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Rodrigues MG, Castro PMV, Almeida TCD, Danziere FR, Sergi Filho FA, Zeballos Sempertegui BE, Branez JR, Mota LT, Perosa de Miranda M, Gomes Dos Santos R, Genzini T. Impact of Cold Ischemia Time on the Function of Liver Grafts Preserved With Custodiol. Transplant Proc 2020; 53:661-664. [PMID: 33139037 DOI: 10.1016/j.transproceed.2020.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 02/21/2020] [Accepted: 03/12/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This study aimed to evaluate how cold ischemia time (CIT) interferes with liver graft function in the first 7 days after surgery for Custodiol (HTK) preserved organs. METHODS This retrospective observational study analyzed the medical records of 38 transplantation patients at Hospital Leforte Liberdade, São Paulo, in 2018. The study population was divided into 2 groups (group A, CIT < 8 hours; group B, CIT > 8 hours). Postoperative parameters-such as international normalized ratio, total bilirubin, aspartate aminotransferase/alanine aminotransferase, alkaline phosphatase, gamma glutamyl transferase (GGT), lactate dehydrogenase, lactate, creatinine, red blood cell transfusion, need for hemodialysis, use of vasoactive drugs, endotracheal intubation time, length of stay in the intensive care unit (ICU), and length of hospital stay-were compared. RESULTS Group A (CIT < 8 hours) presented less need for red blood cell transfusions (odds ratio 0.29; confidence interval 0.06-0.98; P = .04), had a shorter hospital stay (P = .024), and had lower levels of total bilirubin (P = .05) and GGT (P = .05) in the first 7 postoperative days. The other variables showed no statistically significant difference. CONCLUSION In livers preserved with Custodiol, CIT > 8 hours generated higher levels of total bilirubin and GGT in the postoperative period, in addition to higher hospital costs; greater need for red blood cell transfusions; and longer hospitalization, including longer stays in the ICU.
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Affiliation(s)
| | | | | | | | | | | | - Juan Rafel Branez
- Grupo HEPATO-Hepatology, Transplants, and Gastroenterology, São Paulo, Brazil
| | | | - Marcelo Perosa de Miranda
- Grupo HEPATO-Hepatology, Transplants, and Gastroenterology, São Paulo, Brazil; Liver and Pancreas Transplant Program in Hospital Leforte, São Paulo, Brazil
| | | | - Tércio Genzini
- Grupo HEPATO-Hepatology, Transplants, and Gastroenterology, São Paulo, Brazil; Liver and Pancreas Transplant Program in Hospital Leforte, São Paulo, Brazil
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2
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Type of Preservation Solution, UW or HTK, Has an Impact on the Incidence of Biliary Stricture following Liver Transplantation: A Retrospective Study. J Transplant 2019; 2019:8150736. [PMID: 31934445 PMCID: PMC6942894 DOI: 10.1155/2019/8150736] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 12/03/2019] [Indexed: 01/17/2023] Open
Abstract
Organ preservation plays a crucial role in the outcome following solid organ transplantation. The aim of this study was to perform a retrospective outcome analysis following liver transplantation using histidine tryptophan ketoglutarate (HTK) or the University of Wisconsin (UW) solutions for liver graft preservation. We retrospectively reviewed data on adult patients who were liver-transplanted at Karolinska University Hospital between 2007 and 2015. There was evaluation of donor and recipient characteristics, pre- and post-transplant blood chemistry tests, biliary and vascular complications, graft dysfunction and nonfunction, and patient and graft survivals. A total of 433 patients were included in the analyses, with 230 and 203 patients having received livers preserved with HTK and UW, respectively. Mean follow-up was 45 ± 29 months for the HTK group and 42.4 ± 26 for the UW group. There was no difference between the two groups either in terms of patient and graft survival, or of results of postoperative blood chemistry, or incidence of arterial complications, early allograft dysfunction, or primary graft nonfunction. However, the incidence of biliary stricture was higher in the UW group (22.7%) versus the HTK group (13.5%; p=0.013). Use of UW and HTK preservation solution in liver transplantation has no impact on patient and graft survival. However, use of HTK solution results in a lower incidence of posttransplant biliary stricture.
