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Raja K, Panackel C. Post Liver Transplant Renal Dysfunction-Evaluation, Management and Immunosuppressive Practice. J Clin Exp Hepatol 2024; 14:101306. [PMID: 38274509 PMCID: PMC10806298 DOI: 10.1016/j.jceh.2023.101306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 11/21/2023] [Indexed: 01/27/2024] Open
Abstract
Liver transplantation (LT) is an effective and lifesaving treatment for patients with end-stage liver disease and hepatocellular carcinoma. Significant improvement in intermediate and long-term survival has been possible due to advancements in immunosuppressive therapy, perioperative care, and surgical techniques. Despite these advances, metabolic complications, including diabetes mellitus, cardiovascular diseases, malignancies, and renal dysfunction, are challenging issues after LT. Acute kidney injury (AKI) and chronic kidney disease (CKD) after LT are common and result in significant morbidity and mortality. Early diagnosis of kidney injury after LT is challenging, and no technique has yet proven effective in prediction of renal dysfunction. The methods for assessing renal function range from formulas that predict glomerular filtration rate to non-invasive biomarkers. The universal adoption of the model for end-stage liver disease has a direct impact on the incidence of peri-transplant AKI and development of CKD in the long-term. Post-LT renal dysfunction is multifactorial and is usually a result of pre-transplantation comorbidities, occurrence of renal dysfunction on the waiting list, perioperative events, and post-transplant nephrotoxic immunosuppressive medication use. Early identification of patients at risk for renal dysfunction and adoption of preventive measures are crucial in the pre-transplant period. No data are currently available to suggest a surgical technique that reliably demonstrates renal protection. Nephroprotective strategies during LT follow accepted surgical practice guidelines, such as maintenance of intravascular volume and mean arterial pressure. The management of kidney disease following LT is challenging, as by the time the serum creatinine is significantly elevated, few interventions impact the course of progression. Early nephroprotective measures are strongly advised and they mostly center on delaying the administration of calcineurin inhibitors (CNIs) during the initial postoperative period, lowering CNI dosage and combining CNI with mycophenolate mofetil and everolimus. The reasons for renal failure following LT, the techniques used to diagnose it, and the therapies designed to preserve renal function both immediately and late after LT are all critically evaluated in this review.
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Affiliation(s)
- Kaiser Raja
- Department of Gastroenterology and Hepatology, King's College Hospital London, Dubai, United Arab Emirates
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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: 0] [Impact Index Per Article: 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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Wu Z, Wang Y, He L, Jin B, Yao Q, Li G, Wang X, Ma Y. Development of a nomogram for the prediction of acute kidney injury after liver transplantation: a model based on clinical parameters and postoperative cystatin C level. Ann Med 2023; 55:2259410. [PMID: 37734410 PMCID: PMC10515689 DOI: 10.1080/07853890.2023.2259410] [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: 07/07/2023] [Accepted: 09/11/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is common after liver transplantation (LT). We developed a nomogram model to predict post-LT AKI. METHODS A total of 120 patients were eligible for inclusion in the study. Clinical information was extracted from the institutional electronic medical record system. Blood samples were collected prior to surgery and immediately after surgery. Univariable and multivariate logistic regression were used to identify independent risk factors. Finally, a nomogram was developed based on the final multivariable logistic regression model. RESULTS In total, 58 (48.3%) patients developed AKI. Multivariable logistic regression revealed four independent risk factors for post-LT AKI: operation duration [odds ratio (OR) = 1.728, 95% confidence interval (CI) = 1.121-2.663, p = 0.013], intraoperative hypotension (OR = 3.235, 95% CI = 1.316-7.952, p = 0.011), postoperative cystatin C level (OR = 1.002, 95% CI = 1.001-1.004, p = 0.005) and shock (OR = 4.002, 95% CI = 0.893-17.945, p = 0.070). Receiver operating characteristic curve analysis was used to evaluate model discrimination. The area under the curve value was 0.815 (95% CI = 0.737-0.894). CONCLUSION The model based on combinations of clinical parameters and postoperative cystatin C levels had a higher predictive performance for post-LT AKI than the model based on clinical parameters or postoperative cystatin C level alone. Additionally, we developed an easy-to-use nomogram based on the final model, which could aid in the early detection of AKI and improve the prognosis of patients after LT.
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Affiliation(s)
- Zhipeng Wu
- Department of Respiratory and Critical Care Medicine, Beijing Youan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yi Wang
- Department of Intensive Medicine, Beijing Youan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Li He
- Department of Intensive Medicine, Beijing Youan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Boxun Jin
- Department of Intensive Medicine, Beijing Youan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Qinwei Yao
- Department of Intensive Medicine, Beijing Youan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Guangming Li
- Department of General Surgery, Beijing Youan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xin Wang
- Department of Intensive Medicine, Beijing Youan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yingmin Ma
- Department of Respiratory and Critical Care Medicine, Beijing Youan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Beijing Institute of Hepatology, Beijing Youan Hospital, Capital Medical University, Beijing, People’s Republic of China
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Agrawal D, Saigal S. Early allograft dysfunction after living donor liver transplantation-current concepts and future directions. Liver Transpl 2023; 29:871-884. [PMID: 37162155 DOI: 10.1097/lvt.0000000000000173] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/03/2023] [Indexed: 05/11/2023]
Abstract
Early allograft dysfunction (EAD) after liver transplantation is a significant clinical problem that negatively impacts graft and patient outcomes. The rising incidence of EAD and what it means concerning living donor liver transplantation (LDLT) is an area of great interest. However, EAD after LDLT is a complex research topic yet to be reviewed comprehensively. Most of the literature on EAD is based on experience in deceased donor liver transplantation, and limited information is available in the context of LDLT. Thus, in this review, we present an overview of EAD after LDLT and have attempted to present balanced points of view on all its aspects, such as definitions, pathogenesis, risk factors, predictive markers, and management. The review aims to broadly overview the nature and extent of ongoing research evidence on this complex topic and inform practice in the field by identifying key concepts and knowledge gaps and highlighting areas that require further inquiry.
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Affiliation(s)
- Dhiraj Agrawal
- Department of Gastroenterology and Hepatology, PACE Hospitals, Hitec City, Hyderabad, India
| | - Sanjiv Saigal
- Hepatology and Liver Transplant, Centre for Liver & Biliary Sciences, Centre of Gastroenterology, Hepatology & Endoscopy, Max Super Speciality Hospital, Saket, New Delhi, India
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Thiessen C, Wisel SA, Roll GR. Simultaneous thoracic and abdominal donation after circulatory death organ recovery: the abdominal surgeon's perspective. Curr Opin Organ Transplant 2023; 28:139-144. [PMID: 36603197 PMCID: PMC9994842 DOI: 10.1097/mot.0000000000001045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF THE REVIEW To summarize the international experience with heart-liver (joint) donation after circulatory death (DCD) procurements and to explore the technical challenges in joint abdominal and thoracic DCD procurement. RECENT FINDINGS Following completion of the Donors After Circulatory Death Heart Trial in the US, combined thoracic and abdominal DCD is poised to become the standard of care, expanding access to life-saving heart and lung allografts. DCD heart procurement relies on collection of donor blood for priming of the normothermic perfusion pump, which delays cooling of abdominal organs and increases risk of ischemic injury. We review the effect of donor ischemia time on abdominal organs, with several proposed technical solutions to optimize transplant outcomes for all organs. SUMMARY The strategies reviewed in this manuscript may inform clinical decision-making, preoperative coordination between thoracic and abdominal procurement teams, and surgical technique for joint DCD procurements. Several approaches to organ procurement organization (OPO) and national policy, as well as future areas of focus for research are proposed.
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Affiliation(s)
- Carrie Thiessen
- Division of Transplantation, University of Wisconsin, Madison, Wisconsin
| | - Steven A. Wisel
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles
| | - Garrett R. Roll
- Division of Transplantation, University of California, San Francisco, San Francisco, California, USA
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Fundora Y, Hessheimer AJ, Del Prete L, Maroni L, Lanari J, Barrios O, Clarysse M, Gastaca M, Barrera Gómez M, Bonadona A, Janek J, Boscà A, Álamo Martínez JM, Zozaya G, López Garnica D, Magistri P, León F, Magini G, Patrono D, Ničovský J, Hakeem AR, Nadalin S, McCormack L, Palacios P, Zieniewicz K, Blanco G, Nuño J, Pérez Saborido B, Echeverri J, Bynon JS, Martins PN, López López V, Dayangac M, Lodge JPA, Romagnoli R, Toso C, Santoyo J, Di Benedetto F, Gómez-Gavara C, Rotellar F, Gómez-Bravo MÁ, López Andújar R, Girard E, Valdivieso A, Pirenne J, Lladó L, Germani G, Cescon M, Hashimoto K, Quintini C, Cillo U, Polak WG, Fondevila C. Alternative forms of portal vein revascularization in liver transplant recipients with complex portal vein thrombosis. J Hepatol 2023; 78:794-804. [PMID: 36690281 DOI: 10.1016/j.jhep.2023.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 12/22/2022] [Accepted: 01/12/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND & AIMS Complex portal vein thrombosis (PVT) is a challenge in liver transplantation (LT). Extra-anatomical approaches to portal revascularization, including renoportal (RPA), left gastric vein (LGA), pericholedochal vein (PCA), and cavoportal (CPA) anastomoses, have been described in case reports and series. The RP4LT Collaborative was created to record cases of alternative portal revascularization performed for complex PVT. METHODS An international, observational web registry was launched in 2020. Cases of complex PVT undergoing first LT performed with RPA, LGA, PCA, or CPA were recorded and updated through 12/2021. RESULTS A total of 140 cases were available for analysis: 74 RPA, 18 LGA, 20 PCA, and 28 CPA. Transplants were primarily performed with whole livers (98%) in recipients with median (IQR) age 58 (49-63) years, model for end-stage liver disease score 17 (14-24), and cold ischemia 431 (360-505) minutes. Post-operatively, 49% of recipients developed acute kidney injury, 16% diuretic-responsive ascites, 9% refractory ascites (29% with CPA, p <0.001), and 10% variceal hemorrhage (25% with CPA, p = 0.002). After a median follow-up of 22 (4-67) months, patient and graft 1-/3-/5-year survival rates were 71/67/61% and 69/63/57%, respectively. On multivariate Cox proportional hazards analysis, the only factor significantly and independently associated with all-cause graft loss was non-physiological portal vein reconstruction in which all graft portal inflow arose from recipient systemic circulation (hazard ratio 6.639, 95% CI 2.159-20.422, p = 0.001). CONCLUSIONS Alternative forms of portal vein anastomosis achieving physiological portal inflow (i.e., at least some recipient splanchnic blood flow reaching transplant graft) offer acceptable post-transplant results in LT candidates with complex PVT. On the contrary, non-physiological portal vein anastomoses fail to resolve portal hypertension and should not be performed. IMPACT AND IMPLICATIONS Complex portal vein thrombosis (PVT) is a challenge in liver transplantation. Results of this international, multicenter analysis may be used to guide clinical decisions in transplant candidates with complex PVT. Extra-anatomical portal vein anastomoses that allow for at least some recipient splanchnic blood flow to the transplant allograft offer acceptable results. On the other hand, anastomoses that deliver only systemic blood flow to the allograft fail to resolve portal hypertension and should not be performed.
