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Agostini C, Buccianti S, Risaliti M, Fortuna L, Tirloni L, Tucci R, Bartolini I, Grazi GL. Complications in Post-Liver Transplant Patients. J Clin Med 2023; 12:6173. [PMID: 37834818 PMCID: PMC10573382 DOI: 10.3390/jcm12196173] [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: 08/26/2023] [Revised: 09/16/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
Liver transplantation (LT) is the treatment of choice for liver failure and selected cases of malignancies. Transplantation activity has increased over the years, and indications for LT have been widened, leading to organ shortage. To face this condition, a high selection of recipients with prioritizing systems and an enlargement of the donor pool were necessary. Several authors published their case series reporting the results obtained with the use of marginal donors, which seem to have progressively improved over the years. The introduction of in situ and ex situ machine perfusion, although still strongly debated, and better knowledge and treatment of the complications may have a role in achieving better results. With longer survival rates, a significant number of patients will suffer from long-term complications. An extensive review of the literature concerning short- and long-term outcomes is reported trying to highlight the most recent findings. The heterogeneity of the behaviors within the different centers is evident, leading to a difficult comparison of the results and making explicit the need to obtain more consent from experts.
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Affiliation(s)
| | | | | | | | | | | | - Ilenia Bartolini
- Department of Experimental and Clinical Medicine, AOU Careggi, 50134 Florence, Italy; (C.A.); (S.B.); (M.R.); (L.F.); (L.T.); (R.T.); (G.L.G.)
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Lee N, Cha S, Kim J, Lee Y, Kang E, Kim HJ, Hong SH, Rhu J, Choi GS, Joh JW. Ventilator support in the pretransplant period predisposes early graft failure after deceased donor liver transplantation. Ann Surg Treat Res 2023; 105:141-147. [PMID: 37693286 PMCID: PMC10485352 DOI: 10.4174/astr.2023.105.3.141] [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: 05/26/2023] [Revised: 07/31/2023] [Accepted: 08/07/2023] [Indexed: 09/12/2023] Open
Abstract
Purpose Deceased donor liver transplantation (DDLT) recipients in Korea are generally sicker due to an increasing organ shortage. In the present study, the risk factors for early 30-day liver graft failure after DDLT were identified. Methods From August 2017 to February 2021, 265 adult DDLTs were performed. The characteristics of patients with and without 30-day graft failure were compared. Results Liver graft failure occurred in 11 patients (17.7%) after DDLT. Baseline and perioperative characteristics of donors and recipients were not statistically significantly different between the 2 groups. The cumulative graft and overall survival rates at 6 months were 83.9% and 88.7%, respectively. Multivariate analysis showed ventilator support in the pretransplant period was a predisposing factor for 30-day graft failure after DDLT. Conclusion Present study indicates that cautious decision is required when allocating DDLT in critically ill patients on mechanical ventilatory support.
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Affiliation(s)
- Nuri Lee
- Department of Surgery, Veterans Health Service Medical Center, Seoul, Korea
| | - Sora Cha
- Organ Transplant Center, Samsung Medical Center, Seoul, Korea
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yunmi Lee
- Organ Transplant Center, Samsung Medical Center, Seoul, Korea
| | - Enjin Kang
- Organ Transplant Center, Samsung Medical Center, Seoul, Korea
| | - Hyun Jung Kim
- Organ Transplant Center, Samsung Medical Center, Seoul, Korea
| | - Seung Hui Hong
- Organ Transplant Center, Samsung Medical Center, Seoul, Korea
| | - Jinsoo Rhu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gyu-Seong Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
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Shin EM, Westhaver L, Nersesian S, Boudreau JE, Gala-Lopez BL. Predicting Early Graft Dysfunction and Mortality After Liver Transplant Using the De Ritis Ratio. Transplant Proc 2023; 55:586-596. [PMID: 36973148 DOI: 10.1016/j.transproceed.2023.02.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/04/2023] [Accepted: 02/24/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Predicting complications after liver transplantation (LT) remains challenging. We propose incorporating the De Ritis ratio (DRR), a widely known parameter of liver dysfunction, into current or future scoring models to predict early allograft dysfunction (EAD) and mortality after LT. METHODS A retrospective chart review was conducted on 132 adults receiving a deceased donor LT from April 2015 to March 2020 and their matching donors. Donor variables, postoperative liver function, and DRR were correlated with the occurrence of EAD, post-transplant complications expressed by the Clavien-Dindo score, and 30-day mortality as outcome variables. RESULTS Early allograft dysfunction was observed in 26.5% of patients and 7.6% of patients who died within 30 days after transplant. Recipients were more likely to experience EAD when receiving grafts from donation after circulatory death (P = .04), donor risk index (DRI) >2 (P = .006), ischemic injury at time-zero biopsy (P = .02), longer secondary warm ischemia time (P < .05), or higher Clavien-Dindo scores (IIIb-V; P < .001). The DRI, total bilirubin, and DRR on postoperative day 5 yielded significant associations with the primary outcomes and were used to develop the Gala-Lopez score using a weighted scoring model. This accurately predicted EAD, high Clavien-Dindo, and 30-day mortality in 75%, 81%, and 64% of patients. CONCLUSION Including recipient and donor variables in predictive models, and for the first time DRR, as a constituent, should be regarded to predict EAD, severe complications, and 30-day mortality post-LT. Further studies will be required to validate the present findings and their applicability when using normothermic regional and machine perfusion technologies.
