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Wolpert BM, Rothgerber DJ, Rosner AK, Brunier M, Kuchen R, Schramm P, Griemert EV. Evaluation of dynamic cerebrovascular autoregulation during liver transplantation. PLoS One 2024; 19:e0305658. [PMID: 39058695 PMCID: PMC11280153 DOI: 10.1371/journal.pone.0305658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 06/03/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Cerebrovascular autoregulation in patients with acute and chronic liver failure is often impaired, yet an intact autoregulation is essential for the demand-driven supply of oxygenated blood to the brain. It is unclear, whether there is a connection between cerebrovascular autoregulation during liver transplantation (LTX) and the underlying disease, and if perioperative anesthesiologic consequences can result from this. METHODS In this prospective observational pilot study, data of twenty patients (35% female) undergoing LTX were analyzed. Cerebral blood velocity was measured using transcranial doppler sonography and was correlated with arterial blood pressure. The integrity of dynamic cerebrovascular autoregulation (dCA) was evaluated in the frequency domain through transfer function analysis (TFA). Standard clinical parameters were recorded. Mixed one-way ANOVA and generalized estimating equations were fitted to data involving repeated measurements on the same patient. For all other correlation analyses, Spearman's rank correlation coefficient (Spearman's-Rho) was used. RESULTS Indications of impaired dCA are seen in frequency domain during different phases of LTX. No correlation was found between various parameter of dCA and primary disease, delirium, laboratory values, length of ICU or hospital stay, mortality or surgical technique. CONCLUSIONS Although in most cases the dCA has been impaired during LTX, the heterogeneity of the underlying diseases seems to be too diverse to draw valid conclusions from this observational pilot study.
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Affiliation(s)
- Bente Marei Wolpert
- Department of Anesthesiology, University Medical Centre of the Johannes-Gutenberg University Mainz, Mainz, Germany
| | - David Jonas Rothgerber
- Department of Anesthesiology, University Medical Centre of the Johannes-Gutenberg University Mainz, Mainz, Germany
| | - Ann Kristin Rosner
- Department of Anesthesiology, University Medical Centre of the Johannes-Gutenberg University Mainz, Mainz, Germany
| | - Malte Brunier
- Department of Anesthesiology, University Medical Centre of the Johannes-Gutenberg University Mainz, Mainz, Germany
| | - Robert Kuchen
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Centre of the Johannes-Gutenberg University Mainz, Mainz, Germany
| | - Patrick Schramm
- Department of Neurology, University Hospital of the Justus-Liebig-University Giessen, Giessen, Germany
| | - Eva-Verena Griemert
- Department of Anesthesiology, University Medical Centre of the Johannes-Gutenberg University Mainz, Mainz, Germany
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L'Écuyer S, Charbonney E, Carrier FM, Rose CF. Implication of Hypotension in the Pathogenesis of Cognitive Impairment and Brain Injury in Chronic Liver Disease. Neurochem Res 2024; 49:1437-1449. [PMID: 36635437 DOI: 10.1007/s11064-022-03854-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/23/2022] [Accepted: 12/26/2022] [Indexed: 01/14/2023]
Abstract
The incidence of chronic liver disease is on the rise. One of the primary causes of hospital admissions for patients with cirrhosis is hepatic encephalopathy (HE), a debilitating neurological complication. HE is defined as a reversible syndrome, yet there is growing evidence stating that, under certain conditions, HE is associated with permanent neuronal injury and irreversibility. The pathophysiology of HE primarily implicates a strong role for hyperammonemia, but it is believed other pathogenic factors are involved. The fibrotic scarring of the liver during the progression of chronic liver disease (cirrhosis) consequently leads to increased hepatic resistance and circulatory anomalies characterized by portal hypertension, hyperdynamic circulatory state and systemic hypotension. The possible repercussions of these circulatory anomalies on brain perfusion, including impaired cerebral blood flow (CBF) autoregulation, could be implicated in the development of HE and/or permanent brain injury. Furthermore, hypotensive insults incurring during gastrointestinal bleed, infection, or liver transplantation may also trigger or exacerbate brain dysfunction and cell damage. This review will focus on the role of hypotension in the onset of HE as well as in the occurrence of neuronal cell loss in cirrhosis.
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Affiliation(s)
- Sydnée L'Écuyer
- Hepato-Neuro Laboratory, Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900, rue Saint-Denis - Pavillon R, R08.422 Montréal (Québec), Québec, H2X 0A9, Canada
| | - Emmanuel Charbonney
- Department of Medicine, Critical Care Division, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - François Martin Carrier
- Department of Medicine, Critical Care Division, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Carrefour de l'innovation et santé des populations , Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montréal, Canada
| | - Christopher F Rose
- Hepato-Neuro Laboratory, Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900, rue Saint-Denis - Pavillon R, R08.422 Montréal (Québec), Québec, H2X 0A9, Canada.
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Zhou Y, Huang J, Si Z, Zhou Q, Li L. Pathogenic factors of cognitive dysfunction after liver transplantation: an observational study. Eur J Gastroenterol Hepatol 2023; 35:668-673. [PMID: 37115967 DOI: 10.1097/meg.0000000000002551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
OBJECTIVES Neurocognitive complications significantly reduce long-term health-related quality of life in patients undergoing liver transplantation; however, few studies have focused on their perioperative cognitive status. The authors designed a prospective observational study to determine the incidence and risk factors of posttransplant cognitive dysfunction. METHODS This study included patients with end-stage liver disease who were on the liver transplantation waiting list. We performed an investigation with a neuropsychological battery before and 1 week after the successful transplant, analyzed the changes, and further explored the complicated perioperative factors that contribute to cognitive dysfunction. RESULTS A total of 132 patients completed all the investigations. Compared with healthy controls and preoperative cognitive performance, 54 patients experienced deterioration, 50 patients remained unchanged, and 28 patients showed rapid improvement. Logistic regression analysis showed that age [odds ratio (OR) = 1.15, 95% confidence interval (CI, 1.07-1.22), P < 0.001], the model for end-stage liver disease (MELD) score [OR = 1.07, 95% CI (1.03-1.13), P = 0.038], systemic circulation pressure [OR = 0.95, 95% CI (0.91-0.99), P = 0.026] within the first 30 min after portal vein opening, and total bilirubin concentration [OR = 1.02, 95% CI (1.01-1.03), P = 0.036] on the seventh day post-transplant were closely related to the deterioration of cognitive function. CONCLUSION The incidences of deterioration, maintenance, and improvement in cognitive function were 40.9%, 37.9%, and 21.2%, respectively. Increasing age, higher MELD score, lower perfusion pressure in the early stage of the new liver, and higher total bilirubin concentration postoperatively may be independent pathogenic factors.
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Affiliation(s)
- Yongpeng Zhou
- Department of Anesthesiology, The Second Affiliated Hospital of Air Force Medical University, Xi'an
| | - Jun Huang
- Department of Urology, The Second Xiangya Hospital of Central South University
| | - Zhongzhou Si
- Department of Liver Transplantation, The Second Xiangya Hospital of Central South University
| | - Qin Zhou
- Department of Anaesthesiology, The Second Xiangya Hospital of Central South University, Changsha, PR China
| | - Liwen Li
- Department of Anaesthesiology, The Second Xiangya Hospital of Central South University, Changsha, PR China
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Hunt A, Tasker RC, Deep A. Neurocritical care monitoring of encephalopathic children with acute liver failure: A systematic review. Pediatr Transplant 2019; 23:e13556. [PMID: 31407855 DOI: 10.1111/petr.13556] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/14/2019] [Accepted: 07/04/2019] [Indexed: 12/15/2022]
Abstract
Research on non-invasive neuromonitoring specific to PALF is limited. This systematic review identifies and synthesis the existing literature on non-invasive approaches to monitoring for neurological sequelae in patients with PALF. A series of literature searches were performed to identify all publications pertaining to five different non-invasive neuromonitoring modalities, in line with PRISMA guidelines. Each modality was selected on the basis of its potential for direct or indirect measurement of cerebral perfusion; studies on electroencephalographic monitoring were therefore not sought. Data were recorded on study design, patient population, comparator groups, and outcomes. A preponderance of observational studies was observed, most with a small sample size. Few incorporated direct comparisons of different modalities; in particular, comparison to invasive intracranial pressure monitoring was largely lacking. The integration of current evidence is considered in the context of the clinically significant distinctions between pediatric and adult ALF, as well as the implications for planning of future investigations to best support the evidence-based clinical care of these patients.
