1
|
Schurink IJ, de Goeij FHC, van der Heijden FJ, van Rooden RM, van Dijk MC, Polak WG, van der Laan LJW, Huurman VAL, de Jonge J. Liver function maximum capacity test during normothermic regional perfusion predicts graft function after transplantation. EPMA J 2024; 15:545-558. [PMID: 39239110 PMCID: PMC11372035 DOI: 10.1007/s13167-024-00371-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/29/2024] [Indexed: 09/07/2024]
Abstract
Purpose In an effort to reduce waitlist mortality, extended criteria donor organs, including those from donation after circulatory death (DCD), are being used with increasing frequency. These donors carry an increased risk for postoperative complications, and balancing donor-recipient risks is currently based on generalized nomograms. Abdominal normothermic regional perfusion (aNRP) enables individual evaluation of DCD organs, but a gold standard to determine suitability for transplantation is lacking. This study aimed to incorporate individualized and predictive measurements of the liver maximum capacity (LiMAx) test to objectively grade liver function during aNRP and prevent post-op complications. Methods aNRP was performed to salvage 18 DCD liver grafts, otherwise discarded. Continuous variables were presented as the median with the interquartile range. Results The liver function maximum capacity (LiMAx) test was successfully performed within the aNRP circuit in 17 aNRPs (94%). Donor livers with good lactate clearance during aNRP demonstrated significantly higher LiMAx scores (396 (301-451) µg/kg/h versus those who did not 105 (70-158) µg/kg/h; P = 0.006). This was also true for manifesting stress hyperglycemia > 20 mmol/l (P = 0.032). LiMAx score correlated with alanine aminotransferase (ALT; R = - 0.755) and aspartate transaminase (AST; R = - 0.800) levels during perfusion and distinguished livers that were selected for transplantation (397 (346-453) µg/kg/h) from those who were discarded (155 (87-206) µg/kg/h; P < 0.001). Twelve livers were accepted for transplantation, blinded for LiMAx results, and all had LiMAx scores of > 241 µg/kg/h. Postoperatively, LiMAx during aNRP displayed correlation with 24-h lactate levels. Conclusions This study shows for the first time the feasibility to assess liver function during aNRP in individual donor livers. LiMAx presents an objective tool to predict donor liver function and risk of complications in the recipient, thus enabling individualized matching of donor livers for an individual recipient. The LiMAx test may present a valuable test for the prediction of donor liver function, preventing post-transplant complication, and personalizing the selection of donor livers for individual recipients. Supplementary Information The online version contains supplementary material available at 10.1007/s13167-024-00371-7.
Collapse
Affiliation(s)
- Ivo J Schurink
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, Zuid Holland The Netherlands
| | - Femke H C de Goeij
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, Zuid Holland The Netherlands
| | - Fenna J van der Heijden
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, Zuid Holland The Netherlands
| | - Rutger M van Rooden
- LUMC Transplant Center, Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Madeleine C van Dijk
- LUMC Transplant Center, Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Wojciech G Polak
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, Zuid Holland The Netherlands
| | - Luc J W van der Laan
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, Zuid Holland The Netherlands
| | - Volkert A L Huurman
- LUMC Transplant Center, Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen de Jonge
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, Zuid Holland The Netherlands
| |
Collapse
|
2
|
Zubenko SI, Monakhov AR, Boldyrev MA, Salimov VR, Smolianinova AD, Gautier SV. Risk factors in deceased donor liver transplantation: a single centre experience. RUSSIAN JOURNAL OF TRANSPLANTOLOGY AND ARTIFICIAL ORGANS 2022. [DOI: 10.15825/1995-1191-2022-4-7-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Deceased brain-dead donor liver transplantation (LT) is a high-risk intervention. The outcome depends on a large number of modifiable and non-modifiable factors. Objective: to analyze our own experience and identify preoperative and perioperative prognostic factors for poor outcomes in LT. Materials and methods. The study included 301 liver transplants performed between January 2016 and December 2021. Donor and recipient characteristics, intraoperative data, perioperative characteristics including laboratory test data, and the nature and frequency of complications were used for the analysis. Results. The 1-, 3- and 5-year recipient survival rates were 91.8%, 85.1%, and 77.9%, respectively; graft survival rates were 90.4%, 83.7%, and 76.7%, respectively. The most significant predictors of poor outcome of LT on the recipient side were biliary stents (HR 7.203, p < 0.01), acutely decompensated cirrhosis (HR 2.52, p = 0.02); in the postoperative period, non-surgical infectious complications (HR 4.592, p < 0.01) and number of reoperations (HR 4.063, p < 0.01). Donor creatinine level (HR 1.004, p = 0.01, one factor analysis; HR 1.004, p = 0.016, multivariate analysis) was the only reliable prognostic negative factor. Conclusion. LT taking into account established risk factors will improve surgery outcomes and help personalize the therapy for each patient.
