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Infections in Liver Transplantation. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2019. [PMCID: PMC7120017 DOI: 10.1007/978-1-4939-9034-4_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Liver transplantation has become an important treatment modality for patients with end-stage liver disease/cirrhosis, acute liver failure, and hepatocellular carcinoma. Although surgical techniques and immunosuppressive regimens for liver transplantation have improved significantly over the past 20 years, infectious complications continue to contribute to the morbidity and mortality in this patient population. The use of standardized screening protocols for both donors and recipients, coupled with targeted prophylaxis against specific pathogens, has helped to mitigate the risk of infection in liver transplant recipients. Patients with chronic liver disease and cirrhosis have immunological deficits that place them at increased risk for infection while awaiting liver transplantation. The patient undergoing liver transplantation is prone to develop healthcare-acquired infections due to multidrug-resistant organisms that could potentially affect patient outcomes after transplantation. The complex nature of liver transplant surgery that involves multiple vascular and hepatobiliary anastomoses further increases the risk of infection after liver transplantation. During the early post-transplantation period, healthcare-acquired bacterial and fungal infections are the most common types of infection encountered in liver transplant recipients. The period of maximal immunosuppression that occurs at 1–6 months after transplantation can be complicated by opportunistic infections due to both primary infection and reactivation of latent infection. Severe community-acquired infections can complicate the course of liver transplantation beyond 12 months after transplant surgery. This chapter provides an overview of liver transplantation including indications, donor-recipient selection criteria, surgical procedures, and immunosuppressive therapies. A focus on infections in patients with chronic liver disease/cirrhosis and an overview of the specific infectious complications in liver transplant recipients are presented.
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Yoon JU, Byeon GJ, Park JY, Yoon SH, Ryu JH, Ri HS. Bloodless living donor liver transplantation: Risk factors, outcomes, and diagnostic predictors. Medicine (Baltimore) 2018; 97:e13581. [PMID: 30558025 PMCID: PMC6320073 DOI: 10.1097/md.0000000000013581] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Massive bleeding is often unavoidable during liver transplantation (LT). However, blood transfusions are associated with risks and should be avoided whenever possible. This study compares preoperative factors and outcomes between non-transfusion and transfusion groups to identify variables that could be used to predict bloodless surgery in living donor liver transplantation (LDLT) patients.We conducted a retrospective study of 87 LDLT patients. The group of patients who did not require packed red blood cell (PRBC) transfusion (non-PRBC group, n = 44) was compared with those who did (PRBC group, n = 43). We compared risk factors, fluid management, and outcomes between the groups and identified variables for prediction of transfusion during LDLT.Compared with the PRBC group, the non-PRBC group had a lower model for end-stage liver disease (MELD) score (8.1 ± 1.1 vs 18.2 ± 8.8), international normalized ratio (INR) (1.16 ± 0.1 vs 1.80 ± 0.94), and partial thromboplastin time (PTT) (37.1 ± 6.3 vs 54.1 ± 24.0), but higher hemoglobin (Hb) (13.6 ± 1.6 vs 11.5 ± 2.2) and hematocrit (HCT) (39.1 ± 4.4 vs 32.6 ± 6.0). The non-PRBC group were more likely to receive colloid and albumin but had shorter intensive care unit (ICU) and hospital length of stay. The area under the receiver operative characteristic (ROC) curve of the MELD score was the highest (91%) using a cutoff value of 10.5.Patients without PRBC transfusion during LDLT were in better condition preoperatively and had better outcomes. The MELD score is a significant predictor for PRBC transfusion.
