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Gierej P, Radziszewski M, Figiel W, Grąt M. Advancements in Predictive Tools for Primary Graft Dysfunction in Liver Transplantation: A Comprehensive Review. J Clin Med 2024; 13:3762. [PMID: 38999328 PMCID: PMC11242128 DOI: 10.3390/jcm13133762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 06/20/2024] [Accepted: 06/24/2024] [Indexed: 07/14/2024] Open
Abstract
Orthotopic liver transplantation stands as the sole curative solution for end-stage liver disease. Nevertheless, the discrepancy between the demand and supply of grafts in transplant medicine greatly limits the success of this treatment. The increasing global shortage of organs necessitates the utilization of extended criteria donors (ECD) for liver transplantation, thereby increasing the risk of primary graft dysfunction (PGD). Primary graft dysfunction (PGD) encompasses early allograft dysfunction (EAD) and the more severe primary nonfunction (PNF), both of which stem from ischemia-reperfusion injury (IRI) and mitochondrial damage. Currently, the only effective treatment for PNF is secondary transplantation within the initial post-transplant week, and the occurrence of EAD suggests an elevated, albeit still uncertain, likelihood of retransplantation urgency. Nonetheless, the ongoing exploration of novel IRI mitigation strategies offers hope for future improvements in PGD outcomes. Establishing an intuitive and reliable tool to predict upcoming graft dysfunction is vital for early identification of high-risk patients and for making informed retransplantation decisions. Accurate diagnostics for PNF and EAD constitute essential initial steps in implementing future mitigation strategies. Recently, novel methods for PNF prediction have been developed, and several models for EAD assessments have been introduced. Here, we provide an overview of the currently scrutinized predictive tools for PNF and EAD evaluation strategies, accompanied by recommendations for future studies.
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Affiliation(s)
- Piotr Gierej
- Department of General Transplant and Liver Surgery, Medical University of Warsaw, 02-091 Warsaw, Poland
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Mishra S, Taneja S. Algorithmic Approach to Deranged Liver Functions After Transplantation. J Clin Exp Hepatol 2024; 14:101317. [PMID: 38264576 PMCID: PMC10801315 DOI: 10.1016/j.jceh.2023.101317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 12/06/2023] [Indexed: 01/25/2024] Open
Abstract
Liver transplant (LT) recipients require close follow-up with regular monitoring of the liver function tests (LFTs). Evaluation of deranged LFT should be individualized depending upon the time since LT, peri-operative events, clinical course, and any complications. These derangements can range from mild and asymptomatic to severe and symptomatic elevations requiring expedited personalized assessment and management. Pattern of LFT derangement (hepatocellular, cholestatic, or mixed), donor-recipient risk factors, timing after LT (post-operative, 1-12 months, and >12 months since LT) along with clinical context and symptomatology are important considerations before proceeding with the initial evaluation. Compliance to immunosuppression and drug interactions should be ascertained along with local epidemiology of infections. Essential initial evaluation must include an ultrasound abdomen with Doppler to rule out any structural causes such as biliary or vascular complications apart from focussed laboratory evaluation. Early allograft dysfunction, ischemia reperfusion injury, small-for-size syndrome, biliary leaks, hepatic artery, and portal vein thrombosis are usual culprits in the early post-operative period whereas viral hepatitis (acute or reactivation), opportunistic infections, and recurrence of the primary disease are more frequent in the later period. Graft rejection, biliary strictures, sepsis, and drug induced liver injury remain possible etiologies at all times points after LT. Initial evaluation algorithm must be customized based on history, clinical examination, risk factors, and pattern and severity of deranged LFT. Allograft rejection is a diagnosis of exclusion and requires liver biopsy to confirm and assess severity. Empirical treatment of rejection sans liver biopsy is discouraged.
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Affiliation(s)
- Saurabh Mishra
- Department of Gastroenterology and Hepatology, Paras Health, Sector 22, Panchkula, Haryana 134109, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
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Caimano M, Bianco G, Coppola A, Marrone G, Agnes S, Lai Q, Spoletini G. Indocyanine green clearance tests to assess liver transplantation outcomes: a systematic review. Int J Surg 2024; 110:431-440. [PMID: 37800567 PMCID: PMC10793811 DOI: 10.1097/js9.0000000000000779] [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: 05/17/2023] [Accepted: 09/09/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Liver transplantation (LT) is the gold standard for end-stage liver disease, yet postoperative complications challenge patients and physicians. Indocyanine green (ICG) clearance, a quantitative dynamic test of liver function, is a rapid, reproducible, and reliable test of liver function. This study aimed to systematically review and summarize current literature analyzing the association between ICG tests and post-LT outcomes. METHODS This systematic review was conducted according to PRISMA guidelines. MEDLINE and Cochrane Library, as main databases, and other sources were searched until August 2022 to identify articles reporting the prognostic value of postoperative ICG tests associated with outcomes of adult LT recipients.Risk of bias of included articles was assessed using Quality In Prognosis Studies tool. Methodological quality varied from low to high across risk of bias domains. RESULTS Six studies conducted between 1994 and 2018 in Europe, America, and Asia were included. The study population ranged from 50 to 332 participants. ICG clearance on the first postoperative day was associated with early allograft dysfunction, graft loss, 1-month and 3-month patient survival probability, prolonged ICU, and hospital stay. The dichotomized ICG plasma disappearance rate (PDR) provided a strong association with medium-term and long-term outcomes: PDR less than 10%/min with 1-month mortality or re-transplantation (odds ratio: 7.89, 95% CI 3.59-17.34, P <0.001) and PDR less than 16.0%/min with 3-month patient survival probability (hazard ratio: 13.90, 95% CI 4.67-41.35, P <0.01). The preoperative model for end-stage liver disease and body mass index were independent prognostic factors for early allograft dysfunction, early complications, and prolonged ICU stay; post-LT prothrombin time and INR were independently associated with graft loss and bilirubin with a prolonged hospital stay. CONCLUSION This review shows that ICG clearance tests are associated with graft function recovery, suggesting that a potential prognostic role of ICG test, as an aid in predicting the post-LT course, could be considered.
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Affiliation(s)
- Miriam Caimano
- General Surgery and Liver Transplantation, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
| | - Giuseppe Bianco
- General Surgery and Liver Transplantation, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
| | - Alessandro Coppola
- General Surgery and Liver Transplantation, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
| | | | - Salvatore Agnes
- General Surgery and Liver Transplantation, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
| | - Quirino Lai
- Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Gabriele Spoletini
- General Surgery and Liver Transplantation, Fondazione Policlinico Universitario Agostino Gemelli IRCCS
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Ruan W, Galvan NTN, Dike P, Koci M, Faraone M, Fuller K, Koomaraie S, Cerminara D, Fishman DS, Deray KV, Munoz F, Schackman J, Leung D, Akcan-Arikan A, Virk M, Lam FW, Chau A, Desai MS, Hernandez JA, Goss JA. The Multidisciplinary Pediatric Liver Transplant. Curr Probl Surg 2023; 60:101377. [PMID: 37993242 DOI: 10.1016/j.cpsurg.2023.101377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 08/29/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Nhu Thao N Galvan
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Peace Dike
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Melissa Koci
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Marielle Faraone
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Kelby Fuller
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | | | - Dana Cerminara
- Department of Pharmacy, Texas Children's Hospital, Houston, TX
| | - Douglas S Fishman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Kristen Valencia Deray
- Department of Pediatrics, Department of Pharmacy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Flor Munoz
- Department of Pediatrics, Department of Pharmacy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Julie Schackman
- Division of Anesthesiology, Perioperative, & Pain Medicine, Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Daniel Leung
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Ayse Akcan-Arikan
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Manpreet Virk
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Fong W Lam
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Alex Chau
- Division of Interventional Radiology, Department of Radiology, Edward B. Singleton Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Moreshwar S Desai
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Jose A Hernandez
- Division of Interventional Radiology, Department of Radiology, Edward B. Singleton Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - John A Goss
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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Halle-Smith JM, Hall L, Hann A, Arshad A, Armstrong MJ, Bangash MN, Murphy N, Cuell J, Isaac JL, Ferguson J, Roberts KJ, Mirza DF, Perera MTPR. Low C-reactive Protein and Urea Distinguish Primary Nonfunction From Early Allograft Dysfunction Within 48 Hours of Liver Transplantation. Transplant Direct 2023; 9:e1484. [PMID: 37250485 PMCID: PMC10212614 DOI: 10.1097/txd.0000000000001484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/03/2023] [Indexed: 05/31/2023] Open
Abstract
Primary nonfunction (PNF) is a life-threatening complication of liver transplantation (LT), but in the early postoperative period, it can be difficult to differentiate from early allograft dysfunction (EAD). The aim of this study was to determine if serum biomarkers can distinguish PNF from EAD in the initial 48 h following LT. Materials and Methods A retrospective study of adult patients that underwent LT between January 2010 and April 2020 was performed. Clinical parameters, absolute values and trends of C-reactive protein (CRP), blood urea, creatinine, liver function tests, platelets, and international normalized ratio in the initial 48 h after LT were compared between the EAD and PNF groups. Results There were 1937 eligible LTs, with PNF and EAD occurring in 38 (2%) and 503 (26%) patients, respectively. A low serum CRP and urea were associated with PNF. CRP was able to differentiate between the PNF and EAD on postoperative day (POD)1 (20 versus 43 mg/L; P < 0.001) and POD2 (24 versus 77; P < 0.001). The area under the receiver operating characteristic curve (AUROC) of POD2 CRP was 0.770 (95% confidence interval [CI] 0.645-0.895). The urea value on POD2 (5.05 versus 9.0 mmol/L; P = 0.002) and trend of POD2:1 ratio (0.71 versus 1.32 mmol/L; P < 0.001) were significantly different between the groups. The AUROC of the change in urea from POD1 to 2 was 0.765 (95% CI 0.645-0.885). Aspartate transaminase was significantly different between the groups, with an AUROC of 0.884 (95% CI 0.753-1.00) on POD2. Discussion The biochemical profile immediately following LT can distinguish PNF from EAD; CRP, urea, and aspartate transaminase are more effective than ALT and bilirubin in distinguishing PNF from EAD in the initial postoperative 48 h. Clinicians should consider the values of these markers when making treatment decisions.
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Affiliation(s)
- James M. Halle-Smith
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Lewis Hall
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Angus Hann
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Asif Arshad
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Matthew J. Armstrong
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Mansoor N. Bangash
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Nick Murphy
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - James Cuell
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - John L. Isaac
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - James Ferguson
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Keith J. Roberts
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Darius F. Mirza
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - M. Thamara P. R. Perera
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
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Kathawate RG, Ibeabuchi T, Abt PL, Bittermann T. Utilization and outcomes of rescue hepatectomy among U.S. liver retransplant candidates. Clin Transplant 2023; 37:e14890. [PMID: 36544328 PMCID: PMC9911400 DOI: 10.1111/ctr.14890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/06/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The frequency and outcomes of anhepatic patients listed for transplantation in the United States have not been studied. The United Network for Organ Sharing (UNOS) records anhepatic status for patients listed as Status 1A for hepatic artery thrombosis (HAT) or primary non-function (PNF). METHODS Using the UNOS database from 2005 to 2020, demographics and waitlist outcomes of anhepatic candidates relisted as Status 1A for HAT or PNF were assessed. RESULTS Among 1364 adult Status 1A patients relisted for PNF or HAT across 120 distinct transplant centres, 75 (5.5%) patients were anhepatic and 1289 (94.5%) were non-anhepatic. A substantial number of centres (n = 51) had experience with ≥1 anhepatic patient relisted for either PNF or HAT, with individual centre rates ranging from 0% to 11.4%. Waitlist mortality was more than twice as high for anhepatic patients: 42.5% versus 17.0% non-anhepatic patients (p < .001). The post-transplant outcomes of anhepatic patients were markedly inferior to non-anhepatic patients. For example, 41.9% of anhepatic patients died during the index admission versus 23.4% of the non-anhepatic group (p = .006). Patient survival for the anhepatic and non-anhepatic groups was 48.3% versus 66.2% at 1-year and 29.3% versus 46.2% at 5-years, respectively (log-rank test for overall survival p = .014). CONCLUSIONS Rescue hepatectomy after initial liver transplantation is not only associated with high waitlist mortality, but also markedly worse post-transplant outcomes. With less than half of anhepatic patients surviving to the first year post-LT, further research is warranted to better delineate which patients should be considered for rescue hepatectomy.