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Affiliation(s)
- Yiliam Fundora
- General & Digestive Surgery Service, Hospital Clínic, Barcelona, Spain
| | - Amelia J Hessheimer
- General & Digestive Surgery Service, Hospital Clínic, Barcelona, Spain; General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Luca Del Prete
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lorenzo Maroni
- Hepatobiliary Surgery & Transplant Unit, Policlinico Sant'Orsola IRCCS, University of Bologna, Italy
| | - Jacopo Lanari
- Department of Surgery, Oncology, & Gastroenterology, Hepatobiliary & Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Oriana Barrios
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, Hospital Universitari de Bellvitge, Barcelona, Spain
| | | | - Mikel Gastaca
- Hepatobiliary Surgery & Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Bilbao, Spain
| | - Manuel Barrera Gómez
- Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Agnès Bonadona
- Grenoble Alpes University, CHU Grenoble Alpes, Digestive Surgery & Liver Transplantation, Grenoble, France
| | - Julius Janek
- Department of Transplant Surgery, F.D. Roosevelt Hospital, Banská Bystrica, Slovakia
| | - Andrea Boscà
- Liver Transplantation & Hepatology Laboratory, Hepatology, HPB Surgery & Transplant Unit, Health Research Institute Hospital La Fe, La Fe University Hospital, Valencia, Spain
| | | | - Gabriel Zozaya
- HPB and Liver Transplant Unit, Clínica Universidad de Navarra; Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | | | - Paolo Magistri
- Hepato-pancreato-biliary Surgery & Liver Transplantation Unit, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Francisco León
- Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Giulia Magini
- Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Damiano Patrono
- General Surgery 2U - Liver Transplant Centre, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Jiří Ničovský
- Centrum Kardiovaskulární a Transplantační Chirurgie, Brno, Czechia
| | - Abdul Rahman Hakeem
- Department of HPB and Liver Transplant Surgery, St. James's University Hospital, Leeds, UK
| | - Silvio Nadalin
- University of Tübingen, Tübingen, Germany; European Liver and Intestine Transplant Association (ELITA) Board
| | | | - Pilar Palacios
- Hospital Clínico Universitario de Zaragoza, Zaragoza, Spain
| | - Krzysztof Zieniewicz
- Medical University of Warsaw, Warsaw, Poland; European Liver and Intestine Transplant Association (ELITA) Board
| | - Gerardo Blanco
- Hospital Universitario de Badajoz, Universidad de Extremadura, Badajoz, Spain
| | - Javier Nuño
- Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Baltasar Pérez Saborido
- Hepatobiliopancreatic Surgery & Liver Transplant Unit, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Juan Echeverri
- Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - J Steve Bynon
- University of Texas Houston - Memorial Hermann TMC, Houston, Texas, USA
| | - Paulo N Martins
- University of Massachusetts - Memorial Medical Center, Worcester, Massachusetts, USA
| | - Víctor López López
- Department of Surgery & Transplantation, Hospital Clínico Universitario Virgen de la Arrixaca, Murcian Institue of Biosanitary Research (IMIB), Murcia, Spain
| | - Murat Dayangac
- Medipol University Hospital Center for Organ Transplantation, Istanbul, Turkey
| | - J Peter A Lodge
- Department of HPB and Liver Transplant Surgery, St. James's University Hospital, Leeds, UK
| | - Renato Romagnoli
- General Surgery 2U - Liver Transplant Centre, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Christian Toso
- Hôpitaux Universitaires de Genève, Geneva, Switzerland; European Liver and Intestine Transplant Association (ELITA) Board
| | - Julio Santoyo
- Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Fabrizio Di Benedetto
- Hepato-pancreato-biliary Surgery & Liver Transplantation Unit, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | | | - Fernando Rotellar
- HPB and Liver Transplant Unit, Clínica Universidad de Navarra; Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | | | - Rafael López Andújar
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain; Liver Transplantation & Hepatology Laboratory, Hepatology, HPB Surgery & Transplant Unit, Health Research Institute Hospital La Fe, La Fe University Hospital, Valencia, Spain
| | - Edouard Girard
- Grenoble Alpes University, CHU Grenoble Alpes, Digestive Surgery & Liver Transplantation, Grenoble, France
| | - Andrés Valdivieso
- Hepatobiliary Surgery & Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Bilbao, Spain
| | - Jacques Pirenne
- Abdominal Transplant Surgery, UZ Leuven, KUL, Leuven, Belgium
| | - Laura Lladó
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Giacomo Germani
- Department of Surgery, Oncology, & Gastroenterology, Hepatobiliary & Liver Transplantation Unit, Padua University Hospital, Padua, Italy; European Liver and Intestine Transplant Association (ELITA) Board
| | - Matteo Cescon
- Hepatobiliary Surgery & Transplant Unit, Policlinico Sant'Orsola IRCCS, University of Bologna, Italy
| | - Koji Hashimoto
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Cristiano Quintini
- Transplantation Center, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Umberto Cillo
- Department of Surgery, Oncology, & Gastroenterology, Hepatobiliary & Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Wojciech G Polak
- Division of HPB & Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands; European Liver and Intestine Transplant Association (ELITA) Board
| | - Constantino Fondevila
- General & Digestive Surgery Service, Hospital Clínic, Barcelona, Spain; General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, Spain; European Liver and Intestine Transplant Association (ELITA) Board.
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Schurink IJ, van de Leemkolk FEM, Fondevila C, De Carlis R, Savier E, Oniscu GC, Huurman VAL, de Jonge J. Donor eligibility criteria and liver graft acceptance criteria during normothermic regional perfusion: A systematic review. Liver Transpl 2022; 28:1563-1575. [PMID: 35603445 PMCID: PMC9796375 DOI: 10.1002/lt.26512] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 04/23/2022] [Accepted: 05/12/2022] [Indexed: 01/01/2023]
Abstract
Acceptance of liver grafts from donations after circulatory death (DCD) largely remains a "black box," particularly due to the unpredictability of the agonal phase. Abdominal normothermic regional perfusion (aNRP) can reverse ischemic injury early during the procurement procedure, and it simultaneously enables graft viability testing to unravel this black box. This review evaluates current protocols for liver viability assessment to decide upon acceptance or decline during aNRP. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was used, and relevant literature databases were searched. The primary outcome consisted of criteria for liver graft viability assessment. Secondary outcomes included survival, primary nonfunction (PNF), early dysfunction, and biliary complications. A total of 14 articles were included in the analysis. In all protocols, a combination of criteria was used to assess suitability of the liver for transplantation. As many as 12 studies (86%) used macroscopic assessment, 12 studies (86%) used alanine transaminase (ALT) levels in perfusate, 9 studies (64%) used microscopic assessment, and 7 studies (50%) used lactate levels as assessment criteria. The organ utilization rate (OUR) was 16% for uncontrolled donation after circulatory death (uDCD) and 64% for controlled donation after circulatory death (cDCD). The most used acceptation criterion in uDCD is ALT level (31%), while in cDCD macroscopic aspect (48%) is most used. Regarding postoperative complications, PNF occurred in 13% (6%-25%) of uDCD livers and 3% (2%-4%) of cDCD livers. In uDCD, the 1-year graft and patient survival rates were 75% (66%-82%) and 82% (75%-88%). In cDCD, the 1-year graft and patient survival rates were 91% (89%-93%) and 93% (91%-94%), respectively. In conclusion, the currently used assessment criteria consist of macroscopic aspect and transaminase levels. The acceptance criteria should be tailored according to donor type to prevent an unacceptable PNF rate in uDCD and to increase the relatively modest OUR in cDCD.
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Affiliation(s)
- Ivo J. Schurink
- Department of SurgeryErasmus MC Transplant InstituteRotterdamThe Netherlands
| | | | | | - Riccardo De Carlis
- Department of Surgery and TransplantationASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | - Eric Savier
- Department of Hepato‐Biliary and Pancreatic Surgery and Liver TransplantationPitie‐Salpetriere Hospital, Assistance Publique‐Hôpitaux de Paris (AP‐HP), Sorbonne UniversityParisFrance
| | | | - Volkert A. L. Huurman
- Department of Surgery, Transplant CenterLeiden University Medical CenterLeidenThe Netherlands
| | - Jeroen de Jonge
- Department of SurgeryErasmus MC Transplant InstituteRotterdamThe Netherlands
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Parente A, Flores Carvalho M, Eden J, Dutkowski P, Schlegel A. Mitochondria and Cancer Recurrence after Liver Transplantation—What Is the Benefit of Machine Perfusion? Int J Mol Sci 2022; 23:ijms23179747. [PMID: 36077144 PMCID: PMC9456431 DOI: 10.3390/ijms23179747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 11/16/2022] Open
Abstract
Tumor recurrence after liver transplantation has been linked to multiple factors, including the recipient’s tumor burden, donor factors, and ischemia-reperfusion injury (IRI). The increasing number of livers accepted from extended criteria donors has forced the transplant community to push the development of dynamic perfusion strategies. The reason behind this progress is the urgent need to reduce the clinical consequences of IRI. Two concepts appear most beneficial and include either the avoidance of ischemia, e.g., the replacement of cold storage by machine perfusion, or secondly, an endischemic organ improvement through perfusion in the recipient center prior to implantation. While several concepts, including normothermic perfusion, were found to reduce recipient transaminase levels and early allograft dysfunction, hypothermic oxygenated perfusion also reduced IRI-associated post-transplant complications and costs. With the impact on mitochondrial injury and subsequent less IRI-inflammation, this endischemic perfusion was also found to reduce the recurrence of hepatocellular carcinoma after liver transplantation. Firstly, this article highlights the contributing factors to tumor recurrence, including the surgical and medical tissue trauma and underlying mechanisms of IRI-associated inflammation. Secondly, it focuses on the role of mitochondria and associated interventions to reduce cancer recurrence. Finally, the role of machine perfusion technology as a delivery tool and as an individual treatment is discussed together with the currently available clinical studies.