Collapse
Affiliation(s)
- S. I. Zubenko
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - A. R. Monakhov
- Shumakov National Medical Research Center of Transplantology and Artificial Organs; Sechenov University
| | - M. A. Boldyrev
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - V. R. Salimov
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - A. D. Smolianinova
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - S. V. Gautier
- Shumakov National Medical Research Center of Transplantology and Artificial Organs; Sechenov University
| |
Collapse
|
3
|
Okeke RI, Bettag J, Wells R, Wycoff M, Hallcox T, Lok J, Phocas A, Annakie DL, Shoela R, Nazzal M. Intraoperative Doppler Ultrasound for Detection of Early Postoperative Vascular Complications in Orthotopic Liver Transplants. Cureus 2022; 14:e26077. [PMID: 35865449 PMCID: PMC9293270 DOI: 10.7759/cureus.26077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2022] [Indexed: 01/10/2023] Open
Abstract
Liver transplantation is currently the only curative treatment for patients with end-stage liver disease. However, liver transplantation can be associated with catastrophic complications in the early postoperative setting, including hepatic artery thrombosis (HAT) and portal vein thrombosis (PVT). Postoperative complications are associated with hepatic artery resistive index (RI) < 6, systolic acceleration time (SAT) > 0.08 seconds and peak systolic velocity (PSV) > 200 cm/s on doppler ultrasound (DUS). DUS is also used in an intraoperative setting to assess patency and early complications prior to the end of the operative period, allowing for early correction. This literature review evaluates the prevalence of DUS use in intraoperative settings to identify transplant complications. A lack of consistency and minimal knowledge of intraoperative DUS warrants additional research into its usage and standardization.
Collapse
|
4
|
Lozanovski VJ, Probst P, Arefidoust A, Ramouz A, Aminizadeh E, Nikdad M, Khajeh E, Ghamarnejad O, Shafiei S, Ali-Hasan-Al-Saegh S, Seide SE, Kalkum E, Nickkholgh A, Czigany Z, Lurje G, Mieth M, Mehrabi A. Prognostic role of the Donor Risk Index, the Eurotransplant Donor Risk Index, and the Balance of Risk score on graft loss after liver transplantation. Transpl Int 2021; 34:778-800. [PMID: 33728724 DOI: 10.1111/tri.13861] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 02/19/2021] [Accepted: 03/08/2021] [Indexed: 12/12/2022]
Abstract
This study aimed to identify cutoff values for donor risk index (DRI), Eurotransplant (ET)-DRI, and balance of risk (BAR) scores that predict the risk of liver graft loss. MEDLINE and Web of Science databases were searched systematically and unrestrictedly. Graft loss odds ratios and 95% confidence intervals were assessed by meta-analyses using Mantel-Haenszel tests with a random-effects model. Cutoff values for predicting graft loss at 3 months, 1 year, and 3 years were analyzed for each of the scores. Measures of calibration and discrimination used in studies validating the DRI and the ET-DRI were summarized. DRI ≥ 1.4 (six studies, n = 35 580 patients) and ET-DRI ≥ 1.4 (four studies, n = 11 666 patients) were associated with the highest risk of graft loss at all time points. BAR > 18 was associated with the highest risk of 3-month and 1-year graft loss (n = 6499 patients). A DRI cutoff of 1.8 and an ET-DRI cutoff of 1.7 were estimated using a summary receiver operator characteristic curve, but the sensitivity and specificity of these cutoff values were low. A DRI and ET-DRI score ≥ 1.4 and a BAR score > 18 have a negative influence on graft survival, but these cutoff values are not well suited for predicting graft loss.
