1
|
Mendoza Quevedo MD, Vaca-Espinosa MC, Marín Zuluaga JI, Amell Baron BC, Sierra Vargas AK. Refractory Ascites After Liver Transplantation Treated With Splenic Artery Embolization: A Case Report and Literature Review. Cureus 2023; 15:e43910. [PMID: 37746399 PMCID: PMC10512432 DOI: 10.7759/cureus.43910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 09/26/2023] Open
Abstract
After orthotopic liver transplantation, several complications can arise, such as arterial or venous thrombosis, stenosis, biliary leakage, ischemia, or ascites. Although refractory ascites are not a common complication, they can have a significant impact on patients' prognosis and quality of life. This condition can be caused by multiple mechanisms, both intrahepatic and extrahepatic, and one of them is the splenic artery steal syndrome. In this article, we present the case of a patient with advanced cirrhosis who developed refractory ascites following liver transplantation. Despite management with diuretics and paracentesis, the ascites did not respond to conventional treatment. The diagnosis of splenic artery steal syndrome was confirmed through angiography, and subsequent embolization of the splenic artery resulted in symptom resolution.
Collapse
|
2
|
D'Amico G, Partovi S, Del Prete L, Matsushima H, Diago-Uso T, Hashimoto K, Eghtesad B, Fujiki M, Aucejo F, Kwon CHD, Miller C, Gadani S, Quintini C. Proximal Splenic Artery Embolization for Refractory Ascites and Hydrothorax Post-Liver Transplant. Cardiovasc Intervent Radiol 2023; 46:470-479. [PMID: 36797427 DOI: 10.1007/s00270-023-03376-3] [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: 10/01/2022] [Accepted: 01/27/2023] [Indexed: 02/18/2023]
Abstract
PURPOSE Proximal splenic artery embolization (pSAE) has been advocated as a valuable tool to ameliorate portal hyper-perfusion (PHP). The purpose of this study was to determine the safety and efficacy of pSAE to treat refractory ascites (RA) and/or refractory hydrothorax (RH) in the setting of PHP post-liver transplant. MATERIAL AND METHODS A total of 30 patients who underwent pSAE for RA and/or RH after liver transplantation (LT) between January 2007 and December 2017 were analyzed retrospectively. The patients were divided into groups according to the time frame from pSAE to clinical resolution in order to identify predictors of RA/RH response to the procedure. RESULTS Twenty-four (80%) patients responded to pSAE within three months, whereas 6 (20%) still required additional treatments for RA/RH at three months post-pSAE. In all cases clinical symptoms resolved within six months. Complications after pSAE were as follows: 2 cases of splenic infarction (6.6%), one case of post-splenic embolization syndrome (3.3%), one case of hepatic artery thrombosis (3.3%) and one case of portal vein (PV) thrombosis (3.3%). Increased intraoperative PV flow volume and increased pre-pSAE PV velocity, as well as higher estimated glomerular filtration rate were associated with early RA/RH resolution. CONCLUSION pSAE is safe and effective in treating RA and RH due to PHP after LT. This study suggests that clinical parameters indicating more severe PHP and better kidney function are possible predictors for early response to pSAE.
Collapse
Affiliation(s)
- Giuseppe D'Amico
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sasan Partovi
- Department of Interventional Radiology, Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Luca Del Prete
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Department of Health Sciences, PhD School in Translational Medicine, University of Milan, 20142, Milan, Italy
| | - Hajime Matsushima
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Teresa Diago-Uso
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Koji Hashimoto
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bijan Eghtesad
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Masato Fujiki
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Federico Aucejo
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Choon Hyuck David Kwon
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Charles Miller
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sameer Gadani
- Department of Interventional Radiology, Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Cristiano Quintini
- Departments of General Surgery, Liver Transplant Unit, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
3
|
Jiang JG, Ferrell T, Sauaia A, Rodriguez IE, Yoeli D, Nydam TL, Kennealey PT, Pomposelli JJ, Pomfret EA, Moore HB. Low viscoelastic clot strength, platelet transfusions, and graft dysfunction are associated with persistent postoperative ascites following liver transplantation. Am J Surg 2022; 224:1432-1437. [PMID: 36216610 PMCID: PMC10366940 DOI: 10.1016/j.amjsurg.2022.09.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 08/25/2022] [Accepted: 09/28/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION High output, persistent ascites (PA) is a common complication following liver transplant (LT). Recent work has identified that platelets help maintain endothelial integrity and can decrease leakage in pathological states. We sought to assess the association of PA following LT with platelet count and platelet function. METHODS Clot strength (MA) is a measure of platelet function and was quantified using thrombelastography (TEG). Total drain output following surgery was recorded in 24-h intervals during the same time frame as TEG. PA was considered >1 L on POD7, as that much output prohibits drain removal. RESULTS 105 LT recipients with moderate or high volume preoperative ascites were prospectively enrolled. PA occurred in 28%. Platelet transfusions before and after surgery were associated with PA, in addition to POD5 TEG MA and POD5 MELD score. Patients with PA had a longer hospital length of stay and an increased rate of intraabdominal infections. CONCLUSION Persistent ascites following liver transplant is relatively common and associated with platelet transfusions, low clot strength, and graft dysfunction.
