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Lee IK, Chang PH, Yeh CH, Li WF, Yin SM, Lin YC, Tzeng WJ, Chen CL, Lin CC, Wang CC. Risk factors and crucial prognostic indicators of mortality in liver transplant recipients with bloodstream infections: A comprehensives study of 1049 consecutive liver transplants over an 11-year period. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2024:S1684-1182(24)00109-9. [PMID: 38944568 DOI: 10.1016/j.jmii.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/22/2024] [Accepted: 06/15/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND Liver transplantation (LT) is a pivotal treatment for end-stage liver disease. However, bloodstream infections (BSI) in the post-operative period present a significant threat to patient survival. This study aims to identify risk factors for post-LT BSI and crucial prognostic indicators for mortality among affected patients. METHODS We conducted a retrospective study of adults diagnosed with end-stage liver disease who underwent their initial LT between 2010 and 2021. Those who developed BSI post-LT during the same hospital admission were classified into the BSI group. RESULTS In this cohort of 1049 patients, 89 (8.4%) developed BSI post-LT, while 960 (91.5%) did not contract any infection. Among the BSI cases, 17 (19.1%) patients died. The average time to BSI onset was 48 days, with 46% occurring within the first month post-LT. Of the 123 isolated microorganisms, 97 (78.8%) were gram-negative bacteria. BSI patients had significantly longer stays in the intensive care unit and hospital compared to non-infected patients. The 90-day and in-hospital mortality rates for recipients with BSI were significantly higher than those without infections. Multivariate analysis indicated heightened BSI risk in patients with blood loss >3000 mL during LT (odds ratio [OR] 2.128), re-operation within 30 days (OR 2.341), post-LT bile leakage (OR 3.536), and graft rejection (OR 2.194). Additionally, chronic kidney disease (OR 6.288), each 1000 mL increase in intraoperative blood loss (OR 1.147) significantly raised mortality risk in BSI patients, whereas each 0.1 mg/dL increase in albumin levels correlated with a lower risk of death from BSI (OR 0.810). CONCLUSIONS This study underscores the need for careful monitoring and management in the post-LT period, especially for patients at higher risk of BSI. It also suggests that serum albumin levels could serve as a valuable prognostic indicator for outcomes in LT recipients experiencing BSI.
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Affiliation(s)
- Ing-Kit Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Chang Gang University, College of Medicine, Taoyuan, Taiwan
| | - Po-Hsun Chang
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Cheng-Hsi Yeh
- Department of Surgery, Liver Transplantation Program, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Wei-Feng Li
- Department of Surgery, Liver Transplantation Program, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Shih-Min Yin
- Department of Surgery, Liver Transplantation Program, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yu-Cheng Lin
- Department of Surgery, Liver Transplantation Program, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Wei-Juo Tzeng
- Department of Surgery, Liver Transplantation Program, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chao-Long Chen
- Department of Surgery, Liver Transplantation Program, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chih-Che Lin
- Department of Surgery, Liver Transplantation Program, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chih-Chi Wang
- Chang Gang University, College of Medicine, Taoyuan, Taiwan; Department of Surgery, Liver Transplantation Program, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
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Moore HB, Saben J, Rodriguez I, Bababekov YJ, Pomposelli JJ, Yoeli D, Ferrell T, Adams MA, Pshak TJ, Kaplan B, Pomfret EA, Nydam TL. Postoperative fibrinolytic resistance is associated with early allograft dysfunction in liver transplantation: A prospective observational study. Liver Transpl 2023; 29:724-734. [PMID: 36749288 PMCID: PMC10293055 DOI: 10.1097/lvt.0000000000000075] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Indexed: 02/08/2023]
Abstract
Perioperative dysfunction of the fibrinolytic system may play a role in adverse outcomes for liver transplant recipients. There is a paucity of data describing the potential impact of the postoperative fibrinolytic system on these outcomes. Our objective was to determine whether fibrinolysis resistance (FR), on postoperative day one (POD-1), was associated with early allograft dysfunction (EAD). We hypothesized that FR, quantified by tissue plasminogen activator thrombelastography, is associated with EAD. Tissue plasminogen activator thrombelastography was performed on POD-1 for 184 liver transplant recipients at a single institution. A tissue plasminogen activator thrombelastography clot lysis at 30 minutes of 0.0% was identified as the cutoff for FR on POD-1. EAD occurred in 32% of the total population. Fifty-nine percent (n=108) of patients were categorized with FR. The rate of EAD was 42% versus 17%, p <0.001 in patients with FR compared with those without, respectively. The association between FR and EAD risk was assessed using multivariable logistic regression after controlling for known risk factors. The odds of having EAD were 2.43 times (95% CI, 1.07-5.50, p =0.03) higher in recipients with FR [model C statistic: 0.76 (95% CI, 0.64-0.83, p <0.001]. An additive effect of receiving a donation after circulatory determination of death graft and having FR in the rate of EAD was observed. Finally, compared with those without FR, recipients with FR had significantly shorter graft survival time ( p =0.03). In conclusion, FR on POD-1 is associated with EAD and decreased graft survival time. Postoperative viscoelastic testing may provide clinical utility in identifying patients at risk for developing EAD, especially for recipients receiving donation after circulatory determination of death grafts.
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Affiliation(s)
- Hunter B Moore
- Departments of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado
- Department of Surgery, Children’s Hospital Colorado, Aurora, Colorado
| | - Jessica Saben
- Departments of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado
| | - Ivan Rodriguez
- Departments of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado
| | - Yanik J Bababekov
- Departments of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado
| | - James J Pomposelli
- Departments of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado
| | - Dor Yoeli
- Departments of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado
| | - Tanner Ferrell
- Departments of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado
| | - Megan A Adams
- Departments of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado
- Department of Surgery, Children’s Hospital Colorado, Aurora, Colorado
| | - Thomas J Pshak
- Departments of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado
| | - Bruce Kaplan
- Departments of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado
| | - Elizabeth A Pomfret
- Departments of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado
| | - Trevor L Nydam
- Departments of Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
- Colorado Center for Transplantation Care, Research and Education (CCTCARE), Aurora, Colorado
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Stewart E, Nydam TL, Hendrickse A, Pomposelli JJ, Pomfret EA, Moore HB. Viscoelastic Management of Coagulopathy during the Perioperative Period of Liver Transplantation. Semin Thromb Hemost 2023; 49:119-133. [PMID: 36318962 PMCID: PMC10366939 DOI: 10.1055/s-0042-1758058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Viscoelastic testing (VET) in liver transplantation (LT) has been used since its origin, in combination with standard laboratory testing (SLT). There are only a few, small, randomized controlled trials that demonstrated a reduction in transfusion rates using VET to guide coagulation management. Retrospective analyses contrasting VET to SLT have demonstrated mixed results, with a recent concern for overtreatment and the increase in postoperative thrombotic events. An oversight of many studies evaluating VET in LT is a single protocol that does not address the different phases of surgery, in addition to pre- and postoperative management. Furthermore, the coagulation spectrum of patients entering and exiting the operating room is diverse, as these patients can have varying anatomic and physiologic risk factors for thrombosis. A single transfusion strategy for all is short sighted. VET in combination with SLT creates the opportunity for personalized resuscitation in surgery which can address the many challenges in LT where patients are at a paradoxical risk for both life-threatening bleeding and clotting. With emerging data on the role of rebalanced coagulation in cirrhosis and hypercoagulability following LT, there are numerous potential roles in VET management of LT that have been unaddressed.
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Affiliation(s)
- Erin Stewart
- Department of Anesthesia, University of Colorado School of Medicine, Aurora, Colorado
| | - Trevor L. Nydam
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Adrian Hendrickse
- Department of Anesthesia, University of Colorado School of Medicine, Aurora, Colorado
| | - James J. Pomposelli
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Elizabeth A. Pomfret
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Hunter B. Moore
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
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Characteristics and Outcomes of Liver Transplantation Recipients after Tranexamic Acid Treatment and Platelet Transfusion: A Retrospective Single-Centre Experience. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020219. [PMID: 36837421 PMCID: PMC9961269 DOI: 10.3390/medicina59020219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/09/2023] [Accepted: 01/18/2023] [Indexed: 01/26/2023]
Abstract
Background and Objectives: Patients undergoing liver transplantation (LT) often require increased blood product transfusion due to pre-existing coagulopathy and intraoperative fibrinolysis. Strategies to minimise intraoperative bleeding and subsequent blood product requirements include platelet transfusion and tranexamic acid (TXA). Prophylactic TXA administration has been shown to reduce bleeding and blood product requirements intraoperatively. However, its clinical use is still debated. The aim of this study was to report on a single-centre practice and analyse clinical characteristics and outcomes of LT recipients according to intraoperative treatment of TXA or platelet transfusion. Materials and Methods: This was a retrospective observational cohort study in which we reviewed 162 patients' records. Characteristics, intraoperative requirement of blood products, postoperative development of thrombosis and outcomes were compared between patients without or with intraoperative TXA treatment and without or with platelet transfusion. Results: Intraoperative treatment of TXA and platelets was 53% and 57.40%, respectively. Patients who required intraoperative administration of TXA or platelet transfusion also required more transfusion of blood products. Neither TXA nor platelet transfusion were associated with increased postoperative development of hepatic artery and portal vein thrombosis, 90-day mortality or graft loss. There was a significant increase in the median length of intensive care unit (ICU) stay in those who received platelet transfusion only (2.00 vs. 3.00 days; p = 0.021). Time to extubate was significantly different in both those who required TXA and platelet transfusion intraoperatively. Conclusions: Our analysis indicates that LT recipients still required copious intraoperative transfusion of blood products, despite the use of intraoperative TXA and platelets. Our findings have important implications for current transfusion practice in LT recipients and may guide clinicians to act upon these findings, which will support global efforts to encourage a wider use of TXA to reduce transfusion requirements, including platelets.
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Liu Y, Yan P, Bin Y, Qin X, Wu Z. Neutrophil extracellular traps and complications of liver transplantation. Front Immunol 2022; 13:1054753. [PMID: 36466888 PMCID: PMC9712194 DOI: 10.3389/fimmu.2022.1054753] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/26/2022] [Indexed: 08/29/2023] Open
Abstract
Many end-stage liver disease etiologies are attributed to robust inflammatory cell recruitment. Neutrophils play an important role in inflammatory infiltration and neutrophil phagocytosis, oxidative burst, and degranulation. It has also been suggested that neutrophils may release neutrophil extracellular traps (NETs) to kill pathogens. It has been proven that neutrophil infiltration within the liver contributes to an inflammatory microenvironment and immune cell activation. Growing evidence implies that NETs are involved in the progression of numerous complications of liver transplantation, including ischemia-reperfusion injury, acute rejection, thrombosis, and hepatocellular carcinoma recurrence. NETs are discussed in this comprehensive review, focusing on their effects on liver transplantation complications. Furthermore, we discuss NETs as potential targets for liver transplantation therapy.
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Affiliation(s)
- Yanyao Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ping Yan
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yue Bin
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoyan Qin
- Department of General Surgery and Trauma Surgery, Children’s Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Zhongjun Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Tzimas P, Lefkou E, Karakosta A, Argyrou S, Papapetrou E, Pantazi D, Tselepis A, Van Dreden P, Stratigopoulou P, Gerotziafas GT, Glantzounis G. Perioperative coagulation profile in major liver resection for cancer: a prospective observational study. Thromb Haemost 2022; 122:1662-1672. [PMID: 35483884 DOI: 10.1055/a-1839-0355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Hepatectomy induced coagulation disturbances have been well studied over the past decade. Cumulative evidence supports the superiority of global coagulation analysis compared to conventional coagulation tests (i.e. PT or aPTT) for clinical decision making. Cancer, however, represents an acquired prothrombotic state and liver resection for cancer deserves a more thorough investigation. This prospective observational study was conducted to assess the perioperative coagulation status of patients undergoing major hepatectomies for primary or metastatic hepatic malignancy. Patients were followed up to the 10th postoperative day by serial measurements of conventional coagulation tests, plasma levels of coagulation factors and thrombin generation assay parameters. An abnormal coagulation profile was detected at presentation and included elevated FVIII levels, decreased levels of antithrombin and lag time prolongation in thrombin generation. Serial hematological data demonstrated increased vWF, FVIII, D-dimer, fibrinogen and decreased levels of natural anticoagulant proteins in the early postoperative period predisposing to a hypercoagulable state. The ratio of the anticoagulant protein C to the procoagulant FVIII was low at baseline and further declined postoperatively, indicating a prothrombotic state. Though no bleeding complications were reported, one patient experienced pulmonary embolism while under thromboprophylaxis. Overall, patients with hepatic carcinoma presenting for elective major hepatectomy may have baseline malignancy associated coagulation disturbances, aggravating the hypercoagulable state documented in the early postoperative period.
