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Abstract
In organ transplantation, ischemia/reperfusion (I/R) results in damage that may affect cell viability and lead to organ failure. I/R injury involves a complex cascade of events, including loss of energy, derangement of the ionic hemostasis, production of reactive oxygen species, and cell death. In this context, mitochondria may be critical organelles, since they undergo major changes that may contribute to the injury occurring during I/R.
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Affiliation(s)
- Wayel Jassem
- Liver Transplant Unit, Institute of Liver Studies, King's College Hospital, Denmark Hill, London, United Kingdom.
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152
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Ben-Ari Z, Weiss-Schmilovitz H, Sulkes J, Brown M, Bar-Nathan N, Shaharabani E, Yussim A, Shapira Z, Tur-Kaspa R, Mor E. Serum cholestasis markers as predictors of early outcome after liver transplantation. Clin Transplant 2004; 18:130-6. [PMID: 15016125 DOI: 10.1046/j.1399-0012.2003.00135.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Early cholestasis is not uncommon after liver transplantation and usually signifies graft dysfunction. The aim of this study was to determine if serum synthetic and cholestatic parameters measured at various time points after transplantation can predict early patient outcome, and graft function. METHODS The charts of 92 patients who underwent 95 liver transplantations at Rabin Medical Center between 1991 and 2000 were reviewed. Findings on liver function tests and levels of serum bilirubin, alkaline phosphatase (ALP), and gamma glutamyl transpeptidase (GGT) on days 2, 10, 30, and 90 after transplantation were measured in order to predict early (6 months) patient outcome (mortality and sepsis) and initial poor functioning graft. Pearson correlation, chi(2) test, and Student's t-test were performed for univariate analysis, and logistic regression for multivariate analysis. RESULTS Univariate analysis. Serum bilirubin >/=10 mg/dL and international normalized ratio (INR) >1.6 on days 10, 30, and 90, and high serum ALP and low albumin levels on days 30 and 90 were risk factors for 6-month mortality; serum bilirubin >/=10 mg/dL on days 10, 30, and 90, high serum ALP, high GGT, and low serum albumin, on days 30 and 90, and INR >/=1.6 on day 10 were risk factors for sepsis; high serum alanine aminotransferase, INR >1.6, and bilirubin >/=10 mg/dL on days 2 and 10 were risk factors for poor graft function. The 6-month mortality rate was significantly higher in patients with serum bilirubin >/=10 mg/dL on day 10 than in patients with values of <10 mg/dL (29.4% vs. 4.0%, p = 0.004). Patients who had sepsis had high mean serum ALP levels on day 30 than patients who did not (364.5 +/- 229.9 U/L vs. 70.8 +/- 125.6 U/L, p = 0.005). Multivariate analysis. Significant predictors of 6-month mortality were serum bilirubin >/=10 mg/dL [odds ratio (OR) 9.05, 95% confidence intervals (CI) 1.6-49.6] and INR >1.6 (OR 9.11, CI 1.5-54.8) on day 10; significant predictors were high serum ALP level on day 30 (OR 1.005, 1.001-1.01) and high GGT level on day 90 (OR 1.005, CI 1.001-1.01). None of the variables were able to predict initial poor graft functioning. CONCLUSIONS Several serum cholestasis markers may serve as predictors of early outcome of liver transplantation. The strongest correlation was found between serum bilirubin >/=10 mg/dL on day 10 and early death, sepsis, and poor graft function. Early intervention in patients found to be at high risk may ameliorate the high morbidity and mortality associated with early cholestasis.
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Affiliation(s)
- Ziv Ben-Ari
- Liver Institute and Department of Medicine D, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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153
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Bassanello M, De Palo EF, Lancerin F, Vitale A, Gatti R, Montin U, Ciarleglio FA, Senzolo M, Burra P, Brolese A, Zanus G, D'Amico DF, Cillo U. Growth hormone/insulin-like growth factor 1 axis recovery after liver transplantation: a preliminary prospective study. Liver Transpl 2004; 10:692-8. [PMID: 15108263 DOI: 10.1002/lt.20111] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Many studies on cirrhotic patients have shown that insulin-like growth factor 1 (IGF-1) plasma levels are related to the severity of liver dysfunction. This result suggests that IGF-1 is probably useful for monitoring liver function in the perioperative course of orthotopic liver transplantation (OLT). Growth hormone (GH), IGF-1 plasma levels, and routine liver function tests were measured in 15 adult cirrhotic patients undergoing OLT. Measurements were made at the beginning of the operation; during OLT; 24 hours after reperfusion; and in the morning on days 7, 30, and 90. Twenty age-matched healthy volunteers with normal liver function served as controls. The study group had significantly higher GH levels and lower IGF-1 levels in the preoperative period compared with the controls. All patients achieved a complete functional hepatic recovery 1 month after OLT, although in 6 of them, the graft had an initial poor function (Group-IPF). GH and IGF-1 levels achieved near normal range within 1 week after OLT, and they had no significant correlations with other routine biochemistry tests in this period. IGF-1 levels in Group-IPF rose more slowly than in the group with a normal recovery of graft function. Surprisingly, 24 hours after reperfusion, IGF-1 levels were higher in Group-IPF than in the group with normal graft function. In conclusion, the severe GH/IGF-1 axis impairment found in patients with end-stage cirrhosis reverted very rapidly in the first days after successful OLT. Such a quick, postoperative modulation of IGF-1 plasma level by the graft suggests that this hormone has the potential to become one of the early indicators of post-OLT liver function recovery.
