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Lascaris B, Thorne AM, Lisman T, Nijsten MWN, Porte RJ, de Meijer VE. Long-term normothermic machine preservation of human livers: what is needed to succeed? Am J Physiol Gastrointest Liver Physiol 2022; 322:G183-G200. [PMID: 34756122 DOI: 10.1152/ajpgi.00257.2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Although short-term machine perfusion (≤24 h) allows for resuscitation and viability assessment of high-risk donor livers, the donor organ shortage might be further remedied by long-term perfusion machines. Extended preservation of injured donor livers may allow reconditioning, repairing, and regeneration. This review summarizes the necessary requirements and challenges for long-term liver machine preservation, which requires integrating multiple core physiological functions to mimic the physiological environment inside the body. A pump simulates the heart in the perfusion system, including automatically controlled adjustment of flow and pressure settings. Oxygenation and ventilation are required to account for the absence of the lungs combined with continuous blood gas analysis. To avoid pressure necrosis and achieve heterogenic tissue perfusion during preservation, diaphragm movement should be simulated. An artificial kidney is required to remove waste products and control the perfusion solution's composition. The perfusate requires an oxygen carrier, but will also be challenged by coagulation and activation of the immune system. The role of the pancreas can be mimicked through closed-loop control of glucose concentrations by automatic injection of insulin or glucagon. Nutrients and bile salts, generally transported from the intestine to the liver, have to be supplemented when preserving livers long term. Especially for long-term perfusion, the container should allow maintenance of sterility. In summary, the main challenge to develop a long-term perfusion machine is to maintain the liver's homeostasis in a sterile, carefully controlled environment. Long-term machine preservation of human livers may allow organ regeneration and repair, thereby ultimately solving the shortage of donor livers.
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Affiliation(s)
- Bianca Lascaris
- Section of Hepatopancreatobiliary Surgery & Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Adam M Thorne
- Section of Hepatopancreatobiliary Surgery & Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten W N Nijsten
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Section of Hepatopancreatobiliary Surgery & Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Vincent E de Meijer
- Section of Hepatopancreatobiliary Surgery & Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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2
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Post-operative heparin reduces early venous thrombotic complications after orthotopic paediatric liver transplantation. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2021; 19:495-505. [PMID: 33819140 DOI: 10.2450/2021.0388-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/18/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Despite significant improvements in surgical techniques and medical care, thrombotic complications still represent the primary cause of early graft failure and re-transplantation following paediatric liver transplantation. There is still no standardized approach for thrombosis prevention. MATERIALS AND METHODS The study aimed to evaluate the effectiveness of early intravenous unfractionated heparin started 12 hours postoperatively at 10 UI/kg per hour and used a retrospective "before and after" design to compare the incidence of early thrombotic complications prior to (2002-2010) and after (2011-2016) the introduction of heparin in our institute. RESULTS From 2002 to 2016, 479 paediatric patients received liver transplantation in our institution with an overall survival rate over one year of 0.91 (95% CI: 0.87-0.94). Of 365 eligible patients, 244 did not receive heparin while 121 did receive heparin. We reported a lower incidence of venous thrombosis (VT) in the group treated with heparin: 2.5% (3/121) vs 7.9% (19/244) (p=0.038). All clinical and laboratory variables considered potential risk factors for VT were studied. By multivariate stepwise Cox proportional hazards models, heparin prophylaxis resulted significantly associated to a reduction in VT (HR=0.29 [95% CI: 0.08-0.97], p=0.045), while age <1 year was found to be an independent risk factor for VT (HR=2.62 [95% CI: 1.11-6.21]; p=0.028). DISCUSSION Early postoperative heparin could be considered a valid and safe strategy to prevent early VT after paediatric liver transplantation without a concomitant increase in bleeding. A future randomised control trial is mandatory in order to strengthen this conclusion.