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Kumar JI, Wasserman J, Heller RS, Agazzi S. Spontaneous resolution of cerebral arteriovenous malformation after liver transplant: illustrative case. Br J Neurosurg 2021:1-4. [PMID: 34933609 DOI: 10.1080/02688697.2021.2016621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/25/2021] [Accepted: 12/05/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Cerebral arteriovenous malformations (AVMs) have historically been considered congenital lesions with treatment options including surgery, radiation therapy, and observation. Spontaneous resolution of cerebral AVMs remains an exceedingly rare event with poorly understood pathophysiology. MATERIALS AND METHODS Herein we report a retrospective case review of a 28-year-old man with alcoholic cirrhosis who presented with a seizure 3 weeks after liver transplantation. Neuroimaging confirmed the presence of a Spetzler-Martin grade 2 AVM in the right frontal lobe. Due to the recent liver transplantation, treatment was deferred at the time of initial diagnosis and the patient was observed for a course of 1 year. Follow-up imaging 1 year later showed resolution of the AVM, confirmed by a catheter angiogram. CONCLUSION Spontaneous resolution of cerebral AVMs is a rare event. Treatment of chronic liver disease resulted in the normalization of angiogenic factors that likely led to AVM resolution. This case provides valuable insight into the vital role of angiogenesis in the natural history of AVMs.
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Affiliation(s)
- Jay I Kumar
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Jacob Wasserman
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Robert S Heller
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Siviero Agazzi
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
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Is there a procoagulant state long-term after lung transplantation? A prospective study. Respir Med 2021; 188:106584. [PMID: 34560353 DOI: 10.1016/j.rmed.2021.106584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/18/2021] [Accepted: 08/22/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a major complication after lung transplantation (LT). However, its pathophysiology remains unknown, and coagulation profiles have yet to be described. OBJECTIVE The aim of this study was to longitudinally assess coagulation status after LT. METHODS We performed a prospective study and described the coagulation profiles of 48 patients at 5 different time-points: before LT and at 24-72 h, 2 weeks, 4 months, and 1 year after LT. RESULTS At baseline, almost all analyzed coagulation factors were within the normal range, except for FVIII, which was above the normal range. Von Willebrand factor (vWF) and FVIII were increased after LT and remained high at 1 year after transplantation. The cumulative incidence of VTE was 22.9%. Patients who developed VTE had higher FVIII activity 2 weeks after LT. CONCLUSIONS This is the first study to describe coagulation profiles up to 1 year after LT. We show that most markers of a procoagulant state normalize at 2 weeks after LT, but that values of FVIII and vWF remain abnormal at 1 year. This problem has received little attention in the literature. Larger studies are necessary to confirm the results and to design appropriate prophylactic strategies.
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Uchida H, Sakamoto S, Shimizu S, Takeda M, Yanagi Y, Fukuda A, Abdelwahed MS, Miyazaki O, Nosaka S, Kasahara M. Efficacy of intraoperative cine-portogram for complicated portal vein reconstruction in pediatric living donor liver transplantation. Pediatr Transplant 2021; 25:e13835. [PMID: 32886397 DOI: 10.1111/petr.13835] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/01/2020] [Accepted: 08/08/2020] [Indexed: 02/06/2023]
Abstract
Sufficient PV flow is necessary to achieve successful PV reconstruction in pediatric LDLT. IOCP can be used to assess the severity of PV stenosis and to identify potential portosystemic collateral pathways. The present study reviewed the utility of IOCP and the outcomes of patients who underwent assessment with an IOCP. Consecutive primary LDLTs were performed in 488 pediatric recipients between November 2005 and October 2019. IOCP was used in patients who were unable to achieve sufficient PV flow after the ligation of collaterals. In total, 11 patients underwent IOCP to assess potential portosystemic collateral pathways. The median age and body weight was 8 months (IQR, 6-11 months) and 6.6 kg (IQR, 5.7-8.9 kg), respectively. The reasons for using the IOCP were recurrent PV thrombus in seven patients and insufficient PV flow in four patients. IOCP revealed remaining collaterals in six patients and residual hypoplastic PV in eight patients. Two patients required additional interruption of the potential collaterals under IOCP, which were unable to be recognized as a dominant portosystemic collateral pathway on preoperative imaging. All eight patients with residual hypoplastic PV required vein graft interposition for the complete removal of the hypoplastic PV. All the patients are currently doing well with a median follow-up period of 4.9 years (IQR, 2.2-5.6 years). IOCP can be an effective tool for precisely detecting occult portosystemic collateral pathways and for assessing the patency of the PV anastomosis in pediatric LDLT.
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Affiliation(s)
- Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seiichi Shimizu
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Masahiro Takeda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Yusuke Yanagi
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Mohamed Sami Abdelwahed
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Osamu Miyazaki
- Division of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Shunsuke Nosaka
- Division of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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Li Q, Wang Y, Ma T, Ren F, Mu F, Wu R, Lv Y, Wang B. Preoperative platelet count predicts posttransplant portal vein complications in orthotopic liver transplantation: a propensity score analysis. BMC Gastroenterol 2021; 21:1. [PMID: 33407176 PMCID: PMC7789364 DOI: 10.1186/s12876-020-01553-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 11/23/2020] [Indexed: 12/11/2022] Open
Abstract
Background The role of platelets on the prognosis of patients with liver transplantation remains unclear. Thus, we aimed to evaluate the influence of preoperative platelet count on postoperative morbidity after liver transplantation. Methods Clinical data of the patients who received liver transplantation from January 2015 to September 2018 were evaluated. Results Of the 329 patients included, the average age was 46.71 ± 0.55 years, and 243 were men (75.2%). The incidence of posttransplant portal vein complication was significantly higher in the high platelet count group (> 49.5 × 109/L; n = 167) than in the low platelet count group (≤ 49.5 × 109/L, n = 162, 12.6% vs. 1.9%). After multivariable regression analysis, high platelet count was independently associated with postoperative portal vein complication (odds ratio [OR]: 8.821, 95% confidence interval [CI]: 2.260 to 34.437). After the inverse probability of treatment weighting analysis, patients in the high platelet count group had significantly higher risk of portal vein complication (OR: 9.210, 95%CI: 1.907 to 44.498, p = 0.006) and early allograft dysfunction (OR: 2.087, 95%CI: 1.131 to 3.853, p = 0.019). Conclusions Preoperative platelet count > 49.5 × 109/L was an independent risk factor for posttransplant portal vein complication and early allograft dysfunction. High preoperative platelet count could be an adverse prognostic predictor for liver transplantation recipients.
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Affiliation(s)
- Qingshan Li
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, Shaanxi Provincial Center for Regenerative Medicine and Surgical Engineering, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277, West Yanta Road, Xi'an, 710061, Shaanxi Province, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Yue Wang
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, Shaanxi Provincial Center for Regenerative Medicine and Surgical Engineering, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277, West Yanta Road, Xi'an, 710061, Shaanxi Province, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Tao Ma
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, Shaanxi Provincial Center for Regenerative Medicine and Surgical Engineering, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277, West Yanta Road, Xi'an, 710061, Shaanxi Province, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Fenggang Ren
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, Shaanxi Provincial Center for Regenerative Medicine and Surgical Engineering, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277, West Yanta Road, Xi'an, 710061, Shaanxi Province, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Fan Mu
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, Shaanxi Provincial Center for Regenerative Medicine and Surgical Engineering, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277, West Yanta Road, Xi'an, 710061, Shaanxi Province, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Rongqian Wu
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, Shaanxi Provincial Center for Regenerative Medicine and Surgical Engineering, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277, West Yanta Road, Xi'an, 710061, Shaanxi Province, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Yi Lv
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, Shaanxi Provincial Center for Regenerative Medicine and Surgical Engineering, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277, West Yanta Road, Xi'an, 710061, Shaanxi Province, China. .,Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China.
| | - Bo Wang
- National Local Joint Engineering Research Center for Precision Surgery & Regenerative Medicine, Shaanxi Provincial Center for Regenerative Medicine and Surgical Engineering, Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277, West Yanta Road, Xi'an, 710061, Shaanxi Province, China. .,Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China.
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Pietri LD, Montalti R, Bolondi G, Serra V, Benedetto FD. Intraoperative thromboelastography as a tool to predict postoperative thrombosis during liver transplantation. World J Transplant 2020; 10:345-355. [PMID: 33312895 PMCID: PMC7708883 DOI: 10.5500/wjt.v10.i11.345] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/28/2020] [Accepted: 09/02/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Thromboembolic complications are relatively common causes of increased morbidity and mortality in the perioperative period in liver transplant patients. Early postoperative portal vein thrombosis (PVT, incidence 2%-2.6%) and early hepatic artery thrombosis (HAT, incidence 3%-5%) have a poor prognosis in transplant patients, having impacts on graft and patient survival. In the present study, we attempted to identify the predictive factors of these complications for early detection and therefore monitor more closely the patients most at risk of thrombotic complications.
AIM To investigate whether intraoperative thromboelastography (TEG) is useful in detecting the risk of early postoperative HAT and PVT in patients undergoing liver transplantation (LT).
METHODS We retrospectively collected thromboelastographic traces, in addition to known risk factors (cold ischemic time, intraoperative requirement for red blood cells and fresh-frozen plasma transfusion, prolonged operating time), in 27 patients, selected among 530 patients (≥ 18 years old), who underwent their first LT from January 2002 to January 2015 at the Liver University Transplant Center and developed an early PVT or HAT (case group). Analyses of the TEG traces were performed before anesthesia and 120 min after reperfusion. We retrospectively compared these patients with the same number of nonconsecutive control patients who underwent LT in the same study period without developing these complications (1:1 match) (control group). The chosen matching parameters were: Patient graft and donor characteristics [age, sex, body mass index (BMI)], indication for transplantation, procedure details, United Network for Organ Sharing classification, BMI, warm ischemia time (WIT), cold ischemia time (CIT), the volume of blood products transfused, and conventional laboratory coagulation analysis. Normally distributed continuous data are reported as the mean ± SD and compared using one-way Analysis of Variance (ANOVA). Non-normally distributed continuous data are reported as the median (interquartile range) and compared using the Mann-Whitney test. Categorical variables were analyzed with Chi-square tests with Yates correction or Fisher’s exact test depending on best applicability. IBM SPSS Statistics version 24 (SPSS Inc., Chicago, IL, United States) was employed for statistical analysis. Statistical significance was set at P < 0.05.
RESULTS Postoperative thrombotic events were identified as early if they occurred within 21 d postoperatively. The incidence of early hepatic artery occlusion was 3.02%, whereas the incidence of PVT was 2.07%. A comparison between the case and control groups showed some differences in the duration of surgery, which was longer in the case group (P = 0.032), whereas transfusion of blood products, red blood cells, fresh frozen plasma, and platelets, was similar between the two study groups. Thromboelastographic parameters did not show any statistically significant difference between the two groups, except for the G value measured at basal and 120’ postreperfusion time. It was higher, although within the reference range, in the case group than in the control group (P = 0.001 and P < 0.001, respectively). In addition, clot lysis at 60 min (LY60) measured at 120’ postreperfusion time was lower in the case group than in the control group (P = 0.035). This parameter is representative of a fibrinolysis shutdown (LY60 = 0%-0.80%) in 85% of patients who experienced a thrombotic complication, resulting in a statistical correlation with HAT and PVT.
CONCLUSION The end of surgery LY60 and G value may identify those recipients at greater risk of developing early HAT or PVT, suggesting that they may benefit from intense surveillance and eventually anticoagulation prophylaxis in order to prevent these serious complications after LT.
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Affiliation(s)
- Lesley De Pietri
- Department of General Surgery, Division of Anaesthesiology and Intensive Care Unit, Nuovo Ospedale Civile di Sassuolo, Sassuolo 41049, Modena, Italy
| | - Roberto Montalti
- Department of Public Health, Hepato-Pancreato-Biliary Surgery Section, Federico II University of Naples, Napoli 80138, Italy
| | - Giuliano Bolondi
- Surgery and Trauma Department, Intensive Care Unit, Ospedale Bufalini Cesena, Cesena 47521, Italy
| | - Valentina Serra
- Surgery Department, Hepato-Pancreato-Biliary Surgery, Surgical Oncology and Liver Transplantation Unit, Azienda Ospedaliero Universitaria di Modena, University of Modena and Reggio Emilia, Modena 41125, Italy
| | - Fabrizio Di Benedetto
- Surgery Department, Hepato-Pancreato-Biliary Surgery, Surgical Oncology and Liver Transplantation Unit, Azienda Ospedaliero Universitaria di Modena, University of Modena and Reggio Emilia, Modena 41125, Italy
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12
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Li Y, Nieuwenhuis LM, Werner MJM, Voskuil MD, Gacesa R, Blokzijl H, Lisman T, Weersma RK, Porte RJ, Festen EAM, de Meijer VE. Donor tobacco smoking is associated with postoperative thrombosis after primary liver transplantation. J Thromb Haemost 2020; 18:2590-2600. [PMID: 32614986 PMCID: PMC7590074 DOI: 10.1111/jth.14983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 06/16/2020] [Accepted: 06/22/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Thrombosis after liver transplantation is a leading cause of graft loss, morbidity, and mortality. Several known recipient- and surgery-related characteristics have been associated with increased risk of thrombosis after transplantation. Potential donor-related risk factors, however, remain largely undefined. OBJECTIVES We aimed to identify risk factors for early post-transplantation thrombosis (<90 days) and to determine the impact of early postoperative thrombosis on long-term graft and patient survival. PATIENTS/METHODS A post hoc analysis was performed of an observational cohort study including all primary, adult liver transplantations performed between 1993 and 2018. Donor-, recipient-, and surgery-related characteristics were collected. Competing risk model analyses and multivariable regression analyses were performed to identify risk factors for developing early post-transplant thrombosis and graft failure. RESULTS From a total of 748 adult liver transplantations, 58 recipients (7.8%) developed a thrombosis after a median of 7 days. Post-transplantation thrombotic events included 25 hepatic artery thromboses, 13 portal vein thromboses, and 22 other thrombotic complications. Donor history of smoking was independently associated with early postoperative thrombosis (odds ratio [OR] 2.42; 95% confidence interval [CI], 1.29-4.52). Development of early post-transplant thrombosis was independently associated with patient mortality (hazard ratio [HR] 3.61; 95% CI 1.54-8.46) and graft failure (HR 5.80, 95% CI 3.26-10.33), respectively. CONCLUSION Donor history of smoking conveys a more than two-fold increased risk of thrombosis after liver transplantation, independent of other factors. Post-transplant thrombosis was independently associated with decreased patient and graft survival.