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Affiliation(s)
- Marco Bassanello
- Clinica Chirurgica I, Dipartimento di Scienze Chirurgiche e Gastroenterologiche, University of Padua, School of Medicine, Padua, Italy
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154
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Kudo A, Kashiwagi S, Kajimura M, Yoshimura Y, Uchida K, Arii S, Suematsu M. Kupffer cells alter organic anion transport through multidrug resistance protein 2 in the post-cold ischemic rat liver. Hepatology 2004; 39:1099-109. [PMID: 15057914 DOI: 10.1002/hep.20104] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Although Kupffer cells (KCs) may play a crucial role in post-cold ischemic hepatocellular injury, their role in nonnecrotic graft dysfunction remains unknown. This study examined reveal the role of KC in post-cold ischemic liver grafts. Rat livers treated with or without liposome-encapsulated dichloromethylene diphosphonate, a KC-depleting reagent, were stored in University of Wisconsin (UW) solution at 4 degrees C for 8 to 24 hours and reperfused while monitoring biliary output and constituents. The ability of hepatocytes to excrete bile was assessed through laser-confocal microfluorography in situ. Cold ischemia-reperfused grafts decreased their bile output significantly at 8 hours without any notable cell injury. This event coincided with impaired excretion of glutathione and bilirubin-IXalpha (BR-IXalpha), suggesting delayed transport of these organic anions. We examined whether intracellular relocalization of multidrug resistance protein-2 (Mrp2) occurred. Kinetic analyses for biliary excretion of carboxyfluorescein, a fluoroprobe excreted through this transporter, revealed significant delay of dye excretion from hepatocytes into bile canaliculi. The KC-depleting treatment significantly attenuated this decline in biliary anion transport mediated through Mrp2 in the 8-hour cold ischemic grafts via redistribution of Mrp2 from the cytoplasm to the canalicular membrane. Furthermore, thromboxane A(2) (TXA(2)) synthase in KC appeared involved as blocking this enzyme improved 5-carboxyfluorescein excretion while cytoplasmic internalization of Mrp2 disappeared in the KC-depleting grafts. In conclusion, KC activation is an important determinant of nonnecrotic hepatocellular dysfunction, jeopardizing homeostasis of the detoxification capacity and organic anion metabolism of the post-cold ischemic grafts.
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Affiliation(s)
- Atsushi Kudo
- Department of Hepatobiliary Pancreatic Surgery, School of Medicine, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
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155
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Jassem W, Koo DDH, Cerundolo L, Rela M, Heaton ND, Fuggle SV. Cadaveric versus living-donor livers: differences in inflammatory markers after transplantation. Transplantation 2003; 76:1599-603. [PMID: 14702531 DOI: 10.1097/01.tp.0000100400.82135.dc] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Prolonged cold storage of organs for transplantation may lead to inflammatory damage upon reperfusion. The aim of this study was to investigate whether organs from living donors experience less damage upon reperfusion than those retrieved from cadaver donors, where cold ischemia times are significantly longer. METHODS Biopsies were obtained from cadaveric (n=23) and living-related donor (LRD) (n=10) liver transplants before and 2 hours after reperfusion. Cryosections were stained with antibodies against neutrophils, platelets, activated platelets, and endothelium. RESULTS LRD liver allografts showed minimal changes postreperfusion. In contrast, after reperfusion of cadaver allografts, neutrophil infiltration was detected in 22% and increased expression of von Willebrand factor (vWF), CD41, and P-selectin in 48%, 30%, and 13% of allografts, respectively. In cadaver allografts with deposition of activated platelets expressing either P-selectin or vWF, the cold ischemia time was significantly longer (885 +/- 123 min vs. 608 +/- 214 min, P=0.04; 776.8 +/- 171 min vs. 559.3 +/- 216 min, P=0.01, respectively). Increases in neutrophils and platelets after reperfusion were not significantly associated with clinical events posttransplant. However, in cadaver transplants that experienced early acute rejection, the mean cold ischemia time was significantly longer than in allografts with no rejection (732 +/- 174 min vs. 480 +/- 221 min, P=0.006). CONCLUSIONS This study demonstrates that in the clinical situation, cold ischemia causes platelet deposition and neutrophil infiltration after reperfusion of cadaveric liver allografts. These early inflammatory events may contribute to make the graft more susceptible to acute rejection.
