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Tang G, Zhang L, Xia L, Zhang J, Wei Z, Zhou R. Hypothermic oxygenated perfusion in liver transplantation: a meta-analysis of randomized controlled trials and matched studies. Int J Surg 2024; 110:464-477. [PMID: 37738017 PMCID: PMC10793758 DOI: 10.1097/js9.0000000000000784] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/10/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Hypothermic oxygenated machine perfusion (HOPE) is a novel organ-preservation technology designed to optimize organ quality. However, the effects of HOPE on morbidity and mortality after liver transplantation remain unclear. This meta-analysis evaluated the potential benefits of HOPE in liver transplantation. MATERIALS AND METHODS The Embase, Web of Science, PubMed, Cochrane Library, and Scopus databases were searched for articles published up to 15 June 2023 (updated on 12 August 2023). Mean differences (MDs), risk ratios (RRs), and 95% confidence intervals were calculated. RESULTS Eleven studies encompassing five randomized controlled trials and six matched studies were included, with a total of 1000 patients. HOPE did not reduce the incidence of major postoperative complications (RR 0.80), primary non-function (PNF) (RR 0.54), reperfusion syndrome (RR 0.92), hepatic artery thrombosis (RR 0.92), renal replacement therapy (RR 0.98), length of hospital stay (MD, -1.38 days), 1-year recipient death (RR 0.67), or intensive care unit stay (MD, 0.19 days) after liver transplantation. HOPE reduced the incidence of biliary complications (RR 0.74), non-anastomotic biliary strictures (NAS) (RR 0.34), early allograft dysfunction (EAD) (RR 0.54), and acute rejection (RR 0.54). In addition, HOPE improved the retransplantation (RR 0.42) and 1-year graft loss rates (RR 0.38). CONCLUSIONS Compared with static cold storage (SCS), HOPE can reduce the incidence of biliary complications, NAS, EAD, and acute rejection and retransplantation rate after liver transplantation and improve the 1-year graft loss rate. These findings suggest that HOPE, when compared to SCS, can contribute to minimizing complications and enhancing graft survival in liver transplantation. Further research is needed to investigate long-term outcomes and confirm the promising advantages of HOPE in liver transplantation settings.
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Affiliation(s)
- Gang Tang
- Biliary Surgical Department of West China Hospital
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | | | - Lingying Xia
- Biliary Surgical Department of West China Hospital
- Center for Translational Medicine, West China Second University Hospital, Sichuan University, Chengdu, Sichuan
| | - Jie Zhang
- Biliary Surgical Department of West China Hospital
| | - Zhengqiang Wei
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
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2
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Vernuccio F, Mercante I, Tong XX, Crimì F, Cillo U, Quaia E. Biliary complications after liver transplantation: A computed tomography and magnetic resonance imaging pictorial review. World J Gastroenterol 2023; 29:3257-3268. [PMID: 37377585 PMCID: PMC10292145 DOI: 10.3748/wjg.v29.i21.3257] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/23/2023] [Accepted: 04/27/2023] [Indexed: 06/01/2023] Open
Abstract
Biliary complications are the most common complications after liver transplantation. Computed tomography (CT) and magnetic resonance imaging (MRI) are cornerstones for timely diagnosis of biliary complications after liver transplantation. The diagnosis of these complications by CT and MRI requires expertise, mainly with respect to identifying subtle early signs to avoid missed or incorrect diagnoses. For example, biliary strictures may be misdiagnosed on MRI due to size mismatch of the common ducts of the donor and recipient, postoperative edema, pneumobilia, or susceptibility artifacts caused by surgical clips. Proper and prompt diagnosis of biliary complications after transplantation allows the timely initiation of appropriate management. The aim of this pictorial review is to illustrate various CT and MRI findings related to biliary complications after liver transplantation, based on time of presentation after surgery and frequency of occurrence.