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Affiliation(s)
- Ji-Uk Yoon
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital
| | - Gyeong-Jo Byeon
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital
| | - Ju Yeon Park
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital
| | - Seok Hyun Yoon
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital
| | - Je-Ho Ryu
- Department of Surgery, School of Medicine, Pusan National University
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan-si, Republic of Korea
| | - Hyun-Su Ri
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital
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Metcalf RA, Pagano MB, Hess JR, Reyes J, Perkins JD, Montenovo MI. A data-driven patient blood management strategy in liver transplantation. Vox Sang 2018; 113:421-429. [PMID: 29714029 DOI: 10.1111/vox.12650] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/02/2018] [Accepted: 03/05/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Blood utilization during liver transplant has decreased, but remains highly variable due to many complex surgical and physiologic factors. Previous models attempted to predict utilization using preoperative variables to stratify cases into two usage groups, usually using entire blood units for measurement. We sought to develop a practical predictive model using specific transfusion volumes (in ml) to develop a data-driven patient blood management strategy. MATERIALS AND METHODS This is a retrospective evaluation of primary liver transplants at a single institution from 2013 to 2015. Multivariable analysis of preoperative recipient and donor factors was used to develop a model predictive of intraoperative red-blood-cell (pRBC) use. RESULTS Of 256 adult liver transplants, 207 patients had complete transfusion volume data for analysis. The median intraoperative allogeneic pRBC transfusion volume was 1250 ml, and the average was 1563 ± 1543 ml. Preoperative haemoglobin, spontaneous bacterial peritonitis, preoperative haemodialysis and preoperative international normalized ratio together yielded the strongest model predicting pRBC usage. When it predicted <1250 ml of pRBCs, all cases with 0 ml transfused were captured and only 8·6% of the time >1250 ml were used. This prediction had a sensitivity of 0·91 and a specificity of 0·89. If predicted usage was >2000 ml, 75% of the time blood loss exceeded 2000 ml. CONCLUSION Patients likely to require low or high pRBC transfusion volumes were identified with excellent accuracy using this predictive model at our institution. This model may help predict bleeding risk for each patient and facilitate optimized blood ordering.
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Affiliation(s)
- R A Metcalf
- Division of Clinical Pathology, Department of Pathology, University of Utah, Salt Lake City, UT, USA
- ARUP Laboratories, Salt Lake City, UT, USA
| | - M B Pagano
- Division of Transfusion Medicine, Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | - J R Hess
- Division of Transfusion Medicine, Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - J Reyes
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, WA, USA
| | - J D Perkins
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, WA, USA
| | - M I Montenovo
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, WA, USA
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Cleland S, Corredor C, Ye JJ, Srinivas C, McCluskey SA. Massive haemorrhage in liver transplantation: Consequences, prediction and management. World J Transplant 2016; 6:291-305. [PMID: 27358774 PMCID: PMC4919733 DOI: 10.5500/wjt.v6.i2.291] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 03/16/2016] [Accepted: 04/11/2016] [Indexed: 02/05/2023] Open
Abstract
From its inception the success of liver transplantation has been associated with massive blood loss. Massive transfusion is classically defined as > 10 units of red blood cells within 24 h, but describing transfusion rates over a shorter period of time may reduce the potential for survival bias. Both massive haemorrhage and transfusion are associated with increased risk of mortality and morbidity (need for dialysis/surgical site infection) following liver transplantation although causality is difficult to prove due to the observational design of most trials. The blood loss associated with liver transplantation is multifactorial. Portal hypertension secondary to cirrhosis results in extensive collateral circulation, which can bleed during hepatectomy particular if portal pressures are increased. Avoiding volume loading and maintenance of a low central venous pressure together with the use of vasopressors have been shown to reduce blood loss and transfusion during liver transplantation, but may increase the risk of renal impairment post-operatively. Coagulation defects may be present pre-transplant, but haemostasis is often re-balanced due to a deficit in both pro- and anti-coagulation factors. Further derangement of haemostasis may develop in the anhepatic and neohepatic phases due to absent hepatic metabolic function, hyperfibrinolysis and platelet sequestration in the donor liver. Point-of-care tests of coagulation such as the viscoelastic tests rotation thromboelastometry/thromboelastometry allow and more accurate and rapid assessment of these derangements in coagulation and guide the use of factor replacement and antifibrinolytics. Transfusion protocols guided by these tests have been shown to reduce transfusion rates compared with conventional coagulation tests, but have not shown improvements in mortality or morbidity. Pre-operative factors associated with massive transfusion include previous surgery, re-do transplantation, the aetiology and severity of liver disease. Intra-operatively the use of piggy-back technique and avoiding veno-veno bypass has been shown to reduced blood loss.