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Affiliation(s)
- Wayel Jassem
- Liver Transplant Unit, Institute of Liver Studies, King's College Hospital, Denmark Hill, London, UK
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156
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Debonera F, Krasinkas AM, Gelman AE, Aldeguer X, Que X, Shaked A, Olthoff KM. Dexamethasone inhibits early regenerative response of rat liver after cold preservation and transplantation. Hepatology 2003; 38:1563-72. [PMID: 14647067 DOI: 10.1016/j.hep.2003.09.036] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Regeneration is crucial for the recovery of hepatic mass following liver transplantation. Glucocorticoids, immunosuppressive and antiinflammatory agents commonly used in transplantation, are known to inhibit the expression of specific cytokines and growth factors. Some of these proteins, namely tumor necrosis factor alpha (TNF-alpha) and interleukin 6 (IL-6), play a critical role in the initiation of liver regeneration. Following cold preservation and reperfusion of the transplanted liver, the normal recovery process is marked by increased expression of TNF-alpha and IL-6, followed by activation of cytokine-responsive transcription factors and progression of the cell cycle resulting in hepatocyte proliferation. We hypothesized that glucocorticoids may influence the repair mechanisms initiated after extended cold preservation and transplantation. Using a rat orthotopic liver transplant model, recipient animals were treated with dexamethasone at the time of transplantation of liver grafts with prolonged cold storage (16 hours). Treatment with dexamethasone suppressed and delayed the expression of TNF-alpha and IL-6 compared with animals receiving no treatment and attenuated downstream nuclear factor kappaB (NF-kappaB), signal transduction and activator of transcription 3 (STAT3), and activation protein 1 (AP-1) activation. This suppression was accompanied by poor cell-cycle progression, delayed cyclin D1 nuclear transposition, and impaired hepatocyte proliferation by BrdU uptake. Histologically, the liver grafts in treated animals demonstrated more injury than controls, which appeared to be necrosis, rather than apoptosis. In conclusion, these data provide evidence that the administration of glucocorticoids at the time of transplantation inhibits the initiation of the regenerative process and may have a deleterious effect on the recovery of liver grafts requiring significant regeneration. This may be particularly relevant for transplantation of partial liver grafts in the living donor setting.
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Affiliation(s)
- Fotini Debonera
- Department of Surgery, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA
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157
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Heise M, Settmacher U, Pfitzmann R, Wunscher U, Muller AR, Jonas S, Neuhaus P. A survival-based scoring-system for initial graft function following orthotopic liver transplantation. Transpl Int 2003. [DOI: 10.1111/j.1432-2277.2003.tb00243.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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158
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Compagnon P, Wang H, Lindell SL, Ametani MS, Mangino MJ, D'Alessandro AM, Southard JH. Brain death does not affect hepatic allograft function and survival after orthotopic transplantation in a canine model. Transplantation 2002; 73:1218-27. [PMID: 11981412 DOI: 10.1097/00007890-200204270-00006] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Brain death has been shown to decrease graft function and survival in rodent models. The aim of this study was to evaluate how brain death affects graft viability in the donor and liver tolerance to cold preservation as assessed by survival in a canine transplant model. METHODS Beagle dogs were used for the study. Non-brain dead (BD) donors served as controls. Brain death was induced by sudden inflation of a subdural balloon catheter with continuous monitoring of arterial blood pressure and electroencephalographic activity. Sixteen hours after confirmation of brain death, liver grafts were retrieved. All livers were flushed in situ and preserved for 24 hr in cold University of Wisconsin solution before transplantation. Recipient survival rates, serum hepatic enzyme levels, coagulation, and metabolic parameters of the recipients were analyzed. RESULTS No significant changes were observed in serum aminotransferases (alanine and aspartate transaminases) and lactate dehydrogenase levels in the BD donor. After preservation, control (n=6) and BD livers (n=5) showed full functional recovery after transplant with 100% survival in both groups at day 7. There was no significant difference in peak serum alanine, aspartate transaminases, and lactate dehydrogenase after transplantation in recipients who received a liver from BD donor compared to control group. BD livers were functionally as capable as control livers in correcting metabolic acidosis during the first 24 hr posttransplantation. Coagulation profiles (index normalized ratio, activated partial thromboplastin time) after reperfusion were similar between groups. CONCLUSION In contrast to previous reports in rodent models, our study shows that brain death does not cause significant liver dysfunction in the donor before organ removal. Donor brain death and prolonged liver graft preservation do not interact significantly to impair liver function and survival after transplantation.