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Affiliation(s)
- Adam Hunt
- University College Hospital, London, UK
| | - Robert C Tasker
- Harvard Medical School, Chair in Neurocritical Care, Boston Children's Hospital, Boston, MA
| | - Akash Deep
- Paediatric Intensive Care, King's College Hospital, London, UK
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Anand AC, Singh P. Neurological Recovery After Recovery From Acute Liver Failure: Is it Complete? J Clin Exp Hepatol 2019; 9:99-108. [PMID: 30765942 PMCID: PMC6363962 DOI: 10.1016/j.jceh.2018.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 06/11/2018] [Indexed: 12/12/2022] Open
Abstract
Neurologic dysfunction characterised by Hepatic Encephalopathy (HE) and cerebral oedema are the most dramatic presentations of Acute Liver Failure (ALF) and signify poor outcome. Improved critical care and wider availability of emergency Liver Transplantation (LT) has improved survivability in ALF. In most cases absence of clinically overt encephalopathy after spontaneous recovery from ALF or after LT is thought to indicate complete neurologic recovery. Recent data suggests that neurologic recovery may not always be complete. Instances of persistent neurologic dysfunction as well as neuropsychiatric abnormalities are now being recognised and warrant active follow up of these patients. Although evidences irreversible neurologic damage is uncommon after ALF, neuropsychiatric disturbances are not uncommon. Complex pathogenesis is involved in neurocognitive disorders seen after many other conditions including LT that require critical care. Structural damage and persistent neurological abnormalities seen after ALF are more likely to be related to cerebral edema, raised intracranial tension and cerebral hypoxemia, while neurocognitive dysfunctions may be a part of a wider spectrum of disorders commonly seen among those who recover from any critical illness.
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Key Words
- ALF, Acute Liver Failure
- APAP, Acetaminophen
- BBB, Blood Brain Barrier
- CARS, Compensatory Anti-Inflammatory Response Syndrome
- CVVH, Continuous Veno-Venous Hemodialysis
- DAMPS, Damage Associated Molecular Pattern
- DWI, Diffusion-Weighted Imaging
- EEG, Electroencephalography
- FLAIR, Fluid-Attenuated Inversion Recovery
- HE, Hepatic Encephalopathy
- LT, Liver Transplantation
- MPT, Mitochondrial Permeability Transition
- PET, Positron Emission Tomography
- SIRS, Systemic Inflammatory Response Syndrome
- acute liver failure
- cerebral oedema
- hepatic encephalopathy
- neurological dysfunction
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Affiliation(s)
- Anil C. Anand
- Address for correspondence: Anil C. Anand, Senior Consultant, Gastroenterology & Hepatology, Indraprastha Apollo Hospital, New Delhi 110076, India.
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Macías-Rodríguez RU, Ruiz-Margáin A, Cantú-Brito C, Flores-Silva DF, García-Flores OR, Cubero FJ, Larrieta-Carrasco E, Torre A. Changes in Cerebral Hemodynamics in Patients With Cirrhosis After Liver Transplantation. Liver Transpl 2018; 24:1673-1679. [PMID: 30207422 DOI: 10.1002/lt.25335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 08/30/2018] [Indexed: 12/26/2022]
Abstract
Improvement in cognitive function after orthotopic liver transplantation (LT) has been demonstrated in the acute setting immediately after LT and in acute liver failure. However, the longterm changes in cerebral hemodynamics after LT remain unexplored. Therefore, we aimed to evaluate the longterm changes in cerebral hemodynamics of patients with cirrhosis after LT. In this prospective cohort study, we performed transcranial Doppler ultrasonography (TCD) measuring the pulsatility index (PI), resistance index (RI), and breath-holding index (BHI) to evaluate cerebrovascular structural integrity and reactivity, respectively, in both middle cerebral arteries before and after LT. Neuropsychometric tests and West-Haven criteria were used for hepatic encephalopathy (HE) characterization. Interleukin 6 and tumor necrosis factor α plasma levels were measured. Descriptive statistics and Wilcoxon's test were used. There were 27 patients who were included. Median follow-up after LT was 6 months, mean age before LT was 46.3 ± 10.3 years, the main etiology was hepatitis C virus (59%), and most of the patients were Child-Pugh B (15/27). Model for End-Stage Liver Disease (MELD) score was 16 ± 7.5, MELD-Na was 19.3 ± 7.1, Psychometric Hepatic Encephalopathy Score was -3.48 ± 3.66, and critical flicker fusion (CFF) was 40.28 ± 5.70 Hz. Before LT, 17/27 patients had HE and 11/27 ascites. A decrease of 20.8% and 13.5% in PI and RI was observed after LT (P < 0.001, both), together with an increase in BHI (32.4%, P = 0.122). These changes in cerebral hemodynamics paralleled those in systemic inflammation. Clinical improvement in cognition was observed in all patients with overt HE after LT. In conclusion, these results show a significant improvement in cerebral hemodynamics after LT, obtained through TCD, indicating less arterial cerebral vasoconstriction together with a decrease in systemic inflammation. Changes in cerebral vasoconstriction can be the basis for the improvement in cognitive function after LT in the long term.
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Affiliation(s)
| | - Astrid Ruiz-Margáin
- Departments of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Carlos Cantú-Brito
- Neurology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | - Francisco Javier Cubero
- Department of Immunology, Ophtalmology and ORL, Complutense University School of Medicine, Madrid, Spain.,12 de Octubre Health Research Institute, Madrid, Spain
| | - Elena Larrieta-Carrasco
- Departments of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Aldo Torre
- Departments of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Bjerring PN, Gluud LL, Larsen FS. Cerebral Blood Flow and Metabolism in Hepatic Encephalopathy-A Meta-Analysis. J Clin Exp Hepatol 2018; 8:286-293. [PMID: 30302046 PMCID: PMC6175738 DOI: 10.1016/j.jceh.2018.06.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 06/11/2018] [Indexed: 12/12/2022] Open
Abstract
Hepatic Encephalopathy (HE) is associated with abnormalities in brain metabolism of glucose, oxygen and amino acids. In patients with acute liver failure, cortical lactate to pyruvate ratio is increased, which is indicative of a compromised cerebral oxidative metabolism. In this meta-analysis we have reviewed the published data on cerebral blood flow and metabolic rates from clinical studies of patients with HE. We found that hepatic encephalopathy was associated with reduced cerebral metabolic rate of oxygen, glucose, and blood flow. One exemption was in HE type B (shunt/by-pass) were a tendency towards increased cerebral blood flow was seen. We speculate that HE is associated with a disturbed metabolism-cytopathic hypoxia-and that type specific differences of brain metabolism is due to differences in pathogenesis of HE.
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Key Words
- ALF, Acute Liver Failure
- CBF, Cerebral Blood Flow
- CMR, Cerebral Metabolic Rate
- HE, Hepatic Encephalopathy
- ICH, Intracranial Hypertension
- MHE, Minimal Hepatic Encephalopathy
- MRI, Magnetic Resonance Imaging
- OHE, Overt Hepatic Encephalopathy
- PCS, Portocaval Shunt
- cerebral blood flow
- cerebral metabolism
- hepatic encephalopathy
- liver failure
- pcMRI, Phase-Contrast MRI
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Affiliation(s)
- Peter N. Bjerring
- Department of Hepatology, Rigshospitalet, Copenhagen, Denmark
- The Gastro Unit, Medical Division, Hvidovre Hospital, Hvidovre, Denmark
- Address for correspondence: Peter N. Bjerring, Department of Hepatology, Rigshospitalet, Copenhagen, Denmark.