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Affiliation(s)
- Federica Vernuccio
- Department of Radiology, University Hospital of Padova, Padova 35128, Italy
| | - Irene Mercante
- Department of Radiology-DIMED, University of Padova, Padova 35128, Italy
| | - Xiao-Xiao Tong
- Department of Radiology-DIMED, University of Padova, Padova 35128, Italy
| | - Filippo Crimì
- Department of Radiology-DIMED, University of Padova, Padova 35128, Italy
| | - Umberto Cillo
- Department of Surgery, Hepatobiliary Surgery and Liver Transplant Center, Oncology and Gastroenterology (DISCOG), University of Padova, Padova 35128, Italy
| | - Emilio Quaia
- Department of Radiology-DIMED, University of Padova, Padova 35128, Italy
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Vincenzi P, Gaynor JJ, Chen LJ, Figueiro J, Morsi M, Selvaggi G, Tekin A, Vianna R, Ciancio G. No Benefit of Prophylactic Surgical Drainage in Combined Liver and Kidney Transplantation: Our Experience and Review of the Literature. Front Surg 2021; 8:690436. [PMID: 34322515 PMCID: PMC8311022 DOI: 10.3389/fsurg.2021.690436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/08/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Contrasting results have emerged from limited studies investigating the role of prophylactic surgical drainage in preventing wound morbidity after liver and kidney transplantation. This retrospective study analyzes the use of surgical drain and the incidence of wound complications in combined liver and kidney transplantation (CLKTx). Methods: A total of 55 patients aged ≥18 years were divided into two groups: the drain group (D) (n = 35) and the drain-free group (DF) (n = 20). Discretion to place a drain was based exclusively on surgeon preference. All deceased donor kidneys were connected to the LifePort Renal Preservation Machine® prior to transplantation, in both simultaneous and delayed technique of implantation of the renal allograft. The primary outcome was the development of superficial/deep wound complications during the study follow-up. Secondary outcomes included the development of delayed graft function (DGF) of the transplanted kidney, primary non-function (PNF) and early allograft dysfunction (EAD) of the transplanted liver, graft failure, graft and patient survival, overall post-operative morbidity rate and length of hospital stay. Results: With a median follow-up of 14.4 months after transplant, no difference in the incidence of superficial/deep wound complications, except for hematomas, in collections size, intervention rate, PNF, EAD, graft failure and patient survival, was observed between the 2 groups. Significantly lower level of platelets, higher INR values, DGF, morbidity rates and length of hospital stay were reported post-operatively in the D group. Pre-operative hypoalbuminemia and longer CIT were included in the propensity score for receiving a drain and were associated with a significantly higher rate of developing a hematoma post-transplant. Conclusions: Absence of the surgical drain did not appear to adversely affect wound morbidity compared to the prophylactic use of drains in renal transplant patients during CLKTx.
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Affiliation(s)
- Paolo Vincenzi
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States.,Division of Liver and Intestinal Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Jeffrey J Gaynor
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Linda J Chen
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Jose Figueiro
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Mahmoud Morsi
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States.,Division of Liver and Intestinal Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Gennaro Selvaggi
- Division of Liver and Intestinal Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Akin Tekin
- Division of Liver and Intestinal Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Rodrigo Vianna
- Division of Liver and Intestinal Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Gaetano Ciancio
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States.,Department of Urology, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
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Orman ES, Johnson AW, Ghabril M, Sachs GA. Hospice care for end stage liver disease in the United States. Expert Rev Gastroenterol Hepatol 2021; 15:797-809. [PMID: 33599185 PMCID: PMC8282639 DOI: 10.1080/17474124.2021.1892487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Patients with end-stage liver disease (ESLD) have impaired physical, psychological, and social functions, which can diminish patient quality of life, burden family caregivers, and increase health-care utilization. For those with a life expectancy of less than six months, these impairments and their downstream effects can be addressed effectively through high-quality hospice care, delivered by multidisciplinary teams and focused on the physical, emotional, social, and spiritual wellbeing of patients and caregivers, with a goal of improving quality of life. AREAS COVERED In this review, we examine the evidence supporting hospice for ESLD, we compare this evidence to that supporting hospice more broadly, and we identify potential criteria that may be useful in determining hospice appropriateness. EXPERT OPINION Despite the potential for hospice to improve care for those at the end of life, it is underutilized for patients with ESLD. Increasing the appropriate utilization of hospice for ESLD requires a better understanding of patient eligibility, which can be based on predictors of high short-term mortality and liver transplant ineligibility. Such hospice criteria should be data-driven and should accommodate the uncertainty faced by patients and physicians.