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Affiliation(s)
- Philippe Compagnon
- Department of Surgery, Division of Transplantation, University of Wisconsin, Madison, WI 53792, USA
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159
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Jassem W, Fuggle SV, Rela M, Koo DDH, Heaton ND. The role of mitochondria in ischemia/reperfusion injury. Transplantation 2002; 73:493-9. [PMID: 11889418 DOI: 10.1097/00007890-200202270-00001] [Citation(s) in RCA: 170] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In organ transplantation, ischemia/reperfusion injury is a multifactorial process that leads to organ damage and primary graft dysfunction. Injury to the organ is mediated by a complex chain of events that involves depletion of energy substrates, alteration of ionic homeostasis, production of reactive oxygen species, and cell death by apoptosis and necrosis. There is increasing evidence that mitochondria play a role in this process because of the profound changes experienced during ischemia and reperfusion. Understanding the mechanisms that lead to mitochondrial damage may be important for developing strategies aimed at improving graft outcome. In this review, we examine the role of mitochondria in ischemia/reperfusion injury and the possible mechanisms that may contribute to organ dysfunction.
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Affiliation(s)
- Wayel Jassem
- Liver Transplant Unit, Institute of Liver Studies, King's College Hospital, Denmark Hill, London, SE5 9RS, United Kingdom
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160
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Qian YB, Cheng GH, Huang JF. Multivariate regression analysis on early mortality after orthotopic liver transplantation. World J Gastroenterol 2002; 8:128-30. [PMID: 11833087 PMCID: PMC4656602 DOI: 10.3748/wjg.v8.i1.128] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2001] [Revised: 09/23/2001] [Accepted: 10/26/2001] [Indexed: 02/06/2023] Open
Abstract
AIM To identify the risk factors relating to early mortality after orthotopic liver transplantation. METHODS Clinical data of 37 adult patients undergoing liver transplantation were retrospectively collected and divided into two groups: the survived group and the death group (survival time<30 d). The relationship between multivariate risk factors and early mortality after orthotopic liver transplantation were analyzed by stepwise logistic regression. RESULTS The survival rate was 73%. Early mortality rate was 27%. APACAE III, preoperative serum creatinine level and interoperative bleeding quantity had a significant independent association with early mortality. (R=0.1841, 0.2056 and 0.3738). CONCLUSION APACHE III,preoperative serum creatinine level and interoperative bleeding quantity are significant risk factors relating to early mortality after orthotopic liver transplantation. To improve the recipient's preoperative critical condition and renal function and to reduce interoperative bleeding quantity could lower the early mortality after orthotopic liver transplantation.
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Affiliation(s)
- Ye-Ben Qian
- Department of hepatic biliary surgery, first affiliated hospital An Hui Medical University, HeFei 230022, AnHui Province, China.
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161
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Schnitzler MA, Woodward RS, Brennan DC, Whiting JF, Tesi RJ, Lowell JA. The economic impact of preservation time in cadaveric liver transplantation. Am J Transplant 2001; 1:360-5. [PMID: 12099381 DOI: 10.1034/j.1600-6143.2001.10412.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
There has been considerable recent debate concerning the reconfiguration of the cadaveric liver allocation system with the intent to allocate livers to more severely ill patients over greater distances. We sought to assess the economic implications of longer preservation times in cadaveric liver transplantation that may be seen in a restructured allocation system. A total of 683 patients with nonfulminant liver disease, aged 16 years or older, receiving a cadaveric donor liver as their only transplant, were drawn from a prospective cohort of patients who received transplants between January 1991 and July 1994 at the University of California, San Francisco, the Mayo Clinic, Rochester, Minnesota, or the University of Nebraska, Omaha. The primary outcome measure was standardized hospitalization resource utilization from the day of transplantation through discharge. Secondary outcome measures included 2-year patient survival, and 2-year retransplantation rates. Results indicated that each 1-h increase in preservation time was associated with a 1.4% increase in standardized hospital resource utilization (p = 0.014). The effects on 2-year patient survival and retransplantation rates were not measurably affected by an increase in preservation time. We conclude that policies that increase preservation time may be expected to increase the cost of liver transplantation.
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Affiliation(s)
- M A Schnitzler
- Pharmaco-economic Transplant Research, Washington University School of Medicine, St Louis, Missouri, USA.