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Meurisse N, Monbaliu D, Berlakovich G, Muiesan P, Oliverius M, Adam R, Pirenne J. Heterogeneity of Bile Duct Management in the Development of Ischemic Cholangiopathy After Liver Transplantation: Results of a European Liver and Intestine Transplant Association Survey. Transplant Proc 2019; 51:1926-1933. [PMID: 31301856 DOI: 10.1016/j.transproceed.2019.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 04/22/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical factors and direct cytotoxicity of bile salts on cholangiocytes may play a role in the development of ischemic cholangiopathy (IC) after liver transplantation (LTx). There is no validated consensus on how to protect the bile ducts during procurement, static preservation, and LTx. Meanwhile, IC remains the most troublesome complication after LTx. AIM To characterize bile duct management techniques during the LTx process among European transplant centers in cases of donation after brain death (DBD) and circulatory death (DCD). METHOD An European Liver and Intestine Transplant Association-European Liver Transplant Registry web survey designed to conceal respondents' personal information was sent to surgeons procuring and/or transplanting livers in Europe. RESULTS Sixty-five percent of responses came from large transplant centers (>50 procurements/y). In 8% of DBDs and 14% of DCDs the bile duct is not rinsed. In 46% of DBDs and 52% of DCDs surgeons prefer to remove the gallbladder after graft reperfusion. Protocols concerning preservation solutions (nature, pressure, volume) are extremely heterogeneous. In 54% of DBDs and 61% of DCDs an arterial back table pressure perfusion is performed. Steroids (20%-10%), heparin (72%-60%), prostacyclin (3%-7%), and fibrinolytics (4%-11%) are used as donor-protective interventions in DBD and DCD cases, respectively. In 2% of DBD and 6% of DCD cases a hepatic artery reperfusion is performed first. In 4% of DBD and 6% of DCD cases, fibrinolytics are administered through the hepatic artery during the bench and/or implantation. CONCLUSION This European web survey shows for the first time the heterogeneity in the management of bile ducts during procurement, preservation, and transplantation in Europe. In the context of sharing more marginal liver grafts, an expert meeting must be organized to formulate guidelines to be applied to protect liver grafts against IC.
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Affiliation(s)
- Nicolas Meurisse
- Department of Abdominal Transplant Surgery, University of Liege Academic Hospital, ULg CHU, Liege, Belgium; Department of Abdominal Transplant Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Gabriela Berlakovich
- Division of Transplantation, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Paolo Muiesan
- Liver Unit, University of Birmingham, Birmingham, United Kingdom
| | - Martin Oliverius
- Department of Surgery of the 3rd Faculty of Medicine Charles University and Kralovske Vinohrady Hospital, Prague, Czech Republic
| | - René Adam
- APHP Hospital Paul Brousse, Inserm U985, University Paris Sud, Paris, France
| | - Jacques Pirenne
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium.
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4
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Hameed AM, Laurence JM, Lam VWT, Pleass HC, Hawthorne WJ. A systematic review and meta-analysis of cold in situ perfusion and preservation of the hepatic allograft: Working toward a unified approach. Liver Transpl 2017; 23:1615-1627. [PMID: 28734125 PMCID: PMC5725662 DOI: 10.1002/lt.24829] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/03/2017] [Accepted: 07/16/2017] [Indexed: 01/01/2023]
Abstract
The efficacy of cold in situ perfusion and static storage of the liver is a possible determinant of transplantation outcomes. The aim of this study was to determine whether there is evidence to substantiate a preference for a particular perfusion route (aortic or dual) or perfusion/preservation solution in donation after brain death (DBD) liver transplantation. The Embase, MEDLINE, and Cochrane databases were used (1980-2017). Random effects modeling was used to estimate effects on transplantation outcomes based on (1) aortic or dual in situ perfusion and (2) the use of University of Wisconsin (UW), histidine tryptophan ketoglutarate (HTK), Celsior, and/or Institut Georges Lopez-1 (IGL-1) solutions for perfusion/preservation. A total of 22 articles were included (2294 liver transplants). The quality of evidence ranged from very low to moderate Grading of Recommendations, Assessment, Development and Evaluations score. Meta-analyses were conducted for 14 eligible studies. Although there was no difference in the primary nonfunction (PNF) rate, a higher peak alanine aminotransferase (ALT) was recorded in dual compared with aortic-only UW-perfused livers (standardized mean difference, 0.24; 95% confidence interval, 0.01-0.47); a back-table portal venous flush was undertaken in the majority of aortic-only perfused livers. There were no relevant differences in peak enzymes, PNF, thrombotic graft loss, biliary complications, or 1-year graft survival in comparisons between dual-perfused livers using UW, HTK, Celsior, or IGL-1. In conclusion, there is no significant evidence that aortic-only perfusion of the DBD liver compromises transplantation outcomes, and it may be favored because of its simplicity. However, there is currently insufficient evidence to advocate for the use of any particular perfusion/preservation fluid over the others. Liver Transplantation 23 1615-1627 2017 AASLD.