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Affiliation(s)
- Eric S. Orman
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine,Corresponding author: Eric S. Orman, Address: Division of Gastroenterology & Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN 46202,
| | - Amy W. Johnson
- Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine
| | - Marwan Ghabril
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine
| | - Greg A. Sachs
- Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine,Indiana University Center for Aging Research, Regenstrief Institute, Inc
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5
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Postoperative Trends and Prognostic Values of Inflammatory and Nutritional Biomarkers after Liver Transplantation for Hepatocellular Carcinoma. Cancers (Basel) 2021; 13:cancers13030513. [PMID: 33572776 PMCID: PMC7866292 DOI: 10.3390/cancers13030513] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/24/2021] [Accepted: 01/26/2021] [Indexed: 02/08/2023] Open
Abstract
Simple Summary Inflammatory biomarkers have a strong prognostic value in surgically treated patients with hepatocellular carcinoma (HCC), but the underlying pathogenic mechanism has not been completely clarified. Conversely, nutritional biomarkers predict the outcomes after hepatic resection for HCC but not after liver transplantation (LT). Indeed, the impact of LT on the recipient’s nutritional status is heterogeneous, while the data on the patient’s outcome after LT in terms of inflammatory status are limited. Therefore, to address these unsolved questions, we conducted a retrospective analysis on 324 HCC patients treated with LT, exploring the postoperative trend up to 1 year post-LT and the prognostic value of the Platelet-to-Lymphocyte Ratio (PLR), Neutrophil-to-Lymphocyte Ratio (NLR), Controlling Nutritional Status (CONUT), Prognostic Nutritional Index (PNI). It was found that at 1 year post-LT, the nutritional status of liver-transplanted HCC patients significantly improved while their inflammatory state tended to persist. Consequently, post-LT PLR and NLR maintained a prognostic value for LT outcome while post-LT CONUT and PNI acquired it. Abstract Preoperative inflammatory biomarkers such as the Platelet-to-Lymphocyte Ratio (PLR) and the Neutrophil-to-Lymphocyte Ratio (NLR) strongly predict the outcome in surgically treated patients with hepatocellular carcinoma (HCC), while nutritional biomarkers such as the Controlling Nutritional Status (CONUT) and the Prognostic Nutritional Index (PNI) show an analogue prognostic value in hepatic resection (HR) but not in liver transplant (LT) cases. Data on the impact of LT on the inflammatory and nutritional/metabolic function are heterogeneous. Therefore, we investigated the post-LT trend of these biomarkers up to postoperative month (POM) 12 in 324 HCC patients treated with LT. Inflammatory biomarkers peaked in the early post-LT period but at POM 3 leveled off at values similar (NLR) or higher (PLR) than pre-LT ones. CONUT and PNI worsened in the early post-LT period, but at POM 3 they stabilized at significantly better values than pre-LT. In LT recipients with an overall survival >1 year and no evidence of early HCC recurrence, 1 year post-LT NLR and PNI independently predicted patient overall survival, while 1 year post-LT PLR independently predicted late tumor recurrence. In conclusion, at 1 year post-LT, the nutritional status of liver-transplanted HCC patients significantly improved while their inflammatory state tended to persist. Consequently, post-LT PLR and NLR maintained a prognostic value for LT outcome while post-LT CONUT and PNI acquired it.
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6
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Wiering L, Sponholz F, Brandl A, Dziodzio T, Jara M, Dargie R, Eurich D, Schmelzle M, Sauer IM, Aigner F, Kotsch K, Pratschke J, Öllinger R, Ritschl PV. Perioperative Pleural Drainage in Liver Transplantation: A Retrospective Analysis from a High-Volume Liver Transplant Center. Ann Transplant 2020; 25:e918456. [PMID: 31949125 PMCID: PMC6988474 DOI: 10.12659/aot.918456] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Pleural effusions represent a common complication after liver transplantation (LT) and chest drain (CD) placement is frequently necessary. MATERIAL AND METHODS In this retrospective cohort study, adult LT recipients between 2009 and 2016 were analyzed for pleural effusion formation and its treatment within the first 10 postoperative days. The aim of the study was to compare different settings of CD placement with regard to intervention-related complications. RESULTS Overall, 597 patients met the inclusion criteria, of which 361 patients (60.5%) received at least 1 CD within the study period. Patients with a MELD >25 were more frequently affected (75.7% versus 56.0%, P<0.001). Typically, CDs were placed in the intensive care unit (ICU) (66.8%) or in the operating room (14.1% during LT, 11.5% in the context of reoperations). In total, 97.0% of the patients received a right-sided CD, presumably caused by local irritations. Approximately one-third (35.4%) of ICU-patients required pre-interventional optimization of coagulation. Of the 361 patients receiving a CD, 15 patients (4.2%) suffered a post-interventional hemorrhage and 6 patients (1.4%) had a pneumothorax requiring further treatment. Less complications were observed when the CD was performed in the operating room compared to the ICU: 1 out 127 patients (0.8%) versus 20 out of 332 patients (6.0%); P=0.016. CONCLUSIONS CD placement occurring in the operating room was associated with fewer complications in contrast to placement occurring in the ICU. Planned CD placement in the course of surgery might be favorable in high-risk patients.