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Karangwa SA, Lisman T, Porte RJ. Anticoagulant Management and Synthesis of Hemostatic Proteins during Machine Preservation of Livers for Transplantation. Semin Thromb Hemost 2020; 46:743-750. [DOI: 10.1055/s-0040-1715452] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AbstractLiver transplantation remains the only curative treatment for patients with end-stage liver disease. Despite a steadily increasing demand for suitable donor livers, the current pool of donor organs fails to meet this demand. To resolve this discrepancy, livers traditionally considered to be of suboptimal quality and function are increasingly utilized. These marginal livers, however, are less tolerant to the current standard cold preservation of donor organs. Therefore, alternative preservation methods have been sought and are progressively applied into clinical practice. Ex situ machine perfusion is a promising alternative preservation modality particularly for suboptimal donor livers as it provides the ability to resuscitate, recondition, and test the viability of an organ prior to transplantation. This review addresses the modalities of machine perfusion currently being applied, and particularly focuses on the hemostatic management employed during machine perfusion. We discuss the anticoagulant agents used, the variation in dosage, and administration, as well as the implications of perfusion for extended periods of time in terms of coagulation activation associated with production of coagulation factors during perfusion. Furthermore, in regard to viability testing of an organ prior to transplantation, we discuss the possibilities and limitations of utilizing the synthesis of liver-derived coagulation factors as potential viability markers.
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Affiliation(s)
- Shanice A. Karangwa
- Department of Surgery, Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ton Lisman
- Department of Surgery, Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J. Porte
- Section of HPB Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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4
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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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5
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Katneni UK, Ibla JC, Hunt R, Schiller T, Kimchi-Sarfaty C. von Willebrand factor/ADAMTS-13 interactions at birth: implications for thrombosis in the neonatal period. J Thromb Haemost 2019; 17:429-440. [PMID: 30593735 DOI: 10.1111/jth.14374] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Indexed: 12/18/2022]
Abstract
von Willebrand factor (VWF) and its cleaving protease ADAMTS-13 (A Disintegrin and Metalloproteinase with Thrombospondin type 1 motif, member 13) are essential components to hemostasis. These plasma proteins have also been implicated in a number of disease states, including those affecting children. The best described abnormality is the congenital form of thrombotic thrombocytopenic purpura (TTP) resulting from germline mutations in the ADAMTS-13 gene. The VWF/ADAMTS-13 interaction has more recently emerged as a causative risk factor in the pathogenesis of pediatric stroke and secondary microangiopathies. There is now increasing interest and need to measure these coagulation factors during the neonatal period and throughout childhood. Methods adopted from a multitude of technically diverging studies have been used to understand their role during this period. To date, studies of VWF/ADAMTS-13 in this group of patients have reported conflicting results, which makes interpreting values in the clinical setting especially challenging. In this review we describe the historical evolution of the methodology used to measure VWF/ADAMTS-13 and how it may influence the results obtained during the first days of life. We review the individual assays used to analyze VWF/ADAMTS-13 as well as published reference values. Finally, we bring attention to the potential pathophysiologic role of VWF/ADAMTS-13 in neonatal thrombosis. This has significant implications because the pathologic processes that explain thrombosis in neonates remain poorly characterized and thromboembolism remains a significant source of morbidity and mortality, particularly in sick children.
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Affiliation(s)
- Upendra K Katneni
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research, US FDA, Silver Spring, MD, USA
| | - Juan C Ibla
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Cardiac Anesthesia, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ryan Hunt
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research, US FDA, Silver Spring, MD, USA
| | - Tal Schiller
- Diabetes, Endocrinology and Metabolic Disease Unit, Kaplan Medical Center, Rehovot, Israel
| | - Chava Kimchi-Sarfaty
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research, US FDA, Silver Spring, MD, USA
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6
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Karangwa SA, Adelmeijer J, Matton APM, de Meijer VE, Lisman T, Porte RJ. Production of Physiologically Relevant Quantities of Hemostatic Proteins During Ex Situ Normothermic Machine Perfusion of Human Livers. Liver Transpl 2018; 24:1298-1302. [PMID: 30125455 DOI: 10.1002/lt.25290] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 05/29/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Shanice A Karangwa