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Affiliation(s)
- Ranganath G. Kathawate
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Tobenna Ibeabuchi
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Peter L. Abt
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Therese Bittermann
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Minor T, von Horn C, Zlatev H, Saner F, Grawe M, Lüer B, Huessler E, Kuklik N, Paul A. Controlled oxygenated rewarming as novel end-ischemic therapy for cold stored liver grafts. A randomized controlled trial. Clin Transl Sci 2022; 15:2918-2927. [PMID: 36251938 PMCID: PMC9747115 DOI: 10.1111/cts.13409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/29/2022] [Accepted: 09/03/2022] [Indexed: 01/26/2023] Open
Abstract
Abrupt return to normothermia has been shown a genuine factor contributing to graft dysfunction after transplantation. This study tested the concept to mitigate reperfusion injury of liver grafts by gentle warming-up using ex vivo machine perfusion prior to reperfusion. In a single center randomized controlled study, livers were assigned to conventional static cold storage (SCS) alone or to SCS followed by 90 min of ex vivo machine perfusion including controlled oxygenated rewarming (COR) by gentle and protracted elevation of the perfusate temperature from 10°C to 20°C. Primary outcome mean peak aspartate aminotransferase (AST) was 1371 U/L (SD 2871) after SCS versus 767 U/L (SD 1157) after COR (p = 0.273). Liver function test (LiMAx) on postoperative day 1 yielded 187 μg/kg/h (SD 121) after SCS, but rose to 294 μg/kg/h (SD 106) after COR (p = 0.006). Likewise, hepatic synthesis of coagulation factor V was significantly accelerated in the COR group immediately after transplantation (103% [SD 34] vs. 66% [SD 26]; p = 0.001). Fewer severe complications (Clavien-Dindo grade ≥3b) were reported in the COR group (8) than in the SCS group (15). Rewarming/reperfusion injury of liver grafts can be safely and effectively mitigated by controlling of the rewarming kinetics prior to blood reperfusion using end-ischemic ex vivo machine perfusion after cold storage.
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Affiliation(s)
- Thomas Minor
- Surgical Research DepartmentUniversity Hospital EssenEssenGermany
| | | | - Hristo Zlatev
- Surgical Research DepartmentUniversity Hospital EssenEssenGermany
| | - Fuat Saner
- General Visceral and Transplantation SurgeryUniversity Hospital EssenEssenGermany
| | - Melanie Grawe
- Surgical Research DepartmentUniversity Hospital EssenEssenGermany
| | - Bastian Lüer
- Surgical Research DepartmentUniversity Hospital EssenEssenGermany
| | - Eva‐Maria Huessler
- Institute for Medical Informatics, Biometry and EpidemiologyUniversity Hospital EssenEssenGermany
| | - Nils Kuklik
- Institute for Medical Informatics, Biometry and EpidemiologyUniversity Hospital EssenEssenGermany,Centre for Clinical Trials EssenUniversity Hospital EssenEssenGermany
| | - Andreas Paul
- General Visceral and Transplantation SurgeryUniversity Hospital EssenEssenGermany
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Dunn R, Voleti S, Rowley S, Mackintosh C, Aqel B, Mathur A, Rosenfeld D, Cartin-Ceba R. Risk factors associated with urgent surgical reintervention due to postoperative hemorrhage after orthotopic liver transplantation. JOURNAL OF LIVER TRANSPLANTATION 2022. [DOI: 10.1016/j.liver.2022.100124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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9
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LiMAx Prior to Radioembolization for Hepatocellular Carcinoma as an Additional Tool for Patient Selection in Patients with Liver Cirrhosis. Cancers (Basel) 2022; 14:cancers14194584. [PMID: 36230506 PMCID: PMC9558955 DOI: 10.3390/cancers14194584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/16/2022] [Accepted: 09/17/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Aims: Radioembolization (RE) has recently demonstrated a non-inferior survival outcome compared to systemic therapy for advanced hepatocellular carcinoma (HCC). Therefore, current guidelines recommend RE for patients with advanced HCC and preserved liver function who are unsuitable for transarterial chemoembolization (TACE) or systemic therapy. However, despite the excellent safety profile of RE, post-therapeutic hepatic decompensation remains a serious complication that is difficult to predicted by standard laboratory liver function parameters or imaging modalities. LiMAx® is a non-invasive test for liver function assessment, measuring the maximum metabolic capacity for 13C-Methacetin by the liver-specific enzyme CYP 450 1A2. Our study investigates the potential of LiMAx® for predicting post-interventional decompensation of liver function. Patients and methods: In total, 50 patients with HCC with or without liver cirrhosis and not amenable to TACE or systemic treatments were included in the study. For patients prospectively enrolled in our study, LiMAx® was carried out one day before RE (baseline) and 28 and 90 days after RE. Established liver function parameters were assessed at baseline, day 28, and day 90 after RE. The relationship between baseline LiMAx® and pre-and post-interventional liver function parameters, as well as the ability of LiMAx® to predict hepatic decompensation, were analyzed. Results: We observed a strong association between baseline LiMAx® and bilirubin, albumin, ALBI grade, and MELD score. Patients presenting with Child–Pugh score B 28 days after RE or with a deterioration in Child–Pugh score by at least one point had a significantly lower baseline LiMAx® compared to those with Child–Pugh score A or with stable Child–Pugh score. The ability of LiMAx® to predict hepatic decompensation after RE was determined using ROC curve analysis and was compared to MELD score and ALBI grade. LiMAx® achieved a substantial AUC of 0.8117, comparable to MELD score and ALBI grade. Conclusion: Patients with lower LiMAx® values at baseline have a significantly increased risk for hepatic decompensation after RE, despite being categorized as Child–Pugh A. Therefore, LiMAx® can be used as an additional tool to identify patients at high risk of post-interventional hepatic failure.
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Malekhosseini SA, Ghasemi Y, Rousta J, Aghaei R, Kianpour S, Negahdaripour M, Heidari R, Shamsaeefar A, Gholami S, Nikeghbalian S. Clinical Evaluation of an HTK Solution for Liver Transplantation: A Phase 3 Randomized Pilot Clinical Trial Study. ARCHIVES OF IRANIAN MEDICINE 2022; 25:617-623. [PMID: 37543887 PMCID: PMC10685771 DOI: 10.34172/aim.2022.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 02/27/2022] [Indexed: 08/07/2023]
Abstract
BACKGROUND Organ preservation solutions are not easily accessible in Iran, similar to many resource-limited countries. We aimed to evaluate the efficacy of a locally-produced HTK solution among adult liver transplantation candidates in a pilot clinical trial study. METHODS Adult patients undergoing liver transplantation were randomly allocated into two groups. One received the HTK solution (PharMedCina Inc., Shiraz, Iran), and the second received the commercially available HTK solution (Custodiol ®). RESULTS Overall, 28 individuals entered the study, including 11 and 9 males (78.6% and 64.3%) in the Custodiol® and local HTK groups, respectively. Clinical characteristics, including postoperative biliary complications, reperfusion syndrome, infection and primary non-function (PNF) rates, amount of intraoperative bleeding, length of hospital and ICU stay, peak aspartate aminotransferase (AST) and alanine aminotransferase (ALT), and duration of follow-up were similar between the two groups (P>0.05). One patient died in the locally-produced HTK group. The patient underwent re-transplantation 20 days after his first liver transplantation due to PNF. Two patients died in the Custodiol group, both due to PNF of the liver, which occurred five and three days after transplantation. The two groups did not show any difference regarding serum levels of AST, ALT, alkaline phosphatase (ALP), bilirubin, platelet count, prothrombin time and international normalized ratio, white blood cell count, blood urea nitrogen, and creatinine on the first postoperative day and on the day of discharge (P>0.05). CONCLUSION Based on the findings of this pilot study with the current sample size, no statistically significant difference was found between our locally-produced HTK solution and Custodiol® regarding clinical outcomes.
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Affiliation(s)
- Seyed Ali Malekhosseini
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Younes Ghasemi
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pharmaceutical Biotechnology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Javad Rousta
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Roghayyeh Aghaei
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sedigheh Kianpour
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Manica Negahdaripour
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pharmaceutical Biotechnology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Heidari
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Shamsaeefar
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Siavash Gholami
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Saman Nikeghbalian
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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11
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Narayan RR, Abadilla N, Yang L, Chen SB, Klinkachorn M, Eddington HS, Trickey AW, Higgins JP, Melcher ML. Artificial intelligence for prediction of donor liver allograft steatosis and early post-transplantation graft failure. HPB (Oxford) 2022; 24:764-771. [PMID: 34815187 DOI: 10.1016/j.hpb.2021.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Donor livers undergo subjective pathologist review of steatosis before transplantation to mitigate the risk for early allograft dysfunction (EAD). We developed an objective, computer vision artificial intelligence (CVAI) platform to score donor liver steatosis and compared its capability for predicting EAD against pathologist steatosis scores. METHODS Two pathologists scored digitized donor liver biopsy slides from 2014 to 2019. We trained four CVAI platforms with 1:99 training:prediction split. Mean intersection-over-union (IU) characterized CVAI model accuracy. We defined EAD using liver function tests within 1 week of transplantation. We calculated separate EAD logistic regression models with CVAI and pathologist steatosis and compared the models' discrimination and internal calibration. RESULTS From 90 liver biopsies, 25,494 images trained CVAI models yielding peak mean IU = 0.80. CVAI steatosis scores were lower than pathologist scores (median 3% vs 20%, P < 0.001). Among 41 transplanted grafts, 46% developed EAD. The median CVAI steatosis score was higher for those with EAD (2.9% vs 1.9%, P = 0.02). CVAI steatosis was independently associated with EAD after adjusting for donor age, donor diabetes, and MELD score (aOR = 1.34, 95%CI = 1.03-1.75, P = 0.03). CONCLUSION The CVAI steatosis EAD model demonstrated slightly better calibration than pathologist steatosis, meriting further investigation into which modality most accurately and reliably predicts post-transplantation outcomes.
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Affiliation(s)
- Raja R Narayan
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Natasha Abadilla
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Linfeng Yang
- Department of Bioengineering, Stanford University School of Engineering, Stanford, CA, USA
| | - Simon B Chen
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Mac Klinkachorn
- Department of Bioengineering, Stanford University School of Engineering, Stanford, CA, USA
| | - Hyrum S Eddington
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - John P Higgins
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Marc L Melcher
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
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12
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Lascaris B, Thorne AM, Lisman T, Nijsten MWN, Porte RJ, de Meijer VE. Long-term normothermic machine preservation of human livers: what is needed to succeed? Am J Physiol Gastrointest Liver Physiol 2022; 322:G183-G200. [PMID: 34756122 DOI: 10.1152/ajpgi.00257.2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Although short-term machine perfusion (≤24 h) allows for resuscitation and viability assessment of high-risk donor livers, the donor organ shortage might be further remedied by long-term perfusion machines. Extended preservation of injured donor livers may allow reconditioning, repairing, and regeneration. This review summarizes the necessary requirements and challenges for long-term liver machine preservation, which requires integrating multiple core physiological functions to mimic the physiological environment inside the body. A pump simulates the heart in the perfusion system, including automatically controlled adjustment of flow and pressure settings. Oxygenation and ventilation are required to account for the absence of the lungs combined with continuous blood gas analysis. To avoid pressure necrosis and achieve heterogenic tissue perfusion during preservation, diaphragm movement should be simulated. An artificial kidney is required to remove waste products and control the perfusion solution's composition. The perfusate requires an oxygen carrier, but will also be challenged by coagulation and activation of the immune system. The role of the pancreas can be mimicked through closed-loop control of glucose concentrations by automatic injection of insulin or glucagon. Nutrients and bile salts, generally transported from the intestine to the liver, have to be supplemented when preserving livers long term. Especially for long-term perfusion, the container should allow maintenance of sterility. In summary, the main challenge to develop a long-term perfusion machine is to maintain the liver's homeostasis in a sterile, carefully controlled environment. Long-term machine preservation of human livers may allow organ regeneration and repair, thereby ultimately solving the shortage of donor livers.
