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Moore HB, LaRiviere W, Rodriguez I, Brown K, Hadley K, Pomposelli JJ, Adams MA, Wachs ME, Conzen KD, Kennealey PT, Kaplan B, Pomfret EA, Nydam TL. Early predictors of prolonged intensive care utilization following liver transplantation. Am J Surg 2023; 226:829-834. [PMID: 37604748 DOI: 10.1016/j.amjsurg.2023.06.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Creatinine, bilirubin, and fibrinolysis resistance are associated with multi-organ dysfunction and likely risk factors for prolonged intensive care unit (pICU) stay following liver transplantation (LT). We hypothesize postoperative day-1 (POD-1) labs will predict pICU. METHODS LT recipients had clinical laboratories and viscoelastic testing with tissue plasminogen activator thrombelastography (tPA TEG) to quantify fibrinolysis resistance (LY30) on POD-1. pICU was defined as one week or longer in the ICU. Logistic regression was used to identify the relationship between POD-1 labs and pICU. RESULTS Of 304 patients, 50% went to the ICU, with 15% experiencing pICU. Elevated creatinine (OR 6.6, P < 0.001) and low tPA TEG LY30 (OR 3.7, P = 0.004) were independent predictors of pICU after controlling for other risk factors. A 9-fold increase in the rate of 90-day graft loss (19% vs 2% p < 0.001) was observed patients who had these risk factors for pICU. CONCLUSION Elevated creatine and fibrinolysis resistance are associated with pICU and poor outcomes following LT.
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Affiliation(s)
- Hunter B Moore
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Colorado Center for Transplantation Care, Research, and Education, Aurora, CO, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA.
| | - Wells LaRiviere
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA
| | - Ivan Rodriguez
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Kristen Brown
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Kyndall Hadley
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - James J Pomposelli
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Megan A Adams
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Colorado Center for Transplantation Care, Research, and Education, Aurora, CO, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Michael E Wachs
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Colorado Center for Transplantation Care, Research, and Education, Aurora, CO, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Kendra D Conzen
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Peter T Kennealey
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Bruce Kaplan
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Elizabeth A Pomfret
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
| | - Trevor L Nydam
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA; Department of Surgery, Division of Transplant Surgery, Children's Hospital Colorado, USA
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Saner FH, Hoyer DP, Hartmann M, Nowak KM, Bezinover D. The Edge of Unknown: Postoperative Critical Care in Liver Transplantation. J Clin Med 2022; 11:jcm11144036. [PMID: 35887797 PMCID: PMC9322367 DOI: 10.3390/jcm11144036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 06/29/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
Perioperative care of patients undergoing liver transplantation (LT) is very complex. Metabolic derangements, hypothermia, coagulopathy and thromboses, severe infections, and graft dysfunction can affect outcomes. In this manuscript, we discuss several perioperative problems that can be encountered in LT recipients. The authors present the most up-to-date information regarding predicting and treating hemodynamic instability, coagulation monitoring and management, postoperative ventilation strategies and early extubation, management of infections, and ESLD-related pulmonary complications. In addition, early post-transplant allograft dysfunction will be discussed.
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Affiliation(s)
- Fuat H. Saner
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (D.P.H.); (K.M.N.)
- Correspondence: ; Fax: +49-201-723-1145
| | - Dieter P. Hoyer
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (D.P.H.); (K.M.N.)
| | - Matthias Hartmann
- Department of Anaesthesia and Critical Care, Medical Center University Duisburg-Essen, 45147 Essen, Germany;
| | - Knut M. Nowak
- Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany; (D.P.H.); (K.M.N.)
| | - Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Penn State College of Medicine, Hershey, PA 17033, USA;
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3
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Abstract
Severe allograft dysfunction, as opposed to the expected immediate function, following liver transplantation is a major complication, and the clinical manifestations of such that lead to either immediate retransplant or death are the catastrophic end of the spectrum. Primary nonfunction (PNF) has declined in incidence over the years, yet the impact on patient and healthcare teams, and the burden on the organ pool in case of the need for retransplant should not be underestimated. There is no universal test to define the diagnosis of PNF, and current criteria are based on various biochemical parameters surrogate of liver function; moreover, a disparity remains within different healthcare systems on selecting candidates eligible for urgent retransplantation. The impact on PNF from traditionally accepted risk factors has changed somewhat, mainly driven by the rising demand for organs, combined with the concerted approach by clinicians on the in-depth understanding of PNF, optimal graft recipient selection, mitigation of the clinical environment in which a marginal graft is reperfused, and postoperative management. Regardless of the mode, available data suggest machine perfusion strategies help reduce the incidence further but do not completely avert the risk of PNF. The mainstay of management relies on identifying severe allograft dysfunction at a very early stage and aggressive management, while excluding other identifiable causes that mimic severe organ dysfunction. This approach may help salvage some grafts by preventing total graft failure and also maintaining a patient in an optimal physiological state if retransplantation is considered the ultimate patient salvage strategy.
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Affiliation(s)
- Hermien Hartog
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
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4
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Wei Q, Zhou J, Wang K, Zhang X, Chen J, Lu D, Wei X, Zheng S, Xu X. Combination of Early Allograft Dysfunction and Protein Expression Patterns Predicts Outcome of Liver Transplantation From Donation After Cardiac Death. Front Med (Lausanne) 2021; 8:775212. [PMID: 34957150 PMCID: PMC8692269 DOI: 10.3389/fmed.2021.775212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/12/2021] [Indexed: 11/13/2022] Open
Abstract
Early allograft dysfunction (EAD) after liver transplantation (LT) accompanies poor prognosis. This study aims to explore the relationship between pretransplant intrahepatic proteins and the incidence of EAD, and the value of combined EAD and protein profiles for predicting recipient and graft survival prognosis. Liver biopsy specimens of 105 pretransplant grafts used for LT were collected and used for immunohistochemistry analysis of 5 proteins. And matched clinical data of donor, recipient, transplantation, and prognosis were analyzed. The incidence of EAD was 41.9% (44/105) in this cohort. Macrovesicular steatosis (P = 0.016), donor body mass index (P = 0.013), recipients' pretransplant serum creatinine (P = 0.036), and intrahepatic expression of heme oxygenase 1 (HO1) (P = 0.015) and tumor necrosis factor α (TNF-α) (P = 0.039) were independent predictors of EAD. Inferior graft and recipient prognosis were observed in patients who experienced EAD (P = 0.028 and 0.031) or received grafts with higher expression of sirtuin 1 (P = 0.005 and 0.013). The graft and recipient survival were worst in patients with both EAD and high expression of sirtuin 1 (P = 0.001 and 0.004). In conclusion, pretransplant intrahepatic expression of HO1 and TNF-α are associated with the incidence of EAD. The combination of EAD and EAD-unrelated proteins showed superiority in distinguishing recipients with worse prognosis.
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Affiliation(s)
- Qiang Wei
- Department of Hepatobiliary and Pancreatic Surgery, The Center for Integrated Oncology and Precision Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Organ Transplantation, Zhejiang University, Hangzhou, China.,National Health Commission Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, China
| | - Junbin Zhou
- Department of Hepatobiliary and Pancreatic Surgery, The Center for Integrated Oncology and Precision Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Organ Transplantation, Zhejiang University, Hangzhou, China.,National Health Commission Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, China
| | - Kun Wang
- Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xuanyu Zhang
- Institute of Organ Transplantation, Zhejiang University, Hangzhou, China.,National Health Commission Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, China.,Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Junli Chen
- China Liver Transplant Registery, Hangzhou, China
| | - Di Lu
- Department of Hepatobiliary and Pancreatic Surgery, The Center for Integrated Oncology and Precision Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Organ Transplantation, Zhejiang University, Hangzhou, China.,National Health Commission Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, China
| | - Xuyong Wei
- Department of Hepatobiliary and Pancreatic Surgery, The Center for Integrated Oncology and Precision Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Organ Transplantation, Zhejiang University, Hangzhou, China.,National Health Commission Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, China
| | - Shusen Zheng
- Institute of Organ Transplantation, Zhejiang University, Hangzhou, China.,National Health Commission Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, China.,Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiao Xu
- Department of Hepatobiliary and Pancreatic Surgery, The Center for Integrated Oncology and Precision Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Organ Transplantation, Zhejiang University, Hangzhou, China.,National Health Commission Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, China.,Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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5
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The Potential Role of Efficacy and Safety Evaluation of N-Acetylcysteine Administration During Liver Procurement. The NAC-400 Single Center Randomized Controlled Trial. Transplantation 2021; 105:2245-2254. [PMID: 33044432 DOI: 10.1097/tp.0000000000003487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND N-acetylcysteine infusions have been widely used to reduce ischemia/reperfusion damage to the liver; however, convincing evidence of their benefits is lacking. OBJECTIVE To perform the largest randomized controlled trial to compare the impact of N-acetylcysteine infusion during liver procurement on liver transplant outcomes. METHODS Single center, randomized trial with patients recruited from La Fe University Hospital, Spain, from February 2012 to January 2016. A total of 214 grafts were transplanted and randomized to the N-acetylcysteine group (n = 113) or to the standard protocol without N-acetylcysteine (n = 101). The primary endpoint was allograft dysfunction (Olthoff criteria). Secondary outcomes included metabolomic biomarkers of oxidative stress levels, interactions between cold ischemia time and alanine aminotransferase level and graft and patient survival (ID no. NCT01866644). RESULTS The incidence of primary dysfunction was 34% (31% in the N-acetylcysteine group and 37.4% in the control group [P = 0.38]). N-acetylcysteine administration reduced the alanine aminotransferase level when cold ischemia time was longer than 6 h (P = 0.0125). Oxidative metabolites (glutathione/oxidized glutathione and ophthalmic acid) were similar in both groups (P > 0.05). Graft and patient survival rates at 12 mo and 3 y were similar between groups (P = 0.54 and P = 0.69, respectively). CONCLUSIONS N-acetylcysteine administration during liver procurement does not improve early allograft dysfunction according to the Olthoff classification. However, when cold ischemia time is longer than 6 h, N-acetylcysteine improves postoperative ALT levels.
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Early Allograft Dysfunction and Complications in DCD Liver Transplantation: Expert Consensus Statements From the International Liver Transplantation Society. Transplantation 2021; 105:1643-1652. [PMID: 34291765 DOI: 10.1097/tp.0000000000003877] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Livers for transplantation from donation after circulatory death donors are relatively more prone to early and ongoing alterations in graft function that might ultimately lead to graft loss and even patient death. In consideration of this fact, this working group of the International Liver Transplantation Society has performed a critical evaluation of the medical literature to create a set of statements regarding the assessment of early allograft function/dysfunction and complications arising in the setting of donation after circulatory death liver transplantation.
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7
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Lee CF, Hung HC, Lee WC. Using Rotational Thromboelastometry to Identify Early Allograft Dysfunction after Living Donor Liver Transplantation. J Clin Med 2021; 10:jcm10153401. [PMID: 34362183 PMCID: PMC8347977 DOI: 10.3390/jcm10153401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Diagnostic tests for early allograft dysfunction (EAD) after living donor liver transplantation (LDLT) vary widely. We aimed to evaluate the predictive value of rotational thromboelastometry (ROTEM)-derived parameters in EAD. Materials and Methods: A total of 121 patients were reviewed. The definition of EAD proposed by Olthoff et al. included the presence of any of the following at postoperative day 7: bilirubin level ≥ 10 mg/dL, INR ≥ 1.6, or serum AST or ALT levels > 2000 IU/L. All patients underwent ROTEM assay, which consisted of an extrinsically activated thromboelastometric test (EXTEM) before and 24 h after LDLT. Results: The 1-year/2-year OS were 68.%8/64.5% and 94.4%/90.8% for the EAD and non-EAD groups, respectively (p = 0.001). Two independent risks were identified for EAD, the postoperative clotting time (CT, p = 0.026) and time to maximum clot firmness (maximum clot firmness (MCF)-t, p = 0.009) on the EXTEM. CT yielded a specificity of 82.0% and negative predictive value of 83.0%, and MCF-t displayed a specificity of 76.4% and negative predictive value of 81.9% in diagnosing EAD. The use of the 24 h post-LDLT ROTEM increased the effectiveness of predicting overall survival (OS) compared to using the Olthoff’s EAD criteria alone (p < 0.001). Conclusion: We conclude that CT and MCF on EXTEM were independent predictors of EAD. The 24 h post-LDLT ROTEM can be used with conventional laboratory tests to diagnose EAD. It increases the effectiveness of predicting OS.
