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Qureshi S, Elliott H, Noel A, Swift L, Fear C, Webster R, Brown NM, Gaurav R, Butler AJ, Watson CJE. Infection and Prophylaxis During Normothermic Liver Perfusion: Audit of Incidence and Pharmacokinetics of Antimicrobial Therapy. Transplantation 2024; 108:1376-1382. [PMID: 38196099 PMCID: PMC11115456 DOI: 10.1097/tp.0000000000004897] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/23/2023] [Accepted: 10/01/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND Ex situ normothermic liver perfusion (NMP) in a blood-based perfusate is associated with a risk of microbe growth, resulting in life-threatening posttransplant sepsis. Antibiotics are widely used, but the pharmacokinetics of these agents are unknown as is their efficacy. We wished to assess the perfusate concentrations of the meropenem and fluconazole that we use and to audit the incidence of infection with this antimicrobial therapy. METHODS Fluconazole and meropenem (100 mg each) were added to the perfusate before NMP began, and serial samples were taken and assayed for drug concentrations. Perfusate cultures were available from 210 of the 242 perfusions performed between February 1, 2018, and April 6, 2023; these were reviewed. RESULTS Following administration of 100 mg fluconazole, levels fell slightly from a median of 24.9 mg/L at 1 h to 22.6 mg/L at 10 h. In contrast, meropenem concentrations fell over time, from a median of 21.8 mg/L at 1 h to 9.4 mg/L at 10 h. There were 4 significant microorganisms grown in the perfusions, including 3 Candida species and an Enterococcus faecium . All the Candida -infected livers were transplanted with no adverse consequences, the recipients being treated with anidulafungin upon identification of the infecting organism; the Enterococcus -infected liver was not transplanted. CONCLUSIONS Serious infection is a risk with NMP but appears to be mitigated with a protocol combining fluconazole and meropenem. This combination may not be appropriate in areas where resistance is prevalent. Routine culture of NMP perfusate is essential to identify breakthrough organisms early and enable recipient treatment.
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Affiliation(s)
- Saeed Qureshi
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Heather Elliott
- Antimicrobial Reference Laboratory, Pathology Sciences Building, North Bristol NHS Trust, Southmead Hospital, Westbury-on-Trym, Bristol, United Kingdom
| | - Alan Noel
- Antimicrobial Reference Laboratory, Pathology Sciences Building, North Bristol NHS Trust, Southmead Hospital, Westbury-on-Trym, Bristol, United Kingdom
| | - Lisa Swift
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Corrina Fear
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Rachel Webster
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Nicholas M Brown
- Department of Microbiology, Cambridge University Hospitals NHS Foundation Trust, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Rohit Gaurav
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Andrew J Butler
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrookes Hospital, Cambridge, United Kingdom
- The Cambridge NIHR Biomedical Research Centre and the NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Cambridge, United Kingdom
| | - Christopher J E Watson
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrookes Hospital, Cambridge, United Kingdom
- The Cambridge NIHR Biomedical Research Centre and the NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Cambridge, United Kingdom
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Lin J, Li Y, Fang T, Wang T, Liao K, Zhao Q, Wang D, Chen M, Zhu X, Chen Y, Chen H, Guo Y, Zhan L, Zhang J, Zhang T, Zeng P, Peng Y, Yang L, Cai C, Guo Z, He X. Substantial decline of organ preservation fluid contamination following adoption of ischemia-free liver transplantation: a post-hoc analysis. Int J Surg 2024; 110:2855-2864. [PMID: 38329144 PMCID: PMC11093427 DOI: 10.1097/js9.0000000000001163] [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: 11/07/2023] [Accepted: 01/26/2024] [Indexed: 02/09/2024]
Abstract
INTRODUCTION Preservation fluid (PF) contaminations are common in conventional liver transplantation (CLT) and presumably originate from organ or PF exposures to the external environment in a non-strict sterile manner. Such exposures and PF contamination may be avoided in ischaemia-free liver transplantation (IFLT) because of the strict sterile surgical procedures. In this study, the authors evaluated the impact of IFLT on organ PF contamination. METHODS A post-hoc analysis using data from the first randomized controlled trial of IFLT was performed to compare the incidence, pathogenic spectrum of PF contamination, and incidence of early recipient infection between IFLT and CLT. Multivariable logistic regression was used to explore risk factors for PF contamination. RESULTS Of the 68 cases recruited in the trial, 64 were included in this post-hoc analysis. The incidence of culture-positive PF was 9.4% (3/32) in the IFLT group versus 78.1% (25/32) in the CLT group ( P <0.001). Three microorganisms were isolated from PF in the IFLT group, while 43 were isolated in the CLT group. The recipient infection rate within postoperative day 14 was 3.1% (1/32) in the IFLT group vs 15.6% (5/32) in the CLT group, although this difference did not reach statistical significance ( P =0.196). Multivariate analysis revealed that adopting IFLT is an independent protective factor for culture-positive PF. CONCLUSION PF contamination is substantially decreased in IFLT, and IFLT application is an independent protective factor for PF contamination. Using rigorous sterile measures and effective antibiotic therapy during IFLT may decrease PF contamination.