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162
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Compagnon P, Clément B, Campion JP, Boudjema K. Effects of hypothermic machine perfusion on rat liver function depending on the route of perfusion. Transplantation 2001; 72:606-14. [PMID: 11544418 DOI: 10.1097/00007890-200108270-00008] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND METHODS The aim of this study was to evaluate the efficacy of hypothermic machine perfusion (HMP) to preserve rat livers according to the route of perfusion, i.e., via portal vein, hepatic veins (retrograde), or hepatic artery. Livers were preserved for 24 or 48 hr by simple cold storage (SCS) or by HMP. Preservation solution was supplemented with (HMP) or without (SCS) hydroxyethyl starch. After preservation, grafts were reperfused for 2 hr with an oxygenated Krebs-Henseleit bicarbonate buffer. RESULTS After 24 hr of preservation, total glutathione concentrations in HMP livers were similar (1287+/-37, 1418+/-118, and 1471+/-62 nmol/g in hepatic artery, portal vein, and hepatic vein HMP livers, respectively) and higher than in the SCS (833+/-118 nmol/g, P<0.05) group. These higher total glutathione values were due to higher reduced glutathione concentrations. ATP concentrations in the liver tissue were similar in HMP groups (0.75+/-0.4, 0.64+/-0.1, and 0.77+/-0.1 micromol/g in hepatic artery, portal vein, and hepatic vein HMP livers, respectively) and higher than in SCS (0.32+/-0.06 micromol/g, P<0.05). After 2 hr of normothermic reperfusion, bile production in the HMP portal and HMP retrograde groups were similar (391+/-29 ml and 372+/-25 ml) and higher than in the HMP artery or SCS groups (275+/-25 ml and 277+/-32 ml, respectively; P<0.05). Aspartate transaminase, alanine transaminase, lactate dehydrogenase, and purine nucleoside phosphorylase release into the perfusate of HMP portal and HMP retrograde perfused livers was similar and significantly lower compared to the HMP artery and SCS groups. At the end of reperfusion, no statistical differences were found for glutathione concentration and energetic reserves in the livers of each group. After 48 hr of preservation, livers from the HMP portal and HMP retrograde groups did significantly better than livers from the HMP artery or SCS groups. CONCLUSIONS This study confirms the superiority of HMP over SCS to preserve the liver graft. It shows that retrograde perfusion is similar to PV perfusion and that perfusion by HA is less beneficial.
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Affiliation(s)
- P Compagnon
- INSERM U-456, Detoxification and Tissue Repair Unit, University of Rennes I, France
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163
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De Carlis L, Giacomoni A, Slim AO, Pirotta V, Di Benedetto F, Manoochehri F, Lauterio A, Sammartino C, Rondinara GF, Forti D. Factors involved in the functional recovery of a liver graft with particular emphasis on liver steatosis: a multivariate analysis. Transplant Proc 2001; 33:2720-2. [PMID: 11498138 DOI: 10.1016/s0041-1345(01)02160-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- L De Carlis
- Department of Surgery and Abdominal Transplantation, Niguarda Hospital, Milan, Italy
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164
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Russo FP, Bassanello M, Senzolo M, Cillo U, Burra P. Functional and morphological graft monitoring after liver transplantation. Clin Chim Acta 2001; 310:17-23. [PMID: 11485750 DOI: 10.1016/s0009-8981(01)00506-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The development of effective immunosuppressive drugs and the refinement of surgical procedures have led to remarkable improvements in the long-term success of liver transplantation. This procedure is now widely recognised as an effective, preferable therapeutic option for the treatment of end-stage liver disease. The early diagnosis of dysfunction is an indispensable tool for the successful management of the hepatic allograft recipient. Liver function is usually assessed by biochemical and morphological examinations, usually based on coagulation factors (fibrinogen, fibrinogen degradation peptide, factor V, prothrombin time and prolonged thromboplastin time), transaminases, gamma-GT, ALP, bilirubin and lactic acid, and histology. Liver biopsy is usually performed before the implantation of the graft to assess the viability of the liver and following liver transplantation, whenever clinical events warrant it or as part of a routine biopsy schedule.
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Affiliation(s)
- F P Russo
- Department of Surgical and Gastroenterological Sciences, Gastroenterology Section, University of Padua, 35128, Padua, Italy
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165
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Glanemann M, Kaisers U, Langrehr JM, Schenk R, Stange BJ, Müller AR, Bechstein WO, Falke K, Neuhaus P. Incidence and indications for reintubation during postoperative care following orthotopic liver transplantation. J Clin Anesth 2001; 13:377-82. [PMID: 11498321 DOI: 10.1016/s0952-8180(01)00290-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
STUDY OBJECTIVE To analyze the incidence and indications for reintubation during postoperative care following orthotopic liver transplantation (OLT). DESIGN Retrospective chart review. SETTING Large metropolitan teaching hospital. PATIENTS 546 adult liver transplant recipients. MEASUREMENTS AND MAIN RESULTS The medical charts of 546 patients who underwent OLT at our institution between January 1992 and September 1996 were reviewed for the incidence and indications of reintubation throughout primary hospitalization. Eighty-one of 546 patients (14.8%) required one or more episodes of reintubation after OLT. In the majority of cases, reintubation was performed for pulmonary complications (44.6%), followed by cerebral (19.1%) and surgical (14.5%) complications. Cardiac (9.1%) and peripheral neurologic (2.7%) complications were less frequent reasons for reintubation. Overall patient survival, according to the Kaplan-Meier estimates, was 89.9%, 87.5%, 86.5%, and 82.2% after 1, 2, 3, and 5 years, respectively. In patients with one or more episodes of reintubation, overall survival decreased to 62.5% after 1, 2, and 3 years, and to 56.4% after 5 years (p < 0.001). CONCLUSIONS The main indications for reintubation after OLT were pulmonary, cerebral, and surgical complications. These reintubation events had a considerable influence on the patient's postoperative recovery, and were associated with a significantly higher rate of mortality, than for OLT patients who did not undo reintubation.