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Affiliation(s)
- Chen-Fang Lee
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (C.-F.L.); (W.-C.L.)
- College of Medicine, Chang-Gung University, Taoyuan City 333, Taiwan
| | - Hao-Chien Hung
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (C.-F.L.); (W.-C.L.)
- Correspondence: ; Tel.: +886-3-3281200 (ext. 3366); Fax: +886-3-3285818
| | - Wei-Chen Lee
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (C.-F.L.); (W.-C.L.)
- College of Medicine, Chang-Gung University, Taoyuan City 333, Taiwan
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8
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Rhu J, Kim JM, Kim K, Yoo H, Choi GS, Joh JW. Prediction model for early graft failure after liver transplantation using aspartate aminotransferase, total bilirubin and coagulation factor. Sci Rep 2021; 11:12909. [PMID: 34145352 PMCID: PMC8213713 DOI: 10.1038/s41598-021-92298-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/27/2021] [Indexed: 11/14/2022] Open
Abstract
This study was designed to build models predicting early graft failure after liver transplantation. Cox regression model for predicting early graft failure after liver transplantation using post-transplantation aspartate aminotransferase, total bilirubin, and international normalized ratio of prothrombin time was constructed based on data from both living donor (n = 1153) and deceased donor (n = 359) liver transplantation performed during 2004 to 2018. The model was compared with Model for Early Allograft Function Scoring (MEAF) and early allograft dysfunction (EAD) with their C-index and time-dependent area-under-curve (AUC). The C-index of the model for living donor (0.73, CI = 0.67–0.79) was significantly higher compared to those of both MEAF (0.69, P = 0.03) and EAD (0.66, P = 0.001) while C-index for deceased donor (0.74, CI = 0.65–0.83) was only significantly higher compared to C-index of EAD. (0.66, P = 0.002) Time-dependent AUC at 2 weeks of living donor (0.96, CI = 0.91–1.00) and deceased donor (0.98, CI = 0.96–1.00) were significantly higher compared to those of EAD. (both 0.83, P < 0.001 for living donor and deceased donor) Time-dependent AUC at 4 weeks of living donor (0.93, CI = 0.86–0.99) was significantly higher compared to those of both MEAF (0.87, P = 0.02) and EAD. (0.84, P = 0.02) Time-dependent AUC at 4 weeks of deceased donor (0.94, CI = 0.89–1.00) was significantly higher compared to both MEAF (0.82, P = 0.02) and EAD. (0.81, P < 0.001). The prediction model for early graft failure after liver transplantation showed high predictability and validity with higher predictability compared to traditional models for both living donor and deceased donor liver transplantation.
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Affiliation(s)
- Jinsoo Rhu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 135-710, Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 135-710, Korea
| | - Kyunga Kim
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - Heejin Yoo
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - Gyu-Seong Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 135-710, Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, 135-710, Korea.
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9
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Dai WB, Chen LK, Qi SY, Pan ZY, Zhang X, Huang LL, Zhao YH, Tian J, Yu WF, Yang LQ, Su DS. Lactated Ringer's solution versus normal saline in pediatric living-donor liver transplantation: A matched retrospective cohort study. Paediatr Anaesth 2021; 31:702-712. [PMID: 33715251 DOI: 10.1111/pan.14181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 03/04/2021] [Accepted: 03/05/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND In pediatric living-donor liver transplantation, lactated Ringer's solution and normal saline are commonly used for intraoperative fluid management, but the comparative clinical outcomes remain uncertain. AIMS To compare the effect between lactated Ringer's solution and normal saline for intraoperative volume replacement on clinical outcomes among pediatric living-donor liver transplantation patients. METHODS This single-center, retrospective trial study enrolled children who received either lactated Ringer's solution or normal saline during living-donor liver transplantation between January 2010 and August 2016. The groups with comparable clinical characteristics were balanced by propensity score matching. The primary outcome was 90-day all-cause mortality, and the secondary outcomes included early allograft dysfunction, primary nonfunction, acute renal injury, and hospital-free days (days alive postdischarge within 30 days of liver transplantation). RESULTS We included 333 pediatric patients who met the entry criteria for analysis. Propensity score matching identified 61 patients in each group. After matching, the lactated Ringer's solution group had a higher 90-day mortality rate than the normal saline group (11.5% vs. 0.0%). Early allograft dysfunction and primary nonfunction incidences were also more frequent in the lactated Ringer's solution group (19.7% and 11.5%, respectively) than in the normal saline group (3.3% and 0.0%, respectively). In the lactated Ringer's solution group, four (6.6%) recipients developed acute renal injury within 7 days postoperatively compared with three (4.9%) recipients in the normal saline group. Hospital-free days did not differ between groups (9 days [1-13] vs. 9 days [0-12]). CONCLUSIONS For intraoperative fluid management in pediatric living-donor liver transplantation patients, lactated Ringer's solution administration was associated with a higher 90-day mortality rate than normal saline. This finding has important implications for selecting crystalloid in pediatric living-donor liver transplantation. Further randomized clinical trials in larger cohort are necessary to confirm this finding.
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Affiliation(s)
- Wan-Bing Dai
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ling-Ke Chen
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Department of Anesthesiology, Intensive Care Medicine, and Pain Medicine, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Si-Yi Qi
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zhi-Ying Pan
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiao Zhang
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Li-Li Huang
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yan-Hua Zhao
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jie Tian
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wei-Feng Yu
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Li-Qun Yang
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Dian-San Su
- Department of Anesthesiology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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10
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Kitano Y, Allard MA, Nakada S, Beghdadi N, Karam V, Vibert E, Sa Cunha A, Castaing D, Cherqui D, Baba H, Adam R. Early- and long-term outcomes of liver transplantation with rescue allocation grafts. Clin Transplant 2020; 35:e14046. [PMID: 32686220 DOI: 10.1111/ctr.14046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/20/2020] [Accepted: 07/11/2020] [Indexed: 11/30/2022]
Abstract
In France, liver grafts which have been refused by at least five centers are proposed as rescue allocation (RA). The aim of this study is to clarify the feasibility and safety of RA grafts in liver transplantation (LT). Short- and long-term outcomes of patients who received RA grafts (RA group) were compared with those of patients who received standard allocation (SA) grafts (SA group). From a total of 1635 patients, 102 patients received RA grafts. Before matching, the RA group was characterized primarily by less severe liver disease, but the quality of graft was worse. After matching recipients' characteristics of 102 patients who used RA grafts with 306 patients who used SA grafts, recipients' characteristics were well balanced (1:3 matching). Although the rate of primary dysfunction was significantly higher in the RA group, there is no significant difference in the occurrence of major complications, length of hospitalization, and mortality between two groups. Graft survival (GS) and overall survival (OS) in the RA group were not significantly different from the SA group (GS; HR = 1.03 P = .89, OS; HR = 1.03 P = .90). In the French allocation system, the feasibility and safety of RA grafts might be comparable to SA grafts for carefully selected patients.
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Affiliation(s)
- Yuki Kitano
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Sud, Villejuif, France.,Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Marc-Antoine Allard
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Sud, Villejuif, France
| | - Shinichiro Nakada
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Sud, Villejuif, France.,Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Nassiba Beghdadi
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Sud, Villejuif, France
| | - Vincent Karam
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Sud, Villejuif, France
| | - Eric Vibert
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Sud, Villejuif, France
| | - Antonio Sa Cunha
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Sud, Villejuif, France
| | - Denis Castaing
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Sud, Villejuif, France
| | - Daniel Cherqui
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Sud, Villejuif, France
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - René Adam
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris Sud, Villejuif, France
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11
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Diaz-Nieto R, Lykoudis P, Robertson F, Sharma D, Moore K, Malago M, Davidson BR. A simple scoring model for predicting early graft failure and postoperative mortality after liver transplantation. Ann Hepatol 2020; 18:902-912. [PMID: 31405576 DOI: 10.1016/j.aohep.2019.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/15/2019] [Accepted: 06/25/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Graft failure and postoperative mortality are the most serious complications after liver transplantation. The aim of this study is to establish a prognostic scoring system to predict graft and patient survival based on serum transaminases levels that are routinely used during the postoperative period in human cadaveric liver transplants. PATIENTS AND METHODS Postoperative graft failure and patient mortality after liver transplant were analyzed from a consecutive series of 1299 patients undergoing cadaveric liver transplantation. This was correlated with serum liver function tests and the rate of reduction in transaminase levels over the first postoperative week. A cut-off transaminase level correlating with graft and patient survival was calculated and incorporated into a scoring system. RESULTS Aspartate-aminotransferase (AST) on postoperative day one showed significant correlation with early graft failure for levels above 723U/dl and early postoperative mortality for levels above 750U/dl. AST reduction rate (day 1 to 3) greater than 1.8 correlated with reduced graft failure and greater than 2 with mortality. Alanine-aminotransferase (ALT) reduction in the first 48h post transplantation also correlated with outcomes. CONCLUSION A scoring system with these three variables allowed us to classify our patients into three groups of risk for early graft failure and mortality.
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Affiliation(s)
- Rafael Diaz-Nieto
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom; Royal Free Campus, University College London, London, United Kingdom.
| | - Panagis Lykoudis
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom; Royal Free Campus, University College London, London, United Kingdom
| | - Francis Robertson
- Royal Free Campus, University College London, London, United Kingdom
| | - Dinesh Sharma
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom
| | - Kevin Moore
- Royal Free Campus, University College London, London, United Kingdom
| | - Massimo Malago
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom
| | - Brian R Davidson
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom; Royal Free Campus, University College London, London, United Kingdom
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Ly M, Crawford M, Verran D. Biliary complications in donation after circulatory death liver transplantation: the Australian National Liver Transplantation Unit's experience. ANZ J Surg 2020; 91:445-450. [PMID: 32985774 DOI: 10.1111/ans.16304] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 08/19/2020] [Accepted: 08/24/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Biliary complications are the most common complications of donation after circulatory death (DCD) liver transplantation and the international experience with DCD transplants suggests increased rates of biliary complications compared to donation after brain death transplants. Therefore, it is important to understand factors that are associated with the development of biliary complications within the Australian DCD context in order to inform future practice. The aim of this study is to determine the incidence of biliary complications after DCD liver transplantation at the Australian National Liver Transplantation Unit and identify factors associated with this outcome. METHODS A retrospective analysis of all adult DCD liver transplants at the Australian National Liver Transplantation Unit from 2007 to 2015 was undertaken. The primary outcome measure was the incidence of biliary complications and was censored on 31 December 2016. Recipients were then stratified into groups based on the development of biliary complications and risk factor analysis was performed. RESULTS Biliary complications occurred in 35% of DCD transplants, including seven anastomotic strictures and 10 non-anastomotic strictures. Higher donor risk index scores (P = 0.03), post-transplant portal vein complications (P = 0.042) and peak gamma-glutamyl transferase levels within 7 days post-transplant (P = 0.047) were associated with biliary complications. CONCLUSION Findings from this study demonstrate that biliary complications remain common in DCD liver recipients. Recipients who developed a biliary complication tended to have higher donor risk index, elevated peak gamma-glutamyl transferase levels within 7 days post-transplant or a portal vein complication. The presence of any of these factors should prompt close monitoring for post-transplant biliary complications.