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Benson AB, Burton JR, Austin GL, Biggins SW, Zimmerman MA, Kam I, Mandell S, Silliman CC, Rosen H, Moss M. Differential effects of plasma and red blood cell transfusions on acute lung injury and infection risk following liver transplantation. Liver Transpl 2011; 17:149-58. [PMID: 21280188 PMCID: PMC3399914 DOI: 10.1002/lt.22212] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Patients with chronic liver disease have an increased risk of developing transfusion-related acute lung injury (TRALI) from plasma-containing blood products. Similarly, red blood cell transfusions have been associated with postoperative and nosocomial infections in surgical and critical care populations. Patients undergoing liver transplantation receive large amounts of cellular and plasma-containing blood components, but it is presently unclear which blood components are associated with these postoperative complications. A retrospective cohort study of 525 consecutive liver transplant patients revealed a perioperative TRALI rate of 1.3% (7/525, 95% confidence interval = 0.6%-2.7%), which was associated with increases in the hospital mortality rate [28.6% (2/7) versus 2.9% (15/518), P = 0.02] and the intensive care unit length of stay [2 (1-11 days) versus 0 days (0-2 days), P = 0.03]. Only high-plasma-containing blood products (plasma and platelets) were associated with the development of TRALI. Seventy-four of 525 patients (14.1%) developed a postoperative infection, and this was also associated with increased in-hospital mortality [10.8% (8/74) versus 2.0% (9/451), P < 0.01] and a prolonged length of stay. Multivariate logistic regression determined that the number of transfused red blood cell units (adjusted odds ratio = 1.08, 95% confidence interval = 1.02-1.14, P < 0.01), the presence of perioperative renal dysfunction, and reoperation were significantly associated with postoperative infection. In conclusion, patients undergoing liver transplantation have a high risk of developing postoperative complications from blood transfusion. Plasma-containing blood products were associated with the development of TRALI, whereas red blood cells were associated with the development of postoperative infections in a dose-dependent manner.
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Affiliation(s)
- Alexander B. Benson
- Division of Pulmonary Sciences and Critical Care, University of Colorado, Aurora, CO
| | - James R. Burton
- Division of Gastroenterology and Hepatology, University of Colorado, Aurora, CO
| | - Gregory L. Austin
- Division of Gastroenterology and Hepatology, University of Colorado, Aurora, CO
| | - Scott W. Biggins
- Division of Gastroenterology and Hepatology, University of Colorado, Aurora, CO
| | | | - Igal Kam
- Department of Transplant Surgery, University of Colorado, Aurora, CO
| | - Susan Mandell
- Department of Anesthesia, University of Colorado, Aurora, CO
| | | | - Hugo Rosen
- Division of Gastroenterology and Hepatology, University of Colorado, Aurora, CO
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care, University of Colorado, Aurora, CO
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Choi JH, Park CM, Lee GS, Yoo SH. The Heparin Effects Changes before and after Reperfusion and It's Related Effects on Transfusion during Liver Transplantation. Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.52.4.422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jong Ho Choi
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chong Min Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Gyeong Seok Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sie Hyeon Yoo
- Department of Anesthesiology and Pain Medicine, College of Medicine, Soonchunhyang University, Cheonan, Korea
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Frasco PE, Poterack KA, Hentz JG, Mulligan DC. A comparison of transfusion requirements between living donation and cadaveric donation liver transplantation: relationship to model of end-stage liver disease score and baseline coagulation status. Anesth Analg 2005; 101:30-7, table of contents. [PMID: 15976201 DOI: 10.1213/01.ane.0000155288.57914.0d] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The use of living donation is an important option for patients in need of liver transplant. We retrospectively reviewed the preoperative Model for End-Stage Liver Disease (MELD) score, baseline coagulation laboratory results, and intraoperative transfusion of red blood cells and component therapy for 27 living donation transplants and 69 cadaveric donation transplants during a 3-yr period (2001-2004). Patients undergoing living donation transplantation had significantly lower MELD scores and preserved coagulation function compared with cadaveric donation transplantation recipients (P < 0.001). The living donation transplant patients also received significantly fewer transfusions of red blood cells and component therapy compared with the cadaveric donation transplant patients (P < 0.001). For the combined population of both cadaveric donation transplant and living donation transplant patients, there were significant associations between MELD score and preoperative coagulation tests (P < 0.001) and intraoperative transfusion of blood and component therapy. MELD score and preoperative fibrinogen concentration were identified as independent predictors of transfusion exposure. In conclusion, we detected significant differences in severity of disease at time of transplantation, degree of impairment of coagulation function, and need for transfusion of red blood cells and component therapy between patients undergoing living donation transplantation compared with patients undergoing cadaveric donation transplantation.
