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Zhao M, Lin Z, Zheng Z, Yao D, Yang S, Zhao Y, Chen X, Aweya JJ, Zhang Y. The mechanisms and factors that induce trained immunity in arthropods and mollusks. Front Immunol 2023; 14:1241934. [PMID: 37744346 PMCID: PMC10513178 DOI: 10.3389/fimmu.2023.1241934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 08/25/2023] [Indexed: 09/26/2023] Open
Abstract
Besides dividing the organism's immune system into adaptive and innate immunity, it has long been thought that only adaptive immunity can establish immune memory. However, many studies have shown that innate immunity can also build immunological memory through epigenetic reprogramming and modifications to resist pathogens' reinfection, known as trained immunity. This paper reviews the role of mitochondrial metabolism and epigenetic modifications and describes the molecular foundation in the trained immunity of arthropods and mollusks. Mitochondrial metabolism and epigenetic modifications complement each other and play a key role in trained immunity.
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Affiliation(s)
- Mingming Zhao
- Institute of Marine Sciences and Guangdong Provincial Key Laboratory of Marine Biotechnology, Shantou University, Shantou, China
| | - Zhongyang Lin
- Institute of Marine Sciences and Guangdong Provincial Key Laboratory of Marine Biotechnology, Shantou University, Shantou, China
| | - Zhihong Zheng
- Institute of Marine Sciences and Guangdong Provincial Key Laboratory of Marine Biotechnology, Shantou University, Shantou, China
| | - Defu Yao
- Institute of Marine Sciences and Guangdong Provincial Key Laboratory of Marine Biotechnology, Shantou University, Shantou, China
| | - Shen Yang
- College of Ocean Food and Biological Engineering, Fujian Provincial Key Laboratory of Food Microbiology and Enzyme Engineering, Jimei University, Xiamen, Fujian, China
| | - Yongzhen Zhao
- Guangxi Academy of Fishery Sciences, Guangxi Key Laboratory of Aquatic Genetic Breeding and Healthy Aquaculture, Nanning, China
| | - Xiuli Chen
- Guangxi Academy of Fishery Sciences, Guangxi Key Laboratory of Aquatic Genetic Breeding and Healthy Aquaculture, Nanning, China
| | - Jude Juventus Aweya
- Institute of Marine Sciences and Guangdong Provincial Key Laboratory of Marine Biotechnology, Shantou University, Shantou, China
- College of Ocean Food and Biological Engineering, Fujian Provincial Key Laboratory of Food Microbiology and Enzyme Engineering, Jimei University, Xiamen, Fujian, China
| | - Yueling Zhang
- Institute of Marine Sciences and Guangdong Provincial Key Laboratory of Marine Biotechnology, Shantou University, Shantou, China
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2
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Sim J, Kwon H, Jun I, Kim S, Kim B, Kim S, Song J, Hwang G. Association between red blood cell distribution width and blood transfusion in patients undergoing living donor liver transplantation: propensity score analysis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:983-993. [DOI: 10.1002/jhbp.1163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/26/2022] [Accepted: 03/27/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Ji‐Hoon Sim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Hye‐Mee Kwon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - In‐Gu Jun
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Sung‐Hoon Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Bomi Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Sehee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Jun‐Gol Song
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Gyu‐Sam Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
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3
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Douville NJ, Davis R, Jewell E, Colquhoun DA, Ramachandran SK, Engoren MC, Picton P. Volume of packed red blood cells and fresh frozen plasma is associated with intraoperative hypocalcaemia during large volume intraoperative transfusion. Transfus Med 2021; 31:447-458. [PMID: 34142405 DOI: 10.1111/tme.12798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/01/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Severe hypocalcaemia is associated with increased transfusion in the trauma population. Furthermore, trauma patients developing severe hypocalcaemia have higher mortality and coagulopathy. Electrolyte abnormalities associated with massive transfusion have been less studied in the surgical population. Here, we tested the primary hypothesis that volume of packed red blood cells and fresh frozen plasma transfused intraoperatively is associated with lower nadir ionised calcium in the surgical population receiving massive resuscitation. METHODS We performed a retrospective observational study at an academic quaternary care centre to characterise hypocalcaemia following large volume (4 or more units packed red blood cells) intraoperative transfusion. We used multivariable linear regression to assess if volume of transfusion with packed red blood cells and fresh frozen plasma were independently associated with a lower ionised calcium. We then used multivariable logistic regressions to assess the association between ionised calcium and transfusion with: (i) mortality, (ii) acute kidney injury, and (iii) postoperative coagulopathy. RESULTS Hypocalcaemia following large volume resuscitation in the operating room is a very frequent occurrence (70% of cases). After controlling for demographic variables and intraoperative variables, the volume transfused intraoperative was independently associated with hypocalcaemia on multivariable linear regression. Hypocalcaemia, intraoperative transfusion of packed red blood cells, and intraoperative transfusion of fresh frozen plasma were not shown to be associated with clinical outcomes. CONCLUSIONS Hypocalcaemia was associated with increased transfusion volume in this single-centre study. Unlike the trauma population, hypocalcaemia was not associated with increased mortality during surgical care. Our findings suggest that despite improved practice patterns of calcium supplementation, intraoperative hypocalcaemia occurs with relatively high frequency following large volume intraoperative transfusion.