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Affiliation(s)
- Yanni Li
- Department of Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
- Department of GeneticsUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Lianne M. Nieuwenhuis
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Maureen J. M. Werner
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Michiel D. Voskuil
- Department of Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
- Department of GeneticsUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Ranko Gacesa
- Department of Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
- Department of GeneticsUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Hans Blokzijl
- Department of Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Ton Lisman
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Rinse K. Weersma
- Department of Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Robert J. Porte
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Eleonora A. M. Festen
- Department of Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
- Department of GeneticsUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Vincent E. de Meijer
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
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13
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Amaral B, Vicente M, Pereira CSM, Araújo T, Ribeiro A, Pereira R, Perdigoto R, Marcelino P. Approach to the liver transplant early postoperative period: an institutional standpoint. Rev Bras Ter Intensiva 2020; 31:561-570. [PMID: 31967233 PMCID: PMC7009000 DOI: 10.5935/0103-507x.20190076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 03/04/2019] [Indexed: 12/16/2022] Open
Abstract
The liver transplant program in our center started in 1992, and post-liver transplant patients are still admitted to the intensive care unit. For the intensive care physician, a learning curve started then, skills were acquired, and a specific practice was established. Throughout this time, several concepts changed, improving the care of these patients. The practical approach varies between liver transplant centers, according to local specificities. Hence, we wanted to present our routine practice to stimulate the debate between dedicated teams, which can allow the introduction of new ideas and potentially improve each local standard of care.
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Affiliation(s)
- Beatriz Amaral
- Unidade de Terapia Intensiva, Hospital Curry Cabral - Lisboa, Portugal
| | - Madalena Vicente
- Unidade de Terapia Intensiva, Hospital Curry Cabral - Lisboa, Portugal
| | | | - Teresa Araújo
- Departamento de Imunoterapia, Hospital Curry Cabral - Lisboa, Portugal
| | - Ana Ribeiro
- Departamento de Imunoterapia, Hospital Curry Cabral - Lisboa, Portugal
| | - Rui Pereira
- Unidade de Terapia Intensiva, Hospital Curry Cabral - Lisboa, Portugal
| | - Rui Perdigoto
- Unidade de Transplante Hepático, Hospital Curry Cabral - Lisboa, Portugal
| | - Paulo Marcelino
- Unidade de Terapia Intensiva, Hospital Curry Cabral - Lisboa, Portugal
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14
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Werner MJM, Adelmeijer J, de Meijer VE, de Kleine RHJ, Scheenstra R, Bontemps STH, Reyntjens KMEM, Hulscher JBF, Porte RJ, Lisman T. In Vitro Evaluation of Pro- and Anticoagulant Drugs in Children with End-Stage Liver Disease Undergoing Liver Transplantation. Thromb Haemost 2020; 120:1240-1247. [DOI: 10.1055/s-0040-1713752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Abstract
Background Pro- and anticoagulant drugs are commonly used in pediatric liver transplantation to prevent and treat thrombotic and bleeding complications. However, the combination of baseline hemostatic changes in children with liver disease and additional changes induced by transplantation makes this very challenging. This study aimed to analyze the efficacy of clinically available pro- and anticoagulant drugs in plasma from children undergoing liver transplantation.
Methods In vitro effects of pro- and anticoagulant drugs on thrombin generation capacity were tested in plasma samples of 20 children (≤ 16 years) with end-stage liver disease undergoing liver transplantation, and compared with 30 age-matched healthy controls.
Results Addition of pooled normal plasma had no effect in patients or controls, while 4-factor prothrombin complex concentrate increased thrombin generation in both patients and controls, with enhanced activity in patients. At start of transplantation, dabigatran and unfractionated heparin had a higher anticoagulant potency in patients, whereas 30 days after transplantation low molecular weight heparin was slightly less effective in patients. Effects of rivaroxaban were comparable between patients and controls.
Conclusion This study revealed important differences in efficacy of commonly used pro- and anticoagulant drugs in children with end-stage liver disease undergoing liver transplantation. Therefore, dose adjustments of these drugs may be required. The results of this study may be helpful in the development of urgently needed protocols for strategies to prevent and treat bleeding and thrombotic complications in pediatric liver transplantation.
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Affiliation(s)
- Maureen J. M. Werner
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jelle Adelmeijer
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Vincent E. de Meijer
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ruben H. J. de Kleine
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - René Scheenstra
- Department of Pediatric Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sander T. H. Bontemps
- Department of Pediatric Intensive Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Koen M. E. M. Reyntjens
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan B. F. Hulscher
- Section of Pediatric Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert J. Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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15
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Zhang H, Goswami J, Varley P, van der Windt DJ, Ren J, Loughran P, Yazdani H, Neal MD, Simmons RL, Zhang J, Tsung A, Huang H. Hepatic Surgical Stress Promotes Systemic Immunothrombosis That Results in Distant Organ Injury. Front Immunol 2020; 11:987. [PMID: 32528475 PMCID: PMC7256968 DOI: 10.3389/fimmu.2020.00987] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 04/27/2020] [Indexed: 12/16/2022] Open
Abstract
Innate immunity can initiate platelet activation during the development of thrombosis through a process, termed immunothrombosis. Neutrophils form neutrophil extracellular traps (NETs) that have been shown to interact directly with platelets and play pro-coagulant roles in a variety of infectious and sterile inflammatory settings. Hepatic surgical stress initiated by ischemia/reperfusion (I/R) injury has wide systemic consequences on distant organs. However, the mechanisms of this remote injury phenomenon are not well-understood. Here, we sought to determine the role of NETs in causing systemic immunothrombosis and distant organ injury following a local inflammatory insult with liver I/R. Postoperative thromboelastographic revealed that the speed of clot formation (alpha-angle) was significantly increased whereas time to clot formation (R-time) were decreased by in patients undergoing liver resection, indicating a hypercoagulable state after surgery. In mice subjected to liver I/R, circulating platelet activation and platelet-neutrophil aggregates were significantly increased. Injured distant organs such as the lung and kidney displayed NETs and platelet-rich micro-thrombi in the microvasculature following liver I/R. The immune-thrombi and organ damage were dramatically decreased when NETs were inhibited by DNase treatment. Depletion of Tlr4 on platelets limited NET-induced activation of platelets but had no effect on NET formation. Furthermore, platelet-specific TLR4 KO mice had significantly reduced distant organ injury with decreased circulating platelet activation, platelet-neutrophil aggregates following liver I/R in comparison to their control counterparts. These data establish that after an acute local inflammatory process, NET-activated platelets can lead to a systemic pro-coagulant state with resultant remote organ injury by immunothrombosis.
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Affiliation(s)
- Hongji Zhang
- Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, United States.,Department of Surgery, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Julie Goswami
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Patrick Varley
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Dirk J van der Windt
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Jinghua Ren
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Cancer Center, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Patricia Loughran
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Cell Biology, Center for Biologic Imaging, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Hamza Yazdani
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Richard L Simmons
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Jinxiang Zhang
- Department of Surgery, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Allan Tsung
- Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, United States
| | - Hai Huang
- Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, United States
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16
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Stine JG, Intagliata NM, Shah NL, Lisman T, Violi F, Caldwell SH, Argo CK. Clinical Cirrhosis Dilemmas: Survey of Practice from the 7th International Coagulation in Liver Disease Conference. Dig Dis Sci 2020; 65:1334-1339. [PMID: 31628574 PMCID: PMC7160024 DOI: 10.1007/s10620-019-05884-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 10/09/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION AND AIM Hemostatic disorders in chronic liver disease and cirrhosis show continued expansion of research efforts. However, clinical decision making is often practiced on an individual patient level as consensus guidelines are lacking. We aimed to better assess individual day-to-day clinical practice through gauging clinicians' responses to common clinical scenarios. MATERIALS AND METHODS A series of ten clinical scenarios (seven procedural coagulation and three thrombosis management) were posed to conference attendees utilizing real-time polling software (Poll Everywhere). Responses were binomial and were submitted as "Agree" or "Disagree." Results were displayed real time following a standardized response period and an open-forum discussion ensued between conference faculty and attendees following response submission. RESULTS Twenty conference attendees participated in the clinical scenario plenary session. In general, agreement rates were high. All but one of the ten clinical scenarios had ≥ 70% agreement. Agreement was based both on procedural risk, with greatest agreement seen for low-risk procedures (80-93%), and on peri-procedural coagulation parameters of platelet count and fibrinogen level where > 50,000μ/L and 120 mg/dL were the most agreed upon thresholds, respectively. 75-95% agreement was reached when surveying the need for anticoagulation for mesenteric vein thrombosis in liver transplant candidates; slightly less (71%) agreement was found when deciding to proceed with anticoagulation in non-liver transplant candidates with mesenteric vein thrombosis. CONCLUSIONS While large-scale, methodologically rigorous randomized controlled trials are lacking to guide clinical decision making in patients with coagulation disorders and chronic liver disease, consensus expert opinion regarding mitigating peri-procedural bleeding risk and treatment of thrombosis appears consistent and strong.
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Affiliation(s)
- Jonathan G Stine
- Division of Gastroenterology & Hepatology, Department of Medicine, The Pennsylvania State University, Hershey PA, USA,Department of Public Health Sciences, The Pennsylvania State University, Hershey PA, USA
| | - Nicolas M. Intagliata
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Virginia, Charlottesville VA, USA
| | - Neeral L. Shah
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Virginia, Charlottesville VA, USA
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Francesco Violi
- Department of Internal and Specialized Medicine, Sapienza University of Rome, Italy
| | - Stephen H. Caldwell
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Virginia, Charlottesville VA, USA
| | - Curtis K. Argo
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Virginia, Charlottesville VA, USA
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17
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Werner MJM, de Meijer VE, Adelmeijer J, de Kleine RHJ, Scheenstra R, Bontemps STH, Reyntjens KMEM, Hulscher JBF, Lisman T, Porte RJ. Evidence for a rebalanced hemostatic system in pediatric liver transplantation: A prospective cohort study. Am J Transplant 2020; 20:1384-1392. [PMID: 31841272 PMCID: PMC7216958 DOI: 10.1111/ajt.15748] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/12/2019] [Accepted: 12/04/2019] [Indexed: 01/25/2023]
Abstract
In adults with end-stage liver disease concurrent changes in pro- and antihemostatic pathways result in a rebalanced hemostasis. Children though, have a developing hemostatic system, different disease etiologies, and increased risk of thrombosis. This study aimed to assess the hemostatic state of children during and after liver transplantation. Serial blood samples were obtained from 20 children (≤16 years) undergoing primary liver transplantation (September 2017-October 2018). Routine hemostasis tests, thrombomodulin-modified thrombin generation, clot lysis times, and hemostatic proteins were measured. Reference values were established using an age-matched control group of 30 children. Thrombocytopenia was present in study patients. Von Willebrand factors were doubled and ADAMTS13 levels decreased during and after transplantation up until day 30, when platelet count had normalized. Whereas prothrombin time and activated partial thromboplastin time were prolonged during transplantation, thrombin generation was within normal ranges, except during perioperative heparin administration. Fibrinogen, factor VIII levels, and clot lysis time were elevated up until day 30. In conclusion, children with end-stage liver disease are in tight hemostatic balance. During transplantation a temporary heparin-dependent hypocoagulable state is present, which rapidly converts to a hemostatic balance with distinct hypercoagulable features that persist until at least day 30. This hypercoagulable state may contribute to the risk of posttransplant thrombosis.
