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Nie Y, Huang JB, He SJ, Chen HD, Jia JJ, Li JJ, He XS, Zhao Q. Validation and performance of three scoring systems for predicting primary non-function and early allograft failure after liver transplantation. Hepatobiliary Pancreat Dis Int 2024; 23:463-471. [PMID: 37661517 DOI: 10.1016/j.hbpd.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 08/21/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Primary non-function (PNF) and early allograft failure (EAF) after liver transplantation (LT) seriously affect patient outcomes. In clinical practice, effective prognostic tools for early identifying recipients at high risk of PNF and EAF were urgently needed. Recently, the Model for Early Allograft Function (MEAF), PNF score by King's College (King-PNF) and Balance-and-Risk-Lactate (BAR-Lac) score were developed to assess the risks of PNF and EAF. This study aimed to externally validate and compare the prognostic performance of these three scores for predicting PNF and EAF. METHODS A retrospective study included 720 patients with primary LT between January 2015 and December 2020. MEAF, King-PNF and BAR-Lac scores were compared using receiver operating characteristic (ROC) and the net reclassification improvement (NRI) and integrated discrimination improvement (IDI) analyses. RESULTS Of all 720 patients, 28 (3.9%) developed PNF and 67 (9.3%) developed EAF in 3 months. The overall early allograft dysfunction (EAD) rate was 39.0%. The 3-month patient mortality was 8.6% while 1-year graft-failure-free survival was 89.2%. The median MEAF, King-PNF and BAR-Lac scores were 5.0 (3.5-6.3), -2.1 (-2.6 to -1.2), and 5.0 (2.0-11.0), respectively. For predicting PNF, MEAF and King-PNF scores had excellent area under curves (AUCs) of 0.872 and 0.891, superior to BAR-Lac (AUC = 0.830). The NRI and IDI analyses confirmed that King-PNF score had the best performance in predicting PNF while MEAF served as a better predictor of EAD. The EAF risk curve and 1-year graft-failure-free survival curve showed that King-PNF was superior to MEAF and BAR-Lac scores for stratifying the risk of EAF. CONCLUSIONS MEAF, King-PNF and BAR-Lac were validated as practical and effective risk assessment tools of PNF. King-PNF score outperformed MEAF and BAR-Lac in predicting PNF and EAF within 6 months. BAR-Lac score had a huge advantage in the prediction for PNF without post-transplant variables. Proper use of these scores will help early identify PNF, standardize grading of EAF and reasonably select clinical endpoints in relative studies.
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Affiliation(s)
- Yu Nie
- General Surgery Center, Department of Hepatobiliary Surgery II, Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Jin-Bo Huang
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou 510080, China
| | - Shu-Jiao He
- General Surgery Center, Department of Hepatobiliary Surgery II, Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Hua-Di Chen
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou 510080, China
| | - Jun-Jun Jia
- Division of Hepatobiliary Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Jing-Jing Li
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou 510080, China
| | - Xiao-Shun He
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou 510080, China
| | - Qiang Zhao
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou 510080, China.
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Gierej P, Radziszewski M, Figiel W, Grąt M. Advancements in Predictive Tools for Primary Graft Dysfunction in Liver Transplantation: A Comprehensive Review. J Clin Med 2024; 13:3762. [PMID: 38999328 PMCID: PMC11242128 DOI: 10.3390/jcm13133762] [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: 05/29/2024] [Revised: 06/20/2024] [Accepted: 06/24/2024] [Indexed: 07/14/2024] Open
Abstract
Orthotopic liver transplantation stands as the sole curative solution for end-stage liver disease. Nevertheless, the discrepancy between the demand and supply of grafts in transplant medicine greatly limits the success of this treatment. The increasing global shortage of organs necessitates the utilization of extended criteria donors (ECD) for liver transplantation, thereby increasing the risk of primary graft dysfunction (PGD). Primary graft dysfunction (PGD) encompasses early allograft dysfunction (EAD) and the more severe primary nonfunction (PNF), both of which stem from ischemia-reperfusion injury (IRI) and mitochondrial damage. Currently, the only effective treatment for PNF is secondary transplantation within the initial post-transplant week, and the occurrence of EAD suggests an elevated, albeit still uncertain, likelihood of retransplantation urgency. Nonetheless, the ongoing exploration of novel IRI mitigation strategies offers hope for future improvements in PGD outcomes. Establishing an intuitive and reliable tool to predict upcoming graft dysfunction is vital for early identification of high-risk patients and for making informed retransplantation decisions. Accurate diagnostics for PNF and EAD constitute essential initial steps in implementing future mitigation strategies. Recently, novel methods for PNF prediction have been developed, and several models for EAD assessments have been introduced. Here, we provide an overview of the currently scrutinized predictive tools for PNF and EAD evaluation strategies, accompanied by recommendations for future studies.
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Affiliation(s)
- Piotr Gierej
- Department of General Transplant and Liver Surgery, Medical University of Warsaw, 02-091 Warsaw, Poland
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Panayotova GG, Lunsford KE, Quillin RC, Rana A, Agopian VG, Lee-Riddle GS, Markovic D, Paterno F, Griesemer AD, Amin A, Alonso D, Rocca JP, Borja-Cacho D, Hernandez-Alejandro R, Fung JJ, Pelletier SJ, Shah SA, Guarrera JV. Portable hypothermic oxygenated machine perfusion for organ preservation in liver transplantation: A randomized, open-label, clinical trial. Hepatology 2024; 79:1033-1047. [PMID: 38090880 PMCID: PMC11019979 DOI: 10.1097/hep.0000000000000715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/01/2023] [Indexed: 02/27/2024]
Abstract
BACKGROUND AND AIMS In liver transplantation, cold preservation induces ischemia, resulting in significant reperfusion injury. Hypothermic oxygenated machine perfusion (HMP-O 2 ) has shown benefits compared to static cold storage (SCS) by limiting ischemia-reperfusion injury. This study reports outcomes using a novel portable HMP-O 2 device in the first US randomized control trial. APPROACH AND RESULTS The PILOT trial (NCT03484455) was a multicenter, randomized, open-label, noninferiority trial, with participants randomized to HMP-O 2 or SCS. HMP-O 2 livers were preserved using the Lifeport Liver Transporter and Vasosol perfusion solution. The primary outcome was early allograft dysfunction. Noninferiority margin was 7.5%. From April 3, 2019, to July 12, 2022, 179 patients were randomized to HMP-O 2 (n=90) or SCS (n=89). The per-protocol cohort included 63 HMP-O 2 and 73 SCS. Early allograft dysfunction occurred in 11.1% HMP-O 2 (N=7) and 16.4% SCS (N=12). The risk difference between HMP-O 2 and SCS was -5.33% (one-sided 95% upper confidence limit of 5.81%), establishing noninferiority. The risk of graft failure as predicted by Liver Graft Assessment Following Transplant score at seven days (L-GrAFT 7 ) was lower with HMP-O 2 [median (IQR) 3.4% (2.4-6.5) vs. 4.5% (2.9-9.4), p =0.024]. Primary nonfunction occurred in 2.2% of all SCS (n=3, p =0.10). Biliary strictures occurred in 16.4% SCS (n=12) and 6.3% (n=4) HMP-O 2 ( p =0.18). Nonanastomotic biliary strictures occurred only in SCS (n=4). CONCLUSIONS HMP-O 2 demonstrates safety and noninferior efficacy for liver graft preservation in comparison to SCS. Early allograft failure by L-GrAFT 7 was lower in HMP-O 2 , suggesting improved early clinical function. Recipients of HMP-O 2 livers also demonstrated a lower incidence of primary nonfunction and biliary strictures, although this difference did not reach significance.
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Affiliation(s)
- Guergana G. Panayotova
- Department of Surgery, Division of Transplant and HPB Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Keri E. Lunsford
- Department of Surgery, Division of Transplant and HPB Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - R. Cutler Quillin
- Department of Surgery, Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Abbas Rana
- Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Vatche G. Agopian
- Department of Surgery, Dumont-UCLA Liver Cancer and Transplant Center, Pfleger Liver Institute, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Grace S. Lee-Riddle
- Department of Surgery, Division of Transplant and HPB Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Daniela Markovic
- Department of Surgery, Dumont-UCLA Liver Cancer and Transplant Center, Pfleger Liver Institute, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA
| | - Flavio Paterno
- Department of Surgery, Division of Transplant and HPB Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Adam D. Griesemer
- Department of Surgery, Transplant Institute, NYU Langone Medical Center, New York, New York, USA
| | - Arpit Amin
- Department of Surgery, Division of Transplant and HPB Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Diane Alonso
- Department of Transplant, Intermountain Medical Center, Murray, Utah, USA
| | - Juan P. Rocca
- Department of Surgery, Division of Liver Transplantation and Hepatobiliary Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Daniel Borja-Cacho
- Department of Surgery, Division of Transplantation, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Roberto Hernandez-Alejandro
- Department of Surgery, Division of Transplantation and Hepatobiliary Surgery, University of Rochester, Rochester, New York, USA
| | - John J. Fung
- Department of Surgery, Section of Abdominal Organ Transplantation, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Shawn J. Pelletier
- Department of Surgery, Division of Transplantation Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Shimul A. Shah
- Department of Surgery, Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - James V. Guarrera
- Department of Surgery, Division of Transplant and HPB Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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Li S, Luo Q, Chen S, Jia Z, Wang T, Yu X, Wang W, YuyiZhang, Zhu J, Deng F, Sun Q, Guo Z, He X. L-GrAFT 7 has High Accuracy in Predicting Early Allograft Failure after Liver Transplantation: A Multicenter Cohort Study in China. J Clin Transl Hepatol 2024; 12:62-69. [PMID: 38250465 PMCID: PMC10794271 DOI: 10.14218/jcth.2023.00178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/13/2023] [Accepted: 06/30/2023] [Indexed: 01/23/2024] Open
Abstract
Background and Aims Increasing utilization of extended criteria donor leads to an increasing rate of early allograft failure after liver transplantation. However, consensus of definition of early allograft failure is lacking. Methods A retrospective, multicenter study was performed to validate the Liver Graft Assessment Following Transplantation (L-GrAFT) risk model in a Chinese cohort of 942 adult patients undergoing primary liver transplantation at three Chinese centers. L-GrAFT (L-GrAFT7 and L-GrAFT10) was compared with existing models: the Early Allograft Failure Simplified Estimation (EASE) score, the model of early allograft function (MEAF), and the Early Allograft Dysfunction (EAD) model. Univariate and multivariate logistic regression were used to find risk factors of L-GrAFT high-risk group. Results L-GrAFT7 had an area under the curve of 0.85 in predicting 90-day graft survival, significantly superior to MEAF [area under the curve (AUC=0.78, p=0.044)] and EAD (AUC=0.78, p=0.006), while there was no statistical significance between the predicting abilities of L-GrAFT7 and EASE (AUC=0.84, p>0.05). Furthermore, L-GrAFT7 maintains good predicting ability in the subgroup of high-donor risk index (DRI) cases (AUC=0.83 vs. MEAF, p=0.007 vs. EAD, p=0.014) and recipients of donors after cardiac death (AUC=0.92 vs. EAD, p<0.001). Through multivariate analysis, pretransplant bilirubin level, units of packed red blood cells, and the DRI score were selected as independent risk factors of a L-GrAFT7 high-risk group. Conclusions The accuracy of L-GrAFT7 in predicting early allograft failure was validated in a Chinese multicenter cohort, indicating that it has the potential to become an accurate endpoint of clinical practice and transitional study of machine perfusion.
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Affiliation(s)
- Songming Li
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China
- Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, Guangdong, China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, Guangdong, China
| | - Qijie Luo
- General Surgery Dept. 1, Zhongshan People’s Hospital, Zhongshan Hospital of Sun Yat-Sen University, Zhongshan, Guangdong, China
| | - Shirui Chen
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China
- Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, Guangdong, China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, Guangdong, China
| | - Zehua Jia
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China
- Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, Guangdong, China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, Guangdong, China
| | - Tielong Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China
- Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, Guangdong, China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, Guangdong, China
| | - Xinyu Yu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China
- Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, Guangdong, China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, Guangdong, China
| | - Wenjing Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China
- Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, Guangdong, China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, Guangdong, China
| | - YuyiZhang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China
- Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, Guangdong, China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, Guangdong, China
| | - Jiaxing Zhu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China
- Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, Guangdong, China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, Guangdong, China
| | - Feiwen Deng
- Department of Hepatobiliary Surgery, The First People’s Hospital of Foshan, Foshan, Guangdong, China
| | - Qiang Sun
- General Surgery Dept. 1, Zhongshan People’s Hospital, Zhongshan Hospital of Sun Yat-Sen University, Zhongshan, Guangdong, China
| | - Zhiyong Guo
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China
- Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, Guangdong, China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, Guangdong, China
| | - Xiaoshun He
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, Guangdong, China
- Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, Guangdong, China
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, Guangdong, China
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Norén Å, Mölne J, Bennet W, Sörensen G, Herlenius G, Lindnér P, Oltean M. End-ischemic hypothermic oxygenated machine perfusion does not improve renal outcome following liver transplantation from aged donors: A single-center retrospective report. Artif Organs 2023; 47:1854-1864. [PMID: 37737446 DOI: 10.1111/aor.14640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/17/2023] [Accepted: 08/21/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Organ transplantation using grafts from elderly donors entails a higher risk for severe ischemia-reperfusion injury (IRI). Advanced IRI after liver transplantation (LT) seems to be associated with the development of acute kidney injury (AKI). We studied if end-ischemic hypothermic oxygenated machine perfusion (HOPE) of liver grafts, aimed at mitigating liver IRI, impacts on the frequency and severity of AKI after LT. METHODS LTs performed at our center between January 2017 and December 2022 using organs from deceased brain-dead donors aged 70 or older were reviewed. From November 2020 on, HOPE was performed routinely in this donor category. The frequency and severity of AKI (KDIGO criteria) within 48 hours of graft reperfusion and the model of early allograft function (MEAF) were compared between HOPE-LTs (n = 30) and control LTs (n = 71). RESULTS AKI developed in 23/30 (77%) HOPE-LTs and in 40/71 (56%) control LTs (p = n.s.), with no difference in severity and timing between groups. Renal replacement therapy was required in 3/30 (10%) HOPE-LTs and 6/71 (8%) control LTs. In addition, transaminase leak during the first week (marker of IRI) and MEAF were similar between groups. These findings persisted after propensity matching. Histology showed more hepatocyte vacuolization and higher Suzuki score in HOPE-LTs. Although this analysis could have been underpowered, no trends supporting the benefit of HOPE on liver and renal injury after LT were ever identified. CONCLUSIONS In conclusion, HOPE in this group of older donors does not seem to improve either graft IRI, or the incidence of early AKI after LT.