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Affiliation(s)
- Nicholas J Douville
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, USA.,Institute of Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Ryan Davis
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Elizabeth Jewell
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Douglas A Colquhoun
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, USA.,Institute of Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Satya Krishna Ramachandran
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Milo C Engoren
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Paul Picton
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, USA
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4
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Groose MK, Aldred BN, Mezrich JD, Hammel LL. Risk Factors for Intracardiac Thrombus During Liver Transplantation. Liver Transpl 2019; 25:1682-1689. [PMID: 31119833 DOI: 10.1002/lt.25498] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 04/25/2019] [Indexed: 02/07/2023]
Abstract
Intracardiac thrombus (ICT) is an intraoperative complication with high mortality that occurs during orthotopic liver transplantation (OLT). Patients with end-stage liver disease have compromised coagulation pathways, and when combined with stressors of surgery, thrombi can form. However, it is unknown which patients are most likely to develop ICT. We performed a retrospective cohort study of all OLT patients at our hospital from 2010 to 2017 to identify risk factors for ICT. An analysis was performed with conventional bivariate tests and logistic regression. The incidence of ICT during OLT was 4.2% (22/528) with a 45.5% (10/22) mortality. Patients who developed ICT had higher physiologic Model for End-Stage Liver Disease scores at the time of transplant (25.1 versus 32.4; P = 0.004), received grafts from donors with a higher body mass index (28.1 versus 32.2 kg/m2 ; P = 0.007), and had longer intraoperative warm ischemia times (53.1 versus 67.5 minutes; P = 0.001). The odds of developing ICT were significantly lower after administration of intravenous (IV) heparin prior to inferior vena cava (IVC) clamping compared with no administration of heparin (odds ratio, 0.25; 95% confidence interval, 0.08-0.75; P = 0.01). In conclusion, the incidence of ICT at our institution is higher than previously reported, which may be explained by our routine use of transesophageal echocardiography. Although many factors associated with ICT in this study are nonmodifiable, administration of IV heparin prior to IVC cross-clamping is modifiable and was found to be protective. Further studies will be needed to confirm findings and ultimately aid in preventing these lethal events.
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Affiliation(s)
- Molly K Groose
- Departments of Anesthesiology, Transplantation Division, University of Wisconsin Hospital, Madison, WI
| | - Breanna N Aldred
- Departments of Anesthesiology, Transplantation Division, University of Wisconsin Hospital, Madison, WI
| | - Joshua D Mezrich
- Departments of Surgery, Transplantation Division, University of Wisconsin Hospital, Madison, WI
| | - Laura L Hammel
- Departments of Anesthesiology, Transplantation Division, University of Wisconsin Hospital, Madison, WI
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5
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Trautman CL, Palmer WC, Taner CB, Canabal JM, Getz T, Goldman A, Heckman MG, Diehl NN, Lee DD, Stancampiano FF. Thromboelastography as a Predictor of Outcomes Following Liver Transplantation. Transplant Proc 2018; 49:2110-2116. [PMID: 29149970 DOI: 10.1016/j.transproceed.2017.07.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 06/12/2017] [Accepted: 07/30/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Thromboelastography (TEG) has been used perioperatively during liver transplantation (LT) to provide a real-time global hemostasis assessment for targeted blood product replacement. We aimed to analyze the relationship between post-LT TEG results and outcomes. METHODS We retrospectively analyzed patients undergoing LT from November 2008 to December 2014 at Mayo Clinic Florida. All 441 single-organ 1st-time LT patients aged ≥18 years requiring post-LT intensive care unit management were included. TEG parameters including r time, k time, α angle, and maximum amplitude were measured regularly during the first 24 hours after LT. Outcomes included return to the operating room secondary to bleeding, length of hospitalization, survival, and early allograft dysfunction. RESULTS A prolonged and/or lengthening r time, k time, and r+k time were all independently associated with increased length of hospitalization after LT. Increased maximum amplitude on the first post-LT TEG was associated with early allograft dysfunction. No notable associations of TEG parameters with survival or return to operating room were observed. CONCLUSIONS The association of absolute and temporal TEG value changes with increased length of hospitalization and early allograft dysfunction suggests that TEG may have a role in identifying patients at high risk for these outcomes.