Collapse
Affiliation(s)
- Jessie G Jiang
- University of Colorado School of Medicine, CU Anschutz Fitzsimons Building, 13001 East 17th Place, C290, Aurora, CO, 80045, USA; University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA.
| | - Tanner Ferrell
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
| | - Angela Sauaia
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA; University of Colorado Denver School of Public Health, Department of Health Systems, Management and Policy, Fitzsimons Building, 3rd Floor, 13001 E. 17th Place, Mail Stop B119, Aurora, CO, 80045, USA
| | - Ivan E Rodriguez
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA; Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
| | - Dor Yoeli
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA; Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
| | - Trevor L Nydam
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA; Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
| | - Peter T Kennealey
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA; Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
| | - James J Pomposelli
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA; Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
| | - Elizabeth A Pomfret
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA; Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
| | - Hunter B Moore
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA; Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA.
| |
Collapse
|
4
|
Ebada HE, Montasser MF, Abdelghaffar MF, Bahaa MM, Elbaset HSA, Sakr MA, Dabbous HM, Montasser IF, Hassan MS, Aboelmaaty ME, Elmeteini MS. Ascites post-living donor liver transplantation: Risk factors and outcome. JOURNAL OF LIVER TRANSPLANTATION 2022. [DOI: 10.1016/j.liver.2022.100112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
|
5
|
Ostojic A, Petrovic I, Silovski H, Kosuta I, Sremac M, Mrzljak A. Approach to persistent ascites after liver transplantation. World J Hepatol 2022; 14:1739-1746. [PMID: 36185723 PMCID: PMC9521448 DOI: 10.4254/wjh.v14.i9.1739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/08/2022] [Accepted: 09/02/2022] [Indexed: 02/06/2023] Open
Abstract
Persistent ascites (PA) after liver transplantation (LT), commonly defined as ascites lasting more than 4 wk after LT, can be expected in up to 7% of patients. Despite being relatively rare, it is associated with worse clinical outcomes, including higher 1-year mortality. The cause of PA can be divided into vascular, hepatic, or extrahepatic. Vascular causes of PA include hepatic outflow and inflow obstructions, which are usually successfully treated. Regarding modifiable hepatic causes, recurrent hepatitis C and acute cellular rejection are the leading ones. Considering predictors for PA, the presence of ascites, refractory ascites, hepato-renal syndrome type 1, spontaneous bacterial peritonitis, hepatic encephalopathy, and prolonged ischemic time significantly influence the development of PA after LT. The initial approach to patients with PA should be to diagnose the treatable cause of PA. The stepwise approach in evaluating PA includes diagnostic paracentesis, ultrasound with Doppler, and an echocardiogram when a cardiac cause is suspected. Finally, a percutaneous or transjugular liver biopsy should be performed in cases where the diagnosis is unclear. PA of unknown cause should be treated with diuretics and paracentesis, while transjugular intrahepatic portosystemic shunt and splenic artery embolization are treatment methods in patients with refractory ascites after LT.
Collapse
Affiliation(s)
- Ana Ostojic
- Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, Zagreb 10000, Croatia
| | - Igor Petrovic
- Department of Hepatobiliary Surgery and Transplantation, University Hospital Center Zagreb, Zagreb 10000, Croatia
| | - Hrvoje Silovski
- Department of Hepatobiliary Surgery and Transplantation, University Hospital Center Zagreb, Zagreb 10000, Croatia
| | - Iva Kosuta
- Department of Intensive Care Medicine, University Hospital Center Zagreb, Zagreb 10000, Croatia
| | - Maja Sremac
- Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, Zagreb 10000, Croatia
| | - Anna Mrzljak
- Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, Zagreb 10000, Croatia
| |
Collapse
|
6
|
Management of Ascites Following Deceased Donor Liver Transplantation: A Case Series. Transplant Direct 2022; 8:e1350. [PMID: 35923811 PMCID: PMC9298478 DOI: 10.1097/txd.0000000000001350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/31/2022] [Accepted: 02/05/2022] [Indexed: 11/26/2022] Open
|
7
|
Yang N, Du Y, He J, Ge J, Wang M, Sun R, Zhu H, Ge W. Distribution evaluation of tacrolimus in the ascitic fluid of liver transplant recipients with liver cirrhosis by a sensitive ultra-performance liquid chromatography-tandem mass spectrometry method. J Sep Sci 2021; 45:411-421. [PMID: 34694679 DOI: 10.1002/jssc.202100714] [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: 09/04/2021] [Revised: 10/17/2021] [Accepted: 10/21/2021] [Indexed: 11/10/2022]
Abstract
Tacrolimus has a narrow therapeutic index and large individual differences in pharmacokinetics. The distribution of tacrolimus in ascitic fluid and its influence on whole-blood tacrolimus were unclear. In this study, a sensitive ultra-performance liquid chromatography-tandem mass spectrometry method was established and validated for the quantification of tacrolimus in the ascitic fluid of liver transplant recipients. Chromatographic separation was achieved on an Agilent ZORBAX Eclipse Plus Phenyl-Hexyl column (2.1 × 100 mm, 3.5 μm). Mass spectrometry was performed in multiple reaction monitoring conditions of transitions m/z 821.4→768.5 for tacrolimus. The concentrations of tacrolimus in the ascitic fluid range from 0.2 to 3.0 ng/mL, accounting for 1.19-31.87% of whole-blood tacrolimus concentrations. A linear mixed model showed a statistically significant positive correlation between the steady-state trough blood concentration of tacrolimus and the corresponding amount of tacrolimus excreted in the ascitic fluid for 24 consecutive hours, especially after normalization by daily dose per unit body weight. These data suggested that the distribution of tacrolimus in the ascitic fluid has great individual differences. The whole-blood tacrolimus concentration, dose per unit body weight, and other confounding factors may contribute to the excretion of tacrolimus in ascitic fluid, but the influence of tacrolimus excretion in drained ascitic fluid on the whole-blood tacrolimus concentration is negligible.