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Watson CJ, Gaurav R, Butler AJ. Current Techniques and Indications for Machine Perfusion and Regional Perfusion in Deceased Donor Liver Transplantation. J Clin Exp Hepatol 2024; 14:101309. [PMID: 38274508 PMCID: PMC10806097 DOI: 10.1016/j.jceh.2023.101309] [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: 09/20/2023] [Accepted: 11/27/2023] [Indexed: 01/27/2024] Open
Abstract
Since the advent of University of Wisconsin preservation solution in the 1980s, clinicians have learned to work within its confines. While affording improved outcomes, considerable limitations still exist and contribute to the large number of livers that go unused each year, often for fear they may never work. The last 10 years have seen the widespread availability of new perfusion modalities which provide an opportunity for assessing organ viability and prolonged organ storage. This review will discuss the role of in situ normothermic regional perfusion for livers donated after circulatory death. It will also describe the different modalities of ex situ perfusion, both normothermic and hypothermic, and discuss how they are thought to work and the opportunities afforded by them.
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Affiliation(s)
- Christopher J.E. Watson
- University of Cambridge Department of Surgery, Box 210, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
- The Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
| | - Rohit Gaurav
- The Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
| | - Andrew J. Butler
- University of Cambridge Department of Surgery, Box 210, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
- The Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
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Lau NS, Ly M, Dennis C, Toomath S, Huang JL, Huang J, Ly H, Chanda S, Marinelli T, Davis R, Liu K, McCaughan G, Crawford M, Pulitano C. Microbial Contamination During Long-term Ex Vivo Normothermic Machine Perfusion of Human Livers. Transplantation 2024; 108:198-203. [PMID: 37202846 DOI: 10.1097/tp.0000000000004653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
BACKGROUND Normothermic machine perfusion permits the ex vivo preservation of human livers before transplantation. Long-term perfusion for days-to-weeks provides the opportunity for enhanced pretransplant assessment and potential regeneration of organs. However, this risks microbial contamination and infection of the recipient if the organ is transplanted. An understanding of perfusate microbial contamination is required to inform infection control procedures and antimicrobial prophylaxis for this technology. METHODS We modified a liver perfusion machine for long-term use by adding long-term oxygenators and a dialysis filter. Human livers that were not suitable for transplantation were perfused using a red-cell-based perfusate under aseptic and normothermic conditions (36 °C) with a goal of 14 d. Cephazolin was added to the perfusate for antimicrobial prophylaxis. Perfusate and bile were sampled every 72 h for microbial culture. RESULTS Eighteen partial human livers (9 left lateral segment grafts and 9 extended right grafts) were perfused using our perfusion system. The median survival was 7.2 d. All organs surviving longer than 7 d (9/18) had negative perfusate cultures at 24 and 48 h. Half of the grafts (9/18) became culture-positive by the end of perfusion. Microbial contaminants included Gram-negative ( Pseudomonas species, Proteus mirabilis, Stenotrophomonas maltophilia ) and Gram-positive bacteria ( Staphylococcus epidermidis , Enterococcus faecalis , and Bacillus species) as well as yeast ( Candida albicans ). CONCLUSIONS Microbial contamination of perfusate is common during long-term perfusion of human livers with both exogenous and endogenous sources. Enhanced infection control practices and review of targeted antimicrobial prophylaxis are likely to be necessary for translation into the clinical arena.