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Affiliation(s)
- C L Trautman
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida
| | - W C Palmer
- Gastroenterology, Mayo Clinic, Jacksonville, Florida.
| | - C B Taner
- Transplant, Mayo Clinic, Jacksonville, Florida
| | - J M Canabal
- Transplant, Mayo Clinic, Jacksonville, Florida
| | - T Getz
- Clinical Research Internship Study Program, Mayo Clinic, Jacksonville, Florida
| | - A Goldman
- Clinical Research Internship Study Program, Mayo Clinic, Jacksonville, Florida
| | - M G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida
| | - N N Diehl
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida
| | - D D Lee
- Transplant, Mayo Clinic, Jacksonville, Florida
| | - F F Stancampiano
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida
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6
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Dai WC, Chok KSH, Sin SL, Chan ACY, Cheung TT, Wong TCL, Lo CM. Impact of intraoperative blood transfusion on long-term outcomes of liver transplantation for hepatocellular carcinoma. ANZ J Surg 2018; 88:E418-E423. [PMID: 27806436 DOI: 10.1111/ans.13815] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Wing Chiu Dai
- Department of Surgery; The University of Hong Kong; Hong Kong China
| | - Kenneth S. H. Chok
- Department of Surgery; The University of Hong Kong; Hong Kong China
- State Key Laboratory for Liver Research; The University of Hong Kong; Hong Kong China
| | - Sui Ling Sin
- Department of Surgery; The University of Hong Kong; Hong Kong China
| | - Albert C. Y. Chan
- Department of Surgery; The University of Hong Kong; Hong Kong China
- State Key Laboratory for Liver Research; The University of Hong Kong; Hong Kong China
| | - Tan To Cheung
- Department of Surgery; The University of Hong Kong; Hong Kong China
- State Key Laboratory for Liver Research; The University of Hong Kong; Hong Kong China
| | | | - Chung Mau Lo
- Department of Surgery; The University of Hong Kong; Hong Kong China
- State Key Laboratory for Liver Research; The University of Hong Kong; Hong Kong China
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7
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Anesthesia for Liver Transplantation. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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8
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Risk factors for acute kidney injury after orthotopic liver transplantation: A single-center data analysis. Curr Med Sci 2017; 37:861-863. [PMID: 29270744 DOI: 10.1007/s11596-017-1818-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 12/16/2017] [Indexed: 01/18/2023]
Abstract
Acute kidney injury (AKI) is a common complication following orthotopic liver transplantation (OLT) and is associated with increased morbidity and mortality. The aim of the current study was to determine the risk factors for AKI in patients undergoing OLT. A total of 103 patients who received OLT between January 2015 and May 2016 in Tongji Hospital, China, were retrospectively analyzed. Their demographic characteristics and perioperative parameters were collected, and AKI was diagnosed using 2012 Kidney Disease: Improving Global Outcomes (KDIGO) staging criteria. It was found that the incidence of AKI was 40.8% in this cohort and AKI was significantly associated with body mass index, urine volume, operation duration (especially > 480 min), and the postoperative use of vasopressors. It was concluded that relative low urine output, long operation duration, and the postoperative use of vasopressors are risk factors for AKI following OLT.
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Abstract
With the evolution of surgical and anesthetic techniques, liver transplantation has become "routine," allowing for modifications of practice to decrease perioperative complications and costs. There is debate over the necessity for intensive care unit admission for patients with satisfactory preoperative status and a smooth intraoperative course. Postoperative care is made easier when the liver graft performs optimally. Assessment of graft function, vigilance for complications after the major surgical insult, and optimization of multiple systems affected by liver disease are essential aspects of postoperative care. The intensivist plays a vital role in an integrated multidisciplinary transplant team.
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Affiliation(s)
- Mark T Keegan
- Division of Critical Care, Department of Anesthesiology, Mayo Clinic, Charlton 1145, 200 1st Street Southwest, Rochester, MN 55905, USA.
| | - David J Kramer
- Aurora Critical Care Service, 2901 W Kinnickinnic River Parkway, Milwaukee, WI 53215, USA; University of Wisconsin, School of Medicine and Public Health, 750, Highland Avenue, Madison, WI 53705, USA
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10
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EXP CLIN TRANSPLANTExp Clin Transplant 2016; 14. [DOI: 10.6002/ect.2015.0184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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11
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Komorowski AL, Li WF, Millan CA, Huang TS, Yong CC, Lin TS, Lin TL, Jawan B, Wang CC, Chen CL. Temporary abdominal closure and delayed biliary reconstruction due to massive bleeding in patients undergoing liver transplantation: an old trick in a new indication. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:118-24. [PMID: 26692574 PMCID: PMC4764012 DOI: 10.1002/jhbp.311] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 12/17/2015] [Indexed: 12/27/2022]
Abstract
Background Massive bleeding during liver transplantation (LT) is difficult to manage surgical event. Perihepatic packing (PP) and temporary abdominal closure (TAC) with delayed biliary reconstruction (DBR) can be applied in these circumstances. Method A prospective database of LT in a major transplant center was analyzed to identify patients with massive uncontrollable bleeding during LT that was resolved by PP, TAC, and DBR. Results From January 2009 to July 2013, 20 (3.6%) of 547 patients who underwent LT underwent DBR. Mean intraoperative blood loss was 20,500 ml at the first operation. The DBR was performed with a mean of 55.2 h (16–110) after LT. Biliary reconstruction included duct‐to‐duct (n = 9) and hepatico‐jejunostomy (n = 11). Complications occurred in eight patients and included portal vein thrombosis, cholangitis, severe bacteremia, pneumonia. There was one in‐hospital death. In the follow‐up of 18 to 33 months we have seen one patient died 9 months after transplantation. The remaining 18 patients are alive and well. Conclusions In case of massive uncontrollable bleeding and bowel edema during LT, the combined procedures of PP, TAC, and DBR offer an alternatively surgical option to solve the tough situation.