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Affiliation(s)
- Åsa Norén
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Johan Mölne
- Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - William Bennet
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Gustaf Sörensen
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Gustaf Herlenius
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Per Lindnér
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Mihai Oltean
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
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Grąt M, Morawski M, Zhylko A, Rykowski P, Krasnodębski M, Wyporski A, Borkowski J, Lewandowski Z, Kobryń K, Stankiewicz R, Stypułkowski J, Hołówko W, Patkowski W, Mielczarek-Puta M, Struga M, Szczepankiewicz B, Górnicka B, Krawczyk M. Routine End-ischemic Hypothermic Oxygenated Machine Perfusion in Liver Transplantation From Donors After Brain Death: A Randomized Controlled Trial. Ann Surg 2023; 278:662-668. [PMID: 37497636 DOI: 10.1097/sla.0000000000006055] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To assess whether end-ischemic hypothermic oxygenated machine perfusion (HOPE) is superior to static cold storage (SCS) in preserving livers procured from donors after brain death (DBD). BACKGROUND There is increasing evidence of the benefits of HOPE in liver transplantation, but predominantly in the setting of high-risk donors. METHODS In this randomized clinical trial, livers procured from DBDs were randomly assigned to either end-ischemic dual HOPE for at least 2 hours or SCS (1:3 allocation ratio). The Model for Early Allograft Function (MEAF) was the primary outcome measure. The secondary outcome measure was 90-day morbidity (ClinicalTrials. gov, NCT04812054). RESULTS Of the 104 liver transplantations included in the study, 26 were assigned to HOPE and 78 to SCS. Mean MEAF was 4.94 and 5.49 in the HOPE and SCS groups ( P =0.24), respectively, with the corresponding rates of MEAF >8 of 3.8% (1/26) and 15.4% (12/78; P =0.18). Median Comprehensive Complication Index was 20.9 after transplantations with HOPE and 21.8 after transplantations with SCS ( P =0.19). Transaminase activity, bilirubin concentration, and international normalized ratio were similar in both groups. In the case of donor risk index >1.70, HOPE was associated with significantly lower mean MEAF (4.92 vs 6.31; P =0.037) and lower median Comprehensive Complication Index (4.35 vs 22.6; P =0.050). No significant differences between HOPE and SCS were observed for lower donor risk index values. CONCLUSION Routine use of HOPE in DBD liver transplantations does not seem justified as the clinical benefits are limited to high-risk donors.
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Affiliation(s)
- Michał Grąt
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Morawski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Andriy Zhylko
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Paweł Rykowski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Maciej Krasnodębski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Anya Wyporski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Jan Borkowski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Zbigniew Lewandowski
- Department of Epidemiology and Biostatistics, Medical University of Warsaw, Warsaw, Poland
| | - Konrad Kobryń
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Rafał Stankiewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Jan Stypułkowski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Wacław Hołówko
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Waldemar Patkowski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | | | - Marta Struga
- Department of Biochemistry, Medical University of Warsaw, Warsaw, Poland
| | | | - Barbara Górnicka
- Department of Pathology, Medical University of Warsaw, Warsaw, Poland
| | - Marek Krawczyk
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
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Agostini C, Buccianti S, Risaliti M, Fortuna L, Tirloni L, Tucci R, Bartolini I, Grazi GL. Complications in Post-Liver Transplant Patients. J Clin Med 2023; 12:6173. [PMID: 37834818 PMCID: PMC10573382 DOI: 10.3390/jcm12196173] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 09/16/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
Liver transplantation (LT) is the treatment of choice for liver failure and selected cases of malignancies. Transplantation activity has increased over the years, and indications for LT have been widened, leading to organ shortage. To face this condition, a high selection of recipients with prioritizing systems and an enlargement of the donor pool were necessary. Several authors published their case series reporting the results obtained with the use of marginal donors, which seem to have progressively improved over the years. The introduction of in situ and ex situ machine perfusion, although still strongly debated, and better knowledge and treatment of the complications may have a role in achieving better results. With longer survival rates, a significant number of patients will suffer from long-term complications. An extensive review of the literature concerning short- and long-term outcomes is reported trying to highlight the most recent findings. The heterogeneity of the behaviors within the different centers is evident, leading to a difficult comparison of the results and making explicit the need to obtain more consent from experts.
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Affiliation(s)
| | | | | | | | | | | | - Ilenia Bartolini
- Department of Experimental and Clinical Medicine, AOU Careggi, 50134 Florence, Italy; (C.A.); (S.B.); (M.R.); (L.F.); (L.T.); (R.T.); (G.L.G.)
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Tingle SJ, Dobbins JJ, Thompson ER, Figueiredo RS, Mahendran B, Pandanaboyana S, Wilson C. Machine perfusion in liver transplantation. Cochrane Database Syst Rev 2023; 9:CD014685. [PMID: 37698189 PMCID: PMC10496129 DOI: 10.1002/14651858.cd014685.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
BACKGROUND Liver transplantation is the only chance of cure for people with end-stage liver disease and some people with advanced liver cancers or acute liver failure. The increasing prevalence of these conditions drives demand and necessitates the increasing use of donated livers which have traditionally been considered suboptimal. Several novel machine perfusion preservation technologies have been developed, which attempt to ameliorate some of the deleterious effects of ischaemia reperfusion injury. Machine perfusion technology aims to improve organ quality, thereby improving outcomes in recipients of suboptimal livers when compared to traditional static cold storage (SCS; ice box). OBJECTIVES To evaluate the effects of different methods of machine perfusion (including hypothermic oxygenated machine perfusion (HOPE), normothermic machine perfusion (NMP), controlled oxygenated rewarming, and normothermic regional perfusion) versus each other or versus static cold storage (SCS) in people undergoing liver transplantation. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 10 January 2023. SELECTION CRITERIA We included randomised clinical trials which compared different methods of machine perfusion, either with each other or with SCS. Studies comparing HOPE via both hepatic artery and portal vein, or via portal vein only, were grouped. The protocol detailed that we also planned to include quasi-randomised studies to assess treatment harms. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. overall participant survival, 2. quality of life, and 3. serious adverse events. Secondary outcomes were 4. graft survival, 5. ischaemic biliary complications, 6. primary non-function of the graft, 7. early allograft function, 8. non-serious adverse events, 9. transplant utilisation, and 10. transaminase release during the first week post-transplant. We assessed bias using Cochrane's RoB 2 tool and used GRADE to assess certainty of evidence. MAIN RESULTS We included seven randomised trials (1024 transplant recipients from 1301 randomised/included livers). All trials were parallel two-group trials; four compared HOPE versus SCS, and three compared NMP versus SCS. No trials used normothermic regional perfusion. When compared with SCS, it was uncertain whether overall participant survival was improved with either HOPE (hazard ratio (HR) 0.91, 95% confidence interval (CI) 0.42 to 1.98; P = 0.81, I2 = 0%; 4 trials, 482 recipients; low-certainty evidence due to imprecision because of low number of events) or NMP (HR 1.08, 95% CI 0.31 to 3.80; P = 0.90; 1 trial, 222 recipients; very low-certainty evidence due to imprecision and risk of bias). No trials reported quality of life. When compared with SCS alone, HOPE was associated with improvement in the following clinically relevant outcomes: graft survival (HR 0.45, 95% CI 0.23 to 0.87; P = 0.02, I2 = 0%; 4 trials, 482 recipients; high-certainty evidence), serious adverse events in extended criteria DBD liver transplants (OR 0.45, 95% CI 0.22 to 0.91; P = 0.03, I2 = 0%; 2 trials, 156 participants; moderate-certainty evidence) and clinically significant ischaemic cholangiopathy in recipients of DCD livers (OR 0.31, 95% CI 0.11 to 0.92; P = 0.03; 1 trial, 156 recipients; high-certainty evidence). In contrast, NMP was not associated with improvement in any of these clinically relevant outcomes. NMP was associated with improved utilisation compared with SCS (one trial found a 50% lower rate of organ discard; P = 0.008), but the reasons underlying this effect are unknown. We identified 11 ongoing studies investigating machine perfusion technologies. AUTHORS' CONCLUSIONS In situations where the decision has been made to transplant a liver donated after circulatory death or donated following brain death, end-ischaemic HOPE will provide superior clinically relevant outcomes compared with SCS alone. Specifically, graft survival is improved (high-certainty evidence), serious adverse events are reduced (moderate-certainty evidence), and in donors after circulatory death, clinically relevant ischaemic biliary complications are reduced (high-certainty evidence). There is no good evidence that NMP has the same benefits over SCS in terms of these clinically relevant outcomes. NMP does appear to improve utilisation of grafts that would otherwise be discarded with SCS; however, the reasons for this, and whether this effect is specific to NMP, is not clear. Further studies into NMP viability criteria and utilisation, as well as head-to-head trials with other perfusion technologies are needed. In the setting of donation following circulatory death transplantation, further trials are needed to assess the effect of these ex situ machine perfusion methods against, or in combination with, normothermic regional perfusion.
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Affiliation(s)
- Samuel J Tingle
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | | | - Emily R Thompson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | | | | | - Sanjay Pandanaboyana
- HPB and Liver Transplant Surgery, Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Colin Wilson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
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9
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Cherchi V, Vetrugno L, Terrosu G, Deana C, Ventin M, Zanini V, Barbariol F, Pravisani R, Bove T, Risaliti A, Lorenzin D, Baccarani U. Association between artificial nutrition in brain dead donors and early allograft function in liver transplant recipients: an observational study. Clin Transplant 2023; 37:e15034. [PMID: 37212369 DOI: 10.1111/ctr.15034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 04/23/2023] [Accepted: 05/13/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND The role of nutrition in donor after brain deaths (DBDs) has yet to be adequately discussed. The primary aim of this study was to investigate whether the nutritional intake in the 48 h before organ retrieval may play a role on the graft functional recovery assessed with Model for Early Allograft Function (MEAF) Score. METHODS Single-center retrospective study evaluating all liver transplants performed at the University Hospital of Udine from January 2010 to August 2020. Patients receiving grafts from DBD donors fed with artificial enteral nutrition in the 48 h prior to organ procurement (EN-group) or who did not (No-EN-group). Caloric debt was calculated using the difference between the calculated caloric needs and the effective calories delivered through enteral nutrition. RESULTS Livers from EN-group presented a lower mean MEAF score compared to the no-EN-group: 3.39 ± 1.46 versus 4.15 ± 1.51, respectively (p = .04). A positive correlation between caloric debt and the MEAF score was found within the overall population (r = .227, p = .043) as well as in EN-group (r = .306, p = .049). CONCLUSIONS Donor's nutritional intake in the final 48 h before organ procurement correlates with MEAF score, and nutrition probably plays a positive role on the functional recovery of the graft. Large future randomized controlled trials are needed to confirm this preliminary results.
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Affiliation(s)
- Vittorio Cherchi
- General Surgery Clinic and Liver Transplant Center, University-Hospital of Udine, Udine, Italy
| | - Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, Chieti, Italy
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
| | - Giovanni Terrosu
- General Surgery Clinic and Liver Transplant Center, University-Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Cristian Deana
- Department of Anesthesia and Intensive Care, University-Hospital of Udine, Udine, Italy
| | - Marco Ventin
- Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Victor Zanini
- Department of Medicine, University of Udine, Udine, Italy
| | - Federico Barbariol
- Department of Anesthesia and Intensive Care, University-Hospital of Udine, Udine, Italy
| | | | - Tiziana Bove
- Department of Medicine, University of Udine, Udine, Italy
- Department of Anesthesia and Intensive Care, University-Hospital of Udine, Udine, Italy
| | | | - Dario Lorenzin
- General Surgery Clinic and Liver Transplant Center, University-Hospital of Udine, Udine, Italy
| | - Umberto Baccarani
- General Surgery Clinic and Liver Transplant Center, University-Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
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10
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Halle-Smith JM, Hall L, Hann A, Arshad A, Armstrong MJ, Bangash MN, Murphy N, Cuell J, Isaac JL, Ferguson J, Roberts KJ, Mirza DF, Perera MTPR. Low C-reactive Protein and Urea Distinguish Primary Nonfunction From Early Allograft Dysfunction Within 48 Hours of Liver Transplantation. Transplant Direct 2023; 9:e1484. [PMID: 37250485 PMCID: PMC10212614 DOI: 10.1097/txd.0000000000001484] [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: 02/08/2023] [Accepted: 03/03/2023] [Indexed: 05/31/2023] Open
Abstract
Primary nonfunction (PNF) is a life-threatening complication of liver transplantation (LT), but in the early postoperative period, it can be difficult to differentiate from early allograft dysfunction (EAD). The aim of this study was to determine if serum biomarkers can distinguish PNF from EAD in the initial 48 h following LT. Materials and Methods A retrospective study of adult patients that underwent LT between January 2010 and April 2020 was performed. Clinical parameters, absolute values and trends of C-reactive protein (CRP), blood urea, creatinine, liver function tests, platelets, and international normalized ratio in the initial 48 h after LT were compared between the EAD and PNF groups. Results There were 1937 eligible LTs, with PNF and EAD occurring in 38 (2%) and 503 (26%) patients, respectively. A low serum CRP and urea were associated with PNF. CRP was able to differentiate between the PNF and EAD on postoperative day (POD)1 (20 versus 43 mg/L; P < 0.001) and POD2 (24 versus 77; P < 0.001). The area under the receiver operating characteristic curve (AUROC) of POD2 CRP was 0.770 (95% confidence interval [CI] 0.645-0.895). The urea value on POD2 (5.05 versus 9.0 mmol/L; P = 0.002) and trend of POD2:1 ratio (0.71 versus 1.32 mmol/L; P < 0.001) were significantly different between the groups. The AUROC of the change in urea from POD1 to 2 was 0.765 (95% CI 0.645-0.885). Aspartate transaminase was significantly different between the groups, with an AUROC of 0.884 (95% CI 0.753-1.00) on POD2. Discussion The biochemical profile immediately following LT can distinguish PNF from EAD; CRP, urea, and aspartate transaminase are more effective than ALT and bilirubin in distinguishing PNF from EAD in the initial postoperative 48 h. Clinicians should consider the values of these markers when making treatment decisions.