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Affiliation(s)
- Elizabeth M Shin
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lauren Westhaver
- Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sarah Nersesian
- Department of Microbiology and Immunology, Dalhousie University, Halifax, Nova Scotia, Canada; Beatrice Hunter Cancer Research Institute, Halifax, Nova Scotia, Canada
| | - Jeanette E Boudreau
- Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Microbiology and Immunology, Dalhousie University, Halifax, Nova Scotia, Canada; Beatrice Hunter Cancer Research Institute, Halifax, Nova Scotia, Canada
| | - Boris L Gala-Lopez
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Microbiology and Immunology, Dalhousie University, Halifax, Nova Scotia, Canada; Beatrice Hunter Cancer Research Institute, Halifax, Nova Scotia, Canada.
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Early Postoperative Transaminase Activities Affecting Early and Late Liver Graft Survival. Transplant Proc 2022; 54:1021-1024. [PMID: 35461712 DOI: 10.1016/j.transproceed.2022.02.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/09/2022] [Indexed: 11/20/2022]
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Froghi F, Gopalan V, Anastasiou Z, Koti R, Gurusamy K, Eastgate C, McNeil M, Filipe H, Pinto M, Singh J, Longworth L, Mallett S, Schofield N, Thorburn D, Martin D, Davidson BR. Effect of post-operative goal-directed fluid therapy (GDFT) on organ function after orthotopic liver transplantation: Secondary outcome analysis of the COLT randomised control trial. Int J Surg 2022; 99:106265. [PMID: 35181556 DOI: 10.1016/j.ijsu.2022.106265] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/28/2021] [Accepted: 02/09/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Goal-directed fluid therapy (GDFT) has been shown to reduce the complications following a variety of major surgical procedures, possibly mediated by improved organ perfusion and function. We have shown that it is feasible to randomise patients to GDFT or standard fluid management following liver transplant in the cardiac-output optimisation following liver transplantation (COLT) trial. The current study compares end organ function in patients from the COLT trial who received GDFT in comparison to those receiving standard care (SC) following liver transplant. METHODS Adult patients with liver cirrhosis undergoing liver transplantation were randomised to GDFT or SC for the first 12 h following surgery as detailed in a published trial protocol. GDFT protocol was based on stroke volume (SV) optimisation using 250 ml crystalloid boluses. Total fluid administration and time to extubation were recorded. Hourly SV and cardiac output (CO) readings were recorded from the non-invasive cardiac output monitoring (NICOM) device in both groups. Pulmonary function was assessed by arterial blood gas (ABG) and ventilatory parameters. Lung injury was assessed using PaO2:FiO2 ratios and calculated pulmonary compliance. The KDIGO score was used for determining acute kidney injury. Renal and liver graft function were assessed during the post-operative period and at 3 months and 1-year. RESULTS 60 patients were randomised to GDFT (n = 30) or SC (n = 30). All patients completed the 12 h intervention period. GDFT group received a significantly higher total volume of fluid during the 12 h trial intervention period (GDFT 5317 (2335) vs. SC 3807 (1345) ml, p = 0.003); in particular crystalloids (GDFT 3968 (2073) vs. SC 2510 (1027) ml, p = 0.002). There was no evidence of significant difference between the groups in SV or CO during the assessment periods. Time to extubation, PaO2: FIO2 ratios, pulmonary compliance, ventilatory or blood gas measurements were similar in both groups. There was a significant rise in serum creatinine from baseline (77 μmol/L) compared to first (87 μmol/L, p = 0.039) and second (107 μmol/L, p = 0.001) post-operative days. There was no difference between GDFT and SC in the highest KDIGO scores for the first 7 days post-LT. At 1-year follow-up, there was no difference in need for renal replacement therapy or graft function. CONCLUSIONS In this randomised trial of fluid therapy post liver transplant, GDFT was associated with an increased volume of crystalloids administered but did not alter early post-operative pulmonary or renal function when compared with standard care.