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Affiliation(s)
- M Glanemann
- Department of General-, Visceral- & Transplantation Surgery, Charité, Campus Virchow Klinikum, Humboldt University Berlin, Germany.
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166
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Linden PK, Bompart F, Gray S, Talbot GH. Hyperbilirubinemia during quinupristin-dalfopristin therapy in liver transplant recipients: correlation with available liver biopsy results. Pharmacotherapy 2001; 21:661-8. [PMID: 11401179 DOI: 10.1592/phco.21.7.661.34580] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
STUDY OBJECTIVE To review the liver histopathology in transplant recipients who developed hyperbilirubinemia during therapy with quinupristin-dalfopristin, a new streptogramin antibiotic, and to ascertain whether objective histologic evidence of adverse drug effect could be correlated to serum bilirubin levels. DESIGN Retrospective analysis. SETTING University of Pittsburgh Medical Center. PATIENTS From a database of 34 liver recipients who received quinupristin-dalfopristin for vancomycin-resistant Enterococcus faecium infection who were prospectively enrolled in a multicenter, open-label, emergency-use protocol, the data for a subset of 25 patients who underwent one or more liver biopsies during therapy were reviewed for this study. INTERVENTIONS Quinupristin-dalfopristin was administered intravenously at 7.5 mg/kg every 8 hours. Available serum bilirubin levels from before, during, and 1 week after therapy were tabulated. Liver biopsy results obtained within 1 week before and during therapy were retrospectively reviewed. Histopathologic results were characterized and correlated to bilirubin level. MEASUREMENTS AND MAIN RESULTS Cholestatic changes were already present in 15 of 17 patients who underwent biopsy before therapy. During therapy, the most common findings from 40 biopsies (25 patients) were cholestasis (33 biopsies), acute rejection (10), and periportal inflammation (8). There was no evidence of drug-specific histopathologic injury. CONCLUSION Hyperbilirubinemia in these patients was likely multifactorial and most frequently due to sepsis and prior graft injury.
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Affiliation(s)
- P K Linden
- Division of Critical Care Medicine, University of Pittsburgh Medical Center, Pennsylvania 15213, USA.
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167
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Kukan M, Haddad PS. Role of hepatocytes and bile duct cells in preservation-reperfusion injury of liver grafts. Liver Transpl 2001; 7:381-400. [PMID: 11349258 DOI: 10.1053/jlts.2001.23913] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In liver transplantation, it is currently hypothesized that nonparenchymal cell damage and/or activation is the major cause of preservation-related graft injury. Because parenchymal cells (hepatocytes) appear morphologically well preserved even after extended cold preservation, their injury after warm reperfusion is ascribed to the consequences of nonparenchymal cell damage and/or activation. However, accumulating evidence over the past decade indicated that the current hypothesis cannot fully explain preservation-related liver graft injury. We review data obtained in animal and human liver transplantation and isolated perfused animal livers, as well as isolated cell models to highlight growing evidence of the importance of hepatocyte disturbances in the pathogenesis of normal and fatty graft injury. Particular attention is given to preservation time-dependent decreases in high-energy adenine nucleotide levels in liver cells, a circumstance that (1) sensitizes hepatocytes to various stimuli and insults, (2) correlates well with graft function after liver transplantation, and (3) may also underlie the preservation time-dependent increase in endothelial cell damage. We also review damage to bile duct cells, which is increasingly being recognized as important in the long-lasting phase of reperfusion injury. The role of hydrophobic bile salts in that context is particularly assessed. Finally, a number of avenues aimed at preserving hepatocyte and bile duct cell integrity are discussed in the context of liver transplantation therapy as a complement to reducing nonparenchymal cell damage and/or activation.