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Affiliation(s)
- Peter E Frasco
- Mayo Clinic College of Medicine, Department of Anesthesiology, Mayo Clinic Scottsdale, 13400 E. Shea Blvd., Scottsdale, AZ 85259, USA.
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Kaliciński P, Markiewicz M, Kamiński A, Laniewski P, Ismail H, Drewniak T, Szymczak M, Nachulewicz P, Jezierska E. Single pretransplant bolus of recombinant activated factor VII ameliorates influence of risk factors for blood loss during orthotopic liver transplantation. Pediatr Transplant 2005; 9:299-304. [PMID: 15910384 DOI: 10.1111/j.1399-3046.2005.00309.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Large blood loss and transfusions during liver transplantation (LTx) may lead to serious complications and have a negative impact on post-transplant mortality and morbidity. In the retrospective study we compared two groups of recipients of primary cadaveric liver transplantation: group I (study group), consisted of 28 patients with preoperative risk of high intraoperative blood loss, including severe uncorrected coagulopathy. This group was given a bolus of recombinant activated factor VII (rFVIIa) just before LTx. Group II (control group) included 61 patients without a particular risk for increased intraoperative blood loss. These patients were not given rFVIIa. We analyzed both groups for: coagulation parameters before, during and after surgery (INR, APTT, factor VII activity), blood and FFP transfusions, operative time, postoperative complications (vascular thrombosis, reoperation for bleeding), postoperative ICU stay, post-transplant hospitalization time and mortality. Patients from the study group (I) had significantly worse coagulation parameters than patients in the control group (II) at the start of the surgical procedure; however, after administration of a bolus of rFVIIa there was immediate correction of coagulation in all recipients. No significant differences in intraoperative blood transfusions were observed between study and control groups (1980 +/- 311.4 mL vs. 1527 +/- 154.2 mL, respectively), operating time (8.7 h vs. 8.9 h) or ICU and hospital stay (7.03 days vs. 6.15 days and 40.89 days vs. 41.1 days). Re-exploration because of bleeding was performed in three patients from group I (10.7%) and in seven patients (11.5%) from group II. No single case of vascular thrombosis was observed in the study group, while in the control group there were three hepatic artery thromboses, two portal vein thromboses and one hepatic vein thrombosis. We conclude that rFVIIa given preoperatively to liver transplant recipients with several risk factors for high intraoperative bleeding adjusts these patients to a normal risk group, without an increased risk for thrombotic complications.
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Affiliation(s)
- Piotr Kaliciński
- Department of Pediatric Surgery and Organ Transplantation, Children's Memorial Health Institute, Warsaw, Poland.
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Mariette C, Alves A, Benoist S, Bretagnol F, Mabrut JY, Slim K. [Perioperative care in digestive surgery]. ACTA ACUST UNITED AC 2005; 142:14-28. [PMID: 15883504 DOI: 10.1016/s0021-7697(05)80831-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- C Mariette
- Service de chirurgie digestive et générale, Hopital C. Huriez, CHRU, Lille.
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10
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Mariette C, Alves A, Benoist S, Bretagnol F, Mabrut JY, Slim K. [Perioperative care in digestive surgery. Guidelines for the French society of digestive surgery (SFCD)]. ACTA ACUST UNITED AC 2005; 130:108-24. [PMID: 15737324 DOI: 10.1016/j.anchir.2004.12.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2004] [Accepted: 12/13/2004] [Indexed: 12/15/2022]
Affiliation(s)
- C Mariette
- Service de chirurgie digestive et générale, hôpital C. Huriez, CHRU de Lille, place de Verdun, 59037 Lille, France.