Collapse
Affiliation(s)
- Na Yang
- Department of Pharmacy, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing University, Nanjing, P. R. China
| | - Yao Du
- Department of Pharmacy, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing University, Nanjing, P. R. China
| | - Jun He
- Department of Pharmacology, Nanjing University of Chinese Medicine, Nanjing, P. R. China
| | - Jiajia Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing University, Nanjing, P. R. China
| | - Min Wang
- Department of Pharmacy, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing University, Nanjing, P. R. China
| | - Runbin Sun
- Department of Pharmacy, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing University, Nanjing, P. R. China
| | - Huaijun Zhu
- Department of Pharmacy, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing University, Nanjing, P. R. China
| | - Weihong Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing University, Nanjing, P. R. China
| |
Collapse
|
8
|
Jenkins M, Satoskar R. Ascites After Liver Transplantation. Clin Liver Dis (Hoboken) 2021; 17:317-319. [PMID: 33968396 PMCID: PMC8087930 DOI: 10.1002/cld.1050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/22/2020] [Accepted: 10/11/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Michelle Jenkins
- Transplant InstituteMedStar Georgetown University HospitalWashingtonDC
| | - Rohit Satoskar
- Transplant InstituteMedStar Georgetown University HospitalWashingtonDC
| |
Collapse
|
9
|
Shimizu S, Ohira M, Nakano R, Imaoka Y, Sato K, Tahara H, Ide K, Kobayashi T, Kuroda S, Ono H, Tanaka Y, Ohdan H. Management of Refractory Ascites for Liver Transplant Candidates: A Novel Cell-free and Concentrated Ascites Reinfusion Therapy. Transplant Proc 2019; 51:2740-2744. [PMID: 31563243 DOI: 10.1016/j.transproceed.2019.02.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 02/06/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Refractory ascites is one of the major complications of liver transplant (LT) and is associated with increased morbidity and mortality. The aim of this study was to analyze the efficacy and safety of novel cell-free and concentrated ascites reinfusion therapy (KM-CART) for the treatment of refractory ascites during preoperative living donor liver transplant. METHODS Forty KM-CART procedures were performed on 8 liver transplant candidates. We investigated the safety and efficacy of KM-CART in terms of the processed ascites, adverse events, laboratory data, and patient condition. RESULTS By using KM-CART, an average of 12.5 L (range, 2.6-26.1 L) of ascites was filtered and concentrated to 0.5 L (range, 0.1-1.6 L) in 62 minutes (range, 8-187 minutes). Final products contained 21.5 g (range, 2.5-65.6 g) of albumin and 13.5 g (range, 1.5-61.8 g) of globulin. No endotoxin contamination was detected in the ascites. Although the incidence of adverse events was 35.0% (including fever, hypotension, bleeding, leg cramps, and nausea), all of these could be treated conservatively. Body weight and oral intake were significantly improved after KM-CART. Furthermore, the use of fresh frozen plasma for the LT recipients with KM-CART was significantly lower than that for patients without KM-CART. In addition, no patients lost their opportunity for LT because of adverse events due to KM-CART. CONCLUSIONS Our findings show that KM-CART could be a promising option for the treatment of refractory ascites during the preoperative period of LT. This study provides the foundation for further large-scale prospective studies.
Collapse
Affiliation(s)
- Seiichi Shimizu
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masahiro Ohira
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan; Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan.
| | - Ryosuke Nakano
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuki Imaoka
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Koki Sato
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroyuki Tahara
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kentaro Ide
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tsuyoshi Kobayashi
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shintaro Kuroda
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroaki Ono
- Department of Clinical Engineer, Hiroshima University Hospital, Hiroshima, Japan
| | - Yuka Tanaka
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| |
Collapse
|
10
|
Miserachs M, Lurz E, Levman A, Ghanekar A, Cattral M, Ng V, Grant D, Avitzur Y. Diagnosis, Outcome, and Management of Chylous Ascites Following Pediatric Liver Transplantation. Liver Transpl 2019; 25:1387-1396. [PMID: 31301267 PMCID: PMC7165704 DOI: 10.1002/lt.25604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/25/2019] [Indexed: 12/13/2022]
Abstract
Data on postoperative chylous ascites (CA) after pediatric liver transplantation (LT) are scarce. This retrospective study was conducted to identify the incidence, risk factors, management, and outcomes of postoperative CA in a large single-center pediatric LT cohort (2000-2016). The study cohort comprised 317 LTs (153 living donors and 164 deceased donors) in 310 recipients with a median age of 2.7 years. The incidence of CA was 5.4% (n = 17), diagnosed after a median time of 10 days after LT. Compared with chylomicron detection in peritoneal fluid (the gold standard), a triglyceride cutoff value of 187 mg/dL in peritoneal fluid showed insufficient sensitivity (31%) for CA diagnosis. In univariate logistic regression analyses, ascites before LT, younger age, and lower weight, height, and height-for-age z score at LT were associated with CA. Symptomatic management of CA included peritoneal drain (100%) and diuretics (76%). Therapeutic interventions included very low-fat or medium-chain triglyceride-rich diets (94%) and intravenous octreotide (6%), leading to CA resolution in all patients. CA was associated with prolonged hospital length of stay (LOS; 40 days in the CA group versus 24 days in the non-CA group; P = 0.001) but not with reduced patient or graft survival rates after a median follow-up time of 14 years. In conclusion, CA in the pediatric LT recipient is a relatively uncommon complication associated with increased hospital LOS and morbidity. Measurement of chylomicrons is recommended in patients with ascites that is more severe or persistent than expected. Dietary interventions are effective in most patients.