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Affiliation(s)
- Alessandro Parente
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham B15 2GW, UK
| | - Mauricio Flores Carvalho
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Centre of Preclinical Research, 20122 Milan, Italy
| | - Janina Eden
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Andrea Schlegel
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Centre of Preclinical Research, 20122 Milan, Italy
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, 8091 Zurich, Switzerland
- Correspondence:
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9
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Liver perfusion strategies: what is best and do ischemia times still matter? Curr Opin Organ Transplant 2022; 27:285-299. [PMID: 35438271 DOI: 10.1097/mot.0000000000000963] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW This review describes recent developments in the field of liver perfusion techniques. RECENT FINDINGS Dynamic preservation techniques are increasingly tested due to the urgent need to improve the overall poor donor utilization. With their exposure to warm ischemia, livers from donors after circulatory death (DCD) transmit additional risk for severe complications after transplantation. Although the superiority of dynamic approaches compared to static-cold-storage is widely accepted, the number of good quality studies remains limited. Most risk factors, particularly donor warm ischemia, and accepted thresholds are inconsistently reported, leading to difficulties to assess the impact of new preservation technologies. Normothermic regional perfusion (NRP) leads to good outcomes after DCD liver transplantation, with however short ischemia times. While randomized controlled trials (RCT) with NRP are lacking, results from the first RCTs with ex-situ perfusion were reported. Hypothermic oxygenated perfusion was shown to protect DCD liver recipients from ischemic cholangiopathy. In contrast, endischemic normothermic perfusion seems to not impact on the development of biliary complications, although this evidence is only available from retrospective studies. SUMMARY Dynamic perfusion strategies impact posttransplant outcomes and are increasingly commissioned in various countries along with more evidence from RCTs. Transparent reporting of risk and utilization with uniform definitions is required to compare the role of different preservation strategies in DCD livers with prolonged ischemia times.
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10
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Patrono D, Zanierato M, Vergano M, Magaton C, Diale E, Rizza G, Catalano S, Mirabella S, Cocchis D, Potenza R, Livigni S, Balagna R, Romagnoli R. Normothermic Regional Perfusion and Hypothermic Oxygenated Machine Perfusion for Livers Donated After Controlled Circulatory Death With Prolonged Warm Ischemia Time: A Matched Comparison With Livers From Brain-Dead Donors. Transpl Int 2022; 35:10390. [PMID: 35529593 PMCID: PMC9072630 DOI: 10.3389/ti.2022.10390] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/31/2022] [Indexed: 12/29/2022]
Abstract
Prolonged warm ischemia time (WIT) has a negative prognostic value in liver transplantation (LT) using grafts procured after circulatory death (DCD). To assess the value of abdominal normothermic regional perfusion (A-NRP) associated with dual hypothermic oxygenated machine perfusion (D-HOPE) in controlled DCD LT, prospectively collected data on LTs performed between January 2016 and July 2021 were analyzed. Outcome of controlled DCD LTs performed using A-NRP + D-HOPE (n = 20) were compared to those performed with grafts procured after brain death (DBD) (n = 40), selected using propensity-score matching. DCD utilization rate was 59.5%. In the DCD group, median functional WIT, A-NRP and D-HOPE time was 43, 246, and 205 min, respectively. Early outcomes of DCD grafts recipients were comparable to those of matched DBD LTs. In DCD and DBD group, incidence of anastomotic biliary complications and ischemic cholangiopathy was 15% versus 22% (p = 0.73) and 5% versus 2% (p = 1), respectively. One-year patient and graft survival was 100% versus 95% (p = 0.18) and 90% versus 95% (p = 0.82). In conclusion, the association of A-NRP + D-HOPE in DCD LT with prolonged WIT allows achieving comparable outcomes to DBD LT.
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Affiliation(s)
- Damiano Patrono
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Marinella Zanierato
- Department of Anesthesia and Critical Care, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Marco Vergano
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Turin, Italy
| | - Chiara Magaton
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Enrico Diale
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Giorgia Rizza
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Silvia Catalano
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Stefano Mirabella
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Donatella Cocchis
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Raffaele Potenza
- Regional Procurement Organization, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Sergio Livigni
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Turin, Italy
| | - Roberto Balagna
- Anesthesia Department 2, A.O.U. Città Della Salute e Della Scienza di Torino, Turin, Italy
| | - Renato Romagnoli
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
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11
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Abstract
Severe allograft dysfunction, as opposed to the expected immediate function, following liver transplantation is a major complication, and the clinical manifestations of such that lead to either immediate retransplant or death are the catastrophic end of the spectrum. Primary nonfunction (PNF) has declined in incidence over the years, yet the impact on patient and healthcare teams, and the burden on the organ pool in case of the need for retransplant should not be underestimated. There is no universal test to define the diagnosis of PNF, and current criteria are based on various biochemical parameters surrogate of liver function; moreover, a disparity remains within different healthcare systems on selecting candidates eligible for urgent retransplantation. The impact on PNF from traditionally accepted risk factors has changed somewhat, mainly driven by the rising demand for organs, combined with the concerted approach by clinicians on the in-depth understanding of PNF, optimal graft recipient selection, mitigation of the clinical environment in which a marginal graft is reperfused, and postoperative management. Regardless of the mode, available data suggest machine perfusion strategies help reduce the incidence further but do not completely avert the risk of PNF. The mainstay of management relies on identifying severe allograft dysfunction at a very early stage and aggressive management, while excluding other identifiable causes that mimic severe organ dysfunction. This approach may help salvage some grafts by preventing total graft failure and also maintaining a patient in an optimal physiological state if retransplantation is considered the ultimate patient salvage strategy.
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Affiliation(s)
- Hermien Hartog
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
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12
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Savier E, De Rycke Y, Lim C, Goumard C, Rousseau G, Perdigao F, Rufat P, Salloum C, Llado L, Ramos E, Lopez‐Dominguez J, Cachero A, Fabregat J, Azoulay D, Scatton O. Novel Composite Endpoint for Assessing Outcomes in Liver Transplantation: Arterial and Biliary Complication-Free Survival. Liver Transpl 2022; 28:75-87. [PMID: 34403191 PMCID: PMC9293155 DOI: 10.1002/lt.26269] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 07/02/2021] [Accepted: 07/19/2021] [Indexed: 01/13/2023]
Abstract
Transplant and patient survival are the validated endpoints to assess the success of liver transplantation (LT). This study evaluates arterial and biliary complication-free survival (ABCFS) as a new metric. ABC, considered as an event, was an arterial or biliary complication of Dindo-Clavien grade ≥III complication dated at the interventional, endoscopic, or surgical treatment required to correct it. ABCFS was defined as the time from the date of LT to the dates of first ABC, death, relisting, or last follow-up (transplant survival is time from LT to repeat LT or death). Following primary whole LT (n = 532), 106 ABCs occurred and 99 (93%) occurred during the first year after LT. An ABC occurring during the first year after LT (overall rate 19%) was an independent factor associated with transplant survival (hazard ratio [HR], 3.17; P < 0.001) and patient survival (HR, 2.7; P = 0.002) in univariate and multivariate analyses. This result was confirmed after extension of the cohort to split-liver graft, donation after circulatory death, or re-LT (n = 658). Data from 2 external cohorts of primary whole LTs (n = 249 and 229, respectively) confirmed that the first-year ABC was an independent prognostic factor for transplant survival but not for patient survival. ABCFS was correlated with transplant and patient survival (ρ = 0.85 [95% CI, 0.78-0.90] and 0.81 [95% CI, 0.71-0.88], respectively). Preoperative factors known to influence 5-year transplant survival influenced ABCFS after 1 year of follow-up. The 1-year ABCFS was indicative of 5-year transplant survival. ABCFS is a reproducible metric to evaluate the results of LT after 1 year of follow-up and could serve as a new endpoint in clinical trials.
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Affiliation(s)
- Eric Savier
- Service de Chirurgie DigestiveHépato‐Bilio‐PancréatiqueTransplantation HépatiqueCentre Hospitalo‐Universitaire Pitié‐SalpêtriereAssistance Publique‐Hôpitaux de ParisSorbonne UniversitéParisFrance,Centre de Recherche Saint‐AntoineUnité Mixte de Recherche Scientifique‐938Institute of Cardiometabolism and NutritionSorbonne UniversitéInstitut National de la Santé et de la Recherche MédicaleParisFrance
| | - Yann De Rycke
- Institut Pierre Louis d’Epidémiologie et de Santé PubliqueSorbonne UniversitéInstitut National de la Santé et de la Recherche MédicaleParisFrance,Département de Santé PubliqueAssistance Publique‐Hôpitaux de ParisHôpital Pitié SalpêtrièreSorbonne UniversitéParisFrance,Centre de Pharmacoépidémiologie (Cephepi)CHU Pitié‐Salpêtrièrere, Assistance Publique‐Hôpitaux de Paris (APHP), Sorbonne UniversitéParisFrance
| | - Chetana Lim
- Service de Chirurgie DigestiveHépato‐Bilio‐PancréatiqueTransplantation HépatiqueCentre Hospitalo‐Universitaire Pitié‐SalpêtriereAssistance Publique‐Hôpitaux de ParisSorbonne UniversitéParisFrance
| | - Claire Goumard
- Service de Chirurgie DigestiveHépato‐Bilio‐PancréatiqueTransplantation HépatiqueCentre Hospitalo‐Universitaire Pitié‐SalpêtriereAssistance Publique‐Hôpitaux de ParisSorbonne UniversitéParisFrance,Centre de Recherche Saint‐AntoineUnité Mixte de Recherche Scientifique‐938Institute of Cardiometabolism and NutritionSorbonne UniversitéInstitut National de la Santé et de la Recherche MédicaleParisFrance
| | - Geraldine Rousseau
- Service de Chirurgie DigestiveHépato‐Bilio‐PancréatiqueTransplantation HépatiqueCentre Hospitalo‐Universitaire Pitié‐SalpêtriereAssistance Publique‐Hôpitaux de ParisSorbonne UniversitéParisFrance
| | - Fabiano Perdigao
- Service de Chirurgie DigestiveHépato‐Bilio‐PancréatiqueTransplantation HépatiqueCentre Hospitalo‐Universitaire Pitié‐SalpêtriereAssistance Publique‐Hôpitaux de ParisSorbonne UniversitéParisFrance
| | - Pierre Rufat
- Département d'Informatique MédicaleAssistance Publique‐Hôpitaux de ParisHôpitaux Universitaires Pitié Salpêtrière–Charles FoixSorbonne UniversitéParisFrance