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11
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Pirat A, Sargin D, Torgay A, Arslan G. Identification of preoperative predictors of intraoperative blood transfusion requirement in orthotopic liver transplantation. Transplant Proc 2003; 34:2153-5. [PMID: 12270349 DOI: 10.1016/s0041-1345(02)02887-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- A Pirat
- Baskent University Faculty of Medicine, Ankara, Turkey
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12
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Joya-Vazquez PP, Dodson FS, Dvorchik I, Gray E, Chesky A, Demetris AJ, Shakil O, Fung JJ, Vargas HE. Impact of anti-hepatitis Bc-positive grafts on the outcome of liver transplantation for HBV-related cirrhosis. Transplantation 2002; 73:1598-602. [PMID: 12042646 DOI: 10.1097/00007890-200205270-00013] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The present scarcity of organ donors requires consideration of grafts from sources not previously used. Several studies have addressed the use of grafts from donors who have antibodies to the hepatitis B core antigen (anti-HBc+). The aim of this study was to evaluate the impact of the use of anti-HBc+ grafts in patients transplanted for hepatitis B virus (HBV)-related cirrhosis. METHODS Recipients of first hepatic transplants from donors with antibodies to HBV were identified retrospectively. All patients who had serology suggestive of active HBV and were negative for hepatitis C and D were included in the analysis. The Kaplan-Meier method was used to assess the actuarial recurrence-free survival on patients with graft survival longer than 1.5 months. The stepwise Cox regression model was used to identify independent predictors of HBV recurrence. RESULTS One thousand seven hundred seventeen first liver transplants were performed at the Thomas E. Starzl Transplantation Institute from September 1, 1990, to December 31, 1999. HBV was the cause of cirrhosis in 112 patients (6.5%). Thirty-three patients had coexistent viral infection (23 HCV and 10 HDV). Fourteen donors (17.2%) were positive for HBV markers, with nine anti-HBc+ and with five both anti-HBc+ and anti-HB surface-positive; of these, 13 anti-HBc+ organ recipients had long-term survival. Nine (69.2%) of these cases were reinfected versus 20 (35.7%) in the group that received grafts from HBV- donors (P<0.05, Fisher's exact test). The mean time to reinfection was shorter in the anti-HBc+ group (2.9 yr vs. 6.4 yr, P<0.005). There were no statistical differences in graft or patient survival between the two groups. HBV prophylaxis with combined lamivudine and hepatitis B immunoglobulin (HBIG) significantly reduced the reinfection rate (P<0.03). Hepatitis Be (Hbe) antigen-positive recipients trended to faster reinfection (not significant). Cox regression analysis revealed that both anti-HBc graft donor status (RR, 2.796; P=0.020) and combination of lamivudine/HBIG (RR, 0.249; P=0.021) are independently associated with reinfection. CONCLUSIONS The use of anti-HBc+ liver grafts does not affect graft or patient survival. However, patients who receive these organs are 2.5 times more likely to develop HBV recurrence. Lamivudine and HBIG combination decreases HBV recurrence 4-fold.
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Affiliation(s)
- Pedro P Joya-Vazquez
- Thomas E. Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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13
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Findlay JY, Rettke SR. Poor prediction of blood transfusion requirements in adult liver transplantations from preoperative variables. J Clin Anesth 2000; 12:319-23. [PMID: 10960206 DOI: 10.1016/s0952-8180(00)00162-8] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE To assess the ability of preoperative information to predict intraoperative blood transfusion requirements in adult orthotopic liver transplantation. DESIGN Retrospective review. SETTING Liver transplantation program in a referral center. PATIENTS 583 sequential adult patients undergoing orthotopic liver transplantation. MEASUREMENTS Preoperative variables with a previously demonstrated relationship to intraoperative transfusion were identified from the literature. These variables were then collected retrospectively from 583 consecutive liver transplantations. Relationships between these and intraoperative blood transfusion requirements were examined by both univariate analyses and multiple linear regression analysis. RESULTS Univariate analysis revealed significant associations between blood transfused and the following preoperative variables: age, gender, diagnosis, presence of grade 3 or 4 encephalopathy, pseudocholinesterase, creatinine, bilirubin, mean pulmonary artery pressure, activated partial thromboplastin time, and platelet count. Multiple linear regression analysis with correction for diagnosis identified age, creatinine, bilirubin, and pseudocholinesterase as independent predictors; for the final model r(2) = 0.22. CONCLUSION Preoperative variables are poor predictors of intraoperative transfusion requirements even when significant associations exist, identifying a small proportion of the variability observed. A predictive approach based on this method would be too inaccurate to be of clinical use. The majority of the variability in transfusion requirements during liver transplantation most likely results from intraoperative and donor organ factors.