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Affiliation(s)
- Mark Ly
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Michael Crawford
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Upper Gastrointestinal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Deborah Verran
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Zhou J, Chen J, Wei Q, Saeb-Parsy K, Xu X. The Role of Ischemia/Reperfusion Injury in Early Hepatic Allograft Dysfunction. Liver Transpl 2020; 26:1034-1048. [PMID: 32294292 DOI: 10.1002/lt.25779] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/15/2020] [Accepted: 04/06/2020] [Indexed: 12/13/2022]
Abstract
Liver transplantation (LT) is the only available curative treatment for patients with end-stage liver disease. Early allograft dysfunction (EAD) is a life-threatening complication of LT and is thought to be mediated in large part through ischemia/reperfusion injury (IRI). However, the underlying mechanisms linking IRI and EAD after LT are poorly understood. Most previous studies focused on the clinical features of EAD, but basic research on the underlying mechanisms is insufficient, due, in part, to a lack of suitable animal models of EAD. There is still no consensus on definition of EAD, which hampers comparative analysis of data from different LT centers. IRI is considered as an important risk factor of EAD, which can induce both damage and adaptive responses in liver grafts. IRI and EAD are closely linked and share several common pathways. However, the underlying mechanisms remain largely unclear. Therapeutic interventions against EAD through the amelioration of IRI is a promising strategy, but most approaches are still in preclinical stages. To further study the mechanisms of EAD and promote collaborations between LT centers, optimized animal models and unified definitions of EAD are urgently needed. Because IRI and EAD are closely linked, more attention should be paid to the underlying mechanisms and the fundamental relationship between them. Ischemia/reperfusion-induced adaptive responses may play a crucial role in the prevention of EAD, and more preclinical studies and clinical trials are urgently needed to address the current limitation of available therapeutic interventions.
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Affiliation(s)
- Junbin Zhou
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Health and Family Planning Commission (NHFPC) Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, China
| | - Jian Chen
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Health and Family Planning Commission (NHFPC) Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, China
| | - Qiang Wei
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Health and Family Planning Commission (NHFPC) Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, China
| | - Kourosh Saeb-Parsy
- Department of Surgery, University of Cambridge, Cambridge, United Kingdom.,Cambridge National Institute of Health Research Biomedical research Centre, Cambridge, United Kingdom
| | - Xiao Xu
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,National Health and Family Planning Commission (NHFPC) Key Laboratory of Combined Multi-Organ Transplantation, Hangzhou, China
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Arterial Lactate Concentration at the End of Liver Transplantation Is an Early Predictor of Primary Graft Dysfunction. Ann Surg 2020; 270:131-138. [PMID: 29509585 DOI: 10.1097/sla.0000000000002726] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although many prognostic factors of primary graft dysfunction after liver transplantation (LT) are available, it remains difficult to predict failure in a given recipient. OBJECTIVE We aimed to determine whether the intraoperative assay of arterial lactate concentration at the end of LT (LCEOT) might constitute a reliable biological test to predict early outcomes [primary nonfunction (PNF), early graft dysfunction (EAD)]. METHODS We reviewed data from a prospective database in a single center concerning patients transplanted between January 2015 and December 2016 (n = 296). RESULTS There was no statistical imbalance between the training (year 2015) and validation groups (year 2016) for epidemiological and perioperative feature. Ten patients (3.4%) presented with PNF, and EAD occurred in 62 patients (20.9%); 9 patients died before postoperative day (POD) 90. LCEOT ≥5 mmol/L was the best cut-off point to predict PNF (Se=83.3%, SP=74.3%, positive likelihood ratio (LR+)=3.65, negative likelihood ratio (LR-)=0.25, diagnostic odds ratio (DOR)=14.44) and was predictive of PNF (P = 0.02), EAD (P = 0.05), and death ≤ POD90 (P = 0.06). Added to the validated BAR-score, LCEOT improved its predictive value regarding POD 90 survival with a better AUC (0.87) than BAR score (0.74). The predictive value of LCEOT was confirmed in the validation cohort. CONCLUSION As a reflection of both hypoperfusion and tissue damage, the assay of arterial LCEOT ≥5 mmol/L appears to be a strong predictor of early graft outcomes and may be used as an endpoint in studies assessing the impact of perioperative management. Its accessibility and low cost could impose it as a reliable parameter to anticipate postoperative management and help clinicians for decision-making in the first PODs.
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15
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Risk factors, surgical complications and graft survival in liver transplant recipients with early allograft dysfunction. Hepatobiliary Pancreat Dis Int 2019; 18:423-429. [PMID: 30853253 DOI: 10.1016/j.hbpd.2019.02.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 02/18/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Early allograft dysfunction (EAD) is a severe complication after liver transplantation. The associated risk factors and complications have re-gained recent interest. This study investigated risk factors, survival and complications associated with EAD in a large liver transplant center in Latin America. METHODS Retrospective, unicenter, cohort, based on data from adult patients undergoing first deceased-donor liver transplant from January 2009 to December 2013. EAD was defined by one or more of the following: (i) bilirubin ≥10 mg/dL on postoperative day 7; (ii) international normalized ratio ≥1.6 on postoperative day 7, and (iii) alanine aminotransferase or aspartate aminotransferase >2000 IU/L within the first seven days after transplant. RESULTS A total of 602 patients were included; of these 34.2% developed EAD. Donor risk factors were male (P = 0.007), age between 50 and 59 years (P = 0.034), overweight (P = 0.028) or grade I obesity (P = 0.012), sodium >157 mmol/L (P = 0.002) and grade IV ischemia/reperfusion injury (P = 0.002). Cold ischemia time ≥10 h (P = 0.008) and warm ischemia time ≥40 min (P = 0.013) were the surgical factors. Male (P <0.001) was the only recipient protective factor. Compared with the non-EAD group, patients with EAD were submitted to more reoperations (24.3% vs. 13.4%, P = 0.001) and had higher graft loss rates (37.9% vs. 21.2%, P <0.001), with similar patient survival rates (P = 0.238). CONCLUSIONS EAD risk factors are related to donor, surgical procedure and recipient. Donor risk factors for EAD were male, age between 50 and 59 years, donor overweight or grade I obesity, sodium >157 mmol/L and grade IV ischemia/reperfusion injury. Cold ischemia time ≥10 h and warm ischemia time ≥40 min were the surgical risk factors. Male was the only recipient protective factor. Patients with EAD had higher reoperations and graft loss rates.
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16
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Martins PN, Rawson A, Movahedi B, Brüggenwirth IMA, Dolgin NH, Martins AB, Mahboub P, Bozorgzadeh A. Single-Center Experience With Liver Transplant Using Donors With Very High Transaminase Levels. EXP CLIN TRANSPLANT 2019; 17:498-506. [DOI: 10.6002/ect.2017.0172] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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17
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Liver Transplantation from Voluntary Organ Donor System in China: A Comparison between DBD and DCD Liver Transplants. Gastroenterol Res Pract 2019; 2019:5736702. [PMID: 31191649 PMCID: PMC6525890 DOI: 10.1155/2019/5736702] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 04/11/2019] [Indexed: 02/07/2023] Open
Abstract
Background In China, the cases of liver transplantation (LT) from donation after citizens' death have rose year by year since the citizen-based voluntary organ donor system was initiated in 2010. The objective of our research was to investigate the early postoperative and late long-term outcomes of LT from donation after brain death (DBD) and donation after circulatory death (DCD) according to the current organ donation system in China. Methods Sixty-two consecutive cases of LT from donation after citizens' death performed in our hospital between February 2012 and June 2017 were examined retrospectively for short- and long-term outcomes. These included 35 DCD LT and 27 DBD LT. Result Subsequent median follow-up time of 19 months and 1- and 3-year graft survival rates were comparative between the DBD group and the DCD group (81.5% and 66.7% versus 67.1% and 59.7%; P = 0.550), as were patient survival rates (85.2% and 68.7% versus 72.2% and 63.9%; P = 0.358). The duration of ICU stay of recipients was significantly shorter in the DBD group, in comparison with that of the DCD group (1 versus 3 days, P = 0.001). Severe complication incidence (≥grade III) after transplantation was identical among the DBD and DCD groups (48.1% versus 60%, P = 0.352). There was no significant difference in postoperative mortality between the DBD and DCD groups (3 of 27 cases versus 5 of 35 cases). Twenty-one grafts (33.8%) were lost and 18 recipients (29.0%) were dead till the time of follow-up. Malignancy recurrence was the most prevalent reason for patient death (38.8%). There was no significant difference in incidence of biliary stenosis between the DBD and DCD groups (5 of 27 cases versus 6 of 35 cases, P = 0.846). Conclusion Although the sample size was small to some extent, this single-center study first reported that LT from DCD donors showed similar short- and long-term outcomes with DBD donors and justified the widespread implementation of voluntary citizen-based deceased organ donation in China. However, the results should be verified with a multicenter larger study.
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18
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Donor Small-Droplet Macrovesicular Steatosis Affects Liver Transplant Outcome in HCV-Negative Recipients. Can J Gastroenterol Hepatol 2019; 2019:5862985. [PMID: 31187028 PMCID: PMC6521523 DOI: 10.1155/2019/5862985] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 04/03/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND No data are available on liver transplantation (LT) outcome and donor liver steatosis, classified as large droplet macrovesicular (Ld-MaS), small-droplet macrovesicular (Sd-MaS), and true microvesicular (MiS), taking into account the recipient Hepatitis C virus (HCV) status. AIM We investigate the impact of allograft steatosis reclassified according to the Brunt classification on early graft function and survival after LT. METHODS We retrospectively reviewed 204 consecutive preischemia biopsies of grafts transplanted in our center during the period 2001-2011 according to recipient HCV status. RESULTS The median follow-up after LT was 7.5 years (range: 0.0-16.7). In negative recipients (n=122), graft loss was independently associated with graft Sd-MaS, in multivariable Cox regression models comprehending only pre-/intraoperative variables (HR=1.03, 95%CI=1.01-1.05; P=0.003) and when including indexes of early postoperative graft function (HR=1.04, 95%CI=1.02-1.06; P=0.001). Graft Sd-MaS>15% showed a risk for graft loss > 2.5-folds in both the models. Graft Sd-MaS>15% was associated with reduced graft ATP content and, only in HCV- recipients, with higher early post-LT serum AST peaks. CONCLUSIONS In HCV-negative recipients, allografts with >15% Sd-MaS have significantly reduced graft survival and show low ATP and higher AST peaks in the immediate posttransplant period. Donors with >15% Sd-MaS have significantly higher BMI, longer ICU stays, and lower PaO2.
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Lozano P, Orue-Echebarria MI, Asencio JM, Sharma H, Lisbona CJ, Olmedilla L, Pérez Peña JM, Salcedo MM, Skaro A, Velasco E, Colón A, Díaz-Zorita B, Rodríguez L, Ferreiroa J, López-Baena JÁ. Donor Risk Index Has an Impact in Intraoperative Measure of Hepatic Artery Flow and in Clearance of Indocyanine Green: An Observational Cohort Study. Transplant Proc 2019; 51:50-55. [PMID: 30655145 DOI: 10.1016/j.transproceed.2018.03.138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/15/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The increase in indications for liver transplantation has led to acceptance of donors with expanded criteria. The donor risk index (DRI) was validated with the aim of being a predictive model of graft survival based on donor characteristics. Intraoperative arterial hepatic flow and indocyanine green clearance (plasma clearance rate of indocyanine green [ICG-PDR]) are easily measurable variables in the intraoperative period that may be influenced by graft quality. Our aim was to analyze the influence of DRI on intraoperative liver hemodynamic alterations and on intraoperative dynamic liver function testing (ICG-PDR). METHODS This investigation was an observational study of a single-center cohort (n = 228) with prospective data collection and retrospective data analysis. Measurement of intraoperative flow was made with a VeriQ flowmeter based on measurement of transit time (MFTT). The ICG-PDR was obtained from all patients with a LiMON monitor (Pulsion Medical Systems AG, Munich, Germany). DRI was calculated using a previously validated formula. Normally distributed variables were compared using Student's t test. Otherwise, the Mann-Whitney U test or Kruskal-Wallis test was applied, depending on whether there were 2 or more comparable groups. The qualitative variables and risk measurements were analyzed using the chi-square test. P < .05 was considered statistically significant. RESULTS DRI score (mean ± SD) was 1.58 ± 0.31. The group with DRI >1.7 (poor quality) had an intraoperative arterial flow of 234.2 ± 121.35 mL/min compared with the group having DRI < 1.7 (high quality), with an intraoperative arterial flow of 287.24 ± 156.84 mL/min (P = .02). The group with DRI >1.70 had an ICG-PDR of 14.75 ± 6.52%/min at 60 minutes after reperfusion compared to the group with DRI <1.70, with an ICG-PDR of 16.68 ± 6.47%/min at 60 minutes after reperfusion (P = .09). CONCLUSION Poor quality grafts have greater susceptibility to ischemia-reperfusion damage. Decreased intraoperative hepatic arterial flow may represent an increase in intrahepatic resistance early in the intraoperative period.