| | - Chady Salloum
- Centre Hépato‐BiliaireAssistance Publique‐Hôpitaux de Paris Hôpital Paul BrousseVillejuifFrance
| | - Laura Llado
- Department of Hepato‐Biliary and Pancreatic Surgery and Liver TransplantationHospital Universitari de BellvitgeInstitut d'Investigacio Biomedica de BellvitgeBarcelonaSpain
| | - Emilio Ramos
- Department of Hepato‐Biliary and Pancreatic Surgery and Liver TransplantationHospital Universitari de BellvitgeInstitut d'Investigacio Biomedica de BellvitgeBarcelonaSpain
| | - Josefina Lopez‐Dominguez
- Department of Hepato‐Biliary and Pancreatic Surgery and Liver TransplantationHospital Universitari de BellvitgeInstitut d'Investigacio Biomedica de BellvitgeBarcelonaSpain
| | - Alba Cachero
- Department of Hepato‐Biliary and Pancreatic Surgery and Liver TransplantationHospital Universitari de BellvitgeInstitut d'Investigacio Biomedica de BellvitgeBarcelonaSpain
| | - Joan Fabregat
- Department of Hepato‐Biliary and Pancreatic Surgery and Liver TransplantationHospital Universitari de BellvitgeInstitut d'Investigacio Biomedica de BellvitgeBarcelonaSpain
| | - Daniel Azoulay
- Centre Hépato‐BiliaireAssistance Publique‐Hôpitaux de Paris Hôpital Paul BrousseVillejuifFrance
| | - Olivier Scatton
- Service de Chirurgie DigestiveHépato‐Bilio‐PancréatiqueTransplantation HépatiqueCentre Hospitalo‐Universitaire Pitié‐SalpêtriereAssistance Publique‐Hôpitaux de ParisSorbonne UniversitéParisFrance,Centre de Recherche Saint‐AntoineUnité Mixte de Recherche Scientifique‐938Institute of Cardiometabolism and NutritionSorbonne UniversitéInstitut National de la Santé et de la Recherche MédicaleParisFrance
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13
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Guo D, Wang H, Lai X, Li J, Xie D, Zhen L, Jiang C, Li M, Liu X. Development and validation of a nomogram for predicting acute kidney injury after orthotopic liver transplantation. Ren Fail 2021; 43:1588-1600. [PMID: 34865599 PMCID: PMC8648040 DOI: 10.1080/0886022x.2021.2009863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND We aim to develop and validate a nomogram model for predicting severe acute kidney injury (AKI) after orthotopic liver transplantation (OLT). METHODS A total of 576 patients who received OLT in our center were enrolled. They were assigned to the development and validation cohort according to the time of inclusion. Univariable and multivariable logistic regression using the forward variable selection routine were applied to find risk factors for post-OLT severe AKI. Based on the results of multivariable analysis, a nomogram was developed and validated. Patients were followed up to assess the long-term mortality and development of chronic kidney disease (CKD). RESULTS Overall, 35.9% of patients were diagnosed with severe AKI. Multivariable logistic regression analysis revealed that recipients' BMI (OR 1.10, 95% CI 1.04-1.17, p = 0.012), hypertension (OR 2.32, 95% CI 1.22-4.45, p = 0.010), preoperative serum creatine (sCr) (OR 0.96, 95% CI 0.95-0.97, p < 0.001), and intraoperative fresh frozen plasm (FFP) transfusion (OR for each 1000 ml increase 1.34, 95% CI 1.03-1.75, p = 0.031) were independent risk factors for post-OLT severe AKI. They were all incorporated into the nomogram. The area under the ROC curve (AUC) was 0.73 (p < 0.05) and 0.81 (p < 0.05) in the development and validation cohort. The calibration curve demonstrated the predicted probabilities of severe AKI agreed with the observed probabilities (p > 0.05). Kaplan-Meier survival analysis showed that patients in the high-risk group stratified by the nomogram suffered significantly poorer long-term survival than the low-risk group (HR 1.92, p < 0.01). The cumulative risk of CKD was higher in the severe AKI group than no severe AKI group after competitive risk analysis (HR 1.48, p < 0.05). CONCLUSIONS With excellent predictive abilities, the nomogram may be a simple and reliable tool to identify patients at high risk for severe AKI and poor long-term prognosis after OLT.
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Affiliation(s)
- Dandan Guo
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Huifang Wang
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiaoying Lai
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Junying Li
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Demin Xie
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Li Zhen
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Chunhui Jiang
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Min Li
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xuemei Liu
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
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14
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De Carlis R, Schlegel A, Frassoni S, Olivieri T, Ravaioli M, Camagni S, Patrono D, Bassi D, Pagano D, Di Sandro S, Lauterio A, Bagnardi V, Gruttadauria S, Cillo U, Romagnoli R, Colledan M, Cescon M, Di Benedetto F, Muiesan P, De Carlis L. How to Preserve Liver Grafts From Circulatory Death With Long Warm Ischemia? A Retrospective Italian Cohort Study With Normothermic Regional Perfusion and Hypothermic Oxygenated Perfusion. Transplantation 2021; 105:2385-2396. [PMID: 33617211 DOI: 10.1097/tp.0000000000003595] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Donation after circulatory death (DCD) in Italy, given its 20-min stand-off period, provides a unique bench test for normothermic regional perfusion (NRP) and dual hypothermic oxygenated machine perfusion (D-HOPE). METHODS We coordinated a multicenter retrospective Italian cohort study with 44 controlled DCD donors, who underwent NRP, to present transplant characteristics and results. To rank our results according to the high donor risk, we matched and compared a subgroup of 37 controlled DCD livers, preserved with NRP and D-HOPE, with static-preserved controlled DCD transplants from an established European program. RESULTS In the Italian cohort, D-HOPE was used in 84% of cases, and the primary nonfunction rate was 5%. Compared with the matched comparator group, the NRP + D-HOPE group showed a lower incidence of moderate and severe acute kidney injury (stage 2: 8% versus 27% and stage 3: 3% versus 27%; P = 0.001). Ischemic cholangiopathy remained low (2-y proportion free: 97% versus 92%; P = 0.317), despite the high-risk profile resulting from the longer donor warm ischemia in Italy (40 versus 18 min; P < 0.001). CONCLUSIONS These data suggest that NRP and D-HOPE yield good results in DCD livers with prolonged warm ischemia.
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Affiliation(s)
- Riccardo De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Andrea Schlegel
- Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Tiziana Olivieri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Matteo Ravaioli
- UO Chirurgia Generale e dei Trapianti, AOU Sant'Orsola-Malpighi, Alma Mater Studiorum Università di Bologna, Bologna, Italy
| | - Stefania Camagni
- Division of Liver Transplantation, AO Papa Giovanni XXIII, Bergamo, Italy
| | - Damiano Patrono
- General Surgery 2U, Liver Transplant Center, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Domenico Bassi
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplant Unit, Padua University, Padua, Italy
| | - Duilio Pagano
- Abdominal Surgery and Organ Transplantation Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Lauterio
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Salvatore Gruttadauria
- Abdominal Surgery and Organ Transplantation Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Umberto Cillo
- Department of Surgery, Oncology and Gastroenterology, Hepatobiliary Surgery and Liver Transplant Unit, Padua University, Padua, Italy
| | - Renato Romagnoli
- General Surgery 2U, Liver Transplant Center, AOU Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Michele Colledan
- Division of Liver Transplantation, AO Papa Giovanni XXIII, Bergamo, Italy
| | - Matteo Cescon
- UO Chirurgia Generale e dei Trapianti, AOU Sant'Orsola-Malpighi, Alma Mater Studiorum Università di Bologna, Bologna, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Paolo Muiesan
- Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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15
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Lonati C, Schlegel A, Battistin M, Merighi R, Carbonaro M, Dongiovanni P, Leonardi P, Zanella A, Dondossola D. Effluent Molecular Analysis Guides Liver Graft Allocation to Clinical Hypothermic Oxygenated Machine Perfusion. Biomedicines 2021; 9:biomedicines9101444. [PMID: 34680561 PMCID: PMC8533371 DOI: 10.3390/biomedicines9101444] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/30/2021] [Accepted: 10/05/2021] [Indexed: 01/14/2023] Open
Abstract
Hypothermic-oxygenated-machine-perfusion (HOPE) allows assessment/reconditioning of livers procured from high-risk donors before transplantation. Graft referral to HOPE mostly depends on surgeons' subjective judgment, as objective criteria are still insufficient. We investigated whether analysis of effluent fluids collected upon organ flush during static-cold-storage can improve selection criteria for HOPE utilization. Effluents were analyzed to determine cytolysis enzymes, metabolites, inflammation-related mediators, and damage-associated-molecular-patterns. Molecular profiles were assessed by unsupervised cluster analysis. Differences between "machine perfusion (MP)-yes" vs. "MP-no"; "brain-death (DBD) vs. donation-after-circulatory-death (DCD)"; "early-allograft-dysfunction (EAD)-yes" vs. "EAD-no" groups, as well as correlation between effluent variables and transplantation outcome, were investigated. Livers assigned to HOPE (n = 18) showed a different molecular profile relative to grafts transplanted without this procedure (n = 21, p = 0.021). Increases in the inflammatory mediators PTX3 (p = 0.048), CXCL8/IL-8 (p = 0.017), TNF-α (p = 0.038), and ANGPTL4 (p = 0.010) were observed, whereas the anti-inflammatory cytokine IL-10 was reduced (p = 0.007). Peculiar inflammation, cell death, and coagulation signatures were observed in fluids collected from DCD livers compared to those from DBD grafts. AST (p = 0.034), ALT (p = 0.047), and LDH (p = 0.047) were higher in the "EAD-yes" compared to the "EAD-no" group. Cytolysis markers and hyaluronan correlated with recipient creatinine, AST, and ICU stay. The study demonstrates that effluent molecular analysis can provide directions about the use of HOPE.
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Affiliation(s)
- Caterina Lonati
- Center for Preclinical Research, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (M.B.); (R.M.); (D.D.)
- Correspondence: ; Tel.: +39-0255033318
| | - Andrea Schlegel
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, 50139 Florence, Italy;
- Swiss HPB and Transplant Center, Department of Visceral Surgery and Transplantation, University Hospital Zurich, 8000 Zurich, Switzerland
| | - Michele Battistin
- Center for Preclinical Research, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (M.B.); (R.M.); (D.D.)
| | - Riccardo Merighi
- Center for Preclinical Research, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (M.B.); (R.M.); (D.D.)
| | - Margherita Carbonaro
- General and Liver Transplant Sugery Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Paola Dongiovanni
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122 Milan, Italy;
| | - Patrizia Leonardi
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (P.L.); (A.Z.)
| | - Alberto Zanella
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (P.L.); (A.Z.)
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Daniele Dondossola
- Center for Preclinical Research, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (M.B.); (R.M.); (D.D.)
- General and Liver Transplant Sugery Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (P.L.); (A.Z.)