| | - Lise L. Gluud
- The Gastro Unit, Medical Division, Hvidovre Hospital, Hvidovre, Denmark
| | - Fin S. Larsen
- Department of Hepatology, Rigshospitalet, Copenhagen, Denmark
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8
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Sparacia G, Cannella R, Lo Re V, Mamone G, Sakai K, Yamada K, Miraglia R. Brain-core temperature of patients before and after orthotopic liver transplantation assessed by DWI thermometry. Jpn J Radiol 2018; 36:324-330. [DOI: 10.1007/s11604-018-0729-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 03/15/2018] [Indexed: 10/17/2022]
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Hadjihambi A, De Chiara F, Hosford PS, Habtetion A, Karagiannis A, Davies N, Gourine AV, Jalan R. Ammonia mediates cortical hemichannel dysfunction in rodent models of chronic liver disease. Hepatology 2017; 65:1306-1318. [PMID: 28066916 PMCID: PMC5396295 DOI: 10.1002/hep.29031] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 11/22/2016] [Accepted: 12/23/2016] [Indexed: 12/19/2022]
Abstract
UNLABELLED The pathogenesis of hepatic encephalopathy (HE) in cirrhosis is multifactorial and ammonia is thought to play a key role. Astroglial dysfunction is known to be present in HE. Astrocytes are extensively connected by gap junctions formed of connexins, which also exist as functional hemichannels allowing exchange of molecules between the cytoplasm and the extracellular milieu. The astrocyte-neuron lactate shuttle hypothesis suggests that neuronal activity is fueled (at least in part) by lactate provided by neighboring astrocytes. We hypothesized that in HE, astroglial dysfunction could impair metabolic communication between astrocytes and neurons. In this study, we determined whether hyperammonemia leads to hemichannel dysfunction and impairs lactate transport in the cerebral cortex using rat models of HE (bile duct ligation [BDL] and induced hyperammonemia) and also evaluated the effect of ammonia-lowering treatment (ornithine phenylacetate [OP]). Plasma ammonia concentration in BDL rats was significantly reduced by OP treatment. Biosensor recordings demonstrated that HE is associated with a significant reduction in both tonic and hypoxia-induced lactate release in the cerebral cortex, which was normalized by OP treatment. Cortical dye loading experiments revealed hemichannel dysfunction in HE with improvement following OP treatment, while the expression of key connexins was unaffected. CONCLUSION The results of the present study demonstrate that HE is associated with central nervous system hemichannel dysfunction, with ammonia playing a key role. The data provide evidence of a potential neuronal energy deficit due to impaired hemichannel-mediated lactate transport between astrocytes and neurons as a possible mechanism underlying pathogenesis of HE. (Hepatology 2017;65:1306-1318).
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Affiliation(s)
- Anna Hadjihambi
- UCL Institute for Liver and Digestive Health, Division of Medicine, UCL Medical School, Royal Free HospitalRowland Hill StreetLondonUnited Kingdom,Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology and PharmacologyUniversity College LondonLondonUnited Kingdom
| | - Francesco De Chiara
- UCL Institute for Liver and Digestive Health, Division of Medicine, UCL Medical School, Royal Free HospitalRowland Hill StreetLondonUnited Kingdom
| | - Patrick S. Hosford
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology and PharmacologyUniversity College LondonLondonUnited Kingdom
| | - Abeba Habtetion
- UCL Institute for Liver and Digestive Health, Division of Medicine, UCL Medical School, Royal Free HospitalRowland Hill StreetLondonUnited Kingdom
| | | | - Nathan Davies
- UCL Institute for Liver and Digestive Health, Division of Medicine, UCL Medical School, Royal Free HospitalRowland Hill StreetLondonUnited Kingdom
| | - Alexander V. Gourine
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology and PharmacologyUniversity College LondonLondonUnited Kingdom
| | - Rajiv Jalan
- UCL Institute for Liver and Digestive Health, Division of Medicine, UCL Medical School, Royal Free HospitalRowland Hill StreetLondonUnited Kingdom
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10
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Sawhney R, Holland-Fischer P, Rosselli M, Mookerjee RP, Agarwal B, Jalan R. Role of ammonia, inflammation, and cerebral oxygenation in brain dysfunction of acute-on-chronic liver failure patients. Liver Transpl 2016; 22:732-42. [PMID: 27028317 DOI: 10.1002/lt.24443] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 02/01/2016] [Accepted: 02/20/2016] [Indexed: 12/12/2022]
Abstract
Hepatic encephalopathy (HE) is a common feature of acute-on-chronic liver failure (ACLF). Although ammonia, inflammation, and cerebral oxygenation are associated with HE in acute liver failure, their roles in ACLF are unknown. The aim of this prospective, longitudinal study was to determine the role of these pathophysiological variables in ACLF patients with and without HE. We studied 101 patients with ACLF admitted to the intensive care unit. Severity of ACLF and HE, arterial ammonia, jugular venous oxygen saturation (JVO2 ), white blood cell count (WCC), and C-reactive protein were measured at days 0, 1, 3, and 7. Patients were followed until death or hospital discharge. Mortality was high (51 patients, 50.5%), especially in patients with HE of whom 35 of 53 (66.0%) died regardless of ACLF severity. At baseline, increased WCC and abnormal JVO2 (high or low) were independent predictors of death. Further deterioration in inflammation, JVO2 , and ammonia were also predictive of mortality. JVO2 deviation and hyperammonemia were associated with the presence and severity of HE; improvement in these parameters was associated with a reduction in HE grade. No direct interaction was observed between these variables in regards to mortality or HE. In conclusion, this study describes potential mechanisms of HE in ACLF indicating that ammonia and abnormal cerebral oxygenation are important. The results suggest that ammonia, JVO2 , and WCC are important prognostic biomarkers and therapeutic targets. The relative roles of these pathophysiological factors in the pathogenesis of HE in ACLF or guiding therapy to improve survival requires future study. Liver Transplantation 22 732-742 2016 AASLD.
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Affiliation(s)
- Rohit Sawhney
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Hospital, London, UK
| | - Peter Holland-Fischer
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Hospital, London, UK
| | - Matteo Rosselli
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Hospital, London, UK
| | - Rajeshwar P Mookerjee
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Hospital, London, UK
| | - Banwari Agarwal
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Hospital, London, UK
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Hospital, London, UK
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11
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Near-infrared spectroscopy assessed cerebral oxygenation during open abdominal aortic aneurysm repair: relation to end-tidal CO2 tension. J Clin Monit Comput 2015; 30:409-15. [DOI: 10.1007/s10877-015-9732-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 06/27/2015] [Indexed: 10/23/2022]
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12
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Hemin protects against hippocampal damage following orthotopic autologous liver transplantation in adult rats. Life Sci 2015; 135:27-34. [PMID: 26092480 DOI: 10.1016/j.lfs.2015.05.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 04/13/2015] [Accepted: 05/23/2015] [Indexed: 02/08/2023]
Abstract
AIMS Induction of heme oxygenase-1 (HO-1) has been widely accepted to be neuro-protective. This study aimed to examine whether hemin (a HO-1 inducer) attenuates neuronal damage in the hippocampus induced by orthotopic autologous liver transplantation (OALT) in adult rats. MAIN METHODS Rats were randomly allocated into four groups (n=8 each): (i) Sham control group; (ii) OALT model group; (iii) Hemin+OALT group, with intra-peritoneal (i.p.) injection of hemin (5 mg/kg) 24 hours (h) before the OALT; and (iv) ZnPP (a HO-1 inhibitor)+OALT group, with i.p. injection of ZnPP (32 mg/kg) 24h before the OALT. Twenty four hours after the surgery, the hippocampal tissues were collected for electron microscopic examination and terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) analysis. The levels of hippocampal HO-1 protein and serum S-100β, the concentrations of regional tumor necrosis factor-α (TNF-α) and interleukins (IL-6, IL-10), as well as the status of malondialdehyde (MDA), superoxide dismutase (SOD) and catalase (CAT) in the hippocampus were assessed. KEY FINDINGS Rats suffered severe neuronal damage in the hippocampus after OALT, mainly in apoptosis. Pre-treatment with hemin obviously alleviated the damage; up-regulated the HO-1 protein level; inhibited the release of TNF-α, IL-6 and MDA; and promoted the activities of SOD, CAT and IL-10; however, pre-treatment with ZnPP did not exhibit the opposite effect, except that a marked increase in serum S-100β level was detected. SIGNIFICANCE Hemin up-regulated the expression of HO-1 and attenuated hippocampal neuronal damage induced by OALT.
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Schousboe A, Waagepetersen HS, Leke R, Bak LK. Effects of hyperammonemia on brain energy metabolism: controversial findings in vivo and in vitro. Metab Brain Dis 2014; 29:913-7. [PMID: 24577633 DOI: 10.1007/s11011-014-9513-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 02/14/2014] [Indexed: 12/21/2022]
Abstract
The literature related to the effects of elevated plasma ammonia levels on brain energy metabolism is abundant, but heterogeneous in terms of the conclusions. Thus, some studies claim that ammonia has a direct, inhibitory effect on energy metabolism whereas others find no such correlation. In this review, we discuss both recent and older literature related to this controversial topic. We find that it has been consistently reported that hepatic encephalopathy and concomitant hyperammonemia lead to reduced cerebral oxygen consumption. However, this may not be directly linked to an effect of ammonia but related to the fact that hepatic encephalopathy is always associated with reduced brain activity, a condition clearly characterized by a decreased CMRO2. Whether this may be related to changes in GABAergic function remains to be elucidated.