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Affiliation(s)
- P Lozano
- Liver Transplant Unit, Hospital Universitario Gregorio Marañón de Madrid, Madrid, Spain; Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain.
| | - M I Orue-Echebarria
- Liver Transplant Unit, Hospital Universitario Gregorio Marañón de Madrid, Madrid, Spain; Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - J M Asencio
- Liver Transplant Unit, Hospital Universitario Gregorio Marañón de Madrid, Madrid, Spain; Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - H Sharma
- Department of Multi-Organ Transplant Surgery, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - C J Lisbona
- Liver Transplant Unit, Hospital Universitario Gregorio Marañón de Madrid, Madrid, Spain; Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - L Olmedilla
- Liver Transplant Unit, Hospital Universitario Gregorio Marañón de Madrid, Madrid, Spain; Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - J M Pérez Peña
- Liver Transplant Unit, Hospital Universitario Gregorio Marañón de Madrid, Madrid, Spain; Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - M M Salcedo
- Liver Transplant Unit, Hospital Universitario Gregorio Marañón de Madrid, Madrid, Spain; Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - A Skaro
- Department of Multi-Organ Transplant Surgery, University of Western Ontario, London, Ontario, Canada
| | - E Velasco
- Liver Transplant Unit, Hospital Universitario Gregorio Marañón de Madrid, Madrid, Spain; Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - A Colón
- Liver Transplant Unit, Hospital Universitario Gregorio Marañón de Madrid, Madrid, Spain; Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - B Díaz-Zorita
- Liver Transplant Unit, Hospital Universitario Gregorio Marañón de Madrid, Madrid, Spain; Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - L Rodríguez
- Liver Transplant Unit, Hospital Universitario Gregorio Marañón de Madrid, Madrid, Spain; Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - J Ferreiroa
- Liver Transplant Unit, Hospital Universitario Gregorio Marañón de Madrid, Madrid, Spain; Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - J Á López-Baena
- Liver Transplant Unit, Hospital Universitario Gregorio Marañón de Madrid, Madrid, Spain; Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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Early graft dysfunction after liver transplant: Comparison of different diagnostic criteria in a single-center prospective cohort. Med Intensiva 2018; 44:150-159. [PMID: 30528954 DOI: 10.1016/j.medin.2018.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 08/23/2018] [Accepted: 09/05/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Comparison of different diagnostic criteria for early liver allograft dysfunction (EAD) and their capability to predict mortality. DESIGN Single-center, prospective, cohort study. SETTINGS ICU in a Regional Hospital with a liver transplant program since 1997. PATIENTS 253 consecutive patients admitted to our ICU immediately after liver transplantation between 2009 and 2015. VARIABLES OF INTEREST Differences in the incidence of EAD and its relation with ICU, Hospital and 2-year mortality depending on the definition applied using as comparator the UNOS (United Network for Organ Sharing) primary non-function criterion. RESULTS The incidence of early liver allograft dysfunction according to UNOS was 13.8%, to Makowka 6.3%, to Ardite 10.7%, to Nanashima 20.6%, to Dhillon 30.8% and to MEAF 13.4%. Kappa test did not show a good correlation among these criteria. EAD was related with ICU mortality for all diagnostic criteria except Dhillon but only UNOS, Makowka and MEAF were associated with 2-year mortality. Hospital mortality was poorly predicted by all criteria except for the MEAF score. CONCLUSION We found a poor agreement between different criteria analyzed for the diagnosis of EAD. In our population, the MEAF score showed the best relationship with short- and long-term mortality.
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Tomescu D, Popescu M, Dima SO. Rotational thromboelastometry (ROTEM) 24 hours post liver transplantation predicts early allograft dysfunction. Rom J Anaesth Intensive Care 2018; 25:117-122. [PMID: 30393768 DOI: 10.21454/rjaic.7518.252.tms] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Early allograft dysfunction (EAD) represents one of the most common and serious complications after liver transplantation (LT). Methods One hundred sixty-four patients who underwent LT were prospectively included in the present study. Patient demographics, intraoperative blood loss and transfusion were recorded at the time of LT. Lactate levels were recorded during surgery and daily for the first 3 postoperative days. Standard and derived rotational thromboelastometry (ROTEM) parameters were recorded 24 hours after LT. EAD was diagnosed according to Nanashima criteria and post anaesthesia care unit length of stay was recorded. Results Forty-seven patients (28.6%) developed EAD. Intraoperative blood loss (p = 0.01), packed red blood cells (p = 0.04) and fresh frozen plasma (p = 0.01) transfusion represented intraoperative risk factors for EAD. Lactate levels were significantly higher in patients with EAD at all time points. Patients with EAD demonstrated an increased clot formation time and decreased maximum clot firmness in both intrinsically (p < 0.01) and extrinsically (p < 0.01) activated assay, a decreased thrombin potential index (p < 0.01), area under the curve (p < 0.01) and clot elasticity (p < 0.01) on ROTEM assay. Conclusion Our results show that both standard and derived ROTEM parameters may indicate early signs of graft failure and can aid in the diagnosis of EAD.
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Affiliation(s)
- Dana Tomescu
- Fundeni Clinical Institute, Department of Anaesthesia and Critical Care, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Department of Anaesthesia and Critical Care, Bucharest, Romania
| | - Mihai Popescu
- Fundeni Clinical Institute, Department of Anaesthesia and Critical Care, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Department of Anaesthesia and Critical Care, Bucharest, Romania
| | - Simona Olimpia Dima
- Fundeni Clinical Institute, "Dan Setlacec" Center for General Surgery and Liver Transplantation, Bucharest, Romania
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Pollara J, Edwards RW, Lin L, Bendersky VA, Brennan TV. Circulating mitochondria in deceased organ donors are associated with immune activation and early allograft dysfunction. JCI Insight 2018; 3:121622. [PMID: 30089724 PMCID: PMC6129133 DOI: 10.1172/jci.insight.121622] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 06/21/2018] [Indexed: 12/22/2022] Open
Abstract
Brain death that occurs in the setting of deceased organ donation for transplantation is associated with systemic inflammation of unknown origin. It has recently been recognized that mitochondria-derived damage-associated molecular patterns (mtDAMPs) released into the circulation in the setting of trauma and tissue injury are associated with a systemic inflammatory response. We examined the blood of deceased organ donors and found elevated levels of inflammatory cytokines and chemokines that correlated with levels of mtDAMPs. We also found that donor neutrophils are activated and that donor plasma contains a neutrophil-activating factor that is blocked by cyclosporin H, a formyl peptide receptor-1 antagonist. Examination of donor plasma by electron microscopy and flow cytometry revealed that free- and membrane-bound mitochondria are elevated in donor plasma. Interestingly, we demonstrated a correlation between donor plasma mitochondrial DNA levels and early allograft dysfunction in liver transplant recipients, suggesting a role for circulating mtDAMPs in allograft outcomes. Current approaches to prolong allograft survival focus on immune suppression in the transplant recipient; our data indicate that targeting inflammatory factors in deceased donors prior to organ procurement is another potential strategy for improving transplant outcomes.
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Affiliation(s)
- Justin Pollara
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - R. Whitney Edwards
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Liwen Lin
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Victoria A. Bendersky
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Todd V. Brennan
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Hudcova J, Scopa C, Rashid J, Waqas A, Ruthazer R, Schumann R. Effect of early allograft dysfunction on outcomes following liver transplantation. Clin Transplant 2018; 31. [PMID: 28004856 DOI: 10.1111/ctr.12887] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2016] [Indexed: 11/27/2022]
Abstract
Early allograft dysfunction (EAD) following liver transplantation (LT) remains a challenge for patients and clinicians. We retrospectively analyzed the effect of pre-defined EAD on outcomes in a 10-year cohort of deceased-donor LT recipients with clearly defined exclusion criteria. EAD was defined by at least one of the following: AST or ALT >2000 IU/L within first-week post-LT, total bilirubin ≥10 mg/dL, and/or INR ≥1.6 on post-operative day 7. Ten patients developed primary graft failure and were analyzed separately. EAD occurred in 86 (36%) recipients in a final cohort of 239 patients. In univariate and multivariate analyses, EAD was significantly associated with mechanical ventilation ≥2 days or death on days 0, 1, PACU/SICU stay >2 days or death on days 0-2 and renal failure (RF) at time of hospital discharge (all P<.05). EAD was also significantly associated with higher one-year graft loss in both uni- and multivariate Cox hazard analyses (P=.0203 and .0248, respectively). There was no difference in patient mortality between groups in either of the Cox proportional hazard models. In conclusion, we observed significant effects of EAD on short-term post-LT outcomes and lower graft survival.
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Affiliation(s)
- Jana Hudcova
- Department of Surgical Critical Care, Lahey Hospital and Medical Center, Burlington, MA, USA.,Tufts University School of Medicine, Boston, MA, USA
| | - Caitlin Scopa
- Lahey Hospital and Medical Center Burlington, Burlington, MA, USA
| | | | - Ahsan Waqas
- Lahey Hospital and Medical Center Burlington, Burlington, MA, USA
| | - Robin Ruthazer
- Biostatistics, Epidemiology, and Research Design (BERD) Center at Tufts Medical Center, Boston, MA, USA
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Kim JS, Kwon JH, Kim KW, Kim SY, Choi SH, Song GW, Lee SG. Low Graft Attenuation at Unenhanced CT: Association with 1-Month Mortality or Graft Failure after Liver Transplantation. Radiology 2017; 287:167-175. [PMID: 29267144 DOI: 10.1148/radiol.2017171144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Purpose To investigate whether low graft attenuation at unenhanced computed tomography (CT) is associated with 1-month mortality or graft failure after liver transplant and determine its diagnostic performance. Materials and Methods Included were 663 recipients who underwent CT imaging within 7 days after liver transplant between December 2014 and August 2016. Initial poor function (IPF) was diagnosed by using a combination of laboratory values within 7 days after liver transplant and subdivided patients into primary and secondary IPF. At 1 month after the operation, mortality and graft failure or survival in recipients was categorized. Two radiologists who were blinded to clinical data retrospectively and independently evaluated graft attenuation on unenhanced CT images (high or isoattenuation, graft attenuation greater than or equal to that of spleen; low, graft attenuation less than that of spleen). The interobserver agreement was evaluated by using intraclass correlation coefficient and κ statics. Incidence of low graft attenuation between recipients with IPF and those with normal function was compared by using χ2 test. The relationship between graft attenuation and outcome in primary and secondary IPF was evaluated by using log-rank test. Results Of 663 recipients, 114 had IPF (80 primary; 34 secondary). After 1 month, 11 had graft failure or died, whereas 652 survived. Low graft attenuation was more common in patients with IPF than in normal-function patients (P < .001). In the primary group (those without identifiable cause), 15 patients had low graft attenuation, which led to mortality or graft failure within 1 month in seven of those patients. No recipient with high or isoattenuation had 1-month mortality or graft failure (P < .001). The secondary group (those with identifiable cause) showed no significant association between graft attenuation and 1-month mortality and graft failure (P = .181). Values of low graft attenuation for 1-month mortality and graft failure in primary IPF were positive predictive value, 46.7%; negative predictive value, 100%; sensitivity, 100%; specificity, 89.0%; and accuracy, 90.0%. There was excellent interobserver agreement in the assessment of graft attenuation (intraclass correlation coefficient, 0.957; κ = 1.00). Conclusion Low graft attenuation can be associated with 1-month mortality or graft failure in liver graft recipients with primary IPF. © RSNA, 2017.