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Affiliation(s)
- James M. Halle-Smith
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Lewis Hall
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Angus Hann
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Asif Arshad
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Matthew J. Armstrong
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Mansoor N. Bangash
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Nick Murphy
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - James Cuell
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - John L. Isaac
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - James Ferguson
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Keith J. Roberts
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Darius F. Mirza
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - M. Thamara P. R. Perera
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
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11
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Intensive care management of liver transplant recipients. Curr Opin Crit Care 2022; 28:709-714. [PMID: 36226713 DOI: 10.1097/mcc.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Liver transplantation remains the only definitive treatment for advanced liver disease and liver failure. Current allocation schemes utilized for liver transplantation mandate a 'sickest first' approach, thus most liver transplants occur in patients with severe systemic illness. For intensive care providers who care for liver transplant recipients, a foundation of knowledge of technical considerations of orthotopic liver transplantation, basic management considerations, and common complications is essential. This review highlights the authors' approach to intensive care management of the postoperative liver transplant recipient with a review of common issues, which arise in this patient population. RECENT FINDINGS The number of centers offering liver transplantation continues to increase globally and the number of patients receiving liver transplantation also continues to increase. The number of patients with advanced liver disease far outpaces organ availability and, therefore, patients undergoing liver transplant are sicker at the time of transplant. Outcomes for liver transplant patients continue to improve owing to advancements in surgical technique, immunosuppression management, and intensive care management of liver disease both pretransplant and posttransplant. SUMMARY Given a global increase in liver transplantation, an increasing number of intensive care professionals are likely to care for this patient population. For these providers, a foundational knowledge of the common complications and key management considerations is essential.
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12
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Watson CJ, Gaurav R, Fear C, Swift L, Selves L, Ceresa CD, Upponi SS, Brais R, Allison M, Macdonald-Wallis C, Taylor R, Butler AJ. Predicting Early Allograft Function After Normothermic Machine Perfusion. Transplantation 2022; 106:2391-2398. [PMID: 36044364 PMCID: PMC9698137 DOI: 10.1097/tp.0000000000004263] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 04/14/2022] [Accepted: 04/25/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Normothermic ex situ liver perfusion is increasingly used to assess donor livers, but there remains a paucity of evidence regarding criteria upon which to base a viability assessment or criteria predicting early allograft function. METHODS Perfusate variables from livers undergoing normothermic ex situ liver perfusion were analyzed to see which best predicted the Model for Early Allograft Function score. RESULTS One hundred fifty-four of 203 perfused livers were transplanted following our previously defined criteria. These comprised 84/123 donation after circulatory death livers and 70/80 donation after brain death livers. Multivariable analysis suggested that 2-h alanine transaminase, 2-h lactate, 11 to 29 mmol supplementary bicarbonate in the first 4 h, and peak bile pH were associated with early allograft function as defined by the Model for Early Allograft Function score. Nonanastomotic biliary strictures occurred in 11% of transplants, predominantly affected first- and second-order ducts, despite selection based on bile glucose and pH. CONCLUSIONS This work confirms the importance of perfusate alanine transaminase and lactate at 2-h, as well as the amount of supplementary bicarbonate required to keep the perfusate pH > 7.2, in the assessment of livers undergoing perfusion. It cautions against the use of lactate as a sole indicator of viability and also suggests a role for cholangiocyte function markers in predicting early allograft function.
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Affiliation(s)
- Christopher J.E. Watson
- Department of Surgery, University of Cambridge, Level E9, Addenbrooke’s Hospital, Cambridge, United Kingdom
- The National Institute of Health Research, Cambridge Biomedical Research Centre (BRC 1215 20014), Cambridge, United Kingdom
- The National Institute for Health Research Blood and Transplant Research Unit, University of Cambridge in collaboration with Newcastle University and in partnership with National Health Service Blood and Transplant, Cambridge, United Kingdom
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Rohit Gaurav
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Corrina Fear
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Lisa Swift
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Linda Selves
- Department of Surgery, University of Cambridge, Level E9, Addenbrooke’s Hospital, Cambridge, United Kingdom
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Carlo D.L. Ceresa
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Sara S. Upponi
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Rebecca Brais
- Department of Pathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Michael Allison
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Department of Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Corrie Macdonald-Wallis
- Statistics and Clinical Research, National Health Service Blood and Transplant, Bristol, United Kingdom
| | - Rhiannon Taylor
- Statistics and Clinical Research, National Health Service Blood and Transplant, Bristol, United Kingdom
| | - Andrew J. Butler
- Department of Surgery, University of Cambridge, Level E9, Addenbrooke’s Hospital, Cambridge, United Kingdom
- The National Institute of Health Research, Cambridge Biomedical Research Centre (BRC 1215 20014), Cambridge, United Kingdom
- The National Institute for Health Research Blood and Transplant Research Unit, University of Cambridge in collaboration with Newcastle University and in partnership with National Health Service Blood and Transplant, Cambridge, United Kingdom
- The Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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13
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Mohkam K, Nasralla D, Mergental H, Muller X, Butler A, Jassem W, Imber C, Monbaliu D, Perera MTPR, Laing RW, García‐Valdecasas JC, Paul A, Dondero F, Cauchy F, Savier E, Scatton O, Robin F, Sulpice L, Bucur P, Salamé E, Pittau G, Allard M, Pradat P, Rossignol G, Mabrut J, Ploeg RJ, Friend PJ, Mirza DF, Lesurtel M. In situ normothermic regional perfusion versus ex situ normothermic machine perfusion in liver transplantation from donation after circulatory death. Liver Transpl 2022; 28:1716-1725. [PMID: 35662403 PMCID: PMC9796010 DOI: 10.1002/lt.26522] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 03/14/2022] [Accepted: 03/19/2022] [Indexed: 12/30/2022]
Abstract
In situ normothermic regional perfusion (NRP) and ex situ normothermic machine perfusion (NMP) aim to improve the outcomes of liver transplantation (LT) using controlled donation after circulatory death (cDCD). NRP and NMP have not yet been compared directly. In this international observational study, outcomes of LT performed between 2015 and 2019 for organs procured from cDCD donors subjected to NRP or NMP commenced at the donor center were compared using propensity score matching (PSM). Of the 224 cDCD donations in the NRP cohort that proceeded to asystole, 193 livers were procured, resulting in 157 transplants. In the NMP cohort, perfusion was commenced in all 40 cases and resulted in 34 transplants (use rates: 70% vs. 85% [p = 0.052], respectively). After PSM, 34 NMP liver recipients were matched with 68 NRP liver recipients. The two cohorts were similar for donor functional warm ischemia time (21 min after NRP vs. 20 min after NMP; p = 0.17), UK-Donation After Circulatory Death risk score (5 vs. 5 points; p = 0.38), and laboratory Model for End-Stage Liver Disease scores (12 vs. 12 points; p = 0.83). The incidence of nonanastomotic biliary strictures (1.5% vs. 2.9%; p > 0.99), early allograft dysfunction (20.6% vs. 8.8%; p = 0.13), and 30-day graft loss (4.4% vs. 8.8%; p = 0.40) were similar, although peak posttransplant aspartate aminotransferase levels were higher in the NRP cohort (872 vs. 344 IU/L; p < 0.001). NRP livers were more frequently allocated to recipients suffering from hepatocellular carcinoma (HCC; 60.3% vs. 20.6%; p < 0.001). HCC-censored 2-year graft and patient survival rates were 91.5% versus 88.2% (p = 0.52) and 97.9% versus 94.1% (p = 0.25) after NRP and NMP, respectively. Both perfusion techniques achieved similar outcomes and appeared to match benchmarks expected for donation after brain death livers. This study may inform the design of a definitive trial.
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Affiliation(s)
- Kayvan Mohkam
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - David Nasralla
- Department of Hepatopancreatobiliary and Liver Transplant SurgeryRoyal Free HospitalLondonUK
| | - Hynek Mergental
- Liver Unit, Queen Elizabeth HospitalUniversity Hospitals BirminghamBirminghamUK
| | - Xavier Muller
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - Andrew Butler
- Department of Surgery, Addenbrooke's HospitalUniversity of CambridgeCambridgeUK
| | - Wayel Jassem
- Institute of Liver StudiesKing's College HospitalLondonUK
| | - Charles Imber
- Department of Hepatopancreatobiliary and Liver Transplant SurgeryRoyal Free HospitalLondonUK
| | - Diethard Monbaliu
- Abdominal Transplant Surgery Unit, Department of SurgeryUniversity Hospitals LeuvenLeuvenBelgium
| | | | - Richard W. Laing
- Liver Unit, Queen Elizabeth HospitalUniversity Hospitals BirminghamBirminghamUK
| | | | - Andreas Paul
- Department of General, Visceral and Transplantation SurgeryUniversity Hospital EssenEssenGermany
| | - Federica Dondero
- Department of Hepatobiliopancreatic SurgeryDepartment of Hepatopancreatobiliary Surgery and Liver TransplantationBeaujon Hospital, Assitance Publique‐Hôpitaux de Paris (AP‐HP), University Paris CitéClichyFrance
| | - François Cauchy
- Department of Hepatobiliopancreatic SurgeryDepartment of Hepatopancreatobiliary Surgery and Liver TransplantationBeaujon Hospital, Assitance Publique‐Hôpitaux de Paris (AP‐HP), University Paris CitéClichyFrance
| | - Eric Savier
- Department of Hepatobiliary Surgery and Liver Transplantation, Pitié‐Salpêtrière HospitalSorbonne UniversityParisFrance
| | - Olivier Scatton
- Department of Hepatobiliary Surgery and Liver Transplantation, Pitié‐Salpêtrière HospitalSorbonne UniversityParisFrance
| | - Fabien Robin
- Department of Hepatobiliary and Digestive SurgeryPontchaillou University HospitalRennesFrance
| | - Laurent Sulpice
- Department of Hepatobiliary and Digestive SurgeryPontchaillou University HospitalRennesFrance
| | - Petru Bucur
- Department of Digestive, Oncological, Endocrine, Hepato‐Biliary, Pancreatic and Liver Transplant SurgeryTrousseau HospitalToursFrance
| | - Ephrem Salamé
- Department of Digestive, Oncological, Endocrine, Hepato‐Biliary, Pancreatic and Liver Transplant SurgeryTrousseau HospitalToursFrance
| | - Gabriella Pittau
- Centre Hépato‐Biliaire, Hôpital Paul Brousse, Assistance Publique‐Hôpitaux de Paris (AP‐HP)Université Paris SudVillejuifFrance
| | - Marc‐Antoine Allard
- Centre Hépato‐Biliaire, Hôpital Paul Brousse, Assistance Publique‐Hôpitaux de Paris (AP‐HP)Université Paris SudVillejuifFrance
| | - Pierre Pradat
- Clinical Research Centre, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - Guillaume Rossignol
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - Jean‐Yves Mabrut
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - Rutger J. Ploeg
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Peter J. Friend
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Darius F. Mirza
- Liver Unit, Queen Elizabeth HospitalUniversity Hospitals BirminghamBirminghamUK
| | - Mickaël Lesurtel
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
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14
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Ghazaly M, Tiwari N, Sethi P, Surendrakumar V, Duckworth A. Use of Steatotic Donor Livers for Transplantation: Do They Affect Outcome? SURGICAL PRACTICE 2022. [DOI: 10.1111/1744-1633.12563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Mohamed Ghazaly
- Department of Transplant Surgery Addenbrookes Hospital Cambridge United Kingdom
- Department of Surgery Tanta University Tanta Gharbia Egypt
| | - Navneet Tiwari
- Department of Transplant Surgery Addenbrookes Hospital Cambridge United Kingdom
| | - Pulkit Sethi
- Department of Transplant Surgery Addenbrookes Hospital Cambridge United Kingdom
| | - Veena Surendrakumar
- Department of Transplant Surgery Addenbrookes Hospital Cambridge United Kingdom
| | - Adam Duckworth
- Department of Pathology Addenbrookes Hospital Cambridge United Kingdom
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15
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Pravisani R, Isola M, Lorenzin D, Cherchi V, Boscolo E, Mocchegiani F, Terrosu G, Baccarani U. Re-thinking of T-tube use in whole liver transplantation: an analysis on the risk of delayed graft function. Updates Surg 2022; 74:571-577. [PMID: 35325442 PMCID: PMC8995289 DOI: 10.1007/s13304-022-01267-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/28/2022] [Indexed: 02/07/2023]
Abstract
The liver–gut axis has been identified as crucial mediator of liver regeneration. Thus, the use of a T-tube in liver transplantation (LT), which interrupts the enterohepatic bile circulation, may potentially have a detrimental effect on the early allograft functional recovery. We retrospectively analyzed a cohort of 261 patients transplanted with a whole liver graft, with a duct-to-duct biliary anastomosis, who did not develop any surgical complication within postoperative day 14. Early allograft dysfunction (EAD) was defined according to the criteria of Olthoff et al. (EAD-O), and graded according to the Model for Early Allograft Function (MEAF) score. EAD-O developed in 24.7% of recipients and the median MEAF score was 4.0 [interquartile range 2.9–5.5]. Both MEAF and EAD predicted 90-day post-LT mortality. A T-tube was used in 49.4% of cases (n = 129). After a propensity score matching for donor age, cold and warm ischemia time, donor risk index, balance of risk score, Child–Pugh class C, and MELD score, the T-tube group showed a significantly higher prevalence of EAD-O and value of MEAF than the no-T-tube group (EAD-O: 29 [34.1%] vs 16 [19.0%], p = 0.027; MEAF 4.5 [3.5–5.7] vs 3.7 [2.9–5.0], p = 0.014). In conclusion, T-tube use in LT may be a risk factor for EAD and higher MEAF, irrespective of graft quality and severity of pre-LT liver disease.