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Affiliation(s)
- Farid Froghi
- UCL Division of Surgery & Interventional Sciences, HPB and Liver Transplantation, London, United Kingdom UCL Joint Research Office, Biostatistics Group, London, United Kingdom Royal Free Hospital, Critical Care Unit, London, United Kingdom PHMR Limited, London, United Kingdom UCL Institute for Liver and Digestive Health, London, United Kingdom UCL Division of Surgery & Interventional Sciences, London, United Kingdom Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom
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Nguyen TK, Trinh HS, Luong TH, Ninh VK, Pham GA, Nguyen HH, Bui TN, Dang KK, Hoang T, Nguyen QN. Technical characteristics and quality of grafts in liver procurement from brain-dead donors: A single-center study in Vietnamese population. Ann Med Surg (Lond) 2021; 69:102654. [PMID: 34429944 PMCID: PMC8369000 DOI: 10.1016/j.amsu.2021.102654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Donor liver graft quality plays an especially important role that contributes to the success of organ transplantation. Almost all local and international authors are interested in the techniques and results of transplantation, however, in Vietnam, there have not been any studies that report the results of liver procurement from brain-dead donors from a technical perspective as well as the morphology and function of the transplanted organ. Materials and method This study is descriptive cross-section study with analysis of retrospective occurrences of a series of cases of liver procurement from brain-dead donors from March 2010 to March 2020. All cases were proceeded the multiple organ procurement with warm liver dissection and in vivo cannulation and perfusion. Results The average age of brain-dead donors was 29.7 ± 10.7 (18–69), 92.16% of the harvested organs were of good quality macroscopically; and the rate of anatomical modification was 33.3% that occurred mostly in the left hepatic artery (LHA). Technically, warm dissection was proceeded in majority of cases (98,0%), the graft implantation was performed by this technique with mean cold ischemia time (CIT) of 190,0 ± 100,5 min and WIT of 74,0 ± 39,2 s. There were no complications relating to graft injuries occurring during procurement and no primary liver failure, good results accounted for 94.1% of the total number of transplants postoperatively. Conclusion Multiple organ procurement with warm liver dissection and in vivo cannulation and perfusion was a safe technique and may be effective by avoiding any donor's damages in cold-phase dissection. Liver transplantation in brain-dead donors had developed rapidly in recent decades. Several techniques were proceeded depend on experience and faculties of institute. In vivo perfusion and warm dissection can avoid graft's damages in cold dissection. Long-term follow-up is needed to evaluate quality of graft and overall survival.