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Affiliation(s)
- Leke Wiering
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Felix Sponholz
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Andreas Brandl
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Tomasz Dziodzio
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Maximilian Jara
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Richard Dargie
- Division of Emergency and Acute Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dennis Eurich
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Moritz Schmelzle
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Igor M Sauer
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Felix Aigner
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Katja Kotsch
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Robert Öllinger
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Paul Viktor Ritschl
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,BIH Charité Clinician Scientist Program, Berlin Institute of Health (BIH), Berlin, Germany
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7
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Zhu M, Wang J, Wang Q, Xie K, Wang M, Qian C, Deng Y, Han L, Gao Y, Ni Z, Xia Q, Gu L. The Incidence and Risk Factors of Low Oxygenation After Orthotropic Liver Transplantation. Ann Transplant 2019; 24:139-146. [PMID: 30858349 PMCID: PMC6429984 DOI: 10.12659/aot.913716] [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] [Indexed: 11/22/2022] Open
Abstract
Background This study was designed to observe incidence and risk factors of low oxygenation after orthotropic liver transplantation (OLT). Material/Methods We retrospectively evaluated all adult patients who underwent living-donor OLT between January 1, 2017 and December 31, 2017. Postoperative low oxygenation was defined as PaO2/FiO2 <300 mmHg within 24 hours after surgery. Early acute kidney injury (AKI) after OLT was also defined when AKI was happened with 24 hours after operative. Results A total of 301 patients, aged 50.35±10.29 years were enrolled. Of these patients, 100 patients (33.2%) suffered postoperative low oxygenation (PaO2/FiO2=251.80±35.84). Compared with the normal oxygenation group, body mass index (BMI) (24.48±3.53 versus 23.1±3.27 kg/m2, P=0.001), preoperative hemoglobin (115.79±29.27 versus 111.52±29.80 g/L, P=0.033), preoperative MELD (22.25±6.54 versus 20.24±5.74, P=0.008), and intraoperative urinary volume (1.25 [0.76, 1.89] versus 2.04 [1.49, 3.68] mL/kg/h, P=0.003) were higher in low oxygenation group. There were more cases of earlier AKIs that occurred after OLT in low oxygenation patients than that in normal group (47% versus 23.4%, P<0.001). Logistic analysis showed that the preoperative BMI (hazard ration [HR]=1.107, [1.010, 1.212], P=0.029) and early AKI after OLT (HR=2.115, [1.161, 3.855], P=0.014) were independent risk factors for postoperative low oxygenation. Conclusions The incidence of postoperative low oxygenation after liver transplantation in adults was 33.2%. BMI and early AKI after OLT were correlated with postoperative hypoxemia.
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Affiliation(s)
- Mingli Zhu
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (mainland)
| | - Jiemin Wang
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (mainland)
| | - Qiaoling Wang
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (mainland)
| | - Kewei Xie
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (mainland)
| | - Minzhou Wang
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (mainland)
| | - Cheng Qian
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (mainland)
| | - Yuxiao Deng
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (mainland)
| | - Longzhi Han
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (mainland)
| | - Yuan Gao
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (mainland)
| | - Zhaohui Ni
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (mainland)
| | - Qiang Xia
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (mainland)
| | - Leyi Gu
- Department of Nephrology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China (mainland)
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Jayant K, Reccia I, Virdis F, Shapiro AMJ. Systematic Review and Meta-Analysis on the Impact of Thrombolytic Therapy in Liver Transplantation Following Donation after Circulatory Death. J Clin Med 2018; 7:jcm7110425. [PMID: 30413051 PMCID: PMC6262573 DOI: 10.3390/jcm7110425] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/02/2018] [Accepted: 11/06/2018] [Indexed: 02/06/2023] Open
Abstract
Aim: The livers from DCD (donation after cardiac death) donations are often envisaged as a possible option to bridge the gap between the availability and increasing demand of organs for liver transplantation. However, DCD livers possess a heightened risk for complications and represent a formidable management challenge. The aim of this study was to evaluate the effects of thrombolytic flush in DCD liver transplantation. Methods: An extensive search of the literature database was made on MEDLINE, EMBASE, Cochrane, Crossref, Scopus databases, and clinical trial registry on 20 September 2018 to assess the role of thrombolytic tissue plasminogen activator (tPA) flush in DCD liver transplantation. Results: A total of four studies with 249 patients in the tPA group and 178 patients in the non-tPA group were included. The pooled data revealed a significant decrease in ischemic-type biliary lesions (ITBLs) (P = 0.04), re-transplantation rate (P = 0.0001), and no increased requirement of blood transfusion (P = 0.16) with a better one year graft survival (P = 0.02). Conclusions: To recapitulate, tPA in DCD liver transplantation decreased the incidence of ITBLs, re-transplantation and markedly improved 1-year graft survival, without any increased risk for blood transfusion, hence it has potential to expand the boundaries of DCD liver transplantation.
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Affiliation(s)
- Kumar Jayant
- Department of Surgery and Cancer, Imperial College London, London W12 OHS, UK.
| | - Isabella Reccia
- Department of Surgery and Cancer, Imperial College London, London W12 OHS, UK.
| | | | - A M James Shapiro
- Department of Surgery, University of Alberta, Edmonton, AB T6G 2B7, Canada.