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Affiliation(s)
- Bianca Lascaris
- Section of Hepatopancreatobiliary Surgery & Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Adam M Thorne
- Section of Hepatopancreatobiliary Surgery & Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten W N Nijsten
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Section of Hepatopancreatobiliary Surgery & Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Vincent E de Meijer
- Section of Hepatopancreatobiliary Surgery & Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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13
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Abstract
Severe allograft dysfunction, as opposed to the expected immediate function, following liver transplantation is a major complication, and the clinical manifestations of such that lead to either immediate retransplant or death are the catastrophic end of the spectrum. Primary nonfunction (PNF) has declined in incidence over the years, yet the impact on patient and healthcare teams, and the burden on the organ pool in case of the need for retransplant should not be underestimated. There is no universal test to define the diagnosis of PNF, and current criteria are based on various biochemical parameters surrogate of liver function; moreover, a disparity remains within different healthcare systems on selecting candidates eligible for urgent retransplantation. The impact on PNF from traditionally accepted risk factors has changed somewhat, mainly driven by the rising demand for organs, combined with the concerted approach by clinicians on the in-depth understanding of PNF, optimal graft recipient selection, mitigation of the clinical environment in which a marginal graft is reperfused, and postoperative management. Regardless of the mode, available data suggest machine perfusion strategies help reduce the incidence further but do not completely avert the risk of PNF. The mainstay of management relies on identifying severe allograft dysfunction at a very early stage and aggressive management, while excluding other identifiable causes that mimic severe organ dysfunction. This approach may help salvage some grafts by preventing total graft failure and also maintaining a patient in an optimal physiological state if retransplantation is considered the ultimate patient salvage strategy.
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Affiliation(s)
- Hermien Hartog
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
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14
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Current and Potential Applications for Indocyanine Green in Liver Transplantation. Transplantation 2021; 106:1339-1350. [PMID: 34966106 DOI: 10.1097/tp.0000000000004024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Indocyanine green (ICG) is a fluorescent dye taken up and almost exclusively cleared by the liver. Measurement of its clearance and visualization of its fluorescence make it suitable for a number of potential applications in liver transplantation including assessment of liver function and real-time assessment of arterial, venous, and biliary structures. ICG clearance can be used to assess donor graft quality before procurement and graft metabolic function before transplant using normothermic ex vivo machine perfusion. ICG clearance in the post-liver transplantation period is able to predict recipient outcomes with correlations to early allograft dysfunction and postoperative complications. After absorbing light in the near-infrared spectrum, ICG also emits fluorescence at 835 nm. This allows the assessment of vascular patency after reconstruction and patterns of liver perfusion in real time. ICG perfusion patterns after revascularization are also associated with posttransplant graft function and survival. ICG fluorescence cholangiography is routine in a number of centers and acts as an aid to identifying the optimal point of bile duct division during living donor liver transplantation to optimize safety for both donor and recipient. In summary, ICG is a versatile tool and has a number of useful applications in the liver transplantation journey including assessment of liver function, perfusion assessment, and cholangiography. Further research and clinical trials are required to validate and standardize its routine use in liver transplantation.
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15
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A proof of concept study on real-time LiMAx CYP1A2 liver function assessment of donor grafts during normothermic machine perfusion. Sci Rep 2021; 11:23444. [PMID: 34873187 PMCID: PMC8648778 DOI: 10.1038/s41598-021-02641-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/08/2021] [Indexed: 12/12/2022] Open
Abstract
No single reliable parameter exists to assess liver graft function of extended criteria donors during ex-vivo normothermic machine perfusion (NMP). The liver maximum capacity (LiMAx) test is a clinically validated cytochromal breath test, measuring liver function based on 13CO2 production. As an innovative concept, we aimed to integrate the LiMAx breath test with NMP to assess organ function. Eleven human livers were perfused using NMP. After one hour of stabilization, LiMAx testing was performed. Injury markers (ALT, AST, miR-122, FMN, and Suzuki-score) and lactate clearance were measured and related to LiMAx values. LiMAx values ranged between 111 and 1838 µg/kg/h, and performing consecutive LiMAx tests during longer NMP was feasible. No correlation was found between LiMAx value and miR-122 and FMN levels in the perfusate. However, a significant inverse correlation was found between LiMAx value and histological injury (Suzuki-score, R = − 0.874, P < 0.001), AST (R = − 0.812, P = 0.004) and ALT (R = − 0.687, P = 0.028). Furthermore, a significant correlation was found with lactate clearance (R = 0.683, P = 0.043). We demonstrate, as proof of principle, that liver function during NMP can be quantified using the LiMAx test, illustrating a positive correlation with traditional injury markers. This new breath-test application separates livers with adequate cytochromal liver function from inadequate ones and may support decision-making in the safe utilization of extended criteria donor grafts.
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16
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Verhelst X, Geerts A, Colman R, Vanlander A, Degroote H, Abreu de Carvalho L, Meuris L, Berrevoet F, Rogiers X, Callewaert N, Van Vlierberghe H. Serum Glycomics on Postoperative Day 7 Are Associated With Graft Loss Within 3 Months After Liver Transplantation Regardless of Early Allograft Dysfunction. Transplantation 2021; 105:2404-2410. [PMID: 33273318 DOI: 10.1097/tp.0000000000003567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prediction of outcome after liver transplantation (LT) is limited by the lack of robust predictors of graft failure. In this prospective study, we aimed to define a serum glycomic signature in the first week after LT that is associated with graft loss at 3 mo after LT. METHODS Patients were included between January 1, 2011, and February 28, 2017. Glycomic analysis was performed using DNA sequencer-associated fluorophore-associated capillary electrophoresis on a serum sample 1 wk after LT. Making use of Lasso regression, an optimal glycomic signature was identified associated with 3-mo graft survival. RESULTS In this cohort of 131 patients, graft loss at 3 mo occurred in 14 patients (11.9%). The optimal mode, called the GlycoTransplantTest, yielded an area under the curve of 0.95 for association with graft loss at 3 mo. Using an optimized cutoff for this biomarker, sensitivity was 86% and specificity 89%. Negative predictive value was 98%. Odds ratio for graft loss at 3 mo was 70.211 (P < 0.001; 95% confidence interval, 10.876-453.231). CONCLUSIONS A serum glycomic signature is highly associated with graft loss at 3 mo. It could support decision making in early retransplantation.
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Affiliation(s)
- Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
- Hepatology Research Unit, Ghent University, Ghent, Belgium
- European Reference Network, RARE LIVER, Ghent, Belgium
| | - Anja Geerts
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
- Hepatology Research Unit, Ghent University, Ghent, Belgium
- European Reference Network, RARE LIVER, Ghent, Belgium
| | - Roos Colman
- Biostatistical Unit, Ghent University, Ghent, Belgium
| | - Aude Vanlander
- Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University Hospital Medical School, Ghent, Belgium
| | - Helena Degroote
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
- Hepatology Research Unit, Ghent University, Ghent, Belgium
- European Reference Network, RARE LIVER, Ghent, Belgium
| | - Luis Abreu de Carvalho
- Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University Hospital Medical School, Ghent, Belgium
| | - Leander Meuris
- Department for Molecular Biomedical Research, Unit for Medical Biotechnology, VIB, Ghent, Belgium
| | - Frederik Berrevoet
- Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University Hospital Medical School, Ghent, Belgium
| | - Xavier Rogiers
- Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University Hospital Medical School, Ghent, Belgium
| | - Nico Callewaert
- Department for Molecular Biomedical Research, Unit for Medical Biotechnology, VIB, Ghent, Belgium
| | - Hans Van Vlierberghe
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
- Hepatology Research Unit, Ghent University, Ghent, Belgium
- European Reference Network, RARE LIVER, Ghent, Belgium
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17
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Pravisani R, De Simone P, Patrono D, Lauterio A, Cescon M, Gringeri E, Colledan M, Di Benedetto F, di Francesco F, Antonelli B, Manzia TM, Carraro A, Vivarelli M, Regalia E, Vennarecci G, Guglielmo N, Cesaretti M, Avolio AW, Valentini MF, Lai Q, Baccarani U. An Italian survey on the use of T-tube in liver transplantation: old habits die hard! Updates Surg 2021; 73:1381-1389. [PMID: 33792888 PMCID: PMC8397659 DOI: 10.1007/s13304-021-01019-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 03/02/2021] [Indexed: 12/13/2022]
Abstract
There is enough clinical evidence that a T-tube use in biliary reconstruction at adult liver transplantation (LT) does not significantly modify the risk of biliary stricture/leak, and it may even sustain infective and metabolic complications. Thus, the policy on T-tube use has been globally changing, with progressive application of more restrictive selection criteria. However, there are no currently standardized indications in such change, and many LT Centers rely only on own experience and routine. A nation-wide survey was conducted among all the 20 Italian adult LT Centers to investigate the current policy on T-tube use. It was found that 20% of Centers completely discontinued the T-tube use, while 25% Centers used it routinely in all LT cases. The remaining 55% of Centers applied a selective policy, based on criteria of technical complexity of biliary reconstruction (72.7%), followed by low-quality graft (63.6%) and high-risk recipient (36.4%). A T-tube use > 50% of annual caseload was not associated with high-volume Center status (> 70 LT per year), an active pediatric or living-donor transplant program, or use of DCD grafts. Only 10/20 (50%) Centers identified T-tube as a potential risk factor for complications other than biliary stricture/leak. In these cases, the suspected pathogenic mechanism comprised bacterial colonization (70%), malabsorption (70%), interruption of the entero-hepatic bile-acid cycle (50%), biliary inflammation due to an indwelling catheter (40%) and gut microbiota changes (40%). In conclusion, the prevalence of T-tube use among the Italian LT Centers is still relatively high, compared to the European trend (33%), and the potential detrimental effect of T-tube, beyond biliary stricture/leak, seems to be somehow underestimated.
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Affiliation(s)
- Riccardo Pravisani
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation, University Hospital Pisa, Pisa, Italy
| | - Damiano Patrono
- General Surgery 2U, Liver Transplant Center, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Turin, Italy
| | - Andrea Lauterio
- General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Matteo Cescon
- General Surgery and Transplantation Unit, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria-Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Enrico Gringeri
- Hepatobiliary Surgery and Liver Transplantation Unit, University Hospital, Padua, Italy
| | - Michele Colledan
- Chirurgia Generale 3, Trapianti Addominali, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Fabrizio Di Benedetto
- Hepatopancreatobiliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio di Francesco
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS ISMETT-UPMC, Palermo, Italy
| | - Barbara Antonelli
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Tommaso Maria Manzia
- HPB and Transplant Unit, Department of Surgery Science, University of Rome Tor Vergata, Rome, Italy
| | - Amedeo Carraro
- General Surgery and Liver Transplant Unit, University Hospital of Verona, Verona, Italy
| | - Marco Vivarelli
- HPB Surgery and Transplantation Unit, Department of Clinical and Experimental Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Enrico Regalia
- HPB Surgery and Transplantation Unit, Istituto Nazionale Tumori, IRCCS, Milano, Italy
| | - Giovanni Vennarecci
- Laproscopic, Hepatic, and Liver Transplant Unit, AORN A. Cardarelli, Naples, Italy
| | - Nicola Guglielmo
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Italy
| | - Manuela Cesaretti
- Liver Transplant Unit, Department of General Surgery, Azienda Ospedaliera G. Brotzu, Cagliari, Italy
| | - Alfonso Wolfango Avolio
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Maria Filippa Valentini
- General Surgery and Liver Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, Sapienza University of Rome, Rome, Italy
| | - Umberto Baccarani
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy.
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18
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Rinaldi M, Bartoletti M, Ferrarese A, Franceschini E, Campoli C, Coladonato S, Pascale R, Tedeschi S, Gatti M, Cricca M, Ambretti S, Siniscalchi A, Morelli MC, Cescon M, Cillo U, Di Benedetto F, Burra P, Mussini C, Cristini F, Lewis R, Viale P, Giannella M. Breakthrough invasive fungal infection after liver transplantation in patients on targeted antifungal prophylaxis: A prospective multicentre study. Transpl Infect Dis 2021; 23:e13608. [PMID: 33768656 PMCID: PMC8519035 DOI: 10.1111/tid.13608] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/08/2021] [Accepted: 03/14/2021] [Indexed: 01/21/2023]
Abstract
Objective To investigate the rate of and the risk factors for breakthrough‐IFI (b‐IFI) after orthotopic liver transplantation (OLT) according to the new definition proposed by Mycoses‐Study‐Group‐Education‐and‐Research‐Consortium (MSG‐ERC) and the European‐Confederation‐of‐Medical‐Mycology (ECMM). Methods Multicenter prospective study of adult patients who underwent OLT at three Italian hospitals, from January 2015 to December 2018. Targeted antifungal prophylaxis (TAP) protocol was developed and shared among participating centers. Follow‐up was 1‐year after OLT. B‐IFI was defined as infection occurring during exposure to antifungal prophylaxis. Risk factors for b‐IFI were analyzed among patients exposed to prophylaxis by univariable analysis. Results We enrolled 485 OLT patients. Overall compliance to TAP protocol was 64.3%, 220 patients received antifungal prophylaxis, 172 according to TAP protocol. Twenty‐nine patients were diagnosed of IFI within 1 year after OLT. Of them, 11 presented with b‐IFI within 17 (IQR 11‐33) and 16 (IQR 4‐30) days from OLT and from antifungal onset, respectively. Then out of 11 patients with b‐IFI were classified as having high risk of IFI and were receiving anti‐mould prophylaxis, nine with echinocandins and one with polyenes. Comparison of patients with and without b‐IFI showed significant differences for prior Candida colonization, need of renal replacement therapy after OLT, re‐operation, and CMV infection (whole blood CMV‐DNA >100 000 copies/mL). Although non‐significant, a higher rate of b‐IFI in patients on echinocandins was observed (8.2% vs 1.8%, P = .06). Conclusions We observed 5% of b‐IFI among OLT patients exposed to antifungal prophylaxis. The impact of echinocandins on b‐IFI risk in this setting should be further explored.