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Affiliation(s)
- Maureen J. M. Werner
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands,Department of SurgerySurgical Research LaboratoryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Vincent E. de Meijer
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Jelle Adelmeijer
- Department of SurgerySurgical Research LaboratoryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Ruben H. J. de Kleine
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - René Scheenstra
- Department of Pediatric Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Sander T. H. Bontemps
- Department of Pediatric Intensive CareUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Koen M. E. M. Reyntjens
- Department of AnesthesiologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Jan B. F. Hulscher
- Department of SurgerySection of Pediatric SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Ton Lisman
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands,Department of SurgerySurgical Research LaboratoryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Robert J. Porte
- Department of SurgerySection of Hepatobiliary Surgery and Liver TransplantationUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands,Department of SurgerySurgical Research LaboratoryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
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18
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Ichinomiya T, Murata H, Sekino M, Sato S, Higashijima U, Matsumoto S, Ishizaki H, Yoshitomi O, Maekawa T, Eguchi S, Hara T. Postoperative coagulation profiles of patients undergoing adult-to-adult living donor liver transplantation—A single-center experience. TRANSPLANTATION REPORTS 2020. [DOI: 10.1016/j.tpr.2019.100037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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19
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Bhat A, Das S, Yadav G, Chaudhary S, Vyas A, Islam M, Gupta AC, Bajpai M, Maiwall R, Maras JS, Sarin SK. Hyperoxidized Albumin Modulates Platelets and Promotes Inflammation Through CD36 Receptor in Severe Alcoholic Hepatitis. Hepatol Commun 2020; 4:50-65. [PMID: 31909355 PMCID: PMC6939543 DOI: 10.1002/hep4.1440] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/17/2019] [Indexed: 12/14/2022] Open
Abstract
Hyperoxidized albumin promotes inflammation and modulates several immune cells in severe alcoholic hepatitis (SAH). Platelets mediate inflammation by interacting with immune cells, endothelium, and other cells. The role of hyperoxidized albumin in platelet activation and alteration of platelet phenotype/functions is not known. Quantitative platelet proteomics performed in 10 patients with SAH was compared with 10 patients with alcoholic cirrhosis and 10 healthy controls, respectively. Dysregulated pathways were identified and validated in a separate cohort (n = 40). Healthy platelets were exposed to patient plasma or purified albumin or ex vivo modified albumin (human-mercaptalbumin, humannonmercaptalbumin-1, and human nonmercaptalbumin 2) in the presence or absence of CD36 blockade, and platelet secretome was analyzed. Two hundred and two up-regulated proteins linked to platelet activation, complement regulation, lipid transportation, and 321 down-regulated proteins related to platelet hemostasis and coagulation (fold change ± 1.5, P < 0.01) were identified. Blood transcription module enrichment showed an inflammatory phenotype of SAH platelet. Increased level of platelet factor-4, P-selectin, and soluble cluster of differentiation-40 ligand correlated with severity (Model for End-Stage Liver Disease score, r > 0.3, P < 0.05) in SAH. Transcripts linked to platelet activation (increased) and granular secretions (decreased in SAH) correlated with disease severity. SNARE (soluble-N-ethylmaleimide-sensitive-factor-activating-protein-receptor) complex proteins (SNAP-23 [synaptosomal-associated protein 23] and VAMP-8 [vesicle-associated membrane protein 3]) were down-regulated in SAH platelets (P < 0.05). In vitro stimulation of healthy platelets showed enhanced activation with patient plasma, or purified albumin-treatment blocking of CD36 blunted this effect (P < 0.05). Ex vivo modified albumin (primarily nonmercaptalbumin-human nonmercaptalbumin 2 [HNA2; 1 mg/mL]) showed high activation and aggregation and intracellular reactive oxygen species production in healthy platelets (P < 0.05), which significantly reduced after CD36 neutralization. Platelet secretome showed reduced inflammatory mediators and increased repair proteins. Conclusion: Hyperoxidized albumin triggers platelet activation (possibly through the CD36 receptor), promotes inflammation and oxidative stress, and contributes to disease severity in patients with SAH.
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Affiliation(s)
- Adil Bhat
- Department of Molecular and Cellular MedicineInstitute of Liver and Biliary SciencesNew DelhiIndia
| | - Sukanta Das
- Department of Molecular and Cellular MedicineInstitute of Liver and Biliary SciencesNew DelhiIndia
| | - Gaurav Yadav
- Department of Molecular and Cellular MedicineInstitute of Liver and Biliary SciencesNew DelhiIndia
| | - Sudrishti Chaudhary
- Department of Molecular and Cellular MedicineInstitute of Liver and Biliary SciencesNew DelhiIndia
| | - Ashish Vyas
- Department of Molecular and Cellular MedicineInstitute of Liver and Biliary SciencesNew DelhiIndia
| | - Mojahidul Islam
- Department of Molecular and Cellular MedicineInstitute of Liver and Biliary SciencesNew DelhiIndia
| | - Abhishak C. Gupta
- Department of Molecular and Cellular MedicineInstitute of Liver and Biliary SciencesNew DelhiIndia
| | - Meenu Bajpai
- Department of Transfusion MedicineInstitute of Liver and Biliary SciencesNew DelhiIndia
| | - Rakhi Maiwall
- Department of HepatologyInstitute of Liver and Biliary SciencesNew DelhiIndia
| | - Jaswinder Singh Maras
- Department of Molecular and Cellular MedicineInstitute of Liver and Biliary SciencesNew DelhiIndia
| | - Shiv K. Sarin
- Department of Molecular and Cellular MedicineInstitute of Liver and Biliary SciencesNew DelhiIndia
- Department of HepatologyInstitute of Liver and Biliary SciencesNew DelhiIndia
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20
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Premkumar M, Saxena P, Rangegowda D, Baweja S, Mirza R, Jain P, Bhatia P, Kumar G, Bihari C, Kalal C, Vyas T, Choudhury A, Sarin SK. Coagulation failure is associated with bleeding events and clinical outcome during systemic inflammatory response and sepsis in acute-on-chronic liver failure: An observational cohort study. Liver Int 2019; 39:694-704. [PMID: 30589495 DOI: 10.1111/liv.14034] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/12/2018] [Accepted: 12/12/2018] [Indexed: 02/13/2023]
Abstract
BACKGROUND Patients with acute-on-chronic liver failure (ACLF) have coagulation failure in the setting of systemic inflammatory syndrome (SIRS), sepsis and extra-hepatic organ failures. METHODS Consecutive ACLF patients without sepsis at baseline were assessed at days 0, 3 and 7 with thromboelastography (TEG) and specific assays (Factor VIII, von Willebrand factor [vWF], protein C and antithrombin III [ATIII]) and followed for development of sepsis, bleeding and outcome. RESULTS Of 243 patients, 114 (63% ethanol related; mean age 44.3 ± 11.7 years; 90% male) were recruited. SIRS was noted in 39 (34.2%), 45 (39.5%) and 46 (40%) patients at days 0, 3 and 7 and sepsis in 28 (24%) and 52 (56.1%) patients at days 3 and 7 respectively. The 28- and 90-day survivals were 62% and 51% respectively. A hypocoagulable TEG at baseline was a predictor of bleeding (hazard ratio [HR] 2.1; CI 1.6-4.9; P = 0.050) and mortality (HR 1.9; CI 1.3-7.9; P = 0.043). ACLF patients had increased Factor VIII, vWF, tissue factor levels and tissue plasminogen activator (tPA) activity with reduced protein C and ATIII. Coagulation parameters like Coagulation Index (HR 2.1; CI 1.1-4.5; P = 0.044),clot lysis (HR 3.2; CI 1.9-3.4; P = 0.033), low protein C < 30% (HR 2.1; CI 1.5-2.8; P = 0.017), ATIII (HR 1.4; CI 1.7-3.1; P = 0.052) and tPA (HR 1.5; CI 1.1-2.4; P = 0.052) were predictors of mortality at day 28. Protein C activity <30% (HR 1.3; CI 1.0-2.9; P = 0.042) and tPA >20 ng/mL (HR 1.2; CI 1.1-2.1; P = 0.040) predicted mortality when adjusted for age, gender and baseline MELD. CONCLUSIONS Dynamic coagulation derangements, measured by TEG, determine the likelihood of bleeding and mortality in ACLF.
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Priyanka Saxena
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Devaraja Rangegowda
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Sukriti Baweja
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Roshni Mirza
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Priyanka Jain
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Puja Bhatia
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chhagan Bihari
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chetan Kalal
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Tanmay Vyas
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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21
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Balaceanu A. Deep vein thrombosis during long-term surveillance of patients with liver transplantation. Ir J Med Sci 2019; 188:1191-1193. [DOI: 10.1007/s11845-019-01998-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 02/27/2019] [Indexed: 12/25/2022]
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22
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Bezinover D, Deacutis MF, Dalal PG, Moores RP, Stine JG, Wang M, Reeder E, Hollenbeak CS, Saner FH, Riley TR, Janicki PK. Perioperative thrombotic complications associated with pediatric liver transplantation: a UNOS database evaluation. HPB (Oxford) 2019; 21:370-378. [PMID: 30266497 PMCID: PMC7480188 DOI: 10.1016/j.hpb.2018.08.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 08/31/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND This retrospective UNOS database evaluation analyzes the prevalence of preoperative portal vein thromboses (PVT), and postoperative thromboses leading to graft failure in pediatric patients undergoing liver transplantation (LT). METHODS The evaluation was performed in three age groups: I (0-5), II (6-11), III (12-18) years old. Factors predictive of pre- and postoperative thromboses were analyzed. RESULTS Between 2000 and 2015, 8982 pediatric LT were performed in the US. Of those, 390 patients had preoperative PVT (4.3%), and 396 (4.4%) had postoperative thromboses. The prevalence of both types of thromboses was less in Group III than in the other two groups (3.20% vs 4.65%, p = 0.007 and 1.73% vs. 5.13%, p < 0.001, respectively). The prevalence of postoperative thromboses was significantly higher in Group I than in the other two groups (5.49% vs. 2.51%, p < 0.001). Preoperative PVT was independently associated with postoperative thromboses (OR = 1.7, p = 0.02). Children less than 5 years of age were more likely to develop postoperative thromboses leading to graft failure (OR = 2.9, p < 0.001). CONCLUSION Younger children undergoing LT are prone to pre-and postoperative thrombotic complications. Preoperative PVT at the time of transplantation was independently associated with postoperative thromboses. Perioperative antithrombotic therapy should be considered in pediatric patients undergoing LT.
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Affiliation(s)
- Dmitri Bezinover
- Departments of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey
| | - Molly F. Deacutis
- Departments of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey
| | - Priti G. Dalal
- Departments of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey
| | - Robert P. Moores
- Department of Anesthesiology, School of Medicine, Washington University in St Louis, St Louis
| | - Jonathan G. Stine
- Department of Medicine, Division of Hepatology, Penn State Milton S. Hershey Medical Center
| | - Ming Wang
- Department of Public Health Science, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, USA
| | - Ethan Reeder
- Departments of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey
| | - Christopher S. Hollenbeak
- Department of Public Health Science, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, USA
| | - Fuat H. Saner
- Department of General, Visceral and Transplant Surgery, Essen University Medical Center, Essen, Germany
| | - Thomas R. Riley
- Department of Medicine, Division of Hepatology, Penn State Milton S. Hershey Medical Center
| | - Piotr K. Janicki
- Departments of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey
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Burlage LC, Bos S, Adelmeijer J, Sakai T, Porte RJ, Lisman T. Plasma From Patients Undergoing Liver Transplantation Is Resistant to Anticoagulant Activity of Soluble Thrombomodulin. Liver Transpl 2019; 25:252-259. [PMID: 30067306 PMCID: PMC6590179 DOI: 10.1002/lt.25318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 07/23/2018] [Indexed: 01/13/2023]
Abstract
Recombinant human soluble thrombomodulin (ART-123) is an anticoagulant and anti-inflammatory agent clinically used for treatment of disseminated intravascular coagulation. Preclinical studies have shown that ART-123 reduces hepatic ischemia/reperfusion. Although ART-123 may therefore have clinical benefit in orthotopic liver transplantation, the substantial alterations in the hemostatic system may complicate its use in this setting. Here, we studied the in vitro effect of ART-123 on coagulation of patients with end-stage liver disease undergoing liver transplantation. Ten patients with end-stage liver disease undergoing liver transplantation were included in this study. Plasma samples of 10 healthy individuals were included to establish reference values. Different concentrations of ART-123 were added to plasma samples, and peak thrombin generation and clot lysis times (CLTs) were determined. In patient samples, plasma was profoundly resistant to the anticoagulant action of ART-123, as reflected by significantly higher median inhibitory concentration (IC50 ) values of peak thrombin generation compared with controls. This might be partially explained by low levels of protein C, protein S, and elevated levels of factor VIII during transplantation. Intraoperative levels of thrombin activatable fibrinolysis inhibitor were significantly lower when compared with controls. However, ART-123-dependent prolongation of CLTs was not significantly different from healthy controls. In conclusion, this study suggests that ART-123 is unlikely to provoke bleeding in patients undergoing liver transplantation because proposed clinical dosages have a virtually absent anticoagulant effect in these patients. Clinical studies are required to confirm the safety of ART-123 and efficacy on alleviating ischemia/reperfusion injury during liver transplantation.