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Affiliation(s)
- J Y Findlay
- Department of Anesthesiology, Mayo Clinic and Foundation, Rochester, MN 55902, USA.
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14
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Hendriks HG, van der Meer J, Klompmaker IJ, Choudhury N, Hagenaars JA, Porte RJ, de Kam PJ, Slooff MJ, de Wolf JT. Blood loss in orthotopic liver transplantation: a retrospective analysis of transfusion requirements and the effects of autotransfusion of cell saver blood in 164 consecutive patients. Blood Coagul Fibrinolysis 2000; 11 Suppl 1:S87-93. [PMID: 10850571 DOI: 10.1097/00001721-200004001-00017] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Liver transplantation is associated with excessive blood loss. In order to identify factors influencing blood loss and to provide a basis for a pilot study to evaluate recombinant activated factor VII as a haemostatic agent, a retrospective study was performed in 164 consecutive patients with cholestatic or noncholestatic liver disease, who underwent orthotopic liver transplantation at a single centre between 1989 and 1996. Transfusion of allogeneic and autologous (cell saver) blood was used as a measurement of blood loss. Transfusion requirements were associated with age, gender, primary disease, Child-Pugh classification, serum levels of activated partial thromboplastin time, antithrombin III, urea and creatinine, platelet number, year of transplantation, length of cold ischaemia time and autologous blood transfusion. Of these variables, Child-Pugh classification (P = 0.001), urea (P = 0.0007), year of transplantation (P = 0.002), cold ischaemia time (P = 0.01) and autologous blood transfusion (P < 0.0001) were independent predictors of transfusion requirements by multivariate analysis. Thus, blood loss and transfusion requirements depend primarily on the severity of liver disease, quality of the donor liver, experience of the transplantation team and use of autologous (cell saver) blood transfusion. These findings emphasize the need for appropriate drug therapy and a critical reappraisal of current transfusion policy.
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Affiliation(s)
- H G Hendriks
- Department of Anaesthesiology, Groningen University Hospital, The Netherlands.
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15
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Falagas ME, Paya C, Ruthazer R, Badley A, Patel R, Wiesner R, Griffith J, Freeman R, Rohrer R, Werner BG, Snydman DR. Significance of cytomegalovirus for long-term survival after orthotopic liver transplantation: a prospective derivation and validation cohort analysis. Transplantation 1998; 66:1020-8. [PMID: 9808486 DOI: 10.1097/00007890-199810270-00010] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection and disease has been found to be associated with decreased graft and patient survival among heart transplant recipients. We sought to explore the effect of CMV infection and disease on long-term survival in orthotopic liver transplant (OLT) recipients using a derivation and validation cohort. METHODS For derivation-validation modeling, we used data collected from two prospectively followed cohorts as the basis for multivariate analyses: 167 OLT recipients from the Boston Center for Liver Transplantation (the derivation set; median follow-up: 5.5 years, mortality: 40%) and an independent cohort of 294 OLT recipients from the Mayo Clinic (the validation set; median follow-up: 4.8 years, mortality: 27%). RESULTS Underlying liver disease other than primary biliary cirrhosis or sclerosing cholangitis, number of units of red blood cells administered during transplantation, and donor CMV seropositivity were the pre- and intratransplant variables independently associated (P<0.01) with decreased long-term survival in the derivation cohort. For variables collected up to 1 year after transplantation, the need for retransplan. tation, CMV pneumonia, invasive fungal disease, and underlying liver disease other than primary biliary cirrhosis or sclerosing cholangitis were independently associated (P<0.01) with decreased long-term survival in the derivation cohort. The magnitude of the relationship of each pre-, intra-, and posttransplant factor with survival, as measured by the relative risk, did not significantly differ between the derivation and validation cohorts. The derivation model, incorporating pre-, intra-, and posttransplant factors, had receiver operating characteristic areas of 73% and 74% for 5-year mortality in the derivation and validation cohorts, respectively. CONCLUSIONS Data from a derivation and an independent validation cohort demonstrate that CMV factors (reflected by either donor CMV seropositivity at transplantation, CMV pneumonia, or CMV disease within the first posttransplant year) are independently associated with decreased long-term survival in OLT recipients.