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Affiliation(s)
- Jin Sil Kim
- From the Department of Radiology, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea (J.S.K.); Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery (J.H.K., G.W.S., S.G.L.), and Department of Radiology and Research Institute of Radiology (K.W.K., S.Y.K., S.H.C.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
| | - Jae Hyun Kwon
- From the Department of Radiology, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea (J.S.K.); Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery (J.H.K., G.W.S., S.G.L.), and Department of Radiology and Research Institute of Radiology (K.W.K., S.Y.K., S.H.C.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
| | - Kyoung Won Kim
- From the Department of Radiology, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea (J.S.K.); Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery (J.H.K., G.W.S., S.G.L.), and Department of Radiology and Research Institute of Radiology (K.W.K., S.Y.K., S.H.C.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
| | - So Yeon Kim
- From the Department of Radiology, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea (J.S.K.); Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery (J.H.K., G.W.S., S.G.L.), and Department of Radiology and Research Institute of Radiology (K.W.K., S.Y.K., S.H.C.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
| | - Sang Hyun Choi
- From the Department of Radiology, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea (J.S.K.); Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery (J.H.K., G.W.S., S.G.L.), and Department of Radiology and Research Institute of Radiology (K.W.K., S.Y.K., S.H.C.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
| | - Gi Won Song
- From the Department of Radiology, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea (J.S.K.); Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery (J.H.K., G.W.S., S.G.L.), and Department of Radiology and Research Institute of Radiology (K.W.K., S.Y.K., S.H.C.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
| | - Sung Gyu Lee
- From the Department of Radiology, Ewha Womans University Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea (J.S.K.); Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery (J.H.K., G.W.S., S.G.L.), and Department of Radiology and Research Institute of Radiology (K.W.K., S.Y.K., S.H.C.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
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The postoperative Model for End stage Liver Disease score as a predictor of short-term outcome after transplantation of extended criteria donor livers. Eur J Gastroenterol Hepatol 2017; 29:716-722. [PMID: 28441690 DOI: 10.1097/meg.0000000000000851] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recently, the postoperative Model for End stage Liver Disease score (POPMELD) was suggested as a definition of postoperative graft dysfunction and a predictor of outcome after liver transplantation (LT). AIM The aim of the present study was to validate this concept in the context of extended criteria donor (ECD) organs. PATIENTS AND METHODS Single-center prospectively collected data (OPAL study/01/11-12/13) of 116 ECD LTs were utilized. For each recipient, the Model for End stage Liver Disease (MELD) score was calculated for 7 postoperative days (PODs). The ability of international normalized ratio, bilirubin, aspartate aminotransferase, Donor Risk Index, a recent definition of early allograft dysfunction, and the POPMELD was compared to predict 90-day graft loss. Predictive abilities were compared by receiver operating characteristic curves, sensitivity and specificity, and positive and negative predictive values. RESULTS The median Donor Risk Index was 1.8. In all, 60.3% of recipients were men [median age of 54 (23-68) years]. The median POD1-7 peak-aspartate aminotransferase value was 1052 (194-17 577) U/l. The rate of early allograft dysfunction was 22.4%. The 90-day graft survival was 89.7%. Out of possible predictors of the 90-day graft loss MELD on POD5 was the best predictor of outcome (area under the curve=0.84). A MELD score of 16 or more on POD5 predicted the 90-day graft loss with a specificity of 80.8%, a sensitivity of 81.8%, and a positive and negative predictive value of 31 and 97.7%. CONCLUSION A MELD score of 16 or more on POD5 is an excellent predictor of outcome in ECD donor LT. Routine evaluation of POPMELD scores might support clinical decision-making and should be reported routinely in clinical trials.
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Al-Freah MAB, McPhail MJW, Dionigi E, Foxton MR, Auzinger G, Rela M, Wendon JA, O'Grady JG, Heneghan MA, Heaton ND, Bernal W. Improving the Diagnostic Criteria for Primary Liver Graft Nonfunction in Adults Utilizing Standard and Transportable Laboratory Parameters: An Outcome-Based Analysis. Am J Transplant 2017; 17:1255-1266. [PMID: 28199762 DOI: 10.1111/ajt.14230] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 01/11/2017] [Accepted: 02/04/2017] [Indexed: 01/25/2023]
Abstract
Current diagnostic criteria for primary nonfunction (PNF) of liver grafts are based on clinical experience rather than statistical methods. A retrospective, single-center study was conducted of all adults (n = 1286) who underwent primary liver transplant (LT) 2000-2008 in our center. Laboratory variables during the first post LT week were analyzed. Forty-two patients (3.7%) had 2-week graft failure. Transplant albumin, day-1 aspartate aminotransferase (AST), day-1 lactate, day-3 bilirubin, day-3 international normalized ratio (INR), and day-7 AST were independently associated with PNF on multivariate logistic regression. PNF score =(0.000280*D1AST)+ (0.361*D1 Lactate)+(0.00884*D3 Bilirubin)+(0.940*D3 INR)+(0.00153*D7 AST)-(0.0972*TxAlbumin)-4.5503. Receiver operating curve analysis showed the model area under receiver operating curve (AUROC) of 0.912 (0.889-0.932) was superior to the current United Kingdom (UK) PNF criteria of 0.669 (0.634-0.704, p < 0.0001). When applied to a validation cohort (n = 386, 34.4% patients), the model had AUROC of 0.831 (0.789-0.867) compared to the UK early graft dysfunction criteria of 0.674 (0.624-0.721). The new model performed well after exclusion of patients with marginal grafts and when modified to include variables from the first three post-LT days only (AUROC of 0.818, 0.776-0.856, p = 0.001). This model is superior to the current UK PNF criteria and is based on statistical methods. The model is also applicable to recipients of all types of grafts (marginal and nonmarginal).
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Affiliation(s)
- M A B Al-Freah
- Institute of Liver Studies, King's College Hospital, London, UK
| | - M J W McPhail
- Institute of Liver Studies, King's College Hospital, London, UK
| | - E Dionigi
- Institute of Liver Studies, King's College Hospital, London, UK
| | - M R Foxton
- Institute of Liver Studies, King's College Hospital, London, UK
| | - G Auzinger
- Institute of Liver Studies, King's College Hospital, London, UK
| | - M Rela
- Institute of Liver Studies, King's College Hospital, London, UK
| | - J A Wendon
- Institute of Liver Studies, King's College Hospital, London, UK
| | - J G O'Grady
- Institute of Liver Studies, King's College Hospital, London, UK
| | - M A Heneghan
- Institute of Liver Studies, King's College Hospital, London, UK
| | - N D Heaton
- Institute of Liver Studies, King's College Hospital, London, UK
| | - W Bernal
- Institute of Liver Studies, King's College Hospital, London, UK
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27
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Zanchet MV, Silva LLGD, Matias JEF, Coelho JCU. POST-REPERFUSION LIVER BIOPSY AND ITS VALUE IN PREDICTING MORTALITY AND GRAFT DYSFUNCTION AFTER LIVER TRANSPLANTATION. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2017; 29:189-193. [PMID: 27759784 PMCID: PMC5074672 DOI: 10.1590/0102-6720201600030014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 05/20/2016] [Indexed: 12/11/2022]
Abstract
Background: The outcome of the patients after liver transplant is complex and to characterize the risk for complications is not always easy. In this context, the hepatic post-reperfusion biopsy is capable of portraying alterations of prognostic importance. Aim: To compare the results of liver transplantation, correlating the different histologic features of the hepatic post-reperfusion biopsy with graft dysfunction, primary non-function and patient survival in the first year after transplantation. Method: From the 377 transplants performed from 1996 to 2008, 164 patients were selected. Medical records were reviewed and the following clinical outcomes were registered: mortality in 1, 3, 6 and 12 months, graft dysfunction in varied degrees and primary graft non-function. The post-reperfusion biopsies had been examined by a blinded pathologist for the outcomes. The following histological variables had been evaluated: ischemic alterations, congestion, steatosis, neutrophilic exudate, monomorphonuclear infiltrate and necrosis. Results: The variables associated with increased mortality were: steatosis (p=0.02209), monomorphonuclear infiltrate (p=0.03935) and necrosis (p<0.00001). The neutrophilic exudate reduced mortality in this study (p=0.00659). The primary non-function showed significant association (p<0.05) with the necrosis, steatosis and the monomorphonuclear infiltrate. Conclusion: Post-reperfusion biopsy is useful tool to foresee complications after liver transplant.
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Affiliation(s)
- Marcos Vinícius Zanchet
- Postgraduate Program im Sugical clinics, Healtu Sciences Sector, Federal University of Paraná, Curitiba, PR, Brazil
| | | | - Jorge Eduardo Fouto Matias
- Postgraduate Program im Sugical clinics, Healtu Sciences Sector, Federal University of Paraná, Curitiba, PR, Brazil
| | - Júlio Cezar Uili Coelho
- Postgraduate Program im Sugical clinics, Healtu Sciences Sector, Federal University of Paraná, Curitiba, PR, Brazil
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28
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Jin SJ, Kim SK, Choi SS, Kang KN, Rhyu CJ, Hwang S, Lee SG, Namgoong JM, Kim YK. Risk factors for intraoperative massive transfusion in pediatric liver transplantation: a multivariate analysis. Int J Med Sci 2017; 14:173-180. [PMID: 28260994 PMCID: PMC5332847 DOI: 10.7150/ijms.17502] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/21/2016] [Indexed: 01/10/2023] Open
Abstract
Background: Pediatric liver transplantation (LT) is strongly associated with increased intraoperative blood transfusion requirement and postoperative morbidity and mortality. In the present study, we aimed to assess the risk factors associated with massive transfusion in pediatric LT, and examined the effect of massive transfusion on the postoperative outcomes. Methods: We enrolled pediatric patients who underwent LT between December 1994 and June 2015. Massive transfusion was defined as the administration of red blood cells ≥100% of the total blood volume during LT. The cases of pediatric LT were assigned to the massive transfusion or no-massive transfusion (administration of red blood cells <100% of the total blood volume during LT) group. Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors associated with massive transfusion in pediatric LT. Kaplan-Meier survival analysis, with the log rank test, was used to compare graft and patient survival within 6 months after pediatric LT between the 2 groups. Results: The total number of LT was 112 (45.0%) and 137 (55.0%) in the no-massive transfusion and massive transfusion groups, respectively. Multivariate logistic regression analysis indicated that high white blood cell (WBC) count, low platelet count, and cadaveric donors were significant predictive factors of massive transfusion during pediatric LT. The graft failure rate within 6 months in the massive transfusion group tended to be higher than that in the no-massive transfusion group (6.6% vs. 1.8%, P = 0.068). However, the patient mortality rate within 6 months did not differ significantly between the massive transfusion and no-massive transfusion groups (7.3% vs. 7.1%, P = 0.964). Conclusion: Massive transfusion during pediatric LT is significantly associated with a high WBC count, low platelet count, and cadaveric donor. This finding can provide a better understanding of perioperative blood transfusion management in pediatric LT recipients.