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Affiliation(s)
- Laura C. Burlage
- Section of HPB Surgery and Liver Transplantation,Surgical Research Laboratory, Department of SurgeryUniversity Medical Center Groningen, University of GroningenGroningenthe Netherlands
| | - Sarah Bos
- Surgical Research Laboratory, Department of SurgeryUniversity Medical Center Groningen, University of GroningenGroningenthe Netherlands
| | - Jelle Adelmeijer
- Surgical Research Laboratory, Department of SurgeryUniversity Medical Center Groningen, University of GroningenGroningenthe Netherlands
| | - Takumi Sakai
- Development Planning, Clinical Department CenterAsahi Kasei Pharma CorporationTokyoJapan
| | | | - Ton Lisman
- Section of HPB Surgery and Liver Transplantation,Surgical Research Laboratory, Department of SurgeryUniversity Medical Center Groningen, University of GroningenGroningenthe Netherlands
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24
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Goal-directed Management of Coagulation: The Right Treatment, the Right Patient, the Right Time. Transplantation 2019; 102:e303-e304. [PMID: 29557909 DOI: 10.1097/tp.0000000000002179] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Grimaldi C, di Francesco F, Chiusolo F, Angelico R, Monti L, Muiesan P, de Ville de Goyet J. Aggressive prevention and preemptive management of vascular complications after pediatric liver transplantation: A major impact on graft survival and long-term outcome. Pediatr Transplant 2018; 22:e13288. [PMID: 30171665 DOI: 10.1111/petr.13288] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 05/13/2018] [Accepted: 07/30/2018] [Indexed: 12/14/2022]
Abstract
Vascular complications are a major cause of patient and graft loss after LTs. The aim of this study was to evaluate the effect of a multimodal perioperative strategy aimed at reducing the incidence of vascular complications. A total of 126 first isolated LTs-performed between November 2008 and December 2015-were retrospectively analyzed. A minimum follow-up period of 24 months was analyzable for 124/126 patients (98.4%). The aggressive preemptive strategy consisted of identifying and immediately managing any problem and any abnormality in the vascular flow, in any of the hepatic vessels, and at any time after the liver graft revascularization. As a result, with a median follow-up of 57 months (3-112 months), not a single graft has been lost from vascular or biliary problems. The actuarial 8-year graft survival is 96.5%. These results have shown that a combination of technical attention, medical prevention, an early diagnosis, and rapid interventions reduced the negative impact of vascular problems on the outcome of both grafts and patients.
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Affiliation(s)
- Chiara Grimaldi
- Department of Pediatric Surgery and Transplantation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Fabrizio di Francesco
- Department of Pediatrics and Pediatric Transplantation, ISMETT, UPMC, Palermo, Italy
| | - Fabrizio Chiusolo
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Roberta Angelico
- Department of Pediatric Surgery and Transplantation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Lidia Monti
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
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26
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von Meijenfeldt FA, Burlage LC, Bos S, Adelmeijer J, Porte RJ, Lisman T. Elevated Plasma Levels of Cell-Free DNA During Liver Transplantation Are Associated With Activation of Coagulation. Liver Transpl 2018; 24:1716-1725. [PMID: 30168653 PMCID: PMC6718008 DOI: 10.1002/lt.25329] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 08/19/2018] [Indexed: 12/11/2022]
Abstract
Patients undergoing liver transplantation have complex changes in their hemostatic system, and the net effect of these changes appears to be a "rebalanced" hemostatic profile. Recently, a process called NETosis in which a neutrophil expels DNA and proteins that form a weblike structure, has been described as a mechanism of pathogen entrapment. Increasing evidence suggests a pivotal role for neutrophil extracellular traps (NETs) and their main component, cell-free DNA (cfDNA), in activation of coagulation. Because liver transplantation is associated with substantial (hepatocyte) cell death and intrahepatic neutrophil accumulation, NETs might play an important role in the hemostatic balance during liver transplantation. Here, we determined markers for NETs in the plasma of patients undergoing a liver transplantation and examined their association with activation of coagulation. Markers for NETs and markers for activation of coagulation were determined in serial plasma samples taken from patients undergoing a liver transplantation (n = 21) and compared with plasma levels in healthy controls. We found perioperative increases of markers for NETs with levels of cfDNA and nucleosomes that peaked after reperfusion and myeloperoxidase (MPO)-DNA complexes that peaked during the anhepatic phase. CfDNA and nucleosome levels, but not MPO-DNA levels, correlated with prothrombin fragment 1+2 and thrombin-antithrombin complex levels, which are established markers for activation of coagulation. Neutrophils undergoing NETosis were observed by immunostainings in postreperfusion biopsies. In conclusion, although NETosis occurs during liver transplantation, the majority of circulating DNA appears to be derived from cell death within the graft. The perioperative increases in cfDNA and nucleosomes might contribute to the complex hemostatic rebalance during liver transplantation.
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Affiliation(s)
- Fien A. von Meijenfeldt
- Surgical Research LaboratoryUniversity of GroningenGroningenthe Netherlands,Section of Hepatobiliary Surgery and Liver Transplantation, Departments of SurgeryUniversity of GroningenGroningenthe Netherlands
| | - Laura C. Burlage
- Surgical Research LaboratoryUniversity of GroningenGroningenthe Netherlands,Section of Hepatobiliary Surgery and Liver Transplantation, Departments of SurgeryUniversity of GroningenGroningenthe Netherlands
| | - Sarah Bos
- Surgical Research LaboratoryUniversity of GroningenGroningenthe Netherlands,Internal Medicine, University Medical Center GroningenUniversity of GroningenGroningenthe Netherlands
| | - Jelle Adelmeijer
- Surgical Research LaboratoryUniversity of GroningenGroningenthe Netherlands
| | - Robert J. Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Departments of SurgeryUniversity of GroningenGroningenthe Netherlands
| | - Ton Lisman
- Surgical Research LaboratoryUniversity of GroningenGroningenthe Netherlands,Section of Hepatobiliary Surgery and Liver Transplantation, Departments of SurgeryUniversity of GroningenGroningenthe Netherlands
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27
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Hypercoagulability in End-stage Liver Disease: Review of Epidemiology, Etiology, and Management. Transplant Direct 2018; 4:e403. [PMID: 30534594 PMCID: PMC6233657 DOI: 10.1097/txd.0000000000000843] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 09/23/2018] [Indexed: 12/14/2022] Open
Abstract
In this review, we analyze the epidemiology of thromboses related to end-stage liver disease (ESLD), discuss causes of hypercoagulability, describe susceptible populations, and critically evaluate proposed prophylaxis and treatment of thromboses. Classically, ESLD has been regarded as a model for coagulopathy, and patients were deemed to be at high risk for bleeding complications. Patients with ESLD are not auto-anticoagulated, and they do not have a lower risk of portal vein thrombosis, intracardiac thrombus formation, pulmonary embolism or hepatic artery thrombosis. Though the cause of hypercoagulability is multifactorial, endothelial dysfunction likely plays a central role for all patients with ESLD. Some subpopulations, such as patients with nonalcoholic steatohepatitis and autoimmune conditions, are at increased risk of thrombotic events as are patients of Hispanic ethnicity. The science behind prophylaxis of different types of clotting and treatment of thromboses is developing rapidly. A number of medications, including low molecular weight heparin, unfractionated heparin, aspirin, vitamin K antagonists, and direct oral anticoagulants can be used, but clear guidelines are lacking. Acute intraoperative clotting can be associated with high mortality. Routine use of transesophageal echocardiography can be helpful in early recognition and treatment of intraoperative thrombosis. Heparin should be reserved for cases of intracardiac thrombus/pulmonary embolism without hemodynamic instability. In unstable patients, low dose of recombinant tissue plasminogen activator can be used. In this new era of heightened awareness of thrombotic events in ESLD patients, prospective randomized trials are urgently needed to best guide clinical practice.
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28
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Jeng KS, Huang CC, Tsai HY, Hsu JC, Lin CK, Chen KH. Novel use of percutaneous thrombosuction to rescue the early thrombosis of the conduit vein graft after living donor liver transplantation. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2018; 4:204-209. [PMID: 30148240 PMCID: PMC6105764 DOI: 10.1016/j.jvscit.2018.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 04/20/2018] [Indexed: 11/20/2022]
Abstract
A 54-year-old woman with liver cirrhosis and hepatocellular carcinoma received a living donor liver transplant. Thrombosis of the segmental hepatic vein occurred on postoperative day 7. We undertook percutaneous catheter thrombosuction under local anesthesia to extract the thrombus successfully without re-exploration. Thrombosuction has been used for thrombosis of the cardiovascular system, limbs, and brain. We first used it in hepatic venous thrombus after liver transplantation. This procedure is simple, less invasive, feasible, safe, repeatable, and effective.
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Affiliation(s)
- Kuo-Shyang Jeng
- Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Correspondence: Kuo-Shyang Jeng, MD, FACS, Department of Surgery, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nanya S Rd, Banciao Dist, New Taipei City 220, Taiwan, ROC
| | - Chun-Chieh Huang
- Department of Radiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Hao-Yuan Tsai
- Division of Cardiovascular Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Jung-Cheng Hsu
- Division of Cardiovascular Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Cheng-Kuan Lin
- Division of Hepatology and Gastroenterology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Kuo-Hsin Chen
- Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
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29
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De Pietri L, Montalti R, Nicolini D, Troisi RI, Moccheggiani F, Vivarelli M. Perioperative thromboprophylaxis in liver transplant patients. World J Gastroenterol 2018; 24:2931-2948. [PMID: 30038462 PMCID: PMC6054944 DOI: 10.3748/wjg.v24.i27.2931] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/17/2018] [Accepted: 06/21/2018] [Indexed: 02/06/2023] Open
Abstract
Improvements in surgical and anesthetic procedures have increased patient survival after liver transplantation (LT). However, the perioperative period of LT can still be affected by several complications. Among these, thromboembolic complications (intracardiac thrombosis, pulmonary embolism, hepatic artery and portal vein thrombosis) are relatively common causes of increased morbidity and mortality. The benefit of thromboprophylaxis in general surgical patients has already been established, but it is not the standard of care in LT recipients. LT is associated with a high bleeding risk, as it is performed in a setting of already unstable hemostasis. For this reason, the role of routine perioperative prophylactic anticoagulation is usually restricted. However, recent data have shown that the bleeding tendency of cirrhotic patients is not an expression of an acquired bleeding disorder but rather of coexisting factors (portal hypertension, hypervolemia and infections). Furthermore, in cirrhotic patients, the new paradigm of ‘‘rebalanced hemostasis’’ can easily tip towards hypercoagulability because of the recently described enhanced thrombin generation, procoagulant changes in fibrin structure and platelet hyperreactivity. This new coagulation balance, along with improvements in surgical techniques and critical support, has led to a dramatic reduction in transfusion requirements, and the intraoperative thromboembolic-favoring factors (venous stasis, vessels clamping, surgical injury) have increased the awareness of thrombotic complications and led clinicians to reconsider the limited use of anticoagulants or antiplatelets in the postoperative period of LT.
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Affiliation(s)
- Lesley De Pietri
- Division of Anaesthesiology and Intensive Care Unit, Department of General Surgery, AUSL Reggio Emilia-IRCCS, Reggio Emilia 42123, Italy
| | - Roberto Montalti
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
| | - Daniele Nicolini
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
| | - Roberto Ivan Troisi
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital Medical School, Ghent 185 3K3 9000, Belgium
- Department of Clinical Medicine, Federico II University Naples, Naples 80138, Italy
| | - Federico Moccheggiani
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
| | - Marco Vivarelli
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona 60126, Italy
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30
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Borst AJ, Sudan DL, Wang LA, Neuss MJ, Rothman JA, Ortel TL. Bleeding and thrombotic complications of pediatric liver transplant. Pediatr Blood Cancer 2018; 65:e26955. [PMID: 29350493 PMCID: PMC5867241 DOI: 10.1002/pbc.26955] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 12/05/2017] [Accepted: 12/06/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pediatric patients undergoing liver transplant are at significant risk for bleeding and thrombotic complications due to the complex nature of rebalanced hemostasis in patients with liver disease. METHODS/OBJECTIVES We reviewed records of 92 pediatric liver and multivisceral transplant cases at Duke University Medical Center between January 2009 and December 2015. The goal was to define the nature and incidence of bleeding and thrombotic complications in this cohort and define potential risk factors. RESULTS There were 24 major bleeding events in 19 transplants (incidence 20.7%) and 30 thrombotic events in 23 transplants (incidence 25%). Five of the 10 retransplantations were for vascular thrombotic complications. Thirty-day mortality was 4.9%, and three of these four deaths were due to vascular thrombosis. No bleeding events led to retransplantation or mortality. Prophylactic aspirin was associated with decreased risk of thrombosis without increased bleeding. Prophylactic heparin did not increase bleeding risk. Laboratory assays predicted events poorly, apparently failing to capture the nuanced and dynamic interplay between pro- and anticoagulant factors in the posttransplant patient. CONCLUSIONS Both bleeding and thrombosis are frequent in this population, but only thrombotic complications contributed to retransplantation and mortality. A standardized approach to coagulation testing and antithrombotic therapy may be useful in predicting and reducing adverse outcomes. Alternative approaches to monitoring hemostasis need to be prospectively investigated in this complex patient population.
