumont-UCLA Transplant Center, Department of Surgery, Division of Liver and Pancreas Transplantation, University of California, Los Angeles, Los Angeles, CA
| | - Ronald W. Busuttil
- Dumont-UCLA Transplant Center, Department of Surgery, Division of Liver and Pancreas Transplantation, University of California, Los Angeles, Los Angeles, CA
| | - Jerzy W. Kupiec-Weglinski
- Dumont-UCLA Transplant Center, Department of Surgery, Division of Liver and Pancreas Transplantation, University of California, Los Angeles, Los Angeles, CA
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“Model for Early Allograft Function” Outperforms “Early Allograft Dysfunction” as a Predictor of Transplant Survival. Transplantation 2017; 101:e258-e264. [DOI: 10.1097/tp.0000000000001833] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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55
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Martini S, Tandoi F, Terzi di Bergamo L, Strona S, Lavezzo B, Sacco M, Maione F, Gonella F, Strignano P, Dell Olio D, Salizzoni M, Saracco GM, Romagnoli R. Negativization of viremia prior to liver transplant reduces early allograft dysfunction in hepatitis C-positive recipients. Liver Transpl 2017; 23:915-924. [PMID: 28422425 DOI: 10.1002/lt.24772] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/15/2017] [Accepted: 04/07/2017] [Indexed: 12/13/2022]
Abstract
Although early allograft dysfunction (EAD) negatively impacts survival from the first months following liver transplantation (LT), direct-acting antiviral agents (DAAs) have revolutionized hepatitis C virus (HCV) therapy. We investigated the EAD definition best predicting 90-day graft loss and identified EAD risk factors in HCV-positive recipients. From November 2002 to June 2016, 603 HCV-positive patients (hepatocellular carcinoma, 53.4%) underwent a first LT with HCV-negative donors. The median recipient Model for End-Stage Liver Disease (MELD) score was 15, and the median donor age was 63 years. At LT, 77 (12.8%) patients were HCV RNA negative; negativization was achieved and maintained by pre-LT antiviral therapy (61 patients) or pre-LT plus a pre-emptive post-LT course (16 patients); 60 (77.9%) patients received DAAs and 17 (22.1%) interferon. We compared 3 different EAD definitions: (1) bilirubin ≥ 10 mg/dL or international normalized ratio ≥ 1.6 on day 7 after LT or aspartate aminotransferase or alanine aminotransferase > 2000 IU/L within 7 days of LT; (2) bilirubin > 10 mg/dL on days 2-7 after LT; and (3) MELD ≥ 19 on day 5 after LT. EAD defined by MELD ≥ 19 on day 5 after LT had the lowest negative (0.1) and the highest positive (1.9) likelihood ratio to predict 90-day graft loss. At 90 days after LT, 9.2% of recipients with EAD lost their graft as opposed to 0.7% of those without EAD (P < 0.001). At multivariate analysis, considering variables available at LT, MELD at LT of >25 (OR = 7.4) or 15-25 (OR = 3.2), graft macrovesicular steatosis ≥ 30% (OR = 6.7), HCV RNA positive at LT (OR = 2.7), donor age > 70 years (OR = 2.0), earlier LT era (OR = 1.8), and cold ischemia time ≥ 8 hours (OR = 1.8) were significant risk factors for EAD. In conclusion, in HCV-positive patients, MELD ≥ 19 on day 5 after LT best predicts 90-day graft loss. Preventing graft infection by pre-/peri-LT antiviral therapy reduces EAD incidence and could be most beneficial in high-MELD patients and recipients of suboptimal grafts. Liver Transplantation 23 915-924 2017 AASLD.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Dominic Dell Olio
- Regional Transplant Center, Piedmont, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
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The postoperative Model for End stage Liver Disease score as a predictor of short-term outcome after transplantation of extended criteria donor livers. Eur J Gastroenterol Hepatol 2017; 29:716-722. [PMID: 28441690 DOI: 10.1097/meg.0000000000000851] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recently, the postoperative Model for End stage Liver Disease score (POPMELD) was suggested as a definition of postoperative graft dysfunction and a predictor of outcome after liver transplantation (LT). AIM The aim of the present study was to validate this concept in the context of extended criteria donor (ECD) organs. PATIENTS AND METHODS Single-center prospectively collected data (OPAL study/01/11-12/13) of 116 ECD LTs were utilized. For each recipient, the Model for End stage Liver Disease (MELD) score was calculated for 7 postoperative days (PODs). The ability of international normalized ratio, bilirubin, aspartate aminotransferase, Donor Risk Index, a recent definition of early allograft dysfunction, and the POPMELD was compared to predict 90-day graft loss. Predictive abilities were compared by receiver operating characteristic curves, sensitivity and specificity, and positive and negative predictive values. RESULTS The median Donor Risk Index was 1.8. In all, 60.3% of recipients were men [median age of 54 (23-68) years]. The median POD1-7 peak-aspartate aminotransferase value was 1052 (194-17 577) U/l. The rate of early allograft dysfunction was 22.4%. The 90-day graft survival was 89.7%. Out of possible predictors of the 90-day graft loss MELD on POD5 was the best predictor of outcome (area under the curve=0.84). A MELD score of 16 or more on POD5 predicted the 90-day graft loss with a specificity of 80.8%, a sensitivity of 81.8%, and a positive and negative predictive value of 31 and 97.7%. CONCLUSION A MELD score of 16 or more on POD5 is an excellent predictor of outcome in ECD donor LT. Routine evaluation of POPMELD scores might support clinical decision-making and should be reported routinely in clinical trials.
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Al-Freah MAB, McPhail MJW, Dionigi E, Foxton MR, Auzinger G, Rela M, Wendon JA, O'Grady JG, Heneghan MA, Heaton ND, Bernal W. Improving the Diagnostic Criteria for Primary Liver Graft Nonfunction in Adults Utilizing Standard and Transportable Laboratory Parameters: An Outcome-Based Analysis. Am J Transplant 2017; 17:1255-1266. [PMID: 28199762 DOI: 10.1111/ajt.14230] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 01/11/2017] [Accepted: 02/04/2017] [Indexed: 01/25/2023]
Abstract
Current diagnostic criteria for primary nonfunction (PNF) of liver grafts are based on clinical experience rather than statistical methods. A retrospective, single-center study was conducted of all adults (n = 1286) who underwent primary liver transplant (LT) 2000-2008 in our center. Laboratory variables during the first post LT week were analyzed. Forty-two patients (3.7%) had 2-week graft failure. Transplant albumin, day-1 aspartate aminotransferase (AST), day-1 lactate, day-3 bilirubin, day-3 international normalized ratio (INR), and day-7 AST were independently associated with PNF on multivariate logistic regression. PNF score =(0.000280*D1AST)+ (0.361*D1 Lactate)+(0.00884*D3 Bilirubin)+(0.940*D3 INR)+(0.00153*D7 AST)-(0.0972*TxAlbumin)-4.5503. Receiver operating curve analysis showed the model area under receiver operating curve (AUROC) of 0.912 (0.889-0.932) was superior to the current United Kingdom (UK) PNF criteria of 0.669 (0.634-0.704, p < 0.0001). When applied to a validation cohort (n = 386, 34.4% patients), the model had AUROC of 0.831 (0.789-0.867) compared to the UK early graft dysfunction criteria of 0.674 (0.624-0.721). The new model performed well after exclusion of patients with marginal grafts and when modified to include variables from the first three post-LT days only (AUROC of 0.818, 0.776-0.856, p = 0.001). This model is superior to the current UK PNF criteria and is based on statistical methods. The model is also applicable to recipients of all types of grafts (marginal and nonmarginal).
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Affiliation(s)
- M A B Al-Freah
- Institute of Liver Studies, King's College Hospital, London, UK
| | - M J W McPhail
- Institute of Liver Studies, King's College Hospital, London, UK
| | - E Dionigi
- Institute of Liver Studies, King's College Hospital, London, UK
| | - M R Foxton
- Institute of Liver Studies, King's College Hospital, London, UK
| | - G Auzinger
- Institute of Liver Studies, King's College Hospital, London, UK
| | - M Rela
- Institute of Liver Studies, King's College Hospital, London, UK
| | - J A Wendon
- Institute of Liver Studies, King's College Hospital, London, UK
| | - J G O'Grady
- Institute of Liver Studies, King's College Hospital, London, UK
| | - M A Heneghan
- Institute of Liver Studies, King's College Hospital, London, UK
| | - N D Heaton
- Institute of Liver Studies, King's College Hospital, London, UK
| | - W Bernal
- Institute of Liver Studies, King's College Hospital, London, UK
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Rammohan A, Sachan D, Logidasan S, Sathyanesan J, Palaniappan R, Rela M. Role of plasmapheresis in early allograft dysfunction following deceased donor liver transplantation. World J Hematol 2017; 6:24-27. [DOI: 10.5315/wjh.v6.i1.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 09/25/2016] [Accepted: 11/17/2016] [Indexed: 02/05/2023] Open
Abstract
The role of plasmapheresis in liver failure and hepatic encephalopathy is undefined and its use as a strategy to salvage patients with severe allograft dysfunction after liver transplantation remains investigational. We present a case of early allograft dysfunction following deceased donor liver transplantation (DDLT) where plasmapheresis was effective as a bridge to recovery and possibly avoiding a retransplantation. A 16 years old boy, known to have decompensated Wilson’s disease underwent DDLT at our Public Sector Hospital. He received a healthy liver from a brain-dead donor, whose liver was considered too large for the boy. The graft was reduced in situ to a left lobe graft. Surgery was uneventful and the recipient was well for the initial 96 h. On Doppler and further computed tomography scan, a partial portal vein thrombus was noted. He was reexplored and a Fogarty endothombecteomy was performed. Following the second surgery, he developed severe allograft dysfunction with a peak bilirubin of 40 mg/dL. He underwent imaging to rule out technical causes for the dysfunction, followed by a liver biopsy, which revealed acute cellular rejection. Multiple cycles of plasmapheresis were initiated. Over the next two weeks, the graft demonstrated a gradual recovery. He was discharged on the 30th postoperative day, with a serum bilirubin of 5.5 mg/dL. He remains well on follow-up, with the liver function tests improving further. Our report demonstrates the beneficial effect of plasmapheresis, which appears to be an effective treatment option for early allograft dysfunction following liver transplantation and may obviate the need for retransplantation.
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Neves DB, Rusi MB, Diaz LGG, Salvalaggio P. Primary graft dysfunction of the liver: definitions, diagnostic criteria and risk factors. ACTA ACUST UNITED AC 2016; 14:567-572. [PMID: 27783749 DOI: 10.1590/s1679-45082016rw3585] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 04/09/2016] [Indexed: 12/11/2022]
Abstract
Primary graft dysfunction is a multifactorial syndrome with great impact on liver transplantation outcomes. This review article was based on studies published between January 1980 and June 2015 and retrieved from PubMed database using the following search terms: "primary graft dysfunction", "early allograft dysfunction", "primary non-function" and "liver transplantation". Graft dysfunction describes different grades of graft ischemia-reperfusion injury and can manifest as early allograft dysfunction or primary graft non-function, its most severe form. Donor-, surgery- and recipient-related factors have been associated with this syndrome. Primary graft dysfunction definition, diagnostic criteria and risk factors differ between studies. RESUMO A disfunção primária do enxerto hepático é uma síndrome multifatorial com grande impacto no resultado do transplante de fígado. Foi realizada uma ampla revisão da literatura, consultando a base de dados PubMed, em busca de estudos publicados entre janeiro de 1980 e junho de 2015. Os termos descritivos utilizados foram: "primary graft dysfunction", "early allograft dysfunction", "primary non-function" e "liver transplantation". A disfunção traduz graus diferentes da lesão de isquemia e reperfusão do órgão, e pode se manifestar como disfunção precoce ou, na forma mais grave, pelo não funcionamento primário do enxerto. Fatores relacionados ao doador, ao transplante e ao receptor contribuem para essa síndrome. Existem definições diferentes na literatura quanto ao diagnóstico e aos fatores de risco associados à disfunção primária.