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Affiliation(s)
- Seok-Joon Jin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sun-Key Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Keum Nae Kang
- Department of Anesthesiology and Pain Medicine, National Police Hospital, Seoul, Republic of Korea
| | - Chang Joon Rhyu
- Department of Anesthesiology and Pain Medicine, National Police Hospital, Seoul, Republic of Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Gyu Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung-Man Namgoong
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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29
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Postoperative Care of the Liver Transplant Recipient. ANESTHESIA AND PERIOPERATIVE CARE FOR ORGAN TRANSPLANTATION 2017. [PMCID: PMC7120127 DOI: 10.1007/978-1-4939-6377-5_29] [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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30
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Gajate Martín L, González C, Ruiz Torres I, Fernández Martín C, Martín Grande A, Elías Martín E, Parise Roux D, del Rey Sánchez J. Effects of the Hypnotic Agent on Primary Graft Dysfunction After Liver Transplantation. Transplant Proc 2016; 48:3307-3311. [DOI: 10.1016/j.transproceed.2016.08.048] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 07/25/2016] [Accepted: 08/22/2016] [Indexed: 02/06/2023]
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31
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Neves DB, Rusi MB, Diaz LGG, Salvalaggio P. Primary graft dysfunction of the liver: definitions, diagnostic criteria and risk factors. ACTA ACUST UNITED AC 2016; 14:567-572. [PMID: 27783749 DOI: 10.1590/s1679-45082016rw3585] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 04/09/2016] [Indexed: 12/11/2022]
Abstract
Primary graft dysfunction is a multifactorial syndrome with great impact on liver transplantation outcomes. This review article was based on studies published between January 1980 and June 2015 and retrieved from PubMed database using the following search terms: "primary graft dysfunction", "early allograft dysfunction", "primary non-function" and "liver transplantation". Graft dysfunction describes different grades of graft ischemia-reperfusion injury and can manifest as early allograft dysfunction or primary graft non-function, its most severe form. Donor-, surgery- and recipient-related factors have been associated with this syndrome. Primary graft dysfunction definition, diagnostic criteria and risk factors differ between studies. RESUMO A disfunção primária do enxerto hepático é uma síndrome multifatorial com grande impacto no resultado do transplante de fígado. Foi realizada uma ampla revisão da literatura, consultando a base de dados PubMed, em busca de estudos publicados entre janeiro de 1980 e junho de 2015. Os termos descritivos utilizados foram: "primary graft dysfunction", "early allograft dysfunction", "primary non-function" e "liver transplantation". A disfunção traduz graus diferentes da lesão de isquemia e reperfusão do órgão, e pode se manifestar como disfunção precoce ou, na forma mais grave, pelo não funcionamento primário do enxerto. Fatores relacionados ao doador, ao transplante e ao receptor contribuem para essa síndrome. Existem definições diferentes na literatura quanto ao diagnóstico e aos fatores de risco associados à disfunção primária.
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Affiliation(s)
- Douglas Bastos Neves
- Hospital Federal dos Servidores do Estado, Rio de Janeiro, RJ, Brazil; Hospital São Vicente de Paulo, Rio de Janeiro, RJ, Brazil.,Programa de Pós-graduação em Ciências da Saúde, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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32
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Barros MAP, Vasconcelos PRL, Souza CM, Andrade GM, Moraes MO, Costa PEG, Coelho GR, Garcia JHP. L-Alanyl-Glutamine Attenuates Oxidative Stress in Liver Transplantation Patients. Transplant Proc 2016; 47:2478-82. [PMID: 26518955 DOI: 10.1016/j.transproceed.2015.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 07/08/2015] [Accepted: 08/03/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Ischemia/reperfusion injury during liver transplantation can cause severe damage to the graft. The objective of this randomized, double-blind study was to evaluate the possible protective effects of L-alanyl-glutamine on the liver graft. METHODS The sample included 33 patients from a liver transplantation service in Northeastern Brazil. Before cold ischemia, the patients received 50 g of L-alanyl-glutamine (treatment group) or saline (control group) through the portal vein. The graft was biopsied at the time of recovery, at the beginning of warm ischemia, and at the end of transplantation to determine malondialdehyde (MDA), heat-shock protein (Hsp)70, nuclear factor kappa-beta (NFkB), superoxide dismutase (SOD), and reduced glutathione (GSH) levels. RESULTS The blood parameters were similar in the two groups. In the treatment group, MDA did not increase at the beginning of cold ischemia and decreased at the end of transplantation. This phenomenon was not observed in the control group. GSH, SOD, Hsp70, and NFkB levels were similar in the two groups. CONCLUSIONS Our findings suggest that preconditioning with L-alanyl-glutamine attenuates the effects of ischemia/reperfusion-related oxidative stress and reduces lipid peroxidation in the grafts of liver transplantation patients.
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Affiliation(s)
- M A P Barros
- Department of Surgery, HUWC (University Hospital), Universidade Federal do Ceará, Fortaleza, Ceará, Brazil.
| | - P R L Vasconcelos
- Department of Surgery, HUWC (University Hospital), Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | - C M Souza
- Department of Physiology and Pharmacology, School of Medicine, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | - G M Andrade
- Department of Physiology and Pharmacology, School of Medicine, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | - M O Moraes
- Department of Physiology and Pharmacology, School of Medicine, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | - P E G Costa
- Department of Surgery, HUWC (University Hospital), Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | - G R Coelho
- Department of Surgery, HUWC (University Hospital), Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
| | - J H P Garcia
- Department of Surgery, HUWC (University Hospital), Universidade Federal do Ceará, Fortaleza, Ceará, Brazil
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Tomescu D, Popescu M, Jipa L, Fota R, Ungureanu D, Zamfir R, Orban C, Dima SO, Popescu I. The impact of donor liver graft quality on postoperative outcome in liver transplant recipients. A single centre experience. Rom J Anaesth Intensive Care 2016; 23:19-26. [PMID: 28913473 DOI: 10.21454/rjaic.7518.231.gft] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION The Donor Risk Index (DRI) has become a universal score for organ allocation in liver transplantation (LT) worldwide. The aim of this study was to evaluate the impact of liver graft quality measured by DRI, CIT, WIT and donor age on intraoperative hemodynamics (reperfusion syndrome) and early postoperative outcome, defined as initial graft poor function (within 3 days of LT), of deceased donor liver transplant (DDLT) recipients. Secondary end-points were the assessment of the impact of graft quality on the intraoperative and postoperative day 1 hemostasis (evaluated using ROTEM assay). METHODS We retrospectively analyzed 135 patients who underwent deceased-donor LT between January 2013 and December 2014. Patient demographic data (age, sex, cause of End-Stage Liver Disease), preoperative paraclinical data (total bilirubin, creatinine, serum sodium), severity of liver disease scores (Model for End-Stage Liver Disease - MELD and MELD-sodium), intraoperative blood loss and blood products transfusion, incidence of post reperfusion syndrome, postoperative biochemical data (including total bilirubin, hepatic transaminases, lactate levels) and outcome (initial graft poor function diagnosis) were noted. Donor characteristics including DRI, CIT, WIT and donor age were noted. Coagulation was assessed by rotational thromboelastometry (ROTEM) after reperfusion of the graft and on postoperative day 1 in order to determine the effects of liver graft quality on hemostasis. RESULTS Donor age has significantly correlated with decreased derived ROTEM parameters time to the maximum velocity of clot formation - MaxVt (p = 0.000), area under the curve (AUC) (p = 0.008) and maximum clot elasticity (MCE) (p = 0.018) although no difference in transfusion requirements has been observed. A longer CIT was associated with an increase in AST and ALT observed during the early postoperative period: day 1 ALT (p = 0.032) and AST (p = 0.008), day 2 ALT (p = 0.001) and AST (p = 0.001) and day 3 AST (p = 0.010) and ALT (p = 0.001). Higher DRI correlated with higher bilirubin levels measured on postoperative day 1 (p = 0.027) and 2 (p = 0.001). Patients who developed initial graft poor function received liver grafts from older donors (p = 0.05) with a higher DRI (p = 0.002). CONCLUSION Our results suggest a significant impact of donor age and DRI on perioperative coagulation kinetics that may be a result of initial graft poor function. Although CIT and DRI correlated with a more severe cholestasis and hepatocitolysis during the early postoperative period these seems to be short-lived.
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Affiliation(s)
- Dana Tomescu
- Fundeni Clinical Institute, 3 Department of Anaesthesia and Critical Care, Bucharest, Romania.,Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Mihai Popescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Lavinia Jipa
- Fundeni Clinical Institute, 1 Department of Anaesthesia and Critical Care, Bucharest, Romania
| | - Ruxandra Fota
- Fundeni Clinical Institute, 1 Department of Anaesthesia and Critical Care, Bucharest, Romania
| | - Daniela Ungureanu
- Fundeni Clinical Institute, 1 Department of Anaesthesia and Critical Care, Bucharest, Romania
| | - Radu Zamfir
- Fundeni Clinical Institute, Dan Setlacec Department of General Surgery and Liver Transplant, Bucharest, Romania
| | - Carmen Orban
- Fundeni Clinical Institute, 3 Department of Anaesthesia and Critical Care, Bucharest, Romania
| | - Simona Olimpia Dima
- Fundeni Clinical Institute, Dan Setlacec Department of General Surgery and Liver Transplant, Bucharest, Romania
| | - Irinel Popescu
- Fundeni Clinical Institute, Dan Setlacec Department of General Surgery and Liver Transplant, Bucharest, Romania
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Karakhanova S, Oweira H, Steinmeyer B, Sachsenmaier M, Jung G, Elhadedy H, Schmidt J, Hartwig W, Bazhin AV, Werner J. Interferon-γ, interleukin-10 and interferon-inducible protein 10 (CXCL10) as serum biomarkers for the early allograft dysfunction after liver transplantation. Transpl Immunol 2015; 34:14-24. [PMID: 26658573 DOI: 10.1016/j.trim.2015.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 11/14/2015] [Accepted: 12/02/2015] [Indexed: 01/29/2023]
Abstract
Orthotopic liver transplantation (LTP) is nowadays a standard procedure, and provides the chance of survival of patients with end-stage non-treatable chronic liver disease or acute liver failure. Despite long-term survival with a good quality of life in the majority of patients, about 20% develop early allograft dysfunction (EAD), which leads to death or the need for re-transplantation. Therefore, the early diagnosis of EAD and evaluation of its risk factors are very important. Many primary pathological processes leading to EAD are accompanied by the release of different mediators and by a change of biochemical parameters detectable in the peripheral blood. The aim of this study was to investigate cytokines as well as soluble mediators in the serum of patients with and without EAD from our LTP bank, and to evaluate their predictive and prognostic values for EAD. We demonstrated for the first time that the level of IFNγ during the nearest preoperative period may serve as a predictive parameter for EAD. We additionally found that IL-10 and CXCL10 (IP-10) levels in the early postoperative period can be prognostic for EAD. We believe our data expand the spectrum of predictive and prognostic parameters for EAD in LTP.
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Affiliation(s)
- Svetlana Karakhanova
- Department of General Surgery, University of Heidelberg, 69120 Heidelberg, Germany.
| | - Hani Oweira
- Department of General Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Beate Steinmeyer
- Department of General Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Milena Sachsenmaier
- Department of General Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Gregor Jung
- Department of General Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Hazem Elhadedy
- Department of General Surgery, University of Heidelberg, 69120 Heidelberg, Germany
| | - Jan Schmidt
- Department of General Surgery, University of Heidelberg, 69120 Heidelberg, Germany; General and Visceral Surgery Center, 8002 Zurich, Switzerland
| | - Werner Hartwig
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University, 81377 Munich, Germany
| | - Alexandr V Bazhin
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University, 81377 Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig-Maximilians-University, 81377 Munich, Germany
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Surgical Management of Large Spontaneous Portosystemic Splenorenal Shunts During Liver Transplantation: Splenectomy or Left Renal Vein Ligation? Transplant Proc 2015; 47:1866-76. [DOI: 10.1016/j.transproceed.2015.06.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 06/05/2015] [Accepted: 06/16/2015] [Indexed: 12/13/2022]
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Kurian SM, Fouraschen SMG, Langfelder P, Horvath S, Shaked A, Salomon DR, Olthoff KM. Genomic profiles and predictors of early allograft dysfunction after human liver transplantation. Am J Transplant 2015; 15:1605-14. [PMID: 25828101 DOI: 10.1111/ajt.13145] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 11/09/2014] [Accepted: 12/03/2014] [Indexed: 02/06/2023]
Abstract
Early hepatic allograft dysfunction (EAD) manifests posttransplantation with high serum transaminases, persistent cholestasis, and coagulopathy. The biological mechanisms are poorly understood. This study investigates the molecular mechanisms involved in EAD and defines a gene expression signature revealing different biological pathways in subjects with EAD from those without EAD, a potential first step in developing a molecular classifier as a potential clinical diagnostic. Global gene expression profiles of 30 liver transplant recipients of deceased donor grafts with EAD and 26 recipients without graft dysfunction were investigated using microarrays of liver biopsies performed at the end of cold storage and after graft reperfusion prior to closure. Results reveal a shift in inflammatory and metabolic responses between the two time points and differences between EAD and non-EAD. We identified relevant pathways (PPARα and NF-κB) and targets (such as CXCL1, IL1, TRAF6, TIPARP, and TNFRSF1B) associated with the phenotype of EAD. Preliminary proof of concept gene expression classifiers that distinguish EAD from non-EAD patients, with Area Under the Curve (AUC) >0.80 were also identified. This data may have mechanistic and diagnostic implications for EAD.