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16
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van Reeven M, Gilbo N, Monbaliu D, van Leeuwen OB, Porte RJ, Ysebaert D, van Hoek B, Alwayn IPJ, Meurisse N, Detry O, Coubeau L, Cicarelli O, Berrevoet F, Vanlander A, IJzermans JNM, Polak WG. Evaluation of Liver Graft Donation After Euthanasia. JAMA Surg 2021; 155:917-924. [PMID: 32777007 DOI: 10.1001/jamasurg.2020.2479] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance The option of donating organs after euthanasia is not well known. Assessment of the results of organ transplants with grafts donated after euthanasia is essential to justify the use of this type of organ donation. Objectives To assess the outcomes of liver transplants (LTs) with grafts donated after euthanasia (donation after circulatory death type V [DCD-V]), and to compare them with the results of the more commonly performed LTs with grafts from donors with a circulatory arrest after the withdrawal of life-supporting treatment (type III [DCD-III]). Design, Setting, and Participants This retrospective multicenter cohort study analyzed medical records and LT data for most transplant centers in the Netherlands and Belgium. All LTs with DCD-V grafts performed from the start of the donation after euthanasia program (September 2012 for the Netherlands, and January 2005 for Belgium) through July 1, 2018, were included in the analysis. A comparative cohort of patients who received DCD-III grafts was also analyzed. All patients in both cohorts were followed up for at least 1 year. Data analysis was performed from September 2019 to December 2019. Exposures Liver transplant with either a DCD-V graft or DCD-III graft. Main Outcomes and Measures Primary outcomes were recipient and graft survival rates at years 1, 3, and 5 after the LT. Secondary outcomes included postoperative complications (early allograft dysfunction, hepatic artery thrombosis, and nonanastomotic biliary strictures) within the first year after the LT. Results Among the cohort of 47 LTs with DCD-V grafts, 25 organ donors (53%) were women and the median (interquartile range [IQR]) age was 51 (44-59) years. Among the cohort of 542 LTs with DCD-III grafts, 335 organ donors (62%) were men and the median (IQR) age was 49 (37-57) years. Median (IQR) follow-up was 3.8 (2.1-6.3) years. In the DCD-V cohort, 30 recipients (64%) were men, and the median (IQR) age was 56 (48-64) years. Recipient survival in the DCD-V cohort was 87% at 1 year, 73% at 3 years, and 66% at 5 years after LT. Graft survival among recipients was 74% at 1 year, 61% at 3 years, and 57% at 5 years after LT. These survival rates did not differ statistically significantly from those in the DCD-III cohort. Incidence of postoperative complications did not differ between the groups. For example, the occurrence of early allograft dysfunction after the LT was found to be 13 (31%) in the DCD-V cohort and 219 (45%) in the DCD-III cohort. The occurrence of nonanastomotic biliary strictures after the LT was found to be 7 (15%) in the DCD-V cohort and 83 (15%) in the DCD-III cohort. Conclusions and Relevance The findings of this cohort study suggest that LTs with DCD-V grafts yield similar outcomes as LTs with DCD-III grafts; therefore, grafts donated after euthanasia may be a justifiable option for increasing the organ donor pool. However, grafts from these donations should be considered high-risk grafts that require an optimal donor selection process and logistics.
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Affiliation(s)
- Marjolein van Reeven
- Division of Hepato-Pancreato-Biliary and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Nicholas Gilbo
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Otto B van Leeuwen
- Department of Surgery, Section of Hepato-Pancreato-Biliary and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Robert J Porte
- Department of Surgery, Section of Hepato-Pancreato-Biliary and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Dirk Ysebaert
- Department of Hepatobiliary, Transplantation and Endocrine Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ian P J Alwayn
- Division of Transplant Surgery, Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Nicolas Meurisse
- Department of Abdominal Surgery and Transplantation, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Laurent Coubeau
- Department of Abdominal Surgery and Transplantation, University Hospitals Saint-Luc, Brussels, Belgium
| | - Olga Cicarelli
- Department of Abdominal Surgery and Transplantation, University Hospitals Saint-Luc, Brussels, Belgium
| | - Frederik Berrevoet
- Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University Hospital, Ghent, Belgium
| | - Aude Vanlander
- Department of General and Hepatobiliary Surgery, Liver Transplantation Service, Ghent University Hospital, Ghent, Belgium
| | - Jan N M IJzermans
- Division of Hepato-Pancreato-Biliary and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Wojciech G Polak
- Division of Hepato-Pancreato-Biliary and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
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17
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Hung HC, Shen CH, Lee CF, Cheng SM, Lee WC. Sequential Organ Failure Assessment (SOFA) Score-Based Factors Predict Early Mortality in High-Risk Patients with Living Donor Liver Transplant. Ann Transplant 2021; 26:e931045. [PMID: 34112748 PMCID: PMC8204681 DOI: 10.12659/aot.931045] [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] [Indexed: 12/07/2022] Open
Abstract
Background Patients with a Sequential Organ Failure Assessment (SOFA) score >7 on post-transplant day (POD) 7 have been reported to have a higher risk of short-term mortality after living donor liver transplant (LDLT). We sought to identify factors that were associated with early mortality in this high-risk population. Material/Methods A total of 102 patients with a high SOFA score (>7) on POD 7 were enrolled, of which 72 (70.6%) were assigned to the survivor group, and the other 30 (29.4%) patients were assigned to the non-survivor group according to post-transplant 3-month results. Demographics, clinical data, operative parameters, and individual SOFA component scores were collected. Independent risk factors for 3-month mortality were identified by multivariate logistic regression analysis using backward elimination procedures. Results Of 102 high SOFA score patients, the 3-month mortality rate after LDLT in our study was 29.4%. Four independent risk factors were indicative for early death: graft-to-recipient weight ratio (GRWR) <0.8 (hazard ratio [HR]=3.00; 95% CI=1.05–8.09; P=0.041), longer warm ischemia time (HR=37.84; 95% CI=1.63–880.77; P=0.024), high liver component of the SOFA score, and cardiovascular component of the SOFA score (liver component: HR=10.39; 95% CI=1.77–60.89; P=0.009 and cardiovascular component: HR=13.34; 95% CI=2.22–80.12; P=0.005). Conclusions In conclusion, 3-month mortality among patients with high SOFA score on POD 7 is associated with multiple independent risk factors, including smaller GRWR, longer warm ischemia time, and higher category of liver and cardiovascular component of SOFA score. By recognizing high-risk patients earlier, the LDLT outcomes may be improved by timely intensive therapies.
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Affiliation(s)
- Hao-Chien Hung
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Chin-Hsin Shen
- Department of Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Chen-Fang Lee
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.,Chang-Gung University College of Medicine, Taoyuan, Taiwan
| | - Ssu-Min Cheng
- Nursing Department, Chang-Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Wei-Chen Lee
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.,Chang-Gung University College of Medicine, Taoyuan, Taiwan
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18
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Tinti F, Lai S, Noce A, Rotondi S, Marrone G, Mazzaferro S, Di Daniele N, Mitterhofer AP. Chronic Kidney Disease as a Systemic Inflammatory Syndrome: Update on Mechanisms Involved and Potential Treatment. Life (Basel) 2021; 11:419. [PMID: 34063052 PMCID: PMC8147921 DOI: 10.3390/life11050419] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/26/2021] [Accepted: 05/01/2021] [Indexed: 02/07/2023] Open
Abstract
Chronic kidney disease (CKD) is characterized by manifestations and symptoms involving systemic organs and apparatus, associated with elevated cardiovascular morbidity and mortality, bone disease, and other tissue involvement. Arterial hypertension (AH), diabetes mellitus (DM), and dyslipidemia, with glomerular or congenital diseases, are the traditional risk factors recognized as the main causes of progressive kidney dysfunction evolving into uremia. Acute kidney injury (AKI) has recently been considered an additional risk factor for the worsening of CKD or the development of CKD de novo. Evidence underlies the role of systemic inflammation as a linking factor between AKI and CKD, recognizing the role of inflammation in AKI evolution to CKD. Moreover, abnormal increases in oxidative stress (OS) and inflammatory status in CKD seem to exert an important pathogenetic role, with significant involvement in the clinical management of this condition. With our revision, we want to focus on and update the inflammatory mechanisms responsible for the pathologic conditions associated with CKD, with particular attention on the development of AKI and AKI-CKD de novo, the alteration of calcium-phosphorus metabolism with bone disease and CKD-MBD syndrome, the status of malnutrition and malnutrition-inflammation complex syndrome (MICS) and protein-energy wasting (PEW), uremic sarcopenia, the status of OS, and the different inflammatory pathways, highlighting a new approach to CKD. The depth comprehension of the mechanisms underlying the development of inflammation in CKD may present new possible therapeutic approaches in CKD and hopefully improve the management of correlated morbidities and provide a reduction in associated mortality.
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Affiliation(s)
- Francesca Tinti
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell’Università 37, 00185 Rome, Italy; (S.L.); (S.R.); (S.M.)
| | - Silvia Lai
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell’Università 37, 00185 Rome, Italy; (S.L.); (S.R.); (S.M.)
| | - Annalisa Noce
- Department of Systems Medicine, Nephrology and Dialysis Unit, University of Rome Tor Vergata, via Montpellier 1, 00133 Rome, Italy; (A.N.); (G.M.); (N.D.D.)
| | - Silverio Rotondi
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell’Università 37, 00185 Rome, Italy; (S.L.); (S.R.); (S.M.)
| | - Giulia Marrone
- Department of Systems Medicine, Nephrology and Dialysis Unit, University of Rome Tor Vergata, via Montpellier 1, 00133 Rome, Italy; (A.N.); (G.M.); (N.D.D.)
- PhD School of Applied Medical, Surgical Sciences, University of Rome Tor Vergata, via Montpellier 1, 00133 Rome, Italy
| | - Sandro Mazzaferro
- Department of Translational and Precision Medicine, Sapienza University of Rome, Viale dell’Università 37, 00185 Rome, Italy; (S.L.); (S.R.); (S.M.)
| | - Nicola Di Daniele
- Department of Systems Medicine, Nephrology and Dialysis Unit, University of Rome Tor Vergata, via Montpellier 1, 00133 Rome, Italy; (A.N.); (G.M.); (N.D.D.)
| | - Anna Paola Mitterhofer
- Department of Systems Medicine, Nephrology and Dialysis Unit, University of Rome Tor Vergata, via Montpellier 1, 00133 Rome, Italy; (A.N.); (G.M.); (N.D.D.)