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Affiliation(s)
- Douglas Bastos Neves
- Hospital Federal dos Servidores do Estado, Rio de Janeiro, RJ, Brazil; Hospital São Vicente de Paulo, Rio de Janeiro, RJ, Brazil.,Programa de Pós-graduação em Ciências da Saúde, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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60
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Lee DD, Croome KP, Shalev JA, Musto KR, Sharma M, Keaveny AP, Taner CB. Early allograft dysfunction after liver transplantation: an intermediate outcome measure for targeted improvements. Ann Hepatol 2016; 15:53-60. [PMID: 26626641 DOI: 10.5604/16652681.1184212] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The term early allograft dysfunction (EAD) identifies liver transplant (LT) allografts with initial poor function and portends poor allograft and patient survival. Aims of this study are to use EAD as an intermediate outcome measure in a large single center cohort and identify donor, recipient and peri-operative risk factors. MATERIAL AND METHODS In 1950 consecutive primary LT, donor, recipient and peri-operative data were collected. EAD was defined by the presence of one or more of the following: total bilirubin ≥ 10 mg/dL (171 μmol/L) or, INR ≥ 1.6 on day 7, and ALT/AST > 2,000 IU/L within the first 7 days. RESULTS The incidence of EAD was 26.5%. 1-, 3-, and 5-year allograft and patient survival for patients who developed EAD were significantly inferior to those who did not (P < 0.01 at all time points). Multivariate analysis demonstrated associations in the development of EAD with recipient pre-operative ventilator status, donation after cardiac death allografts, donor age, allograft size, degree of steatosis, operative time and intra-operative transfusion requirements (all P < 0.01). Patients with EAD had a significantly longer hospitalization at 20.9 ± 38.9 days (median: 9; range: 4-446) compared with 10.7 ± 13.5 days (median: 7; range: 3-231) in patients with no EAD (P < 0.01). CONCLUSIONS This is the largest single center experience demonstrating incidence of EAD and identifying factors associated with development of EAD. EAD is a useful intermediate outcome measure for allograft and patient survival. Balancing recipient pretransplant conditions, donor risk factors and intra-operative conditions are necessary for avoiding EAD.
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Affiliation(s)
- David D Lee
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
| | - Kristopher P Croome
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
| | - Jefree A Shalev
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
| | - Kaitlyn R Musto
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
| | - Meenu Sharma
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
| | - Andrew P Keaveny
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
| | - C Burcin Taner
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
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61
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Das S, Swain SK, Addala PK, Balasubramaniam R, Gopakumar CV, Zirpe D, Renganathan K, Kollu H, Patel D, Vibhute BB, Rao PS, Krishnan E, Gopasetty M, Khakhar AK, Vaidya A, Ramamurthy A. Initial Poor Function and Primary Nonfunction in Deceased-Donor Orthotopic Liver Transplantation Maintaining Short Cold Ischemic Time. Prog Transplant 2016; 26:340-347. [PMID: 27543202 DOI: 10.1177/1526924816663516] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Nations with emerging deceased-donor liver transplantation programs, such as India, face problems associated with poor donor maintenance. Cold ischemic time (CIT) is typically maintained short by matching donor organ recovery and recipient hepatectomy to achieve maximum favorable outcome. We analyzed different extended criteria donor factors including donor acidosis, which may act as a surrogate marker of poor donor maintenance, to quantify the risk of primary nonfunction (PNF) or initial poor function (IPF). METHODS A single-center retrospective outcome analysis of prospectively collected data of patients undergoing deceased-donor liver transplantation over 2 years to determine the impact of different extended criteria donor factors on IPF and PNF. RESULTS From March 2013 to February 2015, a total of 84 patients underwent deceased-donor liver transplantation. None developed PNF. Thirteen (15.5%) patients developed IPF. Graft macrosteatosis and donor acidosis were only related to IPF ( P = .002 and P = .032, respectively). Cold ischemic time was maintained short (81 cases ≤8 hours, maximum 11 hours) in all cases. CONCLUSION Poor donor maintenance as evidenced by donor acidosis and graft macrosteatosis had significant impact in developing IPF when CIT is kept short. Similar study with larger sample size is required to establish extended criteria cutoff values.
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Affiliation(s)
- Somak Das
- 1 Gastrointestinal Surgery and Liver Transplantation, Apollo Hospital, Chennai, India
| | - Sudeepta Kumar Swain
- 1 Gastrointestinal Surgery and Liver Transplantation, Apollo Hospital, Chennai, India
| | - Pavan Kumar Addala
- 1 Gastrointestinal Surgery and Liver Transplantation, Apollo Hospital, Chennai, India
| | | | - C V Gopakumar
- 1 Gastrointestinal Surgery and Liver Transplantation, Apollo Hospital, Chennai, India
| | - Dinesh Zirpe
- 1 Gastrointestinal Surgery and Liver Transplantation, Apollo Hospital, Chennai, India
| | | | - Harsha Kollu
- 1 Gastrointestinal Surgery and Liver Transplantation, Apollo Hospital, Chennai, India
| | - Darshan Patel
- 1 Gastrointestinal Surgery and Liver Transplantation, Apollo Hospital, Chennai, India
| | - Bipin B Vibhute
- 1 Gastrointestinal Surgery and Liver Transplantation, Apollo Hospital, Chennai, India
| | - Prashantha S Rao
- 1 Gastrointestinal Surgery and Liver Transplantation, Apollo Hospital, Chennai, India
| | - Elankumaran Krishnan
- 1 Gastrointestinal Surgery and Liver Transplantation, Apollo Hospital, Chennai, India
| | - Mahesh Gopasetty
- 1 Gastrointestinal Surgery and Liver Transplantation, Apollo Hospital, Chennai, India
| | - Anand K Khakhar
- 1 Gastrointestinal Surgery and Liver Transplantation, Apollo Hospital, Chennai, India
| | - Anil Vaidya
- 1 Gastrointestinal Surgery and Liver Transplantation, Apollo Hospital, Chennai, India.,3 Oxford Division of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Anand Ramamurthy
- 1 Gastrointestinal Surgery and Liver Transplantation, Apollo Hospital, Chennai, India
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62
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Kim SH, Moon YJ, Lee S, Jeong SM, Song JG, Hwang GS. Atrioventricular conduction disturbances immediately after hepatic graft reperfusion and their outcomes in patients undergoing liver transplantation. Liver Transpl 2016; 22:956-67. [PMID: 26850221 DOI: 10.1002/lt.24415] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 01/22/2016] [Indexed: 12/12/2022]
Abstract
Hemodynamic perturbation during hepatic graft reperfusion in patients undergoing liver transplantation (LT) is challenging and is frequently accompanied by bradyarrhythmia and even asystole. However, detailed data on electrocardiographic (ECG) changes during reperfusion are almost nonexistent, although the correct diagnosis by record is important for the treatment. We aimed to identify ECG rhythm disturbances during graft reperfusion and to investigate risk factors and outcomes. Data from 1065 consecutive patients who underwent adult LT were analyzed. The incidence, type, and detailed characteristics of ECG changes immediately after graft reperfusion were assessed using an electronically archived intraoperative ECG database. We analyzed risk factors, postoperative outcomes including major cardiovascular events, 30-day and 1-year mortalities of recipients based on the occurrence of atrioventricular (AV) block, and asystole during reperfusion. The typical pattern of postreperfusion bradyarrhythmia was progressive PR interval prolongation until a Mobitz type 1 AV block occurred. The overall incidence of AV block was 5.0% (53/1065), and 30.2% of them (16/53) had initiated as AV block and then progressed into ventricular asystole. Fulminant hepatic failure was a significant predictor for occurrence of AV block (odds ratio [OR], 7.20; 95% confidence interval, 3.38-15.32; P < 0.001). Patients with AV block showed significantly higher incidence of postoperative major cardiovascular events (P < 0.001) and 30-day mortality (P = 0.002) than those without AV block, whereas the 1-year mortality was not different between the 2 groups (P = 0.10). The postreperfusion asystole was consistently preceded by a Mobitz type 1 AV block. The occurrence of AV block and asystole appears to be an important prognosticator. Therefore, maintaining an optimal range of physiological status and gradual unclamping of the vena cava to avoid sudden atrial distension are recommended in high-risk patients during reperfusion period. Liver Transplantation 22 956-967 2016 AASLD.
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Affiliation(s)
- Sung-Hoon Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Young-Jin Moon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sooho Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung-Moon Jeong
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Barros MAP, Vasconcelos PRL, Souza CM, Andrade GM, Moraes MO, Costa PEG, Coelho GR, Garcia JHP. L-Alanyl-Glutamine Attenuates Oxidative Stress in Liver Transplantation Patients. Transplant Proc 2016; 47:2478-82. [PMID: 26518955 DOI: 10.1016/j.transproceed.2015.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 07/08/2015] [Accepted: 08/03/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ischemia/reperfusion injury during liver transplantation can cause severe damage to the graft. The objective of this randomized, double-blind study was to evaluate the possible protective effects of L-alanyl-glutamine on the liver graft. METHODS The sample included 33 patients from a liver transplantation service in Northeastern Brazil. Before cold ischemia, the patients received 50 g of L-alanyl-glutamine (treatment group) or saline (control group) through the portal vein. The graft was biopsied at the time of recovery, at the beginning of warm ischemia, and at the end of transplantation to determine malondialdehyde (MDA), heat-shock protein (Hsp)70, nuclear factor kappa-beta (NFkB), superoxide dismutase (SOD), and reduced glutathione (GSH) levels. RESULTS The blood parameters were similar in the two groups. In the treatment group, MDA did not increase at the beginning of cold ischemia and decreased at the end of transplantation. This phenomenon was not observed in the control group. GSH, SOD, Hsp70, and NFkB levels were similar in the two groups. CONCLUSIONS Our findings suggest that preconditioning with L-alanyl-glutamine attenuates the effects of ischemia/reperfusion-related oxidative stress and reduces lipid peroxidation in the grafts of liver transplantation patients.