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Affiliation(s)
- Riccardo Pravisani
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Miriam Isola
- Division of Medical Statistic, Department of Medicine, University of Udine, Udine, Italy
| | - Dario Lorenzin
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Vittorio Cherchi
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Erica Boscolo
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Federico Mocchegiani
- HPB Surgery and Transplantation Unit, Department of Clinical and Experimental Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Giovanni Terrosu
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Umberto Baccarani
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
- Dipartimento Di Area Medica, University of Udine, P.Le Kolbe, Via Colugna 50, 33100 Udine, Italy
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16
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Verstraeten L, Jochmans I. Sense and Sensibilities of Organ Perfusion as a Kidney and Liver Viability Assessment Platform. Transpl Int 2022; 35:10312. [PMID: 35356401 PMCID: PMC8958413 DOI: 10.3389/ti.2022.10312] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/26/2022] [Indexed: 12/13/2022]
Abstract
Predicting organ viability before transplantation remains one of the most challenging and ambitious objectives in transplant surgery. Waitlist mortality is high while transplantable organs are discarded. Currently, around 20% of deceased donor kidneys and livers are discarded because of “poor organ quality”, Decisions to discard are still mainly a subjective judgement since there are only limited reliable tools predictive of outcome available. Organ perfusion technology has been posed as a platform for pre-transplant organ viability assessment. Markers of graft injury and function as well as perfusion parameters have been investigated as possible viability markers during ex-situ hypothermic and normothermic perfusion. We provide an overview of the available evidence for the use of kidney and liver perfusion as a tool to predict posttransplant outcomes. Although evidence shows post-transplant outcomes can be predicted by both injury markers and perfusion parameters during hypothermic kidney perfusion, the predictive accuracy is too low to warrant clinical decision making based upon these parameters alone. In liver, further evidence on the usefulness of hypothermic perfusion as a predictive tool is needed. Normothermic perfusion, during which the organ remains fully metabolically active, seems a more promising platform for true viability assessment. Although we do not yet fully understand “on-pump” organ behaviour at normothermia, initial data in kidney and liver are promising. Besides the need for well-designed (registry) studies to advance the field, the catch-22 of selection bias in clinical studies needs addressing.
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Affiliation(s)
- Laurence Verstraeten
- Lab of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Ina Jochmans
- Lab of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Abdominal Transplantation, University Hospitals Leuven, Leuven, Belgium
- *Correspondence: Ina Jochmans,
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17
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Masior Ł, Grąt M. Primary Nonfunction and Early Allograft Dysfunction after Liver Transplantation. Dig Dis 2022; 40:766-776. [PMID: 35114676 DOI: 10.1159/000522052] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 01/18/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Despite continuous progress in the field of liver transplantation, considerable proportion of patients still suffer from the postoperative graft dysfunction. Clinically, it presents as early allograft dysfunction (EAD), and its more severe form defined as primary nonfunction (PNF). Posttransplant liver dysfunction translates into significantly worse treatment outcomes. SUMMARY Both entities are multifactorial, with donor (graft), recipient, and procedure-related factors playing the key roles. Ischemia-reperfusion injury is a major driver of their development. So far, various noninvasive (pharmacological) and invasive strategies have been tested to mitigate its negative effects. This article pre-sents the current approach to diagnosis, prediction, and management of EAD and PNF. KEY MESSAGES Different pharmacological interventions may be considered to improve graft function after liver transplantation. Machine perfusion seems to be the most effective method at the moment.
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Affiliation(s)
- Łukasz Masior
- Department of General, Vascular and Oncological Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Michał Grąt
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
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18
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Chen S, Wang T, Luo T, He S, Huang C, Jia Z, Zhan L, Wang D, Zhu X, Guo Z, He X. Prediction of Graft Survival Post-liver Transplantation by L-GrAFT Risk Score Model, EASE Score, MEAF Scoring, and EAD. Front Surg 2021; 8:753056. [PMID: 34869560 PMCID: PMC8641658 DOI: 10.3389/fsurg.2021.753056] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/12/2021] [Indexed: 01/14/2023] Open
Abstract
Background: Early allograft dysfunction (EAD) is correlated with poor patient or graft survival in liver transplantation. However, the power of distinct definitions of EAD in prediction of graft survival is unclear. Methods: This retrospective, single-center study reviewed data of 677 recipients undergoing orthotopic liver transplant between July 2015 and June 2020. The following EAD definitions were compared: liver graft assessment following transplantation (L-GrAFT) risk score model, early allograft failure simplified estimation score (EASE), model for early allograft function (MEAF) scoring, and Olthoff criteria. Risk factors for L-GrAFT7 high risk group were evaluated with univariate and multivariable logistic regression analysis. Results: L-GrAFT7 had a satisfied C-statistic of 0.87 in predicting a 3-month graft survival which significantly outperformed MEAF (C-statistic = 0.78, P = 0.01) and EAD (C-statistic = 0.75, P < 0.001), respectively. L-GrAFT10, EASE was similar to L-GrAFT7, and they had no statistical significance in predicting survival. Laboratory model for end-stage liver disease score and cold ischemia time are risk factors of L-GrAFT7 high-risk group. Conclusion: L-GrAFT7 risk score is capable for better predicting the 3-month graft survival than the MEAF and EAD in a Chinese cohort, which might standardize assessment of early graft function and serve as a surrogate endpoint in clinical trial.
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Affiliation(s)
- Shirui Chen
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Tielong Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Tao Luo
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Shujiao He
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Changjun Huang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Zehua Jia
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Liqiang Zhan
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Dongping Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Xiaofeng Zhu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Zhiyong Guo
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
| | - Xiaoshun He
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, China.,Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou, China
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19
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The Need to Update Endpoints and Outcome Analysis in the Rapidly Changing Field of Liver Transplantation. Transplantation 2021; 106:938-949. [PMID: 34753893 DOI: 10.1097/tp.0000000000003973] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Liver transplantation (LT) survival rates have continued to improve over the last decades, mostly due to the reduction of mortality early after transplantation. The advancement is facilitating a liberalization of access to LT, with more patients with higher risk profiles being added to the waiting list. At the same time, the persisting organ shortage fosters strategies to rescue organs of high-risk donors. This is facilitated by novel technologies such as machine perfusion. Owing to these developments, reconsideration of the current and emerging endpoints for the assessment of the efficacy of existing and new therapies is warranted. While conventional early endpoints in LT have focused on the damage induced to the parenchyma, the fate of the bile duct and the recurrence of the underlying disease have a stronger impact on the long-term outcome. In light of this evolving landscape, we here attempt to reflect on the appropriateness of the currently used endpoints in the field of LT trials.
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20
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Ghinolfi D, Jassem W, Martins PN. Ischemia-free liver transplantation. Is this the right answer to overpass organ shortage and post-liver transplant complications? THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2021; 16:100263. [PMID: 34590065 PMCID: PMC8429951 DOI: 10.1016/j.lanwpc.2021.100263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/06/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Davide Ghinolfi
- Division of Hepatic Surgery and Liver Transplantation, University Hospital of Pisa, Pisa, Italy
| | - Wayel Jassem
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Paulo N. Martins
- Department of Surgery, Transplant Division, University of Massachusetts, Worcester, MA, USA
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21
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The Lactate-to-Platelet Ratio: A Novel Predictor for Short-Term Early Allograft Failure After Liver Transplantation. Transplant Proc 2021; 53:2993-2999. [PMID: 34756715 DOI: 10.1016/j.transproceed.2021.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 09/30/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Early allograft dysfunction (EAD) is a criterion to evaluate initial graft dysfunction associated with inferior graft survival and postoperative complications after liver transplantation (LT). This study defined the lactate-to-platelet ratio (LPR) as lactate level immediately post-LT/platelet count on postoperative day 1 and evaluated its association with EAD and short-term graft failure. MATERIALS AND METHODS This study reviewed 434 deceased-donor LTs from individuals with confirmed brain death between January 2008 and December 2014. The area under the curve (AUC) was used to compare the predictive capacity for 3-month graft survival between EAD and the LPR. Along with LPR, the risk factors for 3-month graft failure were analyzed by multivariate analysis. RESULTS EAD was reported in 127 patients (31%). The LPR in patients with EAD was significantly higher than that in patients without EAD (9.8 vs 5.9, P < .001). In the multivariate analysis, both the LPR (per 1.0 increase) and EAD were independent risk factors for 3-month graft failure (hazard ratio [HR] =1.03, P = .03; and HR = 9.14, P = .001). The comparison of the AUCs between the LPR and EAD showed no significant difference (0.79 vs 0.78, P = .84), whereas the combination of EAD and LPR had a better predictive capacity than EAD alone (0.86 vs 0.78, P < .001). The LPR showed an inverse relationship for predicting 3-month graft survival. CONCLUSIONS The LPR is a continuous parameter that enables prediction of initial graft function and estimation of the 3-month graft failure rate with the advantages of early availability and simple calculations.
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22
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Wadei HM, Keaveny AP, Taner CB, Yang L, Mai ML, Hodge DO, White LJ, Mao SA, Jarmi T, Croome KP. Post-Liver Transplant Early Allograft Dysfunction Modifies the Effect of Pre-Liver Transplant Renal Dysfunction on Post-Liver Transplant Survival. Liver Transpl 2021; 27:1291-1301. [PMID: 33687745 DOI: 10.1002/lt.26047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/13/2021] [Accepted: 03/01/2021] [Indexed: 01/13/2023]
Abstract
Pre-liver transplantation (LT) renal dysfunction is associated with poor post-LT survival. We studied whether early allograft dysfunction (EAD) modifies this association. Data on 2,856 primary LT recipients who received a transplant between 1998 and 2018 were retrospectively reviewed. Patients who died within the first post-LT week or received multiorgan transplants and previous LT recipients were excluded. EAD was defined as (1) total bilirubin ≥ 10 mg/dL on postoperative day (POD) 7, (2) international normalized ratio ≥1.6 on POD 7, and/or (3) alanine aminotransferase or aspartate aminotransferase ≥2000 IU/mL in the first postoperative week. Pre-LT renal dysfunction was defined as serum creatinine >1.5 mg/dL or on renal replacement therapy at LT. Patients were divided into 4 groups according to pre-LT renal dysfunction and post-LT EAD development. Recipients who had both pre-LT renal dysfunction and post-LT EAD had the worst unadjusted 1-year, 3-year, and 5-year post-LT patient and graft survival, whereas patients who had neither renal dysfunction nor EAD had the best survival (P < 0.001). After adjusting for multiple factors, the risk of death was significantly higher only in those with both pre-LT renal dysfunction and post-LT EAD (adjusted hazard ratio [aHR], 2.19; 95% confidence interval [CI], 1.58-3.03; P < 0.001), whereas those with renal dysfunction and no EAD had a comparable risk of death to those with normal kidney function at LT (aHR, 1.12; 95% CI, 0.86-1.45; P = 0.41). Results remained unchanged when pre-LT renal dysfunction was redefined using different glomerular filtration rate cutoffs. Pre-LT renal dysfunction negatively impacts post-LT survival only in patients who develop EAD. Livers at higher risk of post-LT EAD should be used with caution in recipients with pre-LT renal dysfunction.