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Affiliation(s)
- Matteo Rinaldi
- Division of Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Michele Bartoletti
- Division of Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Alberto Ferrarese
- Multivisceral Transplant Unit (Gastroenterology), Department of Surgery Oncology and Gastroenterology, Surgical and Gastroenterological Sciences, Padua University Hospital, Padua, Italy
| | - Erica Franceschini
- Infectious Diseases Unit, Department of Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - Caterina Campoli
- Division of Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Simona Coladonato
- Division of Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Renato Pascale
- Division of Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sara Tedeschi
- Division of Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Monica Cricca
- Operative Unit of Clinical Microbiology, PoliclinicoSant' Orsola Malpighi, University of Bologna, Bologna, Italy
| | - Simone Ambretti
- Infectious Diseases Unit, Department of Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - Antonio Siniscalchi
- Division of Anesthesia, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maria Cristina Morelli
- Division of Internal Medicine for the Treatment of Severe Organ Failure, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Cescon
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.,Division of Liver and Multiorgan Transplant, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Umberto Cillo
- Department of Surgical, Oncological, and Gastroenterological Sciences, Hepatobiliary Surgery and Liver Transplantation Unit, Padua University Hospital, Padova, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit (Gastroenterology), Department of Surgery Oncology and Gastroenterology, Surgical and Gastroenterological Sciences, Padua University Hospital, Padua, Italy
| | - Cristina Mussini
- Infectious Diseases Unit, Department of Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - Francesco Cristini
- Infectious Diseases Unit, AUSL Romagna Infermi Hospital Rimini, Rimini, Italy
| | - Russell Lewis
- Division of Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Pierluigi Viale
- Division of Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Maddalena Giannella
- Division of Infectious Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
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19
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Diaz-Nieto R, Lykoudis P, Robertson F, Sharma D, Moore K, Malago M, Davidson BR. A simple scoring model for predicting early graft failure and postoperative mortality after liver transplantation. Ann Hepatol 2020; 18:902-912. [PMID: 31405576 DOI: 10.1016/j.aohep.2019.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/15/2019] [Accepted: 06/25/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Graft failure and postoperative mortality are the most serious complications after liver transplantation. The aim of this study is to establish a prognostic scoring system to predict graft and patient survival based on serum transaminases levels that are routinely used during the postoperative period in human cadaveric liver transplants. PATIENTS AND METHODS Postoperative graft failure and patient mortality after liver transplant were analyzed from a consecutive series of 1299 patients undergoing cadaveric liver transplantation. This was correlated with serum liver function tests and the rate of reduction in transaminase levels over the first postoperative week. A cut-off transaminase level correlating with graft and patient survival was calculated and incorporated into a scoring system. RESULTS Aspartate-aminotransferase (AST) on postoperative day one showed significant correlation with early graft failure for levels above 723U/dl and early postoperative mortality for levels above 750U/dl. AST reduction rate (day 1 to 3) greater than 1.8 correlated with reduced graft failure and greater than 2 with mortality. Alanine-aminotransferase (ALT) reduction in the first 48h post transplantation also correlated with outcomes. CONCLUSION A scoring system with these three variables allowed us to classify our patients into three groups of risk for early graft failure and mortality.
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Affiliation(s)
- Rafael Diaz-Nieto
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom; Royal Free Campus, University College London, London, United Kingdom.
| | - Panagis Lykoudis
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom; Royal Free Campus, University College London, London, United Kingdom
| | - Francis Robertson
- Royal Free Campus, University College London, London, United Kingdom
| | - Dinesh Sharma
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom
| | - Kevin Moore
- Royal Free Campus, University College London, London, United Kingdom
| | - Massimo Malago
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom
| | - Brian R Davidson
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom; Royal Free Campus, University College London, London, United Kingdom
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20
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Singh N, Washburn K, Schenk A, Hill B, Hardy T, Black S, Sims C, Alebrahim M, El-Hinnawi A. Rescue Hepatectomy and Anhepatic Phase Management After Primary Nonfunction in a Liver Transplant. EXP CLIN TRANSPLANT 2020; 20:776-779. [PMID: 32552625 DOI: 10.6002/ect.2020.0129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Primary nonfunction is a rare but lethal complication that occurs in a small number of liver transplants. When primary nonfunction occurs, the only definite treatment is retransplant; however, another liver might not be readily available at that time. Hence, a surgeon should be aware of the various options available at hand for patient care during the time interval between the primary nonfunction and retransplant. Here, we describe the management strategy that was devised to take care of an unstable anhepatic patient in the intensive care unit, care of the patient during anhepatic phase, and successful outcome with a second liver transplant. Our index patient was a recipient of a liver donated after cardiac death. While in the operating room, after reperfusion of the liver, the patient had right heart dysfunction leading to hemodynamic instability and congestion of the liver, which culminated in primary nonfunction. Graft hepatectomy had to be done on postoperative day 1 because of deteriorating condition of the patient, and the patient was maintained in anhepatic phase in the intensive care unit for 27 hours.
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Affiliation(s)
- Navdeep Singh
- >From the Division of Transplantation, Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
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Faria LC, Andrade AMF, Trant CGMC, Lima AS, Machado PAB, Porto RD, Andrade MVM. Circulating levels of High‐mobility group box 1 protein and nucleosomes are associated with outcomes after liver transplant. Clin Transplant 2020; 34:e13869. [DOI: 10.1111/ctr.13869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 03/08/2020] [Accepted: 03/29/2020] [Indexed: 01/21/2023]
Affiliation(s)
- Luciana C. Faria
- Departamento de Clínica Médica Faculdade de Medicina Universidade Federal de Minas Gerais Belo Horizonte Brasil
- Grupo de Transplante de Órgãos Instituto Alfa de Gastroenterologia Hospital das Clínicas Universidade Federal de Minas Gerais Belo Horizonte Brasil
| | - Antônio Márcio F. Andrade
- Grupo de Transplante de Órgãos Instituto Alfa de Gastroenterologia Hospital das Clínicas Universidade Federal de Minas Gerais Belo Horizonte Brasil
| | - Cyntia G. M. C. Trant
- Laboratório de Fisiopatologia Cirúrgica Faculdade de Medicina Universidade Federal de Minas Gerais Belo Horizonte Brasil
| | - Agnaldo S. Lima
- Grupo de Transplante de Órgãos Instituto Alfa de Gastroenterologia Hospital das Clínicas Universidade Federal de Minas Gerais Belo Horizonte Brasil
- Departamento de Cirurgia Faculdade de Medicina Universidade Federal de Minas Gerais Belo Horizonte Brasil
| | - Pedro A. B. Machado
- Faculdade de Medicina Universidade Federal de Minas Gerais Belo Horizonte Brasil
| | - Rodrigo D. Porto
- Faculdade de Medicina Universidade Federal de Minas Gerais Belo Horizonte Brasil
| | - Marcus Vinícius M. Andrade
- Departamento de Clínica Médica Faculdade de Medicina Universidade Federal de Minas Gerais Belo Horizonte Brasil
- Laboratório de Fisiopatologia Cirúrgica Faculdade de Medicina Universidade Federal de Minas Gerais Belo Horizonte Brasil
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Tun-Abraham ME, Wanis K, Garcia-Ochoa C, Sela N, Sharma H, Al Hasan I, Quan D, Al-Judaibi B, Levstik M, Hernandez-Alejandro R. Can we reduce ischemic cholangiopathy rates in donation after cardiac death liver transplantation after 10 years of practice? Canadian single-centre experience. Can J Surg 2019. [PMID: 30484989 DOI: 10.1503/cjs.012017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Outcomes in liver transplantation with organs obtained via donation after cardiocirculatory death (DCD) have been suboptimal compared to donation after brain death, attributed mainly to the high incidence of ischemic cholangiopathy (IC). We evaluated the effect of a 10-year learning curve on IC rates among DCD liver graft recipients at a single centre. Methods We analyzed all DCD liver transplantation procedures from July 2006 to July 2016. Patients were grouped into early (July 2006 to June 2011) and late (July 2011 to July 2016) eras. Those with less than 6 months of follow-up were excluded. Primary outcomes were IC incidence and IC-free survival rate. Results Among the 73 DCD liver transplantation procedures performed, 70 recipients fulfilled the selection criteria, 32 in the early era and 38 in the late era. Biliary complications were diagnosed in 19 recipients (27%). Ischemic cholangiopathy was observed in 8 patients (25%) in the early era and 1 patient (3%) in the late era (p = 0.005). The IC-free survival rate was higher in the late era than the early era (98% v. 79%, p = 0.01). The warm ischemia time (27 v. 24 min, p = 0.049) and functional warm ischemia time (21 v. 17 min, p = 0.002) were significantly lower in the late era than the early era. Conclusion We found a significant reduction in IC rates and improvement in ICfree survival among DCD liver transplantation recipients after a learning curve period that was marked by more judicious donor selection with shorter procurement times.
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Affiliation(s)
- Mauro Enrique Tun-Abraham
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
| | - Kerollos Wanis
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
| | - Carlos Garcia-Ochoa
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
| | - Nathalie Sela
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
| | - Hemant Sharma
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
| | - Ibrahim Al Hasan
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
| | - Douglas Quan
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
| | - Bandar Al-Judaibi
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
| | - Mark Levstik
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
| | - Roberto Hernandez-Alejandro
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
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Barzakova ES, Schulze-Hagen M, Zimmermann M, Lurje G, Bednarsch J, Pedersoli F, Isfort P, Kuhl C, Bruners P. Monitoring Liver Function of Patients Undergoing Transarterial Chemoembolization (TACE) by a 13C Breath Test (LiMAx). Cardiovasc Intervent Radiol 2019; 42:1702-1708. [PMID: 31535181 DOI: 10.1007/s00270-019-02325-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 08/23/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Transarterial chemoembolization (TACE) is associated with the risk of deteriorating liver function, especially in patients with preexisting liver damage. Current liver function tests may fail to accurately predict the functional liver reserve. Aim of this study was to investigate whether changes of liver function caused by TACE are associated with detectable changes of LiMAx values. METHODS AND MATERIALS Forty patients with primary or secondary liver cancer underwent TACE and LiMAx test on the day before, the day after, and 4 weeks after TACE. LiMAx results were evaluated, referenced to liver volume (CT/MR volumetry), correlated with the respective TACE volume (subsegmental vs. segmental vs. lobar), established liver function tests, and Child-Pugh and ALBI scores. RESULTS The individual LiMAx values were significantly reduced by 10% (p = 0.01) on the day after TACE and fully recovered to baseline 1 month after treatment. Similar changes were observed regarding levels of bilirubin, transaminases, albumin, INR, and creatinine. LiMAx did not correlate significantly with the treated liver volume, but did correlate with the baseline liver volume (< 1200 ml vs. > 1200 ml; p < 0.01). No significant changes were observed in the Child-Pugh score or ALBI score. CONCLUSION LiMAx is capable of detecting changes in liver function, even modulations caused by superselective TACE procedures. Accordingly, it could be used as a tool for patient selection and monitoring of transarterial therapy. In comparison, Child-Pugh and ALBI scores did not reflect any of these changes. Some biochemical parameters also changed significantly after TACE, but they tend to be less specific in providing sufficient information on actual cellular dysfunction.