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19
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Hobeika MJ, Saharia A, Mobley CM, Menser T, Nguyen DT, Graviss EA, McMillan RR, Podder H, Nolte Fong JV, Jones SL, Yi SG, Elshawwaf M, Gaber AO, Ghobrial RM. Donation after circulatory death liver transplantation: An in-depth analysis and propensity score-matched comparison. Clin Transplant 2021; 35:e14304. [PMID: 33792971 DOI: 10.1111/ctr.14304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 03/14/2021] [Accepted: 03/24/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Careful donor-recipient matching and reduced ischemia times have improved outcomes following donation after circulatory death (DCD) liver transplantation (LT). This study examines a single-center experience with DCD LT including high-acuity and hospitalized recipients. METHODS DCD LT outcomes were compared to a propensity score-matched (PSM) donation after brain death (DBD) LT cohort (1:4); 32 DCD LT patients and 128 PSM DBD LT patients transplanted from 2008 to 2018 were included. Analyses included Kaplan-Meier estimates and Cox proportional hazards models examining patient and graft survival. RESULTS Median MELD score in the DCD LT cohort was 22, with median MELD of 27 for DCD LT recipients with decompensated cirrhosis. No difference in mortality or graft loss was found (p < .05) between DCD LT and PSM DBD LT at 3 years post-transplant, nor was DCD an independent risk factor for patient or graft survival. Post-LT severe acute kidney injury was similar in both groups. Ischemic-type biliary lesions (ITBL) occurred in 6.3% (n = 2) of DCD LT recipients, resulting in 1 graft loss and 1 death. CONCLUSION This study supports that DCD LT outcomes can be similar to DBD LT, with a low rate of ITBL, in a cohort including high-acuity recipients. Strict donor selection criteria, ischemia time minimization, and avoiding futile donor/recipient combinations are essential considerations.
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Affiliation(s)
- Mark J Hobeika
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA.,Department of Surgery, Weill Cornell Medical College, New York, New York, USA.,Center for Outcomes Research, Houston Methodist, Houston, Texas, USA
| | - Ashish Saharia
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA.,Department of Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Constance M Mobley
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA.,Department of Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Terri Menser
- Center for Outcomes Research, Houston Methodist, Houston, Texas, USA.,Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist, Houston, Texas, USA
| | - Edward A Graviss
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA.,Department of Pathology and Genomic Medicine, Houston Methodist, Houston, Texas, USA
| | - Robert R McMillan
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA
| | - Hemangshu Podder
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA
| | - Joy V Nolte Fong
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA
| | - Stephen L Jones
- Department of Surgery, Weill Cornell Medical College, New York, New York, USA.,Center for Outcomes Research, Houston Methodist, Houston, Texas, USA
| | - Stephanie G Yi
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA.,Department of Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Mahmoud Elshawwaf
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA
| | - Ahmed O Gaber
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA.,Department of Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Rafik M Ghobrial
- Department of Surgery, J.C. Walter, Jr. Transplant Center, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist, Houston, Texas, USA.,Department of Surgery, Weill Cornell Medical College, New York, New York, USA
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20
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Lee HJ, Kim WH, Jung CW, Suh KS, Lee KH. Different Severity of Clinical Outcomes Between the 2 Subgroups of Stage 1 Acute Kidney Injury After Liver Transplantation. Transplantation 2021; 104:2327-2333. [PMID: 31996661 DOI: 10.1097/tp.0000000000003135] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although the Kidney Disease: Improving Global Outcomes (KDIGO) criteria is used to define acute kidney injury (AKI) after liver transplantation, the criteria was criticized for including 2 heterogeneous groups of different serum creatinine (sCr) criteria together in AKI stage 1. We investigated whether there are significant differences in clinical outcomes between 2 subgroups of patients within AKI stage 1. METHODS A total of 1440 cases were reviewed. The AKI stage 1 (n = 443) were divided into 2 subgroups based on changes in sCr level (stage 1a: ≥0.3 mg/dL of absolute sCr increase, n = 251; stage 1b: ≥50% relative sCr increase, n = 192). Propensity score analysis was performed between stage 1a and 1b groups, yielding 157 matched pairs. We compared the length of hospital stay, early allograft dysfunction, and 5-year all-cause mortality between these subgroups after matching. Kaplan-Meier analyses were performed to compare the graft or overall survival between the subgroups after matching. Sensitivity analysis for Acute Kidney Injury Network (AKIN) criteria was performed. RESULTS Length of hospital stay and 5-year all-cause mortality was significantly worse in patients with stage 1b compared to stage 1a after matching. Five-year graft or patient survival was significantly worse in patients with stage 1b compared to stage 1a after matching (Log-rank test P = 0.022 and P = 0.027, respectively). These results were the same regarding AKIN criteria. CONCLUSIONS The KDIGO criteria for AKI stage 1 could be further divided into 2 substages with different severity of clinical outcomes. This modified criteria could give additional prognostic information in patients undergoing liver transplantation.
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Affiliation(s)
- Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chul-Woo Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kook Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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21
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Hypothermic Oxygenated Perfusion Versus Normothermic Regional Perfusion in Liver Transplantation From Controlled Donation After Circulatory Death: First International Comparative Study. Ann Surg 2020; 272:751-758. [PMID: 32833758 DOI: 10.1097/sla.0000000000004268] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To compare HOPE and NRP in liver transplantation from cDCD. SUMMARY OF BACKGROUND DATA Liver transplantation after cDCD is associated with higher rates of graft loss. Dynamic preservation strategies such as NRP and HOPE may offer safer use of cDCD grafts. METHODS Retrospective comparative cohort study assessing outcomes after cDCD liver transplantation in 1 Swiss (HOPE) and 6 French (NRP) centers. The primary endpoint was 1-year tumor-death censored graft and patient survival. RESULTS A total of 132 and 93 liver grafts were transplanted after NRP and HOPE, respectively. NRP grafts were procured from younger donors (50 vs 61 years, P < 0.001), with shorter functional donor warm ischemia (22 vs 31 minutes, P < 0.001) and a lower overall predicted risk for graft loss (UK-DCD-risk score 6 vs 9 points, P < 0.001). One-year tumor-death censored graft and patient survival was 93% versus 86% (P = 0.125) and 95% versus 93% (P = 0.482) after NRP and HOPE, respectively. No differences in non-anastomotic biliary strictures, primary nonfunction and hepatic artery thrombosis were observed in the total cohort and in 32 vs. 32 propensity score-matched recipients CONCLUSION:: NRP and HOPE in cDCD achieved similar post-transplant recipient and graft survival rates exceeding 85% and comparable to the benchmark values observed in standard DBD liver transplantation. Grafts in the HOPE cohort were procured from older donors and had longer warm ischemia times, and consequently achieved higher utilization rates. Therefore, randomized controlled trials with intention-to-treat analysis are needed to further compare both preservation strategies, especially for high-risk donor-recipient combinations.
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22
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Abstract
PURPOSE OF REVIEW Deceased donation represents the largest supply of organs for transplant in the United States. Organs with suboptimal characteristics related to donor disease or recovery-related issues are increasingly discarded at the time of recovery, prompting late allocation to candidates later in the match sequence. Late allocation contributes to organ injury by prolonging cold ischemia, which may further lead to the risk of organ discard, despite the potential to provide benefit to certain transplant candidates. RECENT FINDINGS Expedited placement of marginal organs has emerged as a strategy to address the growing problem of organ discard of marginal organs that have been declined late after recovery. In this review, we describe the basis for expedited organ placement, and approaches to facilitating placement of these grafts, drawing examples from kidney and liver donation and transplantation globally. SUMMARY There is significant global variation in practice related to late allocation. Multiple policy mechanisms exist to facilitate expedited placement, including simultaneous offers to multiple centers, predesignation of aggressive centers, and increasing organ procurement organization autonomy in late allocation. Optimizing late allocation of deceased donor organs holds significant promise to increase the number of transplants.
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23
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Favorable Outcomes of Liver Transplantation from Controlled Circulatory Death Donors Using Normothermic Regional Perfusion Compared to Brain Death Donors. Transplantation 2020; 104:1943-1951. [PMID: 32639402 DOI: 10.1097/tp.0000000000003372] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Liver transplantation (LT) from controlled donation after circulatory death (cDCD) was initiated in France in 2015 under a protocol based on the use of normothermic regional perfusion (NRP) before organ procurement. The aim was to compare outcomes following cDCD LT with NRP and donation after brain death (DBD) LT. METHODS This is a multicenter retrospective study comparing cDCD LT with NRP and DBD LT. A case-matched study (1:2) was performed using the variables such as recipient and donor age, indication of LT. RESULTS A total of 50 patients from the cDCD group were matched to 100 patients from the DBD group. From postoperative days 1-4, serum transaminase release was significantly lower in the cDCD group compared to the DBD group (P < 0.05). Early allograft dysfunction (cDCD: 18% versus DBD: 32%; P = 0.11), acute kidney injury (26% versus 33%; P = 0.49), 90-d graft loss (2% versus 5%; P = 0.66), and arterial (4% versus 12%; P = 0.19) and biliary (16% versus 17%; P = 0.94) complications were similar between the 2 groups. The 2-y graft survival was 88% for cDCD group and 85% for DBD group (P = 0.91). The 2-y patient survival was 90% for cDCD group and 88% for DBD group (P = 0.68). CONCLUSIONS This study provides evidence that cDCD LT following postmortem NRP can be safely and effectively performed in selected recipients with similar graft and patient survival outcomes, without increased rates of biliary complications and early graft dysfunction compared to DBD LT.
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24
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van Leeuwen OB, van Reeven M, van der Helm D, IJzermans JNM, de Meijer VE, van den Berg AP, Darwish Murad S, van Hoek B, Alwayn IPJ, Porte RJ, Polak WG. Donor hepatectomy time influences ischemia-reperfusion injury of the biliary tree in donation after circulatory death liver transplantation. Surgery 2020; 168:160-166. [PMID: 32223984 DOI: 10.1016/j.surg.2020.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/26/2020] [Accepted: 02/10/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Donor hepatectomy time is associated with graft survival after liver transplantation. The aim of this study was to identify the impact of donor hepatectomy time on biliary injury during donation after circulatory death liver transplantation. METHODS First, bile duct biopsies of livers included in (pre)clinical machine perfusion research were analyzed. Secondly, of the same livers, bile samples were collected during normothermic machine perfusion. Lastly, a nationwide retrospective cohort study was performed including 273 adult patients undergoing donation after circulatory death liver transplantation between January 1, 2002 and January 1, 2017. Primary endpoint was development of non-anastomotic biliary strictures within 2 years of donation after circulatory death liver transplantation. Cox proportional-hazards regression analyses were used to assess the influence of hepatectomy time on the development of non-anastomotic biliary strictures. RESULTS Livers with severe histological bile duct injury had a higher median hepatectomy time (P = .03). During normothermic machine perfusion, livers with a hepatectomy time >50 minutes had lower biliary bicarbonate and bile pH levels. In the nationwide retrospective study, donor hepatectomy time was an independent risk factor for non-anastomotic biliary strictures after donation after circulatory death liver transplantation (Hazard Ratio 1.18 per 10 minutes increase, 95% Confidence Interval 1.06-1.30, P value = .002). CONCLUSION Donor hepatectomy time negatively influences histological bile duct injury before normothermic machine perfusion and bile composition during normothermic machine perfusion. Additionally, hepatectomy time is a significant independent risk factor for the development of non-anastomotic biliary strictures after donation after circulatory death liver transplantation.