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Affiliation(s)
- Hani M Wadei
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
| | - Andrew P Keaveny
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
| | - C Burcin Taner
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
| | - Liu Yang
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
| | - Martin L Mai
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic Florida, Jacksonville, FL
| | - Launia J White
- Department of Health Sciences Research, Mayo Clinic Florida, Jacksonville, FL
| | - Shennen A Mao
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
| | - Tambi Jarmi
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL
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23
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Cherchi V, Vetrugno L, Terrosu G, Zanini V, Ventin M, Pravisani R, Tumminelli F, Brollo PP, Boscolo E, Peressutti R, Lorenzin D, Bove T, Risaliti A, Baccarani U. Association between the donor to recipient ICG-PDR variation rate and the functional recovery of the graft after orthotopic liver transplantation: A case series. PLoS One 2021; 16:e0256786. [PMID: 34449820 PMCID: PMC8396715 DOI: 10.1371/journal.pone.0256786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/15/2021] [Indexed: 12/23/2022] Open
Abstract
Background Despite current advances in liver transplant surgery, post-operative early allograft dysfunction still complicates the patient prognosis and graft survival. The transition from the donor has not been yet fully understood, and no study quantifies if and how the liver function changes through its transfer to the recipient. The indocyanine green dye plasma disappearance rate (ICG-PDR) is a simple validated tool of liver function assessment. The variation rate between the donor and recipient ICG-PDR still needs to be investigated. Materials and methods Single-center retrospective study. ICG-PDR determinations were performed before graft retrieval (T1) and 24 hours after transplant (T2). The ICG-PDR relative variation rate between T1 and T2 was calculated to assess the graft function and suffering/recovering. Matched data were compared with the MEAF model of graft dysfunction. Objective To investigate whether the variation rate between the donor ICG-PDR value and the recipient ICG-PDR measurement on first postoperative day (POD1) can be associated with the MEAF score. Results 36 ICG-PDR measurements between 18 donors and 18 graft recipients were performed. The mean donor ICG-PDR was 22.64 (SD 6.35), and the mean receiver’s ICG-PDR on 1st POD was 17.68 (SD 6.60), with a mean MEAF value of 4.51 (SD 1.23). Pearson’s test stressed a good, linear inverse correlation between the ICG-PDR relative variation and the MEAF values, correlation coefficient -0.580 (p = 0.012). Conclusion The direct correlation between the donor to recipient ICG-PDR variation rate and MEAF was found. Measurements at T1 and T2 showed an up- or downtrend of the graft performance that reflect the MEAF values.
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Affiliation(s)
- Vittorio Cherchi
- General Surgery Clinic and Liver Transplant Center, University-Hospital of Udine, Udine, Italy
| | - Luigi Vetrugno
- Department of Anesthesia and Intensive Care, University-Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Giovanni Terrosu
- General Surgery Clinic and Liver Transplant Center, University-Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Victor Zanini
- Department of Anesthesia and Intensive Care, University-Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Marco Ventin
- Department of Medicine, University of Udine, Udine, Italy
- * E-mail:
| | - Riccardo Pravisani
- General Surgery Clinic and Liver Transplant Center, University-Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Francesco Tumminelli
- General Surgery Clinic and Liver Transplant Center, University-Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Pier Paolo Brollo
- General Surgery Clinic and Liver Transplant Center, University-Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Erica Boscolo
- General Surgery Clinic and Liver Transplant Center, University-Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | | | - Dario Lorenzin
- General Surgery Clinic and Liver Transplant Center, University-Hospital of Udine, Udine, Italy
| | - Tiziana Bove
- Department of Anesthesia and Intensive Care, University-Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | | | - Umberto Baccarani
- General Surgery Clinic and Liver Transplant Center, University-Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
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24
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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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25
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Tingle SJ, Thompson ER, Figueiredo RS, Mahendran B, Pandanaboyana S, Wilson CH. Machine perfusion in liver transplantation: a network meta-analysis. Hippokratia 2021. [DOI: 10.1002/14651858.cd014685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Samuel J Tingle
- NIHR Blood and Transplant Research Unit; Newcastle University and Cambridge University; Newcastle upon Tyne UK
| | - Emily R Thompson
- Institute of Transplantation; The Freeman Hospital; Newcastle upon Tyne UK
| | | | | | - Sanjay Pandanaboyana
- HPB and Liver Transplant Surgery; Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle upon Tyne UK
| | - Colin H Wilson
- Institute of Transplantation; The Freeman Hospital; Newcastle upon Tyne UK
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26
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Amygdalos I, Bednarsch J, Meister FA, Erren D, Mantas A, Strnad P, Lang SA, Ulmer TF, Boecker J, Liu W, Jiang D, Bruners P, Neumann UP, Czigany Z. Clinical value and limitations of the preoperative C-reactive-protein-to-albumin ratio in predicting post-operative morbidity and mortality after deceased-donor liver transplantation: a retrospective single-centre study. Transpl Int 2021; 34:1468-1480. [PMID: 34157178 DOI: 10.1111/tri.13957] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/03/2021] [Accepted: 06/16/2021] [Indexed: 12/17/2022]
Abstract
Liver transplantation is still associated with a high risk of severe complications and post-operative mortality. This study examines the predictive value of the preoperative C-reactive-protein-to-albumin ratio (CAR) regarding perioperative morbidity and mortality in deceased-donor liver transplantation (DDLT) recipients. In total, 390 DDLT recipients between 05/2010 and 03/2020 were eligible. Predictive abilities of CAR were examined through receiver operating characteristic curve (ROC) analyses. Groups were compared using parametric and non-parametric tests as appropriate. Independent risk factors for morbidity and mortality were identified using uni- and multivariable logistic regression analyses. A good predictive ability for CAR was shown regarding perioperative morbidity (comprehensive complication index ≥75, Clavien-Dindo score ≥4a) and 12-month mortality, with an ideal cut-off of CAR = 26%. Patients with CAR>26% had significantly higher median CCI scores (60 vs. 43, P < 0.001), longer intensive care unit (ICU, 5 vs. 4 days, P < 0.001) and hospital (28 vs. 21 days, P < 0.001) stays and higher 12-month mortality rates (20% vs 6%, P < 0.001). Multivariable analyses identified CAR>26%, pre-OLT inpatient hospitalization (including ICU) and post-operative red blood cell transfusions as independent predictors of severe cumulative morbidity (CCI≥75). Preoperative CAR might be a reliable additional tool to predict perioperative morbidity and mortality in DDLT recipients.
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Affiliation(s)
- Iakovos Amygdalos
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | | | - David Erren
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Anna Mantas
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Pavel Strnad
- Department of Internal Medicine III, Faculty of Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Sven Arke Lang
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Tom Florian Ulmer
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Joerg Boecker
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Wenjia Liu
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Decan Jiang
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Philipp Bruners
- Institute of Radiology, Faculty of Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany.,Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
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27
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Richards J, Gimson A, Joh Y, Watson CJE, Neuberger J. Trials & Tribulations of Liver Transplantation- are trials now prohibitive without surrogate endpoints? Liver Transpl 2021; 27:747-755. [PMID: 33462951 DOI: 10.1002/lt.25988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/03/2021] [Accepted: 01/06/2021] [Indexed: 01/13/2023]
Abstract
During the past 5 decades, liver transplantation has moved from its pioneering days where success was measured in days to a point where it is viewed as a routine part of medical care. Despite this progress, there are still significant unmet needs and outstanding questions that need addressing in clinical trials to improve outcomes for patients. The traditional endpoint for trials in liver transplantation has been 1-year patient survival, but with rates now approaching 95%, this endpoint now poses a number of significant financial and logistical barriers to conducting trials because of the large numbers of participants required to demonstrate only an incremental improvement. Here, we suggest the following solutions to this challenge: adoption of validated surrogate endpoints; bigger and better collaborative multiarm, multiphase studies; recognition by funders and institutions that work on larger collaborative research projects is potentially more important than smaller, self-led bodies of work; ringfenced areas of research within trial frameworks where individuals can take a lead; and fair funding structures using both industry and public sector money across national and international borders.
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Affiliation(s)
- James Richards
- Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- The National Institute of Health Research Blood and Transplant Research Unit at the University of Cambridge in collaboration with Newcastle University and in partnership with National Health Service Blood and Transplant, Cambridge, UK
- The National Institute of Health Research Cambridge Biomedical Research Centre, Cambridge, UK
| | - Alex Gimson
- The National Institute of Health Research Cambridge Biomedical Research Centre, Cambridge, UK
- Department of Medicine, Cambridge University Hospitals, Addenbrooke's Hospital, Cambridge, UK
| | - Yexin Joh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Christopher J E Watson
- Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- The National Institute of Health Research Blood and Transplant Research Unit at the University of Cambridge in collaboration with Newcastle University and in partnership with National Health Service Blood and Transplant, Cambridge, UK
- The National Institute of Health Research Cambridge Biomedical Research Centre, Cambridge, UK
| | - James Neuberger
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
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28
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Martins PN, Rizzari MD, Ghinolfi D, Jochmans I, Attia M, Jalan R, Friend PJ. Design, Analysis, and Pitfalls of Clinical Trials Using Ex Situ Liver Machine Perfusion: The International Liver Transplantation Society Consensus Guidelines. Transplantation 2021; 105:796-815. [PMID: 33760791 DOI: 10.1097/tp.0000000000003573] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Recent trials in liver machine perfusion (MP) have revealed unique challenges beyond those seen in most clinical studies. Correct trial design and interpretation of data are essential to avoid drawing conclusions that may compromise patient safety and increase costs. METHODS The International Liver Transplantation Society, through the Special Interest Group "DCD, Preservation and Machine Perfusion," established a working group to write consensus statements and guidelines on how future clinical trials in liver perfusion should be designed, with particular focus on relevant clinical endpoints and how different techniques of liver perfusion should be compared. Protocols, abstracts, and full published papers of clinical trials using liver MP were reviewed. The use of a simplified Grading of Recommendations Assessment, Development, and Evaluation working group (GRADE) system was attempted to assess the level of evidence. The working group presented its conclusions at the International Liver Transplantation Society consensus conference "DCD, Liver Preservation, and Machine Perfusion" held in Venice, Italy, on January 31, 2020. RESULTS Twelve recommendations were proposed with the main conclusions that clinical trials investigating the effect of MP in liver transplantation should (1) make the protocol publicly available before the start of the trial, (2) be adequately powered, and (3) carefully consider timing of randomization in function of the primary outcome. CONCLUSIONS There are issues with using accepted primary outcomes of liver transplantation trials in the context of MP trials, and no ideal endpoint could be defined by the working group. The setup of an international registry was considered vital by the working group.
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Affiliation(s)
- Paulo N Martins
- Division of Organ Transplantation, Department of Surgery, University of Massachusetts Memorial Hospital, University of Massachusetts, Worcester, MA
| | - Michael D Rizzari
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Davide Ghinolfi
- Division of Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Tuscany, Italy
| | - Ina Jochmans
- Transplantation Research Group, Lab of Abdominal Transplantation, Department of Microbiology, Immunology and Transplantation, KU Leuven, Belgium
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Magdy Attia
- Department of Hepatobiliary & Transplantation Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, London, United Kingdom
| | - Peter J Friend
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
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Ivanics T, Abreu P, De Martin E, Sapisochin G. Changing Trends in Liver Transplantation: Challenges and Solutions. Transplantation 2021; 105:743-756. [PMID: 32910093 DOI: 10.1097/tp.0000000000003454] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Despite improvements in postliver transplant outcomes through refinements in perioperative management and surgical techniques, several changing trends in liver transplantation have presented challenges. Mortality on the waitlist remains high. In the United States, Europe, and the United Kingdom, there is an increasing need for liver transplantation, primarily as a result of increased incidence of nonalcoholic steatohepatitis-related cirrhosis and cancer indications. Meanwhile, donor suitability has decreased, as donors are often older and have more comorbidities. Despite a mismatch between organ need and availability, many organs are discarded. Notwithstanding this, many solutions have been developed to overcome these challenges. Innovative techniques in allograft preservation, viability assessment, and reconditioning have allowed the use of suboptimal organs with adequate results. Refinements in surgical procedures, including live donor liver transplantations, have increased the organ pool and are decreasing the time and mortality on the waitlist. Despite many challenges, a similar number of solutions and prospects are on the horizon. This review seeks to explore the changing trends and challenges in liver transplantation and highlight possible solutions and future directions.
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Affiliation(s)
- Tommy Ivanics
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Phillipe Abreu
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Eleonora De Martin
- APHP, Hôpital Paul Brousse, Centre Hépato-Biliaire, INSERM 1193, Université Paris-Sud, DHU Hepatinov, Villejuif, France
| | - Gonzalo Sapisochin
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
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Braun HJ, Roberts JP. Current status of left lobe adult to adult living donor liver transplantation. Curr Opin Organ Transplant 2021; 26:139-145. [PMID: 33595983 DOI: 10.1097/mot.0000000000000863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW This review describes the history and current state of left lobe living donor liver transplantation (LDLT). The transplant community continues to face an organ shortage on a global scale, and the expansion of LDLT is attractive because it allows us to provide life-saving liver transplants to individuals without drawing from, or depending on, the limited deceased donor pool. Donor safety is paramount in LDLT, and for this reason, left lobe LDLT is particularly attractive because the donor is left with a larger remnant. RECENT FINDINGS This article reviews the donor and recipient evaluations for left lobe LDLT, discusses small for size syndrome and the importance of portal inflow modification, and reviews recipient outcomes in right lobe versus left lobe LDLT. SUMMARY Left lobe LDLT was the first adult-to-adult LDLT ever to be performed in Japan in 1993. Since that time, the use of both right and left lobe LDLT has expanded immensely. Recent work in left lobe LDLT has emphasized the need for inflow modification to reduce portal hyperperfusion and early graft dysfunction following transplant. Accumulating evidence suggests, however, that even though early graft dysfunction following LDLT may prolong hospitalization, it does not predict graft or patient survival.