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Affiliation(s)
- Emona S Barzakova
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstreet 30, 52074, Aachen, Germany.
| | - Maximilian Schulze-Hagen
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Markus Zimmermann
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Georg Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Federico Pedersoli
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Peter Isfort
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Christiane Kuhl
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Pauwelsstreet 30, 52074, Aachen, Germany
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C-reactive protein at ICU admission as a marker of early graft dysfunction after liver transplant. A prospective, single-center cohort study. Med Intensiva 2019; 44:275-282. [PMID: 31000214 DOI: 10.1016/j.medin.2019.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/26/2019] [Accepted: 02/28/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To explore the behavior of C-reactive protein (CRP) after orthotopic liver transplantation (OLT) during the first postoperative days, and its usefulness as a marker of severe early allograft dysfunction (EAD). DESIGN A prospective, single-center cohort study was carried out. SETTING The Intensive Care Unit (ICU) of a regional hospital with a liver transplant program since 1997. PATIENTS The study comprised a total of 183 patients admitted to our ICU immediately after liver transplantation between 2009 and 2015. VARIABLES OF INTEREST C-reactive protein levels upon ICU admission and after 24 and 48h, severe EAD and hospital mortality. RESULTS The CRP levels after OLT were: upon ICU admission 57.5 (51.6-63.3)mg/L, after 24h 80.1 (72.9-87.3)mg/L and after 48h 69.9 (62.5-77.4)mg/L. Severe EAD patients (14.2%) had higher mortality (23.1 vs 2.5; OR 11.48: 2.98-44.19) and lower CRP upon ICU admission (39.3 [29.8-48.7]mg/L) than the patients without EAD (0.5 [53.9-67.0]; p<0.05] - the best cut-off point being 68mg/L (sensitivity 92.3%; specificity 40.1%; Youden index 0.33). Lower CRP upon ICU admission was correlated to higher mortality (24.5 [9.2-39.7] vs 59.4 [53.4-65.4]; p<0.01, AUC 0.79 [0.65-0.92]). CONCLUSION Liver transplant is a strong inflammatory stimulus accompanied by high levels of C-reactive protein. A blunted rise in CRP on the first postoperative day after OLT may be a marker of poor allograft function and is related to hospital mortality.
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Indocyanine green fluorescence imaging to evaluate graft perfusion during liver transplantation. HPB (Oxford) 2019; 21:387-392. [PMID: 30297305 DOI: 10.1016/j.hpb.2018.09.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/04/2018] [Accepted: 09/02/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Primary graft dysfunction (PGD) is a leading cause of graft loss after liver transplantation. There is no reliable method to anticipate this complication intraoperatively. Indocyanine green (ICG) fluorescence imaging is a technique used in hepatobiliary surgery for detection of liver malignancies, but has never been reported in the setting of liver transplantation (LT) for function assessment. We hypothesized that there could be an association between the type of fluorescence and the occurrence of PGD. METHODS We retrospectively analyzed 72 patients who underwent LT at our center. An assessment of the liver graft with the ICG fluorescence technique was carried out. A classification comprising 3 types of fluorescence was created after evaluation of the recorded images. We assessed the relationship between the type of fluorescence and the occurrence of PGD. RESULTS Crosstabulation analysis of the fluorescent types and occurrence of PGD yielded a statistically significant association (p = 0.002). Univariate analysis showed that an abnormal ICG fluorescence pattern was a risk factor for the occurrence of PGD after LT. CONCLUSIONS Our findings suggest that there could be an association between ICG fluorescence imaging and graft function. This intraoperative tool could be useful to detect patients at risk of developing PGD after LT.
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Fuhrmann I, Brünn K, Probst U, Verloh N, Stroszczynski C, Jung EM, Wiggermann P, Haimerl M. Proof of principle: Estimation of liver function using color coded Doppler sonography of the portal vein. Clin Hemorheol Microcirc 2019; 70:585-594. [DOI: 10.3233/ch-189323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Irene Fuhrmann
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - Karin Brünn
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - Ute Probst
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - Niklas Verloh
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | | | - Ernst Michael Jung
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - Philipp Wiggermann
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - Michael Haimerl
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
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Noninvasive Evaluation of Liver Function in Morbidly Obese Patients. Gastroenterol Res Pract 2019; 2019:4307462. [PMID: 30863439 PMCID: PMC6378040 DOI: 10.1155/2019/4307462] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 12/30/2018] [Indexed: 12/12/2022] Open
Abstract
Background More than half of the obese patients develop nonalcoholic fatty liver disease (NAFLD), which may further progress to nonalcoholic steatohepatitis (NASH) and cirrhosis. The aim of this study was to assess alterations in liver function in obese patients with a noninvasive liver function test. Methods In a prospective cohort study 102 morbidly obese patients undergoing bariatric surgery were evaluated for their liver function. Liver function capacity was determined by the LiMAx® test (enzymatic capacity of cytochrome P450 1A2). Liver biopsy specimens were obtained intraoperatively and classified according to the NAFLD Activity Score (NAS). NASH clinical score was additionally calculated from laboratory and clinical parameters. Results Median liver function capacity was 286 (IQR = 141) μg/kg/h. 27% of patients were histologically categorized as definite NASH, 39% as borderline, and 34% as not NASH. A significant correlation was observed between liver function capacity and NAS (r = −0.492; p < 0.001). The sensitivity and specificity of the LiMAx® test to distinguish between definite NASH and not NASH were 85.2% and 82.9% (AUROC 0.859), respectively. According to the NASH clinical scoring system, 14% were classified as low risk, 31% as intermediate, 26% as high, and 29% as very high risk. Liver function capacity is also significantly correlated with the NASH clinical scoring system (r = −0.411; p < 0.001). Conclusions Obese patients show a diminished liver function capacity, especially those suffering from type 2 diabetes. The liver function capacity correlates with histological and clinical scoring systems. The LiMAx® test may be a valuable tool for noninvasive screening for NASH in obese patients.
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Tun-Abraham ME, Wanis K, Garcia-Ochoa C, Sela N, Sharma H, Al Hasan I, Quan D, Al-Judaibi B, Levstik M, Hernandez-Alejandro R. Can we reduce ischemic cholangiopathy rates in donation after cardiac death liver transplantation after 10 years of practice? Canadian single-centre experience. CANADIAN JOURNAL OF SURGERY. JOURNAL CANADIEN DE CHIRURGIE 2019; 62:44-51. [PMID: 30484989 DOI: 10.503/cjs.012017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Outcomes in liver transplantation with organs obtained via donation after cardiocirculatory death (DCD) have been suboptimal compared to donation after brain death, attributed mainly to the high incidence of ischemic cholangiopathy (IC). We evaluated the effect of a 10-year learning curve on IC rates among DCD liver graft recipients at a single centre. Methods We analyzed all DCD liver transplantation procedures from July 2006 to July 2016. Patients were grouped into early (July 2006 to June 2011) and late (July 2011 to July 2016) eras. Those with less than 6 months of follow-up were excluded. Primary outcomes were IC incidence and IC-free survival rate. Results Among the 73 DCD liver transplantation procedures performed, 70 recipients fulfilled the selection criteria, 32 in the early era and 38 in the late era. Biliary complications were diagnosed in 19 recipients (27%). Ischemic cholangiopathy was observed in 8 patients (25%) in the early era and 1 patient (3%) in the late era (p = 0.005). The IC-free survival rate was higher in the late era than the early era (98% v. 79%, p = 0.01). The warm ischemia time (27 v. 24 min, p = 0.049) and functional warm ischemia time (21 v. 17 min, p = 0.002) were significantly lower in the late era than the early era. Conclusion We found a significant reduction in IC rates and improvement in ICfree survival among DCD liver transplantation recipients after a learning curve period that was marked by more judicious donor selection with shorter procurement times.
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Affiliation(s)
- Mauro Enrique Tun-Abraham
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
| | - Kerollos Wanis
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
| | - Carlos Garcia-Ochoa
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
| | - Nathalie Sela
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
| | - Hemant Sharma
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
| | - Ibrahim Al Hasan
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
| | - Douglas Quan
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
| | - Bandar Al-Judaibi
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
| | - Mark Levstik
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
| | - Roberto Hernandez-Alejandro
- From the Multi-Organ Transplant Program, London Health Sciences Centre, London, Ont. (Tun-Abraham, Wanis, GarciaOchoa, Sela, Sharma, Quan, Hernandez-Alejandro); the Division of Transplantation, Prince Sultan Military Medical City, Riyadh, Saudi Arabia (Al Hasan); and the Division of Solid Organ Transplantation, University of Rochester, Rochester, NY (Al-Judaibi, Levstik, Hernandez-Alejandro)
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Prospective Assessment of Liver Function by an Enzymatic Liver Function Test to Estimate Short-Term Survival in Patients with Liver Cirrhosis. Dig Dis Sci 2019; 64:576-584. [PMID: 30406480 DOI: 10.1007/s10620-018-5360-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/29/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND MELD attempts to objectively predict the risk of mortality of patients with liver cirrhosis and is commonly used to prioritize organ allocation. Despite the usefulness of the MELD, updated metrics could further improve the accuracy of estimates of survival. AIMS To assess and compare the prognostic ability of an enzymatic 13C-based liver function test (LiMAx) and distinct markers of liver function to predict 3-month mortality of patients with chronic liver failure. METHODS We prospectively investigated liver function of 268 chronic liver failure patients without hepatocellular carcinoma. Primary study endpoint was liver-related death within 3 months of follow-up. Prognostic values were calculated using Cox proportional hazards and logistic regression analysis. RESULTS The Cox proportional hazard model indicated that LiMAx (p < 0.001) and serum creatinine values (p < 0.001) were the significant parameters independently associated with the risk of liver failure-related death. Logistic regression analysis revealed LiMAx and serum creatinine to be independent predictors of mortality. Areas under the receiver-operating characteristic curves for MELD (0.86 [0.80-0.92]) and for a combined score of LiMAx and serum creatinine (0.83 [0.76-0.90]) were comparable. CONCLUSIONS Apart from serum creatinine levels, enzymatic liver function measured by LiMAx was found to be an independent predictor of short-term mortality risk in patients with liver cirrhosis. A risk score combining both determinants allows reliable prediction of short-term prognosis considering actual organ function. Trial Registration Number (German Clinical Trials Register) # DRKS00000614.
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Early graft dysfunction after liver transplant: Comparison of different diagnostic criteria in a single-center prospective cohort. Med Intensiva 2018; 44:150-159. [PMID: 30528954 DOI: 10.1016/j.medin.2018.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 08/23/2018] [Accepted: 09/05/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Comparison of different diagnostic criteria for early liver allograft dysfunction (EAD) and their capability to predict mortality. DESIGN Single-center, prospective, cohort study. SETTINGS ICU in a Regional Hospital with a liver transplant program since 1997. PATIENTS 253 consecutive patients admitted to our ICU immediately after liver transplantation between 2009 and 2015. VARIABLES OF INTEREST Differences in the incidence of EAD and its relation with ICU, Hospital and 2-year mortality depending on the definition applied using as comparator the UNOS (United Network for Organ Sharing) primary non-function criterion. RESULTS The incidence of early liver allograft dysfunction according to UNOS was 13.8%, to Makowka 6.3%, to Ardite 10.7%, to Nanashima 20.6%, to Dhillon 30.8% and to MEAF 13.4%. Kappa test did not show a good correlation among these criteria. EAD was related with ICU mortality for all diagnostic criteria except Dhillon but only UNOS, Makowka and MEAF were associated with 2-year mortality. Hospital mortality was poorly predicted by all criteria except for the MEAF score. CONCLUSION We found a poor agreement between different criteria analyzed for the diagnosis of EAD. In our population, the MEAF score showed the best relationship with short- and long-term mortality.
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Stockmann M, Vondran FWR, Fahrner R, Tautenhahn HM, Mittler J, Bektas H, Malinowski M, Jara M, Klein I, Lock JF. Randomized clinical trial comparing liver resection with and without perioperative assessment of liver function. BJS Open 2018; 2:301-309. [PMID: 30263981 PMCID: PMC6156169 DOI: 10.1002/bjs5.81] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 04/13/2018] [Indexed: 12/11/2022] Open
Abstract
Background Liver function tests may help to predict outcomes after liver surgery. The aim of this study was to evaluate the clinical impact on postoperative outcome and patient management of perioperative liver function testing using the LiMAx® test. Methods A multicentre RCT was conducted in six academic liver centres. Patients with intrahepatic tumours scheduled for open liver resection of at least one segment were eligible. Patients were randomized to undergo additional perioperative liver function tests (LiMAx® group) or standard care (control group). Patients in the intervention arm received two perioperative LiMAx® tests, one before the operation for surgical planning and another after surgery for postoperative management. The primary endpoint was the proportion of patients transferred directly to a general ward. Secondary endpoints were severe complications, length of hospital stay (LOS) and length of intermediate care/ICU (LOI) stay. Results Some 148 patients were randomized. Thirty‐six of 58 patients (62 per cent) in the LiMAx® group were transferred directly to a general ward, compared with one of 60 (2 per cent) in the control group (P < 0·001). The rate of severe complications was significantly lower in the LiMAx® group (14 per cent versus 28 per cent in the control group; P = 0·022). LOS and LOI were significantly shorter in the LiMAx® group (LOS: 10·6 versus 13·3 days respectively, P = 0·012; LOI: 0·8 versus 3·0 days, P < 0·001). Conclusion Perioperative use of the LiMAx® test improves postoperative management and reduces the incidence of severe complications after liver surgery. Registration number: NCT01785082 (
https://clinicaltrials.gov).