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Affiliation(s)
- Alexandra J Borst
- Duke University Medical Center, Division of Pediatric Hematology-Oncology
- Vanderbilt University Medical Center, Division of Pediatric Hematology-Oncology
| | - Debra L Sudan
- Duke University Medical Center, Division of Abdominal Transplant Surgery
| | | | - Michael J Neuss
- Vanderbilt University Medical Center, Department of Medicine
| | - Jennifer A Rothman
- Duke University Medical Center, Division of Pediatric Hematology-Oncology
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31
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Moghadamyeghaneh Z, Alameddine M, Jue JS, Guerra G, Selvaggi G, Nishida S, Fan J, Beduschi T, Vianna R. A nationwide analysis of re-exploration after liver transplant. HPB (Oxford) 2018; 20:216-221. [PMID: 29129486 DOI: 10.1016/j.hpb.2017.08.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 08/12/2017] [Accepted: 08/29/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND A retrospective review to investigate rate and outcomes of re-exploration following liver transplantation in the United States. METHODS The NIS database was used to examine outcomes of patients who underwent re-exploration following liver transplantation from 2002 to 2012. Multivariate regression analysis was performed to compare outcomes of patients with and without reoperation. RESULTS We sampled a total of 12,075 patients who underwent liver transplantation. Of these, 1505 (12.5%) had re-exploration during the same hospitalization. Hemorrhagic (67.9%) and biliary tract anastomosis complication (14.8%) were the most common reasons for reoperation. Patients with reoperation had a significantly higher mortality than those who did not (11.6% vs. 3.8%, AOR: 3.01, P < 0.01). Preoperative coagulopathy (AOR: 1.71, P < 0.01) and renal failure (AOR: 1.57, P < 0.01) were associated with hemorrhagic complications. Peripheral vascular disorders (AOR: 2.15, P < 0.01) and coagulopathy (AOR: 1.32, P < 0.01) were significantly associated with vascular complications. Risk of wound disruption was significantly higher in patients with chronic pulmonary disease (AOR: 1.50, P < 0.01). CONCLUSION Re-exploration after liver transplantation is relatively common (12.5%), with hemorrhagic complication as the most common reason for reoperation. Preoperative coagulation disorders significantly increase hemorrhagic and vascular complications. Further clinical trails should investigate prophylactic strategies in high risk patients to prevent unplanned reoperation.
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Affiliation(s)
- Zhobin Moghadamyeghaneh
- Department of Surgery, Division of Transplant Surgery, Jackson Memorial Hospital/University of Miami, Miami, FL, USA
| | - Mahmoud Alameddine
- Department of Surgery, Division of Transplant Surgery, Jackson Memorial Hospital/University of Miami, Miami, FL, USA
| | - Joshua S Jue
- Department of Surgery, Division of Transplant Surgery, Jackson Memorial Hospital/University of Miami, Miami, FL, USA
| | - Giselle Guerra
- Department of Surgery, Division of Transplant Surgery, Jackson Memorial Hospital/University of Miami, Miami, FL, USA
| | - Gennaro Selvaggi
- Department of Surgery, Division of Transplant Surgery, Jackson Memorial Hospital/University of Miami, Miami, FL, USA
| | - Seigo Nishida
- Department of Surgery, Division of Transplant Surgery, Jackson Memorial Hospital/University of Miami, Miami, FL, USA
| | - J Fan
- Department of Surgery, Division of Transplant Surgery, Jackson Memorial Hospital/University of Miami, Miami, FL, USA
| | - Thiago Beduschi
- Department of Surgery, Division of Transplant Surgery, Jackson Memorial Hospital/University of Miami, Miami, FL, USA
| | - Rodrigo Vianna
- Department of Surgery, Division of Transplant Surgery, Jackson Memorial Hospital/University of Miami, Miami, FL, USA.
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Abstract
Platelets are key players in thrombosis and hemostasis. Alterations in platelet count and function are common in liver disease, and may contribute to bleeding or thrombotic complications in liver diseases and during liver surgery. In addition to their hemostatic function, platelets may modulate liver diseases by mechanisms that are incompletely understood. Here, we present clinical evidence for a role of platelets in the progression of chronic and acute liver diseases, including cirrhosis, acute liver failure, and hepatocellular carcinoma. We also present clinical evidence that platelets promote liver regeneration following partial liver resection. Subsequently, we summarize studies in experimental animal models that support these clinical observations, and also highlight studies that are in contrast with clinical observations. The combined results of clinical and experimental studies suggest that platelets may be a therapeutic target in the treatment of liver injury and repair, but the gaps in our understanding of mechanisms involved in platelet-mediated modulation of liver diseases call for caution in clinical application of these findings.
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Affiliation(s)
- Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation and Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - James P. Luyendyk
- Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
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Oualha M, Chardot C, Debray D, Lesage F, Harroche A, Renolleau S, Treluyer JM, Urien S. Population pharmacokinetics of enoxaparin in early stage of paediatric liver transplantation. Br J Clin Pharmacol 2018; 84:1206-1214. [PMID: 29423936 DOI: 10.1111/bcp.13543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 01/28/2018] [Accepted: 01/29/2018] [Indexed: 11/30/2022] Open
Abstract
AIMS Preventing post-liver transplantation (LT) hepatic artery and portal vein thrombosis includes enoxaparin administration. Enoxaparin pharmacokinetics (PK) has not been investigated in children following LT. We described an enoxaparin PK model in 22 children the first week following LT. METHODS Anti-Xa activity time-courses were analysed using a nonlinear mixed effects approach with Monolix version 2016R. RESULTS Anti-Xa activity time-courses were well described by a one-compartment model with first order absorption and elimination. Bodyweight prior to surgery (BWPREOP ) and the related postoperative variation (BW(t)) were the main covariates explaining CL and V between subject variabilities. Parameter estimates were CLi = CLTYP * (BWPREOP /70)3/4 ; Vi = VTYP * (BW(t)/70)1 ; where typical clearance (CLTYP ) and typical volume of distribution (VTYP ) were 1.23 l h-1 and 14.6 l, respectively. Standard dosing regimens of 50 IU kg-1 12 h-1 were insufficient to reach the target range of anti-Xa activity of 0.2-0.4 IU ml-1 . Specifically, seven children (32%) never attained the target range during the whole period of treatment and all children were at least once underdosed. According to the final results, we simulated individualized dosing regimens within 4 h following the first administration. More than 100 IU kg-1 12 h-1 are suggested to reach the target range of anti-Xa activity of 0.2-0.4 IU ml-1 from the first day. CONCLUSION Thanks to this model, the initial and maintenance doses could be assessed to rapidly achieve the target range. Higher doses per kg, especially in the youngest children, are suggested.
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Affiliation(s)
- Mehdi Oualha
- Service de réanimation et surveillance continue médico-chirurgicales, Hôpital Necker Enfants-Malades, Université Paris Descartes, Sorbonne-Paris Cité, 149 rue de Sèvres, 75015, Paris, France.,EA7323, Evaluation des thérapeutiques et pharmacologie périnatale et pédiatrique, Université Paris Descartes, Paris, France
| | - Christophe Chardot
- Service de chirurgie viscérale pédiatrique, Hôpital Necker Enfants-Malades, Université Paris Descartes, Sorbonne-Paris Cité, 149 rue de Sèvres, 75015, Paris, France
| | - Dominique Debray
- Unité d'hépatologie pédiatrique, Hôpital Necker Enfants-Malades, Université Paris Descartes, Sorbonne-Paris Cité, 149 rue de Sèvres, 75015, Paris, France
| | - Fabrice Lesage
- Service de réanimation et surveillance continue médico-chirurgicales, Hôpital Necker Enfants-Malades, Université Paris Descartes, Sorbonne-Paris Cité, 149 rue de Sèvres, 75015, Paris, France
| | - Annie Harroche
- Service d'hématologie clinique, Hôpital Necker Enfants-Malades, Université Paris Descartes, Sorbonne-Paris Cité, 149 rue de Sèvres, 75015, Paris, France
| | - Sylvain Renolleau
- Service de réanimation et surveillance continue médico-chirurgicales, Hôpital Necker Enfants-Malades, Université Paris Descartes, Sorbonne-Paris Cité, 149 rue de Sèvres, 75015, Paris, France
| | - Jean-Marc Treluyer
- Service de réanimation et surveillance continue médico-chirurgicales, Hôpital Necker Enfants-Malades, Université Paris Descartes, Sorbonne-Paris Cité, 149 rue de Sèvres, 75015, Paris, France.,EA7323, Evaluation des thérapeutiques et pharmacologie périnatale et pédiatrique, Université Paris Descartes, Paris, France
| | - Saïk Urien
- EA7323, Evaluation des thérapeutiques et pharmacologie périnatale et pédiatrique, Université Paris Descartes, Paris, France
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34
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Low Platelet Counts and Prolonged Prothrombin Time Early After Operation Predict the 90 Days Morbidity and Mortality in Living-donor Liver Transplantation. Ann Surg 2017; 265:166-172. [PMID: 28009742 DOI: 10.1097/sla.0000000000001634] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The aim of the study was to investigate the association between platelet count/prothrombin time early after transplant and short-term outcomes among living-donor liver transplant (LDLT) recipients. BACKGROUND Postoperative platelet count and prothrombin time-international normalized ratio (PT-INR) were critical biomarkers in LDLT. METHODS The study participants consisted of 445 initial LDLT recipients, and perioperative variables, including platelet count and PT-INR, were assessed for their association with severe complications (Clavien-Dindo classification grade IIIb/IV) and mortality within 90 days after operation. RESULTS Severe complications and operative mortality occurred in 161 (36%) and 23 patients (5%), respectively. Cox regression analysis revealed that a high body mass index [hazard ratio (HR) 1.2; 95% confidence interval (CI), 1.1-1.4; P = 0.004] and low platelet count on postoperative day (POD)3 (HR 0.88; 95% CI, 0.57-0.97; P < 0.001) were independent predictors for grade IIIb/IV complications after LDLT, whereas high PT-INR on POD5 (HR 1.1; 95% CI, 1.1-1.3; P = 0.021) was the only independent factor for operative mortality. In addtion, the progonostic scoring with low platelet count (<50 × 10/L) and prolonged prothrombin time (PT-INR >1.6) within POD5, 1 point for each, was demonstrated to be useful in predicting the development of Clavien-Dindo grade IIIb/IV/V complications after LDLT (30% for score 0, 46% for score 1, and 72% for score 2: 0 vs 1, P = 0.004; 0 vs 2, P < 0.001; 1 vs 2, P = 0.002). CONCLUSIONS PT-INR above 1.6 and platelet count below 50 × 10/L within POD5 were useful predictors of mortality and severe complications after LDLT.
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Ziaziaris WA, Darani A, Holland AJA, Alexander A, Karpelowsky J, Barbaro P, Stormon M, O'Loughlin E, Shun A, Thomas G. Reducing the incidence of hepatic artery thrombosis in pediatric liver transplantation: Effect of microvascular techniques and a customized anticoagulation protocol. Pediatr Transplant 2017; 21. [PMID: 28332273 DOI: 10.1111/petr.12917] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2017] [Indexed: 12/14/2022]
Abstract
We aimed to assess the incidence of HAT over three eras following implementation of microvascular techniques and a customized anticoagulation protocol in a predominantly cadaveric split liver transplant program. We retrospectively reviewed pediatric liver transplants performed between April 1986 and 2016 and analyzed the incidence HAT over three eras. In E1, 1986-2008, each patient received a standard dose of 5 U/kg/h of heparin and coagulation profiles normalized passively. In E2, 2008-2012, microvascular techniques were introduced. In E3, 2012-2016, in addition, a customized anticoagulation protocol was introduced which included replacement of antithrombin 3, protein C and S, and early heparinization. A total of 317 liver transplants were completed during the study period, with a median age of 31.7 months. In E1, 22% of grafts were cadaveric in situ split grafts, while the second and third eras used split grafts in 59.0% and 64.9% of cases, respectively. HAT occurred in 9.5% in the first era, 11.5% (P=.661) in the second, and dropped to 1.8% in the third era (P=.043). A routine anticoagulation protocol has significantly reduced the incidence of HAT post-liver transplantation in children in a predominantly cadaveric in situ split liver transplant program.
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Affiliation(s)
- William A Ziaziaris
- Douglas Cohen Department of Paediatric Surgery, The Children's Hospital at Westmead, Westmead, NSW, Australia.,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Alexandre Darani
- Douglas Cohen Department of Paediatric Surgery, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Andrew J A Holland
- Douglas Cohen Department of Paediatric Surgery, The Children's Hospital at Westmead, Westmead, NSW, Australia.,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Angus Alexander
- Douglas Cohen Department of Paediatric Surgery, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Jonathan Karpelowsky
- Douglas Cohen Department of Paediatric Surgery, The Children's Hospital at Westmead, Westmead, NSW, Australia.,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Pasquale Barbaro
- Department of Haematology, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Michael Stormon
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.,Department of Gastroenterology, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Edward O'Loughlin
- Department of Gastroenterology, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Albert Shun
- Douglas Cohen Department of Paediatric Surgery, The Children's Hospital at Westmead, Westmead, NSW, Australia.,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Gordon Thomas
- Douglas Cohen Department of Paediatric Surgery, The Children's Hospital at Westmead, Westmead, NSW, Australia.,Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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36
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Stine JG, Northup PG. Coagulopathy Before and After Liver Transplantation: From the Hepatic to the Systemic Circulatory Systems. Clin Liver Dis 2017; 21:253-274. [PMID: 28364812 DOI: 10.1016/j.cld.2016.12.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The hemostatic environment in patients with cirrhosis is a delicate balance between prohemostatic and antihemostatic factors. There is a lack of effective laboratory measures of the hemostatic system in patients with cirrhosis. Many are predisposed to pulmonary embolus, deep vein thrombosis, and portal vein thrombosis in the pretransplantation setting. This pretransplantation hypercoagulable milieu seems to extend for at least several months post-transplantation. Patients with nonalcoholic fatty liver disease, inherited thrombophilia, portal hypertension in the absence of cirrhosis, and hepatocellular carcinoma often require individualized approach to anticoagulation. Early reports suggest a potential role for low-molecular-weight heparins and direct-acting anticoagulants.