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Affiliation(s)
- S M Kurian
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | - S M G Fouraschen
- Penn Transplant Institute, Department of Surgery, University of Pennsylvania, Philadelphia, PA.,Department of Surgery and Laboratory of Experimental Transplantation and Intestinal Surgery, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - P Langfelder
- Department of Human Genetics, University of California, Los Angeles, CA
| | - S Horvath
- Department of Human Genetics, University of California, Los Angeles, CA
| | - A Shaked
- Penn Transplant Institute, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - D R Salomon
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, CA
| | - K M Olthoff
- Penn Transplant Institute, Department of Surgery, University of Pennsylvania, Philadelphia, PA
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Ali JM, Davies SE, Brais RJ, Randle LV, Klinck JR, Allison MED, Chen Y, Pasea L, Harper SFJ, Pettigrew GJ. Analysis of ischemia/reperfusion injury in time-zero biopsies predicts liver allograft outcomes. Liver Transpl 2015; 21:487-99. [PMID: 25545865 DOI: 10.1002/lt.24072] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Revised: 12/04/2014] [Accepted: 12/14/2014] [Indexed: 12/12/2022]
Abstract
Ischemia/reperfusion injury (IRI) that develops after liver implantation may prejudice long-term graft survival, but it remains poorly understood. Here we correlate the severity of IRIs that were determined by histological grading of time-zero biopsies sampled after graft revascularization with patient and graft outcomes. Time-zero biopsies of 476 liver transplants performed at our center between 2000 and 2010 were graded as follows: nil (10.5%), mild (58.8%), moderate (26.1%), and severe (4.6%). Severe IRI was associated with donor age, donation after circulatory death, prolonged cold ischemia time, and liver steatosis, but it was also associated with increased rates of primary nonfunction (9.1%) and retransplantation within 90 days (22.7%). Longer term outcomes in the severe IRI group were also poor, with 1-year graft and patient survival rates of only 55% and 68%, respectively (cf. 90% and 93% for the remainder). Severe IRI on the time-zero biopsy was, in a multivariate analysis, an independent determinant of 1-year graft survival and was a better predictor of 1-year graft loss than liver steatosis, early graft dysfunction syndrome, and high first-week alanine aminotransferase with a positive predictive value of 45%. Time-zero biopsies predict adverse clinical outcomes after liver transplantation, and severe IRI upon biopsy signals the likely need for early retransplantation.
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Affiliation(s)
- Jason M Ali
- Departments of Surgery, Cambridge University Hospitals National Health Service Trust, Cambridge, United Kingdom
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Pareja E, Cortes M, Hervás D, Mir J, Valdivieso A, Castell JV, Lahoz A. A score model for the continuous grading of early allograft dysfunction severity. Liver Transpl 2015; 21:38-46. [PMID: 25204890 DOI: 10.1002/lt.23990] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 07/10/2014] [Accepted: 09/02/2014] [Indexed: 01/12/2023]
Abstract
Early allograft dysfunction (EAD) dramatically influences graft and patient outcomes. A lack of consensus on an EAD definition hinders comparisons of liver transplant outcomes and management of recipients among and within centers. We sought to develop a model for the quantitative assessment of early allograft function [Model for Early Allograft Function Scoring (MEAF)] after transplantation. A retrospective study including 1026 consecutive liver transplants was performed for MEAF score development. Multivariate data analysis was used to select a small number of postoperative variables that adequately describe EAD. Then, the distribution of these variables was mathematically modeled to assign a score for each actual variable value. A model, based on easily obtainable clinical parameters (ie, alanine aminotransferase, international normalized ratio, and bilirubin) and scoring liver function from 0 to 10, was built. The MEAF score showed a significant association with patient and graft survival at 3-, 6- and 12-month follow-ups. Hepatic steatosis and age for donors; cold/warm ischemia times and postreperfusion syndrome for surgery; and intensive care unit and hospital stays, Model for End-Stage Liver Disease and Child-Pugh scores, body mass index, and fresh frozen plasma transfusions for recipients were factors associated significantly with EAD. The model was satisfactorily validated by its application to an independent set of 200 patients who underwent liver transplantation at a different center. In conclusion, a model for the quantitative assessment of EAD severity has been developed and validated for the first time. The MEAF provides a more accurate graft function assessment than current categorical classifications and may help clinicians to make early enough decisions on retransplantation benefits. Furthermore, the MEAF score is a predictor of recipient and graft survival. The standardization of the criteria used to define EAD may allow reliable comparisons of recipients' treatments and transplant outcomes among and within centers.
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Affiliation(s)
- Eugenia Pareja
- Unidad de Hepatología Experimental, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
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Hoyer DP, Paul A, Gallinat A, Molmenti EP, Reinhardt R, Minor T, Saner FH, Canbay A, Treckmann JW, Sotiropoulos GC, Mathé Z. Donor information based prediction of early allograft dysfunction and outcome in liver transplantation. Liver Int 2015; 35:156-63. [PMID: 24351095 DOI: 10.1111/liv.12443] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 12/12/2013] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Poor initial graft function was recently newly defined as early allograft dysfunction (EAD) [Olthoff KM, Kulik L, Samstein B, et al. Validation of a current definition of early allograft dysfunction in liver transplant recipients and analysis of risk factors. Liver Transpl 2010; 16: 943]. Aim of this analysis was to evaluate predictive donor information for development of EAD. METHODS Six hundred and seventy-eight consecutive adult patients (mean age 51.6 years; 60.3% men) who received a primary liver transplantation (LT) (09/2003-12/2011) were included. Standard donor data were correlated with EAD and outcome by univariable/multivariable logistic regression and Cox proportional hazards to identify prognostic donor factors after adjustment for recipient confounders. Estimates of relevant factors were utilized for construction of a new continuous risk index to develop EAD. RESULTS 38.7% patients developed EAD. 30-day survival of grafts with and without EAD was 59.8% and 89.7% (P < 0.0001). 30-day survival of patients with and without EAD was 68.5% and 93.1% (P < 0.0001) respectively. Donor body mass index (P = 0.0112), gGT (P = 0.0471), macrosteatosis (P = 0.0006) and cold ischaemia time (CIT) (P = 0.0031) were predictors of EAD. Internal cross validation showed a high predictive value (c-index = 0.622). CONCLUSIONS Early allograft dysfunction correlates with early results of LT and can be predicted by donor data only. The newly introduced risk index potentially optimizes individual decisions to accept/decline high risk organs. Outcome of these organs might be improved by shortening CIT.
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Affiliation(s)
- Dieter P Hoyer
- Department of General, Visceral and Transplantation Surgery, University Hospital, Essen, Germany
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Kim WH, Lee JH, Ko JS, Min JJ, Gwak MS, Kim GS, Lee SK. Effect of remote ischemic postconditioning on patients undergoing living donor liver transplantation. Liver Transpl 2014; 20:1383-92. [PMID: 25046844 DOI: 10.1002/lt.23960] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 07/05/2014] [Accepted: 07/12/2014] [Indexed: 02/07/2023]
Abstract
The aim of this study was to evaluate the protective effect of remote ischemic postconditioning (RIPostC) on graft function and acute kidney injury (AKI) after living donor liver transplantation (LT). Recipients undergoing elective living donor LT were randomly assigned to either the RIPostC group or the control group. Immediately after reperfusion, 4 cycles of ischemia and reperfusion lasting for 5 minutes each were performed on 1 upper limb in the RIPostC group. Graft function was assessed through evaluations of the serum levels of total bilirubin and liver enzymes and the prothrombin time for 28 days after surgery. The incidence of AKI, as defined by the Risk, Injury, Failure, Loss, and End-Stage Kidney Disease classification, was evaluated within 28 days of the operation. In addition, the incidences of graft dysfunction, acute cellular rejection, and major complications; the 1-, 3-, and 6-month mortality rates; the length of stay in the intensive care unit; and the length of hospital stay were also investigated. In all, 78 patients were enrolled in the analysis (n = 39 in each group). No differences in graft function or clinical outcomes were observed between the groups. The incidences of postoperative AKI were 38% (n = 15) in the RIPostC group and 72% (n = 28) in the control group (P = 0.006). Despite no improvements in postoperative graft function, RIPostC decreased the incidence of postoperative AKI after living donor LT in this study. However, no other clinical benefits with respect to the complication rate, length of hospital stay, or short-term mortality rate were observed. Thus, further studies will be needed to evaluate the clinical efficacy of RIPostC in LT fully.
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Affiliation(s)
- Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
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41
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Hoyer DP, Sotiropoulos GC, Saner FH, Treckmann JW, Paul A, Mathé Z. MELD at POD 1 as a predictor of outcome in liver allografts with peak AST >5000 U/l. Transpl Int 2014; 27:1285-93. [DOI: 10.1111/tri.12417] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 05/26/2014] [Accepted: 07/26/2014] [Indexed: 12/23/2022]
Affiliation(s)
- Dieter P. Hoyer
- Department of General, Visceral and Transplantation Surgery; University Hospital Essen; Essen Germany
| | - Georgios C. Sotiropoulos
- Department of General, Visceral and Transplantation Surgery; University Hospital Essen; Essen Germany
| | - Fuat H. Saner
- Department of General, Visceral and Transplantation Surgery; University Hospital Essen; Essen Germany
| | - Jürgen W. Treckmann
- Department of General, Visceral and Transplantation Surgery; University Hospital Essen; Essen Germany
| | - Andreas Paul
- Department of General, Visceral and Transplantation Surgery; University Hospital Essen; Essen Germany
| | - Zoltan Mathé
- Department of General, Visceral and Transplantation Surgery; University Hospital Essen; Essen Germany
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Abstract
BACKGROUND Primary graft dysfunction (PGD) causes complications in liver transplantation, which result in poor prognosis. Recipients who develop PGD usually experience a longer intensive care unit and hospital stay and have higher mortality and graft loss rates compared with those without graft dysfunction. However, because of the lack of universally accepted definition, early diagnosis of graft dysfunction is difficult. Additionally, numerous factors affect the allograft function after transplantation, making the prediction of PGD more difficult. The present review was to analyze the literature available on PGD and to propose a definition. DATA SOURCE A search of PubMed (up to the end of 2012) for English-language articles relevant to PGD was performed to clarify the characteristics, risk factors, and possible treatments or interventions for PGD. RESULTS There is no pathological diagnostic standard; many documented definitions of PGD are different. Many factors, such as donor status, procurement and transplant process and recipient illness may affect the function of graft, and ischemia-reperfusion injury is considered the direct cause. Potential managements which are helpful to improve graft function were investigated. Some of them are promising. CONCLUSIONS Our analyses suggested that the definition of PGD should include one or more of the following variables: (1) bilirubin ≥ 10 mg/dL on postoperative day 7; (2) international normalized ratio ≥ 1.6 on postoperative day 7; and (3) alanine aminotransferase or aspartate aminotransferase >2000 IU/L within 7 postoperative days. Reducing risk factors may decrease the incidence of PGD. A majority of the recipients could recover from PGD; however, when the graft progresses into primary non-function, the patients need to be treated with re-transplantation.