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Affiliation(s)
- Andrzej L Komorowski
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan.,Department of Surgical Oncology, Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Kraków, Poland
| | - Wei-Feng Li
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Carlos A Millan
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Tun-Sung Huang
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan.,Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chee-Chien Yong
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Tsan-Shiun Lin
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Ting-Lung Lin
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
| | - Bruno Jawan
- Liver Transplantation Program and Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Chi Wang
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan. .,Department of Surgery, Chang Gung Memorial Hospital Chiayi, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Chao-Long Chen
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Song, Kaohsiung, 833, Taiwan
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12
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Donohue CI, Mallett SV. Reducing transfusion requirements in liver transplantation. World J Transplant 2015; 5:165-182. [PMID: 26722645 PMCID: PMC4689928 DOI: 10.5500/wjt.v5.i4.165] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/10/2015] [Accepted: 11/25/2015] [Indexed: 02/05/2023] Open
Abstract
Liver transplantation (LT) was historically associated with massive blood loss and transfusion. Over the past two decades transfusion requirements have reduced dramatically and increasingly transfusion-free transplantation is a reality. Both bleeding and transfusion are associated with adverse outcomes in LT. Minimising bleeding and reducing unnecessary transfusions are therefore key goals in the perioperative period. As the understanding of the causes of bleeding has evolved so too have techniques to minimize or reduce the impact of blood loss. Surgical “piggyback” techniques, anaesthetic low central venous pressure and haemodilution strategies and the use of autologous cell salvage, point of care monitoring and targeted correction of coagulopathy, particularly through use of factor concentrates, have all contributed to declining reliance on allogenic blood products. Pre-emptive management of preoperative anaemia and adoption of more restrictive transfusion thresholds is increasingly common as patient blood management (PBM) gains momentum. Despite progress, increasing use of marginal grafts and transplantation of sicker recipients will continue to present new challenges in bleeding and transfusion management. Variation in practice across different centres and within the literature demonstrates the current lack of clear transfusion guidance. In this article we summarise the causes and predictors of bleeding and present the evidence for a variety of PBM strategies in LT.
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13
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Is There a Role for Desmopressin in Liver Transplantation? A Case Report. Transplant Proc 2015; 47:2782-5. [DOI: 10.1016/j.transproceed.2015.09.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 09/17/2015] [Indexed: 12/19/2022]
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14
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De Pietri L, Mocchegiani F, Leuzzi C, Montalti R, Vivarelli M, Agnoletti V. Transoesophageal echocardiography during liver transplantation. World J Hepatol 2015; 7:2432-2448. [PMID: 26483865 PMCID: PMC4606199 DOI: 10.4254/wjh.v7.i23.2432] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 06/22/2015] [Accepted: 09/09/2015] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation (LT) has become the standard of care for patients with end stage liver disease. The allocation of organs, which prioritizes the sickest patients, has made the management of liver transplant candidates more complex both as regards their comorbidities and their higher risk of perioperative complications. Patients undergoing LT frequently display considerable physiological changes during the procedures as a result of both the disease process and the surgery. Transoesophageal echocardiography (TEE), which visualizes dynamic cardiac function and overall contractility, has become essential for perioperative LT management and can optimize the anaesthetic management of these highly complex patients. Moreover, TEE can provide useful information on volume status and the adequacy of therapeutic interventions and can diagnose early intraoperative complications, such as the embolization of large vessels or development of pulmonary hypertension. In this review, directed at clinicians who manage TEE during LT, we show why the procedure merits a place in challenging anaesthetic environment and how it can provide essential information in the perioperative management of compromised patients undergoing this very complex surgical procedure.