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Affiliation(s)
- Ahmer M. Hameed
- Centre for Transplant and Renal Research, Westmead Institute for Medical ResearchWestmeadNew South WalesAustralia,Department of SurgeryWestmead HospitalWestmeadNew South WalesAustralia,Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Jerome M. Laurence
- Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia,Department of Surgery,Institute of Academic Surgery, Royal Prince Alfred HospitalUniversity of SydneyCamperdownNew South WalesAustralia
| | - Vincent W. T. Lam
- Department of SurgeryWestmead HospitalWestmeadNew South WalesAustralia,Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Henry C. Pleass
- Department of SurgeryWestmead HospitalWestmeadNew South WalesAustralia,Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia,Department of Surgery
| | - Wayne J. Hawthorne
- Centre for Transplant and Renal Research, Westmead Institute for Medical ResearchWestmeadNew South WalesAustralia,Department of SurgeryWestmead HospitalWestmeadNew South WalesAustralia,Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
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Kaltenborn A, Gwiasda J, Amelung V, Krauth C, Lehner F, Braun F, Klempnauer J, Reichert B, Schrem H. Comparable outcome of liver transplantation with histidine-tryptophan-ketoglutarate vs. University of Wisconsin preservation solution: a retrospective observational double-center trial. BMC Gastroenterol 2014; 14:169. [PMID: 25263587 PMCID: PMC4193146 DOI: 10.1186/1471-230x-14-169] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 09/12/2014] [Indexed: 02/07/2023] Open
Abstract
Background The question of whether the choice of preservation solution affects outcome after liver transplantation is still not satisfactorily answered. The purpose of this study is to examine the preservation solutions’ impact on outcome after liver transplantation. Methods A double-center retrospective study of short- and long-term results of 3134 consecutive liver transplantations with follow-up periods up to 23 years was performed applying multivariate, risk-adjusted analyses with a subset for living-donor transplants, pediatric transplants and cases with prolonged cold ischemic times. An additional focus was put on biliary complications. The primary study endpoints were short- and long-term patient survival and death-censored graft survival. Secondary study endpoints were the occurrence of post-transplant complications, the necessity of operative revisions, the length of hospital stay, and the length of intensive care unit stay. Results Although long-term graft survival appears to be increased by Histidine-Tryptophan-Ketoglutarate-use (p = 0.018), this effect could not be confirmed in risk-adjusted analysis (p = 0.641). Multivariate regression analysis revealed that 3-month mortality (p = 0.120), 3-month graft survival (p = 0.103) and long-term patient survival (p = 0.235) were not influenced by the choice of preservation solution. There was no difference in the occurrence of common complications or necessity of operative revisions after liver transplantation. This was confirmed in subgroup analyses for living donor and pediatric transplantation and cases with prolonged cold ischemic time. Analysis of the preservation solutions’ impact on length of hospital (p = 0.113) and intensive care unit stay (p = 0.481) revealed no significant difference. Conclusions University of Wisconsin and Histidine-Tryptophan-Ketoglutarate solutions are clinically equivalent. Histidine-Tryptophan-Ketoglutarate solution could have an economically superior profile. The notion that the choice of preservation solution can have an impact on the onset of biliary complications after liver transplantation remains a matter of controversy. Electronic supplementary material The online version of this article (doi:10.1186/1471-230X-14-169) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexander Kaltenborn
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str, 1, Hannover 30625, Germany.