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Affiliation(s)
- Arne Schousboe
- Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Universitetsparken 2, 2100, Copenhagen Ø, Denmark
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14
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Sørensen H, Grocott HP, Niemann M, Rasmussen A, Hillingsø JG, Frederiksen HJ, Secher NH. Ventilatory strategy during liver transplantation: implications for near-infrared spectroscopy-determined frontal lobe oxygenation. Front Physiol 2014; 5:321. [PMID: 25202281 PMCID: PMC4142416 DOI: 10.3389/fphys.2014.00321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 08/04/2014] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND As measured by near infrared spectroscopy (NIRS), cerebral oxygenation (ScO2) may be reduced by hyperventilation in the anhepatic phase of liver transplantation surgery (LTx). Conversely, the brain may be subjected to hyperperfusion during reperfusion of the grafted liver. We investigated the relationship between ScO2 and end-tidal CO2 tension (EtCO2) during the various phases of LTx. METHODS In this retrospective study, 49 patients undergoing LTx were studied. Forehead ScO2, EtCO2, minute ventilation (VE), and hemodynamic variables were recorded from the beginning of surgery through to the anhepatic and reperfusion phases during LTx. RESULTS In the anhepatic phase, ScO2 was reduced by 4.3% (95% confidence interval: 2.5-6.0%; P < 0.0001), EtCO2 by 0.3 kPa (0.2-0.4 kPa; P < 0.0001), and VE by 0.4 L/min (0.1-0.7 L/min; P = 0.0018). Conversely, during reperfusion of the donated liver, ScO2 increased by 5.5% (3.8-7.3%), EtCO2 by 0.7 kPa (0.5-0.8 kPa), and VE by 0.6 L/min (0.3-0.9 L/min; all P < 0.0001). Changes in ScO2 were correlated to those in EtCO2 (Pearson r = 0.74; P < 0.0001). CONCLUSION During LTx, changes in ScO2 are closely correlated to those of EtCO2. Thus, this retrospective analysis suggests that attention to maintain a targeted EtCO2 would result in a more stable ScO2 during the operation.
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Affiliation(s)
- Henrik Sørensen
- Department of Anesthesia, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Hilary P. Grocott
- Department of Anesthesia and Perioperative Medicine, St. Boniface Hospital, University of ManitobaWinnipeg, MB, Canada
| | - Mads Niemann
- Department of Anesthesia, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Allan Rasmussen
- Department of Surgery and Transplantation, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Jens G. Hillingsø
- Department of Surgery and Transplantation, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Hans J. Frederiksen
- Department of Anesthesia, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Niels H. Secher
- Department of Anesthesia, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
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15
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Seo H, Kim YK, Shin W, Hwang G. Ultrasonographic Optic Nerve Sheath Diameter Is Correlated With Arterial Carbon Dioxide Concentration During Reperfusion in Liver Transplant Recipients. Transplant Proc 2013; 45:2272-6. [DOI: 10.1016/j.transproceed.2012.12.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 12/30/2012] [Indexed: 02/09/2023]
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16
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Dam G, Keiding S, Munk OL, Ott P, Vilstrup H, Bak LK, Waagepetersen HS, Schousboe A, Sørensen M. Hepatic encephalopathy is associated with decreased cerebral oxygen metabolism and blood flow, not increased ammonia uptake. Hepatology 2013; 57:258-65. [PMID: 22886493 DOI: 10.1002/hep.25995] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 12/15/2011] [Accepted: 07/11/2012] [Indexed: 12/19/2022]
Abstract
UNLABELLED Studies have shown decreased cerebral oxygen metabolism (CMRO(2)) and blood flow (CBF) in patients with cirrhosis with hepatic encephalopathy (HE). It remains unclear, however, whether these disturbances are associated with HE or with cirrhosis itself and how they may relate to arterial blood ammonia concentration and cerebral metabolic rate of blood ammonia (CMRA). We addressed these questions in a paired study design by investigating patients with cirrhosis during and after recovery from an acute episode of HE type C. CMRO(2), CBF, and CMRA were measured by dynamic positron emission tomography (PET)/computed tomography (CT). Ten patients with cirrhosis were studied during an acute episode of HE; nine were reexamined after recovery. Nine patients with cirrhosis with no history of HE served as controls. Mean CMRO(2) increased from 0.73 μmol oxygen/mL brain tissue/min during HE to 0.91 μmol oxygen/mL brain tissue/min after recovery (paired t test; P < 0.05). Mean CBF increased from 0.28 mL blood/mL brain tissue/min during HE to 0.38 mL blood/mL brain tissue/min after recovery (P < 0.05). After recovery from HE, CMRO(2) and CBF were not significantly different from values in the control patients. Arterial blood ammonia concentration decreased 20% after recovery (P < 0.05) and CMRA was unchanged (P > 0.30); both values were higher than in the control patients (both P < 0.05). CONCLUSION The low values of CMRO(2) and CBF observed during HE increased after recovery from HE and were thus associated with HE rather than the liver disease as such. The changes in CMRO(2) and CBF could not be linked to blood ammonia concentration or CMRA.
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Affiliation(s)
- Gitte Dam
- PET Centre & Department of Nuclear Medicine, Aarhus University Hospital, Aarhus, Denmark.
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17
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Frederick RT. Extent of reversibility of hepatic encephalopathy following liver transplantation. Clin Liver Dis 2012; 16:147-58. [PMID: 22321470 DOI: 10.1016/j.cld.2011.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Although hepatic encephalopathy (HE) is prevalent in the cirrhotic population, it has also been considered a potentially reversible condition. Liver transplantation represents the ultimate reversal of the decompensated cirrhotic state and should provide the best option for the reversibility of HE. However, the neurologic compromise associated with HE in the cirrhotic patient may not be completely reversible. Theories regarding fixed structural and reversible metabolic deficits as well as persistence of the hyperdynamic state with continued portosystemic shunting have been proposed to explain this lack of complete reversibility. Whether this remnant neurologic deficit is clinically significant remains unclear.
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Affiliation(s)
- R Todd Frederick
- Division of Hepatology, Department of Transplantation, California Pacific Medical Center, 2340 Clay Street, 3rd Floor, San Francisco, CA 94115, USA.
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18
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Jalan R, Olde Damink SWM, Ter Steege JC, Redhead DN, Lee A, Hayes PC, Deutz NEP. Acute endotoxemia following transjugular intrahepatic stent-shunt insertion is associated with systemic and cerebral vasodilatation with increased whole body nitric oxide production in critically ill cirrhotic patients. J Hepatol 2011; 54:265-71. [PMID: 21067839 DOI: 10.1016/j.jhep.2010.06.042] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 06/03/2010] [Accepted: 06/20/2010] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Transjugular intrahepatic stent-shunt (TIPSS) insertion, in patients with uncontrolled gastro-intestinal bleeding, often results in worsening of the systemic hemodynamics which can be associated with intracranial hypertension but the underlying mechanisms are unclear. This study explored the hypothesis that TIPSS insertion results in acute endotoxemia which is associated with increased nitric oxide production resulting in systemic and cerebral vasodilatation. METHODS Twelve patients with cirrhosis who were undergoing TIPSS for uncontrolled variceal bleeding were studied prior to and 1-h after TIPSS insertion. Changes in cardiac output (CO) and cerebral blood flow (CBF) were measured. NO production was measured using stable isotopes using l-[guanidino-(15)N(2)] arginine and l-[ureido-(13)C;5,5-(2)H(2)] citrulline infusion. The effect of pre- and post-TIPSS plasma on nitric oxide synthase (NOS) activity on human endothelial cell-line (HUVEC) was measured. RESULTS TIPSS insertion resulted in a significant increase in CO and CBF. Endotoxin and induced neutrophil oxidative burst increased significantly without any significant changes in cytokines. Whole body NO production increased significantly and this was associated with increased iNOS activity in the HUVEC lines. The change in NO production correlated with the changes in CO and CBF. Brain flux of ammonia increased without significant changes in arterial ammonia. CONCLUSIONS In conclusion, the insertion of TIPSS results in acute endotoxemia which is associated with increased nitric oxide production possibly through an iNOS dependent mechanism which may have important pathophysiological and therapeutic relevance to understanding the basis of circulatory failure in the critically ill cirrhotic patient.
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Affiliation(s)
- R Jalan
- Liver Failure Group, UCL Hepatology, Upper Third Medical School, UCL Medical School, Rowland Hill Street, Royal Free Hospital, London NW3 2PF, UK.