Collapse
Affiliation(s)
- Vladimir J Lozanovski
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany.,Liver Cancer Center Heidelberg (LCCH), University Hospital Heidelberg, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany.,The Study Center of the German Surgical Society (SDGC), University Hospital Heidelberg, Heidelberg, Germany
| | - Alireza Arefidoust
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ali Ramouz
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ehsan Aminizadeh
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Mohammadsadegh Nikdad
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Omid Ghamarnejad
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Saeed Shafiei
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Sadeq Ali-Hasan-Al-Saegh
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Svenja E Seide
- Institute of Medical Biometry and Informatics (IMBI), University of Heidelberg, Heidelberg, Germany
| | - Eva Kalkum
- The Study Center of the German Surgical Society (SDGC), University Hospital Heidelberg, Heidelberg, Germany
| | - Arash Nickkholgh
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Georg Lurje
- Department of Surgery, Charité -Universitätsmedizin Berlin, Berlin, Germany
| | - Markus Mieth
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany.,Liver Cancer Center Heidelberg (LCCH), University Hospital Heidelberg, Heidelberg, Germany
| |
Collapse
|
5
|
Agbim U, Satapathy SK. PRO: Portal Vein Thrombosis Impacts Liver Transplantation Outcomes. Clin Liver Dis (Hoboken) 2020; 16:127-131. [PMID: 33163162 PMCID: PMC7609705 DOI: 10.1002/cld.932] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 12/28/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Uchenna Agbim
- Methodist Transplant InstituteMethodist University HospitalMemphisTN
| | - Sanjaya K. Satapathy
- Division of Transplant SurgeryDepartment of SurgeryUniversity of Tennessee Health Science CenterMemphisTN,Division of Hepatology and Sandra Atlas Bass Center for Liver DiseasesNorth Shore University HospitalNorthwell HealthManhassetNY,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell HealthManhassetNY
| |
Collapse
|
6
|
Gaballa D, Bezinover D, Kadry Z, Eyster E, Wang M, Northup PG, Stine JG. Development of a Model to Predict Portal Vein Thrombosis in Liver Transplant Candidates: The Portal Vein Thrombosis Risk Index. Liver Transpl 2019; 25:1747-1755. [PMID: 31436367 PMCID: PMC6864229 DOI: 10.1002/lt.25630] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 08/14/2019] [Indexed: 02/06/2023]
Abstract
Portal vein thrombosis (PVT) is associated with inferior pretransplantation and posttransplantation outcomes. We aimed to create a predictive model to risk stratify transplant candidates for PVT. Data on adult transplants in the United States during the Model for End-Stage Liver Disease (MELD) era through September 2016 were reviewed. We constructed and validated a scoring system composed of routine, readily available clinical information to predict the development of incident PVT at 12 months from transplantation listing. A total of 66,568 liver transplant candidates were dichotomized into 2 groups to construct (n = 34,751) and validate (n = 31,817) a scoring system. In general, the derivation and validation cohorts were clinically similar. Although nonalcoholic steatohepatitis was a significant predictor of incident PVT (hazard ratio, 1.29; 95% confidence interval, 1.08-1.54; P < 0.001), age, MELD score, and moderate-to-severe ascites were also associated with increased risk. African American race was associated with decreased risk. A scoring system (PVT risk index [RI]) of these 5 variables had an area under the curve of 0.71 and 0.70 in both derivation and validation cohorts, respectively. By applying the low cutoff score of 2.6, incident PVT could be accurately excluded (negative predictive value 94%). Using the high cutoff score of 4.6 (positive predictive value 85%), PVT could be diagnosed with high accuracy. The PVT-RI predicts which candidates awaiting lifesaving liver transplantation will and will not develop future PVT. Although this scoring system will require prospective validation, it provides a powerful new tool for the clinician when risk stratifying cirrhosis patients prior to liver transplantation for future PVT development.