- Surgical Research Laboratory , Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.,Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, 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
| | - Alix P M Matton
- Surgical Research Laboratory , Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.,Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Vincent E de Meijer
- Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ton Lisman
- Surgical Research Laboratory , Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.,Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Robert J Porte
- Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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7
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Nacoti M, Cazzaniga S, Colombo G, Corbella D, Fazzi F, Fochi O, Gattoni C, Zambelli M, Colledan M, Bonanomi E. Postoperative complications in cirrhotic pediatric deceased donor liver transplantation: Focus on transfusion therapy. Pediatr Transplant 2017; 21. [PMID: 28681471 DOI: 10.1111/petr.13020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2017] [Indexed: 12/28/2022]
Abstract
Intraoperative transfusions seem associated with patient death and graft failure after PLTx. A retrospective analysis of recipients' and donors' characteristics and transplantation data in a cohort of patients undergoing PLTx from 2002 to 2009 at the Bergamo General Hospital was performed. A two-stage hierarchical Cox proportional hazard regression with forward stepwise selection was used to identify the main risk factors for major complications. In addition, propensity score analysis was used to adjust risk estimates for possible selection biases in the use of blood products. Over the 12-year period, 232 pediatric cirrhotic patients underwent PLTx. One-year patient and graft survival rates were 92.3% and 83.7%, respectively. The Kaplan-Meier shows that the main decrease in both graft and patient survival occurs during the first months post-transplantation. At the same time, it appears that most of the complications occur during the first month post-transplantation. One-month and 1-year patient complication-free survival rates were 24.8% and 12.1%, respectively. Our study shows that intraoperative red blood cells and platelet transfusions are independent risk factors for developing one or more major complications in the first year after PLTx. Decreasing major complications will improve the health status and overall long-term patient survival after pediatric PLTx.
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Affiliation(s)
- M Nacoti
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy.,Bergamo Anesthesia and Intensive Care Community (BAIC), Bergamo, Italy
| | | | - G Colombo
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - D Corbella
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy.,Bergamo Anesthesia and Intensive Care Community (BAIC), Bergamo, Italy
| | - F Fazzi
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy.,Bergamo Anesthesia and Intensive Care Community (BAIC), Bergamo, Italy
| | - O Fochi
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - C Gattoni
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - M Zambelli
- Liver Transplant Unit, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - M Colledan
- Liver Transplant Unit, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - E Bonanomi
- Pediatric Intensive Care Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy
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8
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Preoperative Thromboelastography as a Sensitive Tool Predicting Those at Risk of Developing Early Hepatic Artery Thrombosis After Adult Liver Transplantation. Transplantation 2017; 100:2382-2390. [PMID: 27780186 DOI: 10.1097/tp.0000000000001395] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Whilst causes of hepatic artery thrombosis (HAT) after liver transplantation (LT) are multifactorial, early HAT (E-HAT) remains pertinent complication impacting on graft and patient survival. Currently there is no screening tool that would identify patients with increased risk of developing E-HAT. METHODS We analyzed the native procoagulant state of LT recipients, identified through pretransplant thromboelastographic (TEG) data among other known risk factors, to identify risk factors for E-HAT. RESULTS The outcomes of 828 adult patients undergoing LT between 2008 and 2013 were analyzed. Overall, 79 (9.5%) patients experienced HAT, E-HAT was diagnosed in 23, and in the remainder this was "late" HAT. The maximum amplitude (MA) on preoperative TEG was significantly higher in patients diagnosed with E-HAT compared with those who did not (71.2 mm vs 57.9 mm; P < 0.0001). Receiver operating characteristic analysis with the cutoff value for MA of 65 mm or greater returned area under the curve of 0.750 (P < 0.001) predicting E-HAT with a sensitivity of 70%. A total of 7% of patients with an MA of 65 mm or greater went on to develop E-HAT (hazard ratio, 5.28; 95% confidence interval, 2.10-12.29; P < 0.001), whereas only 1.2% patients with an MA less than 65 mm experienced E-HAT. CONCLUSIONS Preoperative TEG may reliably identify group of recipients at greater risk of developing E-HAT, and intense surveillance and anticoagulation prophylaxis may avoid this serious complication after LT.