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6
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Abstract
Liver transplantation is the best therapy in end-stage liver disease. Donor organ shortage and efforts to expand the donor organ pool are permanent issues given that advances in perioperative management and immunosuppressive therapy have brought the procedure into widespread clinical use. The management of organ procurement, including donor preconditioning and adequate organ storage, has a key role in transplantation. However, the organ procurement process can differ substantially between transplant centres, depending on local and national preferences. Advances in the field have come from experimental and clinical research on dynamic storage systems, such as machine perfusion devices, as an alternative to static cold storage. Determination of the clinical significance of these new systems is a topic worthy of future investigations.
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Abstract
PURPOSE OF REVIEW The incidence, pathogenesis and management of the most common biliary complications are summarized, with an emphasis on nonanastomotic biliary strictures (NAS) and potential strategies to prevent NAS after liver transplantation. RECENT FINDINGS NAS have variable presentations in time and localization, suggesting various underlying pathogeneses. Early-onset NAS (presentation within 1 year) have shown to be largely related to ischemia-induced bile duct injury, whereas late-onset NAS [>1 year after orthotopic liver transplantation (OLT)] have more immune-mediated causes. Cytotoxic hydrophobic bile salts and impaired biliary HCO3 secretion may also play a role in the occurrence of NAS. Recently, insufficient biliary epithelial regeneration capacity after transplantation has also been suggested to play a major role in the pathogenesis of NAS. A potential strategy to prevent NAS has been proposed to be preservation by machine perfusion instead of classical static cold storage. Although machine perfusion has been shown to be a better preservation method for the liver parenchyma, efficacy in preventing ischemic injury of the biliary epithelium is largely unknown. SUMMARY The potential advantages of machine perfusion are very promising as it may provide better protection of the vulnerable bile ducts against ischemia-reperfusion injury. Clinical trials will be needed to demonstrate the impact of machine perfusion in reducing the incidence of biliary complications, especially NAS, after OLT.
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Brunner SM, Junger H, Ruemmele P, Schnitzbauer AA, Doenecke A, Kirchner GI, Farkas SA, Loss M, Scherer MN, Schlitt HJ, Fichtner-Feigl S. Bile duct damage after cold storage of deceased donor livers predicts biliary complications after liver transplantation. J Hepatol 2013; 58:1133-9. [PMID: 23321317 DOI: 10.1016/j.jhep.2012.12.022] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 12/12/2012] [Accepted: 12/22/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS The aim of this study was to examine the development of biliary epithelial damage between organ retrieval and transplantation and its clinical relevance for patients. METHODS Common bile duct samples during donor hepatectomy, after cold storage, and after reperfusion were compared to healthy controls by hematoxylin and eosin (H&E) staining and immunofluorescence for tight junction protein 1 and Claudin-1. A bile duct damage score to quantify biliary epithelial injury was developed and correlated with recipient and donor data and patient outcome. RESULTS Control (N=16) and donor hepatectomy bile ducts (N=10) showed regular epithelial morphology and tight junction architecture. After cold storage (N=37; p=0.0119), and even more after reperfusion (N=62; p=0.0002), epithelial damage, as quantified by the bile duct damage score, was markedly increased, and both tight junction proteins were detected with inappropriate morphology. Patients with major bile duct damage after cold storage had a significantly increased risk of biliary complications (relative risk 18.75; p<0.0001) and graft loss (p=0.0004). CONCLUSIONS In many cases, the common bile duct epithelium shows considerable damage after cold ischemia with further damage occurring after reperfusion. The extent of epithelial damage can be quantified by our newly developed bile duct damage score and is a prognostic parameter for biliary complications and graft loss. Possibly, in an intraoperative histological examination, this bile duct damage score may influence decision-making in transplantation surgery.