Collapse
Affiliation(s)
- Daniel Gaballa
- Department of Medicine, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey PA, USA
| | - Dmitri Bezinover
- Department of Anesthesia, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey PA, USA
| | - Zakiyah Kadry
- Division of Transplant Surgery, Department of Surgery, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey PA, USA
| | - Elaine Eyster
- Division of Hematology & Oncology, Department of Medicine, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey PA, USA
| | - Ming Wang
- Department of Public Health Sciences, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey PA, USA
| | - Patrick G. Northup
- Center for the Study of Coagulation Disorders in Liver Disease, Division of Gastroenterology & Hepatology, Department of Medicine, University of Virginia Health System, Charlottesville VA, USA
| | - Jonathan G. Stine
- Department of Public Health Sciences, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey PA, USA,Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University- Milton S. Hershey Medical Center, Hershey PA, USA
| |
Collapse
|
7
|
Bhangui P, Lim C, Levesque E, Salloum C, Lahat E, Feray C, Azoulay D. Novel classification of non-malignant portal vein thrombosis: A guide to surgical decision-making during liver transplantation. J Hepatol 2019; 71:1038-1050. [PMID: 31442476 DOI: 10.1016/j.jhep.2019.08.012] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 07/25/2019] [Accepted: 08/12/2019] [Indexed: 02/07/2023]
Abstract
Non-tumoral portal vein thrombosis (PVT) is present at liver transplantation in 5% to 26% of cirrhotic patients, and the prevalence of complex PVT as defined here (grade 4 Yerdel, and grade 3,4 Jamieson and Charco) has been reported in 0% to 2.2%. Adequate portal inflow is mandatory to ensure graft and patient survival after liver transplantation. With time, the proposed classifications of non-tumoral chronic PVT have evolved from being anatomy-based, to also incorporating functional parameters. However, none of the currently proposed classifications are directed towards decision-making, regarding the choice of inflow to the graft during transplantation and the outcomes thereof. The present scoping review i) addresses the limits of the currently available classifications in terms of surgical decisiveness, ii) clarifies the concept of physiological or non-physiological portal inflow reconstruction, and subsequently, iii) proposes a new classification of non-tumoral PVT in candidates for liver transplantation; to help tailor the surgical strategy to an individual patient, in order to provide portal inflow to the graft together with control of prehepatic portal hypertension whenever feasible.
Collapse
Affiliation(s)
- Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, New Delhi, India
| | - Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Pitié-Salpêtrière Hospital, Paris, France
| | - Eric Levesque
- Liver Intensive Care Unit, Henri Mondor Hospital, Créteil, France
| | - Chady Salloum
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France
| | - Eylon Lahat
- Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Israel
| | - Cyrille Feray
- Department of Hepatology, Paul Brousse Hospital, Villejuif, France
| | - Daniel Azoulay
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France; Department of Hepatobiliary and Pancreatic Surgery and Transplantation, Sheba Medical Center, Faculty of Medicine Tel Aviv University, Israel.
| |
Collapse
|
8
|
Ma SD, Wang J, Bezinover D, Kadry Z, Northup PG, Stine JG. Inherited thrombophilia and portal vein thrombosis in cirrhosis: A systematic review and meta-analysis. Res Pract Thromb Haemost 2019; 3:658-667. [PMID: 31624785 PMCID: PMC6781918 DOI: 10.1002/rth2.12253] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/23/2019] [Accepted: 07/28/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Portal vein thrombosis (PVT) is common in cirrhosis. PVT is associated with high morbidity and mortality. Individual reports suggest that PVT occurs more frequently in patients with cirrhosis and inherited thrombophilia. The relationship between cirrhosis, PVT development, and inherited thrombophilia was explored in this study. The aim of the study was to determine whether cirrhotic patients with nontumoral PVT have an increased rate of inherited thrombophilia. METHODS Studies were identified by searching electronic databases up to October 2017 with English language and human subject restrictions. Two independent reviewers screened citations and extracted data. Magnitude of effect was calculated to obtain aggregate estimates of effect size and 95% confidence intervals (CIs). Between-study variability and heterogeneity were assessed. RESULTS Of 2893 citations identified, 9 studies composed of 1929 subjects with cirrhosis were included. The overall prevalence of PVT was 6.5% (n = 125). Both prothrombin G20210A mutation (odds ratio [OR], 2.43; 95% CI, 1.07-5.53; P = 0.03) and factor V Leiden (FVL) (OR, 1.98; 95% CI, 1.06-3.68; P = 0.03) were significantly associated with PVT risk. Methyltetrahydrofolate reductase C677T mutation was not associated with increased PVT risk. No heterogeneity or publication bias was observed. One important study with opposite findings could not be included due to lack of primary data. CONCLUSIONS FVL and PTG20210A mutation were associated with increased PVT risk in patients with cirrhosis. This finding reframes the role of inherited thrombophilia in PVT development in patients with cirrhosis. Future prospective studies investigating screening for inherited thrombophilia in all cirrhosis patients with PVT seem warranted.