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Affiliation(s)
- M A P Barros
- Department of Surgery, HUWC (University Hospital), Universidade Federal do Ceará, Fortaleza, Ceará, Brazil.
| | - P R L Vasconcelos
- Department of Surgery, HUWC (University Hospital), Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | - C M Souza
- Department of Physiology and Pharmacology, School of Medicine, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | - G M Andrade
- Department of Physiology and Pharmacology, School of Medicine, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | - M O Moraes
- Department of Physiology and Pharmacology, School of Medicine, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | - P E G Costa
- Department of Surgery, HUWC (University Hospital), Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | - G R Coelho
- Department of Surgery, HUWC (University Hospital), Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | - J H P Garcia
- Department of Surgery, HUWC (University Hospital), Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
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64
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Choe W, Kwon SW, Kim SS, Hwang S, Song GW, Lee SG. Effects of therapeutic plasma exchange on early allograft dysfunction after liver transplantation. J Clin Apher 2016; 32:147-153. [PMID: 27306278 DOI: 10.1002/jca.21472] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 03/14/2016] [Accepted: 04/21/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Early allograft dysfunction (EAD) is a serious complication of liver transplantation (LT) and is associated with graft failure, which can result in patient mortality. Due to the shortage of organs for retransplantation, only a small proportion of EAD patients undergo retransplantation. Thus, liver support is needed for most patients with EAD. METHODS We evaluated the effects of therapeutic plasma exchange (TPE) in EAD patients. EAD was defined as a sustained hyperbilirubinemia (≥10 mg/dL) within 30 days of LT without concurrent biliary complications. In a 13-year period, 107 EAD patients underwent TPE while 36 EAD patients did not. We investigated the laboratory and clinical outcomes of TPE and non-TPE groups. RESULTS The TPE group showed 1-month and 1-year survival rates of 82.2% and 53.8%, respectively, whereas the non-TPE group showed 58.3% and 22.2%, respectively. In TPE group, statistically significant decreases (P < 0.05) in total bilirubin (15.2 ± 5.2 to 13.1 ± 5.4 mg/dL), and INR (1.72 ± 1.04 to 1.38 ± 1.14), were seen after the final TPE session. TPE responder groups with age <51 years, total bilirubin <11.1 mg/dL, or INR <1.15 after final TPE showed better prognosis. TPE decreased the hazard risk of death in EAD patients whereas older age, male gender, and higher INR on the day of EAD onset increased the risk. CONCLUSIONS TPE effectively removed plasma bilirubin and improved coagulation function in EAD patients, with higher survival in the TPE group than in the non-TPE group. TPE may be an effective liver support for EAD patients. J. Clin. Apheresis 32:147-153, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Wonho Choe
- Department of Laboratory Medicine, Eulji University School of Medicine, Seoul, Korea.,Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seog-Woon Kwon
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Soo Kim
- Departmnt of Healthcare Management, Cheongju University College of Health Science, Cheongju, Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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65
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Nure E, Lirosi MC, Frongillo F, Bianco G, Silvestrini N, Fiorillo C, Sganga G, Agnes S. Overextended Criteria Donors: Experience of an Italian Transplantation Center. Transplant Proc 2016; 47:2102-5. [PMID: 26361653 DOI: 10.1016/j.transproceed.2014.11.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 11/19/2014] [Indexed: 02/06/2023]
Abstract
The increasing gap between the number of patients who could benefit from liver transplantation and the number of available donors has fueled efforts to maximize the donor pool using marginal grafts that usually were discarded for transplantation. This study included data of all patients who received decreased donor liver grafts between January 2004 and January 2013 (n = 218) with the use of a prospectively collected database. Patients with acute liver failure, retransplantation, pediatric transplantation, and split liver transplantation were excluded. Donors were classified as standard donor (SD), extended criteria donor (ECD), and overextended criteria donor (OECD). The primary endpoints of the study were early allograft primary dysfunction (PDF), primary nonfunction (PNF), and patient survival (PS), whereas incidence of major postoperative complications was the secondary endpoint. In our series we demonstrated that OECD have similar outcome in terms of survival and incidence of complication after liver transplantation as ideal grafts.
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Affiliation(s)
- E Nure
- Department of Surgery-Transplantation Service, Catholic University of the Sacred Heart, Policlinico "A. Gemelli," Rome, Italy
| | - M C Lirosi
- Department of Surgery-Transplantation Service, Catholic University of the Sacred Heart, Policlinico "A. Gemelli," Rome, Italy.
| | - F Frongillo
- Department of Surgery-Transplantation Service, Catholic University of the Sacred Heart, Policlinico "A. Gemelli," Rome, Italy
| | - G Bianco
- Department of Surgery-Transplantation Service, Catholic University of the Sacred Heart, Policlinico "A. Gemelli," Rome, Italy
| | - N Silvestrini
- Department of Surgery-Transplantation Service, Catholic University of the Sacred Heart, Policlinico "A. Gemelli," Rome, Italy
| | - C Fiorillo
- Department of Surgery-Transplantation Service, Catholic University of the Sacred Heart, Policlinico "A. Gemelli," Rome, Italy
| | - G Sganga
- Department of Surgery-Transplantation Service, Catholic University of the Sacred Heart, Policlinico "A. Gemelli," Rome, Italy
| | - S Agnes
- Department of Surgery-Transplantation Service, Catholic University of the Sacred Heart, Policlinico "A. Gemelli," Rome, Italy
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66
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Fenkel JM, Halegoua-DeMarzio DL. Management of the Liver Transplant Recipient: Approach to Allograft Dysfunction. Med Clin North Am 2016; 100:477-86. [PMID: 27095640 DOI: 10.1016/j.mcna.2016.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Liver transplant (LT) recipients are living longer than ever today and many will experience some form of allograft dysfunction. The common causes of allograft dysfunction vary significantly depending on the timing since LT. Most allograft abnormalities are manageable with minimally invasive procedures, medications, and lifestyle modification. The most common differential diagnoses by time period after LT, and diagnostic and management considerations, are highlighted. Collaboration and comanagement of LT recipients between primary care and the transplant hepatologist is essential for optimizing recipient and allograft outcomes.
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Affiliation(s)
- Jonathan M Fenkel
- Division of Gastroenterology and Hepatology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, 132 South 10th Street, Suite 480, Main Building, Philadelphia, PA 19107, USA.
| | - Dina L Halegoua-DeMarzio
- Division of Gastroenterology and Hepatology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, 132 South 10th Street, Suite 480, Main Building, Philadelphia, PA 19107, USA
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67
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Perrakis A, Stirkat F, Croner RS, Vassos N, Raptis D, Yedibela S, Hohenberger W, Müller V. Prognostic and diagnostic value of procalcitonin in the post-transplant setting after liver transplantation. Arch Med Sci 2016; 12:372-9. [PMID: 27186183 PMCID: PMC4848368 DOI: 10.5114/aoms.2016.59264] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 11/24/2014] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The aim of the study was to assess the diagnostic accuracy of procalcitonin (PCT) as a marker for complications and as a prognostic factor for mortality after liver transplantation. MATERIAL AND METHODS Liver transplant patients between January 2007 and April 2011 were prospectively included in the study. Procalcitonin serum concentration was recorded before, 6 h after reperfusion and then daily. Postoperative clinical course was prospectively analyzed from admission to discharge. Main surgical data such as operating procedure, type of reperfusion, operating and ischemic times, high urgency (HU) status and MELD score at the time of transplantation were also recorded. RESULTS Sixteen patients with initial PCT > 5 ng/ml suffered ≥ 1 complication (p = 0.03). However, there was no association between the level of the 1(st) peak PCT and the further postoperative course or the occurrence of complications. Patients in whom a 2(nd) PCT peak occurred had a significantly higher risk for a complicated course, for a complicated sepsis course and for mortality (p < 0.0001). Warm ischemic time over 58 min, operating time over 389 min and HU status were significant independent factors for a complicated postoperative course (p < 0.001, p < 0.001 and p = 0.03 respectively). CONCLUSIONS Based on our results, we believe that PCT course and the occurrence of a 2(nd) peak seem to possess important diagnostic and prognostic power in the post-transplant setting after liver transplantation.
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Affiliation(s)
| | - Falk Stirkat
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Roland S Croner
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Nikolaos Vassos
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Dimitrios Raptis
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Süleyman Yedibela
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | | | - Volker Müller
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
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68
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Karakhanova S, Oweira H, Steinmeyer B, Sachsenmaier M, Jung G, Elhadedy H, Schmidt J, Hartwig W, Bazhin AV, Werner J. Interferon-γ, interleukin-10 and interferon-inducible protein 10 (CXCL10) as serum biomarkers for the early allograft dysfunction after liver transplantation. Transpl Immunol 2015; 34:14-24. [PMID: 26658573 DOI: 10.1016/j.trim.2015.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 11/14/2015] [Accepted: 12/02/2015] [Indexed: 01/29/2023]
Abstract
Orthotopic liver transplantation (LTP) is nowadays a standard procedure, and provides the chance of survival of patients with end-stage non-treatable chronic liver disease or acute liver failure. Despite long-term survival with a good quality of life in the majority of patients, about 20% develop early allograft dysfunction (EAD), which leads to death or the need for re-transplantation. Therefore, the early diagnosis of EAD and evaluation of its risk factors are very important. Many primary pathological processes leading to EAD are accompanied by the release of different mediators and by a change of biochemical parameters detectable in the peripheral blood. The aim of this study was to investigate cytokines as well as soluble mediators in the serum of patients with and without EAD from our LTP bank, and to evaluate their predictive and prognostic values for EAD. We demonstrated for the first time that the level of IFNγ during the nearest preoperative period may serve as a predictive parameter for EAD. We additionally found that IL-10 and CXCL10 (IP-10) levels in the early postoperative period can be prognostic for EAD. We believe our data expand the spectrum of predictive and prognostic parameters for EAD in LTP.
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Affiliation(s)
- Svetlana Karakhanova
- Department of General Surgery, University of Heidelberg, 69120 Heidelberg, Germany.
| | - Hani Oweira
- Department of General Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Beate Steinmeyer
- Department of General Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Milena Sachsenmaier
- Department of General Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Gregor Jung
- Department of General Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Hazem Elhadedy
- Department of General Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Jan Schmidt
- Department of General Surgery, University of Heidelberg, 69120 Heidelberg, Germany; General and Visceral Surgery Center, 8002 Zurich, Switzerland
| | - Werner Hartwig
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University, 81377 Munich, Germany
| | - Alexandr V Bazhin
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University, 81377 Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University, 81377 Munich, Germany
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69
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Kurian SM, Fouraschen SMG, Langfelder P, Horvath S, Shaked A, Salomon DR, Olthoff KM. Genomic profiles and predictors of early allograft dysfunction after human liver transplantation. Am J Transplant 2015; 15:1605-14. [PMID: 25828101 DOI: 10.1111/ajt.13145] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 11/09/2014] [Accepted: 12/03/2014] [Indexed: 02/06/2023]
Abstract
Early hepatic allograft dysfunction (EAD) manifests posttransplantation with high serum transaminases, persistent cholestasis, and coagulopathy. The biological mechanisms are poorly understood. This study investigates the molecular mechanisms involved in EAD and defines a gene expression signature revealing different biological pathways in subjects with EAD from those without EAD, a potential first step in developing a molecular classifier as a potential clinical diagnostic. Global gene expression profiles of 30 liver transplant recipients of deceased donor grafts with EAD and 26 recipients without graft dysfunction were investigated using microarrays of liver biopsies performed at the end of cold storage and after graft reperfusion prior to closure. Results reveal a shift in inflammatory and metabolic responses between the two time points and differences between EAD and non-EAD. We identified relevant pathways (PPARα and NF-κB) and targets (such as CXCL1, IL1, TRAF6, TIPARP, and TNFRSF1B) associated with the phenotype of EAD. Preliminary proof of concept gene expression classifiers that distinguish EAD from non-EAD patients, with Area Under the Curve (AUC) >0.80 were also identified. This data may have mechanistic and diagnostic implications for EAD.