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Affiliation(s)
- M Stockmann
- Department of General, Visceral and Transplantation Surgery Charité - Universitätsmedizin Berlin Germany.,Department of General, Visceral and Vascular Surgery Evangelisches Krankenhaus Paul Gerhardt Stift Lutherstadt Wittenberg Germany
| | - F W R Vondran
- Department of General, Visceral and Transplant Surgery Hannover Medical School Hannover Germany
| | - R Fahrner
- Department of General, Visceral and Vascular Surgery University of Jena Jena Germany
| | - H M Tautenhahn
- Department of General, Visceral and Vascular Surgery University of Jena Jena Germany.,Department of Visceral, Transplant, Thoracic and Vascular Surgery University Hospital Leipzig Leipzig Germany
| | - J Mittler
- Department of Hepatobiliary and Transplantation Surgery Johannes Gutenberg University Mainz Germany
| | - H Bektas
- Department of General, Visceral and Transplant Surgery Hannover Medical School Hannover Germany.,Department of General, Visceral and Oncological Surgery Bremen Mitte Clinic Bremen Germany
| | - M Malinowski
- Department of General, Visceral and Transplantation Surgery Charité - Universitätsmedizin Berlin Germany.,Department of General, Visceral, Vascular and Paediatric Surgery University of Saarland Homburg Germany
| | - M Jara
- Department of General, Visceral and Transplantation Surgery Charité - Universitätsmedizin Berlin Germany
| | - I Klein
- Department of General, Visceral, Vascular and Paediatric Surgery University Hospital of Würzburg Würzburg Germany
| | - J F Lock
- Department of General, Visceral, Vascular and Paediatric Surgery University Hospital of Würzburg Würzburg Germany
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Núñez K, Thevenot P, Alfadhli A, Cohen A. Complement Activation in Liver Transplantation: Role of Donor Macrosteatosis and Implications in Delayed Graft Function. Int J Mol Sci 2018; 19:ijms19061750. [PMID: 29899265 PMCID: PMC6032339 DOI: 10.3390/ijms19061750] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 05/28/2018] [Accepted: 06/08/2018] [Indexed: 12/16/2022] Open
Abstract
The complement system anchors the innate inflammatory response by triggering both cell-mediated and antibody-mediated immune responses against pathogens. The complement system also plays a critical role in sterile tissue injury by responding to damage-associated molecular patterns. The degree and duration of complement activation may be a critical variable controlling the balance between regenerative and destructive inflammation following sterile injury. Recent studies in kidney transplantation suggest that aberrant complement activation may play a significant role in delayed graft function following transplantation, confirming results obtained from rodent models of renal ischemia/reperfusion (I/R) injury. Deactivating the complement cascade through targeting anaphylatoxins (C3a/C5a) might be an effective clinical strategy to dampen reperfusion injury and reduce delayed graft function in liver transplantation. Targeting the complement cascade may be critical in donor livers with mild to moderate steatosis, where elevated lipid burden amplifies stress responses and increases hepatocyte turnover. Steatosis-driven complement activation in the donor liver may also have implications in rejection and thrombolytic complications following transplantation. This review focuses on the roles of complement activation in liver I/R injury, strategies to target complement activation in liver I/R, and potential opportunities to translate these strategies to transplanting donor livers with mild to moderate steatosis.
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Affiliation(s)
- Kelley Núñez
- Institute of Translational Research, Ochsner Health System, New Orleans, LA 70121, USA.
| | - Paul Thevenot
- Institute of Translational Research, Ochsner Health System, New Orleans, LA 70121, USA.
| | - Abeer Alfadhli
- Institute of Translational Research, Ochsner Health System, New Orleans, LA 70121, USA.
| | - Ari Cohen
- Institute of Translational Research, Ochsner Health System, New Orleans, LA 70121, USA.
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Hepatobiliary MRI: Signal intensity based assessment of liver function correlated to 13C-Methacetin breath test. Sci Rep 2018; 8:9078. [PMID: 29899400 PMCID: PMC5998051 DOI: 10.1038/s41598-018-27401-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 06/01/2018] [Indexed: 12/11/2022] Open
Abstract
Gadoxetic acid (Gd-EOB-DTPA) is a paramagnetic MRI contrast agent with raising popularity and has been used for evaluation of imaging-based liver function in recent years. In order to verify whether liver function as determined by real-time breath analysis using the intravenous administration of 13C-methacetin can be estimated quantitatively from Gd-EOB-DTPA-enhanced MRI using signal intensity (SI) values. 110 patients underwent Gd-EOB-DTPA-enhanced 3-T MRI and, for the evaluation of liver function, a 13C-methacetin breath test (13C-MBT). SI values from before (SIpre) and 20 min after (SIpost) contrast media injection were acquired by T1-weighted volume-interpolated breath-hold examination (VIBE) sequences with fat suppression. The relative enhancement (RE) between the plain and contrast-enhanced SI values was calculated and evaluated in a correlation analysis of 13C-MBT values to SIpost and RE to obtain a SI-based estimation of 13C-MBT values. The simple regression model showed a log-linear correlation of 13C-MBT values with SIpost and RE (p < 0.001). Stratified by 3 different categories of 13C-MBT readouts, there was a constant significant decrease in both SIpost (p ≤ 0.002) and RE (p ≤ 0.033) with increasing liver disease progression as assessed by the 13C-MBT. Liver function as determined using real-time 13C-methacetin breath analysis can be estimated quantitatively from Gd-EOB-DTPA-enhanced MRI using SI-based indices.
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Sun Y, Yu L, Liu Y. Predictive Value of Indocyanine Green Plasma Disappearance Rate on Liver Function and Complications After Liver Transplantation. Med Sci Monit 2018; 24:3661-3669. [PMID: 29855460 PMCID: PMC6007494 DOI: 10.12659/msm.907783] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the correlation between indocyanine green plasma disappearance rate (ICG-PDR) and allograft function as well as postoperative complications after liver transplantation. MATERIAL AND METHODS In this prospective study, 115 cases of adult liver transplantation performed from 1 June 2016 to 1 December 2016 were enrolled. These 115 patients were divided into a group of PDR <18%/min (50 cases) and a group of PDR ≥18%/min (65 cases). The rates of liver recovery, postoperative complications, and survival were compared between these 2 groups. RESULTS Among the total of 115 patients, 111 patients recovered well and were discharged, whereas 4 patients died during the first month after the operation. Between the 2 groups, significant differences were observed in terms of the model for end-stage liver disease (MELD) score, intraoperative bleeding volume, and the level of hemoglobin (Hb), pre-albumin (PA) and total bilirubin (TB) the first week after the operation. Overall, the incidence of hepatic arterial complications and pneumonia was much higher in the PDR<18%/min group (P<0.05). CONCLUSIONS The early postoperative value of ICG-PDR was closely related to graft function and could act as a good predictor for the incidence of postoperative arterial complications.
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Affiliation(s)
- Yan Sun
- Department of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China (mainland)
| | - Lixin Yu
- Department of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China (mainland)
| | - Yihe Liu
- Department of Organ Transplantation, Tianjin First Central Hospital, Tianjin, China (mainland)
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Lieber SR, Schiano TD, Rhodes R. Should living donor liver transplantation be an option when deceased donation is not? J Hepatol 2018; 68:1076-1082. [PMID: 29100996 PMCID: PMC5893415 DOI: 10.1016/j.jhep.2017.10.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 09/20/2017] [Accepted: 10/15/2017] [Indexed: 12/20/2022]
Abstract
When a liver transplantation candidate is declined for listing to receive a deceased organ, sometimes a loved one comes forward and offers to be a living donor. This raises the ethical question of whether a patient who is not eligible for deceased donor liver transplantation should be eligible for living donor liver transplantation. We compare living organ donation in kidney and liver transplantation and explore key ethical concepts of justice, fairness, and societal trust. Ultimately, because there is no alternative life-preserving therapy in end-stage liver disease, and because transplantation with a living donor organ does not involve removing a resource from the common pool of transplant organs, we argue that a standard of "slightly less benefit" than that required for deceased transplantation should be used to determine the acceptability of living donor liver transplantation.
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Affiliation(s)
- Sarah R Lieber
- University of North Carolina Hospitals Department of Gastroenterology and Hepatology, Chapel Hill, NC, United States.
| | - Thomas D Schiano
- Icahn School of Medicine at Mount Sinai Hospital, New York, NY, United States; Recanati/Miller Liver Transplantation Institute, New York, NY, United States
| | - Rosamond Rhodes
- Icahn School of Medicine at Mount Sinai Hospital, New York, NY, United States
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Haimerl M, Fuhrmann I, Poelsterl S, Fellner C, Nickel MD, Weigand K, Dahlke MH, Verloh N, Stroszczynski C, Wiggermann P. Gd-EOB-DTPA-enhanced T1 relaxometry for assessment of liver function determined by real-time 13C-methacetin breath test. Eur Radiol 2018. [PMID: 29532241 DOI: 10.1007/s00330-018-5337-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To determine whether liver function as determined by intravenous administration of 13C-methacetin and continuous real-time breath analysis can be estimated quantitatively from gadoxetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance (MR) relaxometry. METHODS Sixty-six patients underwent a 13C-methacetin breath test (13C-MBT) for evaluation of liver function and Gd-EOB-DTPA-enhanced T1-relaxometry at 3 T. A transverse 3D VIBE sequence with an inline T1 calculation based on variable flip angles was acquired prior to (T1 pre) and 20 min post-Gd-EOB-DTPA (T1 post) administration. The reduction rate of T1 relaxation time (rrT1) and T1 relaxation velocity index (∆R1) between pre- and post-contrast images was evaluated. 13C-MBT values were correlated with T1post, ∆R1 and rrT1, providing an MRI-based estimated 13C-MBT value. The interobserver reliability was assessed by determining the intraclass correlation coefficient (ICC). RESULTS Stratified by three different categories of 13C-MBT readouts, there was a constant increase of T1 post with increasing progression of diminished liver function (p ≤ 0.030) and a constant significant decrease of ∆R1 (p ≤ 0.025) and rrT1 (p < 0.018) with progression of liver damage as assessed by 13C-methacetin breath analysis. ICC for all T1 relaxation values and indices was excellent (> 0.88). A simple regression model showed a log-linear correlation of 13C-MBT values with T1post (r = 0.57; p < 0.001), ∆R1 (r = 0.59; p < 0.001) and rrT1 (r = 0.70; p < 0.001). CONCLUSION Liver function as determined using real-time 13C-methacetin breath analysis can be estimated quantitatively from Gd-EOB-DTPA-enhanced MR relaxometry. KEY POINTS • Gd-EOB-DTPA-enhanced T1 relaxometry quantifies liver function • Gd-EOB-DTPA-enhanced MR relaxometry may provide parameters for assessing liver function before surgery • Gd-EOB-DTPA-enhanced MR relaxometry may be useful for monitoring liver disease progression • Gd-EOB-DTPA-enhanced MR relaxometry has the potential to become a novel liver function index.
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Affiliation(s)
- Michael Haimerl
- Department of Radiology, University Hospital Regensburg, 93042, Regensburg, Germany.
| | - Irene Fuhrmann
- Department of Radiology, University Hospital Regensburg, 93042, Regensburg, Germany
| | - Stefanie Poelsterl
- Department of Radiology, University Hospital Regensburg, 93042, Regensburg, Germany
| | - Claudia Fellner
- Department of Radiology, University Hospital Regensburg, 93042, Regensburg, Germany
| | - Marcel D Nickel
- MR Applications Predevelopment, Siemens Healthcare GmbH, Erlangen, Germany
| | - Kilian Weigand
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | - Marc H Dahlke
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Niklas Verloh
- Department of Radiology, University Hospital Regensburg, 93042, Regensburg, Germany
| | | | - Philipp Wiggermann
- Department of Radiology, University Hospital Regensburg, 93042, Regensburg, Germany
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Abstract
Preoperative estimation of future remnant liver function is critical for major hepatic surgery to avoid postoperative morbidity and mortality. Among several liver function tests, the indocyanine green (ICG) clearance test is still the most popular dynamic method. The usefulness of ICG clearance test parameters, such as ICGR15, KICG, or PDRICG, has been reported by many investigators. The transcutaneous non-invasive pulse dye densitometry system has made the ICG clearance test more convenient and attractive, even in Western countries. The concept of future remnant KICG (rem KICG), which combines the functional aspect and the volumetric factor of the future remnant liver, seems ideal for determining the maximum extent of major hepatic resection that will not cause postoperative liver failure. For damaged livers with functional heterogeneity among the hepatic segments, fusion images combining technetium-99m-diethylenetriaminepentaacetic acid-galactosyl human serum albumin single photon emission computed tomography (99mTc-GSA SPECT) and X-ray CT are helpful to precisely estimate the functional reserve of the future remnant liver. Another technique for image-based liver function estimation, gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid(Gd-EOB)-enhanced magnetic resonance imaging, may be an ideal candidate for the preoperative determination of future remnant liver function. Using these methods effectively, morbidity and mortality after major hepatic resection could be reduced.