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Affiliation(s)
- Stefan M Brunner
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
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9
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Ischemia-Reperfusion Injury and Ischemic-Type Biliary Lesions following Liver Transplantation. J Transplant 2012; 2012:164329. [PMID: 22530107 PMCID: PMC3316988 DOI: 10.1155/2012/164329] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 12/19/2011] [Accepted: 12/23/2011] [Indexed: 12/14/2022] Open
Abstract
Ischemia-reperfusion (I-R) injury after liver transplantation (LT) induces intra- and/or extrahepatic nonanastomotic ischemic-type biliary lesions (ITBLs). Subsequent bile duct stricture is a significant cause of morbidity and even mortality in patients who underwent LT. Although the pathogenesis of ITBLs is multifactorial, there are three main interconnected mechanisms responsible for their formation: cold and warm I-R injury, injury induced by cytotoxic bile salts, and immunological-mediated injury. Cold and warm ischemic insult can induce direct injury to the cholangiocytes and/or damage to the arterioles of the peribiliary vascular plexus, which in turn leads to apoptosis and necrosis of the cholangiocytes. Liver grafts from suboptimal or extended-criteria donors are more susceptible to cold and warm I-R injury and develop more easily ITBLs than normal livers. This paper, focusing on liver I-R injury, reviews the risk factors and mechanisms leading to ITBLs following LT.
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10
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Gunawansa N, McCall JL, Holden A, Plank L, Munn SR. Biliary complications following orthotopic liver transplantation: a 10-year audit. HPB (Oxford) 2011; 13:391-9. [PMID: 21609371 PMCID: PMC3103095 DOI: 10.1111/j.1477-2574.2011.00300.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Biliary complications following liver transplantation result in major morbidity. We undertook a 10-year audit of the incidence, management and outcomes of post-transplant biliary complications at the New Zealand Liver Transplant Unit. METHODS Prospectively collected data on 348 consecutive liver transplants performed between February 1998 and October 2008 were reviewed. The minimum follow-up was 6 months. RESULTS A total of 309 adult and 39 paediatric transplants were performed over the study period. Of these, 296 (85%) were whole liver grafts and 52 (15%) were partial liver grafts (24 split-liver, eight reduced-size and 20 live-donor grafts). There were 80 biliary complications, which included 63 (18%) strictures and 17 (5%) bile leaks. Partial graft, a paediatric recipient and a Roux-en-Y biliary anastomosis were independent predictors of biliary strictures. Twenty-five (40%) strictures were successfully managed non-operatively and 38 (60%) required surgery (31 biliary reconstructions, three segmental resections and four retransplants). Seven (41%) bile leaks required surgical revision and 10 (59%) were managed non-operatively. There was no mortality related directly to biliary complications. CONCLUSIONS Biliary complications affected one in five transplant recipients. Paediatric status, partial graft and Roux-en-Y anastomosis were independently associated with the occurrence of biliary strictures. Over half of the affected patients required surgical revision, but no mortality resulted from biliary complications.
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Affiliation(s)
- Nalaka Gunawansa
- National Hospital of Sri Lanka and New Zealand Liver Transplant Unit, National Hospital of Sri LankaColombo, Sri Lanka
| | - John L McCall
- Department of Surgery, Faculty of Medicine, University of OtagoDunedin, New Zealand
| | - Andrew Holden
- Department of Radiology, Auckland City HospitalAuckland, New Zealand
| | - Lindsay Plank
- Department of Surgery, Faculty of Medicine, University of AucklandAuckland, New Zealand
| | - Stephen R Munn
- Department of Surgery, Faculty of Medicine, University of AucklandAuckland, New Zealand,Department of SurgeryAuckland District Health Board, Auckland, New Zealand
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11
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Akamatsu N, Sugawara Y, Hashimoto D. Biliary reconstruction, its complications and management of biliary complications after adult liver transplantation: a systematic review of the incidence, risk factors and outcome. Transpl Int 2010; 24:379-92. [PMID: 21143651 DOI: 10.1111/j.1432-2277.2010.01202.x] [Citation(s) in RCA: 224] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Biliary reconstruction remains common in postoperative complications after liver transplantation. A systematic search was conducted on the PubMed database and 61 studies of retrospective or prospective institutional data were eligible for this review. The study comprised a total of 14,359 liver transplantations. The overall incidence of biliary stricture was 13%; 12% among deceased donor liver transplantation (DDLT) patients and 19% among living donor liver transplantation (LDLT) recipients. The overall incidence of biliary leakage was 8.2%, 7.8% among DDLT patients and 9.5% among LDLT recipients. An endoscopic strategy is the first choice for biliary complications; 83% of patients with biliary stricture were treated by endoscopic modalities with a success rate of 57% and 38% of patients with leakage were indicated for endoscopic biliary drainage. T-tube placement was not performed in 82% of duct-to-duct reconstruction. The incidence of biliary stricture was 10% with a T-tube and 13% without a T-tube and the incidence of leakage was 5% with a T-tube and 6% without a T-tube. A preceding bile leak and LDLT procedure are accepted risk factors for anastomotic stricture. Biliary complications remain common, which requires further investigation and the refinement of reconstruction techniques and management strategies.