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Affiliation(s)
- S M Kurian
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | - S M G Fouraschen
- Penn Transplant Institute, Department of Surgery, University of Pennsylvania, Philadelphia, PA.,Department of Surgery and Laboratory of Experimental Transplantation and Intestinal Surgery, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - P Langfelder
- Department of Human Genetics, University of California, Los Angeles, CA
| | - S Horvath
- Department of Human Genetics, University of California, Los Angeles, CA
| | - A Shaked
- Penn Transplant Institute, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - D R Salomon
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | - K M Olthoff
- Penn Transplant Institute, Department of Surgery, University of Pennsylvania, Philadelphia, PA
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70
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Pareja E, Cortes M, Hervás D, Mir J, Valdivieso A, Castell JV, Lahoz A. A score model for the continuous grading of early allograft dysfunction severity. Liver Transpl 2015; 21:38-46. [PMID: 25204890 DOI: 10.1002/lt.23990] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 07/10/2014] [Accepted: 09/02/2014] [Indexed: 01/12/2023]
Abstract
Early allograft dysfunction (EAD) dramatically influences graft and patient outcomes. A lack of consensus on an EAD definition hinders comparisons of liver transplant outcomes and management of recipients among and within centers. We sought to develop a model for the quantitative assessment of early allograft function [Model for Early Allograft Function Scoring (MEAF)] after transplantation. A retrospective study including 1026 consecutive liver transplants was performed for MEAF score development. Multivariate data analysis was used to select a small number of postoperative variables that adequately describe EAD. Then, the distribution of these variables was mathematically modeled to assign a score for each actual variable value. A model, based on easily obtainable clinical parameters (ie, alanine aminotransferase, international normalized ratio, and bilirubin) and scoring liver function from 0 to 10, was built. The MEAF score showed a significant association with patient and graft survival at 3-, 6- and 12-month follow-ups. Hepatic steatosis and age for donors; cold/warm ischemia times and postreperfusion syndrome for surgery; and intensive care unit and hospital stays, Model for End-Stage Liver Disease and Child-Pugh scores, body mass index, and fresh frozen plasma transfusions for recipients were factors associated significantly with EAD. The model was satisfactorily validated by its application to an independent set of 200 patients who underwent liver transplantation at a different center. In conclusion, a model for the quantitative assessment of EAD severity has been developed and validated for the first time. The MEAF provides a more accurate graft function assessment than current categorical classifications and may help clinicians to make early enough decisions on retransplantation benefits. Furthermore, the MEAF score is a predictor of recipient and graft survival. The standardization of the criteria used to define EAD may allow reliable comparisons of recipients' treatments and transplant outcomes among and within centers.
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Affiliation(s)
- Eugenia Pareja
- Unidad de Hepatología Experimental, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
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71
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Hoyer DP, Paul A, Gallinat A, Molmenti EP, Reinhardt R, Minor T, Saner FH, Canbay A, Treckmann JW, Sotiropoulos GC, Mathé Z. Donor information based prediction of early allograft dysfunction and outcome in liver transplantation. Liver Int 2015; 35:156-63. [PMID: 24351095 DOI: 10.1111/liv.12443] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 12/12/2013] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Poor initial graft function was recently newly defined as early allograft dysfunction (EAD) [Olthoff KM, Kulik L, Samstein B, et al. Validation of a current definition of early allograft dysfunction in liver transplant recipients and analysis of risk factors. Liver Transpl 2010; 16: 943]. Aim of this analysis was to evaluate predictive donor information for development of EAD. METHODS Six hundred and seventy-eight consecutive adult patients (mean age 51.6 years; 60.3% men) who received a primary liver transplantation (LT) (09/2003-12/2011) were included. Standard donor data were correlated with EAD and outcome by univariable/multivariable logistic regression and Cox proportional hazards to identify prognostic donor factors after adjustment for recipient confounders. Estimates of relevant factors were utilized for construction of a new continuous risk index to develop EAD. RESULTS 38.7% patients developed EAD. 30-day survival of grafts with and without EAD was 59.8% and 89.7% (P < 0.0001). 30-day survival of patients with and without EAD was 68.5% and 93.1% (P < 0.0001) respectively. Donor body mass index (P = 0.0112), gGT (P = 0.0471), macrosteatosis (P = 0.0006) and cold ischaemia time (CIT) (P = 0.0031) were predictors of EAD. Internal cross validation showed a high predictive value (c-index = 0.622). CONCLUSIONS Early allograft dysfunction correlates with early results of LT and can be predicted by donor data only. The newly introduced risk index potentially optimizes individual decisions to accept/decline high risk organs. Outcome of these organs might be improved by shortening CIT.
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Affiliation(s)
- Dieter P Hoyer
- Department of General, Visceral and Transplantation Surgery, University Hospital, Essen, Germany
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72
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Guarrera JV, Henry SD, Samstein B, Reznik E, Musat C, Lukose TI, Ratner LE, Brown RS, Kato T, Emond JC. Hypothermic machine preservation facilitates successful transplantation of "orphan" extended criteria donor livers. Am J Transplant 2015; 15:161-9. [PMID: 25521639 DOI: 10.1111/ajt.12958] [Citation(s) in RCA: 233] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/21/2014] [Accepted: 07/22/2014] [Indexed: 02/06/2023]
Abstract
Hypothermic machine preservation (HMP) remains investigational in clinical liver transplantation. It is widely used to preserve kidneys for transplantation with improved results over static cold storage (SCS). At our center, we have used HMP in 31 adults receiving extended criteria donor (ECD) livers declined by the originating United Network for Organ Sharing region ("orphan livers"). These cases were compared to ECD SCS cases in a matched cohort study design. Livers were matched for donor age, recipient age, cold ischemic time, donor risk index and Model for End-Stage Liver Disease (MELD) score. HMP was performed for 3-7 h at 4-8 °C using our previously published protocol. Early allograft dysfunction rates were 19% in the HMP group versus 30% in the control group (p = 0.384). One-year patient survival was 84% in the HMP group versus 80% in the SCS group (p = NS). Post hoc analysis revealed significantly less biliary complications in the HMP group versus the SCS group (4 vs. 13, p = 0.016). Mean hospital stay was significantly shorter in the HMP group (13.64 ± 10.9 vs. 20.14 ± 11.12 days in the SCS group, p = 0.001). HMP provided safe and reliable preservation in orphan livers transplanted at our center.
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Affiliation(s)
- J V Guarrera
- Center for Liver Disease and Transplantation, Department of Surgery, Columbia University Medical Center, New York, NY
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73
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Guarrera JV. Donation: Where are our opportunities for expansion? Liver Transpl 2014; 20 Suppl 2:S2-4. [PMID: 25220934 DOI: 10.1002/lt.24001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 09/12/2014] [Indexed: 01/12/2023]
Affiliation(s)
- James V Guarrera
- Center for Liver Disease and Transplantation, Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY
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74
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The effect of preservation solutions for storage of liver allografts on transplant outcomes: a systematic review and meta-analysis. Ann Surg 2014; 260:46-55. [PMID: 24374537 DOI: 10.1097/sla.0000000000000402] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The objective of this review was to systematically evaluate the evidence comparing preservation fluids for liver allografts on transplant outcomes. BACKGROUND Adequate preservation of liver allografts for transplantation is essential for successful transplant outcomes. There are several preservation fluids available that have been specifically designed for the static cold storage of livers. These fluids differ in composition and cost. METHODS literature search was performed using MEDLINE, EMBASE, Cochrane Library, Transplant Library, and the International Clinical Trials Registry Platform. Only randomized controlled trials were included. Studies were assessed for methodological quality. Primary outcomes were the risk of early dysfunction, primary nonfunction, retransplantation, patient survival, and graft survival. Secondary outcomes were serum biochemical parameters in the first week and biliary complications. Summary effects were calculated as relative risk and relative log survival with 95% confidence intervals (95% CIs). RESULTS Sixteen randomized controlled trials met the full inclusion criteria (1619 livers). There is good evidence that the University of Wisconsin and Celsior solutions are associated with the same rates of early dysfunction (relative risk = 1.08, 95% CI = 0.63-1.86, P = 0.77), primary nonfunction (relative risk = 0.73, 95% CI = 0.22-2.40, P = 0.60), patient survival (relative log survival = 0.86, 95% CI = 0.58-1.28, P = 0.46), and graft survival (relative log survival = 0.85, 95% CI = 0.59-1.23, P = 0.39). There was no good evidence of any difference in outcomes when comparing histidine-tryptophan-ketoglutarate with either of the University of Wisconsin or Celsior solution, although data were limited. CONCLUSIONS Data from included studies suggest that preservation of deceased donor livers with the University of Wisconsin or Celsior solution results in equivalent outcomes.
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Graham JA, Guarrera JV. "Resuscitation" of marginal liver allografts for transplantation with machine perfusion technology. J Hepatol 2014; 61:418-31. [PMID: 24768755 DOI: 10.1016/j.jhep.2014.04.019] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Revised: 04/13/2014] [Accepted: 04/16/2014] [Indexed: 12/17/2022]
Abstract
As the rate of medically suitable donors remains relatively static worldwide, clinicians have looked to novel methods to meet the ever-growing demand of the liver transplant waiting lists worldwide. Accordingly, the transplant community has explored many strategies to offset this deficit. Advances in technology that target the ex vivo "preservation" period may help increase the donor pool by augmenting the utilization and improving the outcomes of marginal livers. Novel ex vivo techniques such as hypothermic, normothermic, and subnormothermic machine perfusion may be useful to "resuscitate" marginal organs by reducing ischemia/reperfusion injury. Moreover, other preservation techniques such as oxygen persufflation are explored as they may also have a role in improving function of "marginal" liver allografts. Currently, marginal livers are frequently discarded or can relegate the patient to early allograft dysfunction and primary non-function. Bench to bedside advances are rapidly emerging and hold promise for expanding liver transplantation access and improving outcomes.
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Affiliation(s)
- Jay A Graham
- Center for Liver Disease and Transplantation, Department of Surgery, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, NY 10032, USA
| | - James V Guarrera
- Center for Liver Disease and Transplantation, Department of Surgery, Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York, NY 10032, USA.
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Comparison of outcomes in ideal donor and extended criteria donor in deceased donor liver transplant: a prospective study. Int J Surg 2014; 12:774-7. [PMID: 24947949 DOI: 10.1016/j.ijsu.2014.06.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 06/05/2014] [Accepted: 06/11/2014] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The number of patients who could benefit from liver transplantation markedly exceeds the number of available donors. This increasing gap has fuelled efforts to maximize existing donor pool and identify new avenues. AIMS AND OBJECTIVES To compare the outcome in deceased donor liver transplant (DDLT) based on extended donor selection criteria. MATERIALS AND METHODS Donor and recipients' data were analyzed following DDLT from Mar 2007 to Feb 2013. Donors were grouped into either ideal donor (ID) or extended criteria donor (ECD) based on donor and graft related characteristics. Primary nonfunction (PNF) and patient survival were the primary endpoints while early graft dysfunction (EGD) and incidence of major postoperative complications were the secondary endpoints of the study. RESULTS We had a total of 6 mortalities (13%) at the end of 1 year. The Kaplan Meier survival analysis at 7 days, 3, 6 and 12 months were not statistically different (p > 0.05). PNF occurred in three (6.5%) patients and was not significantly different nor influenced by cumulative number of risk factors in the subgroup analysis (p < 0.3). However, the incidence of EGD was significantly influenced by the cumulative number of risk factors (p < 0.005). A total of 12 (26.1%) patients were graded with 3 or more complications according to the 'Clavien Dindo Grade' for major post operative complications, although it did not reach a statistical significance in the various subgroups. Univariate analysis of the donor risk factors showed that none of these factors were predictive for PNF and mortality in deceased donor liver transplant recipients. CONCLUSION Although the incidence of early graft dysfunction is statistically more with increase in number of donor risk factors, the overall survival and outcome in extended criteria liver donors are similar to that of an ideal donor. With the supply demand gap widening, extended criteria for selection of deceased donors will definitely expand the donor pool without adversely affecting the outcome of liver transplantation.