Collapse
Affiliation(s)
- Mar Miserachs
- Transplant and Regenerative Medicine CentreHospital for Sick ChildrenTorontoOntarioCanada
- Division of Pediatric Gastroenterology, Hepatology and NutritionHospital for Sick Children, University of TorontoTorontoOntarioCanada
- Universitat Autònoma de BarcelonaBellaterraSpain
| | - Eberhard Lurz
- Transplant and Regenerative Medicine CentreHospital for Sick ChildrenTorontoOntarioCanada
- Division of Pediatric Gastroenterology, Hepatology and Nutritionvon Haunersches Kinderspitak, Ludwig Maximillians University MunichMunichGermany
| | - Aviva Levman
- Transplant and Regenerative Medicine CentreHospital for Sick ChildrenTorontoOntarioCanada
| | - Anand Ghanekar
- Multi‐Organ Transplant ProgramUniversity Health NetworkTorontoOntarioCanada
- Department of SurgeryUniversity of TorontoTorontoOntarioCanada
| | - Mark Cattral
- Multi‐Organ Transplant ProgramUniversity Health NetworkTorontoOntarioCanada
- Department of SurgeryUniversity of TorontoTorontoOntarioCanada
| | - Vicky Ng
- Transplant and Regenerative Medicine CentreHospital for Sick ChildrenTorontoOntarioCanada
- Division of Pediatric Gastroenterology, Hepatology and NutritionHospital for Sick Children, University of TorontoTorontoOntarioCanada
| | - David Grant
- Multi‐Organ Transplant ProgramUniversity Health NetworkTorontoOntarioCanada
- Department of SurgeryUniversity of TorontoTorontoOntarioCanada
| | - Yaron Avitzur
- Transplant and Regenerative Medicine CentreHospital for Sick ChildrenTorontoOntarioCanada
- Division of Pediatric Gastroenterology, Hepatology and NutritionHospital for Sick Children, University of TorontoTorontoOntarioCanada
| |
Collapse
|
11
|
Lee TY, Fan HL, Wang CW, Hsieh CB, Chen TW. Somatostatin Therapy in Patients with Massive Ascites After Liver Transplantation. Ann Transplant 2019; 24:1-8. [PMID: 30598518 PMCID: PMC6327785 DOI: 10.12659/aot.911788] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background Patients with massive ascites (MA) after liver transplantation (LT, defined here as daily ascitic drainage more than 1000 ml per day for more than 7 days after liver transplantation) are at increased risks of infection, hypoalbuminemia, graft loss, and even mortality. The aim of this retrospective cohort study was to investigate the effects of somatostatin on patients with MA after LT. Material/Methods Twenty-eight patients with liver cirrhosis or hepatocellular carcinoma who underwent LT complicated by MA postoperatively were included. Ten participants were receiving somatostatin therapy. The postoperative course and adverse drug effects were investigated. Daily postoperative ascitic drainage and urine output were also recorded and compared to those in the non-somatostatin group. Results The somatostatin group had significantly less ascites drainage after LT compared to the non-somatostatin group (p=0.002). Urine output was significantly increased after somatostatin administration (p<0.001). No serious adverse effects influencing graft function or fatal complications occurred after somatostatin therapy. Conclusions Somatostatin treatment is beneficial for the management of MA after liver transplantation.
Collapse
Affiliation(s)
- Ting-Ying Lee
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hsiu-Lung Fan
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Wen Wang
- Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chung-Bao Hsieh
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Teng-Wei Chen
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| |
Collapse
|
12
|
Prediction of the Development of Persistent Massive Ascites After Living Donor Liver Transplantation Using a Perioperative Risk Score. Transplantation 2018; 102:e275-e281. [DOI: 10.1097/tp.0000000000002174] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
|
13
|
Abstract
BACKGROUND No protocol has been established for the diagnosis and management of chylous ascites after liver transplantation (LT). In this study, we retrospectively reviewed our cases of posttransplant chylous ascites (PTCA) and aimed to propose a diagnostic and management protocol. PATIENTS AND METHODS We retrospectively reviewed the clinical records of 96 LT recipients who underwent LT at our department. The incidence of PTCA and the associated risk factors were analyzed and our protocol for chylous ascites was evaluated. RESULTS PTCA occurred in 6 (6.3%) patients (mean age: 10.7±11.0years) at a mean of 10.8±3.6days after LT. The primary disease in all of PTCA cases was biliary atresia (BA). The periportal lymphadnopathy was an independent risk factor for PTCA. In all cases PTCA successfully resolved according to our protocol. Octreotide was administered in 4 of our 6 PTCA cases. The mean postoperative hospital stay was 40.2±8.4days, which was similar to that of cases without PTCA. CONCLUSIONS The incidence of PTCA in LT patients, especially in those with BA, is relatively high. Our diagnostic criteria and our management protocol were helpful for patients with refractory ascites after LT. TYPE OF STUDY Diagnostic test: Level II. Treatment study: Level III.
Collapse
|
14
|
Arudchelvam J, Bartlett A, McCall J, Johnston P, Gane E, Munn S. Hepatic venous outflow obstruction in piggyback liver transplantation: single centre experience. ANZ J Surg 2015; 87:182-185. [PMID: 26471387 DOI: 10.1111/ans.13344] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND Hepatic venous outflow obstruction (HVOO) is a rare but serious complication in liver transplantation (LT). METHODS We conducted a retrospective analysis of HVOO with venography and gradient measurement in consecutive LT from a single centre. RESULTS Five hundred and six LTs were performed in 486 patients with a median age of 49 years (range 3 months to 71 years). Nineteen (3.8%) cases of HVOO were identified. Diagnosis was confirmed at a median of 26 days post-LT (1-2312). The incidence fell from 5.5% in the first 253 LT, to 2.0% in the second 253 (P = 0.03). Seventeen were due to narrowing at the anastomosis and two cases were due to thrombosis. In adult patients, reconstruction of the supra-hepatic donor inferior vena cava (IVC) onto two veins versus modified 2-3 hepatic veins did not alter the likelihood of HVOO. 17/19 cases were managed successfully by stenting or venoplasty. Two paediatric patients with early onset HVOO had attempted surgical thrombectomy, one was successful and the other required retransplantation. CONCLUSION The incidence of HVOO appears to fall with increasing experience and does not appear to be related to the number of veins the donor IVC is anastomosed to in adult recipients.