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Affiliation(s)
- Jonathan G Stine
- Center for the Study of Coagulation Disorders in Liver Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia, 1215 JPA and Lee Street, Charlottesville, VA 22908, USA
| | - Patrick G Northup
- Center for the Study of Coagulation Disorders in Liver Disease, Division of Gastroenterology and Hepatology, Department of Medicine, University of Virginia, 1215 JPA and Lee Street, Charlottesville, VA 22908, USA.
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Almeida-Carvalho SR, Gomes-Ferraz ML, Loureiro-Matos CA, Benedito-Silva AE, Carvalho-Filho RJ, Renato-Perez R, Miziara-Gonzalez A, Salzedas-Netto AA, Szejnfeld D, D'Ippolito G, Pereira-Lanzoni V, Souza-Silva I. Practical Considerations of Real Life of Hepatocellular Carcinoma in a Tertiary Center of Brazil. Ann Hepatol 2017; 16:255-262. [PMID: 28233747 DOI: 10.5604/16652681.1231584] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is the most common malignancy that develops in cirrhotic livers. Its clinical and epidemiological characteristics and mortality rates vary according to geographical region. The objective of this study was to evaluate the clinical profile, epidemiological characteristics, laboratory parameters, treatment and survival of patients with HCC. MATERIAL AND METHODS Patients with HCC seen between 2000 and 2012 were studied. The Kaplan-Meier method was used for survival analysis according to variables in question. RESULTS The study included 247 patients with a mean age of 60 ± 10 years. There was a predominance of males (74%). The main etiologies of HCC were HCV infection (55%), excessive alcohol consumption (12%), and HBV infection (8%). Liver cirrhosis was present in 92% of cases. The mean tumor number and diameter were 2 and 5 cm, respectively. Patients meeting the Milan criteria corresponded to 43% of the sample. Liver transplantation was performed in 22.4% of patients of the Milan subset and in 10% of the whole sample. The overall mean survival was 60 months, with a 1-, 3- and 5-year survival probability of 74%, 40% and 29%, respectively. Lower survival was observed among patients with alcoholic etiology. Survival was higher among patients submitted to liver transplantation (P &lt; 0.001), TACE (P &lt; 0.001), or any kind of treatment (P &lt; 0.001). However, no difference was found for surgical resection (P = 0.1) or sorafenib (P = 0.1). CONCLUSION Patients with HCC were mainly older men diagnosed at an advanced stage. Treatment was associated with better overall survival, but few patients survived to be treated.
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Affiliation(s)
- Sandra R Almeida-Carvalho
- Department of Gastroenterology, Hepatology Unit. Federal University of Sao Paulo (Unifesp), Sao Paulo, SP, Brazil
| | - Maria L Gomes-Ferraz
- Department of Gastroenterology, Hepatology Unit. Federal University of Sao Paulo (Unifesp), Sao Paulo, SP, Brazil
| | - Carla A Loureiro-Matos
- Department of Gastroenterology, Hepatology Unit. Federal University of Sao Paulo (Unifesp), Sao Paulo, SP, Brazil
| | - Antônio E Benedito-Silva
- Department of Gastroenterology, Hepatology Unit. Federal University of Sao Paulo (Unifesp), Sao Paulo, SP, Brazil
| | - Roberto J Carvalho-Filho
- Department of Gastroenterology, Hepatology Unit. Federal University of Sao Paulo (Unifesp), Sao Paulo, SP, Brazil
| | - Rogério Renato-Perez
- Department of Surgery, Liver Transplant Unit. Federal University of Sao Paulo (Unifesp), Sao Paulo, SP, Brazil
| | - Adriano Miziara-Gonzalez
- Department of Surgery, Liver Transplant Unit. Federal University of Sao Paulo (Unifesp), Sao Paulo, SP, Brazil
| | - Alcides A Salzedas-Netto
- Department of Pediatric Surgery. Federal University of Sao Paulo (Unifesp), Sao Paulo, SP, Brazil
| | - Denis Szejnfeld
- Department of Diagnostic Radiology. Federal University of Sao Paulo (Unifesp), Sao Paulo, SP, Brazil
| | - Giuseppe D'Ippolito
- Department of Diagnostic Radiology. Federal University of Sao Paulo (Unifesp), Sao Paulo, SP, Brazil
| | - Valéria Pereira-Lanzoni
- Department of Diagnostic Pathology. Federal University of Sao Paulo (Unifesp), Sao Paulo, SP, Brazil
| | - Ivonete Souza-Silva
- Department of Gastroenterology, Hepatology Unit. Federal University of Sao Paulo (Unifesp), Sao Paulo, SP, Brazil
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38
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Taura P, Martinez-Palli G, Blasi A, Rivas E, Beltran J, Balust J. Intraoperative Management of High-Risk Liver Transplant Recipients: Concerns and Challenges. Transplant Proc 2017; 48:2491-2494. [PMID: 27742332 DOI: 10.1016/j.transproceed.2016.08.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Liver transplantation (LT) offers patients with liver disease a real chance for long-term survival. In the past decade, successful survival after LT along with the Model for End-Stage Liver Disease-based allocation policy have increased willingness to accept patients with a higher risk profile and marginal organs and to prioritize the sickest patients on the waiting list. Therefore, the anesthesiologist now deals with very challenging patients. In the present review, we aimed to highlight key aspects of intraoperative LT management in high-risk patients and to place these aspects in the perspective of their impact on perioperative outcomes. Conservative standardized perioperative strategies mandate a switch toward accurate and tailored perioperative anesthetic care to maintain the steady improvement in recipient survival rates after LT. In our opinion, continuous assessment of fluid status and cardiac performance, strategies promoting graft decongestion, rational hemostatic management, and the identification of LT recipients with potential risk of vascular complications should constitute the cornerstone of intraoperative management.
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Affiliation(s)
- P Taura
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain.
| | - G Martinez-Palli
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain; Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - A Blasi
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain; Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - E Rivas
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - J Beltran
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - J Balust
- Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
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39
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Emergent Management of Intracardiac Thrombosis during Liver Transplantation. Case Rep Transplant 2016; 2016:6268370. [PMID: 28070442 PMCID: PMC5192313 DOI: 10.1155/2016/6268370] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 11/20/2016] [Indexed: 01/28/2023] Open
Abstract
Intraoperative thromboembolism is a well-documented complication associated with orthotopic liver transplantation (OLT) but its identification and intraoperative treatment are still an emerging topic in anesthesia. Intracardiac thrombus during OLT is associated with a high mortality rate. There are only a few reports describing the successful management of thromboembolism during OLT. We describe a case where routine intraoperative transesophageal echocardiography during a live donor liver transplantation enabled early detection of an intracardiac thrombus with subsequent successful heparin treatment. Our case suggests that if an intracardiac thrombus is identified early (before hemodynamic instability occurs), the use of IV heparin may be a safe therapeutic option.
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40
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Blasi A, Hernandez V, Fernandez J, Colmenero J, Beltran J, Garcia-Valdecasas JC, Reverter JC. Venous Thrombotic Events After Liver Transplantation. Clin Appl Thromb Hemost 2016; 24:317-322. [PMID: 27899521 DOI: 10.1177/1076029616680477] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Thromboprophylaxis is not well defined after liver transplantation (LT). The aim of this study was to evaluate the incidence of splanchnic vein thrombosis (SVT) and nonsplanchnic vein thrombosis (NSVT) after LT. Liver transplantations performed between 2009 and 2013 in our institution were reviewed. Demographic, intraoperative, and postoperative data were recorded. Low-molecular-weight heparin was only administered postoperatively if intraoperative thrombectomy was performed or in patients preoperatively anticoagulated. Of a total of 328 patients, 72% were male with a median age of 56 years, score of model for end-stage liver disease 18 (11-23), and 88% had liver cirrhosis. The incidence of postoperative venous thrombotic events was 4.6%: 8 (2.4%) patients had SVT and 7 (2.1%) patients had NSVT. After logistic regression analysis, intraoperative thrombectomy and Child A classification emerged as risk factors for SVT (odds ratio [OR]: 77, 95% confidence interval [95% CI]: 14-421) and NSVT (OR: 20, 95% CI: 3-170), respectively. The incidence of SVT in patients who undergo intraoperative thrombectomy was 33%, whereas the incidence of NSVT in patients grouped as Child A was 7.5%. Our results suggest that thromboprophylaxis should be considered after LT in patients with cirrhosis grouped as Child A and in patients who undergo intraoperative thrombectomy.
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Affiliation(s)
- Annabel Blasi
- 1 Anesthesia Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Virginia Hernandez
- 2 Hepatic Hemodynamic Laboratory, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Javier Fernandez
- 3 Hepatology Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Jordi Colmenero
- 3 Hepatology Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Joan Beltran
- 1 Anesthesia Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Joan Carles Reverter
- 5 Hemotherapy Hemostasis Department, Hospital Clinic de Barcelona, Barcelona, Spain
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41
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Bester J, Soma P, Kell DB, Pretorius E. Viscoelastic and ultrastructural characteristics of whole blood and plasma in Alzheimer-type dementia, and the possible role of bacterial lipopolysaccharides (LPS). Oncotarget 2016; 6:35284-303. [PMID: 26462180 PMCID: PMC4742105 DOI: 10.18632/oncotarget.6074] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/28/2015] [Indexed: 12/22/2022] Open
Abstract
Alzheimer-type dementia (AD) is a neurodegenerative disorder and the most common form of dementia. Patients typically present with neuro- and systemic inflammation and iron dysregulation, associated with oxidative damage that reflects in hypercoagulability. Hypercoagulability is closely associated with increased fibrin(ogen) and in AD patients fibrin(ogen) has been implicated in the development of neuroinflammation and memory deficits. There is still no clear reason precisely why (a) this hypercoagulable state, (b) iron dysregulation and (c) increased fibrin(ogen) could together lead to the loss of neuronal structure and cognitive function. Here we suggest an alternative hypothesis based on previous ultrastructural evidence of the presence of a (dormant) blood microbiome in AD. Furthermore, we argue that bacterial cell wall components, such as the endotoxin lipopolysaccharide (LPS) of Gram-negative strains, might be the cause of the continuing and low-grade inflammation, characteristic of AD. Here, we follow an integrated approach, by studying the viscoelastic and ultrastructural properties of AD plasma and whole blood by using scanning electron microscopy, Thromboelastography (TEG®) and the Global Thrombosis Test (GTT®). Ultrastructural analysis confirmed the presence and close proximity of microbes to erythrocytes. TEG® analysis showed a hypercoagulable state in AD. TEG® results where LPS was added to naive blood showed the same trends as were found with the AD patients, while the GTT® results (where only platelet activity is measured), were not affected by the added LPS, suggesting that LPS does not directly impact platelet function. Our findings reinforce the importance of further investigating the role of LPS in AD.
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Affiliation(s)
- Janette Bester
- Department of Physiology, Faculty of Health Sciences, University of Pretoria, Arcadia, South Africa
| | - Prashilla Soma
- Department of Physiology, Faculty of Health Sciences, University of Pretoria, Arcadia, South Africa
| | - Douglas B Kell
- School of Chemistry and The Manchester Institute of Biotechnology, The University of Manchester, Manchester, UK
| | - Etheresia Pretorius
- Department of Physiology, Faculty of Health Sciences, University of Pretoria, Arcadia, South Africa
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42
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Stine JG, Argo CK, Pelletier SJ, Maluf DG, Northup PG. Liver transplant recipients with portal vein thrombosis receiving an organ from a high-risk donor are at an increased risk for graft loss due to hepatic artery thrombosis. Transpl Int 2016; 29:1286-1295. [PMID: 27714853 DOI: 10.1111/tri.12855] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 05/23/2016] [Accepted: 09/02/2016] [Indexed: 12/11/2022]
Abstract
We hypothesize that recipients with pretransplant portal vein thrombosis (PVT) receiving organs from high-risk donors (HRD) are at an increased risk of HAT. Data on all liver transplants in the United States from February 2002 to March 2015 were analyzed. Recipients were sorted into two groups: those with PVT and those without. HRDs were defined by donor risk index (DRI) >1.7. Multivariable logistic regression models were constructed to assess the independent risk factors for HAT with the resultant graft loss ≤90 days from transplantation. A total of 60 404 candidates underwent liver transplantation; of those recipients, 623 (1.0%) had HAT, of which 66.0% (n = 411) received organs from HRDs compared with 49.3% (n = 29 473) in recipients without HAT (P < 0.001); 2250 (3.7%) recipients had pretransplantation PVT and received organs from HRDs. On adjusted multivariable analysis, PVT with a HRD organ was the most significant independent risk factor (OR 3.56, 95% CI 2.52-5.02, P < 0.001) for the development of HAT. Candidates with pretransplant PVT who receive an organ from a HRD are at the highest risk for postoperative HAT independent of other measurable factors. Recipients with pretransplant PVT would benefit from careful donor selection and possibly anticoagulation perioperatively.