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Affiliation(s)
- M E Falagas
- Department of Medicine, New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts 02111, USA
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Mason AL, Xu L, Guo L, Kuhns M, Perrillo RP. Molecular basis for persistent hepatitis B virus infection in the liver after clearance of serum hepatitis B surface antigen. Hepatology 1998; 27:1736-42. [PMID: 9620351 DOI: 10.1002/hep.510270638] [Citation(s) in RCA: 164] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Hepatitis B virus (HBV) DNA has been detected by polymerase chain reaction (PCR) in the liver of patients with resolved chronic HBV infection and sustained clearance of hepatitis B surface antigen (HBsAg) from serum. However, it is unknown whether the virus is transcriptionally active at this time or if the covalently closed circular (CCC) replicative intermediate of HBV DNA can still be detected. Therefore, hepatic nucleic acid extracts from seven patients who had cleared serum HBsAg were assessed by (PCR) for either reverse-transcribed HBV RNA, or an intact direct repeat region of the HBV genome indicative of the CCC replicative intermediate of HBV DNA. HBV transcripts were detected in four of seven patients in the study group, whereas an intact direct repeat region of the HBV genome was detected in three. Evidence for viral transcription and replication was more frequently detected in patients who had recently cleared serum HBsAg, but HBV RNA was also detected in one patient 5 years after HBsAg clearance, and an intact direct repeat region of HBV DNA was detected in another subject at nearly 4 years after resolution of disease. Therefore, hepatic HBV transcription may be associated with replicative intermediates of persistent HBV DNA in patients who have cleared HBsAg from serum, suggesting that, on occasion, HBV may not be in a latent state but undergoing low-level replication.
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Affiliation(s)
- A L Mason
- Section of Gastroenterology and Hepatology, Ochsner Medical Institutions, New Orleans, LA 70121, USA
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Falagas ME, Arbo M, Ruthazer R, Griffith JL, Werner BG, Rohrer R, Freeman R, Lewis WD, Snydman DR. Cytomegalovirus disease is associated with increased cost and hospital length of stay among orthotopic liver transplant recipients. Transplantation 1997; 63:1595-601. [PMID: 9197352 DOI: 10.1097/00007890-199706150-00010] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Cytomegalovirus (CMV) is a cause of considerable morbidity and mortality among orthotopic liver transplant (OLT) recipients. To study the impact of CMV on cost and hospital length of stay in this population, we undertook an analysis of a cohort of OLT recipients from four transplant centers in Boston who participated in a CMV prophylaxis trial. First posttransplant year hospital length of stay (including the hospital stay after transplantation and readmissions within 1 year after transplantation) was available for all 141 patients included in the study. In a multiple linear regression model bacteremia (P=0.0001), CMV disease (P=0.0007), abdominal reexploration (excluding retransplantation) (P=0.0070), recipient age < or = 16 years (P=0.0352), and the number of units of blood products (red blood cells, platelets, or fresh frozen plasma) administered during transplantation (P=0.0523) were shown to be independently associated with longer first posttransplant year hospital length of stay. Cost data for in-hospital care for the year beginning with admission for liver transplantation were available for 66 OLT recipients. Using a multiple linear regression model, development of CMV disease (P=0.0001), the number of units of blood products administered during transplantation (P=0.0001), bacteremia (P=0.0002), decreased pretransplant renal function (estimated by creatinine clearance) (P=0.0109), and need for retransplantation (P=0.0619) were shown to be independently associated with higher cost. These data strongly suggest that CMV disease has a direct impact on cost and hospital length of stay in liver transplantation.