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15
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Roullet S, Freyburger G, Cruc M, Quinart A, Stecken L, Audy M, Chiche L, Sztark F. Management of bleeding and transfusion during liver transplantation before and after the introduction of a rotational thromboelastometry-based algorithm. Liver Transpl 2015; 21:169-79. [PMID: 25331016 DOI: 10.1002/lt.24030] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 09/30/2014] [Accepted: 10/12/2014] [Indexed: 02/07/2023]
Abstract
Orthotopic liver transplantation (OLT) remains a potentially hemorrhagic procedure. Rotational thromboelastometry (ROTEM) is a point-of-care device used to monitor coagulation during OLT. Whether it allows blood loss and transfusions to be reduced during OLT remains controversial. Excellent correlations and predictive values have been found between ROTEM parameters and fibrinogen. We hypothesized that the use of a ROTEM-based transfusion algorithm during OLT would lead to more fibrinogen transfusion and decreased bleeding and blood transfusion. Sixty adult patients were consecutively included in a prospective, without-versus-with study: 30 in the group without ROTEM results and 30 in the group with the ROTEM-based algorithm. A small and nonsignificant increase in median fibrinogen transfusions was found for the with group (6.0 g versus 4.5 g, P = 0.50). It was not associated with a decrease in blood transfusions or in the number of patients exposed to blood products.
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Affiliation(s)
- Stéphanie Roullet
- Anesthesia and Intensive care Department I, Bordeaux, France; Liver Transplant Unit, Bordeaux, France
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16
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Anaesthetic and Perioperative Management for Liver Transplantation. ABDOMINAL SOLID ORGAN TRANSPLANTATION 2015. [PMCID: PMC7124066 DOI: 10.1007/978-3-319-16997-2_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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17
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Abstract
Blood loss and blood transfusion have been inherently associated with liver transplantation. Bleeding has been attributed to the various factors which are associated with chronic liver dysfunction. Various surgical and anaesthetic strategies have been developed over the years to reduce bleeding and also to optimise the usage of various blood and blood products perioperatively. The present day success of liver transplantation can be attributed to these issues where transfusion practices have changed. Although several centres are successfully performing liver transplantations in large numbers, there is still a large variability in the usage of blood and blood products perioperatively among the institutions and even among different anaesthesiologists from the same institution. The present article deals with the various factors confounding this concept of blood transfusion practices and the various strategies adopted to reduce the transfusion requirements in the perioperative period.
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Affiliation(s)
- Mn Chidananda Swamy
- Department of Anaesthesia and Critical Care, Sakra World Hospitals, Devarabeesanahalli, Bengaluru, Karnataka, India
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18
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Jawan B, Wang CH, Chen CL, Huang CJ, Cheng KW, Wu SC, Shih TH, Yang SC. Review of anesthesia in liver transplantation. ACTA ACUST UNITED AC 2014; 52:185-96. [PMID: 25477262 DOI: 10.1016/j.aat.2014.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 09/26/2014] [Indexed: 01/10/2023]
Abstract
Liver transplantation (LT) is a well-accepted treatment modality of many end-stage liver diseases. The main issue in LT is the shortage of deceased donors to accommodate the needs of patients waiting for such transplants. Live donors have tremendously increased the pool of available liver grafts, especially in countries where deceased donors are not common. The main ethical concern of this procedure is the safety of healthy donors, who undergo a major abdominal surgery not for their own health, but to help cure others. The first part of the review concentrates on live donor selection, preanesthetic evaluation, and intraoperative anesthetic care for living liver donors. The second part reviews patient evaluation, intraoperative anesthesia monitoring, and fluid management of the recipient. This review provides up-to-date information to help improve the quality of anesthesia, and contribute to the success of LT and increase the long-term survival of the recipients.
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Affiliation(s)
- Bruno Jawan
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Chih-Hsien Wang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chao-Long Chen
- Liver Transplant Program, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Jung Huang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kwok-Wai Cheng
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tsung-Hsiao Shih
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Sheng-Chun Yang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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19
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Coêlho GR, Feitosa Neto BA, de G Teixeira CC, Marinho DS, Rangel MLM, Garcia JHP. Single-center transfusion rate for 555 consecutive liver transplantations: impact of two eras. Transplant Proc 2014; 45:3305-9. [PMID: 24182806 DOI: 10.1016/j.transproceed.2013.07.062] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 07/16/2013] [Accepted: 07/30/2013] [Indexed: 01/24/2023]
Abstract
Orthotopic liver transplantation (OLT) is the treatment of choice for patients with acute or chronic end-stage liver disease, irresectable primary liver tumor, and metabolic disorders. Historically, OLT has been associated with considerable blood loss and the need for transfusions. However, over the years there has been reduction is need for blood products. The aim of this article was to compare two distinct eras for perioperative blood transfusion rate among patients undergoing OLT; Era I, 200 transplantations in 188 patients, and Era II, 355 transplantations in 339 patients. The donor mean age was 33.70 (Era I) versus 35.34 (Era II). Cause of death in both eras was traumatic brain injury followed by cerebral vascular accident. Organ recipient data showed a mean age of 48.87 (Era I) versus 46.49 (Era II). During Era I patients with Child B (56.8%) prevailed, followed by Child C (35.4%) and Child A (7.8%). In Era II also patients with Child B (53.1%) prevailed, followed by Child C (39.6%) and Child A (7.3%). The prevalence of hepatocellular carcinoma (HCC) during Era I was 9% (18) and in Era II 20% (71). The use of blood products in the perioperative period: was as follows packed red blood cells 1.76 (Era I) versus 0.57 (Era II) units; fresh frozen plasma 1.89 (Era I) versus 0.49 (Era II) units; platelets 2.16 (Era I) versus 0.28 (Era II) units; and cryoprecipitate 0.08 (Era I) versus 0.03 (Era II) units. OLT using the piggyback technique was performed with a transfusion rate below <30%, and it reduced blood loss and prevented severe hemodynamic instability.