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9
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N-Acetylcysteine inhalation improves pulmonary function in patients received liver transplantation. Biosci Rep 2018; 38:BSR20180858. [PMID: 30217943 PMCID: PMC6165840 DOI: 10.1042/bsr20180858] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 09/02/2018] [Accepted: 09/12/2018] [Indexed: 02/08/2023] Open
Abstract
Postoperative pulmonary complications (PPCs) following orthotopic liver transplantation (OLT) are associated with high morbidity and mortality rates. The effect of N-acetylcysteine (NAC) inhalation on the incidence of PPCs and the outcomes of patients undergoing OLT is unknown. This prospective randomized controlled clinical trial was conducted to investigate the effect of NAC inhalation during OLT on PPCs. Sixty patients were randomly assigned to the NAC group (n = 30) or the control group (n = 30) to receive inhaled NAC or sterilized water, respectively, for 30 min before surgery and 3 h after reperfusion. The incidence of early PPCs and outcomes including survival rate were assessed. Biomarkers including tumor necrosis factor (TNF)-α, interleukin (IL)-8, Clara cell secretory protein (CC16), intercellular adhesion molecule (ICAM)-1, and superoxide dismutase (SOD) were measured in exhaled breath condensate (EBC) at T1 (before surgery) and T2 (at the end of operation) as well as in serum at T1, T2, T3 (12 h after operation), and T4 (24 h after operation). A total of 42 patients (20 in the NAC group and 22 in the control group) were enrolled in the final analysis. Atomization inhaled NAC significantly reduced the incidence of PPCs after OLT. The levels of TNF-α, IL-8, CC16, and ICAM-1 in EBC were significantly lower, and SOD activity was higher, at T2 in the NAC group; similar data were found in serum at T2, T3, and T4. In summary, perioperative NAC inhalation may reduce the incidence of PPCs and improve patient outcomes after OLT.
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Abstract
Since 1988 nearly 150,000 liver transplants have been performed in the United States. Over the past 3 decades the indications for liver transplant have changed from end-stage liver disease from alcohol and cholestatic liver diseases to hepatitis C and most recently nonalcoholic fatty liver disease. Liver transplant recipients are living longer with 10-year survival rates exceeding 60%. Gastroenterologists are likely to encounter or consult on postliver transplant recipients as they live longer and seek care closer to home. Complications after liver transplant are related to immunosuppression, malignancy, recurrent disease, and conditions associated with metabolic syndrome. This review will discuss postliver transplant care and complications in liver transplant recipients.
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Affiliation(s)
- Mark W Russo
- Division of Hepatology, Carolinas HealthCare System, Charlotte, NC
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11
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Posner AD, Sultan ST, Zaghloul NA, Twaddell WS, Bruno DA, Hanish SI, Hutson WR, Hebert L, Barth RN, LaMattina JC. Resolution of donor non-alcoholic fatty liver disease following liver transplantation. Clin Transplant 2017. [PMID: 28636211 DOI: 10.1111/ctr.13032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Transplant surgeons conventionally select against livers displaying high degrees (>30%) of macrosteatosis (MaS), out of concern for primary non-function or severe graft dysfunction. As such, there is relatively limited experience with such livers, and the natural history remains incompletely characterized. We present our experience of transplanted livers with high degrees of MaS and microsteatosis (MiS), with a focus on the histopathologic and clinical outcomes. METHODS Twenty-nine cases were identified with liver biopsies available from both the donor and the corresponding liver transplant recipient. Donor liver biopsies displayed either MaS or MiS ≥15%, while all recipients received postoperative liver biopsies for cause. RESULTS The mean donor MaS and MiS were 15.6% (range 0%-60%) and 41.3% (7.5%-97.5%), respectively. MaS decreased significantly from donor (M=15.6%) to recipient postoperative biopsies (M=0.86%), P<.001. Similarly, MiS decreased significantly from donor biopsies (M=41.3%) to recipient postoperative biopsies (M=1.8%), P<.001. At a median of 68 days postoperatively (range 4-384), full resolution of MaS and MiS was observed in 27 of 29 recipients. CONCLUSIONS High degrees of MaS and MiS in donor livers resolve in recipients following liver transplantation. Further insight into the mechanisms responsible for treating fatty liver diseases could translate into therapeutic targets.