Collapse
Affiliation(s)
- Joel Arudchelvam
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - Adam Bartlett
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand.,Department of Surgery, Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - John McCall
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand.,Department of Surgery, University of Otago, Dunedin, New Zealand
| | - Peter Johnston
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - Edward Gane
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| | - Stephen Munn
- New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand
| |
Collapse
|
15
|
Khorsandi SE, Athale A, Vilca-Melendez H, Jassem W, Prachalias A, Srinivasan P, Rela M, Heaton N. Presentation, diagnosis, and management of early hepatic venous outflow complications in whole cadaveric liver transplant. Liver Transpl 2015; 21:914-21. [PMID: 25907399 DOI: 10.1002/lt.24154] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 03/30/2015] [Accepted: 04/11/2015] [Indexed: 02/07/2023]
Abstract
Early hepatic venous outflow obstruction (HVOO) can be a devastating complication leading to graft loss after liver transplantation (LT). A retrospective study on 777 adult LT recipients over a 5-year period (August 2007 to August 2012) was undertaken to determine the incidence of early HVOO presenting within 3 months of transplant, its clinical features and management, and potential technical risk factors related to the implanting technique. Cases of early HVOO were screened for by identifying recipients with problematic ascites within 3 months of transplant. Definitive diagnosis for HVOO was based on a wedge pressure of >12 mm Hg. Considering only whole livers, the incidence of early problematic ascites was 3% (20/695) of which more than one-third (35%, 7/20) were then confirmed to have HVOO. Overall, the incidence of early HVOO was 1% (7/695). Two hepatic veins (HVs) with extension piggybacks (PBs; n = 423) were the dominant implanting technique in the time period of study rather than the 3 HV PB (n = 182) and caval replacement techniques (n = 82). Considering the implantation technique, all cases of HVOO occurred after 2 HVs when extension PBs had been used with an incidence of 1.7% (7/423). Institutionally, early HVOO was mainly managed surgically by either cavoplasty within a month of transplant (n = 4) or retransplant (n = 1), and the remainder (n = 2) were medically managed with diuretics. In conclusion, early HVOO is rare, and there is no evidence from this study that a given implantation technique is at a higher risk of developing HVOO (2 HV with extension versus 3 HV and caval replacement; P = 0.11). However, early revisional surgery for HVOO can preserve graft function with retransplantation being reserved for when surgical cavoplasty or radiological stenting is technically not possible.
Collapse
Affiliation(s)
| | - Anuja Athale
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | | | - Wayel Jassem
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Andreas Prachalias
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Parthi Srinivasan
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Mohamed Rela
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| |
Collapse
|
16
|
Novelli PM, Shields J, Krishnamurthy V, Cho K. Two Unusual but Treatable Causes of Refractory Ascites After Liver Transplantation. Cardiovasc Intervent Radiol 2015; 38:1663-9. [PMID: 26017456 DOI: 10.1007/s00270-015-1120-5] [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: 03/24/2015] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
Abstract
Refractory ascites (RA) is thought to complicate the postoperative course of 5-7% (Nishida et al. in Am J Transplant. 6: 140-149, 2006; Gotthardt et al. in Ann Transplant. 18: 378-383, 2013) of liver transplant recipients. RA after liver transplantation is often a frustrating diagnostic dilemma with few good management options unless an obvious mechanical factor is identified. Supportive therapies often fail until a treatable precipitating cause is identified and removed. We describe two patients who developed RA following liver transplantation for primary sclerosing cholangitis, and hepatitis C and alcoholic liver disease, respectively. The cause for RA was hyperkinetic portal hypertension secondary to splenomegaly in the first case and a pancreatic AVM in the 2nd case. After failure of other interventions, surgical splenectomy resulted in immediate and durable resolution of the previously intractable ascites.
Collapse
Affiliation(s)
- P M Novelli
- Department of Radiology, University of Michigan Medical Center, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA.
| | - J Shields
- Department of Radiology, University of Michigan Medical Center, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - V Krishnamurthy
- Department of Radiology, University of Michigan Medical Center, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - K Cho
- Department of Radiology, University of Michigan Medical Center, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
| |
Collapse
|
17
|
Presser N, Quintini C, Tom C, Wang W, Liu Q, Diago-Uso T, Fujiki M, Winans C, Kelly D, Aucejo F, Hashimoto K, Eghtesad B, Miller C. Safety and efficacy of splenic artery embolization for portal hyperperfusion in liver transplant recipients: a 5-year experience. Liver Transpl 2015; 21:435-41. [PMID: 25604488 DOI: 10.1002/lt.24081] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 10/26/2014] [Accepted: 12/04/2014] [Indexed: 02/07/2023]
Abstract
Severe portal hyperperfusion (PHP) after liver transplantation has been shown to cause intrahepatic arterial vasoconstriction secondary to increased adenosine washout (hepatic artery buffer response). Clinically, posttransplant PHP can cause severe cases of refractory ascites and hydrothorax. In the past, we reported our preliminary experience with the use of splenic artery embolization (SAE) as a way to reduce PHP. Here we present our 5-year experience with SAE in orthotopic liver transplantation (OLT). Between January 2007 and December 2011, 681 patients underwent OLT at our institution, and 54 of these patients underwent SAE for increased hepatic arterial resistance and PHP (n=42) or refractory ascites/hepatic hydrothorax (n=12). Patients undergoing SAE were compared to a control group matched by year of embolization, calculated Model for End-Stage Liver Disease score, and liver weight. SAE resulted in improvements in hepatic artery resistive indices (0.92±0.14 and 0.76±0.10 before and after SAE, respectively; P<0.001) and improved hepatic arterial blood flow (HAF; 15.6±9.69 and 28.7±14.83, respectively; P<0.001). Calculated splenic volumes and spleen/liver volume ratios were correlated with patients requiring SAE versus matched controls (P=0.002 and P=0.001, respectively). Among the 54 patients undergoing SAE, there was 1 case of postsplenectomy syndrome. No abscesses, significant infections, or bleeding was noted. We thus conclude that SAE is a safe and effective technique able to improve HAF parameters in patients with elevated portal venous flow and its sequelae.