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Affiliation(s)
- Otto B van Leeuwen
- Division of HPB Surgery & Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Marjolein van Reeven
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Danny van der Helm
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, the Netherlands
| | - Jan N M IJzermans
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Vincent E de Meijer
- Division of HPB Surgery & Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Aad P van den Berg
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Sarwa Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, the Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, the Netherlands
| | - Ian P J Alwayn
- Department of Surgery, Division of Transplant Surgery, Leiden University Medical Center, the Netherlands
| | - Robert J Porte
- Division of HPB Surgery & Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Wojciech G Polak
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC University Medical Center Rotterdam, the Netherlands.
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25
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Kim WH, Lee HJ, Yoon HC, Lee KH, Suh KS. Intraoperative Oxygen Delivery and Acute Kidney Injury after Liver Transplantation. J Clin Med 2020; 9:E564. [PMID: 32092886 PMCID: PMC7073538 DOI: 10.3390/jcm9020564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/02/2020] [Accepted: 02/17/2020] [Indexed: 01/04/2023] Open
Abstract
Although intraoperative hemodynamic variables were reported to be associated with acute kidney injury (AKI) after liver transplantation, the time-dependent association between intraoperative oxygen delivery and AKI has not yet been evaluated. We reviewed 676 cases of liver transplantation. Oxygen delivery index (DO2I) was calculated at least ten times during surgery. AKI was defined according to the Kidney Disease Improving Global Outcomes criteria. The area under the curve (AUC) was calculated as below a DO2I of 300 (AUC < 300), 400 and 500 mL/min/m2 threshold. Also, the cumulative time below a DO2I of 300 (Time < 300), 400, and 500 mL/min/m2 were calculated. Multivariable logistic regression analysis was performed to evaluate whether AUC < 300 or time < 300 was independently associated with the risk of AKI. As a sensitivity analysis, propensity score matching analysis was performed between the two intraoperative mean DO2I groups using a cutoff of 500 ml/min/m2, and the incidence of AKI was compared between the groups. Multivariable analysis showed that AUC < 300 or time < 300 was an independent predictor of AKI (AUC < 300: odds ratio [OR] = 1.10, 95% confidence interval [CI] 1.06-1.13, time < 300: OR = 1.10, 95% CI 1.08-1.14). Propensity score matching yielded 192 pairs of low and high mean DO2I groups. The incidence of overall and stage 2 or 3 AKI was significantly higher in the lower DO2I group compared to the higher group (overall AKI: lower group, n = 64 (33.3%) vs. higher group, n = 106 (55.2%), P < 0.001). In conclusion, there was a significant time-dependent association between the intraoperative poor oxygen delivery <300 mL/min/m2 and the risk of AKI after liver transplantation. The intraoperative optimization of oxygen delivery may mitigate the risk of AKI.
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Affiliation(s)
- Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-J.L.); (H.-C.Y.); (K.H.L.)
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-J.L.); (H.-C.Y.); (K.H.L.)
| | - Hee-Chul Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-J.L.); (H.-C.Y.); (K.H.L.)
| | - Kook Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-J.L.); (H.-C.Y.); (K.H.L.)
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea;
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26
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Kalisvaart M, Schlegel A, Umbro I, de Haan JE, Polak WG, IJzermans JN, Mirza DF, Perera MTP, Isaac JR, Ferguson J, Mitterhofer AP, de Jonge J, Muiesan P. The AKI Prediction Score: a new prediction model for acute kidney injury after liver transplantation. HPB (Oxford) 2019; 21:1707-1717. [PMID: 31153834 DOI: 10.1016/j.hpb.2019.04.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 03/29/2019] [Accepted: 04/08/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a frequent complication after liver transplantation. Although numerous risk factors for AKI have been identified, their cumulative impact remains unclear. Our aim was therefore to design a new model to predict post-transplant AKI. METHODS Risk analysis was performed in patients undergoing liver transplantation in two centres (n = 1230). A model to predict severe AKI was calculated, based on weight of donor and recipient risk factors in a multivariable regression analysis according to the Framingham risk-scheme. RESULTS Overall, 34% developed severe AKI, including 18% requiring postoperative renal replacement therapy (RRT). Five factors were identified as strongest predictors: donor and recipient BMI, DCD grafts, FFP requirements, and recipient warm ischemia time, leading to a range of 0-25 score points with an AUC of 0.70. Three risk classes were identified: low, intermediate and high-risk. Severe AKI was less frequently observed if recipients with an intermediate or high-risk were treated with a renal-sparing immunosuppression regimen (29 vs. 45%; p = 0.007). CONCLUSION The AKI Prediction Score is a new instrument to identify recipients at risk for severe post-transplant AKI. This score is readily available at end of the transplant procedure, as a tool to timely decide on the use of kidney-sparing immunosuppression and early RRT.
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Affiliation(s)
- Marit Kalisvaart
- The Liver Unit, Queen Elizabeth University Hospital, Birmingham, United Kingdom; Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Andrea Schlegel
- The Liver Unit, Queen Elizabeth University Hospital, Birmingham, United Kingdom
| | - Ilaria Umbro
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Rome, Italy; Department of Clinical Medicine, Nephrology Unit, Sapienza University of Rome, Rome, Italy
| | - Jubi E de Haan
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Wojciech G Polak
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jan N IJzermans
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Darius F Mirza
- The Liver Unit, Queen Elizabeth University Hospital, Birmingham, United Kingdom
| | - M Thamara Pr Perera
- The Liver Unit, Queen Elizabeth University Hospital, Birmingham, United Kingdom
| | - John R Isaac
- The Liver Unit, Queen Elizabeth University Hospital, Birmingham, United Kingdom
| | - James Ferguson
- The Liver Unit, Queen Elizabeth University Hospital, Birmingham, United Kingdom
| | - Anna P Mitterhofer
- Department of Clinical Medicine, Nephrology Unit, Sapienza University of Rome, Rome, Italy
| | - Jeroen de Jonge
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth University Hospital, Birmingham, United Kingdom.
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Intraoperative Hepatic Blood Inflow Can Predict Early Acute Kidney Injury following DCD Liver Transplantation: A Retrospective Observational Study. BIOMED RESEARCH INTERNATIONAL 2019; 2019:4572130. [PMID: 31467891 PMCID: PMC6699273 DOI: 10.1155/2019/4572130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 06/16/2019] [Accepted: 07/10/2019] [Indexed: 12/30/2022]
Abstract
Purpose Acute kidney injury (AKI) is a major and severe complication following donation-after-circulatory-death (DCD) liver transplantation (LT) and is associated with increased postoperative morbidity and mortality. However, the risk factors and the prognosis factors of AKI still need to be further explored, and the relativity of intraoperative hepatic blood inflow (HBI) and AKI following LT has not been discussed yet. The purpose of this study was to investigate the correlation between HBI and AKI and to construct a prediction model of early acute kidney injury (EAKI) following DCD LT with the combination of HBI and other clinical parameters. Methods Clinical data of 132 patients who underwent DCD liver transplantation at the first hospital of China Medical University from April 2005 to March 2017 were analyzed. Data of 105 patients (the first ten years of patients) were used to develop the prediction model. Then we assessed the clinical usefulness of the prediction models in the validation cohort (27 patients). EAKI according to Kidney Disease Improving Global Outcomes (KDIGO) criteria based on serum creatinine increase during 7-day of postoperative follow-up. Results After Least Absolute Shrinkage and Selection Operator (LASSO) regression and simplification, a simplified prediction model consisting of the Child-Turcotte-Pugh (CTP) score (p=0.033), anhepatic phase (p=0.014), packed red blood cell (pRBC) transfusion (p=0.027), and the HBI indexed by height (HBI/h) (p=0.002) was established. The C-indexes of the model in the development and validation cohort were 0.823 [95% CI, 0.738-0.908] and 0.921 [95% CI, 0.816-1.000], respectively. Conclusions In this study, we demonstrated the utility of HBI/h as a predictor for EAKI following DCD LT, as well as the clinical usefulness of the prediction model through the combination of the CTP score, anhepatic phase, pRBC transfusion and HBI/h.
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Mihaylov P, Mangus R, Ekser B, Cabrales A, Timsina L, Fridell J, Lacerda M, Ghabril M, Nephew L, Chalasani N, Kubal CA. Expanding the Donor Pool With the Use of Extended Criteria Donation After Circulatory Death Livers. Liver Transpl 2019; 25:1198-1208. [PMID: 30929303 DOI: 10.1002/lt.25462] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 03/16/2019] [Indexed: 02/07/2023]
Abstract
Use of donation after circulatory death (DCD) donor livers for transplantation has remained cautious in the United States. The aim of this study was to demonstrate the expansion of a DCD liver transplantation (LT) program with the use of extended criteria donor (ECD) DCD livers. After institutional review board approval, 135 consecutive DCD LTs were retrospectively studied. ECD DCD livers were defined as those with 1 of the following factors: donor age >50 years, donor body mass index >35 kg/m2 , donor functional warm ischemia time >30 minutes, and donor liver macrosteatosis >30%. An optimization protocol was introduced in July 2011 to improve outcomes of DCD LT, which included thrombolytic donor flush and efforts to minimize ischemia times. The impact of this protocol on outcomes was evaluated in terms of graft loss, ischemic cholangiopathy (IC), and change in DCD LT volume. Of 135 consecutive DCD LTs, 62 were ECD DCDs. In total, 24 ECD DCD LTs were performed before (era 1) and 38 after the institution of optimization protocol (era 2), accounting for an increase in the use of ECD DCD livers from 39% to 52%. Overall outcomes of ECD DCD LT improved in era 2, with a significantly lower incidence of IC (5% versus 17% in era 1; P = 0.03) and better 1-year graft survival (93% versus 75% in era 1; P = 0.07). Survival outcomes for ECD DCD LT in era 2 were comparable to matched deceased donor LT. With the expansion of the DCD donor pool, the number of DCD LTs performed at our center gradually increased in era 2 to account for >20% of the center's LT volume. In conclusion, with the optimization of perioperative conditions, ECD DCD livers can be successfully transplanted to expand the donor pool for LT.