Collapse
Affiliation(s)
- Steven D. Ma
- College of MedicinePennsylvania State UniversityHersheyPennsylvania
| | - Jennifer Wang
- Department of MedicineUniversity of VirginiaCharlottesvilleVirginia
| | - Dmitri Bezinover
- Department of Anesthesiology & Perioperative MedicinePennsylvania State University Milton S. Hershey Medical CenterHersheyPennsylvania
| | - Zakiyah Kadry
- Department of SurgeryPennsylvania State University Milton S. Hershey Medical CenterHersheyPennsylvania
| | - Patrick G. Northup
- Center for the Study of Coagulation Disorders in Liver DiseaseDivision of Gastroenterology & HepatologyDepartment of MedicineUniversity of VirginiaCharlottesvilleVirginia
| | - Jonathan G. Stine
- Division of Gastroenterology & HepatologyDepartment of MedicinePennsylvania State University Milton S. Hershey Medical CenterHersheyPennsylvania
- Department of Public Health SciencesPennsylvania State UniversityHersheyPennsylvania
| |
Collapse
|
9
|
Yokoyama APH, Kutner JM, Sakashita AM, Nakazawa CY, de Paula TAO, Zamper RPC, Pedroso PT, de Almeida MD, Meira Filho SP, Orsi FA. Risk Factors for Transfusion after Orthotopic Liver Transplantation. Transfus Med Hemother 2019; 46:431-439. [PMID: 31933573 DOI: 10.1159/000499120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/25/2019] [Indexed: 12/13/2022] Open
Abstract
Background Transfusion of blood products during orthotopic liver transplantation (OLT) is associated with increased morbidity and mortality. Although risk factors associated with intraoperative transfusion requirements have been widely assessed, published data on the prediction of postoperative transfusion requirements are sparse. Objectives The aim of this study was to evaluate risk factors for postoperative allogeneic transfusion requirements in OLT. Methods Clinical characteristics and intraoperative parameters of 645 consecutive adult patients undergoing OLT were retrospectively reviewed. Multivariate logistic regression was used to determine the main determinants for postoperative transfusion requirements. Results Determinants of postoperative transfusion requirements of any blood product in the postoperative period were the number of blood products transfused in the intraoperative period (OR 1.17, 95% CI 1.08-1.28), warm ischemia time (OR 1.05, 95% CI 1.02-1.08), MELD score (OR 1.05, 95% CI 1.01-1.08) and hepatocellular carcinoma (OR 0.45, 95% CI 0.28-0.72). A dose-dependent effect between the number of units transfused in the intraoperative period and transfusion requirements in the postoperative period was also observed. The relative risk of postoperative allogeneic transfusion of any blood component was 5.9 (95% CI 3.4-10.4) for patients who received 1-2 units in the intraoperative period, 7.3 (95% CI 3.6-14.7) for those who received 3-5 units in the intraoperative period, and 11.1 (95% CI 4.7-26.4) for those who received 6 or more units, when compared to no intraoperative blood transfusion. Conclusion Our study demonstrated an association between intraoperative transfusion and warm ischemia time with postoperative transfusion requirements. The identification of risk factors for transfusion in the postoperative period may improve management of these patients by increasing awareness to bleeding complications in this high-risk population and by expanding hemostasis monitoring to the postoperative period.