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Affiliation(s)
- Hillary J Braun
- Department of Surgery, University of California, San Francisco, California, USA
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31
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Pravisani R, De Simone P, Patrono D, Lauterio A, Cescon M, Gringeri E, Colledan M, Di Benedetto F, di Francesco F, Antonelli B, Manzia TM, Carraro A, Vivarelli M, Regalia E, Vennarecci G, Guglielmo N, Cesaretti M, Avolio AW, Valentini MF, Lai Q, Baccarani U. An Italian survey on the use of T-tube in liver transplantation: old habits die hard! Updates Surg 2021; 73:1381-1389. [PMID: 33792888 PMCID: PMC8397659 DOI: 10.1007/s13304-021-01019-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 03/02/2021] [Indexed: 12/13/2022]
Abstract
There is enough clinical evidence that a T-tube use in biliary reconstruction at adult liver transplantation (LT) does not significantly modify the risk of biliary stricture/leak, and it may even sustain infective and metabolic complications. Thus, the policy on T-tube use has been globally changing, with progressive application of more restrictive selection criteria. However, there are no currently standardized indications in such change, and many LT Centers rely only on own experience and routine. A nation-wide survey was conducted among all the 20 Italian adult LT Centers to investigate the current policy on T-tube use. It was found that 20% of Centers completely discontinued the T-tube use, while 25% Centers used it routinely in all LT cases. The remaining 55% of Centers applied a selective policy, based on criteria of technical complexity of biliary reconstruction (72.7%), followed by low-quality graft (63.6%) and high-risk recipient (36.4%). A T-tube use > 50% of annual caseload was not associated with high-volume Center status (> 70 LT per year), an active pediatric or living-donor transplant program, or use of DCD grafts. Only 10/20 (50%) Centers identified T-tube as a potential risk factor for complications other than biliary stricture/leak. In these cases, the suspected pathogenic mechanism comprised bacterial colonization (70%), malabsorption (70%), interruption of the entero-hepatic bile-acid cycle (50%), biliary inflammation due to an indwelling catheter (40%) and gut microbiota changes (40%). In conclusion, the prevalence of T-tube use among the Italian LT Centers is still relatively high, compared to the European trend (33%), and the potential detrimental effect of T-tube, beyond biliary stricture/leak, seems to be somehow underestimated.
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Affiliation(s)
- Riccardo Pravisani
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation, University Hospital Pisa, Pisa, Italy
| | - Damiano Patrono
- General Surgery 2U, Liver Transplant Center, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Turin, Italy
| | - Andrea Lauterio
- General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Matteo Cescon
- General Surgery and Transplantation Unit, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria-Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Enrico Gringeri
- Hepatobiliary Surgery and Liver Transplantation Unit, University Hospital, Padua, Italy
| | - Michele Colledan
- Chirurgia Generale 3, Trapianti Addominali, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Fabrizio Di Benedetto
- Hepatopancreatobiliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio di Francesco
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS ISMETT-UPMC, Palermo, Italy
| | - Barbara Antonelli
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Tommaso Maria Manzia
- HPB and Transplant Unit, Department of Surgery Science, University of Rome Tor Vergata, Rome, Italy
| | - Amedeo Carraro
- General Surgery and Liver Transplant Unit, University Hospital of Verona, Verona, Italy
| | - Marco Vivarelli
- HPB Surgery and Transplantation Unit, Department of Clinical and Experimental Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Enrico Regalia
- HPB Surgery and Transplantation Unit, Istituto Nazionale Tumori, IRCCS, Milano, Italy
| | - Giovanni Vennarecci
- Laproscopic, Hepatic, and Liver Transplant Unit, AORN A. Cardarelli, Naples, Italy
| | - Nicola Guglielmo
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Italy
| | - Manuela Cesaretti
- Liver Transplant Unit, Department of General Surgery, Azienda Ospedaliera G. Brotzu, Cagliari, Italy
| | - Alfonso Wolfango Avolio
- General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Maria Filippa Valentini
- General Surgery and Liver Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, Sapienza University of Rome, Rome, Italy
| | - Umberto Baccarani
- Liver-Kidney Transplantation Unit, Department of Medicine, University of Udine, Udine, Italy.
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Agopian VG, Markovic D, Klintmalm GB, Saracino G, Chapman WC, Vachharajani N, Florman SS, Tabrizian P, Haydel B, Nasralla D, Friend PJ, Boteon YL, Ploeg R, Harlander-Locke MP, Xia V, DiNorcia J, Kaldas FM, Yersiz H, Farmer DG, Busuttil RW. Multicenter validation of the liver graft assessment following transplantation (L-GrAFT) score for assessment of early allograft dysfunction. J Hepatol 2021; 74:881-892. [PMID: 32976864 DOI: 10.1016/j.jhep.2020.09.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 08/29/2020] [Accepted: 09/15/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Early allograft dysfunction (EAD) following liver transplantation (LT) negatively impacts graft and patient outcomes. Previously we reported that the liver graft assessment following transplantation (L-GrAFT7) risk score was superior to binary EAD or the model for early allograft function (MEAF) score for estimating 3-month graft failure-free survival in a single-center derivation cohort. Herein, we sought to externally validate L-GrAFT7, and compare its prognostic performance to EAD and MEAF. METHODS Accuracies of L-GrAFT7, EAD, and MEAF were compared in a 3-center US validation cohort (n = 3,201), and a Consortium for Organ Preservation in Europe (COPE) normothermic machine perfusion (NMP) trial cohort (n = 222); characteristics were compared to assess generalizability. RESULTS Compared to the derivation cohort, patients in the validation and NMP trial cohort had lower recipient median MELD scores; were less likely to require pretransplant hospitalization, renal replacement therapy or mechanical ventilation; and had superior 1-year overall (90% and 95% vs. 84%) and graft failure-free (88% and 93% vs. 81%) survival, with a lower incidence of 3-month graft failure (7.4% and 4.0% vs. 11.1%; p <0.001 for all comparisons). Despite significant differences in cohort characteristics, L-GrAFT7 maintained an excellent validation AUROC of 0.78, significantly superior to binary EAD (AUROC 0.68, p = 0.001) and MEAF scores (AUROC 0.72, p <0.001). In post hoc analysis of the COPE NMP trial, the highest tertile of L-GrAFT7 was significantly associated with time to liver allograft (hazard ratio [HR] 2.17, p = 0.016), Clavien ≥IIIB (HR 2.60, p = 0.034) and ≥IVa (HR 4.99, p = 0.011) complications; post-LT length of hospitalization (p = 0.002); and renal replacement therapy (odds ratio 3.62, p = 0.016). CONCLUSIONS We have validated the L-GrAFT7 risk score as a generalizable, highly accurate, individualized risk assessment of 3-month liver allograft failure that is superior to existing scores. L-GrAFT7 may standardize grading of early hepatic allograft function and serve as a clinical endpoint in translational studies (www.lgraft.com). LAY SUMMARY Early allograft dysfunction negatively affects outcomes following liver transplantation. In independent multicenter US and European cohorts totaling 3,423 patients undergoing liver transplantation, the liver graft assessment following transplantation (L-GrAFT) risk score is validated as a superior measure of early allograft function that accurately discriminates 3-month graft failure-free survival and post-liver transplantation complications.
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Affiliation(s)
- Vatche G Agopian
- Dumont-UCLA Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA.
| | - Daniela Markovic
- Department of Biomathematics, David Geffen School of Medicine at UCLA
| | - Goran B Klintmalm
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Giovanna Saracino
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - William C Chapman
- Section of Transplantation, Department of Surgery, Washington University in St. Louis, St. Louis, MO
| | - Neeta Vachharajani
- Section of Transplantation, Department of Surgery, Washington University in St. Louis, St. Louis, MO
| | - Sander S Florman
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY
| | - Parissa Tabrizian
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY
| | - Brandy Haydel
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY
| | - David Nasralla
- Department of Hepatopancreaticobiliary and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | - Peter J Friend
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - Rutger Ploeg
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Michael P Harlander-Locke
- Dumont-UCLA Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA
| | - Victor Xia
- Department of Anesthesia, David Geffen School of Medicine at UCLA
| | - Joseph DiNorcia
- Dumont-UCLA Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA
| | - Fady M Kaldas
- Dumont-UCLA Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA
| | - Hasan Yersiz
- Dumont-UCLA Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA
| | - Douglas G Farmer
- Dumont-UCLA Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA
| | - Ronald W Busuttil
- Dumont-UCLA Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA
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Navas-Blanco JR, Martini A, Fabbro M. Expert Consensus Decision Pathway of the American College of Cardiology on Management of Bleeding in Patients With Oral Anticoagulants: A Review of the 2020 Update for Perioperative Physicians. J Cardiothorac Vasc Anesth 2021; 35:2471-2479. [PMID: 33726942 DOI: 10.1053/j.jvca.2021.02.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/05/2021] [Accepted: 02/07/2021] [Indexed: 11/11/2022]
Abstract
The use and evolution of oral anticoagulation therapies continue to advance for multiple reasons, including a growing segment of older patients with associated chronic prothrombotic illnesses including cardiovascular, pulmonary, hematologic and oncologic conditions. Correlated to this increased use of oral anticoagulants is bleeding complications associated with their use. Based on these trends, it is expected that perioperative physicians will be facing more and more of these patients requiring scheduled, urgent or emergent surgical procedures During May 2020, the American College of Cardiology updated its Expert Consensus Decision Pathway devoted to the approach of bleeding in patients on oral anticoagulants. This updated version emphasized the expanding role of the direct-acting oral anticoagulants in other conditions beyond nonvalvular atrial fibrillation, such as venous thromboembolism. Several details discussed within this most recent update are pertinent to perioperative physicians, who frequently deal with bleeding in the setting of anticoagulation. The purpose of this narrative review is to highlight and expand on these salient points because they relate to perioperative management.
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Affiliation(s)
- Jose R Navas-Blanco
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL
| | - Adriana Martini
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL
| | - Michael Fabbro
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL.
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Live Confocal Imaging as a Novel Tool to Assess Liver Quality: Insights From a Murine Model. Transplantation 2021; 104:2528-2537. [PMID: 33215899 DOI: 10.1097/tp.0000000000003405] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In an experimental murine liver clamping model, we aimed to investigate the efficacy of real-time confocal microscopy (RCM) in assessing viability of steatotic livers in comparison to standard assessment tools, including histopathological evaluation. METHODS C57Bl/6 mice were subjected to a methionine-choline-deficient diet causing nonalcoholic fatty liver disease or to Lieber DeCarli diet causing ethanol-induced liver injury. Untreated animals served as controls. Liver biopsies were analyzed following challenge with 45 min of warm ischemia time and either 4 h of reperfusion or 24 h of cold storage. Organ quality assessment was performed at defined time points by RCM, histological staining, measurement of serum alanine aminotransferase activity, and expression analyses of proinflammatory cytokines. Additionally, survival analysis was performed. RESULTS Cold as well as warm ischemia time resulted in a significant decrease in cell viability when compared with naive livers as well as nonischemic-challenged steatotic livers (P < 0.05) as assessed by RCM. Furthermore, RCM revealed the actual cellular damage at early time points, while established methods including H&E-staining and serum transaminase profile failed. CONCLUSIONS In a translational attempt, we demonstrate that RCM is a suitable diagnostic tool to obtain information about functional damage of the liver apart from standard approaches.
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Avolio AW, Franco A, Schlegel A, Lai Q, Meli S, Burra P, Patrono D, Ravaioli M, Bassi D, Ferla F, Pagano D, Violi P, Camagni S, Dondossola D, Montalti R, Alrawashdeh W, Vitale A, Teofili L, Spoletini G, Magistri P, Bongini M, Rossi M, Mazzaferro V, Di Benedetto F, Hammond J, Vivarelli M, Agnes S, Colledan M, Carraro A, Cescon M, De Carlis L, Caccamo L, Gruttadauria S, Muiesan P, Cillo U, Romagnoli R, De Simone P. Development and Validation of a Comprehensive Model to Estimate Early Allograft Failure Among Patients Requiring Early Liver Retransplant. JAMA Surg 2020; 155:e204095. [PMID: 33112390 PMCID: PMC7593884 DOI: 10.1001/jamasurg.2020.4095] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Question Can the individual risk estimation for early allograft failure (EAF) be improved in view of liver retransplant? Findings In this multicenter cohort study investigating the association between donor-recipient factors and EAF, a novel Early Allograft Failure Simplified Estimation (EASE) score was developed. The score includes Model for End-stage Liver Disease score, transfused packed red blood cells, and hepatic vessel early thrombosis as well as transaminases, platelet, and bilirubin kinetics as variables on day 10 after transplant. The EASE score outperformed previous model scores, estimating EAF risk with 87% accuracy on day 90 after transplant; EASE was developed on a multicenter Italian database (1609 recipients) and validated on an external UK database (538 recipients). Meaning In this study, the EASE score rated the EAF risk (0%-100%) and identified cases at unsustainable risk to be listed for retransplant. Importance Expansion of donor acceptance criteria for liver transplant increased the risk for early allograft failure (EAF), and although EAF prediction is pivotal to optimize transplant outcomes, there is no consensus on specific EAF indicators or timing to evaluate EAF. Recently, the Liver Graft Assessment Following Transplantation (L-GrAFT) algorithm, based on aspartate transaminase, bilirubin, platelet, and international normalized ratio kinetics, was developed from a single-center database gathered from 2002 to 2015. Objective To develop and validate a simplified comprehensive model estimating at day 10 after liver transplant the EAF risk at day 90 (the Early Allograft Failure Simplified Estimation [EASE] score) and, secondarily, to identify early those patients with unsustainable EAF risk who are suitable for retransplant. Design, Setting, and Participants This multicenter cohort study was designed to develop a score capturing a continuum from normal graft function to nonfunction after transplant. Both parenchymal and vascular factors, which provide an indication to list for retransplant, were included among the EAF determinants. The L-GrAFT kinetic approach was adopted and modified with fewer data entries and novel variables. The population included 1609 patients in Italy for the derivation set and 538 patients in the UK for the validation set; all were patients who underwent transplant in 2016 and 2017. Main Outcomes and Measures Early allograft failure was defined as graft failure (codified by retransplant or death) for any reason within 90 days after transplant. Results At day 90 after transplant, the incidence of EAF was 110 of 1609 patients (6.8%) in the derivation set and 41 of 538 patients (7.6%) in the external validation set. Median (interquartile range) ages were 57 (51-62) years in the derivation data set and 56 (49-62) years in the validation data set. The EASE score was developed through 17 entries derived from 8 variables, including the Model for End-stage Liver Disease score, blood transfusion, early thrombosis of hepatic vessels, and kinetic parameters of transaminases, platelet count, and bilirubin. Donor parameters (age, donation after cardiac death, and machine perfusion) were not associated with EAF risk. Results were adjusted for transplant center volume. In receiver operating characteristic curve analyses, the EASE score outperformed L-GrAFT, Model for Early Allograft Function, Early Allograft Dysfunction, Eurotransplant Donor Risk Index, donor age × Model for End-stage Liver Disease, and Donor Risk Index scores, estimating day 90 EAF in 87% (95% CI, 83%-91%) of cases in both the derivation data set and the internal validation data set. Patients could be stratified in 5 classes, with those in the highest class exhibiting unsustainable EAF risk. Conclusions and Relevance This study found that the developed EASE score reliably estimated EAF risk. Knowledge of contributing factors may help clinicians to mitigate risk factors and guide them through the challenging clinical decision to allocate patients to early liver retransplant. The EASE score may be used in translational research across transplant centers.