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Affiliation(s)
- Nobuhisa Akamatsu
- Department of Hepato-biliary-pancreatic Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
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12
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Stewart ZA, Cameron AM, Singer AL, Montgomery RA, Segev DL. Histidine-Tryptophan-Ketoglutarate (HTK) is associated with reduced graft survival in deceased donor livers, especially those donated after cardiac death. Am J Transplant 2009; 9:286-93. [PMID: 19067658 DOI: 10.1111/j.1600-6143.2008.02478.x] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Single-center studies have reported that liver allograft survival is not affected by preservation in histidine-tryptophan-ketoglutarate (HTK) versus University of Wisconsin (UW) solution. We analyzed the UNOS database of liver transplants performed from July, 2004, through February, 2008, to determine if preservation with HTK (n = 4755) versus UW (n = 12 673) impacted graft survival. HTK preservation of allografts increased from 16.8% in 2004 to 26.9% in 2008; this was particularly striking among donor after cardiac death (DCD) allografts, rising from 20.7% in 2004 to 40.9% in 2008. After adjusting for donor, recipient and graft factors that affect graft survival, HTK preservation was associated with an increased risk of graft loss (HR 1.14, p = 0.002), especially with DCD allografts (HR 1.44, P = 0.025) and those with cold ischemia time over 8 h (HR 1.16, P = 0.009). Furthermore, HTK preservation was associated with a 1.2-fold higher odds of early (< 30 days) graft loss as compared to UW preservation (OR 1.20, p = 0.012), with a more pronounced effect on allografts with cold ischemia time over 8 h (OR 1.31, p = 0.007), DCD allografts (OR 1.63, p = 0.09) and donors over 70 years (OR 1.67, p = 0.081). These results suggest that the increasing use of HTK for abdominal organ preservation should be reexamined.
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Affiliation(s)
- Z A Stewart
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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13
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Olschewski P, Hunold G, Eipel C, Neumann U, Schöning W, Schmitz V, Vollmar B, Neuhaus P, Puhl G. Improved microcirculation by low-viscosity histidine- tryptophan-ketoglutarate graft flush and subsequent cold storage in University of Wisconsin solution: results of an orthotopic rat liver transplantation model. Transpl Int 2008; 21:1175-80. [PMID: 18699843 DOI: 10.1111/j.1432-2277.2008.00741.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
As previously shown in a model of isolated rat liver perfusion, the combined use of an initial graft flush with low-viscosity histidine-tryptophan-ketoglutarate (HTK) solution followed by cold storage in University of Wisconsin (UW) solution markedly improved the preservation during an extended cold storage period. In this study, we aimed to transfer our results into an in vivo model of orthotopic rat liver transplantation, and to elucidate the potential mechanism of the improved preservation by focusing on the hepatic microcirculation. Livers were harvested from male Wistar rats. Aortic perfusion with a pressure of 100 cm H(2)O was performed with either UW (group UW) or HTK (groups UW and HTK_UW), followed by additional back-table perfusion with UW (group HTK_UW). After 20-h cold storage at 4 degrees C, livers were orthotopically transplanted with reconstructing the hepatic artery. As measured by bile flow and liver enzymes, HTK flush followed by UW storage was superior compared to single use of either UW or HTK solution. The hepatic microcirculation was significantly improved, as shown by the increased percentage of reperfused sinusoids and reduced sinusoidal leucostasis. HTK and UW effectively reduce ischaemia-reperfusion injury after liver transplantation. By combining the comparative advantages of both solutions, a cumulative effect resulting in an improved preservation was shown. Thus, this mechanism improves microcirculatory reperfusion.