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9
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Magnusson M, Ignjatovic V, Hardikar W, Monagle P. A conceptual and practical approach to haemostasis in paediatric liver disease. Arch Dis Child 2016; 101:854-9. [PMID: 27013527 DOI: 10.1136/archdischild-2015-309535] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 03/02/2016] [Indexed: 12/15/2022]
Abstract
UNLABELLED Children with liver disease can develop severe bleeding episodes and thrombosis. Liver failure usually results in decreased levels of procoagulant and anticoagulant factors. Additional risk factors, including changes in vascular flow and endothelial function, are of importance for the development of bleeding or thrombosis in individual vascular beds. Detailed studies of haemostatic disturbances in the setting of paediatric liver disease are sparse and extrapolation from adult studies is common. The spectrum of liver diseases and the haemostatic system differs between children and adults. Specific paediatric liver diseases are reported to have more distinctive effects on haemostasis and the risk of bleeding and/or thrombosis. CONCLUSION we propose a model regarding haemostasis in paediatric liver disease, taking into account a number of specific variables and mechanisms, as well as the type of liver disease, which will provide a framework for clinical decision-making in these complex patients.
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Affiliation(s)
- Maria Magnusson
- CLINTEC, Division of Pediatrics, Karolinska Institutet, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden MMK, Clinical Chemistry and Blood Coagulation Research, Karolinska Institutet, Stockholm, Sweden Department of Paediatrics, University of Melbourne, Melbourne, Australia Haematology Research, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Vera Ignjatovic
- Department of Paediatrics, University of Melbourne, Melbourne, Australia Haematology Research, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Winita Hardikar
- Department of Paediatrics, University of Melbourne, Melbourne, Australia Department of Gastroenterology, Royal Children's Hospital, Melbourne, Australia
| | - Paul Monagle
- Department of Paediatrics, University of Melbourne, Melbourne, Australia Haematology Research, Murdoch Childrens Research Institute, Melbourne, Australia Department of Clinical Haematology, Royal Children's Hospital, Melbourne, Australia
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10
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Nacoti M, Corbella D, Fazzi F, Rapido F, Bonanomi E. Coagulopathy and transfusion therapy in pediatric liver transplantation. World J Gastroenterol 2016; 22:2005-23. [PMID: 26877606 PMCID: PMC4726674 DOI: 10.3748/wjg.v22.i6.2005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Revised: 11/23/2015] [Accepted: 12/30/2015] [Indexed: 02/06/2023] Open
Abstract
Bleeding and coagulopathy are critical issues complicating pediatric liver transplantation and contributing to morbidity and mortality in the cirrhotic child. The complexity of coagulopathy in the pediatric patient is illustrated by the interaction between three basic models. The first model, "developmental hemostasis", demonstrates how a different balance between pro- and anticoagulation factors leads to a normal hemostatic capacity in the pediatric patient at various ages. The second, the "cell based model of coagulation", takes into account the interaction between plasma proteins and cells. In the last, the concept of "rebalanced coagulation" highlights how the reduction of both pro- and anticoagulation factors leads to a normal, although unstable, coagulation profile. This new concept has led to the development of novel techniques used to analyze the coagulation capacity of whole blood for all patients. For example, viscoelastic methodologies are increasingly used on adult patients to test hemostatic capacity and to guide transfusion protocols. However, results are often confounding or have limited impact on morbidity and mortality. Moreover, data from pediatric patients remain inadequate. In addition, several interventions have been proposed to limit blood loss during transplantation, including the use of antifibrinolytic drugs and surgical techniques, such as the piggyback and lowering the central venous pressure during the hepatic dissection phase. The rationale for the use of these interventions is quite solid and has led to their incorporation into clinical practice; yet few of them have been rigorously tested in adults, let alone in children. Finally, the postoperative period in pediatric cohorts of patients has been characterized by an enhanced risk of hepatic vessel thrombosis. Thrombosis in fact remains the primary cause of early graft failure and re-transplantation within the first 30 d following surgery, and it occurs despite prolongation of standard coagulation assays. Data, however, are currently lacking regarding the use of anti-aggregation/anticoagulation therapies and how to best monitor for thrombosis in the early postoperative period in pediatric patients. Therefore, further studies are necessary to elucidate the interaction between the development of the coagulation system and cirrhosis in children. Moreover, strategies to optimize blood transfusion and anticoagulation must be tested specifically in pediatric patients. In conclusion, data from the adult world can be translated with difficulty into the pediatric field as indication for transplantation, baseline pathologies and levels of pro- and anticoagulation factors are not comparable between the two populations.