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Godara R, Naidu CS, Rao PP, Sharma S, Banerjee JK, Saha A, Vijay K. Use of marginal grafts in deceased donor liver transplant: assessment of early outcomes. Indian J Gastroenterol 2014; 33:136-40. [PMID: 23999685 DOI: 10.1007/s12664-013-0379-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 07/30/2013] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Orthotopic liver transplantation has become a routinely applied therapy for an expanding group of patients with end-stage liver disease. Shortage of organs has led centers to expand their criteria for the acceptance of marginal donors. There is current debate about the regulation and results of liver transplantation using marginal grafts. METHODS The study included data of all patients who received deceased donor liver grafts between March 2007 to December 2011. Patients with acute liver failure, living donor transplantation, split liver transplantation, and retransplantation were excluded. Early allograft dysfunction, primary nonfunction, patient survival, and incidence of surgical complications were measured. RESULTS A total of 33 patients were enrolled in this study. There were 20 marginal and 13 nonmarginal grafts. The two groups were well matched regarding age, sex and indication of liver transplantation, model for end-stage liver disease score, technique of transplant, requirement of vascular reconstruction, warm ischemia time, blood loss, mean operative time, etc. In our study, posttransplant peak level of liver enzymes, international normalization ratio, and bilirubin were not statistically significant in the marginal and nonmarginal group. Wound infection occurred in 10 % of marginal compared with 7.7 % of nonmarginal graft recipients (p > 0.05). In the marginal group, the incidences of vascular complications, hepatic artery thrombosis (four), and portal vein thrombosis (one) were not statistically significant compared to the nonmarginal group. Acute rejection was observed in a total of seven patients (21.2 %)-five (25 %) in the marginal group and two (15.4 %) in the nonmarginal graft recipients. Primary nonfunction occurred in three (9.1 %) patients-two (10 %) in the marginal and one (7.7 %) in the nonmarginal group. Average patient survival for the whole group was 91 % at 1 week, 87.8 % at 3 months, and 84.8 % at 6 months. CONCLUSION Because organ scarcity persists, additional pressure will build to use a greater proportion of the existing donor pool. The study, although small, clearly indicates that marginal livers can assure a normal early functional recovery after transplantation.
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Affiliation(s)
- Rajesh Godara
- Department of Gastrointestinal Surgery and Liver Transplantation, Army Hospital (Research & Referral), Delhi, 110 010, India,
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Dunn W, O'Neil M, Zhao J, Wu CH, Roberts B, Chakraborty S, Sherman C, Weaver B, Taylor R, Olson J, Olyaee M, Gilroy R, Schmitt T, Wan YJY, Weinman SA. Donor PNPLA3 rs738409 genotype affects fibrosis progression in liver transplantation for hepatitis C. Hepatology 2014; 59:453-60. [PMID: 24123231 PMCID: PMC7224311 DOI: 10.1002/hep.26758] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 08/12/2013] [Accepted: 09/17/2013] [Indexed: 12/18/2022]
Abstract
UNLABELLED The rs738409 G>C single nucleotide polymorphism occurring in the patatin-like phospholipase 3 gene has been identified as a novel genetic marker for hepatic steatosis. Recent studies also associated rs738409 with fibrosis in hepatitis C (HCV). Therefore, we sought to determine the impact of donor and recipient rs738409 genotype on the progression of fibrosis after liver transplantation for HCV. This cohort study included 101 patients infected with HCV who underwent liver transplantation between January 2008, and June 2011. Donor and recipient rs738409 genotypes were determined from donor wedge biopsies and recipient explants. The time to Ishak stage 3 fibrosis, or HCV-related mortality/graft loss was analyzed by the Cox model adjusting for HCV-Donor Risk Index, warm ischemic time, pretransplant Model for Endstage Liver Disease (MELD) and viral load. The rs738409 CC variant was present in 56% of donors and 57% of recipients. The median follow-up period was 620 days. A total of 39 patients developed the primary outcome of ≥stage 3 fibrosis or HCV-related mortality/graft loss, the time to which differed by donor (P = 0.019) but not recipient (P = 0.89) genotype. In the multivariate model, donor GC or GG variants had 2.53 times the risk (95% confidence interval [CI] 1.25-5.02, P = 0.008) compared to CC variants. In the alternative endpoint: stage 3 fibrosis or all-cause mortality/graft loss, the effect of donor genotype was attenuated but remained significant at 1.98 (95% CI 1.11-3.53). CONCLUSIONS The rs738409 genotype is an important predictor of posttransplant outcome in HCV. Liver, and not adipocytes, is the site at which this effect occurs. Our finding may be useful in donor selection for liver transplantation with HCV, and may guide decisions regarding early antiviral treatment.
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Affiliation(s)
- Winston Dunn
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Maura O'Neil
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Jie Zhao
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Chuang Hong Wu
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Benjamin Roberts
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Shweta Chakraborty
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Craig Sherman
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Brandy Weaver
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Ryan Taylor
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Jody Olson
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Mojtaba Olyaee
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Richard Gilroy
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Timothy Schmitt
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Yu-Jui Yvonne Wan
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Steven A. Weinman
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
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A non-interventional study of the genetic polymorphisms of NOD2 associated with increased mortality in non-alcoholic liver transplant patients. BMC Gastroenterol 2014; 14:4. [PMID: 24393249 PMCID: PMC3890629 DOI: 10.1186/1471-230x-14-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 12/30/2013] [Indexed: 12/24/2022] Open
Abstract
Background Infections after liver transplantation are the main cause of death in the first year. Recent reports indicate that NOD2 gene mutations increase the risk for inflammatory bowl disease and the severity of graft-versus-host disease in bone marrow transplant patients. Data on polymorphisms in liver transplant patients are sparse. We analyzed 13 single-nucleotide polymorphisms (SNPs) of 13 different gene variants including the SNPs of NOD2 genes from liver recipients. The aim of the study was to evaluate the impact of the SNPs on dialysis-dependent kidney failure, the incidence of infections and patient survival. Methods During a period of 20-months, 231 patients were recruited in this non-interventional, prospective study. Thirteen different SNPs and their impact on the patients’ survival, infection rate, and use of dialysis were assessed. Results NOD 2 wildtype genes were protective with respect to the survival of non-alcoholic, cirrhotic transplant patients (3 year survival: 66.8% wildtype vs. 42.6% gene mutation, p = 0.026). This effect was not observed in alcoholic transplant recipients. The incidence of dialysis-dependent kidney failure and infection in the liver transplant patients was not influenced by NOD 2 gene polymorphisms. No effect was noted in the remaining 12 SNPs. Patients with early allograft dysfunction experienced significantly more infections, required dialysis and had significantly worse survival. In contrast, the donor-risk-index had no impact on the infection rate, use of dialysis or survival. Conclusion NOD2 gene variants seem to play a key role in non-alcoholic, liver transplant recipients. However these data should be validated in a larger cohort.
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Bodonyi-Kovacs G, Strom TB, Putheti P. A20—A Biomarker of Allograft Outcome: A Showcase in Kidney Transplantation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2014; 809:103-16. [DOI: 10.1007/978-1-4939-0398-6_7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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81
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Salvalaggio P, Afonso RC, Felga G, Ferraz-Neto BH. A proposal to grade the severity of early allograft dysfunction after liver transplantation. EINSTEIN-SAO PAULO 2013; 11:23-31. [PMID: 23579740 PMCID: PMC4872964 DOI: 10.1590/s1679-45082013000100006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 08/25/2012] [Indexed: 12/19/2022] Open
Abstract
Objective: To propose a grading system for early hepatic graft dysfunction. Methods: A retrospective study from a single transplant center. Recipients of liver transplants from deceased donors, transplanted under the MELD system were included. Early graft dysfunction was defined by Olthoff criteria. Multiple cut-off points of post-transplant laboratory tests were used to create a grading system for early graft dysfunction. The primary outcome was 6-months grafts survival. Results: The peak of aminotransferases during the first postoperative week correlated with graft loss. The recipients were divided into mild (aminotransferase peak >2,000IU/mL, but <3,000IU/mL); moderate (aminotransferase peak >3,000IU/mL); and severe (aminotransferase peak >3,000IU/mL + International Normalized Ratio ≥1.6 and/or bilirubin ≥ 10mg/dL in the 7th postoperative day) early allograft dysfunction. Moderate and severe early dysfunctions were independent risk factors for graft loss. Patients with mild early dysfunction presented with graft and patient survival comparable to those without graft dysfunction. However, those with moderate early graft dysfunction showed worse graft survival than those who had no graft dysfunction. Patients with severe early dysfunction had graft and patient survival rates worse than those of any other groups. Conclusion: Early graft dysfunction can be graded by a simple and reliable criteria based on the peak of aminotransferases during the first postoperative week. The severity of the early graft dysfunction is an independent risk factor for allograft loss. Patients with moderate early dysfunction showed worsening of graft survival. Recipients with severe dysfunction had a significantly worse prognosis for graft and patient survival.
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Affiliation(s)
- Paolo Salvalaggio
- Unidade de Transplante de Fígado, Hospital Israelita Albert Einstein, São Paulo, SP, Brasil
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82
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Curry MP. Systematic investigation of elevated transaminases during the third posttransplant month. Liver Transpl 2013; 19 Suppl 2:S17-22. [PMID: 24019297 DOI: 10.1002/lt.23737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 08/27/2013] [Indexed: 12/15/2022]
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83
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Deschenes M. Early allograft dysfunction: causes, recognition, and management. Liver Transpl 2013; 19 Suppl 2:S6-8. [PMID: 24038766 DOI: 10.1002/lt.23746] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 08/27/2013] [Indexed: 12/12/2022]
Affiliation(s)
- Marc Deschenes
- Division of Hepatology, Royal Victoria Hospital, McGill University Health Center, Montreal, Quebec, Canada
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Ren Z, Cui G, Lu H, Chen X, Jiang J, Liu H, He Y, Ding S, Hu Z, Wang W, Zheng S. Liver ischemic preconditioning (IPC) improves intestinal microbiota following liver transplantation in rats through 16s rDNA-based analysis of microbial structure shift. PLoS One 2013; 8:e75950. [PMID: 24098410 PMCID: PMC3788797 DOI: 10.1371/journal.pone.0075950] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Accepted: 08/16/2013] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Ischemia-reperfusion (I/R) injury is associated with intestinal microbial dysbiosis. The "gut-liver axis" closely links gut function and liver function in health and disease. Ischemic preconditioning (IPC) has been proven to reduce I/R injury in the surgery. This study aims to explore the effect of IPC on intestinal microbiota and to analyze characteristics of microbial structure shift following liver transplantation (LT). METHODS The LT animal models of liver and gut IPC were established. Hepatic graft function was assessed by histology and serum ALT/AST. Intestinal barrier function was evaluated by mucosal ultrastructure, serum endotoxin, bacterial translocation, fecal sIgA content and serum TNF-α. Intestinal bacterial populations were determined by quantitative PCR. Microbial composition was characterized by DGGE and specific bacterial species were determined by sequence analysis. PRINCIPAL FINDINGS Liver IPC improved hepatic graft function expressed as ameliorated graft structure and reduced ALT/AST levels. After administration of liver IPC, intestinal mucosal ultrastructure improved, serum endotoxin and bacterial translocation mildly decreased, fecal sIgA content increased, and serum TNF-α decreased. Moreover, liver IPC promoted microbial restorations mainly through restoring Bifidobacterium spp., Clostridium clusters XI and Clostridium cluster XIVab on bacterial genus level. DGGE profiles indicated that liver IPC increased microbial diversity and species richness, and cluster analysis demonstrated that microbial structures were similar and clustered together between the NC group and Liver-IPC group. Furthermore, the phylogenetic tree of band sequences showed key bacteria corresponding to 10 key band classes of microbial structure shift induced by liver IPC, most of which were assigned to Bacteroidetes phylum. CONCLUSION Liver IPC cannot only improve hepatic graft function and intestinal barrier function, but also promote restorations of intestinal microbiota following LT, which may further benefit hepatic graft by positive feedback of the "gut-liver axis".