Collapse
Affiliation(s)
- Naftali Presser
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Li C, Lu Q, Luo J, Zhang Z. Independent risk factors for massive ascites after living donor liver transplantation in adults. Transplant Proc 2015; 46:883-7. [PMID: 24767372 DOI: 10.1016/j.transproceed.2013.11.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 11/20/2013] [Accepted: 11/27/2013] [Indexed: 02/05/2023]
Abstract
OBJECTIVES This study sought to define the perioperative recipient and donor factors that contribute to the occurrence of massive ascites after living donor liver transplantation (LDLT) in adults. METHODS A retrospective review of medical records and computerized databases was performed, and 105 adult patients who underwent LDLT from 2005 to 2011 in the West China Hospital, Sichuan University, were included. Patients were divided into group 1 (n = 27, massive ascites defined as >7000 mL of ascitic fluid produced during the first 7 days after LDLT) or group 2 (n = 78, no massive ascites). Perioperative recipient and donor factors were assessed using a univariate analysis followed by 2 logistic regression analyses. RESULTS The recipients' median age was 44 years (range, 27 to 69 years), and the male-to-female ratio was 92:13. Massive ascites developed in 27 patients (25.7%). The average amount of ascites in group 1 and group 2 patients within the first 7 postoperative days was 11,285 mL and 3311 mL, respectively. The univariate analysis showed that recipient's age, primary liver disease, preoperative MELD score, Child-Pugh score, operating time, postoperative sequential organ failure assessment (SOFA) score, postoperative total bilirubin, right hepatic vein graft diameter, and hepatic portal vein graft diameter were significantly different between the 2 groups (P < .05). The 2 logistic regressions showed that the Child-Pugh score, operating time, and right hepatic vein graft diameter were independent risk factors for massive ascites after LDLT. CONCLUSION It is important to improve the perioperative liver function and portal hypertension and to shorten operating time to reduce massive ascites after LDLT.
Collapse
Affiliation(s)
- C Li
- Department of ICU, West China Hospital, Sichuan University, Chendu 610041, China
| | - Q Lu
- Department of ICU, West China Hospital, Sichuan University, Chendu 610041, China
| | - J Luo
- Department of ICU, West China Hospital, Sichuan University, Chendu 610041, China
| | - Z Zhang
- Department of ICU, West China Hospital, Sichuan University, Chendu 610041, China.
| |
Collapse
|
19
|
Tripon S, Francoz C, Albuquerque A, Paradis V, Boudjema H, Voitot H, Belghiti J, Valla D, Durand F. Interactions between virus-related factors and post-transplant ascites in patients with hepatitis C and no cirrhosis: role of cryoglobulinemia. Transpl Int 2014; 28:162-9. [PMID: 25267442 DOI: 10.1111/tri.12466] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 06/02/2014] [Accepted: 09/21/2014] [Indexed: 12/11/2022]
Abstract
Refractory ascites may appear in liver transplant recipients with recurrence of hepatitis C virus infection, even in the absence of advanced fibrosis. The mechanisms are unclear. The aim was to determine whether post-transplant cryoglobulinemia could be a predisposing factor for ascites in this population. Retrospective data of 82 liver transplant recipients with HCV recurrence surviving more than 1 year were collected. Cryoglobulinemia was systematically tested after transplantation. All patients had 1-year protocol biopsy with assessment of sinusoidal distension, perisinusoidal fibrosis, and centrolobular necrosis. Additional biopsies were performed when needed. Fourteen of 82 patients (17%) developed refractory ascites. When ascites appeared, fibrosis was stage F0-F1 in 36% and F2-F3 in 57%. Factors independently associated with post-transplant ascites were pretransplant refractory ascites (P = 0.001), fibrosis ≥stage 2 at 1 year (P = 0.002), perisinusoidal fibrosis at 1 year (P = 0.02), and positive cryoglobulinemia (P = 0.02). Patients with ascites had a significantly worse prognosis compared to those without ascites. Refractory ascites may occur in liver transplant recipients with HCV recurrence in the absence of advanced fibrosis. The finding that both positive cryoglobulinemia and perisinusoidal fibrosis at 1 year were significantly associated with ascites suggests that liver microangiopathy is involved in the mechanisms of HCV-related ascites.
Collapse
Affiliation(s)
- Simona Tripon
- Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy, France
| | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Bonnel AR, Bunchorntavakul C, Rajender Reddy K. Transjugular intrahepatic portosystemic shunts in liver transplant recipients. Liver Transpl 2014; 20:130-9. [PMID: 24142390 DOI: 10.1002/lt.23775] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 10/06/2013] [Accepted: 10/12/2013] [Indexed: 12/12/2022]
Abstract
The insertion of a transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive procedure used to relieve the signs and symptoms of portal hypertension in patients with liver disease. The most common indications for placement are refractory ascites and variceal hemorrhage. In properly selected candidates, TIPS placement can serve as a bridge to liver transplantation. Expertise in TIPS placement after transplantation has significantly increased, which has allowed the procedure to become a viable option for retransplant candidates suffering the consequences of recurrent portal hypertension due to portal vein thrombosis, recurrent liver disease, or hepatic venous outflow obstruction (HVOO). However, TIPSs in liver transplant recipients are associated with a lower clinical response rate and a higher rate of complications in comparison with patients with native liver disease, and they are, therefore, generally reserved for patients with a Model for End-Stage Liver Disease (MELD) score ≤ 15 and ≤ 12 in patients with HCV. The role of TIPS placement in nonliver transplant recipients has been well studied in large trials, and it translates well into clinical applicability to candidates for orthotopic liver transplantation (OLT). However, the experience with OLT recipients is heterogeneous and restricted to small series. Thus, we focus here on reviewing the current literature and discussing the proper use of TIPSs in liver transplant recipients.