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Affiliation(s)
- M E Falagas
- Department of Medicine, New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts 02111, USA
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McNicol PL, Liu G, Harley ID, McCall PR, Przybylowski GM, Bowkett J, Angus PW, Hardy KJ, Jones RM. Blood loss and transfusion requirements in liver transplantation: experience with the first 75 cases. Anaesth Intensive Care 1994; 22:666-71. [PMID: 7892969 DOI: 10.1177/0310057x9402200604] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The blood loss data and transfusion requirements including blood bank, salvaged washed red cells, fresh frozen plasma and cryoprecipitate were analysed for the first 75 cases of liver transplantation performed at the Austin Hospital between June 1988 and October 1992. The mean blood loss was 8.8 litres (standard deviation 14.1) with a median value of 4.0 litres. Blood product use expressed as mean number of units (SD) was bank red blood cells 7.1 (12.7), washed red blood cells 3.9 (5.9), fresh frozen plasma 7.1 (9.1), platelets 5.1 (7.4), and cryoprecipitate 1.7 (5.1). These results demonstrate that liver transplantation can be performed without imposing excessive demands on blood transfusion services. Management should include surgical techniques to minimize bleeding and use of autologous transfusion. Use of component therapy (FFP, platelets and cryoprecipitate) should not be empirical. It should be selective on the basis of clinical bleeding assessment and guided by results of the laboratory coagulation profile and changes in thrombelastographic (TEG) parameters.
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Affiliation(s)
- P L McNicol
- Department of Anaesthesia, Austin Hospital, Melbourne, Victoria
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Ritter DM, Owen CA, Bowie EJ, Rettke SR, Cole TL, Taswell HF, Ilstrup DM, Wiesner RH, Krom RA. Evaluation of preoperative hematology-coagulation screening in liver transplantation. Mayo Clin Proc 1989; 64:216-23. [PMID: 2646479 DOI: 10.1016/s0025-6196(12)65676-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
We retrospectively reviewed the results of preoperative hematology-coagulation studies in 66 patients who underwent orthotopic liver transplantation-24 with the primary diagnosis of chronic active hepatitis (CAH), 22 with primary sclerosing cholangitis (PSC), and 20 with primary biliary cirrhosis (PBC). The mean prothrombin time was above normal in all three diagnostic groups, patients with CAH having the highest values. The mean activated partial thromboplastin time was normal in patients with PSC or PBC but elevated in those with CAH. Fibrinogen levels were above normal in patients with PBC but decreased in 1 patient (5%) with PSC and 10 (42%) with CAH. Mean platelet counts were below normal in 68% and 55% of patients with PSC and PBC, respectively, but in 96% of those with CAH. The mean Ivy bleeding time was normal in patients with PSC or PBC but prolonged in those with CAH. Patients with PSC or PBC had normal mean activity levels of factors II, V, VII, IX, and X, whereas those with CAH had below normal mean values for factors II and VII. The antithrombin III activity level was normal in patients with PSC or PBC but reduced in those with CAH. Thus, patients with CAH have a greater derangement in results of clotting studies in comparison with those who have PSC or PBC, but the use of blood did not differ among the three diagnostic groups.
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Affiliation(s)
- D M Ritter
- Department of Anesthesiology, Emory University Hospital, Atlanta, Georgia
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Motschman TL, Taswell HF, Brecher ME, Rettke SR, Wiesner RH, Krom RA. Blood bank support of a liver transplantation program. Mayo Clin Proc 1989; 64:103-11. [PMID: 2492063 DOI: 10.1016/s0025-6196(12)65309-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Successful implementation of a liver transplantation program is dependent on extensive blood bank support. Careful planning, organization, and coordination of the blood bank and other clinical services are necessary. In our first 100 orthotopic liver transplantations, our median intraoperative erythrocyte use was 12.6 units, and 30% of the erythrocytes were provided by intraoperative cell salvage. Thus, the need for homologous blood and the number of donors to whom recipients were exposed were reduced. Use of intraoperative cell salvage and expansion of our erythrocyte inventory through the use of AS-1 preservative helped us meet the demands of the liver transplant program without compromising the availability of blood products for all other surgical and medical patients.
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