2018 Clinical Update in Liver Transplantation

Incidence of Postreperfusion Hyperfibrinolysis in Liver Transplantation by Donor Type and Observed Treatment Strategies

BACKGROUND

Hyperfibrinolysis is a possible complication during liver transplantation, particularly immediately after reperfusion.

METHODS

We performed a retrospective study to examine the incidence, treatment, and resolution of postreperfusion hyperfibrinolysis in patients undergoing liver transplantation at Duke University Hospital from 2015 to 2020.

RESULTS

Out of 535 patients undergoing liver transplantation, 21 or 3.9%, 95% CI (2.5-5.9), had hyperfibrinolysis after reperfusion. Hyperfibrinolysis occurred in 16 of 511 (3.1%) patients receiving livers from DBD donors, 5 of 18 (27.8%) patients receiving livers from donation after circulatory death (DCD) donors, and 0 of 6 (0.0%) patients receiving livers from living donors. Fibrinolysis was treated with cryoprecipitate (12/21), a combination of cryoprecipitate and tranexamic acid (3/21), or neither (6/21) and resolved within several hours in all cases.

CONCLUSIONS

Anesthesiologists should be aware of the possibility of postreperfusion hyperfibrinolysis in liver transplantation, particularly with DCD donors, and may consider treatment with cryoprecipitate or tranexamic acid. Further work is needed to identify any potential differences, such as faster resolution of fibrinolysis, between different treatment modalities.

Individualized Management of Coagulopathy in Patients with End-Stage Liver Disease

Over the last decades, individualized approaches and a better understanding of coagulopathy complexity in end-stage liver disease (ESLD) patients has evolved. The risk of both thrombosis and bleeding during minimally invasive interventions or surgery is associated with a worse outcome in this patient population. Despite deranged quantitative and qualitative coagulation laboratory parameters, prophylactic coagulation management is unnecessary for patients who do not bleed. Transfusion of red blood cells (RBCs) and blood products carries independent risks for morbidity and mortality, including modulation of the immune system with increased risk for nosocomial infections. Optimal coagulation management in these complex patients should be based on the analysis of standard coagulation tests (SCTs) and viscoelastic tests (VETs). VETs represent an individualized approach to patients and can provide information about coagulation dynamics in a concise period of time. This narrative review will deliver the pathophysiology of deranged hemostasis in ESLD, explore the difficulties of evaluating the coagulopathies in liver disease patients, and examine the use of VET assays and management of coagulopathy using coagulation factors. Methods: A selective literature search with PubMed as the central database was performed with the following.

Patterns of Use in Transesophageal Echocardiography for Liver Transplantation: A Systematic Review

Transesophageal echocardiography is frequently but not always used to guide anesthetic management during liver transplantation. We performed a systematic review of the literature to identify and summarize any studies reporting on the frequency and characteristics of TEE use for liver transplantation. Studies were identified by searching several relevant terms on PubMed and citation searching of relevant reviews. We identified 5 studies reporting the results of surveys performed between 2003 and 2018. Use of TEE for liver transplantation increased from 11.3% of centers in 2003 to greater than 90% of centers by 2014 and 2018. Only 38%-56% of centers use it routinely with the rest using it only in special circumstances. About a third of centers usually perform a comprehensive exam, with the majority performing a more limited exam based on the needs of the case. Use of TEE for liver transplantation is common but not universal. This review summarizes the current knowledge about the frequency and circumstances of use, but there is an opportunity for further systematic study and discussion.

Bleeding Complications from Transesophageal Echocardiography for Liver Transplantation: A Systematic Review

Transesophageal echocardiography (TEE) for liver transplant has historically been avoided due to concern it may cause bleeding from esophageal varices. However, several recent studies, as well as increasing clinical experience, have indicated that it may be safe in many circumstances. We performed a systematic review of the literature to identify and summarize studies reporting complications in patients having TEE during liver transplant. Studies were identified by searching relevant key terms on PubMed as well as citation searching in relevant reviews. We identified 6 studies between 1996 and 2015 which evaluated complications of TEE during liver transplant. They reported an overall bleeding complication rate between .3% and 2.8% and a major bleeding complication rate between .0% and .8%. Most of the major bleeds had identifiable high-risk features such as recent variceal bleeding or banding. Review of the literature suggests that TEE may be safely used in patients undergoing liver transplantation, even with known varices, with a complication rate similar to that of all patients undergoing TEE. However, the risks of TEE may outweigh the potential benefits among patients undergoing liver transplant with particular high-risk features.

Lateral Access Spine Surgery following Liver Transplantation: A Report of Two Cases

With improving prognosis for recipients of liver transplantation, the necessity of medical care for musculoskeletal disorders, including spinal diseases, of these patients is also increasing. Only a few reports are available on cases of spine surgery following liver transplantation. Furthermore, a case of lateral access surgery following liver transplantation has not thus far been reported. The purpose of this study is to present the first two cases of patients treated with lateral access spine surgery following liver transplantation. Case 1. A 49-year-old female had received living donor liver transplantation (LT) for acute-on-chronic liver failure (ACLF) ten years prior to spine surgery. The patient underwent two levels of lateral lumbar interbody fusion (LLIF) followed by posterior lumbar interbody fusion (PLIF) for degenerative lumbar disease. Although neurological symptoms in the lower extremity improved, a liver disorder resulting from acetaminophen-induced hepatotoxicity occurred at an early stage following spine surgery. Case 2. A 66-year-old female had received living donor liver transplantation for hepatocellular carcinoma (HCC) six years prior to spine surgery. She underwent posterior instrumentation surgery followed by a T12 corpectomy using a wide-foot print expandable cage for T12 vertebral collapse. Following surgery, her weakened muscle strength in the lower extremities was significantly improved. Lateral access spine surgery for lumbar and thoracolumbar lesions can be successfully performed for patients following liver transplantation. However, careful follow-up should be performed for complications related to the function of the liver graft following spine surgery.