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Affiliation(s)
- Zhigang Ren
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Guangying Cui
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Haifeng Lu
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xinhua Chen
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jianwen Jiang
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hui Liu
- Institute of Immunology, Zhejiang University School of Medicine, Hangzhou, China
| | - Yong He
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Songming Ding
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhenhua Hu
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Weilin Wang
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shusen Zheng
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Croome KP, Hernandez-Alejandro R, Chandok N. Early allograft dysfunction is associated with excess resource utilization after liver transplantation. Transplant Proc 2013; 45:259-64. [PMID: 23375312 DOI: 10.1016/j.transproceed.2012.07.147] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 07/19/2012] [Indexed: 12/27/2022]
Abstract
BACKGROUND There are limited data on length of stay (LOS) following liver transplantation (LT), yet this is an important health services metric that directly correlates with early post-LT health care costs. The primary objective of this study was to examine the relationship between early allograft dysfunction (EAD) and LOS after LT. The secondary objective was to identify additional recipient, donor, and operative factors associated with LOS. METHODS Adult patients undergoing primary LT over a 32-month period were prospectively examined at a single center. Subjects fulfilling standard criteria for EAD were compared with those not meeting the definition. Variables associated with increased LOS on ordinal logistic regression were identified. RESULTS Subjects with EAD had longer mean hospital LOS than those without (42.5 ± 38.9 days vs 27.4 ± 31 days; P = .003). Subjects with EAD also had longer mean intensive care LOS (8.61 ± 10.28 days vs 5.45 ± 11.6 days; P = .048). Additional factors significantly associated with LOS included Model for End-Stage Liver Disease (MELD) score, recipient location before LT, and postoperative surgical complications. CONCLUSIONS EAD is associated with longer hospitalization after LT. MELD score, preoperative recipient location, and postoperative complications were significantly associated with LOS. From a cost-containment perspective, these findings have implications on resource allocation.
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Affiliation(s)
- K P Croome
- Multi-Organ Transplant Program, London Health Sciences Centre, Western University, London, Ontario, Canada
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Vos JJ, Scheeren TWL, Lukes DJ, de Boer MT, Hendriks HGD, Wietasch JKG. Intraoperative ICG plasma disappearance rate helps to predict absence of early postoperative complications after orthotopic liver transplantation. J Clin Monit Comput 2013; 27:591-8. [DOI: 10.1007/s10877-013-9474-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 05/06/2013] [Indexed: 01/27/2023]
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Wagener G, Raffel B, Young AT, Minhaz M, Emond J. Predicting early allograft failure and mortality after liver transplantation: the role of the postoperative model for end-stage liver disease score. Liver Transpl 2013; 19:534-42. [PMID: 23576469 DOI: 10.1002/lt.23634] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 02/15/2013] [Indexed: 02/06/2023]
Abstract
Early allograft dysfunction (EAD) is a serious complication after liver transplantation (LT). There is no uniform definition of EAD, and most definitions are based on arbitrary laboratory values. The aim of this study was to devise a definition of EAD that maximizes the predictive power for early death and graft failure. In this single-center, retrospective study, the ability of the international normalized ratio (INR), total bilirubin, aspartate aminotransferase (AST), physiological Model for End-Stage Liver Disease (MELD) score, and serum albumin levels within 7 days after LT to predict 90-day mortality or graft loss was compared with 2 previously used definitions of EAD: (1) peak total bilirubin level >10 mg/dL on days 2 to 7 and (2) either a total bilirubin level >10 mg/dL or an INR >1.6 on day 7 or an AST or alanine aminotransferase level >2000 IU/L within the first 7 days. Of 572 enrolled LT patients 38 died or required retransplantation within 90 days. Peak INR, total bilirubin level, AST levels, and MELD scores were predictors of 90-day graft failure. MELD score on postoperative day 5 was the best predictor with an area under the curve of the receiver operating characteristic curve of 0.812 (95% CI: 0.739-0.886, P < 0.001). The best cutoff of MELD score on day 5 for predicting 90-day mortality or graft loss was 18.9. A MELD score >18.9 on postoperative day 5 was a better predictor than any other laboratory value or definition of EAD. This study has demonstrated that the MELD score can be a useful tool not only for pretransplant graft allocation but also for postoperative risk stratification.
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Affiliation(s)
- Gebhard Wagener
- Department of Anesthesiology, Columbia University, New York, NY, USA.
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Salvalaggio PR, Felga GE, Afonso RC, Ferraz-Neto BH. Early allograft dysfunction and liver transplant outcomes: a single center retrospective study. Transplant Proc 2013; 44:2449-51. [PMID: 23026617 DOI: 10.1016/j.transproceed.2012.08.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Early allograft dysfunction (EAD) had been related to poor transplant outcomes during the early years of liver transplantation. We sought to determine the incidence of EAD at our unit and to evaluate its impact on posttransplant outcomes. METHODS This single-center retrospective study included primary deceased donor liver grafts transplanted under the model for end-stage liver disease system. EAD was defined as a peak values of aminotransferase >2000 IU/mL during the first week or an international normalized ratio of ≥1.6 and/or bilirubin ≥10 mg/dL at day 7. The main endpoints were patient and graft survivals. RESULTS Patients with versus without EAD showed similar recipient characteristics. Donors who experienced EAD who comprises 56% of recipients were heavier with larger body mass indices. EAD was an independent risk factor for allograft loss. Most retransplants were performed early due to nonfunction. The primary nonfunction rate among subjects with versus without EAD were 7% and 12% respectively (P < .05). Patient survival among those with EAD was 87.4%, while without EAD it was 90% (P = NS) with graft survivals of 81.4% and 88.7% respectively (P < .05). CONCLUSION Patients with EAD show a significantly higher risk for allograft loss, but with a comparable survival after transplantation. Despite their worse outcomes, it seems that not all of these recipients behave equally.
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Affiliation(s)
- P R Salvalaggio
- Liver Transplantation Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil.
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Bärthel E, Rauchfuss F, Hoyer H, Breternitz M, Jandt K, Settmacher U. The PRAISE study: a prospective, multi-center, randomized, double blinded, placebo-controlled study for the evaluation of iloprost in the early postoperative period after liver transplantation (ISRCTN12622749). BMC Surg 2013; 13:1. [PMID: 23356494 PMCID: PMC3564693 DOI: 10.1186/1471-2482-13-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Accepted: 01/23/2013] [Indexed: 01/30/2023] Open
Abstract
Background Liver graft dysfunction can deteriorate to complete organ failure and increases perioperative morbidity and mortality after liver transplantation. Therapeutic strategies reducing the rate of graft dysfunction are of current clinical relevance. One approach is the systemic application of prostaglandins, which were demonstrated to be beneficial in reducing ischemia-reperfusion injury. Preliminary data indicate a positive effect of prostacyclin analogue iloprost on allograft viability after liver transplantation. The objective of the study is to evaluate the impact of iloprost in a multi-center trial. Methods/Design A prospective, double-blinded, randomized, placebo-controlled multicenter study in a total of 365 liver transplant recipients was designed to assess the effect of intravenous iloprost after liver transplantation. Primary endpoint will be the primary graft dysfunction characterized as presentation of one or more of the following criteria: ALAT or ASAT level > 2000 IU/ml within the first 7 postoperative days, bilirubine ≥ 10 mg/dl on postoperative day 7; INR ≥ 1.6 on postoperative day 7 or initial non-function. Secondary endpoints are parameters of post-transplant morbidity, like rates of infections, biliary complications, need of clotting factors or renal replacement therapy and the graft and patient survival. Discussion A well-established treatment concept to avoid graft dysfunction after liver transplantation does not exist at the moment. If the data of this research project confirm prior findings, iloprost would improve the general outcome after liver transplantation. Trial Registration German Clinical Trials Register: DRKS00003514. Current Controlled Trials Register: ISRCTN12622749.
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Affiliation(s)
- Erik Bärthel
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Erlanger Allee 101, D-07740, Jena, Germany.
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90
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Hong SH, Kwak JA, Jeon JY, Park CS. Prediction of early allograft dysfunction using serum phosphorus level in living donor liver transplantation. Transpl Int 2013; 26:402-10. [DOI: 10.1111/tri.12058] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Revised: 08/26/2012] [Accepted: 12/23/2012] [Indexed: 02/07/2023]
Affiliation(s)
- Sang Hyun Hong
- Department of Anaesthesiology and Pain Medicine; Seoul St. Mary's Hospital; College of Medicine; The Catholic University of Korea; Seoul; Korea
| | - Jung Ah Kwak
- Department of Anaesthesiology and Pain Medicine; Seoul St. Mary's Hospital; College of Medicine; The Catholic University of Korea; Seoul; Korea
| | - Jin Yeong Jeon
- Department of Anaesthesiology and Pain Medicine; Yeouido St. Mary's Hospital; College of Medicine; The Catholic University of Korea; Seoul; Korea
| | - Chul Soo Park
- Department of Anaesthesiology and Pain Medicine; Seoul St. Mary's Hospital; College of Medicine; The Catholic University of Korea; Seoul; Korea
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91
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Ben Mosbah I, Mouchel Y, Pajaud J, Ribault C, Lucas C, Laurent A, Boudjema K, Morel F, Corlu A, Compagnon P. Pretreatment with mangafodipir improves liver graft tolerance to ischemia/reperfusion injury in rat. PLoS One 2012; 7:e50235. [PMID: 23226251 PMCID: PMC3511495 DOI: 10.1371/journal.pone.0050235] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 10/22/2012] [Indexed: 01/17/2023] Open
Abstract
Ischemia/reperfusion injury occurring during liver transplantation is mainly due to the generation of reactive oxygen species (ROS) upon revascularization. Thus, delivery of antioxidant enzymes might reduce the deleterious effects of ROS and improve liver graft initial function. Mangafodipir trisodium (MnDPDP), a contrast agent currently used in magnetic resonance imaging of the liver, has been shown to be endowed with powerful antioxidant properties. We hypothesized that MnDPDP could have a protective effect against liver ischemia reperfusion injury when administrated to the donor prior to harvesting. Livers from Sprague Dawley rats pretreated or not with MnDPDP were harvested and subsequently preserved for 24 h in Celsior® solution at 4°C. Organs were then perfused ex vivo for 120 min at 37°C with Krebs Henseleit solution. In MnDPDP (5 µmol/kg) group, we observed that ATP content was significantly higher at the end of the cold preservation period relative to untreated group. After reperfusion, livers from MnDPDP-treated rats showed better tissue integrity, less hepatocellular and endothelial cell injury. This was accompanied by larger amounts of bile production and higher ATP recovery as compared to untreated livers. The protective effect of MnDPDP was associated with a significant decrease of lipid peroxidation, mitochondrial damage, and apoptosis. Interestingly, MnDPDP-pretreated livers exhibited activation of Nfr2 and HIF-1α pathways resulting in a higher catalase and HO-1 activities. MnDPDP also increased total nitric oxide (NO) production which derived from higher expression of constitutive NO synthase and lower expression of inducible NO synthase. In conclusion, our results show that donor pretreatment with MnDPDP protects the rat liver graft from cold ischemia/reperfusion injury and demonstrate for the first time the potential interest of this molecule in the field of organ preservation. Since MnDPDP is safely used in liver imaging, this preservation strategy holds great promise for translation to clinical liver transplantation.