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Affiliation(s)
- Alfonso W Avolio
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Franco
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | | | | | | | | | | | | | | | | | - Duilio Pagano
- ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | | | | | - Daniele Dondossola
- Fondazione IRCCS Ospedale Maggiore Policlinico, Università degli Studi, Milan, Italy
| | | | | | | | - Luciana Teofili
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gabriele Spoletini
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy.,Newcastle Upon Tyne Hospital, Newcastle Upon Tyne, United Kingdom
| | | | - Marco Bongini
- Istituto Nazionale Tumori, IRCCS, and Università degli Studi, Milan, Italy
| | | | | | | | - John Hammond
- Newcastle Upon Tyne Hospital, Newcastle Upon Tyne, United Kingdom
| | | | - Salvatore Agnes
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | | | | | - Matteo Cescon
- S. Orsola-Malpighi University Hospital, Bologna, Italy
| | | | - Lucio Caccamo
- Fondazione IRCCS Ospedale Maggiore Policlinico, Università degli Studi, Milan, Italy
| | - Salvatore Gruttadauria
- ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | - Paolo Muiesan
- Queen Elizabeth Hospital, Birmingham, United Kingdom
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Uutela A, Helanterä I, Lemström K, Passov A, Syrjälä S, Åberg F, Mäkisalo H, Nordin A, Lempinen M, Sallinen V. Randomised sham-controlled double-blind trial evaluating remote ischaemic preconditioning in solid organ transplantation: a study protocol for the RIPTRANS trial. BMJ Open 2020; 10:e038340. [PMID: 33199419 PMCID: PMC7670950 DOI: 10.1136/bmjopen-2020-038340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Remote ischaemic preconditioning (RIPC) using a non-invasive pneumatic tourniquet is a potential method for reducing ischaemia-reperfusion injury. RIPC has been extensively studied in animal models and cardiac surgery, but scarcely in solid organ transplantation. RIPC could be an inexpensive and simple method to improve function of transplanted organs. Accordingly, we aim to study whether RIPC performed in brain-dead organ donors improves function and longevity of transplanted organs. METHODS AND ANALYSES RIPTRANS is a multicentre, sham-controlled, parallel group, randomised superiority trial comparing RIPC intervention versus sham-intervention in brain-dead organ donors scheduled to donate at least one kidney. Recipients of the organs (kidney, liver, pancreas, heart, lungs) from a randomised donor will be included provided that they give written informed consent. The RIPC intervention is performed by inflating a thigh tourniquet to 300 mm Hg 4 times for 5 min. The intervention is done two times: first right after the declaration of brain death and second immediately before transferring the donor to the operating theatre. The sham group receives the tourniquet, but it is not inflated. The primary endpoint is delayed graft function (DGF) in kidney allografts. Secondary endpoints include short-term functional outcomes of transplanted organs, rejections and graft survival in various time points up to 20 years. We aim to show that RIPC reduces the incidence of DGF from 25% to 15%. According to this, the sample size is set to 500 kidney transplant recipients. ETHICS AND DISSEMINATION This study has been approved by Helsinki University Hospital Ethics Committee and Helsinki University Hospital's Institutional Review Board. The study protocol was be presented at the European Society of Organ Transplantation congress in Copenhagen 14-15 September 2019. The study results will be submitted to an international peer-reviewed scientific journal for publication. TRIAL REGISTRATION NUMBER NCT03855722.
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Affiliation(s)
- Aki Uutela
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ilkka Helanterä
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Karl Lemström
- Department of Cardiothoracic Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Arie Passov
- Department of Perioperative, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Simo Syrjälä
- Department of Cardiothoracic Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Fredrik Åberg
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Heikki Mäkisalo
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Arno Nordin
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marko Lempinen
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ville Sallinen
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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37
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Martucci G, Volpes R, Panarello G, Tuzzolino F, Di Carlo D, Ricotta C, Gruttadauria S, Conaldi PG, Luca A, Amrein K, Arcadipane A. Vitamin D levels in liver transplantation recipients and early postoperative outcomes: Prospective observational DLiverX study. Clin Nutr 2020; 40:2355-2363. [PMID: 33158589 DOI: 10.1016/j.clnu.2020.10.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 09/16/2020] [Accepted: 10/17/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS In critically ill patients with liver disease, vitamin D deficiency is associated with higher disease severity, increased frequency of infections, and worse outcomes. This study sought to describe the trend of vitamin D in orthotopic liver transplantation (OLT) recipients and its association with outcomes. METHODS Prospective observational study of 67 consecutive OLT recipients enrolled between September, 2016 and August, 2017 at IRCCS-ISMETT, Palermo (Italy). Trend of vitamin D levels and potential factors influencing it levels were evaluated through a generalized linear mixed regression model. RESULTS Sixty-four (95.5%) recipients were vitamin D deficient (<20 ng/ml), with a median value of 8.8 ng/ml [6.2-12.9], and forty-seven of these (70.1%) showed severe deficiency (<12 ng/ml) at baseline, 7.9 ng/ml [5.4-8.9]. The baseline vitamin D showed an inverse correlation with liver disease severity: Child-Pugh, MELD score, bilirubin, INR, and organ failure (p < 0.01) at baseline. Vitamin D increased on postoperative day (POD) 28 compared with POD1: +4.5 ng/ml, C.I. 95% 3.6-5.3 ng/ml, p < 0.01. Lower baseline vitamin D, donor age, transfusion of fresh frozen plasma (negative impact, all p < 0.05), and intra-operative bypass (positive impact at POD 28, p < 0.01) were associated with variation of vitamin D levels after transplantation. Incomplete graft recovery was associated with lower vitamin D on POD28: 8.2 ± 4.4 versus 13.8 ± 9.4 ng/ml, p < 0.01; the odds ratio (OR) was 0.84; CI 95% 0.73-0.97, p = 0.014. The OR for infections within POD 28 was inversely associated with baseline vitamin D: 0.87; CI 95% 0.79-0.98, p = 0.02, and with vitamin D level at baseline <12 ng/ml: OR 6.44; CI 95% 1.66-24.94; p < 0.01. CONCLUSIONS Preoperative Vitamin D is correlated with disease severity, and was highly associated with invasive infection in the first 28 PODs. After OLT, the value on POD 28 had a strong association with graft function.
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Affiliation(s)
- Gennaro Martucci
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy.
| | - Riccardo Volpes
- Hepatology and Gastroenterology Unit, Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Giovanna Panarello
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Fabio Tuzzolino
- Research Office, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Daniele Di Carlo
- Department of Laboratory Medicine and Advanced Biotechnologies, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Calogero Ricotta
- Abdominal Surgery and Organ Transplantation Unit, Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Salvatore Gruttadauria
- Abdominal Surgery and Organ Transplantation Unit, Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Pier Giulio Conaldi
- CEO, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Angelo Luca
- CEO, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Antonio Arcadipane
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
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38
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Richards JA, Sherif AE, Butler AJ, Hunt F, Allison M, Oniscu GC, Watson CJE. Model for early allograft function is predictive of early graft loss in donation after circulatory death liver transplantation. Clin Transplant 2020; 34:e13982. [PMID: 32441409 DOI: 10.1111/ctr.13982] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/06/2020] [Accepted: 05/16/2020] [Indexed: 12/17/2022]
Abstract
Donation after circulatory death (DCD) liver transplantation is associated with higher rates of graft loss. In this paper, we explored whether the Model for Early Allograft Function (MEAF) predicted outcome in DCD liver transplantation. We performed a retrospective analysis of prospectively collected data from all adult DCD (Maastricht 3) livers transplanted in Cambridge and Edinburgh between 1 January 2011 and 30 June 2017, excluding those undergoing any form of machine perfusion. 187 DCD liver transplants were performed during the study period. DCD liver transplants with a lower MEAF score had a significantly better survival compared to those with a high MEAF score (Mantel-Cox P < .0001); this was largely due to early graft loss. Beyond 28 days post-transplant, there were no significant long-term graft or patient survival differences irrespective of the grade of MEAF (Mantel-Cox P = .64 and P = .43, respectively). The MEAF score correlated with the length of ICU (P = .0011) and hospital stay (P = .0007), but did not predict the requirement for retransplantation for ischemic cholangiopathy (P = .37) or readmission (P = .74). In this study, a high MEAF score predicted early graft loss, but not the subsequent need for re-transplantation or late graft failure as a result of intrahepatic ischemic bile duct pathology.
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Affiliation(s)
- James A Richards
- University of Cambridge Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,The NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK.,The National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Ahmed E Sherif
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrew J Butler
- University of Cambridge Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,The NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK.,The National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Fiona Hunt
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Michael Allison
- The National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK.,Department of Medicine, Cambridge University Hospitals, Addenbrooke's Hospital, Cambridge, UK
| | - Gabriel C Oniscu
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Christopher J E Watson
- University of Cambridge Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,The NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK.,The National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
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39
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Kusakabe J, Hata K, Tanaka S, Omae K, Okamura Y, Tajima T, Tamaki I, Miyauchi H, Kubota T, Tanaka H, Uemoto S. Prognostic index consisting of early post-transplant variables <2 weeks in adult living-donor liver transplantation. Hepatol Res 2020; 50:741-753. [PMID: 32012392 PMCID: PMC7317571 DOI: 10.1111/hepr.13489] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 01/21/2020] [Accepted: 01/26/2020] [Indexed: 12/11/2022]
Abstract
AIM Six-month recipient mortality after adult-to-adult living-donor liver transplantation (LDLT) remains high. Early and accurate prediction of recipient outcome and continuous monitoring of recipient severity after surgery are both essential for guiding appropriate care. This study was designed to identify early post-transplant parameters associated with 6-month mortality, and thereby to construct a discriminatory prognostic index (PI). METHODS We retrospectively analyzed 400 consecutive primary adult-to-adult LDLTs in our center (2006-2017). Perioperative variables were comprehensively analyzed for their accuracy in predicting recipient mortality by comparing the area under the receiver operating characteristic (AUROC) of each factor. RESULTS The AUROCs of preoperative predictive factors, for example, Model for End-stage Liver Disease (MELD) score and donor age, were 0.56 and 0.64, respectively, whereas those of post-transplant platelet count (PLT), total bilirubin (T-BIL), and prothrombin time - international normalized ratio (INR) on postoperative day (POD)-7-14 were 0.71/0.84, 0.68/0.82, and 0.71/0.78, respectively. Logistic regression analysis provided a formula: PIPOD-14 = 3.39 + 0.12 × PLTPOD-14 - 0.09 × T-BILPOD-14 - 1.23 × INRPOD-14 , indicating a high AUROC of 0.87. Recipient 6-month survival with PIPOD-14 < 2.38 (n = 173) was 71.7%, whereas that with PIPOD-14 ≥ 2.38 (n = 222) was 97.7% (P < 0.001). The AUROCs of PIPOD-7 were as high as 0.8 in the subgroups with younger donors (<50 years of age), right lobe grafts, ABO-identical/compatible combinations, or low MELD score (<20), indicating usefulness of PI to identify unexpectedly complicated cases within the first week. CONCLUSIONS A novel, post-transplant survival estimator, PI, accurately predicts recipient 6-month mortality within 1-2 weeks after adult LDLT. Daily monitoring of PI could facilitate early interventions including retransplantation in critically ill patients.