Hepatic Vein Flow Index During Orthotopic Liver Transplantation as a Predictive Factor for Postoperative Early Allograft Dysfunction

OBJECTIVES

The authors devised a hepatic vein flow index (HVFi), using intraoperative transesophageal echocardiography and graft weight, and investigated its predictive value for postoperative graft function in orthotopic liver transplant.

DESIGN

Prospective clinical trial.

SETTING,

Single-center tertiary academic hospital.

PARTICIPANTS

Ninety-seven patients who had orthotopic liver transplant with the piggy-back technique between February 2018 and December 2019.

MEASUREMENTS AND MAIN RESULTS

HVFi was defined with HV flow/graft weight. Patients who developed early graft dysfunction (EAD) had low HVFi in systole (HVFi sys, 1.23 v 2.19 L/min/kg, p < 0.01), low HVFi in diastole (HVFi dia, 0.87 v 1.54 L/min/kg, p < 0.01), low hepatic vein flow (HVF) in systole (HVF sys, 2.04 v 3.95 L/min, p < 0.01), and low HVF in diastole (HVF dia, 1.44 v 2.63 L/min, p < 0.01). More cardiac death, more vasopressors at the time of measurement, more acute rejection, longer time to normalize total bilirubin (TIME t-bil), longer surgery time, longer neohepatic time, and more packed red blood cell transfusion were observed in the EAD patients. All HVF parameters were negatively correlated with TIME t-bil (HVFi sys R = -0.406, p < 0.01; HFVi dia R = -0.442, p < 0.01; HVF sys R = -0.44, p < 0.01; HVF dia R = -0.467, p < 0.01). The receiver operating characteristic curve analysis determined the best cut-off levels of HVFi to predict occurrence of EAD (HVFi sys <1.608, HVFi dia <0.784 L/min/kg), acute rejection (HVFi sys <1.388, HVFi dia <1.077 L/min/kg), and prolonged high total bilirubin (HVFi sys <1.471, HVFi dia <1.087 L/min/kg).

CONCLUSIONS

The authors' devised HVFi has the potential to predict the postoperative graft function.

Analogies and differences between cirrhotic cardiomyopathy and hepatopulmonary syndrome

Cirrhotic cardiomyopathy and hepatopulmonary syndrome are two quite frequent clinical entities that may complicate the course of liver cirrhosis. The common pathophysiological origin and the same clinical presentation make them difficult to compare. Cirrhotic cardiomyopathy and hepatopulmonary syndrome may start with dyspnea and breathlessness but the former is characterized by a chronic cardiac dysfunction and the latter by a defect of oxygenation due to pulmonary shunts formation. The focus is to differentiate them as soon as possible since the treatment is different until the patient undergoes liver transplant that is the real unique cure for them.

Potassium levels after liver reperfusion in adult patients undergoing cadaveric liver transplantation: A retrospective cohort study

Background

Hyperkalemia is a common cause of arrhythmias in patients undergoing liver transplantation. We examined the pattern of change of potassium levels during and immediately after reperfusion of the donor liver.

Materials and methods

Potassium levels of 30 consecutive adult patients undergoing cadaveric liver transplantation were assessed before and after liver reperfusion. Changes in potassium levels over 13 predefined timepoints were analyzed. Primary aim: to describe the pattern of change of potassium levels during the reperfusion period. Correlation between changes in potassium levels during reperfusion and a-priori variables were investigated.

Results

Baseline median (IQR) potassium levels were 4.1 (3.8:4.5) mmol/L. Thirteen patients (43%) developed hyperkalemia, 10 (33%) of whom developed severe hyperkalemia. Potassium levels peaked at 80 s post reperfusion, plateaued until 2 min, before returning toward baseline values at 5 min. There was a strong association between pre-reperfusion/baseline potassium levels and peak potassium values during reperfusion (95%CI: 0.26 to 0.77, p < 0.001). A baseline potassium level of 4.45 mmol/L was a good predictor of reperfusion hyperkalemia with a sensitivity of 69.2% and specificity of 94.1% (AUC = 0.894, 95%CI: 0.779 to 1.000, p < 0.001).

Conclusion

Hyperkalemia during cadaveric liver transplantation is common affecting almost 1 in 2 patients during reperfusion. During reperfusion potassium levels peaked within 2 min and over a third of patients developed severe hyperkalemia. Higher peak potassium levels correlated strongly with higher pre-reperfusion potassium values. These findings guide clinicians with timing of sampling of blood to check for hyperkalemia and identify modifiable factors associated with the development of hyperkalemia.

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Hyperkalemia during the reperfusion phase of cadaveric liver transplantation is common.

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Potassium levels peaked at 80 s post reperfusion, plateaued for 2 min, and returned to baseline at 5 min.

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There was a strong association between pre-reperfusion potassium levels and peak potassium values during reperfusion.

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Timing of blood sampling to check for hyperkalemia is paramount.

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A baseline potassium level of greater than 4.45 mmol/L was a good predictor of reperfusion hyperkalemia.