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Affiliation(s)
- Ismail Ben Mosbah
- Inserm, UMR991, “Foie, Métabolismes et Cancer,” CHU Pontchaillou, Rennes, France
- Université de Rennes 1, Rennes, France
| | - Yann Mouchel
- Inserm, UMR991, “Foie, Métabolismes et Cancer,” CHU Pontchaillou, Rennes, France
- Université de Rennes 1, Rennes, France
| | - Julie Pajaud
- Inserm, UMR991, “Foie, Métabolismes et Cancer,” CHU Pontchaillou, Rennes, France
- Université de Rennes 1, Rennes, France
| | - Catherine Ribault
- Inserm, UMR991, “Foie, Métabolismes et Cancer,” CHU Pontchaillou, Rennes, France
- Université de Rennes 1, Rennes, France
| | - Catherine Lucas
- Laboratoire de Biochimie Générale et Enzymologie, CHU Pontchaillou, Rennes, France
| | - Alexis Laurent
- Service de Chirurgie Digestive et Hépatobiliaire-Transplantation hépatique, CHU Henri Mondor, AP-HP, Créteil, France
- Inserm, UMR955,- IMRB Université Paris Est, Créteil, France
| | - Karim Boudjema
- Inserm, UMR991, “Foie, Métabolismes et Cancer,” CHU Pontchaillou, Rennes, France
- Université de Rennes 1, Rennes, France
- Service de Chirurgie Hépatobiliaire et Digestive, Hôpital Pontchaillou, Rennes, France
| | - Fabrice Morel
- Inserm, UMR991, “Foie, Métabolismes et Cancer,” CHU Pontchaillou, Rennes, France
- Université de Rennes 1, Rennes, France
| | - Anne Corlu
- Inserm, UMR991, “Foie, Métabolismes et Cancer,” CHU Pontchaillou, Rennes, France
- Université de Rennes 1, Rennes, France
| | - Philippe Compagnon
- Inserm, UMR991, “Foie, Métabolismes et Cancer,” CHU Pontchaillou, Rennes, France
- Service de Chirurgie Hépatobiliaire et Digestive, Hôpital Pontchaillou, Rennes, France
- * E-mail:
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MELD-based graft allocation system fails to improve liver transplantation efficacy in a single-center intent-to-treat analysis. Clin Res Hepatol Gastroenterol 2012; 36:464-72. [PMID: 22959095 DOI: 10.1016/j.clinre.2012.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Revised: 06/13/2012] [Accepted: 07/04/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Since March 2007, priority access to liver transplantation in France has been given to patients with the highest MELD scores. OBJECTIVE To undertake an intent-to-treat comparison of center-based vs. MELD-based liver graft allocation. METHODS Retrospective cohort analysis (patients listed 6th March 2007 to 5th March 2009; MELD period) with a matched historical cohort (patients listed 6th March 2005 to 5th March 2007; pre-MELD period) in a single high-volume center. Analysis was on an intent-to-treat basis, i.e. starting on the day of wait listing. RESULTS Compared to pre-MELD, fewer patients with a MELD score less or equal to 14 (P=0.002), and more patients with a MELD greater or equal to 24 (P<0.05) were transplanted during the MELD period. For HCC candidates, median waiting time increased (121 vs. 54 days, P=0.01), transplantation rate halved (35% vs. 73.5%, P<0.001) and dropouts due to tumor progression increased (16% vs. 0%, P<0.001). Moreover, postoperative course did not change significantly except for infectious complications (35% vs. 24%, P=0.02); overall patient survival was 69.8 ± 3.1% vs. 76 ± 2.9% (P=0.29) and overall graft survival was 77.6 ± 3.4% vs. 82.8 ± 2.9% (P=0.29). Transplant failures were mainly due to deaths on the waiting list in the previous system, but to dropouts related to disease progression in the new system. Cirrhotic patient survival rate did not change (78.1 ± 4.4% vs. 73.5 ± 4.5%, P=0.42), while that of HCC patients decreased (65.3 ± 5.3% vs. 86.8 ± 4.4%, P=0.01). Post-transplant survival worsened significantly according to pre-transplant MELD score (P=0.009). CONCLUSION The MELD-based graft allocation system introduced discrimination against HCC patients, whose incidence has increased dramatically, and should be reevaluated.
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Wagener G, Diaz G, Guarrera JV, Minhaz M, Renz JF, Sladen RN. Protein C activity and postoperative metabolic liver function after liver transplantation. Transplant Proc 2012; 44:1336-40. [PMID: 22664011 DOI: 10.1016/j.transproceed.2012.01.116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Accepted: 01/25/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND Protein C is a natural thrombin antagonist produced by hepatocytes. Its levels are low in liver failure and predispose patients to increased risk for thrombosis. Little is known about the relationship between protein C activity and hepatic function after orthotopic liver transplantation (OLT). METHODS We measured protein C activity of 41 patients undergoing liver transplantation by the Staclot method (normal range, 70%-130%) preoperatively and then daily on postoperative days (POD) 0-5. RESULTS The mean protein C activity was low before OLT (34.3 ± 4.3%) and inversely correlated with the preoperative Model for End-Stage Liver Disease score (Spearman's r = -0.643; P < .0001). Mean activity increased significantly on POD 1 (58.9 ± 4.5%), and remained above preoperative levels through POD 5. Ten patients developed metabolic liver dysfunction defined by a serum total bilirubin >5 mg/dL on POD 7. These patients had significantly lower protein C activity from POD 3 (47.2 ± 9.6% vs 75.9 ± 5.8%; P = .01) to POD 5. Preoperative protein C activity correlated inversely with the severity of liver failure as indicated by preoperative MELD score. CONCLUSION Protein C activity recovered rapidly in patients with good allograft function but remained significantly lower in patients who had limited metabolic function as evidenced by increased total bilirubin levels.
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Affiliation(s)
- G Wagener
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, NY 10032-3784, USA.
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94
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Chung IS, Park M, Ko JS, Gwak MS, Kim GS, Lee SK. Which score system can best predict recipient outcomes after living donor liver transplantation? Transplant Proc 2012; 44:393-5. [PMID: 22410025 DOI: 10.1016/j.transproceed.2012.01.064] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Many scoring systems have been suggested to predict the outcomes of deceased donor liver transplantations. The aims of this study were to compare the Model for End-Stage Liver Disease (MELD) score with respect to other scores among patients who underwent living donor liver transplantation (LDLT) seeking to evaluate the best system to correlate with postoperative outcomes after LDLT. METHODS We analyzed retrospectively data from 202 adult patients who underwent LDLT from January 2008 to July 2010. We calculated preoperative MELD, MELD-sodium, MELD to serum sodium ratio (MESO), integrated MELD, United Kingdom MELD, Child-Turcotte-Pugh, Acute Physiology and Chronic Health evaluation II (APACHE II), and Sequential Organ Failure Assessment (SOFA) scores in all patients. We analyzed the correlation of each score with postoperative laboratory results, as well as survival at 1, 3, 6 and 12 months after LDLT. RESULTS There was significant positive correlation between all scores and peak total bilirubin during the first 7 days after LDLT. The MELD score showed the greatest correlation with peak total bilirubin (r=0.745). APACHE II and SOFA scores at 6 months and 1 year after LDLT and MESO score at 1 year after LDLT showed acceptable discrimination performance {area under the receiver operating characteristic curves (AUC)>0.7, while other scoring systems showed poor discrimination. However, the AUCs of each score were not significantly different from the MELD score AUC. CONCLUSION The MELD score most correlated with total bilirubin after LDLT, while the APACHE II and SOFA scores seemed to correlate with mortality after LDLT.
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Affiliation(s)
- I S Chung
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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95
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Friedman BH, Wolf JH, Wang L, Putt ME, Shaked A, Christie JD, Hancock WW, Olthoff KM. Serum cytokine profiles associated with early allograft dysfunction in patients undergoing liver transplantation. Liver Transpl 2012; 18:166-76. [PMID: 22006860 PMCID: PMC3266982 DOI: 10.1002/lt.22451] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Early allograft dysfunction (EAD) occurring in the first week post-liver transplantation is associated with increased graft failure and mortality and is believed to be largely due to ischemia/reperfusion injury. We anticipated that the presence of EAD would be reflected by alterations in expression of serum proteins associated with an inflammatory response in the peri-operative period, and hypothesized that a specific pattern of expression might correlate with the development of EAD. The serum levels of 25 cytokines, chemokines, and immunoreceptors were measured by Luminex multiplex assays pre- and post-liver transplantation. Levels of each cytokine biomarker were compared in adult recipients with or without EAD at serial time points using samples collected pre-operatively and at 1, 7, 14, and 30 days post-transplant. EAD was defined according to standard criteria as maximum alanine transferase (ALT) or aspartate transferase (AST) levels on days 1-7 of >2000 U/ml, day 7 bilirubin level ≥10 mg/dl, or a day 7 international normalized ratio (INR) ≥1.7. Multivariable analyses showed that patients experiencing EAD had lower pre-operative IL-6 and higher IL-2R levels. Patients with EAD also showed higher MCP-1 (CCL2), IL-8 (CXCL8), and RANTES (CCL5) chemokine levels in the early post-operative period, suggesting up-regulation of the NF-kB pathway, in addition to higher levels of chemokines and cytokines associated with T cell immunity, including MIG (CXCL9), IP-10 (CXCL10) and IL-2R. These findings identify several possible biomarkers and pathways associated with EAD, that may guide future validation studies and investigation of specific cellular and molecular mechanisms of graft dysfunction. Furthermore, if validated, our findings may contribute to perioperative prediction of the occurrence of EAD and ultimately lead to identification of potential interventional therapies.