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Affiliation(s)
- Yuji Iimuro
- Department of Surgery, Hepato-Biliary-Pancreatic Disease Center, Yamanashi Prefectural Central Hospital, Yamanashi, Japan
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Rubin TM, Heyne K, Luchterhand A, Jan Bednarsch, W. R. Vondran F, Polychronidis G, Malinowski M, Nikolic A, Tautenhahn HM, Jara M, Wünsch T, Stockmann M, Friso Lock J. Kinetic validation of the LiMAx test during 10 000 intravenous
13
C-methacetin breath tests. J Breath Res 2017; 12:016005. [DOI: 10.1088/1752-7163/aa820b] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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39
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Post-reperfusion syndrome during orthotopic liver transplantation, which definition best predicts postoperative graft failure and recipient mortality? J Crit Care 2017; 41:156-160. [DOI: 10.1016/j.jcrc.2017.05.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 05/09/2017] [Accepted: 05/20/2017] [Indexed: 01/15/2023]
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40
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Liu S, Miao J, Shi X, Wu Y, Jiang C, Zhu X, Wu X, Ding Y, Xu Q. Risk Factors for Post-Transplant Death in Donation after Circulatory Death Liver Transplantation. J INVEST SURG 2017; 31:393-401. [PMID: 28829664 DOI: 10.1080/08941939.2017.1339152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE In spite of the increasing success of liver transplantation, there remains inevitable risk of postoperative complications, re-operations, and even death. Risk factors that correlate with post-transplant death have not been fully identified. MATERIALS AND METHODS We performed a retrospective analysis of 65 adults that received donation after circulatory death liver transplantation. Binary logistic regression and Cox's proportional hazards regression were employed to identify risk factors that associate with postoperative death and the length of survival period. RESULTS Twenty-two recipients (33.8%) deceased during 392.3 ± 45.6 days. The higher preoperative Child-Pugh score (p = .007), prolonged postoperative ICU stay (p = .02), and more postoperative complications (p = .0005) were observed in deceased patients. Advanced pathological staging (p = .02) with more common nerve invasion (p = .03), lymph node invasion (p = .02), and para-tumor satellite lesion (p = .01) were found in deceased group. The higher pre-transplant Child-Pugh score was a risk factor for post-transplant death (OR = 4.38, p = .011), and was correlated with reduced post-transplant survival period (OR = 0.35, p = .009). Nerve invasion was also a risk factor for post-transplant death (OR = 13.85, p = .014), although it failed to affect survival period. CONCLUSIONS Our study emphasizes the impact of recipient's pre-transplant liver function as well as pre-transplant nerve invasion by recipient's liver cancer cells on postoperative outcome and survival period in patients receiving liver transplantation.
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Affiliation(s)
- Song Liu
- a Department of Hepatobiliary Surgery, Nanjing Drum Tower Hospital , the Affiliated Hospital of Nanjing University Medical School , Nanjing , 210008 , China
| | - Ji Miao
- a Department of Hepatobiliary Surgery, Nanjing Drum Tower Hospital , the Affiliated Hospital of Nanjing University Medical School , Nanjing , 210008 , China
| | - Xiaolei Shi
- a Department of Hepatobiliary Surgery, Nanjing Drum Tower Hospital , the Affiliated Hospital of Nanjing University Medical School , Nanjing , 210008 , China
| | - Yafu Wu
- a Department of Hepatobiliary Surgery, Nanjing Drum Tower Hospital , the Affiliated Hospital of Nanjing University Medical School , Nanjing , 210008 , China
| | - Chunping Jiang
- a Department of Hepatobiliary Surgery, Nanjing Drum Tower Hospital , the Affiliated Hospital of Nanjing University Medical School , Nanjing , 210008 , China
| | - Xinhua Zhu
- a Department of Hepatobiliary Surgery, Nanjing Drum Tower Hospital , the Affiliated Hospital of Nanjing University Medical School , Nanjing , 210008 , China
| | - Xingyu Wu
- a Department of Hepatobiliary Surgery, Nanjing Drum Tower Hospital , the Affiliated Hospital of Nanjing University Medical School , Nanjing , 210008 , China
| | - Yitao Ding
- a Department of Hepatobiliary Surgery, Nanjing Drum Tower Hospital , the Affiliated Hospital of Nanjing University Medical School , Nanjing , 210008 , China
| | - Qingxiang Xu
- a Department of Hepatobiliary Surgery, Nanjing Drum Tower Hospital , the Affiliated Hospital of Nanjing University Medical School , Nanjing , 210008 , China
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Wicha SG, Frey OR, Roehr AC, Pratschke J, Stockmann M, Alraish R, Wuensch T, Kaffarnik M. Linezolid in liver failure: exploring the value of the maximal liver function capacity (LiMAx) test in a pharmacokinetic pilot study. Int J Antimicrob Agents 2017; 50:557-563. [PMID: 28711678 DOI: 10.1016/j.ijantimicag.2017.06.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 06/22/2017] [Accepted: 06/24/2017] [Indexed: 01/12/2023]
Abstract
Patients in the intensive care unit frequently require antibiotic treatment. Liver impairment poses substantial challenges for dose selection in these patients. The aim of the present pilot study was to assess the novel maximal liver function capacity (LiMAx test) in comparison with conventional liver function markers as covariates of drug clearance in liver failure using linezolid as a model drug. A total of 28 patients with different degrees of liver failure were recruited. LiMAx test as well as plasma, dialysate and urine sampling were performed under linezolid steady-state therapy (600 mg twice daily). NONMEM® was used for a pharmacometric analysis in which the different clearance routes of linezolid were elucidated. Linezolid pharmacokinetics was highly variable in patients with liver failure. The LiMAx score displayed the strongest association with non-renal clearance (CLnon-renal) [ = 4.46∙(body weight/57.9) 0.75∙(LiMAx/221.5)0.388 L/h], which reduced interindividual variability in CLnon-renal from 46.6% to 33.6%, thereby being superior to other common markers of liver function (international normalised ratio, gamma-glutaryl transferase, bilirubin, thrombocytes, alanine aminotransferase, aspartate aminotransferase). For LiMAx < 100 µg/kg/h, 64% of linezolid trough concentrations were above the recommended trough concentration of 8 mg/L, indicating the necessity of therapeutic drug monitoring in these patients. This is the first pilot application of the LiMAx test in a pharmacokinetic (PK) study demonstrating its potential to explain PK variability in linezolid clearance. Further studies with a larger patient collective and further drugs are highly warranted to guide dosing in patients with severe liver impairment.
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Affiliation(s)
- Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Bundesstr. 45, 20146 Hamburg, Germany.
| | - Otto R Frey
- Klinikum Heidenheim, Clinical Pharmacy, Schlosshaustraße 100, 89522 Heidenheim, Germany
| | - Anka C Roehr
- Klinikum Heidenheim, Clinical Pharmacy, Schlosshaustraße 100, 89522 Heidenheim, Germany
| | - Johann Pratschke
- Charité-Universitätsmedizin Berlin, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum Augustenburger Platz 1, 13353 Berlin, Germany
| | - Martin Stockmann
- Charité-Universitätsmedizin Berlin, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum Augustenburger Platz 1, 13353 Berlin, Germany
| | - Rawan Alraish
- Charité-Universitätsmedizin Berlin, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum Augustenburger Platz 1, 13353 Berlin, Germany
| | - Tilo Wuensch
- Charité-Universitätsmedizin Berlin, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum Augustenburger Platz 1, 13353 Berlin, Germany
| | - Magnus Kaffarnik
- Charité-Universitätsmedizin Berlin, Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum Augustenburger Platz 1, 13353 Berlin, Germany
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The postoperative Model for End stage Liver Disease score as a predictor of short-term outcome after transplantation of extended criteria donor livers. Eur J Gastroenterol Hepatol 2017; 29:716-722. [PMID: 28441690 DOI: 10.1097/meg.0000000000000851] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recently, the postoperative Model for End stage Liver Disease score (POPMELD) was suggested as a definition of postoperative graft dysfunction and a predictor of outcome after liver transplantation (LT). AIM The aim of the present study was to validate this concept in the context of extended criteria donor (ECD) organs. PATIENTS AND METHODS Single-center prospectively collected data (OPAL study/01/11-12/13) of 116 ECD LTs were utilized. For each recipient, the Model for End stage Liver Disease (MELD) score was calculated for 7 postoperative days (PODs). The ability of international normalized ratio, bilirubin, aspartate aminotransferase, Donor Risk Index, a recent definition of early allograft dysfunction, and the POPMELD was compared to predict 90-day graft loss. Predictive abilities were compared by receiver operating characteristic curves, sensitivity and specificity, and positive and negative predictive values. RESULTS The median Donor Risk Index was 1.8. In all, 60.3% of recipients were men [median age of 54 (23-68) years]. The median POD1-7 peak-aspartate aminotransferase value was 1052 (194-17 577) U/l. The rate of early allograft dysfunction was 22.4%. The 90-day graft survival was 89.7%. Out of possible predictors of the 90-day graft loss MELD on POD5 was the best predictor of outcome (area under the curve=0.84). A MELD score of 16 or more on POD5 predicted the 90-day graft loss with a specificity of 80.8%, a sensitivity of 81.8%, and a positive and negative predictive value of 31 and 97.7%. CONCLUSION A MELD score of 16 or more on POD5 is an excellent predictor of outcome in ECD donor LT. Routine evaluation of POPMELD scores might support clinical decision-making and should be reported routinely in clinical trials.
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Kaffarnik MF, Ahmadi N, Lock JF, Wuensch T, Pratschke J, Stockmann M, Malinowski M. Correlation between plasma endothelin-1 levels and severity of septic liver failure quantified by maximal liver function capacity (LiMAx test). A prospective study. PLoS One 2017; 12:e0178237. [PMID: 28542386 PMCID: PMC5441649 DOI: 10.1371/journal.pone.0178237] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 04/28/2017] [Indexed: 12/26/2022] Open
Abstract
Aim To investigate the relationship between the degree of liver dysfunction, quantified by maximal liver function capacity (LiMAx test) and endothelin-1, TNF-α and IL-6 in septic surgical patients. Methods 28 septic patients (8 female, 20 male, age range 35–80y) were prospectively investigated on a surgical intensive care unit. Liver function, defined by LiMAx test, and measurements of plasma levels of endothelin-1, TNF-α and IL-6 were carried out within the first 24 hours after onset of septic symptoms, followed by day 2, 5 and 10. Patients were divided into 2 groups (group A: LiMAx ≥100 μg/kg/h, moderate liver dysfunction; group B: LiMAx <100 μg/kg/h, severe liver dysfunction) for analysis and investigated regarding the correlation between endothelin-1 and the severity of liver failure, quantified by LiMAx test. Results Group B showed significant higher results for endothelin-1 than patients in group A (P = 0.01, d5; 0.02, d10). For TNF-α, group B revealed higher results than group A, with a significant difference on day 10 (P = 0.005). IL-6 showed a non-significant trend to higher results in group B. The Spearman's rank correlation coefficient revealed a significant correlation between LiMAx and endothelin-1 (-0.434; P <0.001), TNF-α (-0.515; P <0.001) and IL-6 (-0.590; P <0.001). Conclusions Sepsis-related hepatic dysfunction is associated with elevated plasma levels of endothelin-1, TNF-α and IL-6. Low LiMAx results combined with increased endothelin-1 and TNF-α and a favourable correlation between LiMAx and cytokine values support the findings of a crucial role of Endothelin-1 and TNF-α in development of septic liver failure.