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Affiliation(s)
- Ngee-Soon Lau
- Centre for Organ Assessment, Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Mark Ly
- Centre for Organ Assessment, Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Claude Dennis
- Department of Tissue Pathology and Diagnostic Oncology, NSW Health Pathology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Shamus Toomath
- Centre for Organ Assessment, Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Joanna Lou Huang
- Centre for Organ Assessment, Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Joanna Huang
- Centre for Organ Assessment, Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Hayden Ly
- Centre for Organ Assessment, Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Sumon Chanda
- Centre for Organ Assessment, Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Tina Marinelli
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Microbiology and Infectious Diseases, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Rebecca Davis
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Department of Microbiology and Infectious Diseases, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Ken Liu
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Geoff McCaughan
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Michael Crawford
- Centre for Organ Assessment, Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Carlo Pulitano
- Centre for Organ Assessment, Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Lombardi A, Renisi G, Dondossola D, Palomba E, Del Prete L, Viero G, Zefelippo A, Azzarà C, Maccaro A, Perali C, Alagna L, Franchi E, Muscatello A, Gori A, Grasselli G, Donato MF, Matinato C, Caccamo L, Antonelli B, Bandera A. Perfusion fluid-related infections in liver transplant recipients: A 5-year, single-center, retrospective study. Transpl Infect Dis 2023; 25:e14130. [PMID: 37605507 DOI: 10.1111/tid.14130] [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: 04/12/2023] [Revised: 07/16/2023] [Accepted: 08/10/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Perfusion fluid (PRF) is employed in liver transplantation (LTx) to maintain graft viability. Still, it represents a new potential way of infection transmission in LTx recipients (LTRs). Currently, no systematic research has investigated this topic. METHODS Five-year single-center retrospective study conducted on LTRs from January 2017 to December 2021. We analyzed the incidence of positive PRF culture (PRF+) and perfusion fluid-related infections (PRF-RI) and their associated factors. We also assessed 1-year mortality, both overall and infection-related. RESULTS Overall, 234 LTx were included. PRF+ were found in 31/234 (13.2%) LTx for a total of 37 isolates, with >1 isolate identified in 5 (2.1%) cases. High-risk microorganisms (Enterobacterales 13/37, Enterococcus spp. 4/37, S. aureus 3/37, P. aeruginosa 2/37) were isolated in 25/37 (67.6%) LTRs, the remaining being coagulase-negative staphylococci (12/37, 32.4%). Antimicrobial prophylaxis was administered to all LTRs, always active against the isolate even if suboptimal in 19 cases (61.3%). PRF-RI developed in 4/234 LTx (1.7%), and prophylaxis was considered suboptimal in 2/4 of them. The isolation of >1 microorganism in PRF culture was associated with an increased risk of developing PRF-RI (OR 37.5 [95%CI 2.6-548.4], p = .01). PRF-RI were associated with longer ICU stays (p = .005) and higher 1-year mortality, both overall and related to infections (p = .001). CONCLUSION Despite PRF+ being infrequent, only a minority of patients develops PRF-RI. Nonetheless, once occurred, PRF-RI seems to increase morbidity and mortality rates.