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Affiliation(s)
- M Kukan
- Laboratory of Perfused Organs, Slovak Centre for Organ Transplantation, Institute of Preventive and Clinical Medicine, Bratislava, Slovakia
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168
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Sieders E, Peeters PM, TenVergert EM, de Jong KP, Porte RJ, Zwaveling JH, Bijleveld CM, Slooff MJ. Prognostic factors for long-term actual patient survival after orthotopic liver transplantation in children. Transplantation 2000; 70:1448-53. [PMID: 11118088 DOI: 10.1097/00007890-200011270-00009] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Orthotopic liver transplantation has become the treatment of choice for children with end-stage liver disease. Although results have improved the last decades, still a considerable number of children die after transplantation. The aim of this study was to analyze long-term actual survival and to identify prognostic factors for such survival rates. METHODS A consecutive series of 66 children receiving transplants who had or could have had a follow-up of at least 5 years was retrospectively analyzed. Actual survival and prognostic factors in relation to patient, donor, and operation related variables were assessed after multivariate analysis. RESULTS Actual 1-, 3-, and 5-year patient survival was 86%, 79%, and 73%, respectively. A high Child-Pugh (C-P) score or C-P class C, high donor age, high blood loss index, and retransplantation were predictive factors for actual patient survival. A high blood loss index was correlated with biliary atresia, low recipient age and weight, and with previous upper abdominal operations. The duration of stay of the donor at the intensive care unit (ICU) was a predictive factor for retransplantation. CONCLUSIONS Children with diseases eligible for liver transplantation should be seen early in the course of their disease in a transplantation center. All possible measures should be taken during the transplantation procedure to keep the blood loss at a minimum. Children with biliary atresia deserve special attention in this respect. The choice of donors has implications for survival.
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Affiliation(s)
- E Sieders
- University Hospital Groningen, Department of Surgery, The Netherlands.
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169
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Zamir GA, Markmann JF, Abrams J, Macatee MR, Nunes FA, Shaked A, Olthoff KM. The fate of liver grafts declined for subjective reasons and transplanted out of a local organ procurement organization. Transplantation 2000; 70:1149-54. [PMID: 11063332 DOI: 10.1097/00007890-200010270-00004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Decisions made by transplant surgeons to decline liver grafts for local use are based on both objective and ill-defined subjective parameters. These livers may be offered and subsequently transplanted at non-local centers. We analyzed the fate of these exported livers, focusing on the outcome of grafts declined for subjective reasons. The aim is to determine whether local surgeons' concerns about inferior graft function are justified. METHODS Over a 3-year period, 13.3% of 555 livers in our organ procurement organization (OPO) were exported and transplanted out of the local area. Donor data and reason for decline were obtained from an extensive OPO database. Objective reasons for decline were based on no appropriate matched recipient due to donor size, serologies, or malignancy with potential for spread. Subjective parameters were related to the procuring surgeon's assessment and included variables such as medical and social history, abnormal liver enzymes, older age, organ visualization, and biopsy. Recipient data were obtained from questionnaires sent to outside transplant centers. RESULTS There was a significantly higher rate of nonfunction in the subjective group (17.1%), compared to the objective group (0%). One-year graft and patient survival were 79 and 83% for the objective group and 59 and 68% for the subjective group (P=NS). When donors declined for medical/social history were excluded from the subjective group, leaving only grafts declined based solely on the surgeon's assessment of graft quality, there is a significant difference in graft survival (79% for objective and 46% for this subjective subgroup, P=0.03). CONCLUSIONS Livers declined for local use based on subjective assessment by the procuring surgeon have a high nonfunction rate, associated with a high morbidity. Therefore, the use of these grafts should be restricted to recipients at the most urgent status.
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Affiliation(s)
- G A Zamir
- Department of Surgery, University of Pennsylvania, Philadelphia 19104, USA
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170
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Chung SW, Kirkpatrick AW, Kim HL, Scudamore CH, Yoshida EM. Correlation between physiological assessment and outcome after liver transplantation. Am J Surg 2000; 179:396-9. [PMID: 10930489 DOI: 10.1016/s0002-9610(00)00362-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Critical shortages of organ donors for transplantation require appropriate utilization of this scarce resource. The purpose of this study was to assess whether use of physiological parameters of preliver transplant recipients is helpful in determining eventual outcome. METHODS Between October 1989 and June 1999, 215 liver transplants were performed on 199 patients at the Vancouver Hospital nad Health Sciences Centre. Thirty-one patients undergoing transplantation between May 1993 and June 1994 were retrospectively evaluated to obtain a minimum 5-year follow-up. Variables examined included pretransplant activation status (status 1, at home; status 2, hospitalized; status 3, admitted to intensive care; status 4, mechanical ventilation), simplified acute physiological score (SAPS), Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II, and APACHE III scores at the time of transplantation. The scores were correlated to posttransplant mortality and functional outcome. RESULTS The 5-year mortality for status 1 patients was 14.3% versus 30% for patients listed as status 2 or greater (P = not significant). There were no significant differences in any of the physiological scoring assessments with regard to posttransplant mortality or functional assessment. Of the surviving patients, 18 of 22 who were employed, in school, or active at home pretransplant returned to their pretransplant activity. CONCLUSIONS Detailed physiological scoring systems are no more accurate in predicting outcome after liver transplant than current listing status parameters.