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Affiliation(s)
- G R Coêlho
- Department of Surgery, Hospital Universitário Walter Cantídio, Federal University of Ceará, Ceará, Brazil
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20
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Clevenger B, Mallett SV. Transfusion and coagulation management in liver transplantation. World J Gastroenterol 2014; 20:6146-6158. [PMID: 24876736 PMCID: PMC4033453 DOI: 10.3748/wjg.v20.i20.6146] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 02/10/2014] [Accepted: 03/13/2014] [Indexed: 02/06/2023] Open
Abstract
There is wide variation in the management of coagulation and blood transfusion practice in liver transplantation. The use of blood products intraoperatively is declining and transfusion free transplantations take place ever more frequently. Allogenic blood products have been shown to increase morbidity and mortality. Primary haemostasis, coagulation and fibrinolysis are altered by liver disease. This, combined with intraoperative disturbances of coagulation, increases the risk of bleeding. Meanwhile, the rebalancing of coagulation homeostasis can put patients at risk of hypercoagulability and thrombosis. The application of the principles of patient blood management to transplantation can reduce the risk of transfusion. This includes: preoperative recognition and treatment of anaemia, reduction of perioperative blood loss and the use of restrictive haemoglobin based transfusion triggers. The use of point of care coagulation monitoring using whole blood viscoelastic testing provides a picture of the complete coagulation process by which to guide and direct coagulation management. Pharmacological methods to reduce blood loss include the use of anti-fibrinolytic drugs to reduce fibrinolysis, and rarely, the use of recombinant factor VIIa. Factor concentrates are increasingly used; fibrinogen concentrates to improve clot strength and stability, and prothrombin complex concentrates to improve thrombin generation. Non-pharmacological methods to reduce blood loss include surgical utilisation of the piggyback technique and maintenance of a low central venous pressure. The use of intraoperative cell salvage and normovolaemic haemodilution reduces allogenic blood transfusion. Further research into methods of decreasing blood loss and alternatives to blood transfusion remains necessary to continue to improve outcomes after transplantation.
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Abstract
Orthotopic liver transplantation is the only definitive treatment for end-stage liver disease. More than 6000 procedures are performed in the United States annually with excellent survival rates. The shortage of donor organs leads to continued interest in techniques to enlarge the potential donor pool. Patients presenting for liver transplant suffer from important cardiovascular, respiratory, renal, neurological, and gastroenterological comorbidity. In the Western world, liver failure is increasingly caused by steatohepatitis, and transplant candidates are thus becoming older and more comorbid. The role of the transplant anesthesiologist is highly important in the preoperative assessment, intraoperative management, and postoperative care of these complex and sick patients. Appropriate investigation and management of comorbidities such as coronary artery disease and portopulmonary hypertension is controversial and differs between programs. The transplant procedure is a major surgery, and although massive transfusion is no longer commonplace, there is potential for significant hemodynamic instability, coagulopathy, and metabolic disturbance. Liver transplant surgery can be divided into the preanhepatic phase, the anhepatic phase, and the reperfusion phase, with important anesthetic considerations at each point. An understanding of the surgical techniques used for vascular exclusion of the liver and the role of venovenous bypass is crucial for the anesthesiologist. Recent trends in perioperative care include the use of antifibrinolytic drugs and point-of-care coagulation tests, intraoperative renal replacement therapy, and “fast-track” extubation and postoperative care. Care of patients with fulminant hepatic failure or those receiving split-liver grafts requires special consideration.