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19
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Campagna F, Biancardi A, Cillo U, Gatta A, Amodio P. Neurocognitive-neurological complications of liver transplantation: a review. Metab Brain Dis 2010; 25:115-24. [PMID: 20204483 DOI: 10.1007/s11011-010-9183-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Accepted: 01/28/2010] [Indexed: 12/20/2022]
Abstract
Neurological complications are common after liver transplantation (LT) and they are associated with a significant morbidity. Long-term effects of LT on cognitive and psychological outcomes are not clear. The objective of this study was to summarize the present knowledge on the neurological and cognitive complications of LT, resulting from a systematic review of the literature in the last 10 years. Several studies have investigated the incidence and the pathophysiology of neurological complications; in contrast, the knowledge of cognitive and psychological status after LT is poor. Currently, the effect of LT on mental performance is debated. Some studies have shown an improvement of cognitive function after OLTX and, at the same time, a persistence of different cognitive deficits. In addition, the quality of life (QoL) and the psychological status after LT seem to improve but LT recipients have significant deficiencies in most QoL domains. Consequently, future studies are necessary in order to investigate cognitive alterations and QoL in LT recipients.
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Affiliation(s)
- Francesca Campagna
- Department of Clinical and Experimental Medicine, University of Padova, Clinica Medica 5, Via Giustiniani, 35128, Padova, Italy.
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20
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Iversen P, Sørensen M, Bak LK, Waagepetersen HS, Vafaee MS, Borghammer P, Mouridsen K, Jensen SB, Vilstrup H, Schousboe A, Ott P, Gjedde A, Keiding S. Low cerebral oxygen consumption and blood flow in patients with cirrhosis and an acute episode of hepatic encephalopathy. Gastroenterology 2009; 136:863-71. [PMID: 19041869 DOI: 10.1053/j.gastro.2008.10.057] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2008] [Revised: 09/30/2008] [Accepted: 10/23/2008] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS It is unclear whether patients with hepatic encephalopathy (HE) have disturbed brain oxygen metabolism and blood flow. METHODS We measured cerebral oxygen metabolism rate (CMRO(2)) by using (15)O-oxygen positron emission tomography (PET); and cerebral blood flow (CBF) by using (15)O-water PET in 6 patients with liver cirrhosis and an acute episode of overt HE, 6 cirrhotic patients without HE, and 7 healthy subjects. RESULTS Neither whole-brain CMRO(2) nor CBF differed significantly between cirrhotic patients without HE and healthy subjects, but were both significantly reduced in cirrhotic patients with HE (P < .01). CMRO(2) was 0.96 +/- 0.07 mumol oxygen/mL brain tissue/min (mean +/- SEM) in cirrhotic patients with HE, 1.34 +/- 0.08 in cirrhotic patients without HE, and 1.35 +/- 0.05 in healthy subjects; and CBF was 0.29 +/- 0.01 mL blood/mL brain tissue/min in patients with HE, 0.47 +/- 0.02 in patients without HE, and 0.49 +/- 0.03 in healthy subjects. CMRO(2) and CBF were correlated, and both variables correlated negatively with arterial ammonia concentration. Analysis of regional values, using individual magnetic resonance co-registrations, showed that the reductions in CMRO(2) and CBF in patients with HE were essentially generalized throughout the brain. CONCLUSIONS The observations imply that reduced cerebral oxygen consumption and blood flow in cirrhotic patients with an acute episode of overt HE are associated with HE and not cirrhosis as such, and that the primary event in the pathogenesis of HE could be inhibition of cerebral energy metabolism by increased blood ammonia.
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Affiliation(s)
- Peter Iversen
- PET Centre, Aarhus University Hospital, Aarhus, Denmark
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21
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Taudorf S, Berg RMG, Bailey DM, Møller K. Cerebral blood flow and oxygen metabolism measured with the Kety-Schmidt method using nitrous oxide. Acta Anaesthesiol Scand 2009; 53:159-67. [PMID: 19076112 DOI: 10.1111/j.1399-6576.2008.01788.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The Kety-Schmidt method is the reference method for measuring global cerebral blood flow (CBF), cerebral metabolic rates (CMR) and flux, especially where scanners are unavailable or impractical. Our primary objective was to assess the repeatability of the Kety-Schmidt method in a variety of different approaches using inhaled nitrous oxide (N2O) as the tracer, combined with photoacoustic spectrometry. A secondary objective was to assess the impact of this tracer on the systemic vascular concentration of nitrite (NO2(-)). METHODS Twenty-nine healthy male volunteers underwent 61 CBF measurements by breathing a normoxic gas mixture containing 5% N2O until tension equilibrium. Paired blood samples were collected from an arterial and a jugular bulb catheter in the saturation or desaturation phase, by continuous or the discontinuous sampling. N2O concentration was measured with photoacoustic spectrometry after equilibration of blood samples with air. CBF was calculated by the Kety-Schmidt equation. CMR of oxygen (CMRO2) was determined by the Fick principle. NO2(-) in plasma and red blood cells (RBC) was measured by ozone-based chemiluminescence. RESULTS The most robust approach for CBF measurement was achieved by discontinuous sampling in the desaturation phase [CBF, 64 (95% confidence interval, 59-71 ml)] 100 g/min; CMRO2 1.8 (1.7-2.0) micromol/g/min). The tracer did not influence plasma or RBC NO2(-) (P>0.05 vs. baseline). CONCLUSION These findings confirm the reliability and robustness of the Kety-Schmidt method using inhaled N2O for the measurement of global CBF and CMR. At the low tracer concentration used, altered NO metabolism is unlikely to have affected cerebral haemodynamic function.
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Affiliation(s)
- S Taudorf
- Department of Infectious Diseases, Centre of Inflammation and Metabolism, Rigshospitalet, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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22
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Long B, Li Y, Chen WM. Changes of serum S-100β protein concentration in patients with original liver transplantation and its possible mechanism. Shijie Huaren Xiaohua Zazhi 2008; 16:640-644. [DOI: 10.11569/wcjd.v16.i6.640] [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] [Indexed: 02/06/2023] Open
Abstract
AIM: To detect the changes of S-100β protein concentration in serum of the patients with original liver transplantation and discuss its possible reasons.
METHODS: Five patients of late-stage hepatic disease and with original liver transplantation were collected. The mean arterial pressure (MAP), heart rate (HR), cardiac output (CO), central venous pressure (CVP) and blood-gas analysis were recorded at preoperative, pre-clamp, anhepatic 10, 30 and 60 min, post-reperfusion 10, 90 min and the end of operation. The concentration of S-100β and interleukin-1β (IL-1β) in serum was also tested at preoperation, the end of anhepatic phase, reperfusion 1 h, postoperative 24 h and 48 h.
RESULTS: Before operation, serum S-100β level was in normal range and had no difference between patients, but increased 1 h after reperfusion (0.437 ± 0.148 mg/L vs 0.132 ± 0.061 mg/L); at 24 h, S-100β level (0.480 ± 0.340 mg/L) was still higher than that before operation, and then it decreased gradually to the level of the end of anhepatic period at 48 h of postoperation (0.239 ± 0.090 mg/L). IL-1β level increased to the highest level 24 h after reperfusion (63.7 ± 21.9 ng/L vs 32.2 ± 19.1 ng/L) and then decreased gradually. Thirty minutes after vena cava was clamped, MAP remained in normal level after drug adjustment, and HR was still higher than that before clamping. Meanwhile, cardiac output (CO) decreased significantly (5.4 ± 2.42 L/min vs 9.9 ± 2.33 L/min); at the first 10 min after reperfusion, CO was still lower than that before clamping (6.7 ± 1.81 L/min); all those were recovered to the preoperative level after treatment by blood vessel active drugs, hydragogue, etc. Partial pressure of carbon dioxide increased obviously during the earlier period after reperfusion; though sodium bicarbonate had been used during the last period of anhepatic phase and earlier period of reperfusion, the value of pH still decreased (i.e. acidemia) and then increased to the normal level before the end of operation; the level of ion remained in normal range on the whole after careful adjustment. Correlation analysis showed that the change of S-100β had no apparent correlation with CO or IL-1β (r = -0.327, r = 0.248, P > 0.05).
CONCLUSION: The increase of S-100β was due to the increase of permeability of blood brain barrier after reperfusion of the new liver and had no correlation with CO or IL-1β.