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Affiliation(s)
- Andrea Lombardi
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giulia Renisi
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
| | - Daniele Dondossola
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, General and Liver Transplant Surgery Unit, Milan, Italy
| | - Emanuele Palomba
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
| | - Luca Del Prete
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, General and Liver Transplant Surgery Unit, Milan, Italy
| | - Giulia Viero
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
| | - Arianna Zefelippo
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, General and Liver Transplant Surgery Unit, Milan, Italy
| | - Cecilia Azzarà
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
| | - Angelo Maccaro
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
| | - Carolina Perali
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, General and Liver Transplant Surgery Unit, Milan, Italy
| | - Laura Alagna
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
| | - Eloisa Franchi
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, General and Liver Transplant Surgery Unit, Milan, Italy
| | - Antonio Muscatello
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
| | - Andrea Gori
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anaesthesiology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Intensive Care and Emergency, Milan, Italy
| | - Maria Francesca Donato
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, A.M. & A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Milan, Italy
| | - Caterina Matinato
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Medical Laboratory of Clinical Chemistry and Microbiology, Milan, Italy
| | - Lucio Caccamo
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, General and Liver Transplant Surgery Unit, Milan, Italy
| | - Barbara Antonelli
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, General and Liver Transplant Surgery Unit, Milan, Italy
| | - Alessandra Bandera
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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6
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Lombardi A, Dondossola D, Renisi G, Caccamo L, Antonelli B, Bandera A. Re: 'Which trial do we need? Culture of preservation fluid in abdominal-organ transplant recipients' by Manuel et al. Clin Microbiol Infect 2023; 29:1202-1203. [PMID: 37179004 DOI: 10.1016/j.cmi.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Andrea Lombardi
- Infectious Diseases Unit, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Daniele Dondossola
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; General and Liver Transplant Surgery Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Renisi
- Infectious Diseases Unit, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lucio Caccamo
- General and Liver Transplant Surgery Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Barbara Antonelli
- General and Liver Transplant Surgery Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Bandera
- Infectious Diseases Unit, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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7
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Choudhary D, Seth A, Singh S. Does machine perfusion enhance graft contamination risk? Fungal graft arteritis following normothermic machine perfusion of neonatal en-bloc kidney: A case study. Transpl Infect Dis 2023; 25:e14069. [PMID: 37222109 DOI: 10.1111/tid.14069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/01/2023] [Accepted: 05/06/2023] [Indexed: 05/25/2023]
Affiliation(s)
- Devprakash Choudhary
- Department of Renal Transplant Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Abhinav Seth
- Department of Renal Transplant Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sarbpreet Singh
- Department of Renal Transplant Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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8
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Viero G, Lombardi A, Antonelli B. Hypothermic oxygenated machine-perfusion fluid-related infection in a liver transplant recipient: First case report in the literature. Transpl Infect Dis 2023; 25:e14056. [PMID: 36987663 DOI: 10.1111/tid.14056] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/30/2023]
Affiliation(s)
- Giulia Viero
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Lombardi
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Barbara Antonelli
- General and Liver Transplant Surgery Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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9
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Bacterial and Viral Infections in Liver Transplantation: New Insights from Clinical and Surgical Perspectives. Biomedicines 2022; 10:biomedicines10071561. [PMID: 35884867 PMCID: PMC9313066 DOI: 10.3390/biomedicines10071561] [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: 04/12/2022] [Revised: 06/11/2022] [Accepted: 06/27/2022] [Indexed: 01/03/2023] Open
Abstract
End-stage liver disease patients undergoing liver transplantation are prone to develop numerous infectious complications because of immunosuppression, surgical interventions, and malnutrition. Infections in transplant recipients account for the main cause of mortality and morbidity with rates of up to 80%. The challenges faced in the early post-transplant period tend to be linked to transplant procedures and nosocomial infections commonly in bloodstream, surgical, and intra-abdominal sites. Viral infections represent an additional complication of immunosuppression; they can be donor-derived, reactivated from a latent virus, nosocomial or community-acquired. Bacterial and viral infections in solid organ transplantation are managed by prophylaxis, multi-drug resistant screening, risk assessment, vaccination, infection control and antimicrobial stewardship. The aim of this review was to discuss the epidemiology of bacterial and viral infections in liver transplants, infection control issues, as well as surgical frontiers of ex situ liver perfusion.
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10
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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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11
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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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12
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Anaphylaxis to Machine Perfusion Substrate at Reperfusion: A Cautionary Tale. Transplant Direct 2021; 7:e696. [PMID: 34036166 PMCID: PMC8133232 DOI: 10.1097/txd.0000000000001144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 02/11/2021] [Indexed: 11/30/2022] Open
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