Collapse
|
21
|
Acute Cellular Rejection Resulting in Sinusoidal Obstruction Syndrome and Ascites Postliver Transplantation. Transplantation 2011; 92:1152-8. [DOI: 10.1097/tp.0b013e318234119d] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|
22
|
MELD score less than 15 predicts prolonged survival after transjugular intrahepatic portosystemic shunt for refractory ascites after liver transplantation. Transplantation 2011; 91:786-92. [PMID: 21304440 DOI: 10.1097/tp.0b013e31820e014e] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is used in the management of refractory ascites (RA) and variceal bleeds. Little data exist on TIPS safety, efficacy, and survival after liver transplantation (LT). METHODS We conducted a retrospective analysis of patients who underwent TIPS placement after LT for RA. Clinical success was defined as a reduction of portosystemic gradient (PSG) and resolution of RA. RESULTS Twenty-six patients underwent TIPS. The most common indication for LT was hepatitis C virus (88%). Median time from LT to TIPS was 17 months (1-89 months). Median pre-TIPS model for end-stage liver disease (MELD) score was 15 (7-33). The median pre-TIPS PSG was 18 mm Hg (7-38 mm Hg). Median change in the PSG after TIPS was 11 mm Hg (1-27 mm Hg). Fifty-eight percent (15/26) of TIPS were considered clinically successful. Median post-TIPS patient survival was 15 months (1-109 months). Cumulative 1-year post-TIPS patient survival was 50%. On multivariate analysis, pre-TIPS MELD was a significant and independent predictor of patient survival (P<0.01). The 3- and 6-month patient mortality and graft loss for patients with a pre-TIPS MELD of more than or equal to 15 were significantly higher than those with a pre-TIPS MELD score of less than 15 (P<0.01). The overall median survival for patients with a pre-TIPS MELD score of more than or equal to 15 was 3 months (1-59 months) compared with 45 months (2-109 months) for patients with pre-TIPS MELD score of less than 15. CONCLUSIONS TIPS after LT can be clinically effective in patients with RA with a MELD score less than 15. This suggests that TIPS could be used as a means to extend posttransplant survival but should be carefully individualized in patients with a MELD score more than or equal to 15.
Collapse
|
23
|
Quintini C, D'Amico G, Brown C, Aucejo F, Hashimoto K, Kelly DM, Eghtesad B, Sands M, Fung JJ, Miller CM. Splenic artery embolization for the treatment of refractory ascites after liver transplantation. Liver Transpl 2011; 17:668-73. [PMID: 21618687 DOI: 10.1002/lt.22280] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Refractory ascites (RA) is a challenging complication after orthotopic liver transplantation. Its treatment consists of the removal of the precipitating factors. When the etiology is unknown, supportive treatment can be attempted. In severe cases, transjugular intrahepatic portosystemic shunts, portocaval shunts, and liver retransplantation have been used with marginal results. Recently, splenic artery embolization (SAE) has been described as an effective procedure for reducing portal hyperperfusion in patients undergoing partial or whole liver transplantation. Here we describe our experience with SAE for the treatment of RA. Between June 2004 and June 2010, 6 patients underwent proximal SAE for RA. Intraoperative flow measurements, graft characteristics, embolization portal vein (PV) velocities before and after SAE, and spleen/liver volume ratios were collected and analyzed. The response to treatment was assessed with imaging (ultrasound/computed tomography) and on the basis of clinical outcomes (weight changes, diuretic requirements, and the time to ascites resolution). The PV velocity decreased significantly for each patient after the embolization (median = 66.5 cm/second before SAE and median = 27.5 cm/second after SAE, P < 0.01). All patients experienced a significant postprocedural weight loss (mean = 88.1 ± 28.4 kg before SAE and mean = 75.8 ± 28.4 kg after SAE, P < 0.01) and a dramatic decrease in their diuretic requirements. All but 1 of the patients experienced a complete resolution of ascites after a median time of 49.5 days (range = 12-295 days). No patient presented with postembolization complications. In conclusion, SAE was effective in reducing the PV velocity immediately after the procedure. Clinically, this translated into a dramatic weight loss, a reduction of diuretic use, and a resolution of ascites. SAE appears to be a safe and effective treatment for RA.
Collapse
Affiliation(s)
- Cristiano Quintini
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH 44106, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Gastaca M, Valdivieso A, Ruiz P, Gonzalez J, Ventoso A, de Urbina JO. Venous outflow obstruction after orthotopic liver transplantation: use of a breast implant to maintain graft position. Clin Transplant 2011; 25:E320-6. [DOI: 10.1111/j.1399-0012.2011.01423.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|
25
|
Darius T, Monbaliu D, Aerts R, Laleman W, Roskams T, Van Steenbergen W, Cassiman D, Verslype C, Maleux G, Nevens F, Pirenne J. Rescue of a Marginal Liver Graft by Sequential Treatment With Molecular Adsorbent Recirculating System and Transjugular Intrahepatic Portosystemic Shunt: A Case Report. Transplant Proc 2009; 41:3427-9. [DOI: 10.1016/j.transproceed.2009.09.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|
26
|
Durand F. [Liver transplantation of refractory ascites]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2008; 32:721-726. [PMID: 18619750 DOI: 10.1016/j.gcb.2008.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- F Durand
- Inserm U773, Pôle des Maladies de l'Appareil Digestif, Centre de Recherche Biomédicale Bichat-Beaujon, Service d'Hépatologie, Hôpital Beaujon, Université Denis-Diderot Paris-7, Clichy, France.