Collapse
Affiliation(s)
| | - José Mauro Kutner
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Araci Massami Sakashita
- Hemotherapy and Cell Therapy Department, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | | | - Pamella Tung Pedroso
- Liver Transplantation Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | | | - Fernanda Andrade Orsi
- Department of Clinical Pathology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
| |
Collapse
|
10
|
Abstract
Non-tumoral portal vein thrombosis (PVT) remains a highly relevant topic in the field of hepatology and liver transplantation with much surrounding controversy. Although multiple studies have shown that PVT is associated with adverse outcomes with increased morbidity and mortality rates, others have not reported the same clinical impact of PVT, arguing rather that incident PVT reflects worsening portal hypertension and the natural history of the disease. Despite this uncertainly, PVT is a dilemma facing the clinician on a daily basis often requiring a multidisciplinary team-based approach between hepatologists, transplant surgeons, interventional radiologists and hematologists. In this review, the authors provide a summary of the evidence supporting best clinical practices in the management of non-tumoral PVT in patients with cirrhosis.
Collapse
Affiliation(s)
- Jonathan G Stine
- Division of Gastroenterology and Hepatology, Department of Medicine, The Pennsylvania State University Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA.
- Department of Public Health Sciences, The Pennsylvania State University Milton S. Hershey Medical Center, Hershey, PA, USA.
| | - Patrick G Northup
- Department of Medicine, Center for the Study of Coagulation Disorders in Liver Disease, Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| |
Collapse
|
11
|
Agbim U, Jiang Y, Kedia SK, Singal AK, Ahmed A, Bhamidimarri KR, Bernstein DE, Harrison SA, Younossi ZM, Satapathy SK. Impact of Nonmalignant Portal Vein Thrombosis in Transplant Recipients With Nonalcoholic Steatohepatitis. Liver Transpl 2019; 25:68-78. [PMID: 30091296 DOI: 10.1002/lt.25322] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 07/17/2018] [Indexed: 12/12/2022]
Abstract
Nonalcoholic fatty liver disease is an increasingly prevalent condition, and its more severe progressive state, nonalcoholic steatohepatitis (NASH), is currently the second most common indication for wait-listed adults in the United States. The association of portal vein thrombosis (PVT) prior to or at transplant and poor graft and patient outcomes is not well established, particularly among NASH patients who inherently have an increased hypercoagulable profile. Using the United Network for Organ Sharing data set, we analyzed graft and patient outcomes of patients transplanted for the indication of NASH with and without PVT. Of 3689 NASH transplant recipients, the prevalence of PVT was 12% (450 with PVT and 3239 without PVT). NASH transplant recipients with PVT had inferior graft and patient survival compared with NASH transplant recipients without PVT, even after adjusting for recipient and donor demographic characteristics, body mass index, synthetic dysfunction, and presence of diabetes. In a multivariate Cox regression model, NASH transplant recipients with PVT had a 37% increased risk of graft failure (hazard ratio [HR], 1.37; 95% confidence interval [CI], 1.15-1.63; P < 0.001) and 31% increased risk of overall death (HR, 1.31; 95% CI, 1.09-1.58; P < 0.001) compared with NASH transplant recipients without PVT at transplant. This difference in graft and patient survival was most pronounced in the early posttransplant period. These results demonstrate that NASH patients with PVT have decreased graft and patient survival independent of recipient and donor factors.
Collapse
Affiliation(s)
- Uchenna Agbim
- Division of Transplant Surgery, Department of Surgery, Methodist University Hospital Transplant Institute, University of Tennessee Health Science Center, Memphis, TN
| | - Yu Jiang
- School of Public Health, University of Memphis, Memphis, TN
| | - Satish K Kedia
- School of Public Health, University of Memphis, Memphis, TN
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA
| | | | - David E Bernstein
- Division of Hepatology and Sandra Atlas Bass Center for Liver Diseases, Northwell Health, Manhasset, NY
| | - Stephen A Harrison
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Zobair M Younossi
- Department of Medicine, Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA
| | - Sanjaya K Satapathy
- Division of Transplant Surgery, Department of Surgery, Methodist University Hospital Transplant Institute, University of Tennessee Health Science Center, Memphis, TN
| |
Collapse
|
12
|
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: 26] [Impact Index Per Article: 4.3] [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.