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Affiliation(s)
- Peter Olschewski
- Clinic for General, Visceral and Transplantation Surgery, Charité Campus Virchow-Klinikum, University Medicine Berlin, Berlin, Germany.
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14
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Comparison of Histidine-Tryptophan-Ketoglutarate Solution and University of Wisconsin Solution in Intestinal and Multivisceral Transplantation. Transplantation 2008; 86:298-302. [DOI: 10.1097/tp.0b013e31817ef074] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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15
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Nemes B, Zádori G, Hartmann E, Németh A, Fehérvári I, Görög D, Máthé Z, Dávid A, Jakab K, Sárváry E, Piros L, Tóth S, Fazakas J, Gerlei Z, Járay J, Doros A. Biliary complications following orthotopic liver transplantation. The Hungarian experience. Orv Hetil 2008; 149:963-73. [DOI: 10.1556/oh.2008.28363] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A szerzők összefoglalják a magyar májátültetési program epeúti szövődményeinek jellemzőit. Feltárják az epeúti szövődmények előfordulási gyakoriságát. Elemzik az epeúti szövődmények típusait és azok megoszlását, valamint hatásukat a beteg-, illetve graftvesztésre. Elemzik az irodalomban már ismert rizikófaktorokat a hazai betegpopulációban. Ismertetik az epeúti szövődmények kezelési lehetőségeit. Retrospektív vizsgálat során a betegeket két csoportba osztották aszerint, hogy a májátültetés után kialakult-e epeúti szövődmény, vagy nem, majd a két csoportot összehasonlították számos vizsgált paraméter, valamint a túlélések szempontjából. Az epeúti szövődményes betegeket tovább csoportosították annak alapján, hogy a szövődmény a májátültetés után három hónapon belül vagy később alakult ki. Ezt a két csoportot szintén összehasonlították a fentebb említett kontrollcsoporttal. Egyvariációs összehasonlítások esetén a folytonos adatokat a populáció homogenitásának vizsgálata után (Levene-teszt) kétmintás
t
-próbával, illetve Mann–Whitney-féle U-teszttel, a kategorikus adatokat χ
2
-próbával, illetve Kaplan–Meier-analízissel vizsgálták. A túlélést Kaplan–Meier-metodikával vizsgálták. Az eredményeket valamennyi statisztikai próbánál akkor tekintették szignifikánsnak, ha a
p
< 0,05 volt.
Eredmények:
Epeúti szövődmény a betegek 26%-ában jelent meg, 290 vizsgált beteg közül 76 esetben. A leggyakoribb a szűkület (18%), majd az epecsorgás (9%), a necrosis (6%), végül az ischaemiás típusú epeúti károsodás (3%). Epeúti szövődmények esetén az 5 éves kumulatív túlélés rosszabb (55%), mint ezek hiányában (66%), és a retranszplantációk aránya is magasabb (15%) volt. A leggyakoribb kezelési típusok: intervenciós radiológiai (69%), sebészi (17%), ERCP (14%).
Következtetések:
Az epeúti szövődmények aránya megfelel a nemzetközi közléseknek, 2002 óta arányuk csökkent. Epeúti szövődmények kialakulásának rizikófaktorai: cholangitis, az arteria hepatica thrombosisa és stenosisa, magas bevitt intraoperatív volumen, valamint az akut rejectio. Korai epeúti szövődmények gyakran társultak a beültetett májgraft kezdeti gyenge működésével (ún. „initial poor function”). A korai epeúti szövődmények felelősek a túlélés csökkenéséért, a késői szövődmények inkább az életminőséget rontják. Az epeúti szövődményes betegeket döntően intervenciós radiológiai módszerekkel kezelték.