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Affiliation(s)
| | - Achal Dhir
- London Health Sciences Centre, London, ON, Canada
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22
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Bindi ML, Miccoli M, Marietta M, Meacci L, Esposito M, Bisà M, Mozzo R, Mazzoni A, Baggiani A, Scatena F, Filipponi F, Biancofiore G. Solvent detergent vs. fresh frozen plasma in cirrhotic patients undergoing liver transplant surgery: a prospective randomized control study. Vox Sang 2013; 105:137-43. [DOI: 10.1111/vox.12021] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 12/05/2012] [Accepted: 12/08/2012] [Indexed: 02/01/2023]
Affiliation(s)
- M. L. Bindi
- Liver Transplant Anaesthesia and Critical Care Medicine; Azienda Ospedaliera Universitaria Pisana; Pisa; Italy
| | - M. Miccoli
- Biostatistic Research Unit; University of Pisa; Pisa; Italy
| | - M. Marietta
- Haemostasis and Thrombosis Unit; Department of Haematology and Oncology; Azienda Ospedaliera Universitaria Modena; Modena; Italy
| | - L. Meacci
- Liver Transplant Anaesthesia and Critical Care Medicine; Azienda Ospedaliera Universitaria Pisana; Pisa; Italy
| | - M. Esposito
- Liver Transplant Anaesthesia and Critical Care Medicine; Azienda Ospedaliera Universitaria Pisana; Pisa; Italy
| | - M. Bisà
- Liver Transplant Anaesthesia and Critical Care Medicine; Azienda Ospedaliera Universitaria Pisana; Pisa; Italy
| | - R. Mozzo
- Liver Transplant Anaesthesia and Critical Care Medicine; Azienda Ospedaliera Universitaria Pisana; Pisa; Italy
| | - A. Mazzoni
- Immunohematology Unit; Azienda Ospedaliera Universitaria Pisana; Pisa; Italy
| | - A. Baggiani
- Biostatistic Research Unit; University of Pisa; Pisa; Italy
| | - F. Scatena
- Immunohematology Unit; Azienda Ospedaliera Universitaria Pisana; Pisa; Italy
| | - F. Filipponi
- Liver Transplant Unit; University School of Medicine; Pisa; Italy
| | - G. Biancofiore
- Liver Transplant Anaesthesia and Critical Care Medicine; Azienda Ospedaliera Universitaria Pisana; Pisa; Italy
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Paolo F, Marialuisa B, Stefania B, Helmut G, Moira M, Cristiana C, Carlo O. Blood loss, predictors of bleeding, transfusion practice and strategies of blood cell salvaging during liver transplantation. World J Hepatol 2013; 5:1-15. [PMID: 23383361 PMCID: PMC3562721 DOI: 10.4254/wjh.v5.i1.1] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 01/19/2013] [Indexed: 02/06/2023] Open
Abstract
Blood loss during liver transplantation (OLTx) is a common consequence of pre-existing abnormalities of the hemostatic system, portal hypertension with multiple collateral vessels, portal vein thrombosis, previous abdominal surgery, splenomegaly, and poor “functional” recovery of the new liver. The intrinsic coagulopathic features of end stage cirrhosis along with surgical technical difficulties make transfusion-free liver transplantation a major challenge, and, despite the improvements in understanding of intraoperative coagulation profiles and strategies to control blood loss, the requirements for blood or blood products remains high. The impact of blood transfusion has been shown to be significant and independent of other well-known predictors of posttransplant-outcome. Negative effects on immunomodulation and an increased risk of postoperative complications and mortality have been repeatedly demonstrated. Isovolemic hemodilution, the extensive utilization of thromboelastogram and the use of autotransfusion devices are among the commonly adopted procedures to limit the amount of blood transfusion. The use of intraoperative blood salvage and autologous blood transfusion should still be considered an important method to reduce the need for allogenic blood and the associated complications. In this article we report on the common preoperative and intraoperative factors contributing to blood loss, intraoperative transfusion practices, anesthesiologic and surgical strategies to prevent blood loss, and on intraoperative blood salvaging techniques and autologous blood transfusion. Even though the advances in surgical technique and anesthetic management, as well as a better understanding of the risk factors, have resulted in a steady decrease in intraoperative bleeding, most patients still bleed extensively. Blood transfusion therapy is still a critical feature during OLTx and various studies have shown a large variability in the use of blood products among different centers and even among individual anesthesiologists within the same center. Unfortunately, despite the large number of OLTx performed each year, there is still paucity of large randomized, multicentre, and controlled studies which indicate how to prevent bleeding, the transfusion needs and thresholds, and the “evidence based” perioperative strategies to reduce the amount of transfusion.
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24
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Effect of low central venous pressure on postoperative pulmonary complications in patients undergoing liver transplantation. Surg Today 2012; 43:777-81. [PMID: 23238884 DOI: 10.1007/s00595-012-0419-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 08/20/2012] [Indexed: 12/22/2022]
Abstract
PURPOSE To investigate the effect of the low central venous pressure (LCVP) technique on postoperative pulmonary complications in patients undergoing liver transplantation. METHODS Sixty-five adult patients were randomly divided into a LCVP group (n = 33) and a control group (n = 32). The CVP was maintained below 5 mmHg or 40 % lower than baseline in the LCVP group, by manipulating the patient's posture, limiting infusion volume, and administration of nitroglycerine. Recipients in the control group received standard care. The volume of intraoperative blood loss and transfusion, and postoperative pulmonary complications of the two groups were compared. RESULTS The LCVP group had a significantly earlier tracheal extubation (33 ± 33 vs. 53 ± 36 h, P < 0.05), and lower rate of postoperative pulmonary complications (42.8 vs. 71.4 %, P < 0.05) in comparison to the control group. The most frequent complication was pleural effusion (28.5 vs. 67.8 %, P < 0.05), followed by pneumonia (24.2 vs. 57.1 %, P < 0.05) and pulmonary edema (3.1 vs. 14.3 %, P < 0.05). CONCLUSIONS The LCVP technique during liver transplantation could decrease postoperative pulmonary complications.
