Critical Care Management of Living Donor Liver Transplants

Evaluation of clinical characteristics and outcomes of postoperative ınfections in living liver donors

AIM

To analyze developing infections after living donor hepatectomy (LDH) in living liver donors (LLDs).

METHODS

Demographic and clinical characteristics of 1106 LLDs were retrospectively analyzed in terms of whether postoperative infection development. Therefore, LLDs were divided into two groups: with (n = 190) and without (n = 916) antimicrobial agent use.

RESULTS

The median age was 29.5 (min-max: 18-55). A total of 257 (23.2%) infection attacks (min-max: 1-8) was developed in 190 (17.2%) LLDs. The patients with the infection that were longer intensive care unit (ICU) and hospital stays, higher hospital admissions, emergency transplantation, invasive procedures for ERCP, PTC biloma, and abscess drainage, and the presence of relaparatomies and transcystic catheters. Infection attacks are derived from a 58.3% hepatobiliary system, 13.2% urinary system, 6.6% surgical site, and 5.8% respiratory system. The most common onset symptoms were fever, abdominal pain, nausea, and vomiting. A total of 125 positive results was detected from 77 patients with culture positivity. The most detected microorganisms from the cultures taken are Extended-Spectrum β-lactamases (ESBL) producing Klebsiella pneumonia (16.8%) and Escherichia coli (16%), Methicillin-Resistant Staphylococcus aureus [(MRSA) (9.6%)], Methicillin-susceptible S aureus [(MSSA) (9.6%)], and Pseudomonas aeruginosa (8.8%), respectively. The average number of ICU hospitalization days was 3 ± 2 (min 1-max 30, IQR:1) and hospitalization days was 14 ± 12 (min 3-max 138, IQR: 8). All infection attacks were successfully treated. No patients died because of infection or another surgical complication.

CONCLUSION

Infections commonly observed infected biloma, cholangitis, and abscess arising from the biliary system and other nosocomial infections are the feared complications in LLDs. These infections should be managed multidisciplinary without delay and carefully.

Multimodal Analgesia Decreases Postoperative Opioid Consumption in Living Liver Donation

Objective

To evaluate the effects of multimodal analgesia on postoperative opioid consumption and perioperative pain management in patients undergoing living liver donation.

Methods

A retrospective study was conducted of 129 patients who underwent living liver donation between 2006 and 2015. Patients were separated into 2 cohorts, pre–multimodal analgesia and multimodal analgesia, to allow intergroup analysis. All patients received an intrathecal opioid injection and underwent donor hepatectomy. Primary outcome data compared opioid consumption in oral morphine equivalents for postoperative days (PODs) 0 to 4 between the cohorts. Secondary outcomes compared yearly averaged cumulative opioid consumption on PODs 0 to 4 in oral morphine equivalents; yearly averaged numeric rating scale pain scores; hospital length of stay; and percentage of patients receiving intravenous ketorolac, ketamine, or transversus abdominis plane blocks.

Results

For PODs 0 to 4, a 50% reduction in overall opioids administered postoperatively (359 mg vs 179 mg; P<.01) was observed in the multimodal analgesia cohort, whereas no significant difference was found in year-to-year average postoperative pain scores (4.5 vs 3.6). The proportion of patients receiving ketorolac increased to more than 90% by 2013. More than 40% of all patients in the multimodal analgesia group received a perioperative regimen of acetaminophen, gabapentin, ketamine, and transverse abdominal plane blocks (0% in pre–multimodal analgesia). Mean hospital length of stay was reduced from 7.7 to 6.6 days (P<.01).

Conclusion

Implementation of multimodal analgesia to manage perioperative pain in living liver donation resulted in a 50% reduction of postoperative opioid consumption. Clinically satisfactory average pain scores were maintained for PODs 0 to 4.

Understanding, predicting and achieving liver transplant tolerance: from bench to bedside

In the past 40 years, liver transplantation has evolved from a high-risk procedure to one that offers high success rates for reversal of liver dysfunction and excellent patient and graft survival. The liver is the most tolerogenic of transplanted organs; indeed, immunosuppressive therapy can be completely withdrawn without rejection of the graft in carefully selected, stable long-term liver recipients. However, in other recipients, chronic allograft injury, late graft failure and the adverse effects of anti-rejection therapy remain important obstacles to improved success. The liver has a unique composition of parenchymal and immune cells that regulate innate and adaptive immunity and that can promote antigen-specific tolerance. Although the mechanisms underlying liver transplant tolerance are not well understood, important insights have been gained into how the local microenvironment, hepatic immune cells and specific molecular pathways can promote donor-specific tolerance. These insights provide a basis for the identification of potential clinical biomarkers that might correlate with tolerance or rejection and for the development of novel therapeutic targets. Innovative approaches aimed at promoting immunosuppressive drug minimization or withdrawal include the adoptive transfer of donor-derived or recipient-derived regulatory immune cells to promote liver transplant tolerance. In this Review, we summarize and discuss these developments and their implications for liver transplantation.

Intra-abdominal infections in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

This new guideline from the AST IDCOP reviews intra-abdominal infections (IAIs), which cause substantial morbidity and mortality among abdominal SOT recipients. Each transplant type carries unique risks for IAI, though peritonitis occurs in all abdominal transplant recipients. Biliary infections, bilomas, and intra-abdominal and intrahepatic abscesses are common after liver transplantation and are associated with the type of biliary anastomosis, the presence of vascular thrombosis or ischemia, and biliary leaks or strictures. IAIs after kidney transplantation include renal and perinephric abscesses and graft-site candidiasis, which is uncommon but may require allograft nephrectomy. Among pancreas transplant recipients, duodenal anastomotic leaks can have catastrophic consequences, and polymicrobial abscesses can lead to graft loss and death. Intestinal transplant recipients are at the highest risk for sepsis, infection due to multidrug-resistant organisms, and death from IAI, as the transplanted intestine is a contaminated, highly immunological, pathogen-rich organ. Source control and antibiotics are the cornerstone of the management of IAIs. Empiric antimicrobial regimens should be tailored to local susceptibility patterns and pathogens with which the patient is known to be colonized, with subsequent optimization once the results of cultures are reported.