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Key Words
- BDD, Brain-dead donors
- BMI, Body mass index
- Brain-dead donation
- CD, Cold dissection
- CIT, Cold ischemia time
- GDA, Gastroduodenal artery
- HA, Hepatic artery
- HV, Hepatic vein
- IVC, Inferior vena cava
- LT, Liver transplantation
- Liver transplantation
- MOP, Multiple organ procurement
- MPV, Main portal vein
- Multiple organ procurement and transplantation
- OLT, Orthotopic liver transplantation
- PGD, Primary graft dysfunction
- SA, Splenic artery
- WD, Warm dissection
- WIT, Warm ischemia time
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Affiliation(s)
- Thanh Khiem Nguyen
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Bach Mai Hospital, Hanoi, Viet Nam
| | - Hong Son Trinh
- Department of Oncology, Viet Duc University Hospital, Hanoi, Viet Nam
| | - Tuan Hiep Luong
- Department of Surgery, Hanoi Medical University, Hanoi, Viet Nam
| | - Viet Khai Ninh
- Center of Organ Transplantation, Viet Duc University Hospital, Hanoi, Viet Nam
| | - Gia Anh Pham
- Department of Oncology, Viet Duc University Hospital, Hanoi, Viet Nam
| | - Ham Hoi Nguyen
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Bach Mai Hospital, Hanoi, Viet Nam
| | - Trung Nghia Bui
- Department of Oncology, Viet Duc University Hospital, Hanoi, Viet Nam
| | - Kim Khue Dang
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Bach Mai Hospital, Hanoi, Viet Nam
| | - Tuan Hoang
- Center of Organ Transplantation, Viet Duc University Hospital, Hanoi, Viet Nam
| | - Quang Nghia Nguyen
- Center of Organ Transplantation, Viet Duc University Hospital, Hanoi, Viet Nam
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Early Allograft Dysfunction and Complications in DCD Liver Transplantation: Expert Consensus Statements From the International Liver Transplantation Society. Transplantation 2021; 105:1643-1652. [PMID: 34291765 DOI: 10.1097/tp.0000000000003877] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Livers for transplantation from donation after circulatory death donors are relatively more prone to early and ongoing alterations in graft function that might ultimately lead to graft loss and even patient death. In consideration of this fact, this working group of the International Liver Transplantation Society has performed a critical evaluation of the medical literature to create a set of statements regarding the assessment of early allograft function/dysfunction and complications arising in the setting of donation after circulatory death liver transplantation.
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Milliner DS, McGregor TL, Thompson A, Dehmel B, Knight J, Rosskamp R, Blank M, Yang S, Fargue S, Rumsby G, Groothoff J, Allain M, West M, Hollander K, Lowther WT, Lieske JC. End Points for Clinical Trials in Primary Hyperoxaluria. Clin J Am Soc Nephrol 2020; 15:1056-1065. [PMID: 32165440 PMCID: PMC7341772 DOI: 10.2215/cjn.13821119] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Patients with primary hyperoxaluria experience kidney stones from a young age and can develop progressive oxalate nephropathy. Progression to kidney failure often develops over a number of years, and is associated with systemic oxalosis, intensive dialysis, and often combined kidney and liver transplantation. There are no therapies approved by the Food and Drug Association. Thus, the Kidney Health Initiative, in partnership with the Oxalosis and Hyperoxaluria Foundation, initiated a project to identify end points for clinical trials. A workgroup of physicians, scientists, patients with primary hyperoxaluria, industry, and United States regulators critically examined the published literature for clinical outcomes and potential surrogate end points that could be used to evaluate new treatments. Kidney stones, change in eGFR, urine oxalate, and plasma oxalate were the strongest candidate end points. Kidney stones affect how patients with primary hyperoxaluria feel and function, but standards for measurement and monitoring are lacking. Primary hyperoxaluria registry data suggest that eGFR decline in most patients is gradual, but can be unpredictable. Epidemiologic data show a strong relationship between urine oxalate and long-term kidney function loss. Urine oxalate is reasonably likely to predict clinical benefit, due to its causal role in stone formation and kidney damage in CKD stages 1-3a, and plasma oxalate is likely associated with risk of systemic oxalosis in CKD 3b-5. Change in slope of eGFR could be considered the equivalent of a clinically meaningful end point in support of traditional approval. A substantial change in urine oxalate as a surrogate end point could support traditional approval in patients with primary hyperoxaluria type 1 and CKD stages 1-3a. A substantial change in markedly elevated plasma oxalate could support accelerated approval in patients with primary hyperoxaluria and CKD stages 3b-5. Primary hyperoxaluria type 1 accounts for the preponderance of available data, thus heavily influences the conclusions. Addressing gaps in data will further facilitate testing of promising new treatments, accelerating improved outcomes for patients with primary hyperoxaluria.
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Affiliation(s)
| | | | - Aliza Thompson
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | | | - John Knight
- Department of Urology, The University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Melanie Blank
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Sixun Yang
- Division of Vaccines and Related Products Applications, Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Sonia Fargue
- Department of Urology, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Gill Rumsby
- University College London Hospitals, London, United Kingdom
| | - Jaap Groothoff
- Department of Pediatric Nephrology, University of Amsterdam Medical Center, Amsterdam, Netherlands
| | | | | | - Kim Hollander
- Oxalosis and Hyperoxaluria Foundation, New Paltz, New York
| | - W Todd Lowther
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - John C Lieske
- Division of Nephrology, Mayo Clinic, Rochester, Minnesota
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