| |
Collapse
|
27
|
Taner C, Nguyen J. Mesocaval Shunt as an Alternative Treatment for Persistent Ascites After Liver Transplantation: Case Reports. Transplant Proc 2008; 40:1534-5. [DOI: 10.1016/j.transproceed.2008.03.083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2007] [Accepted: 03/06/2008] [Indexed: 01/16/2023]
|
28
|
Lan BY, Landry GM, Tan VO, Bostrom A, Feng S. Ascites in hepatitis C liver transplant recipients frequently occurs in the absence of advanced fibrosis. Am J Transplant 2008; 8:366-76. [PMID: 18093276 DOI: 10.1111/j.1600-6143.2007.02046.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Ascites after liver transplantation is uncommon (3-7%) but causes morbidity and mortality. Although hepatitis C (HCV), pretransplant ascites, encephalopathy and cold ischemia time have been identified as predictors, neither posttransplant renal function nor the severity of recurrent HCV (inflammatory grade; fibrosis stage) has been systematically assessed. Among 173 HCV transplants (1 January 1998 to 31 December 2002), 18 patients (10%) developed posttransplant ascites. Cox proportional hazards models identified recipient female gender (hazard ratio [HR]= 12.18; p = 0.0001), cold ischemia time (HR = 1.17 per incremental hour; p = 0.021) and posttransplant creatinine (Cr) (HR = 1.56 per incremental 1.0 mg/dL; p = 0.0052) as independent predictors. Ludwig-Batts inflammation grade (HR = 1.32; p = 0.36) and fibrosis stage (HR = 1.63; p = 0.12) were not significant predictors. The 18 recipients had 19 ascites episodes; 12/19 had fibrosis stage 0, 1 or 2 (10/12 with stage 0 or 1). All 12 lacked diagnostic parenchymal or vascular histopathology. Renal function at ascites diagnosis were similar for transplants with fibrosis stage 0, 1 or 2 versus 3 or 4 (1.8 +/- 1.6 vs. 1.6 +/- 0.6 mg/dL; Cr clearance 39.6 +/- 15.6 vs. 39.3 +/- 13.4 mL/min/1.73 m(2)). In conclusion, recipient female gender, cold ischemia time and poor posttransplant renal function were independent predictors of ascites after HCV liver transplantation. Two thirds of ascites episodes, however, occurred without significant fibrosis or histopathology.
Collapse
Affiliation(s)
- B Y Lan
- Department of Surgery, Division of Transplantation, University of California - San Francisco, San Francisco, CA, USA
| | | | | | | | | |
Collapse
|
29
|
Gaynor JJ, Moon JI, Kato T, Nishida S, Selvaggi G, Levi DM, Island ER, Pyrsopoulos N, Weppler D, Ganz S, Ruiz P, Tzakis AG. A cause-specific hazard rate analysis of prognostic factors among 877 adults who received primary orthotopic liver transplantation. Transplantation 2007; 84:155-65. [PMID: 17667806 DOI: 10.1097/01.tp.0000269090.90068.0f] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND In orthotopic liver transplantation (OLT) distinct causes of graft failure (GF) and death with a functioning graft (DFG) exist. Prognostic factors for one failure type may be distinctly different from those predictive of other types, and an accurate portrayal of these relationships may more clearly explain each factor's importance. METHODS A multivariable cause-specific hazard (CSH) rate analysis using Cox stepwise regression was performed among 877 adults who received primary OLT during 1996-2004 with tacrolimus+steroids as immunosuppression. RESULTS Older donor age (P=0.004) implied greater primary dysfunction GF, while primary sclerosing cholangitis (PSC; P=0.0002) implied greater vascular thrombosis GF. Recurrent nonmalignant liver disease GF was higher among hepatitis C virus patients (P<0.00001), and younger recipient age (P=0.005) implied greater death from recurrent (metastatic) hepatocellular carcinoma. African-American race (P<0.00001), PSC (P=0.003), and younger recipient age (P=0.005) were independently associated with greater GF due to chronic rejection. Older donor age (P=0.003) implied greater infection DFG, while older recipient age (P=0.003) and pretransplant diabetes (P=0.03) were independently associated with greater cardiovascular/cerebrovascular DFG. Finally, most of these cause-specific predictors were not significant in an overall Cox model for graft survival. CONCLUSIONS The CSH approach should be more widely used in investigations of prognostic factors. The result of older donor age implying greater primary dysfunction GF and infection DFG but having no association with other failure types demonstrates that its impact is specific to the graft's early posttransplant functional status. In addition, while recipient age was an important prognosticator, its direction of association reverses depending upon the outcome being analyzed.
Collapse
Affiliation(s)
- Jeffrey J Gaynor
- Department of Surgery, University of Miami School of Medicine, Miami, FL, 33101, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Kahn J, Müller H, Iberer F, Kniepeiss D, Duller D, Rehak P, Tscheliessnigg K. Incisional hernia following liver transplantation: incidence and predisposing factors. Clin Transplant 2007; 21:423-6. [PMID: 17488396 DOI: 10.1111/j.1399-0012.2007.00666.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Patients after orthotopic liver transplantation (OLT) have a high risk of developing incisional hernia (IH). In the literature incidences between 5% and 17% are reported. PATIENTS AND METHODS In 90 patients, who underwent OLT between October 1998 and December 2005, a retrospective analysis on the occurrence of IH was performed. Surgical access for OLT was a transversal upper laparotomy. Age, gender, primary disease, ICU stay, immunosuppressive regimen and two different closure techniques (running suture or single sutures in layers) were evaluated. RESULTS In 73 patients (76.7%, group 2) healing of the incision was without problems, in 17 patients (23.3%, group 1), IH occurred. Total survival was similar between the groups (86.3% vs. 94.1%, n.s.). No significant differences between the groups concerning age, gender, body mass index, platelet count and duration of ICU stay were found. Also, the technique of abdominal closure had no impact on the development of IH. No IH was found in patients with hepatocellular carcinoma (n = 15), whereas end-stage liver cirrhosis (n = 75) was associated with development of IH (p = 0.064). Multivariate analysis revealed end-stage liver cirrhosis, Sirolimus, and MMF to be independent significant risk factors for IH after OLT. CONCLUSION IH following OLT has to be regarded a frequent complication. While technique of abdominal closure seems to have no impact, primary diagnosis and kind of immunosuppressive regimen exerted a significant influence on the formation of IH.
Collapse
Affiliation(s)
- Judith Kahn
- Department of Transplant Surgery, Medical University Graz, University Clinic of Surgery, Graz, Austria.
| | | | | | | | | | | | | |
Collapse
|