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Affiliation(s)
- Andrew D Posner
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Samuel T Sultan
- Division of Transplantation, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | - David A Bruno
- Division of Transplantation, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Steven I Hanish
- Division of Transplantation, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Laci Hebert
- Division of Transplantation, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rolf N Barth
- Division of Transplantation, University of Maryland School of Medicine, Baltimore, MD, USA
| | - John C LaMattina
- Division of Transplantation, University of Maryland School of Medicine, Baltimore, MD, USA
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12
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Surgical Site Infections After Liver Transplantation: Prospective Surveillance and Evaluation of 250 Transplant Recipients in Canada. Infect Control Hosp Epidemiol 2017; 38:1084-1090. [DOI: 10.1017/ice.2017.131] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVETo evaluate the incidence of surgical-site infections (SSIs) in a cohort of liver transplant recipients and to assess risk factors predisposing patients to these infections.DESIGNProspective observational cohort study.SETTINGSingle transplant center in Canada.PATIENTSPatients who underwent liver transplantation between February 2011 and August 2014.METHODSMultivariate logistic regression was used to identify independent risk factors for SSIs in liver transplant patients.RESULTSWe enrolled 250 liver transplant recipients. The recipients’ median age at the time of transplantation was 56 years (range, 19–70 years), and 166 patients (66.4%) were male. Moreover, 47 SSIs were documented in 43 patients (17.2%). Organ-space, superficial, and deep SSIs were noted in 29, 7, and 3 patients, respectively. In addition, 2 patients developed superficial and organ-space SSIs, and another 2 patients were found to have deep as well as organ-space infections. In total, we identified 33 organ-space SSIs (70.2%), 9 superficial SSIs (19.1%), and 5 deep SSIs (10.6%). Factors predictive of SSIs by multivariate analysis were duct-to-duct anastomosis (odds ratio [OR], 3.88; 95% CI, 1.85–8.13; P<.001) and dialysis (OR, 3.57; 95% CI, 1.02–12.50; P=.046). Of the 66 organisms isolated in both deep and organ-space SSIs, 55 (83%) were resistant to cefazolin.CONCLUSIONSOrgan-space SSIs are a common complication after liver transplantation. Duct-to-duct anastomosis and dialysis were independent risk factors associated with SSIs. Appropriate perioperative prophylaxis targeting patients with duct-to-duct anastomosis and dialysis while simultaneously providing optimum coverage for the potential pathogens causing SSIs is warranted.Infect Control Hosp Epidemiol 2017;38:1084–1090
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13
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Abstract
Indications for liver transplant have been extended, and older and sicker patients are undergoing transplantation. Infectious, malignant, and cardiovascular diseases account for the most posttransplant deaths. Cirrhotic patients can develop heart disease through systemic diseases affecting the heart and the liver, cirrhosis-specific heart disease, or common cardiovascular. No single factor can predict posttransplant cardiovascular complications. Patients with history of cardiovascular disease, and specific abnormalities on echocardiography, electrocardiography, or serum markers of heart disease seem to be at increased risk of complications. Pretransplant cardiovascular evaluation is essential to detecting these risk factors so their effects can be mitigated through appropriate intervention.
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14
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Wiesen P, Massion PB, Joris J, Detry O, Damas P. Incidence and risk factors for early renal dysfunction after liver transplantation. World J Transplant 2016; 6:220-232. [PMID: 27011921 PMCID: PMC4801799 DOI: 10.5500/wjt.v6.i1.220] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 10/20/2015] [Accepted: 12/18/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine renal dysfunction post liver transplantation, its incidence and risk factors in patients from a Belgian University Hospital.
METHODS: Orthotopic liver transplantations performed from January 2006 until September 2012 were retrospectively reviewed (n = 187). Patients with no renal replacement therapy (RRT) before transplantation were classified into four groups according to their highest creatinine plasma level during the first postoperative week. The first group had a peak creatinine level below 12 mg/L, the second group between 12 and 20 mg/L, the third group between 20 and 35 mg/L, and the fourth above 35 mg/L. In addition, patients who needed RRT during the first week after transplantation were also classified into the fourth group. Perioperative parameters were recorded as risk factors, namely age, sex, body mass index (BMI), length of preoperative hospital stay, prior bacterial infection within one month, preoperative ascites, preoperative treatment with β-blocker, angiotensin-converting enzyme inhibitor or non steroidal anti-inflammatory drugs, preoperative creatinine and bilirubin levels, donor status (cardiac death or brain death), postoperative lactate level, need for intraoperative vasopressive drugs, surgical revision, mechanical ventilation for more than 24 h, postoperative bilirubin and transaminase peak levels, postoperative hemoglobin level, amount of perioperative blood transfusions and type of immunosuppression. Univariate and multivariate analysis were performed using logistic ordinal regression method. Post hoc analysis of the hemostatic agent used was also done.
RESULTS: There were 78 patients in group 1 (41.7%), 46 in group 2 (24.6%), 38 in group 3 (20.3%) and 25 in group 4 (13.4%). Twenty patients required RRT: 13 (7%) during the first week after transplantation. Using univariate analysis, the severity of renal dysfunction was correlated with presence of ascites and prior bacterial infection, preoperative bilirubin, urea and creatinine level, need for surgical revision, use of vasopressor, postoperative mechanical ventilation, postoperative bilirubin and urea, aspartate aminotransferase (ASAT), and hemoglobin levels and the need for transfusion. The multivariate analysis showed that BMI (OR = 1.1, P = 0.004), preoperative creatinine level (OR = 11.1, P < 0.0001), use of vasopressor (OR = 3.31, P = 0.0002), maximal postoperative bilirubin level (OR = 1.44, P = 0.044) and minimal postoperative hemoglobin level (OR = 0.059, P = 0.0005) were independent predictors of early post-liver transplantation renal dysfunction. Neither donor status nor ASAT levels had significant impact on early postoperative renal dysfunction in multivariate analysis. Absence of renal dysfunction (group 1) was also predicted by the intraoperative hemostatic agent used, independently of the extent of bleeding and of the preoperative creatinine level.
CONCLUSION: More than half of receivers experienced some degree of early renal dysfunction after liver transplantation. Main predictors were preoperative renal dysfunction, postoperative anemia and vasopressor requirement.