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24
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Wright G, Shawcross D, Olde Damink SWM, Jalan R. Brain cytokine flux in acute liver failure and its relationship with intracranial hypertension. Metab Brain Dis 2007; 22:375-88. [PMID: 17899343 DOI: 10.1007/s11011-007-9071-4] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND In acute liver failure (ALF), it is unclear whether the systemic inflammatory response associated with intracranial hypertension is related to brain cytokine production. AIM To determine the relationship of brain cytokine production with severity of intracranial hypertension in ALF patients. METHOD We studied 16 patients with ALF. All patients were mechanically ventilated and cerebral blood flow measured using the Kety-Schmidt technique and intracranial pressure (ICP) measured with a Camino subdural catheter. We sampled blood from an artery and a reverse jugular catheter to measure proinflammatory cytokines (TNF-alpha, IL-6 and IL-1beta) and ammonia. Additionally, in 3 patients, serial samples were obtained over a 72 h period. RESULTS In ALF patients a good correlation between arterial pro-inflammatory cytokines and ICP (r (2) = 0.34, 0.50 and 0.52; for IL-6, IL-1beta and TNF-alpha respectively) was observed. There was a positive cerebral cytokine 'flux' (production), in ALF patients with uncontrolled ICP. Plasma ammonia between groups was not statistically significant. In the ALF patients studied longitudinally, brain proinflammatory cytokine production was associated with uncontrolled ICP. CONCLUSION Our results provide novel data supporting brain production of cytokines in patients with uncontrolled intracranial hypertension indicating activation of the inflammatory cascade in the brain. Also, the appearance of these cytokines in the jugular bulb catheter may indicate a compromised blood brain barrier at this late stage.
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Affiliation(s)
- Gavin Wright
- Liver Failure Group, The Institute of Hepatology, Division of Medicine, University College London, 69-75 Chenies Mews, London, UK
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25
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Amodio P, Biancardi A, Montagnese S, Angeli P, Iannizzi P, Cillo U, D'Amico D, Gatta A. Neurological complications after orthotopic liver transplantation. Dig Liver Dis 2007; 39:740-7. [PMID: 17611177 DOI: 10.1016/j.dld.2007.05.004] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2006] [Revised: 05/08/2007] [Accepted: 05/08/2007] [Indexed: 12/11/2022]
Abstract
BACKGROUND The number of orthotopic liver transplantation performed each year is increasing due to increased safety and logistic facilities. Therefore, the importance of reducing adverse events is progressively growing. AIM To review present knowledge on the neurological complications of orthotopic liver transplantation. METHODS The epidemiology, the clinical features and the pathophysiology of the neurological complications of orthotopic liver transplants, resulting from a systematic review of the literature in the last 25 years, are summarized. RESULTS AND CONCLUSIONS The review highlights that a relevant variety of neurological adverse events can occur in patients undergoing orthotopic liver transplantation. The knowledge of neurological complications of orthotopic liver transplantation is important for transplantation teams to reduce their prevalence and improve their management. In addition, the likelihood of neurological adverse effects provides evidence for the need of a careful cognitive and neurological work up of patients in the orthotopic liver transplantation waiting list, in order to recognize and interpret neurological dysfunction occurring after orthotopic liver transplantation.
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Affiliation(s)
- P Amodio
- Clinical Medicine 5 and Veneto Regional Reference Centre for Hepatic Diseases, University of Padova, Padova, Italy.
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26
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Panzera P, Greco L, Carravetta G, Gentile A, Catalano G, Cicco G, Memeo V. Alteration of brain oxygenation during "piggy back" liver transplantation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2007; 578:269-75. [PMID: 16927704 DOI: 10.1007/0-387-29540-2_43] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Affiliation(s)
- Piercarmine Panzera
- CEMOT Centre of research in Hemorheology, Microcirculation and Oxygen Transport, University of Bari
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27
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Abstract
The rare but potentially devastating clinical syndrome of fulminant hepatic failure has as its components severe encephalopathy and finally cerebral edema, hemodynamic instability, renal failure, coagulopathy, profound metabolic disturbances and a particular susceptibility to bacterial and fungal infection. Despite advances in medical management, fulminant hepatic failure in its most severe form carries a high mortality rate unless urgent orthotopic liver transplantation is carried out. However, availability of cadaveric donor organs is limited and, due to the rapidly progressive clinical course in many cases, a substantial proportion of patients will die or develop contraindications to transplantation before the procedure can be performed. Consequently, recent interest has centred on living donor transplantation and the possibility of providing temporary liver support, either through auxiliary partial organ transplantation, extracorporeal perfusion or transplantation of hepatocytes, to allow time for either a liver graft to become available or native liver regeneration, on which spontaneous survival ultimately depends, to occur.
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Affiliation(s)
- Jelica Kurtovic
- Institute of Hepatology, Royal Free and University College Medical School, 69-75 Chenies Mews, London, WC1E 6HX, England
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28
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Jalan R, Olde Damink SWM, Hayes PC, Deutz NEP, Lee A. Pathogenesis of intracranial hypertension in acute liver failure: inflammation, ammonia and cerebral blood flow. J Hepatol 2004; 41:613-20. [PMID: 15464242 DOI: 10.1016/j.jhep.2004.06.011] [Citation(s) in RCA: 170] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2004] [Revised: 05/12/2004] [Accepted: 06/17/2004] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIMS The study aims were to determine the role of inflammation in the pathogenesis of increased intracranial pressure (ICP) in patients with acute liver failure (ALF) and its interplay with cerebral blood flow (CBF) and ammonia. METHODS Twenty-one patients with ALF were studied from the time they were ventilated for grade 4 encephalopathy until receiving specific treatment for increased ICP. Depending upon the ICP, the patients were divided into two groups; those that required specific treatment (ICP>20 mmHg, group 1: n=8, ICP: 32 (28-54) mmHg); and those that did not (ICP< or =20 mmHg, group 2: n=13, ICP: 15 (10-20) mmHg). RESULTS Inflammatory markers, arterial ammonia and CBF were significantly higher in the group 1 patients. TNFalpha levels correlated with CBF (r=0.80). Four patients from group 2 developed surges of increased ICP (32 (15-112) hours from enrolment). These were associated increases in markers of inflammation and TNFalpha, and an increase in CBF. There was no change in these inflammatory markers, CBF or ICP in the other 9 group 2 patients. CONCLUSIONS The results of this study suggest that inflammation plays an important synergistic role in the pathogenesis of increased ICP possibly through its effects on CBF.
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Affiliation(s)
- Rajiv Jalan
- Liver Failure Group, Institute of Hepatology, Royal Free and University College London Medical School and University College London Hospitals, 69-75 Chenies Mews, London WC1E 6HX, UK.
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Plachky J, Hofer S, Volkmann M, Martin E, Bardenheuer HJ, Weigand MA. Regional cerebral oxygen saturation is a sensitive marker of cerebral hypoperfusion during orthotopic liver transplantation. Anesth Analg 2004; 99:344-9, table of contents. [PMID: 15271702 DOI: 10.1213/01.ane.0000124032.31843.61] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Neurological complications contribute significantly to morbidity and mortality of patients after orthotopic liver transplantation (OLT). One possible cause of postoperative neurological complications is cerebral ischemia during the surgical procedure. In this study, we investigated the relationship between intraoperative changes in regional cerebral oxygen saturation (rSo(2)) and postoperative values of neuron-specific enolase (NSE) and S-100, which are specific variables that indicate cerebral disturbances due to hypoxia/ischemia. The rSo(2) was monitored continuously by near-infrared spectroscopy in 16 patients undergoing OLT. In addition, NSE and S-100 were determined in arterial blood before surgery and 24 h after reperfusion of the donor liver. Interestingly, clamping of the recipient's liver led to a significant decline in rSo(2) in eight patients, whereas the others tolerated clamping without major changes in rSo(2). The decrease in rSo(2) after clamping correlated significantly with postoperative increases in NSE (r(2) = 0.57) and S-100 (r(2) = 0.52). However, there were no significant differences between patients with and without rSo(2) decline concerning hemodynamic variables. There were no significant correlations between DeltarSo(2) and cardiac output (r(2) = 0.20), NSE and cardiac output (r(2) = 0.37), or S-100 and cardiac output (r(2) = 0.24). Monitoring of rSo(2) may be a useful noninvasive tool to estimate disturbances in rSo(2) during OLT.
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Affiliation(s)
- Jens Plachky
- Department of Anesthesiology, University of Heidelberg, Im Neuenheimer Feld 110, D-69120 Heidelberg, Germany.