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Affiliation(s)
- Balázs Nemes
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Gergely Zádori
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Erika Hartmann
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Andrea Németh
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Imre Fehérvári
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Dénes Görög
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Zoltán Máthé
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Andrea Dávid
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Katalin Jakab
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Enikő Sárváry
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - László Piros
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Szabolcs Tóth
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - János Fazakas
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Zsuzsa Gerlei
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Jenő Járay
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
| | - Attila Doros
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23. 1082
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Feng L, Zhao N, Yao X, Sun X, Du L, Diao X, Li S, Li Y. Histidine-tryptophan-ketoglutarate solution vs. University of Wisconsin solution for liver transplantation: a systematic review. Liver Transpl 2007; 13:1125-36. [PMID: 17665493 DOI: 10.1002/lt.21208] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
University of Wisconsin (UW) solution has been recognized as the gold standard in liver preservation, but its limitations are becoming obvious, such as risk of biliary complications and its high cost. Alternatively, the effects of histidine-tryptophan-ketoglutarate (HTK), such as improved biliary protection and low cost, have been observed. This systematic review is conducted to compare the efficacy and safety of these 2 solutions. Databases from 1966 to June 2006 were searched. Randomized clinical trials (RCTs) and cohort studies comparing HTK and UW solutions for liver transplantation were included. Ten articles including 11 comparisons (1,200 patients) met the inclusion criteria, containing 2 RCTs and 9 cohort studies. No marked differences existed between the 2 groups in patient and graft survival rates, acute rejection, primary nonfunction, primary dysfunction, delayed graft function, and ALT and AST levels after transplantation. The only positive result was observed in the bile production after deceased donor liver transplantation (DDLT), which was statistically significantly higher in HTK group than that of UW group (95% confidence interval, 18.65-57.47; P=0.0001). Although the difference in biliary complications between the 2 groups did not reach statistical significance, HTK was thought to be more effective for biliary tract flush and prevention of biliary complications in some studies. There was no statistically significant difference of effects (except bile production) between HTK and UW. But trends were documented in some studies for the superiority of HTK in biliary tract flush, prevention of biliary complications, and cost saving. Adequately powered RCTs with longer follow-up periods are required to evaluate the long-term effect of these 2 solutions.
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Affiliation(s)
- Li Feng
- Key Laboratory of Transplant Engineering and Immunology, Ministry of Health, West China Hospital, Sichuan University, PR China.
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17
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Machine perfusion preservation of the liver: a worthwhile clinical activity? Curr Opin Organ Transplant 2007; 12:224-230. [DOI: 10.1097/mot.0b013e32814e6bc2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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18
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Moench C, Heimann A, Foltys D, Schneider B, Minouchehr S, Schwandt E, Knaak M, Kempski O, Otto G. Flow and Pressure during Liver Preservation under ex situ and in situ Perfusion with University of Wisconsin Solution and Histidine-Tryptophan-Ketoglutarate Solution. Eur Surg Res 2007; 39:175-81. [PMID: 17351323 DOI: 10.1159/000100800] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2006] [Accepted: 12/19/2006] [Indexed: 12/14/2022]
Abstract
Effective preservation of liver grafts is the first essential step for successful liver transplantation. Insufficient perfusion leads to ischemic-type biliary lesions after transplantation. Perfusion of the graft can be performed either in situ or ex situ, with gravity flow or pressure-controlled. Mainly University of Wisconsin (UW) and histidine-tryptophan-ketoglutarate (HTK) solutions are used widespread in clinical liver transplantation. Due to a persistent lack of data, we performed this systematic investigation of in situ and ex situ perfusion of liver grafts with HTK (low-viscous) and UW (high-viscous) solutions at different pressure steps on the perfusion solution (gravity flow, 50, 100, 150, and 200 mm Hg). End points were perfusion flow and pressure in the hepatic artery. A pig model was used with n = 8 pigs randomized to each (HTK and UW) group. In situ perfusion was ineffective for both solutions at any pressure on the perfusate bag. Ex situ perfusion showed significantly improved flow and pressure in the hepatic artery and, therefore, was highly effective. No major differences between HTK and UW solutions could be detected. Therefore, an additional ex situ perfusion of the hepatic artery should be mandatory in every liver procurement.
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Affiliation(s)
- C Moench
- Department of Transplantation and Hepatobiliarypancreatic Surgery, Johannes Gutenberg University, Mainz, Germany.
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