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Affiliation(s)
- Magnus F. Kaffarnik
- Charité–Universitätsmedizin Berlin, Department of General, Visceral and Transplantation Surgery, Augustenburger Platz 1, Berlin, Germany
- * E-mail:
| | - Navid Ahmadi
- Charité–Universitätsmedizin Berlin, Department of General, Visceral and Transplantation Surgery, Augustenburger Platz 1, Berlin, Germany
| | - Johan F. Lock
- Charité–Universitätsmedizin Berlin, Department of General, Visceral and Transplantation Surgery, Augustenburger Platz 1, Berlin, Germany
- University Hospital of Wuerzburg, Department of General-, Visceral-, Vascular- and Paediatric Surgery, Wuerzburg, Germany
| | - Tilo Wuensch
- Charité–Universitätsmedizin Berlin, Department of General, Visceral and Transplantation Surgery, Augustenburger Platz 1, Berlin, Germany
| | - Johann Pratschke
- Charité–Universitätsmedizin Berlin, Department of General, Visceral and Transplantation Surgery, Augustenburger Platz 1, Berlin, Germany
| | - Martin Stockmann
- Charité–Universitätsmedizin Berlin, Department of General, Visceral and Transplantation Surgery, Augustenburger Platz 1, Berlin, Germany
| | - Maciej Malinowski
- Charité–Universitätsmedizin Berlin, Department of General, Visceral and Transplantation Surgery, Augustenburger Platz 1, Berlin, Germany
- University Hospital of Homburg, Department of General-, Visceral-, Vascular- and Paediatric Surgery, Homburg, Germany
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Yang QJ, Kluger M, Goryński K, Pawliszyn J, Bojko B, Yu AM, Noh K, Selzner M, Jerath A, McCluskey S, Pang KS, Wąsowicz M. Comparing early liver graft function from heart beating and living-donors: A pilot study aiming to identify new biomarkers of liver injury. Biopharm Drug Dispos 2017; 38:326-339. [DOI: 10.1002/bdd.2066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/28/2016] [Accepted: 01/16/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Qi Joy Yang
- Leslie Dan Faculty of Pharmacy; University of Toronto; Canada
| | - Michael Kluger
- Department of Anesthesia and Pain Management, Toronto General Hospital; University Health Network; Toronto Ontario Canada
| | - Krzysztof Goryński
- Department of Chemistry; University of Waterloo; Canada
- Department of Pharmacodynamics and Molecular Pharmacology, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz; Nicolaus Copernicus University in Toruń; Poland
| | | | - Barbara Bojko
- Department of Chemistry; University of Waterloo; Canada
- Department of Pharmacodynamics and Molecular Pharmacology, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz; Nicolaus Copernicus University in Toruń; Poland
| | - Ai-Ming Yu
- Departments of Biochemistry and Molecular Medicine; Comprehensive Cancer Center; UC Davis; Davis CA 95817 USA
| | - Keumhan Noh
- Leslie Dan Faculty of Pharmacy; University of Toronto; Canada
| | - Markus Selzner
- Department of Surgery, Toronto General Hospital; University Health Network; Toronto ON M5G 2N2 Canada
| | - Angela Jerath
- Department of Anesthesia and Pain Management, Toronto General Hospital; University Health Network; Toronto Ontario Canada
- Department of Anesthesia, Faculty of Medicine; University of Toronto; Toronto ON M5G 1E2 Canada
| | - Stuart McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital; University Health Network; Toronto Ontario Canada
- Department of Anesthesia, Faculty of Medicine; University of Toronto; Toronto ON M5G 1E2 Canada
| | - K. Sandy Pang
- Leslie Dan Faculty of Pharmacy; University of Toronto; Canada
| | - Marcin Wąsowicz
- Department of Anesthesia and Pain Management, Toronto General Hospital; University Health Network; Toronto Ontario Canada
- Department of Anesthesia, Faculty of Medicine; University of Toronto; Toronto ON M5G 1E2 Canada
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Postoperative Care of the Liver Transplant Recipient. ANESTHESIA AND PERIOPERATIVE CARE FOR ORGAN TRANSPLANTATION 2017. [PMCID: PMC7120127 DOI: 10.1007/978-1-4939-6377-5_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Irreversible Graft Failure Requiring 3 Repeated Liver Transplantations Combined With a 2-Stage Liver Transplantation: A Case Report. Transplant Proc 2016; 48:242-6. [PMID: 26915875 DOI: 10.1016/j.transproceed.2015.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 10/31/2015] [Accepted: 11/18/2015] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Although repeated liver transplantation (RLT) for irreversible graft failure is relatively rare, RLT is the only life-saving option available for a patient with failure of a previous liver transplant (LT). In cases in which failure of a previous LT is combined with TLS and exsanguination, waiting for organ allocation is not feasible and 2-stage liver transplantation (TSLT) is required. The aim of our case report was to describe the clinical management, including the criteria informing clinical decisions, for a patient who required 3 RLTs combined with TSLT. CASE A 55-year-old man was admitted with liver cirrhosis associated with hepatitis B and multiple hepatocellular carcinomas. LT was performed using an emergent deceased donor graft of marginal quality. The graft was unsuccessful, with the patient showing hemodynamic deterioration and primary nonfunction of the graft. A total hepatectomy, with temporary portocaval shunt, was performed, with a second transplantation performed 3 days later. The second graft was from a 71-year-old, non-heart-beating donor, which resulted in a second episode of primary nonfunction. A third transplantation was performed 4 days later. The patient progressively recovered with extensive rehabilitation. CONCLUSION We report the successful outcome for a patient requiring 3 RLTs, with TSLT used as a bridge between transplants to reduce the duration of the anhepatic state. In selected cases, the combination of RLT and TSLT can provide a chance of survival from life-threatening liver failure.
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Neves DB, Rusi MB, Diaz LGG, Salvalaggio P. Primary graft dysfunction of the liver: definitions, diagnostic criteria and risk factors. ACTA ACUST UNITED AC 2016; 14:567-572. [PMID: 27783749 DOI: 10.1590/s1679-45082016rw3585] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 04/09/2016] [Indexed: 12/11/2022]
Abstract
Primary graft dysfunction is a multifactorial syndrome with great impact on liver transplantation outcomes. This review article was based on studies published between January 1980 and June 2015 and retrieved from PubMed database using the following search terms: "primary graft dysfunction", "early allograft dysfunction", "primary non-function" and "liver transplantation". Graft dysfunction describes different grades of graft ischemia-reperfusion injury and can manifest as early allograft dysfunction or primary graft non-function, its most severe form. Donor-, surgery- and recipient-related factors have been associated with this syndrome. Primary graft dysfunction definition, diagnostic criteria and risk factors differ between studies. RESUMO A disfunção primária do enxerto hepático é uma síndrome multifatorial com grande impacto no resultado do transplante de fígado. Foi realizada uma ampla revisão da literatura, consultando a base de dados PubMed, em busca de estudos publicados entre janeiro de 1980 e junho de 2015. Os termos descritivos utilizados foram: "primary graft dysfunction", "early allograft dysfunction", "primary non-function" e "liver transplantation". A disfunção traduz graus diferentes da lesão de isquemia e reperfusão do órgão, e pode se manifestar como disfunção precoce ou, na forma mais grave, pelo não funcionamento primário do enxerto. Fatores relacionados ao doador, ao transplante e ao receptor contribuem para essa síndrome. Existem definições diferentes na literatura quanto ao diagnóstico e aos fatores de risco associados à disfunção primária.
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Affiliation(s)
- Douglas Bastos Neves
- Hospital Federal dos Servidores do Estado, Rio de Janeiro, RJ, Brazil; Hospital São Vicente de Paulo, Rio de Janeiro, RJ, Brazil.,Programa de Pós-graduação em Ciências da Saúde, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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48
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Monte da Silva AG, deA Roza Aguiar B, Chiavegato LD. Association Between Dyspnea and Severity of Liver Disease in Patients in the Pre-transplantation Period-A Pilot Study. Transplant Proc 2016; 48:2328-2332. [PMID: 27742290 DOI: 10.1016/j.transproceed.2016.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Liver transplantation is indicated at the end stage of chronic liver failure, and severity of disease will determine the precocity of this happening. At this stage, the presence of chronic dyspnea is one of several manifestations of progression of the disease, which leads the patient to inactivity. A rehabilitation program can positively influence the evolution of liver transplant recipients. The objective of this study was to establish an association between the perception of dyspnea and the severity of liver disease in patients at a single center of a Brazilian liver pre-transplantation clinic. METHODS Measurements were performed at a liver pre-transplantation clinic. The severity of liver disease was assessed with the use of the Model for End-Stage Liver Disease (MELD) score, and dyspnea was assessed with the use of a modified Medical Research Council scale of dyspnea (mMRC). RESULTS Men had a higher prevalence of viral hepatitis. Dyspnea was reported only during intense exercise. Duration of disease and MELD score showed medians of 49 months and 20, respectively. CONCLUSIONS We found no correlation between mMRC and the MELD score. In addition, no correlation was found between duration of disease and MELD score or mMRC.
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Affiliation(s)
| | | | - L D Chiavegato
- Universidade Federal de São Paulo, São Paulo, Brazil; Master's and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil.
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Bittencourt PL, Terra C, Parise ER, Farias AQ, Arroyo V, Fernandez J, Pereira G, Maubouisson LM, Andrade GM, Costa FGDB, Codes L, Andrade AR, Mattos AAD, Torres A, Couto F, Zyngier I. Intensive care management of patients with liver disease: proceedings of a single-topic conference sponsored by the Brazilian Society of Hepatology. ARQUIVOS DE GASTROENTEROLOGIA 2016; 52 Suppl 1:55-72. [PMID: 26959806 DOI: 10.1590/s0004-28032015000500004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Survival rates of critically ill patients with liver disease has sharply increased in recent years due to several improvements in the management of decompensated cirrhosis and acute liver failure. This is ascribed to the incorporation of evidence-based strategies from clinical trials aiming to reduce mortality. In order to discuss the cutting-edge evidence regarding critical care of patients with liver disease, a joint single topic conference was recently sponsored by the Brazilian Society of Hepatology in cooperation with the Brazilian Society of Intensive Care Medicine and the Brazilian Association for Organ Transplantation. This paper summarizes the proceedings of the aforementioned meeting and it is intended to guide intensive care physicians, gastroenterologists and hepatologists in the care management of patients with liver disease.
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Affiliation(s)
- Paulo Lisboa Bittencourt
- Hospital Português, Salvador, Brazil.,Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, BA, Brasil
| | - Carlos Terra
- Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, RJ, Brazil
| | | | - Alberto Queiroz Farias
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | | | | | - Gustavo Pereira
- Departamento de Gastroenterologia, Hospital Federal do Bonsucesso, Rio de Janeiro, RJ, Brasil
| | | | | | | | - Liana Codes
- Hospital Português, Salvador, Brazil.,Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, BA, Brasil
| | - Antônio Ricardo Andrade
- Hospital Português, Salvador, Brazil.,Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, BA, Brasil
| | | | - André Torres
- Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, RJ, Brazil
| | - Fernanda Couto
- Departamento de Gastroenterologia, Hospital Federal do Bonsucesso, Rio de Janeiro, RJ, Brasil
| | - Ivan Zyngier
- Departamento de Gastroenterologia, Hospital Federal do Bonsucesso, Rio de Janeiro, RJ, Brasil
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Bolondi G, Mocchegiani F, Montalti R, Nicolini D, Vivarelli M, De Pietri L. Predictive factors of short term outcome after liver transplantation: A review. World J Gastroenterol 2016; 22:5936-5949. [PMID: 27468188 PMCID: PMC4948266 DOI: 10.3748/wjg.v22.i26.5936] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 05/17/2016] [Accepted: 06/02/2016] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation represents a fundamental therapeutic solution to end-stage liver disease. The need for liver allografts has extended the set of criteria for organ acceptability, increasing the risk of adverse outcomes. Little is known about the early postoperative parameters that can be used as valid predictive indices for early graft function, retransplantation or surgical reintervention, secondary complications, long intensive care unit stay or death. In this review, we present state-of-the-art knowledge regarding the early post-transplantation tests and scores that can be applied during the first postoperative week to predict liver allograft function and patient outcome, thereby guiding the therapeutic and surgical decisions of the medical staff. Post-transplant clinical and biochemical assessment of patients through laboratory tests (platelet count, transaminase and bilirubin levels, INR, factor V, lactates, and Insulin Growth Factor 1) and scores (model for end-stage liver disease, acute physiology and chronic health evaluation, sequential organ failure assessment and model of early allograft function) have been reported to have good performance, but they only allow late evaluation of patient status and graft function, requiring days to be quantified. The indocyanine green plasma disappearance rate has long been used as a liver function assessment technique and has produced interesting, although not univocal, results when performed between the 1th and the 5th day after transplantation. The liver maximal function capacity test is a promising method of metabolic liver activity assessment, but its use is limited by economic cost and extrahepatic factors. To date, a consensual definition of early allograft dysfunction and the integration and validation of the above-mentioned techniques, through the development of numerically consistent multicentric prospective randomised trials, are necessary. The medical and surgical management of transplanted patients could be greatly improved by using clinically reliable tools to predict early graft function.
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