Impact of Three Methods of Ischemic Preconditioning on Ischemia-Reperfusion Injury in a Pig Model of Liver Transplantation

A Review of the Risk Factors and Approaches to Prevention of Post-Reperfusion Syndrome During Liver Transplantation

Post-reperfusion syndrome (PRS) is a severe and highly lethal syndrome that occurs after declamping the portal vein forceps during liver transplantation. It is marked by severe hemodynamic disturbances manifested by decreased mean arterial pressure, increased heart rate and elevated pulmonary artery pressure. The complex pathogenesis of PRS remains understudied. It is generally believed to be related to the large amount of acidic, cold blood that enters the circulation after release of the portal clamp. This blood is rich in oxygen-free radicals and metabolic toxins, which not only aggravate the ischemia-reperfusion injury of the liver but also further attack the systemic organs indiscriminately. Considering the range of possible adverse prognoses including acute kidney injury, delirium and graft nonfunction, it is imperative that clinicians increase their awareness and prevention of PRS. The aim of this article is to review the current risk factors, pathophysiological mechanisms and prevention strategies for PRS.

NGAL in the Development of Acute Kidney Injury in a Murine Model of Remote Ischaemic Preconditioning and Liver Ischaemia Reperfusion

Acute kidney injury (AKI) is common following liver transplantation and is associated with liver ischeamia reperfusion (IR) injury. The purpose of this study was to use a mouse model of liver IR injury and AKI to study the role of Neutrophil Gelatinase Associated Lipocalin (NGAL), a biomarker of AKI, in liver IR injury and AKI. We demonstrate an adapted, reproducible model of liver IR injury and AKI in which remote ischemic preconditioning (RIPC) by repeated episodes of hindleg ischemia prior to liver IR reduced the severity of the IR injury. In this model, serum NGAL at 2 h post reperfusion correlated with AKI development early following IR injury. This early rise in serum NGAL was associated with hepatic but not renal upregulation of NGAL mRNA, suggesting NGAL production in the liver but not the kidney in the early phase post liver IR injury.

Effects of local and remote ischemic postconditioning methods on ischemiareperfusion injury in a young animal model of acute mesenteric ischemia

PURPOSE

Acute mesenteric ischemia (AMI) is a condition in pediatric surgery that ranges from intestine necrosis to death. Ischemic postconditioning (IPoC) methods were developed to reduce the damage caused by revascularization. This study aimed to evaluate the efficacy of these methods in an experimental weaning rat model.

METHODS

Thirty-two 21-day-old Wistar rats were allocated into four groups according to the surgical procedure performed: control, ischemia-reperfusion injury (IRI), local (LIPoC) and remote IPoC (RIPoC). At euthanasia, fragments of the intestine, liver, lungs, and kidneys were submitted to histological, histomorphometric, and molecular analyses.

RESULTS

In the duodenum, intestines, and kidneys histological alterations promoted by IRI were reversed by remote postconditioning method. In the distal ileum, the histomorphometric alterations could be reversed by the postconditioning methods with more evident effects promoted by the remote method. The molecular analysis found that the levels of expression of Bax (proapoptotic) and Bcl-XL (antiapoptotic) genes in the intestine were increased by IRI. These alterations were equally reversed by the postconditioning methods, with more evident effects of the remote method.

CONCLUSIONS

IPoC methods positively reduced the damage caused by IRI in weaning rats.

Protective role of remote ischemic conditioning in renal transplantation and partial nephrectomy: A systematic review and meta-analysis of randomized controlled trials

Objective

Studies have shown that remote ischemic conditioning (RIC) can effectively attenuate ischemic-reperfusion injury in the heart and brain, but the effect on ischemic-reperfusion injury in patients with kidney transplantation or partial nephrectomy remains controversial. The main objective of this systematic review and meta-analysis was to investigate whether RIC provides renal protection after renal ischemia-reperfusion injury in patients undergoing kidney transplantation or partial nephrectomy.

Methods

A computer-based search was conducted to retrieve relevant publications from the PubMed database, Embase database, Cochrane Library and Web of Science database. We then conducted a systematic review and meta-analysis of randomized controlled trials that met our study inclusion criteria.

Results

Eleven eligible studies included a total of 1,145 patients with kidney transplantation or partial nephrectomy for systematic review and meta-analysis, among whom 576 patients were randomly assigned to the RIC group and the remaining 569 to the control group. The 3-month estimated glomerular filtration rate (eGFR) was improved in the RIC group, which was statistically significant between the two groups on kidney transplantation [P < 0.001; mean difference (MD) = 2.74, confidence interval (CI): 1.41 to 4.06; I 2 = 14%], and the 1- and 2-day postoperative Scr levels in the RIC group decreased, which was statistically significant between the two groups on kidney transplantation (1-day postoperative: P < 0.001; MD = 0.10, CI: 0.05 to 0.15, I 2 = 0; 2-day postoperative: P = 0.006; MD = 0.41, CI: 0.12 to 0.70, I 2 = 0), but at other times, there was no significant difference between the two groups in Scr levels. The incidence of delayed graft function (DGF) decreased, but there was no significant difference (P = 0.60; 95% CI: 0.67 to 1.26). There was no significant difference between the two groups in terms of cross-clamp time, cold ischemia time, warm ischemic time, acute rejection (AR), graft loss or length of hospital stay.

Conclusion

Our meta-analysis showed that the effect of remote ischemia conditioning on reducing serum creatinine (Scr) and improving estimate glomerular filtration rate (eGFR) seemed to be very weak, and we did not observe a significant protective effect of RIC on renal ischemic-reperfusion. Due to small sample sizes, more studies using stricter inclusion criteria are needed to elucidate the nephroprotective effect of RIC in renal surgery in the future.

Does Arterialization of Portal Vein Have Any Effects in Large-for-Size Liver Transplantation? Hemodynamic, Histological, and Biomolecular Experimental Studies

BACKGROUND

In pediatric liver transplantation, the optimal size of the transplanted liver ranges between 0.8% and 4.0% of the recipient's weight. Sometimes, the graft weight exceeds this upper limit, characterizing the large-for-size condition potentially associated with reduced blood flow and worsening of ischemia-reperfusion injury. Therefore, it would be beneficial to increase the portal flow through arterialization of the portal vein. Materials and methods: Fifteen pigs underwent large-for-size liver transplants. They were divided into two groups: control (CTRL 6 animals - conventional technique) and arterialization - a shunt was established between the portal vein and the splenic artery (ART 9 animals). Hemodynamic, biochemical, histological, and molecular variables were compared. Results: Arterialization resulted in a significant increase in portal vein pressure but no changes in other hemodynamic variables, as shown in the analysis of variance. It was observed lower ALT values (p = 0.007), with no differences regarding the values of blood pH and lactate (p = 0.54 and p = 0.699 respectively) or histological variables (edema, steatosis, inflammation, necrosis, and IRI - p = 1.0, p = 0.943, p = 0.174, p = 0.832, p = 0.662, respectively). The molecular studies showed significantly increased expression of IL6 after 3 hours of reperfusion (p = 0.048) and decreased expression of ICAM immediately after reperfusion (p = 0.03). The regression analysis suggested a positive influence of portal flow and pressure on biochemical parameters. Conclusion: Arterialization of the portal vein showed no histological, biochemical, or molecular benefits in large-for-size transplantation.