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15
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Atar F, Gedik E, Kaplan Ş, Zeyneloğlu P, Pirat A, Haberal M. Late Intensive Care Unit Admission in Liver Transplant Recipients: 10-Year Experience. EXP CLIN TRANSPLANT 2015; 13 Suppl 3:15-21. [PMID: 26640903 DOI: 10.6002/ect.tdtd2015.o10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES We evaluated late intensive care unit admission in liver transplant recipients to identify incidences and causes of acute respiratory failure in the postoperative period and to compare these results with results in patients who did not have acute respiratory failure. MATERIALS AND METHODS We retrospectively screened the data of 173 consecutive adult liver transplant recipients from January 2005 through March 2015 to identify patients with late admission (> 30 d posttransplant) to an intensive care unit. Patients were divided into 2 groups: patients with and without acute respiratory failure. Acute respiratory failure was defined as severe dyspnea, respiratory distress, decreased oxygen saturation, hypoxemia or hypercapnia on room air, or need for noninvasive or invasive mechanical ventilation. Demographic, laboratory, clinical, and respiratory data were collected. Model for End-Stage Liver Disease, Acute Physiology and Chronic Health Evaluation II, and Sequential Organ Failure Assessment scores; lengths of intensive care unit and hospital stays; and hospital mortality were assessed. RESULTS Among 173 patients, 37 (21.4%) were admitted to an intensive care unit, including 22 (59.5%) with acute respiratory failure. The leading cause of acute respiratory failure was pneumonia (n = 19, 86.4%). Patients with acute respiratory failure had significantly lower levels of albumin before intensive care unit admission (P = .003). In patients with acute respiratory failure, severe sepsis and septic shock were more frequently observed and tracheotomy was more frequently performed (P = .041). CONCLUSIONS Acute respiratory failure developed in 59.5% of liver transplant recipients with late intensive care unit admission. The leading cause was pneumonia, with this group of patients having higher requirements for invasive mechanical ventilation and tracheotomy, longer stays in an intensive care unit, and higher mortality.
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Affiliation(s)
- Funda Atar
- From the Department of Anesthesiology and Reanimation, Başkent University Faculty of Medicine, Ankara, Turkey
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16
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Delayed primary closure and the incidence of surgical complications in pediatric liver transplant recipients. J Pediatr Surg 2015; 50:2137-40. [PMID: 26388124 DOI: 10.1016/j.jpedsurg.2015.08.045] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 08/24/2015] [Indexed: 01/02/2023]
Abstract
PURPOSE The purpose of this study was to analyze the general surgical complications in pediatric liver transplant recipients and the safety of delayed primary closure at a single tertiary center. METHODS A retrospective review of all liver transplant recipients between April 1986 and May 2014 was performed. All general and gastrointestinal complications were recorded and analyzed. The incidence and risk of these complications were compared between children who had a primary versus those who had a delayed closure, with or without the use of Surgisis®, of their abdomen. RESULTS 242 patients underwent 281 liver transplants. The median age of the children was 31months. Whole (77), reduced size (91), split (96), and living related grafts (17) were used. General surgical complications were observed in 33 cases (11.7%). 135 cases underwent delayed primary closure (DPC) of their abdomen, 35 with Surgisis®. Patients with biliary atresia had a higher rate (4.6%) of bowel perforation (p=0.013). The majority of complications occurred within 3months of transplantation. CONCLUSION General surgical complications postpediatric liver transplantation were common but usually not life threatening. Delayed primary closure was safe, had no significant long-term issues, and was not associated with higher incidence of wound related complications.
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17
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Fosby B, Melum E, Bjøro K, Bennet W, Rasmussen A, Andersen IM, Castedal M, Olausson M, Wibeck C, Gotlieb M, Gjertsen H, Toivonen L, Foss S, Makisalo H, Nordin A, Sanengen T, Bergquist A, Larsson ME, Soderdahl G, Nowak G, Boberg KM, Isoniemi H, Keiding S, Foss A, Line PD, Friman S, Schrumpf E, Ericzon BG, Höckerstedt K, Karlsen TH. Liver transplantation in the Nordic countries - An intention to treat and post-transplant analysis from The Nordic Liver Transplant Registry 1982-2013. Scand J Gastroenterol 2015; 50:797-808. [PMID: 25959101 PMCID: PMC4487534 DOI: 10.3109/00365521.2015.1036359] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIM AND BACKGROUND The Nordic Liver Transplant Registry (NLTR) accounts for all liver transplants performed in the Nordic countries since the start of the transplant program in 1982. Due to short waiting times, donor liver allocation has been made without considerations of the model of end-stage liver disease (MELD) score. We aimed to summarize key outcome measures and developments for the activity up to December 2013. MATERIALS AND METHODS The registry is integrated with the operational waiting-list and liver allocation system of Scandiatransplant (www.scandiatransplant.org) and accounted at the end of 2013 for 6019 patients out of whom 5198 were transplanted. Data for recipient and donor characteristics and relevant end-points retransplantation and death are manually curated on an annual basis to allow for statistical analysis and the annual report. RESULTS Primary sclerosing cholangitis, acute hepatic failure, alcoholic liver disease, primary biliary cirrhosis and hepatocellular carcinoma are the five most frequent diagnoses (accounting for 15.3%, 10.8%, 10.6%, 9.3% and 9.0% of all transplants, respectively). Median waiting time for non-urgent liver transplantation during the last 10-year period was 39 days. Outcome has improved over time, and for patients transplanted during 2004-2013, overall one-, five- and 10-year survival rates were 91%, 80% and 71%, respectively. In an intention-to-treat analysis, corresponding numbers during the same time period were 87%, 75% and 66%, respectively. CONCLUSION The liver transplant program in the Nordic countries provides comparable outcomes to programs with a MELD-based donor liver allocation system. Unique features comprise the diagnostic spectrum, waiting times and the availability of an integrated waiting list and transplant registry (NLTR).