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Affiliation(s)
- Jonathan G Stine
- Division of Gastroenterology & Hepatology, Department of Medicine, Center for the Study of Coagulation Disorders in Liver Disease, University of Virginia, Charlottesville, VA, USA
| | - Curtis K Argo
- Division of Gastroenterology & Hepatology, Department of Medicine, Center for the Study of Coagulation Disorders in Liver Disease, University of Virginia, Charlottesville, VA, USA
| | - Shawn J Pelletier
- Division of Transplant, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Daniel G Maluf
- Division of Transplant, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Patrick G Northup
- Division of Gastroenterology & Hepatology, Department of Medicine, Center for the Study of Coagulation Disorders in Liver Disease, University of Virginia, Charlottesville, VA, USA
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43
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Bezinover D, Iskandarani K, Chinchilli V, McQuillan P, Saner F, Kadry Z, Riley TR, Janicki PK. Autoimmune conditions are associated with perioperative thrombotic complications in liver transplant recipients: A UNOS database analysis. BMC Anesthesiol 2016; 16:26. [PMID: 27207434 PMCID: PMC4875607 DOI: 10.1186/s12871-016-0192-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 05/04/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND End stage liver disease (ESLD) is associated with significant thrombotic complications. In this study, we attempted to determine if patients with ESLD, due to oncologic or autoimmune diseases, are susceptible to thrombosis to a greater extent than patients with ESLD due to other causes. METHODS In this retrospective study, we analyzed the UNOS database to determine the incidence of thrombotic complications in orthotopic liver transplant (OLT) recipients with autoimmune and oncologic conditions. Between 2000 and 2012, 65,646 OLTs were performed. We found 4,247 cases of preoperative portal vein thrombosis (PVT) and 1,233 cases of postoperative vascular thrombosis (VT) leading to graft failure. RESULTS Statistical evaluation demonstrated that patients with either hepatocellular carcinoma (HCC) or autoimmune hepatitis (AIC) had a higher incidence of PVT (p = 0.05 and 0.03 respectively). Patients with primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC) and AIC had a higher incidence of postoperative VT associated with graft failure (p < 0.0001, p < 0.0001, p = 0.05 respectively). Patients with preoperative PVT had a higher incidence of postoperative VT (p < 0.0001). Multivariable logistic regression demonstrated that patients with AIC, and BMI ≥40, having had a transjugular intrahepatic portosystemic shunt, and those with diabetes mellitus were more likely to have preoperative PVT: odds ratio (OR)(1.36, 1.19, 1.78, 1.22 respectively). Patients with PSC, PBC, AIC, BMI ≤18, or with a preoperative PVT were more likely to have a postoperative VT: OR (1.93, 2.09, 1.64, 1.60, and 2.01, respectively). CONCLUSION Despite the limited number of variables available in the UNOS database potentially related to thrombotic complications, this analysis demonstrates a clear association between autoimmune causes of ESLD and perioperative thrombotic complications. Perioperative management of patients at risk should include strategies to reduce the potential for these complications.
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Affiliation(s)
- Dmitri Bezinover
- Department of Anesthesiology, Penn State College of Medicine/Penn State Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA.
| | - Khaled Iskandarani
- Department of Public Health Sciences, Penn State College of Medicine/Penn State Hershey Medical Center, 90 Hope Drive, Hershey, PA, 17033, USA
| | - Vernon Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine/Penn State Hershey Medical Center, 90 Hope Drive, Hershey, PA, 17033, USA
| | - Patrick McQuillan
- Department of Anesthesiology, Penn State College of Medicine/Penn State Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - Fuat Saner
- Department of General, Visceral- and Transplant Surgery/Essen University Medical Center, Hufelandstr. 55, Essen, 45147, Germany
| | - Zakiyah Kadry
- Department of Surgery, Penn State College of Medicine/Penn State Hershey Medical Center, 500 University Dr, Hershey, PA, 17033, USA
| | - Thomas R Riley
- Department of Gastroenterology, Penn State College of Medicine/Penn State Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - Piotr K Janicki
- Department of Anesthesiology, Penn State College of Medicine/Penn State Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
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Kopec AK, Luyendyk JP. Role of Fibrin(ogen) in Progression of Liver Disease: Guilt by Association? Semin Thromb Hemost 2016; 42:397-407. [PMID: 27144445 DOI: 10.1055/s-0036-1579655] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Strong experimental evidence indicates that components of the hemostatic system, including thrombin, exacerbate diverse features of experimental liver disease. Clinical studies have also begun to address this connection and some studies have suggested that anticoagulants can improve outcome in patients with liver disease. Among the evidence of coagulation cascade activation in models of liver injury and disease is the frequent observation of thrombin-driven hepatic fibrin(ogen) deposition. Indeed, hepatic fibrin(ogen) deposition has long been recognized as a consequence of hepatic injury. Although commonly inferred as pathologic due to protective effects of anticoagulants in mouse models, the role of fibrin(ogen) in acute liver injury and chronic liver disease may not be universally detrimental. The localization of hepatic fibrin(ogen) deposits within the liver is connected to the disease stimulus and in animal models of liver toxicity and chronic disease, fibrin(ogen) deposition may not always be synonymous with large vessel thrombosis. Here, we provide a balanced review of the experimental evidence supporting a direct connection between fibrin(ogen) and liver injury/disease pathogenesis, and suggest a path forward bridging experimental and clinical research to improve our knowledge on the nature and function of fibrin(ogen) in liver disease.
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Affiliation(s)
- Anna K Kopec
- Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, Michigan
| | - James P Luyendyk
- Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, Michigan
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Mallett SV, Sugavanam A, Krzanicki DA, Patel S, Broomhead RH, Davidson BR, Riddell A, Gatt A, Chowdary P. Alterations in coagulation following major liver resection. Anaesthesia 2016; 71:657-68. [PMID: 27030945 DOI: 10.1111/anae.13459] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2016] [Indexed: 12/13/2022]
Abstract
The international normalised ratio is frequently raised in patients who have undergone major liver resection, and is assumed to represent a potential bleeding risk. However, these patients have an increased risk of venous thromboembolic events, despite conventional coagulation tests indicating hypocoagulability. This prospective, observational study of patients undergoing major hepatic resection analysed the serial changes in coagulation in the early postoperative period. Thrombin generation parameters and viscoelastic tests of coagulation (thromboelastometry) remained within normal ranges throughout the study period. Levels of the procoagulant factors II, V, VII and X initially fell, but V and X returned to or exceeded normal range by postoperative day five. Levels of factor VIII and Von Willebrand factor were significantly elevated from postoperative day one (p < 0.01). Levels of the anticoagulants, protein C and antithrombin remained significantly depressed on postoperative day five (p = 0.01). Overall, the imbalance between pro- and anticoagulant factors suggested a prothrombotic environment in the early postoperative period.
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Affiliation(s)
- S V Mallett
- Department of Anaesthesia, Royal Free Hospital, London, UK
| | - A Sugavanam
- Department of Anaesthesia, Brighton and Sussex University Hospitals, Brighton, UK
| | - D A Krzanicki
- Department of Anaesthesia, Royal Free Hospital, London, UK
| | - S Patel
- Department of Anaesthesia, University College London Hospital, London, UK
| | - R H Broomhead
- Department of Anaesthesia, Kings College Hospital, London, UK
| | - B R Davidson
- University Department of Surgery, Royal Free Campus, University College London, London, UK
| | - A Riddell
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free Hospital, London, UK
| | - A Gatt
- University of Malta, Tal-Qroqq, Msida, Malta
| | - P Chowdary
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free Hospital, London, UK
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46
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Stine JG, Pelletier SJ, Schmitt TM, Porte RJ, Northup PG. Pre-transplant portal vein thrombosis is an independent risk factor for graft loss due to hepatic artery thrombosis in liver transplant recipients. HPB (Oxford) 2016; 18:279-86. [PMID: 27017168 PMCID: PMC4814623 DOI: 10.1016/j.hpb.2015.10.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 10/12/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatic artery thrombosis is an uncommon but catastrophic complication following liver transplantation. We hypothesize that recipients with portal vein thrombosis are at increased risk. METHODS Data on all liver transplants in the U.S. during the MELD era through September 2014 were obtained from UNOS. Status one, multivisceral, living donor, re-transplants, pediatric recipients and donation after cardiac death were excluded. Logistic regression models were constructed for hepatic artery thrombosis with resultant graft loss within 90 days of transplantation. RESULTS 63,182 recipients underwent transplantation; 662 (1.1%) recipients had early hepatic artery thrombosis; of those, 91 (13.8%) had pre-transplant portal vein thrombosis, versus 7.5% with portal vein thrombosis but no hepatic artery thrombosis (p < 0.0001). Portal vein thrombosis was associated with an increased independent risk of hepatic artery thrombosis (OR 2.17, 95% CI 1.71-2.76, p < 0.001) as was donor risk index (OR 2.02, 95% CI 1.65-2.48, p < 0.001). Heparin use at cross clamp, INR, and male donors were all significantly associated with lower risk. DISCUSSION Pre-transplant portal vein thrombosis is associated with post-transplant hepatic artery thrombosis independent of other factors. Recipients with portal vein thrombosis might benefit from aggressive coagulation management and careful donor selection. More research is needed to determine causal mechanism.
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Affiliation(s)
- Jonathan G Stine
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Virginia, United States
| | - Shawn J Pelletier
- Division of Transplant Surgery, Department of Surgery, University of Virginia, United States
| | - Timothy M Schmitt
- Division of Transplant Surgery, Department of Surgery, University of Kansas, United States
| | - Robert J Porte
- Department of Surgery, University of Groningen, University Medical Center Groningen, Netherlands
| | - Patrick G Northup
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Virginia, United States.
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47
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Donohue CI, Mallett SV. Reducing transfusion requirements in liver transplantation. World J Transplant 2015; 5:165-182. [PMID: 26722645 PMCID: PMC4689928 DOI: 10.5500/wjt.v5.i4.165] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/10/2015] [Accepted: 11/25/2015] [Indexed: 02/05/2023] Open
Abstract
Liver transplantation (LT) was historically associated with massive blood loss and transfusion. Over the past two decades transfusion requirements have reduced dramatically and increasingly transfusion-free transplantation is a reality. Both bleeding and transfusion are associated with adverse outcomes in LT. Minimising bleeding and reducing unnecessary transfusions are therefore key goals in the perioperative period. As the understanding of the causes of bleeding has evolved so too have techniques to minimize or reduce the impact of blood loss. Surgical “piggyback” techniques, anaesthetic low central venous pressure and haemodilution strategies and the use of autologous cell salvage, point of care monitoring and targeted correction of coagulopathy, particularly through use of factor concentrates, have all contributed to declining reliance on allogenic blood products. Pre-emptive management of preoperative anaemia and adoption of more restrictive transfusion thresholds is increasingly common as patient blood management (PBM) gains momentum. Despite progress, increasing use of marginal grafts and transplantation of sicker recipients will continue to present new challenges in bleeding and transfusion management. Variation in practice across different centres and within the literature demonstrates the current lack of clear transfusion guidance. In this article we summarise the causes and predictors of bleeding and present the evidence for a variety of PBM strategies in LT.
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48
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Is There a Role for Desmopressin in Liver Transplantation? A Case Report. Transplant Proc 2015; 47:2782-5. [DOI: 10.1016/j.transproceed.2015.09.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 09/17/2015] [Indexed: 12/19/2022]
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49
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Kell DB, Pretorius E. The simultaneous occurrence of both hypercoagulability and hypofibrinolysis in blood and serum during systemic inflammation, and the roles of iron and fibrin(ogen). Integr Biol (Camb) 2015; 7:24-52. [PMID: 25335120 DOI: 10.1039/c4ib00173g] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Although the two phenomena are usually studied separately, we summarise a considerable body of literature to the effect that a great many diseases involve (or are accompanied by) both an increased tendency for blood to clot (hypercoagulability) and the resistance of the clots so formed (hypofibrinolysis) to the typical, 'healthy' or physiological lysis. We concentrate here on the terminal stages of fibrin formation from fibrinogen, as catalysed by thrombin. Hypercoagulability goes hand in hand with inflammation, and is strongly influenced by the fibrinogen concentration (and vice versa); this can be mediated via interleukin-6. Poorly liganded iron is a significant feature of inflammatory diseases, and hypofibrinolysis may change as a result of changes in the structure and morphology of the clot, which may be mimicked in vitro, and may be caused in vivo, by the presence of unliganded iron interacting with fibrin(ogen) during clot formation. Many of these phenomena are probably caused by electrostatic changes in the iron-fibrinogen system, though hydroxyl radical (OH˙) formation can also contribute under both acute and (more especially) chronic conditions. Many substances are known to affect the nature of fibrin polymerised from fibrinogen, such that this might be seen as a kind of bellwether for human or plasma health. Overall, our analysis demonstrates the commonalities underpinning a variety of pathologies as seen in both hypercoagulability and hypofibrinolysis, and offers opportunities for both diagnostics and therapies.
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Affiliation(s)
- Douglas B Kell
- School of Chemistry and The Manchester Institute of Biotechnology, The University of Manchester, 131, Princess St, Manchester M1 7DN, Lancs, UK.
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50
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Deep vein thrombosis and pulmonary embolism after solid organ transplantation: an unresolved problem. Transplant Rev (Orlando) 2015; 29:85-92. [DOI: 10.1016/j.trre.2014.12.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 12/11/2014] [Accepted: 12/12/2014] [Indexed: 01/15/2023]
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