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Shawcross DL, Davies NA, Mookerjee RP, Hayes PC, Williams R, Lee A, Jalan R. Worsening of cerebral hyperemia by the administration of terlipressin in acute liver failure with severe encephalopathy. Hepatology 2004; 39:471-5. [PMID: 14768000 DOI: 10.1002/hep.20044] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
There is increasing evidence that terlipressin is useful in patients with cirrhosis and hepatorenal syndrome, but there are no data of its use in patients with acute liver failure (ALF) in whom hepatorenal syndrome is common. Although terlipressin produces systemic vasoconstriction, it produces cerebral vasodilatation and may increase cerebral blood flow (CBF). Increased CBF contributes to intracranial hypertension in patients with ALF. The aim of this study was to evaluate the safety of terlipressin in patients with ALF with respect to cerebral hemodynamics. Six successive patients with ALF were ventilated electively for grade IV hepatic encephalopathy. Patients were monitored invasively and CBF was measured (Kety-Schmidt technique). Measurements were made before and at 1, 3, and 5 hours after intravenous (single bolus) administration of terlipressin (0.005 mg/kg), median, 0.25 mg (range, 0.2-0.3 mg). There was no significant change in heart rate, mean arterial pressure, or cardiac output. CBF and jugular venous oxygen saturation both increased significantly at 1 hour (P = 0.016). Intracranial pressure increased significantly at 1 hour (P = 0.031), returning back to baseline values at 2 hours. In conclusion, administration of terlipressin, at a dose that did not alter systemic hemodynamics, resulted in worsening of cerebral hyperemia and intracranial hypertension in patients with ALF and severe hepatic encephalopathy. These data suggest the need to exercise extreme caution in the use of terlipressin in these patients in view of its potentially deleterious consequences on cerebral hemodynamics.
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Affiliation(s)
- Debbie L Shawcross
- Liver Failure Group, Institute of Hepatology, Royal Free and University College London Medical School, London, UK
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31
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Rose C, Jalan R. Is minimal hepatic encephalopathy completely reversible following liver transplantation? Liver Transpl 2004; 10:84-7. [PMID: 14755783 DOI: 10.1002/lt.20030] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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32
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Walsh TS, Garden OJ, Lee A. Metabolic, cardiovascular, and acid-base status after hepatic artery or portal vein reperfusion during orthotopic liver transplantation. Liver Transpl 2002; 8:537-44. [PMID: 12037785 DOI: 10.1053/jlts.2002.33481] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
During liver transplantation, reperfusion traditionally is performed through the portal vein. After anecdotal observations that patients who underwent reperfusion first through the hepatic artery were more hemodynamically stable, we performed an exploratory, prospective, observational, nonrandomized study to compare cardiovascular stability, acid-base status, and metabolic gas exchange between patients who underwent reperfusion through either the portal vein or hepatic artery. We studied 20 patients undergoing liver transplantation (10 patients, reperfusion first through the portal vein; 10 patients, reperfusion first through the hepatic artery). Cardiovascular and acid-base parameters were compared at times before and after anastomosis of each vessel, and epinephrine use was recorded. Oxygen consumption (VO2) and carbon dioxide elimination (VCO2) were measured continuously by using an indirect calorimeter. Alanine aminotransferase (ALT) concentrations 24 hours after transplantation were compared as an index of reperfusion injury. Cardiovascular changes (mean arterial pressure, cardiac output) were similar for both groups, but more epinephrine was administered to the portal-vein group (P =.014). There was a greater increase in PaCO2 after portal reperfusion (median portal vein, 1.01 kPa; hepatic artery, 0.29 kPa; P =.015) and a trend toward more severe acidemia. VO2 increased more rapidly in the portal-vein group (P =.005), but overall changes in VO2 during the study period were similar. There were no differences in VCO2 between the groups or ALT concentrations 24 hours posttransplantation. These observational data suggest that hepatic arterial reperfusion may be associated with reduced epinephrine requirements and a slower rate of acid release, which could be advantageous in unstable patients. VO2 increases more slowly after hepatic artery reperfusion, which could indicate slower reoxygenation of the graft. Further studies of the relative merits of each technique are warranted.
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Affiliation(s)
- Timothy S Walsh
- Department of Clinical and Surgical SciencesRoyal Infirmary of Edinburgh, Scotland.
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33
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Jaggy C, Lachat M, Inderbitzin D, Leskosek B, Candinas D, Burkhard T, Turina M. Optimized veno-venous bypass with the affinity pump. ASAIO J 2001; 47:56-9. [PMID: 11199316 DOI: 10.1097/00002480-200101000-00013] [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] Open
Abstract
Veno-venous bypass (VVBP) is increasingly used to avoid acute venous hypertension and low cardiac output after clamping the vena cava. Air embolism upon accidental decannulation of the inflow line and endothelial damage due to suction of the blood collecting cannula to the vessel wall are known complications specific to the currently used roller and centrifugal pumps, because they generate negative pressure at the inflow site of the pump. The Affinity pump has a unique chamber design with an occlusive segment, that collapses in low filling states preventing negative pressure at the inflow site of the pump chamber. This device was tested for VVBP in three pigs (each weighing 52.3 +/- 5.1 kg) with hepatic vascular exclusion. Blood was pumped from the femoral and portal veins to the external jugular vein and perfusion was maintained for 6 hours. The hemodynamic state of the animals was assessed by recording heart rate; systolic, mean arterial, and diastolic pressure; as well as central venous pressure. Mean pump flow during the experiment was 1,629.3 +/- 372.2 ml/min. After clamping, the inflow line of the pump mean arterial pressure significantly decreased (from 69.5 +/- 4.4 to 43.1 +/- 3.5 mm Hg), and mean pressure in the femoral vein increased significantly (from 16.1 +/- 2.6 to 26.8 +/- 5.9 mm Hg), whereas the mean pressure in the internal jugular vein did not significantly change (from 6.0 +/- 1.7 to 5.0 +/- 2.1 mm Hg). There was no suction by the blood collecting cannula on the vessel wall, and neither bubbles nor air emboli were detected and no operator intervention was needed. In conclusion, the Affinity pump eliminates device related complications due to negative pressure generated at the inlet, and guarantees stable hemodynamics. Its application is simple and safe and minimal operator intervention is needed, making the Affinity pump particularly suited for veno-venous bypass.
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Affiliation(s)
- C Jaggy
- Clinic for Cardiovascular Surgery, University Hospital Zurich, Switzerland
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34
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Pere P, Höckerstedt K, Isoniemi H, Lindgren L. Cerebral blood flow and oxygenation in liver transplantation for acute or chronic hepatic disease without venovenous bypass. Liver Transpl 2000; 6:471-9. [PMID: 10915171 DOI: 10.1053/jlts.2000.8186] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The autoregulation of cerebral blood flow (CBF) is impaired in patients with end-stage liver disease and encephalopathy. These patients are vulnerable to sudden deterioration of cerebral perfusion and oxygenation during liver transplantation. We compared CBF and metabolism during liver transplantation without venovenous bypass and 24 hours postoperatively in 9 patients with acute liver failure (ALF) and 16 patients with chronic liver disease. A fiberoptic catheter was inserted cranially through the left internal jugular vein for determination of jugular venous oxygen saturation, cerebral oxygen extraction ratio (COER), lactate level, and neuron-specific enolase (NSE) level. Arterial concentrations of lactate were also measured. Flow velocity in the middle cerebral arteries was monitored bilaterally using transcranial Doppler sonography. Mean flow velocity and pulsatility index (PI) were regarded as indicators of intracranial pressure. Core body temperatures were recorded. Mild hyperventilation, perioperative hemofiltration, and N-acetylcysteine infusion were used according to our clinical practice. NSE level was greater in acute patients at the end of surgery (P <.05), but not 24 hours later. Lactate concentrations were greater in patients with ALF (P <.001) preoperatively and intraoperatively but were similar in both groups 24 hours postoperatively. There was no difference between arterial and jugular venous concentrations of lactate. Changes in blood flow velocity, PI, and COER were parallel and without statistical significance between the groups. The patients' core temperature did not correlate with CBF, NSE level, or clinical outcome. Caval clamping was well tolerated in both patient groups.
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Affiliation(s)
- P Pere
- Departments of Anesthesia and Intensive Care Medicine, Helsinki University Central Hospital, Helsinki, Finland.