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Affiliation(s)
- Bjarte Fosby
- Section for Transplantation Surgery, Department of Transplantation Medicine, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Oslo, Norway
| | - Espen Melum
- Section for Gastroenterology, Department of Transplantation Medicine, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway,Research Institute of Internal Medicine and Norwegian PSC Research Centre, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kristian Bjøro
- Section for Gastroenterology, Department of Transplantation Medicine, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway,Institute of Clinical Medicine, University of Oslo, Oslo, Norway,Correspondence: Kristian Bjøro, Department of Transplantation Medicine, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Pb 4950 Nydalen, N-0424 Oslo, Norway. +47 90 18 6524. +47 23 07 3510. and Tom Hemming Karlsen, Department of Transplantation Medicine, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Pb 4950 Nydalen, N-0424 Oslo, Norway. +47 23 07 3616. +47 23 07 3510. .
| | - William Bennet
- Department of Transplantation, Sahlgrenska Academy at University of Gothenburg and The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Allan Rasmussen
- Department of Surgical Gastroenterology and Liver Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ina Marie Andersen
- Research Institute of Internal Medicine and Norwegian PSC Research Centre, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Maria Castedal
- Department of Transplantation, Sahlgrenska Academy at University of Gothenburg and The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Michael Olausson
- Department of Transplantation, Sahlgrenska Academy at University of Gothenburg and The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christina Wibeck
- Department of Transplantation, Sahlgrenska Academy at University of Gothenburg and The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mette Gotlieb
- Department of Surgical Gastroenterology and Liver Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Gjertsen
- Department of Gastroenterology and Hepatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Leena Toivonen
- Department of Transplantation and Liver Surgery, University Hospital, Helsinki, Finland
| | - Stein Foss
- Section for Transplantation Surgery, Department of Transplantation Medicine, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Oslo, Norway
| | - Heikki Makisalo
- Department of Transplantation and Liver Surgery, University Hospital, Helsinki, Finland
| | - Arno Nordin
- Department of Transplantation and Liver Surgery, University Hospital, Helsinki, Finland
| | - Truls Sanengen
- Department of Pediatrics, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Annika Bergquist
- Department of Gastroenterology and Hepatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marie E. Larsson
- Division of Transplantation Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Gunnar Soderdahl
- Division of Transplantation Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Greg Nowak
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Kirsten Muri Boberg
- Section for Gastroenterology, Department of Transplantation Medicine, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway,Research Institute of Internal Medicine and Norwegian PSC Research Centre, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Helena Isoniemi
- Department of Transplantation and Liver Surgery, University Hospital, Helsinki, Finland
| | - Susanne Keiding
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Aksel Foss
- Section for Transplantation Surgery, Department of Transplantation Medicine, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Oslo, Norway
| | - Pål-Dag Line
- Section for Transplantation Surgery, Department of Transplantation Medicine, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Oslo, Norway
| | - Styrbjörn Friman
- Department of Transplantation, Sahlgrenska Academy at University of Gothenburg and The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Erik Schrumpf
- Section for Gastroenterology, Department of Transplantation Medicine, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway,Research Institute of Internal Medicine and Norwegian PSC Research Centre, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Bo-Göran Ericzon
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Krister Höckerstedt
- Department of Transplantation and Liver Surgery, University Hospital, Helsinki, Finland
| | - Tom H. Karlsen
- Section for Gastroenterology, Department of Transplantation Medicine, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway,Research Institute of Internal Medicine and Norwegian PSC Research Centre, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway,Institute of Clinical Medicine, University of Oslo, Oslo, Norway,Correspondence: Kristian Bjøro, Department of Transplantation Medicine, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Pb 4950 Nydalen, N-0424 Oslo, Norway. +47 90 18 6524. +47 23 07 3510. and Tom Hemming Karlsen, Department of Transplantation Medicine, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Pb 4950 Nydalen, N-0424 Oslo, Norway. +47 23 07 3616. +47 23 07 3510. .
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