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Affiliation(s)
- S W Chung
- Departments of Surgery and Medicine, University of British Columbia, and the British Columbia Transplant Society, Vancouver, British Columbia, Canada
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171
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Lütkes P, Lutz J, Loock J, Daul A, Broelsch C, Philipp T, Heemann U. Continuous venovenous hemodialysis treatment in critically ill patients after liver transplantation. Kidney Int 1999. [DOI: 10.1046/j.1523-1755.56.s72.4.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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172
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Wall WJ. Predicting outcome after liver transplantation. LIVER TRANSPLANTATION AND SURGERY : OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES AND THE INTERNATIONAL LIVER TRANSPLANTATION SOCIETY 1999; 5:458-9. [PMID: 10477850 DOI: 10.1002/lt.500050511] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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173
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Deschênes M, Forbes C, Tchervenkov J, Barkun J, Metrakos P, Tector J, Alpert E. Use of older donor livers is associated with more extensive ischemic damage on intraoperative biopsies during liver transplantation. LIVER TRANSPLANTATION AND SURGERY : OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES AND THE INTERNATIONAL LIVER TRANSPLANTATION SOCIETY 1999; 5:357-61. [PMID: 10477834 DOI: 10.1002/lt.500050501] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Initial poor graft function is associated with increased morbidity and graft loss after liver transplantation. Donor age is a risk factor for the development of initial poor function. The severity of ischemic damage on intraoperative postreperfusion (0Post) allograft biopsy specimens is predictive of subsequent initial poor function. This study was performed to assess whether donor age is a risk factor for the development of ischemic damage on 0Post biopsy specimens. The records of 94 liver transplantations were reviewed. 0Post biopsy specimens were obtained after complete allograft revascularization. The severity of ischemic damage was graded as follows: 0, none; 1, minimal; 2, mild; 3, moderate; and 4, severe. Grafts were defined as older when donor age was 50 years or older. Other independent variables examined included donor cause of death, length of hospital stay, acidosis, serum alanine aminotransferase level, graft cold ischemia time, and degree of steatosis. Older grafts were associated with higher grades of ischemic damage than younger grafts (2.3 +/- 1.0 v 1.3 +/- 1.1; P =.003). Univariate and multivariate analysis identified donor age of 50 years or older as the only significant predictive variable of the severity of ischemic damage. In 16 transplantations involving older grafts, there was no statistically significant association between the severity of ischemic damage and incidence of initial poor function and graft loss. The use of older liver grafts is associated with more extensive ischemic damage immediately after graft reperfusion. Whether this early lesion identifies among older graft recipients those at risk for a worst outcome remains to be determined.
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Affiliation(s)
- M Deschênes
- Department of Medicine, Liver Transplant Program, Royal Victoria Hospital, McGill University Health Center, Montréal, Québec, Canada
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174
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Abstract
The growing disparity between available organs for liver transplantation and the number of waiting recipients has prompted significant debate over organ allocation and distribution. In light of this debate, recipient selection and prediction of factors relating to outcome have become increasingly important. Current immunosuppressive regimens provide excellent short-and long-term survival for patients and grafts. Increasingly, efforts are being made to decrease or withdraw immunosuppression late after transplantation to minimize long-term side effects. Viral disease, particularly cytomegalovirus infection, results in significant morbidity and mortality in patients. However, strategies for targeting high-risk patients with prophylactic antiviral therapy have been successful in reducing the incidence of cytomegalovirus disease. Recurrent viral hepatitis following liver transplantation may limit long-term graft success. Lamivudine appears to limit recurrent infection with hepatitis B virus in a significant number of patients who develop this condition following liver transplantation and may represent a cost savings over hepatitis B immunoglobulin. Although the overall survival of patients with chronic hepatitis C virus infection after orthotopic liver transplantation is excellent, significant morbidity and mortality occur in the subset of patients with severe recurrent disease. Interferon may delay the onset of disease in patients infected with hepatitis C virus following orthotopic liver transplantation, and investigation continues into antiviral therapy in this group of patients.
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Affiliation(s)
- K A Brown
- Henry Ford Hospital, Detroit, Michigan, USA
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175
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Solution development in organ preservation: The University of Wisconsin perspective. Transplant Rev (Orlando) 1999. [DOI: 10.1016/s0955-470x(99)80048-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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