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35
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Riordan SM, Williams R. Use and validation of selection criteria for liver transplantation in acute liver failure. Liver Transpl 2000; 6:170-3. [PMID: 10719015 DOI: 10.1002/lt.500060221] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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36
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Abstract
In recent years, considerable progress has been made in developing specific and supportive medical measures that have improved prognosis in FHF. Although new techniques for cell culture and perfusion have also resulted in a number of promising devices for the provision of temporary liver support, their clinical efficacy is as yet uncertain. Controlled multicenter trials in well-defined patient groups and with standardized outcome measures will be essential to evaluate the clinical value of these devices properly. The same considerations must also apply in assessing the efficacy of hepatocyte transplantation in FHF. A better understanding of mechanisms responsible for liver cell death and multiorgan failure, and the development of strategies to enhance liver regeneration may, in the future, allow a more targeted approach to therapy.
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Affiliation(s)
- S M Riordan
- Institute of Hepatology, University College London, United Kingdom
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Madsen PL, Skak C, Rasmussen A, Secher NH. Interference of cerebral near-infrared oximetry in patients with icterus. Anesth Analg 2000; 90:489-93. [PMID: 10648345 DOI: 10.1097/00000539-200002000-00046] [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: 11/25/2022]
Abstract
UNLABELLED Near-infrared spectrophotometry assesses cerebral oxygen saturation (ScO(2)) based on the absorption spectra of oxygenated and deoxygenated hemoglobin and the translucency of biological tissue in the near-infrared band. In patients with icterus, however, bilirubin can potentially hinder cerebral oximetry. In 48 patients undergoing orthotopic liver transplantation, we related total plasma bilirubin to ScO(2) as determined from spectrophotometry with wavelengths of 733 and 809 nm. Before surgery, ScO(2) was 59% (15%-78%) (median with range) and bilirubin was 71 (6-619) micromol/L with a negative correlation (r = -0.72; P < 0.05). The 95% prediction interval included the lowest measurable ScO(2) of 15% at a bilirubin level of 370 micromol/L. During reperfusion of the grafted liver, the ScO(2) increased by 7% (-8% to 17%) (P < 0.05), and bilirubin did not influence this increase. In one patient, the ScO(2) remained below 15% despite a decrease in bilirubin from 619 to 125 micromol/L, suggesting that tissue pigmentation deposits also absorb light. In conclusion, bilirubin dampens the spectrophotometry-determined cerebral oxygen saturation at 733 and 809 nm. A bilirubin level of 370 micromol/L, tissue pigment deposits, or both, may render determination of cerebral oxygen saturation impossible. Even at high bilirubin values, changes in cerebral perfusion may be visible. IMPLICATIONS In 48 patients undergoing liver transplantation, the interference of icterus on cerebral oximetry by near-infrared light was investigated. Bilirubin absorbed the near-infrared light and lowered the measured cerebral oxygen saturation. Even at high bilirubin values, changes in cerebral oxygenation, as seen during reperfusion of the grafted liver, may be visible.
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Affiliation(s)
- P L Madsen
- Departments of Anesthesia and Transplantation, Rigshospitalet, Copenhagen, Denmark.
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38
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Madsen PL, Skak C, Rasmussen A, Secher NH. Interference of Cerebral Near-Infrared Oximetry in Patients with Icterus. Anesth Analg 2000. [DOI: 10.1213/00000539-200002000-00046] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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39
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Larsen FS, Ejlersen E, Strauss G, Rasmussen A, Kirkegaard P, Hansen BA, Secher N. Cerebrovascular metabolic autoregulation is impaired during liver transplantation. Transplantation 1999; 68:1472-6. [PMID: 10589941 DOI: 10.1097/00007890-199911270-00007] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND We determined whether the coupling between cerebral blood flow (CBF) and oxygen metabolism (CMRO2) is preserved during liver transplantation. Because of cerebrovascular dilatation, we hypothesized that cerebral metabolic autoregulation is impaired, because CBF becomes uncoupled from CMRO2 during the reperfusion phase of the operation. MATERIALS AND METHODS In a prospective study, 13 patients (8 women, median age 46, range 21-6) with liver failure (10 with end-stage chronic liver disease and 3 with acute liver failure) were enrolled. Catheters were placed in a femoral artery and in the internal jugular vein for calculation of the cerebral arteriovenous oxygen content difference (AVDO2). CBF was recorded by the 133Xenon injection technique, and by transcranial Doppler sonography determined mean flow velocity (Vmean) in the middle cerebral artery. The CMRO2 was calculated as the AVDO2 times CBF and the cerebrovascular resistance (CVR) as the mean arterial pressure to CBF ratio. An index of large cerebral artery diameter was expressed by the CBF to Vmean ratio. RESULTS From induction of anesthesia to the anhepatic period, CBF decreased from a median of 47 (interquartiles 31-55) to 41 (37-48) ml 100 g(-1) min(-1), whereas the CMRO2 remained unchanged (1.3 [0.9-2.5] vs. 1.7 [0.9-2.3] ml 100 g(-1) min(-1)). In the reperfusion phase, the CBF increased to 51 (45-54) ml 100 g(-1) min(-1), whereas the CMRO2 remained unchanged at 1.1 (1.0-2.5) ml 100 g(-1) min(-1). The CVR decreased from 2.0 mm Hg (1.4-2.1) to 1.4 (1.1-1.8) mm Hg(-1) min 100 g ml. In the anhepatic phase, mean arterial pressure decreased from 92 mm Hg (84-98) to 85 (80-92) mm Hg and at reperfusion it was 80 (71-105) mm Hg. From the anhepatic to the reperfusion phase, the CBF increased 7% (0 to 26) for each mm Hg concomitant increase in PaCO2. The CBF to Vmean ratio remained stable (1.0 [0.8-1.2] vs. 0.9 [0.7-1.1] ml 100 g(-1) min(-1) cm(-1) sec). CONCLUSION During the reperfusion phase of liver transplantations, cerebrovascular dilatation uncouples cerebral oxidative metabolism from blood flow. The increase in CBF is beyond what can be explained by changes in arterial carbon dioxide tension and arterial pressure.
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Affiliation(s)
- F S Larsen
- Department of Hepatology, Rigshospitalet, University of Copenhagen, Denmark.
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40
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Jalan R, O Damink SW, Deutz NE, Lee A, Hayes PC. Moderate hypothermia for uncontrolled intracranial hypertension in acute liver failure. Lancet 1999; 354:1164-8. [PMID: 10513710 DOI: 10.1016/s0140-6736(98)12440-6] [Citation(s) in RCA: 282] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Increased intracranial pressure as a complication of acute liver failure has a mortality of about 90% in patients who do not respond to treatment with mannitol and ultrafiltration. We investigated the safety and efficacy of moderate hypothermia for uncontrolled increase in intracranial pressure in patients with acute liver failure. METHODS We studied seven consecutive patients aged 16-46 years (five women, four candidates for orthotopic liver transplantation [OLT]) with acute liver failure who fulfilled criteria for poor-prognosis liver failure and had increased intracranial pressure that was unresponsive to two treatments with mannitol and ultrafiltration. We used cooling blankets to lower the patients' core temperature to 32-33 degrees C. Patients who were not suitable candidates for OLT (patients 1-3) were cooled for 8 h and then gradually rewarmed over 1 h to a baseline temperature of 37 degrees C. Patients who were suitable candidates for OLT (patients 4-7) were cooled before and during the OLT procedure. We measured cerebral blood flow and metabolic indices before and after cooling. FINDINGS The four patients who were candidates for OLT were successfully maintained until transplantation with 13 (range 10-14) h of hypothermia. The three patients who were unsuitable candidates for OLT died after rewarming. Intracranial pressure before cooling was 45 (25-49) mm Hg and was reduced in all patients to 16 (13-17) mm Hg (p<0.05). Cerebral blood flow decreased from 103 (25-134) mL 100 g(-1) min(-1) before cooling to 44 (24-75) mL 100 g(-1) min(-1) after cooling (p<0.05). The corresponding changes for cerebral perfusion pressure was an increase from 45 (37-56) mm Hg to 70 (60-78) mm Hg (p<0.05) and for cardiac index a decrease from 9.8 (7-13) to 5.1 (4.3-6.1) L per min per m2 of body surface area. During hypothermia there was no significant relapse of increased intracranial pressure. Arterial ammonia and cerebral uptake of ammonia were significantly reduced with cooling. No adverse effects of hypothermia were observed. INTERPRETATION Moderate hypothermia is useful in the treatment of uncontrolled increase in intracranial pressure in patients with acute liver failure and may serve as a bridge to OLT.
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Affiliation(s)
- R Jalan
- Liver Unit, Royal Infirmary of Edinburgh, UK.
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