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Affiliation(s)
- Jiro Kusakabe
- Department of Surgery, Division of Hepato‐Biliary‐Pancreatic Surgery and TransplantationKyoto University Graduate School of MedicineKyotoJapan
| | - Koichiro Hata
- Department of Surgery, Division of Hepato‐Biliary‐Pancreatic Surgery and TransplantationKyoto University Graduate School of MedicineKyotoJapan
| | - Shiro Tanaka
- Department of Clinical BiostatisticsKyoto University Graduate School of MedicineKyotoJapan
| | - Katsuhiro Omae
- Department of Clinical BiostatisticsKyoto University Graduate School of MedicineKyotoJapan
| | - Yusuke Okamura
- Department of Surgery, Division of Hepato‐Biliary‐Pancreatic Surgery and TransplantationKyoto University Graduate School of MedicineKyotoJapan
| | - Tetsuya Tajima
- Department of Surgery, Division of Hepato‐Biliary‐Pancreatic Surgery and TransplantationKyoto University Graduate School of MedicineKyotoJapan
| | - Ichiro Tamaki
- Department of Surgery, Division of Hepato‐Biliary‐Pancreatic Surgery and TransplantationKyoto University Graduate School of MedicineKyotoJapan
| | - Hidetaka Miyauchi
- Department of Surgery, Division of Hepato‐Biliary‐Pancreatic Surgery and TransplantationKyoto University Graduate School of MedicineKyotoJapan
| | - Toyonari Kubota
- Department of Surgery, Division of Hepato‐Biliary‐Pancreatic Surgery and TransplantationKyoto University Graduate School of MedicineKyotoJapan
| | - Hirokazu Tanaka
- Department of Surgery, Division of Hepato‐Biliary‐Pancreatic Surgery and TransplantationKyoto University Graduate School of MedicineKyotoJapan
| | - Shinji Uemoto
- Department of Surgery, Division of Hepato‐Biliary‐Pancreatic Surgery and TransplantationKyoto University Graduate School of MedicineKyotoJapan
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40
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Lin ZB, Yang PJ, Zhang X, Wang JL, Liu K, Dou KF. Translationally controlled tumor protein exerts a proinflammatory role in acute rejection after liver transplantation. Hepatobiliary Pancreat Dis Int 2020; 19:235-243. [PMID: 32224126 DOI: 10.1016/j.hbpd.2020.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 03/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Translationally controlled tumor protein (TCTP), which has been verified to have a proinflammatory activity, plays an important role in allergy. However, it remains unclear whether TCTP has an impact on the acute rejection (AR) after liver transplantation. METHODS Three protocols were used to delineate the role of TCTP in AR after liver transplantation. First, in rat orthotopic liver transplantation (OLT), the expression of TCTP was measured by enzyme-linked immunosorbent assay (ELISA), real-time PCR, Western blot and immunofluorescence assays. Second, in mixed lymphocyte reaction (MLR), the role of TCTP in lymphocyte proliferation was measured by carboxyfluorescein succinimidyl ester (CFSE) labeling and the impact of TCTP on inflammatory factor release was detected by cytokine arrays. Third, in human OLT, the level of serum TCTP was detected by ELISA, and the relationship between TCTP and model for early allograft function (MEAF) score was assessed by Spearman's correlation. RESULTS In rat OLT, AR resulted in great harm to allografts, manifesting as deterioration of liver function, increasing inflammatory factors and infiltrating lymphocytes. Meanwhile, TCTP was overexpressed in serum and allografts. Higher level of TCTP was associated with higher rejection activity index (RAI). In an MLR protocol, TCTP knockdown inhibited the proliferation of mixed inflammatory cells and significantly suppressed the release of 15 cytokines and chemokines. In human OLT, the serum TCTP was up-regulated within a week after operation. Additionally, the increasing speed of serum TCTP positively correlated with MEAF scores (r = 0.449; P = 0.0088). CONCLUSIONS Up-regulated TCTP positively affects AR after liver transplantation.
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Affiliation(s)
- Zhi-Bin Lin
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Pei-Jun Yang
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Xuan Zhang
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Jian-Lin Wang
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Kun Liu
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China
| | - Ke-Feng Dou
- Department of Hepatobiliary Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an 710032, China.
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41
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Lv T, Kong L, Yang J, Wu H, Wen T, Jiang L, Yang J. The postoperative hepatic artery resistance index after living donor liver transplantation can predict early allograft dysfunction. Medicine (Baltimore) 2020; 99:e18677. [PMID: 31977857 PMCID: PMC7004676 DOI: 10.1097/md.0000000000018677] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
To investigate whether postoperative hepatic hemodynamics have an impact on graft function.Using a retrospective cohort with 262 adult living donor liver transplantation (LDLT) recipients, we discussed the relationship between postoperative hepatic hemodynamics and patient outcomes.According to the definition of early allograft dysfunction (EAD), the patients were classified into the EAD group (43 patients) and the non-EAD group (219 patients). In terms of postoperative hemodynamic parameters, there was no significant differences between these 2 groups regarding hepatic artery flow (HAF), hepatic artery velocity (HAV), portal vein flow (PVF), and portal vein velocity (PVV), except for the hepatic artery resistance index (HARI) which was somewhat higher in the EAD group on postoperative day 3 (POD3) (0.70 vs 0.61, P < .05). According to these results, we used a ROC curve and found that a HARI of 0.68 was the cutoff point (with 73.8% sensitivity and 58.3% specificity) for predicting EAD after LDLT. In addition, multivariate analysis showed that fulminant hepatic failure, pretransplant hepatorenal syndrome, and HARI ≥ 0.68 on POD3 were independent risk factors for postoperative EAD.Our results showed that postoperative hemodynamics might influence graft function by altering hepatic artery flow.
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42
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Glycocalyx Damage Within Human Liver Grafts Correlates With Graft Injury and Postoperative Graft Function After Orthotopic Liver Transplantation. Transplantation 2020; 104:72-78. [DOI: 10.1097/tp.0000000000002838] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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43
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Serum Factor V Is a Continuous Biomarker of Graft Dysfunction and a Predictor of Graft Loss After Liver Transplantation. Transplantation 2019; 103:944-951. [PMID: 30130328 DOI: 10.1097/tp.0000000000002429] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Factor V has never been compared to a validated early allograft dysfunction (EAD) definition. We aimed to assess factor V as a biomarker of EAD and a predictor of graft loss after liver transplantation (LT). METHODS We retrospectively assessed the serum factor V levels on postoperative day 1 after LT. Patients were divided according to their factor V levels into the ≤36.1 U/mL and > 36.1 U/mL groups. The primary outcome was graft loss within 1, 3, and 6 months. The secondary outcome was EAD, as defined by Olthoff et al. Predictors of outcomes were identified by multivariable logistic regression. RESULTS Two hundred twenty-seven patients were included in the study: 74 with factor V of 36.1 U/mL or less and 153 with factor V >36.1 U/mL. EAD was diagnosed in 41 (55.4%) of 74 patients with factor V of 36.1 U/mL or less and in 20/153 (13.1%) patients with factor V >36.1 U/mL (P < 0.001). According to the multivariable regression model, factor V was a continuous marker of EAD (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.94-0.98 per U/mL). Among the study groups, the 1-, 3-, and 6-month graft survival rates were 82%, 74%, and 74%, respectively, for patients with factor V of 36.1 U/mL or less and 98%, 95%, and 95%, respectively, for patients with factor V >36.1 U/mL (P = 0.001). Factor V was a continuous predictor for 3- and 6-month graft losses (OR, 0.96; 95% CI, 0.94-0.99 and OR, 0.97; 95% CI, 0.94-0.99 per U/mL), whereas EAD was not significant when adjusted for factor V. CONCLUSION Factor V is an early marker for EAD and is a continuous predictor of short-term graft loss after LT.
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44
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Ceresa CDL, Nasralla D, Watson CJE, Butler AJ, Coussios CC, Crick K, Hodson L, Imber C, Jassem W, Knight SR, Mergental H, Ploeg RJ, Pollok JM, Quaglia A, Shapiro AMJ, Weissenbacher A, Friend PJ. Transient Cold Storage Prior to Normothermic Liver Perfusion May Facilitate Adoption of a Novel Technology. Liver Transpl 2019; 25:1503-1513. [PMID: 31206217 DOI: 10.1002/lt.25584] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 05/16/2019] [Indexed: 12/12/2022]
Abstract
Clinical adoption of normothermic machine perfusion (NMP) may be facilitated by simplifying logistics and reducing costs. This can be achieved by cold storage of livers for transportation to recipient centers before commencing NMP. The purpose of this study was to assess the safety and feasibility of post-static cold storage normothermic machine perfusion (pSCS-NMP) in liver transplantation. In this multicenter prospective study, 31 livers were transplanted. The primary endpoint was 30-day graft survival. Secondary endpoints included the following: peak posttransplant aspartate aminotransferase (AST), early allograft dysfunction (EAD), postreperfusion syndrome (PRS), adverse events, critical care and hospital stay, biliary complications, and 12-month graft survival. The 30-day graft survival rate was 94%. Livers were preserved for a total of 14 hours 10 minutes ± 4 hours 46 minutes, which included 6 hours 1 minute ± 1 hour 19 minutes of static cold storage before 8 hours 24 minutes ± 4 hours 4 minutes of NMP. Median peak serum AST in the first 7 days postoperatively was 457 U/L (92-8669 U/L), and 4 (13%) patients developed EAD. PRS was observed in 3 (10%) livers. The median duration of initial critical care stay was 3 days (1-20 days), and median hospital stay was 13 days (7-31 days). There were 7 (23%) patients who developed complications of grade 3b severity or above, and 2 (6%) patients developed biliary complications: 1 bile leak and 1 anastomotic stricture with no cases of ischemic cholangiopathy. The 12-month overall graft survival rate (including death with a functioning graft) was 84%. In conclusion, this study demonstrates that pSCS-NMP was feasible and safe, which may facilitate clinical adoption.
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Affiliation(s)
- Carlo D L Ceresa
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - David Nasralla
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Christopher J E Watson
- Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Andrew J Butler
- Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Constantin C Coussios
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Keziah Crick
- Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Leanne Hodson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, United Kingdom
| | - Charles Imber
- Department of Hepatopancreatobiliary and Liver Transplant Surgery, Royal Free Hospital, London, United Kingdom
| | - Wayel Jassem
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Simon R Knight
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Hynek Mergental
- Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Rutger J Ploeg
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Joerg M Pollok
- Department of Hepatopancreatobiliary and Liver Transplant Surgery, Royal Free Hospital, London, United Kingdom
| | - Alberto Quaglia
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - A M James Shapiro
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Annemarie Weissenbacher
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Peter J Friend
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
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45
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Effect of the Selective NLRP3 Inflammasome Inhibitor mcc950 on Transplantation Outcome in a Pig Liver Transplantation Model With Organs From Donors After Circulatory Death Preserved by Hypothermic Machine Perfusion. Transplantation 2019; 103:353-362. [PMID: 30247318 DOI: 10.1097/tp.0000000000002461] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND We investigated whether the outcome of organs from donors after circulatory death (DCD) can be improved by the addition of mcc950 to the perfusate of the hypothermic machine perfusion (HMP) system and intravenous mcc950 injection after transplantation in a pig liver transplantation model. METHODS Thirty-six healthy Bama mini pigs randomized into 3 groups. All the DCD livers were preserved in an HMP system after 2 hours of simple cold storage. In HMP-Postop group, mcc950 was added to the perfusate; in the control group and Postop group, the perfusate was normal LPS. After transplantation, the pigs in the Postop group and HMP-Postop group were intravenously administered 3 mg/kg mcc950, at the time of reperfusion and on day 2 and day 3 after transplantation. During the 3-day follow-up period, general operative characteristics, and serological markers and histological features related to ischemia reperfusion injury were examined. RESULTS The HMP-Postop group suffer the lightest ischemia reperfusion injury (IRI), and functioned best after transplantation. Model for the Early Allograft Function Score (predictor of long-term survival), degree of injury in the hepatocytes and rate of apoptosis was lowest in the HMP-Postop group. Further, in the HMP-Postop group, the nucleotide-binding domain leucine-rich repeat containing family pyrin domain containing 3 inflammasome pathway activation was lowest, and the level of IL-1β was lowest. Postop group functioned better than control group, but not comparable with HMP-Postop group. CONCLUSIONS The outcome of DCD organs can be improved by the addition of mcc950 to the perfusate of the HMP system and intravenous injection of mcc950 after transplantation.
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46
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The Impact of Deceased Donor Liver Extraction Time on Early Allograft Function in Adult Liver Transplant Recipients. Transplantation 2018; 102:e466-e471. [DOI: 10.1097/tp.0000000000002380] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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47
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Abstract
Graft dysfunction of the liver allograft manifests across a spectrum in both timing posttransplantation and clinical presentation. This can range from mild transient abnormalities of liver tests to acute liver failure potentially leading to graft failure. The causes of graft dysfunction can be divided into those resulting in early and late graft dysfunction. Although nonspecific, liver biochemistry abnormalities are still the mainstay investigation used in monitoring for dysfunction. This article provides a summary of the main causes and management strategies for liver graft dysfunction in the early through late posttransplant stages.
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Affiliation(s)
- Beverley Kok
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, 1-40 Zeidler Ledcor Building, Edmonton, Alberta T6G-2X8, Canada
| | - Victor Dong
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, 1-40 Zeidler Ledcor Building, Edmonton, Alberta T6G-2X8, Canada
| | - Constantine J Karvellas
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, 1-40 Zeidler Ledcor Building, Edmonton, Alberta T6G-2X8, Canada.
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48
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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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Lindenmeyer CC, Kim A, Sanghi V, Lopez R, Niyazi F, Mehta NA, Flocco G, Kapoor A, Carey WD, Romero-Marrero C. The EMALT Score: An Improved Model for Prediction of Early Mortality in Liver Transplant Recipients. J Intensive Care Med 2018; 35:781-788. [PMID: 29996705 DOI: 10.1177/0885066618784869] [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: 12/28/2022]
Abstract
PURPOSE Needs, risks, and outcomes of patients admitted to a post liver transplant intensive care unit (POLTICU) differ in important ways from those admitted to pretransplant intensive care units (ICUs). The aim of this study was to create the optimal model to risk stratify POLTICU patients. METHODS Consecutive patients who underwent first deceased donor liver transplantation (LT) at a large United States center between 2008 and 2014 were followed from admission to LT and to discharge or death. Receiver-operating characteristic analysis was performed to assess the value of various scores in predicting in-hospital mortality. A predictive model was developed using logistic regression analysis. RESULTS A total of 697 patients underwent LT, and 3.2% died without leaving the hospital. A model for in-hospital mortality was derived from variables available within 24 hours of admission to the POLTICU. Key variables best predicting survival were white blood cell count, 24-hour urine output, and serum glucose. A model using these variables performed with an area under the curve (AUC) of 0.88, compared to the Acute Physiology and Chronic Health Evaluation III and Model for End-Stage Liver Disease, which performed with AUCs of 0.74 and 0.60, respectively. CONCLUSION An improved model, the early mortality after LT (EMALT) score, performs better than conventional models in predicting in-hospital mortality after LT.
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Affiliation(s)
| | - Ahyoung Kim
- Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Vedha Sanghi
- Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Rocio Lopez
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Fadi Niyazi
- Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Neal A Mehta
- Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Gianina Flocco
- Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Aanchal Kapoor
- Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - William D Carey
- Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
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