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Affiliation(s)
- Xiao-Bo Chen
- Department of Liver and Vascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, China.
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43
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Reis H, Peterek PT, Wohlschlaeger J, Kaiser GM, Mathe Z, Juntermanns B, Sotiropoulos GC, Beckhove U, Canbay A, Wirges U, Scherag A, Treckmann JW, Paul A, Baba HA. Oil Red O-assessed macrosteatosis in liver transplant donor biopsies predicts ischemia-reperfusion injury and clinical outcome. Virchows Arch 2013; 464:165-74. [PMID: 24297629 DOI: 10.1007/s00428-013-1512-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 11/04/2013] [Accepted: 11/07/2013] [Indexed: 12/17/2022]
Abstract
Steatosis in donor livers is an accepted adverse prognostic factor after liver transplantation. While its semiquantitative assessment shows varying reproducibility, it is questioned as a standard method. Additionally, the influence of hepatic steatosis on ischemia/reperfusion injury (I/R injury) has not been evaluated in biopsies after reperfusion. We compared different staining and analyzing methods for the assessment of donor liver steatosis in order to predict I/R injury and clinical outcome after transplantation. To do this, 56 paired pre- and post-reperfusion liver biopsies were analyzed for macro- (MaS)/micro- (MiS) and total steatosis in cryo and permanent sections by special fat (Oil Red O or ORO) and standard stains. Computerized morphometrical analyses were compared to the semiquantitative assessment by a pathologist. I/R injury was determined histopathologically and by M30 immunohistochemistry. We found ORO to be more sensitive in detecting hepatic steatosis with higher reproducibility for MaS. Semiquantitative analyses were highly reproducible and not inferior to computerized morphometry. Categorized MaS as determined by ORO correlated with the extent of I/R injury, initial poor function, liver enzymes, and survival. Therefore fat stains like ORO are a reliable and easy method comprising significant advantages in the evaluation of hepatic steatosis and are thereby of prognostic value. Computerized analysis is a precise tool though not superior to semiquantitative analyses.
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Affiliation(s)
- Henning Reis
- Institute of Pathology and Neuropathology, University Hospital of Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany
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Wagener G, Raffel B, Young AT, Minhaz M, Emond J. Predicting early allograft failure and mortality after liver transplantation: the role of the postoperative model for end-stage liver disease score. Liver Transpl 2013; 19:534-42. [PMID: 23576469 DOI: 10.1002/lt.23634] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 02/15/2013] [Indexed: 02/06/2023]
Abstract
Early allograft dysfunction (EAD) is a serious complication after liver transplantation (LT). There is no uniform definition of EAD, and most definitions are based on arbitrary laboratory values. The aim of this study was to devise a definition of EAD that maximizes the predictive power for early death and graft failure. In this single-center, retrospective study, the ability of the international normalized ratio (INR), total bilirubin, aspartate aminotransferase (AST), physiological Model for End-Stage Liver Disease (MELD) score, and serum albumin levels within 7 days after LT to predict 90-day mortality or graft loss was compared with 2 previously used definitions of EAD: (1) peak total bilirubin level >10 mg/dL on days 2 to 7 and (2) either a total bilirubin level >10 mg/dL or an INR >1.6 on day 7 or an AST or alanine aminotransferase level >2000 IU/L within the first 7 days. Of 572 enrolled LT patients 38 died or required retransplantation within 90 days. Peak INR, total bilirubin level, AST levels, and MELD scores were predictors of 90-day graft failure. MELD score on postoperative day 5 was the best predictor with an area under the curve of the receiver operating characteristic curve of 0.812 (95% CI: 0.739-0.886, P < 0.001). The best cutoff of MELD score on day 5 for predicting 90-day mortality or graft loss was 18.9. A MELD score >18.9 on postoperative day 5 was a better predictor than any other laboratory value or definition of EAD. This study has demonstrated that the MELD score can be a useful tool not only for pretransplant graft allocation but also for postoperative risk stratification.
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Affiliation(s)
- Gebhard Wagener
- Department of Anesthesiology, Columbia University, New York, NY, USA.
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45
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Bärthel E, Rauchfuss F, Hoyer H, Breternitz M, Jandt K, Settmacher U. The PRAISE study: a prospective, multi-center, randomized, double blinded, placebo-controlled study for the evaluation of iloprost in the early postoperative period after liver transplantation (ISRCTN12622749). BMC Surg 2013; 13:1. [PMID: 23356494 PMCID: PMC3564693 DOI: 10.1186/1471-2482-13-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Accepted: 01/23/2013] [Indexed: 01/30/2023] Open
Abstract
Background Liver graft dysfunction can deteriorate to complete organ failure and increases perioperative morbidity and mortality after liver transplantation. Therapeutic strategies reducing the rate of graft dysfunction are of current clinical relevance. One approach is the systemic application of prostaglandins, which were demonstrated to be beneficial in reducing ischemia-reperfusion injury. Preliminary data indicate a positive effect of prostacyclin analogue iloprost on allograft viability after liver transplantation. The objective of the study is to evaluate the impact of iloprost in a multi-center trial. Methods/Design A prospective, double-blinded, randomized, placebo-controlled multicenter study in a total of 365 liver transplant recipients was designed to assess the effect of intravenous iloprost after liver transplantation. Primary endpoint will be the primary graft dysfunction characterized as presentation of one or more of the following criteria: ALAT or ASAT level > 2000 IU/ml within the first 7 postoperative days, bilirubine ≥ 10 mg/dl on postoperative day 7; INR ≥ 1.6 on postoperative day 7 or initial non-function. Secondary endpoints are parameters of post-transplant morbidity, like rates of infections, biliary complications, need of clotting factors or renal replacement therapy and the graft and patient survival. Discussion A well-established treatment concept to avoid graft dysfunction after liver transplantation does not exist at the moment. If the data of this research project confirm prior findings, iloprost would improve the general outcome after liver transplantation. Trial Registration German Clinical Trials Register: DRKS00003514. Current Controlled Trials Register: ISRCTN12622749.
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Affiliation(s)
- Erik Bärthel
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Erlanger Allee 101, D-07740, Jena, Germany.
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46
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Hong SH, Kwak JA, Jeon JY, Park CS. Prediction of early allograft dysfunction using serum phosphorus level in living donor liver transplantation. Transpl Int 2013; 26:402-10. [DOI: 10.1111/tri.12058] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Revised: 08/26/2012] [Accepted: 12/23/2012] [Indexed: 02/07/2023]
Affiliation(s)
- Sang Hyun Hong
- Department of Anaesthesiology and Pain Medicine; Seoul St. Mary's Hospital; College of Medicine; The Catholic University of Korea; Seoul; Korea
| | - Jung Ah Kwak
- Department of Anaesthesiology and Pain Medicine; Seoul St. Mary's Hospital; College of Medicine; The Catholic University of Korea; Seoul; Korea
| | - Jin Yeong Jeon
- Department of Anaesthesiology and Pain Medicine; Yeouido St. Mary's Hospital; College of Medicine; The Catholic University of Korea; Seoul; Korea
| | - Chul Soo Park
- Department of Anaesthesiology and Pain Medicine; Seoul St. Mary's Hospital; College of Medicine; The Catholic University of Korea; Seoul; Korea
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Novelli G, Morabito V, Lai Q, Levi Sandri G, Melandro F, Pugliese F, Novelli S, Rossi M, Berloco P. Glasgow Coma Score and Tumor Necrosis Factor α as Predictive Criteria for Initial Poor Graft Function. Transplant Proc 2012; 44:1820-5. [DOI: 10.1016/j.transproceed.2012.06.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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48
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Croome KP, Wall W, Quan D, Vangala S, McAlister V, Marotta P, Hernandez-Alejandro R. Evaluation of the updated definition of early allograft dysfunction in donation after brain death and donation after cardiac death liver allografts. Hepatobiliary Pancreat Dis Int 2012; 11:372-6. [PMID: 22893463 DOI: 10.1016/s1499-3872(12)60194-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND An updated definition of early allograft dysfunction (EAD) was recently validated in a multicenter study of 300 deceased donor liver transplant recipients. This analysis did not differentiate between donation after brain death (DBD) and donation after cardiac death (DCD) allograft recipients. METHODS We reviewed our prospectively entered database for all DBD (n=377) and DCD (n=38) liver transplantations between January 1, 2006 and October 30, 2011. The incidence of EAD as well as its ability to predict graft failure and survival was compared between DBD and DCD groups. RESULTS EAD was a valid predictor of both graft and patient survival at six months in DBD allograft recipients, but in DCD allograft recipients there was no significant difference in the rate of graft failure in those with EAD (11.5%) compared with those without EAD (16.7%) (P=0.664) or in the rate of death in recipients with EAD (3.8%) compared with those without EAD (8.3%) (P=0.565). The graft failure rate in the first 6 months in those with international normalized ratio ≥1.6 on day 7 who received a DCD allograft was 37.5% compared with 6.7% for those with international normalized ratio <1.6 on day 7 (P=0.022). CONCLUSIONS The recently validated definition of EAD is a valid predictor of patient and graft survival in recipients of DBD allografts. On initial assessment, it does not appear to be a useful predictor of patient and graft survival in recipients of DCD allografts, however a study with a larger sample size of DCD allografts is needed to confirm these findings. The high ALT/AST levels in most recipients of DCD livers as well as the predisposition to biliary complications and early cholestasis make these parameters as poor predictors of graft failure. An alternative definition of EAD that gives greater weight to the INR on day 7 may be more relevant in this population.
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Affiliation(s)
- Kris P Croome
- Multi-Organ Transplant Program, London Health Sciences Centre, The University of Western Ontario, London, Canada.
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Sirivatanauksorn Y, Taweerutchana V, Limsrichamrern S, Kositamongkol P, Mahawithitwong P, Asavakarn S, Tovikkai C. Recipient and perioperative risk factors associated with liver transplant graft outcomes. Transplant Proc 2012; 44:505-8. [PMID: 22410056 DOI: 10.1016/j.transproceed.2012.01.065] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Orthotopic liver transplantation (OLT) is currently considered to be the ultimate form of therapy for most patients with end-stage liver diseases. The identification of recipient and various perioperative factors that may affect the graft outcomes is critical. This study sought to analyze the preoperative and perioperative factors associated with graft outcomes in our institute. METHODS This retrospective study of liver transplanted patients from January 2002 to December 2009 determined the incidence of 2 forms of primary dysfunction (PDF): Primary nonfunction (PNF) and initial poor function (IPF). RESULTS The 97 posttransplant patients included in the study had an average age of 52.74 years. The majority of indications for OLT were hepatitis B and/or C cirrhosis, alcoholic cirrhosis, and hepatocellular carcinoma. The incidence of PDF was 31.9% (31/97) with 7.2% (7/97) PNF and 24.7% (24/97) IPF. Additionally, we observed 68.1% (66/97) to display immediate function (IF). Warm ischemic time (WIT) and operative time were significantly longer in the PDF compared with the IF group. The logistic regression model showed a WIT of >45 minutes to be a risk factor leading to PDF (odds ratio, 11.74; P<.05). An operative time of >6 hours and operative blood loss of >2 L were possible risk factors. CONCLUSION Prolonged WIT (>45 minutes) was the only significant risk factor among other established parameters for graft function. Nevertheless, reduced operative times and blood loss may improve the outcomes of OLT.
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Affiliation(s)
- Y Sirivatanauksorn
- Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Protection of the intrahepatic biliary tree by contemporaneous portal and arterial reperfusion: results of a prospective randomized pilot study. Updates Surg 2012; 64:173-7. [DOI: 10.1007/s13304-012-0164-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 06/21/2012] [Indexed: 01/26/2023]
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