Collapse
|
13
|
Stine JG, Niccum BA, Zimmet AN, Intagliata N, Caldwell SH, Argo CK, Northup PG. Increased risk of venous thromboembolism in hospitalized patients with cirrhosis due to non-alcoholic steatohepatitis. Clin Transl Gastroenterol 2018; 9:140. [PMID: 29511162 PMCID: PMC5862151 DOI: 10.1038/s41424-018-0002-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 12/22/2017] [Indexed: 12/19/2022] Open
Abstract
Objective Patients with cirrhosis are at increased risk for venous thromboembolism (VTE) and portal vein thrombosis (PVT). Cirrhosis due to non-alcoholic steatohepatitis (NASH) appears to be particularly prothrombotic. We investigated hospitalized patients with NASH cirrhosis to determine if they are at increased risk for VTE. Methods Data on adult hospitalized patients with cirrhosis and VTE (deep vein thrombosis and/or pulmonary embolism) between November 1, 2010 and December 31, 2015 were obtained. Cases with VTE were matched by age, gender, and model for end stage liver disease (MELD) score to corresponding controls without VTE. Results Two hundred and ninety subjects (145 matched pairs) with mean age of 58.4 ± 11.8 years and MELD score of 16.0 ± 7.2 were included. Baseline characteristics were similar between cases and controls. Independent adjusted risk factors for VTE included NASH (OR: 2.46, 95% CI: 1.07–5.65, p = 0.034), prior VTE (OR: 7.12, 95% CI: 1.99–25.5, p = 0.003), and presence of PVT (OR: 2.18, 95% CI: 1.03–4.58, p = 0.041). Thrombocytopenia was associated with decreased risk (OR: 0.49, 95% CI: 0.26–0.95, p = 0.035). Conclusions NASH is an independent risk factor for VTE among cirrhosis patients and provides further evidence that NASH is a hypercoagulable state. While all hospitalized patients with cirrhosis at risk for VTE should be considered for medical thromboprophylaxis, those with NASH cirrhosis are at particularly increased risk and therefore a high index of suspicion for VTE should be maintained even in the presence of thromboprophylaxis.
Collapse
Affiliation(s)
- Jonathan G Stine
- Center for the Study of Coagulation Disorders in Liver Disease, Division of Gastroenterology & Hepatology, Department of Medicine, University of Virginia, Charlottesville, VA, USA. .,Division of Gastroenterology and Hepatology, The Pennsylvania State University, Hershey, PA, USA.
| | - Blake A Niccum
- School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Alex N Zimmet
- School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Nicolas Intagliata
- Center for the Study of Coagulation Disorders in Liver Disease, Division of Gastroenterology & Hepatology, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Stephen H Caldwell
- Center for the Study of Coagulation Disorders in Liver Disease, Division of Gastroenterology & Hepatology, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Curtis K Argo
- Center for the Study of Coagulation Disorders in Liver Disease, Division of Gastroenterology & Hepatology, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Patrick G Northup
- Center for the Study of Coagulation Disorders in Liver Disease, Division of Gastroenterology & Hepatology, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| |
Collapse
|
14
|
Flores A, Asrani SK. The donor risk index: A decade of experience. Liver Transpl 2017; 23:1216-1225. [PMID: 28590542 DOI: 10.1002/lt.24799] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 05/22/2017] [Accepted: 05/24/2017] [Indexed: 02/07/2023]
Abstract
In 2006, derivation of the donor risk index (DRI) highlighted the importance of donor factors for successful liver transplantation. Over the last decade, the DRI has served as a useful metric of donor quality and has enhanced our understanding of donor factors and their impact upon recipients with hepatitis C virus, those with low Model for End-Stage Liver Disease (MELD) score, and individuals undergoing retransplantation. DRI has provided the transplant community with a common language for describing donor organ characteristics and has served as the foundation for several tools for organ risk assessment. It is a useful tool in assessing the interactions of donor factors with recipient factors and their impact on posttransplant outcomes. However, limitations of statistical modeling, choice of donor factors, exclusion of unaccounted donor and geographic factors, and the changing face of the liver transplant recipient have tempered its widespread use. In addition, the DRI was derived from data before the MELD era but is currently being applied to expand the donor pool while concurrently meeting the demands of a dynamic allocation system. A decade after its introduction, DRI remains relevant but may benefit from being updated to provide guidance in the use of extended criteria donors by accounting for the impact of geography and unmeasured donor characteristics. DRI could be better adapted for recipients with nonalcoholic fatty liver disease by examining and including recipient factors unique to this population. Liver Transplantation 23 1216-1225 2017 AASLD.
Collapse
Affiliation(s)
- Avegail Flores
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
| | | |
Collapse
|