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Affiliation(s)
- Benjamin H. Friedman
- Department of Surgery, Penn Transplant Institute, University of Pennsylvania School of Medicine, Philadelphia, PA,Division of Transplantation Immunology, Department of Pathology and Laboratory Medicine, Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Joshua H. Wolf
- Department of Surgery, Penn Transplant Institute, University of Pennsylvania School of Medicine, Philadelphia, PA,Division of Transplantation Immunology, Department of Pathology and Laboratory Medicine, Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Liqing Wang
- Division of Transplantation Immunology, Department of Pathology and Laboratory Medicine, Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Mary E. Putt
- Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Abraham Shaked
- Department of Surgery, Penn Transplant Institute, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Jason D. Christie
- Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA,Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Wayne W. Hancock
- Division of Transplantation Immunology, Department of Pathology and Laboratory Medicine, Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Kim M. Olthoff
- Department of Surgery, Penn Transplant Institute, University of Pennsylvania School of Medicine, Philadelphia, PA,Correspondence and proofs: Kim M. Olthoff, M.D., Department of Surgery, Liver Transplant Program, University of Pennsylvania, 3400 Spruce Street, 2 Dulles Building, Philadelphia, PA 19104, Phone: 215-662-6136; Fax: 215-662-2244;
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96
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Ling Q, Xu X, Wei Q, Liu X, Guo H, Zhuang L, Chen J, Xia Q, Xie H, Wu J, Zheng S, Li L. Downgrading MELD improves the outcomes after liver transplantation in patients with acute-on-chronic hepatitis B liver failure. PLoS One 2012; 7:e30322. [PMID: 22291934 PMCID: PMC3265473 DOI: 10.1371/journal.pone.0030322] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2011] [Accepted: 12/19/2011] [Indexed: 12/23/2022] Open
Abstract
Background High score of model for end-stage liver diseases (MELD) before liver transplantation (LT) indicates poor prognosis. Artificial liver support system (ALSS) has been proved to effectively improve liver and kidney functions, and thus reduce the MELD score. We aim to evaluate whether downgrading MELD score could improve patient survival after LT. Methodology/Principal Findings One hundred and twenty-six LT candidates with acute-on-chronic hepatitis B liver failure and MELD score ≥30 were included in this prospective study. Of the 126 patients, 42 received emergency LT within 72 h (ELT group) and the other 84 were given ALSS as salvage treatment. Of the 84 patients, 33 were found to have reduced MELD score (<30) on the day of LT (DGM group), 51 underwent LT with persistent high MELD score (N-DGM group). The median waiting time for a donor was 10 for DGM group and 9.5 days for N-DGM group. In N-DGM group there is a significantly higher overall mortality (43.1%) than that in ELT group (16.7%) and DGM group (15.2%). N-DGM (vs. ECT and DGM) was the only independent risk factor of overall mortality (P = 0.003). Age >40 years and the interval from last ALSS to LT >48 h were independent negative influence factors of downgrading MELD. Conclusions/Significance Downgrading MELD for liver transplant candidates with MELD score ≥30 was effective in improving patient prognosis. An appropriate ALSS treatment within 48 h prior to LT is potentially beneficial.
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Affiliation(s)
- Qi Ling
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiao Xu
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qiang Wei
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaoli Liu
- State Key Lab for Diagnosis and Treatment of Infectious Diseases, Department of Infectious Diseases, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Haijun Guo
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Li Zhuang
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jiajia Chen
- State Key Lab for Diagnosis and Treatment of Infectious Diseases, Department of Infectious Diseases, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qi Xia
- State Key Lab for Diagnosis and Treatment of Infectious Diseases, Department of Infectious Diseases, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Haiyang Xie
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jian Wu
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Shusen Zheng
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- * E-mail: (LL) (LL); (SZ) (SZ)
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97
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Chung IS, Kim HY, Shin YH, Ko JS, Gwak MS, Sim WS, Kim GS, Lee SK. Incidence and predictors of post-reperfusion syndrome in living donor liver transplantation. Clin Transplant 2011; 26:539-43. [PMID: 22168355 DOI: 10.1111/j.1399-0012.2011.01568.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A characteristic pattern of hemodynamic changes that may occur in reperfusion phase of liver transplantation (LT) is known as post-reperfusion syndrome (PRS). In this study, we determined the frequency of PRS and evaluated possible predictors of PRS. The medical records of 152 patients who underwent living donor LT were reviewed. PRS was defined as a decrease in mean arterial pressure of more than 30% from the baseline value for more than one min during the first five min after reperfusion. The frequency of PRS was determined, and patients were divided into two groups: PRS group and non-PRS group. Donor factors, preoperative and intraoperative recipient factors, and postoperative outcomes were compared between the two groups. PRS occurred in 58 recipients (34.2%). Preoperative model for end-stage liver disease scores of recipients and percentage of graft steatotic changes were higher in PRS group. PRS group showed higher heart rates and lower hemoglobin values preoperatively. Before reperfusion, PRS group received more transfusion and their urine output was less than that of non-PRS group. Postoperatively, peak bilirubin during the first five d after LT was higher in PRS group. In conclusion, both severity of liver disease and graft steatosis may increase risk for PRS in LT. Further prospective studies of PRS in its relationship to outcome are indicated.
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Affiliation(s)
- In S Chung
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-Gu, Seoul, South Korea
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98
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Cavalcanti AB, De Vasconcelos CP, Perroni de Oliveira M, Rother ET, Ferraz L. Prostaglandins for adult liver transplanted patients. Cochrane Database Syst Rev 2011:CD006006. [PMID: 22071826 DOI: 10.1002/14651858.cd006006.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Prostaglandins may reduce ischaemic injury after liver transplantation. Several small randomised trials have evaluated the effects of prostaglandins in patients undergoing liver transplantation. Results of these trials are inconsistent, and none has enough power to reliably exclude effects of prostaglandins. OBJECTIVES To assess the benefits and harms of prostaglandin E1 or E2 in adult liver-transplanted patients. SEARCH METHODS We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and LILACS (search on 20 April 2011). In addition, we perused the reference lists of the identified studies and contacted trials investigators, and national and international experts in order to identify more trials for the review. SELECTION CRITERIA We included randomised clinical trials evaluating prostaglandin E1 or E2 initiated in the perioperative period versus placebo or standard treatment for adult patients undergoing liver transplantation. We did not apply any language or publication status restrictions. DATA COLLECTION AND ANALYSIS Two authors independently evaluated methodological quality, ie, risk of bias of the included trials, and extracted data using standardised data extraction forms. We contacted trial investigators in attempt to retrieve information not available in the original manuscripts. We used random-effects model meta-analyses and fixed-effect model meta-analyses to estimate the odds ratio with 95% confidence interval (CI). MAIN RESULTS We included ten trials in which 652 patients were randomised. The risk of bias was considered high in most trials. There was no significant effect of prostaglandins on all-cause mortality (37/298[12.4%] in prostaglandin group versus 47/312[15.1%] in control group; OR 0.84, 95% CI 0.53 to 1.37; I(2) = 0%), on primary non-function of the allograft (8/238 [3.4%] versus. 16/250[6.4%] ;OR 0.55, 95% CI 0.23 to 1.33; I(2) = 0%), and on liver re-transplantation (12/161[7.5%] versus 14/171[8.2%]; OR 0.99, 95% CI 0.44 to 2.25; I(2) = 0%). Prostaglandins seemed to significantly decrease the risk of acute kidney failure requiring dialysis (13/158[8.2%] versus 34/171[9.9%]; OR 0.37, 95% CI 0.18 to 0.75; I(2) = 0%). There was no significant increase in the risk of adverse events with prostaglandins. AUTHORS' CONCLUSIONS We found no evidence that the administration of prostaglandins to liver transplanted patients reduces the risk of death, primary non-function of the allograft, or liver re-transplantation. Prostaglandins might reduce the risk of acute kidney failure requiring dialysis, but the quality of the evidence is considered only moderate due to high risk of bias in most of the included trials. Moreover, there are risks of outcome measure reporting bias and random errors. Therefore, further randomised, placebo-controlled trials are deemed necessary.
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99
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Henry SD, Guarrera JV. Protective effects of hypothermic ex vivo perfusion on ischemia/reperfusion injury and transplant outcomes. Transplant Rev (Orlando) 2011; 26:163-75. [PMID: 22074785 DOI: 10.1016/j.trre.2011.09.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2011] [Revised: 07/08/2011] [Accepted: 09/02/2011] [Indexed: 12/14/2022]
Abstract
Hypothermic machine preservation (HMP) has been used in renal transplantation since the late 1960s with recent robust prospective, multicenter data showing lower rates of delayed graft function and improved graft survival. Although now clearly beneficial for renal transplantation, extrarenal machine perfusion has remained predominantly in preclinical investigations. Pancreatic HMP has drawn little clinical interest because HMP has been suggested to cause graft edema and congestion, which is associated with early venous thrombosis and graft failure. Early investigation showed no benefit of HMP in whole-organ pancreas transplant. One report did show that HMP increases islet cell yield after isolation. Preclinical work in liver HMP has been promising. Short- and long-term HMP has been shown to improve graft viability and reduce preservation injury, even in animal models of steatotic and donation after cardiac death. The first clinical study of liver HMP using a centrifugal dual perfusion technique showed excellent results with lower hepatocellular injury markers and no adverse perfusion-related outcomes. In addition, a dramatic attenuation of proinflammatory cytokine expression was observed. Further studies of liver HMP are planned with focus on developing a reproducible and standard protocol that will allow the widespread availability of this technology. Future research and clinical trials of novel organ preservation techniques, solutions, and interventions are likely to bring about developments that will allow further reduction of preservation-related ischemia/reperfusion injury and improved outcomes and allow safer utilization of the precious and limited resource of donor organs.
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Affiliation(s)
- Scot D Henry
- Division of Abdominal Organ Transplantation and Molecular Therapies and Organ Preservation Research Laboratory, Department of Surgery Columbia University Medical Center, New York, NY 10032-3784, USA
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Bärthel E, Rauchfuss F, Hoyer H, Habrecht O, Jandt K, Götz M, Voigt R, Heise M, Marx G, Settmacher U. Impact of stable PGI₂ analog iloprost on early graft viability after liver transplantation: a pilot study. Clin Transplant 2011; 26:E38-47. [PMID: 21919966 DOI: 10.1111/j.1399-0012.2011.01516.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Ischemia/reperfusion injury after liver transplantation (LT) may be associated with primary graft dysfunction (PDF) or non-function. Prostaglandins were demonstrated to be beneficial in reducing ischemic injury by improving microcirculation and protecting endothelial cells. The aim of this study was to analyze the effect of the continuously administered prostaglandin I(2) analog iloprost on allograft function after LT. METHODS Eighty patients were prospectively randomized and assigned to two groups. Patients in the treatment group received iloprost for seven d after transplantation, and those in the control group did not. The primary end point was graft dysfunction. RESULTS The incidence of PDF was 20% (n = 8) in the control group and 5% (n = 2) in the treatment group, respectively (p = 0.087). Four patients in the control group underwent re-transplantation for initial non-function (INF). There was no evidence for INF in the treatment group. Iloprost was associated with improved allograft function. Clinical course and outcome were comparable. CONCLUSIONS We suggest iloprost to be beneficial for early post-transplant liver function. If the rate of PDF can be significantly reduced with this treatment concept, it should be analyzed in a larger number of patients (ISRCTN95672167).
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Affiliation(s)
- Erik Bärthel
- Department of General, Visceral and Vascular Surgery, Friedrich-Schiller-University, Jena, Germany.
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