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Affiliation(s)
- Plamen Mihaylov
- Transplant Division, Indiana University School of Medicine, Indianapolis, IN
| | - Richard Mangus
- Transplant Division, Indiana University School of Medicine, Indianapolis, IN
| | - Burcin Ekser
- Transplant Division, Indiana University School of Medicine, Indianapolis, IN
| | - Arianna Cabrales
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Lava Timsina
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Jonathan Fridell
- Transplant Division, Indiana University School of Medicine, Indianapolis, IN
| | - Marco Lacerda
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Lauren Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN
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Serrano OK, Vock DM, Snyder JJ, Chinnakotla S, Kandaswamy R, Pruett TL, Matas AJ, Finger EB. Influence of the procurement surgeon on transplanted abdominal organ outcomes: An SRTR analysis to evaluate regional organ procurement collaboration. Am J Transplant 2019; 19:2219-2231. [PMID: 30748093 DOI: 10.1111/ajt.15301] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 01/22/2019] [Accepted: 01/26/2019] [Indexed: 01/25/2023]
Abstract
Single-center studies have demonstrated regional organ procurement collaboration to reduce travel redundancy and improve procurement efficiency. We studied deceased donor kidney, liver, and pancreas transplants performed in the United States between 2002 and 2014 using the Scientific Registry of Transplant Recipients (SRTR). We compared graft failure (GF), death-censored graft failure (DCGF), and patient death (PD) between organs procured by surgeons from the recipient's center (transplant procurement team [TPT]) versus surgeons from a different center (NTPT). Primary nonfunction (PNF) was assessed for liver and kidney and delayed graft function (DGF) for kidney using mixed-effects logistic modeling. There were 64 906 liver (61.6% TPT), 118 152 kidney (26.1% TPT), 10 832 simultaneous pancreas kidney (SPK; 56.6% TPT), and 4378 solitary pancreas (SP; 34.0% TPT) transplants. When compared to NTPT, DCGF for organs procured by TPT was significantly less for liver (adjusted HR: 0.93; 95% CI: 0.88-0.98) and marginally significant for kidney (0.97; 0.93-1.00) and SPK (0.90; 0.82-1.00), and not significant for SP (0.98; 0.86 -1.11). DGF for TPT kidney was significantly lower (adjusted OR 0.91; 0.87-0.95). Albeit modest, our findings demonstrate a difference between locally procured organs and those procured by the implanting team. Elucidating the etiology of these differences will enhance regional organ procurement collaboration.
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Affiliation(s)
- Oscar K Serrano
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - David M Vock
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Jon J Snyder
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Srinath Chinnakotla
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Raja Kandaswamy
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Timothy L Pruett
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Arthur J Matas
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Erik B Finger
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
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Kalisvaart M, Schlegel A, Trivedi PJ, Roberts K, Mirza DF, Perera T, Isaac JI, Ferguson J, de Jonge J, Muiesan P. Chronic Kidney Disease After Liver Transplantation: Impact of Extended Criteria Grafts. Liver Transpl 2019; 25:922-933. [PMID: 30947384 DOI: 10.1002/lt.25468] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 03/03/2019] [Indexed: 12/13/2022]
Abstract
The use of extended criteria donor (ECD) grafts has been associated with acute kidney injury (AKI) after liver transplantation. However, the relation between graft quality and development of chronic kidney disease (CKD) remains unknown. Therefore, the aim of this study was to analyze the impact of ECD grafts for CKD after liver transplantation. All patients (2007-2015) transplanted for end-stage liver disease at our center were assessed. Longterm kidney function was divided into 4 groups: no CKD (estimated glomerular filtration rate [eGFR], ≥60 mL/minute/1.73 m2 ), mild CKD (eGFR, 30-59 mL/minute/1.73 m2 ), severe CKD (eGFR, 15-29 mL/minute/1.73 m2 ), and end-stage renal disease (ESRD). Marginal donation after brain death (DBD) grafts (donor age, >70 years; body mass index, >35 kg/m2 ; cold storage, >12 hours) and donation after circulatory death (DCD) grafts were considered ECD grafts. Overall, 926 patients were included, and 43% received an ECD graft (15% marginal DBD; 28% DCD). After 5 years, 35% developed CKD; severe CKD and ESRD occurred in only 2% and 1%, respectively. CKD rates were comparable for all 3 graft groups (standard group, 36%; marginal DBD group, 29%; DCD group, 35%; standard versus marginal DBD groups, P = 0.16; standard versus DCD group, P = 0.80). None of the ECD criteria were identified as independent risk factors in a Cox regression model for CKD. Risk factors included recipient age, female sex, and preoperative kidney function. Furthermore, recipients who had severe acute kidney injury (AKI; Kidney Disease: Improving Global Outcomes stages 2 and 3) had a 1.8-fold increased risk for CKD. Longterm kidney function of recipients with severe AKI depended on the recovery of kidney function in the first postoperative week. In conclusion, there is no direct relation between the use of ECD grafts and CKD after liver transplantation. However, caution should be taken in recipients who experience severe AKI, regardless of graft type.
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Affiliation(s)
- Marit Kalisvaart
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom.,Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Andrea Schlegel
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom
| | - Palak J Trivedi
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom.,National Institute for Health Research Birmingham Biomedical Research Centre, Birmingham, United Kingdom
| | - Keith Roberts
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom
| | - Darius F Mirza
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom
| | - Thamara Perera
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom
| | - John I Isaac
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom
| | - James Ferguson
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom.,National Institute for Health Research Birmingham Biomedical Research Centre, Birmingham, United Kingdom
| | - Jeroen de Jonge
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom
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Revascularization Time in Liver Transplantation: Independent Prediction of Inferior Short- and Long-term Outcomes by Prolonged Graft Implantation. Transplantation 2019; 102:2038-2055. [PMID: 29757901 DOI: 10.1097/tp.0000000000002263] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Strategies for successful transplantation are much needed in the era of organ shortage, and there has been a resurgence of interest on the impact of revascularization time (RT) on outcomes in liver transplantation (LT). METHODS All primary LT performed in Birmingham between 2009 and 2014 (n = 678) with portal reperfusion first were stratified according to RT (<44 minutes vs ≥44 minutes) and graft quality (standard liver graft [SLG], Donor Risk Index < 2.3 vs marginal liver graft [MLG], Donor Risk Index ≥ 2.3). RESULTS Revascularization time of 44 minutes or longer resulted in significantly greater incidence of early allograft dysfunction (EAD) (29% vs 47%, P < 0.001), posttransplant acute kidney injury (AKI) (39% vs 60%, P < 0.001), and new-onset AKI (37% vs 56%, P < 0.001), along with poor long-term outcome (3-year graft survival 92% vs 83%, P = 0.001; 3-year patient survival 87% vs 79%, P = 0.004). On multivariable analysis, RT ≥ 44 was a significant independent predictor of EAD, renal dysfunction, and overall graft survival, but not patient survival. The cumulative effect of prolonged revascularization in marginal grafts (MLG) resulted in the worst transplant outcome compared with all other groups, which could be mitigated by rapid revascularization (SLG, SLG, MLG vs MLG; EAD 24%, 39%, 39% vs 69%; AKI 32%, 46%, 51% vs 70%; 3-year graft survival 94%, 87%, 88% vs 70%, respectively; each P < 0.001). Factors associated with lack of abdominal space, larger grafts, and surgical skills were predictive of RT ≥ 44. CONCLUSIONS Shorter graft revascularization is a protective factor in LT, particularly in the setting of graft marginality. Careful graft-recipient matching and emphasis on surgical expertise may aid in achieving better outcomes in LT.
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Early Persistent Progressive Acute Kidney Injury and Graft Failure Post Liver Transplantation. Transplant Direct 2019; 5:e429. [PMID: 30882034 PMCID: PMC6411224 DOI: 10.1097/txd.0000000000000868] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 12/17/2018] [Accepted: 01/12/2019] [Indexed: 12/24/2022] Open
Abstract
Background Acute kidney injury (AKI) in the setting of liver transplantation is a common and multifaceted complication. Studies in the general population have demonstrated worse prognosis with AKI episodes that persist for a longer duration. Our primary objective was to evaluate the impact of early AKI episodes that are persistent or progressive in nature, on patient outcomes and graft survival. Methods This was a retrospective cohort study including all patients who received a liver transplant between 2011 and 2015 at our center. Moderate to severe AKI episodes (AKIN II or III) were recorded immediately before transplantation and after surgery until hospital discharge. We evaluated the incidence density rate (IDR) of graft failure and the time to graft failure in patients with persistent or progressive AKI (ppAKI) as compared to controls. Results Two hundred seventy-nine patients received 301 deceased donor liver allografts. Progressive or persistent AKI was documented in more than half of transplant cases (152/301). The rate of graft loss was 3 times higher in the ppAKI group (25%) versus the controls (8.7%). The IDR of graft failure was 13.79 per 100 case-years in the ppAKI group as compared with 3.79 per 100 case-years in the controls (IDR ratio, 3.64; 95 % confidence interval, 1.88–7.50). After adjusting for hepatic artery thrombosis, ischemic cholangiopathy, infectious complications and Model for End-stage Liver Disease, ppAKI was associated with a decreased graft survival time. Conclusions Persistent or progressive AKI after liver transplantation is associated with an increased incidence rate of graft failure and is an independent predictor of decreased graft survival time.
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Lee HC, Yoon SB, Yang SM, Kim WH, Ryu HG, Jung CW, Suh KS, Lee KH. Prediction of Acute Kidney Injury after Liver Transplantation: Machine Learning Approaches vs. Logistic Regression Model. J Clin Med 2018; 7:jcm7110428. [PMID: 30413107 PMCID: PMC6262324 DOI: 10.3390/jcm7110428] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 10/29/2018] [Accepted: 11/06/2018] [Indexed: 12/15/2022] Open
Abstract
Acute kidney injury (AKI) after liver transplantation has been reported to be associated with increased mortality. Recently, machine learning approaches were reported to have better predictive ability than the classic statistical analysis. We compared the performance of machine learning approaches with that of logistic regression analysis to predict AKI after liver transplantation. We reviewed 1211 patients and preoperative and intraoperative anesthesia and surgery-related variables were obtained. The primary outcome was postoperative AKI defined by acute kidney injury network criteria. The following machine learning techniques were used: decision tree, random forest, gradient boosting machine, support vector machine, naïve Bayes, multilayer perceptron, and deep belief networks. These techniques were compared with logistic regression analysis regarding the area under the receiver-operating characteristic curve (AUROC). AKI developed in 365 patients (30.1%). The performance in terms of AUROC was best in gradient boosting machine among all analyses to predict AKI of all stages (0.90, 95% confidence interval [CI] 0.86–0.93) or stage 2 or 3 AKI. The AUROC of logistic regression analysis was 0.61 (95% CI 0.56–0.66). Decision tree and random forest techniques showed moderate performance (AUROC 0.86 and 0.85, respectively). The AUROC of support the vector machine, naïve Bayes, neural network, and deep belief network was smaller than that of the other models. In our comparison of seven machine learning approaches with logistic regression analysis, the gradient boosting machine showed the best performance with the highest AUROC. An internet-based risk estimator was developed based on our model of gradient boosting. However, prospective studies are required to validate our results.
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Affiliation(s)
- Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
| | - Soo Bin Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
| | - Seong-Mi Yang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Ho-Geol Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Chul-Woo Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Kook Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.
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