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Nandhakumar A, McCluskey SA, Srinivas C, Chandy TT. Liver transplantation: Advances and perioperative care. Indian J Anaesth 2012; 56:326-35. [PMID: 23087453 PMCID: PMC3469909 DOI: 10.4103/0019-5049.100812] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Liver transplantation is one of the treatments for many-life threatening liver diseases. Numerous advances in liver transplant surgery, anaesthesia and perioperative care have allowed for an increasing number of these procedures. The purpose of this review is to consider some of the important advances in perioperative care of liver transplant patients such as pre-operative evaluation, intraoperative monitoring and management and early extubation. A PubMed and EMBASE search of terms “Anaesthesia” and “Liver Transplantation” were performed with filters of articles in “English”, “Adult” and relevant recent publications of randomised control trial, editorial, systemic review and non-systemic review were selected and synthesized according to the author's personal and professional perspective in the field of liver transplantation and anaesthesia. The article outlines strategies in organ preservation, training and transplant database for further research.
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Affiliation(s)
- Amar Nandhakumar
- Department of Anaesthesia, Toronto General Hospital, University of Toronto, Toronto, ON M5G 2C4, Canada
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26
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Abstract
PURPOSE OF REVIEW An increasing number of patients requiring surgery are presenting with chronic or end stage liver disease. The management of these patients demands anesthesiologists with in-depth knowledge of the consequences of hepatic dysfunction, the effects on other organs, the risk of surgery, and the impact of anesthesia. RECENT FINDINGS Chronic or end stage liver disease is associated with an increased risk of perioperative morbidity and mortality. It is essential to preoperatively assess possible hepatic encephalopathy, pleural effusions, hepatopulmonary syndrome, hepatopulmonary hypertension, hepatorenal syndrome, cirrhotic cardiomyopathy, and coagulation disorders. The application of two scoring systems, that is, Child-Turcotte-Pugh and model for end stage liver disease, helps to estimate the risk of surgery. The use of propofol is superior to benzodiazepines as intravenous narcotics. Although enflurane and halothane are discouraged for maintenance of anesthesia, all modern volatile anesthetics appear comparable with respect to outcome. Fentanyl, sufentanil, and remifentanil as opioids and cis-atracurium for relaxation may be the best choices in liver insufficency. Regional anesthesia is valuable for postoperative pain management. SUMMARY Current studies have employed different anesthetic approaches in the preoperative and intraoperative management in order to improve outcomes of patients with liver disease.
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Dunn LK, Thiele RH, Ma JZ, Sawyer RG, Nemergut EC. Duration of red blood cell storage and outcomes following orthotopic liver transplantation. Liver Transpl 2012; 18:475-81. [PMID: 22238247 DOI: 10.1002/lt.23379] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Liver transplantation may be complicated by massive intraoperative bleeding, and red blood cell (RBC) transfusions may be required. The storage duration or age of transfused RBCs has been shown to affect the morbidity and mortality of critically ill, trauma, and cardiac surgery patients. Here we investigate the effect of RBC age on the outcomes of liver transplant patients. Five hundred thirty-one patients underwent orthotopic liver transplantation between January 1, 2000 and August 15, 2010. The patient demographics, the Model for End-Stage Liver Disease-sodium (MELD-Na) score, and the number and age of RBC units were evaluated with univariate and multivariate models of outcomes, which included mortality rates 2 years after transplantation, postoperative infections, and organ rejection. In a univariate analysis, the number of RBC units (but not the RBC age) was associated with increased 2-year mortality, an increased risk of infection, and a decreased risk of organ rejection. Only the number of RBC units was associated with increased 2-year mortality in a multivariate Cox regression model. The mortality risk was decreased by two-thirds for patients who received <10 U of RBCs versus those who received ≥10 U (hazard ratio = 0.33, 95% confidence interval = 0.16-0.69, P = 0.003). The number of transfused RBC units was not associated with the risk of infection or organ rejection in a multivariate logistic regression model. In conclusion, the RBC age is not associated with infection, organ rejection, or death in liver transplant patients. Patients who receive more blood have an increased risk of death. In a multivariate model, the MELD-Na score was not associated with increased mortality, and this is consistent with previous studies demonstrating that the MELD-Na score is a poor predictor of long-term survival after transplantation.
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Affiliation(s)
- Lauren K Dunn
- Departments of Anesthesiology, University of Virginia Health System, Charlottesville, VA 22908, USA
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29
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Deceased donor liver transplantation: A surgical view from the west. INDIAN JOURNAL OF TRANSPLANTATION 2011. [DOI: 10.1016/s2212-0017(11)60077-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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