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11
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Abstract
Neonatal hematology is a complex and dynamic process in the pediatric population. Surgeons frequently encounter hematologic issues regarding hemostasis, inflammation, and wound healing. This publication provides a surgeon-directed review of hematopoiesis in the newborn, as well as an overview of the current understanding of their hemostatic profile under normal and pathologic conditions.
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Affiliation(s)
- Jose Diaz-Miron
- Division of Pediatric Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Jacob Miller
- Division of Pediatric Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Adam M Vogel
- Division of Pediatric Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri.
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12
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Lisman T, Pittau G, Leite FJT, De Boer MT, Meijer K, Kluin-Nelemans HC, Huls G, Te Boome LCJ, Kuball J, Nowak G, Fan ST, Azoulay D, Porte RJ. The circulating platelet count is not dictated by the liver, but may be determined in part by the bone marrow: analyses from human liver and stem cell transplantations. J Thromb Haemost 2012; 10:1624-30. [PMID: 22642442 DOI: 10.1111/j.1538-7836.2012.04800.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The platelet count varies considerably between individuals, but within an individual the platelet count is remarkably stable over time. Mechanisms controlling the platelet count are not yet established. OBJECTIVE In the present study, we tested the hypothesis that the liver is important in controlling the circulating platelet count, as the liver is the main producer of thrombopoietin. METHODS We compared the platelet count prior to and after liver transplantation in >250 patients transplanted for familial amyloidotic polyneuropathy (FAP). In contrast to most patients undergoing liver transplantation, patients with FAP have normal liver function before transplantation. Furthermore, we compared platelet counts in 89 living liver donors with the platelet count in the recipients of these grafts. Finally we compared platelet counts in donor-recipient pairs of hematopoietic stem cells. RESULTS AND CONCLUSIONS The platelet count prior to transplantation correlated with the platelet count at 3 or 12 months after transplantation in patients with FAP (r=0.48, P<0.0001 at 3 months, r=0.39, P<0.0001 at 12 months), whereas the platelet count in a living liver donor did not correlate with the platelet count in the recipient at 3 or 12 months after transplantation (r=0.16, P=0.26 at 3 months, r=0.11, P=0.30 at 12 months). The platelet count of related donors of hematopoietic stem cells correlated with the platelet count in the recipient after transplantation (r=0.25, P=0.011). CONCLUSIONS These results suggest that the liver, in spite of being the prime producer of thrombopoietin, does not dictate the circulating platelet count, whereas the bone marrow does appear to play a role.
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Affiliation(s)
- T Lisman
- Section of Hepatobiliairy Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
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13
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Nacoti M, Cazzaniga S, Lorusso F, Naldi L, Brambillasca P, Benigni A, Corno V, Colledan M, Bonanomi E, Vedovati S, Buoro S, Falanga A, Lussana F, Barbui T, Sonzogni V. The impact of perioperative transfusion of blood products on survival after pediatric liver transplantation. Pediatr Transplant 2012; 16:357-66. [PMID: 22429563 DOI: 10.1111/j.1399-3046.2012.01674.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Intraoperative transfusion of red blood cells (RBC) is associated with adverse outcome after LT in adult patients. This relationship in pediatric patients has not been studied in depth, and its analysis is the scope of this study. Forty-one variables associated with outcome, including blood product transfusions, were studied in a cohort of 243 pediatric patients undergoing a cadaveric LT between 2002 and 2009 at the General Hospital of Bergamo. Multivariate stepwise Cox proportional hazards models were adopted with adjustment by propensity scores to minimize factors associated with the use of blood products. Median age at transplant was 1.37 yr. In uni- and multivariate analyses, perioperative transfusion of FFP and RBC was an independent risk factor for predicting one-yr patient and graft survival. The effect on one-yr survival was dose-related with a hazard ratio of 3.15 for three or more units of RBC (p = 0.033) and 3.35 for three or more units of FFP (p = 0.021) when compared with 1 or no units transfused. The negative impact of RBC and FFP transfusion was confirmed by propensity score-adjusted analysis. These findings may have important implications for transfusion practice in the LT pediatric recipients.
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Affiliation(s)
- M Nacoti
- Department of Anesthesia and Intensive Care, Riuniti Hospital, Bergamo, Italy.
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