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Zeng X, Jin X, Wu Z, Hu J, Zhou W, Shen X, Du J. Enhanced external counterpulsation treatment improves multi-organ hemodynamics for postoperative liver transplantation patient. A case report. J Cardiothorac Surg 2024; 19:284. [PMID: 38730503 PMCID: PMC11088020 DOI: 10.1186/s13019-024-02783-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
INTRODUCTION Post liver transplantation (LT) patients endure high morbidity rate of multi-organ ischemic symptoms following reperfusion. We hypothesize that enhanced external counterpulsation (EECP) as a typical non-invasive assisted circulation procedure, which can efficiently inhibit the relative ischemic symptoms via the systemic improvement of hemodynamics. CASE PRESENTATION A 51-year-old male patient, 76 kg, 172 cm, received orthotopic LT surgery for viral hepatitis B induced acute-on-chronic liver failure hepatic failure. His medical records revealed ischemic symptoms in multi-organ at the time of hospital discharge, including headache, refractory insomnia, abdominal paralysis, and lower limb pain. The EECP treatment was introduced for assisted rehabilitation and to improve the postoperative quality of life. Doppler Ultrasound examination showed significant augmentation of blood flow volume in the carotid arteries, the hepatic artery, the portal vein and the femoral artery during EECP intervention. A standard 35-hour EECP treatment led to significant improvement in quality of life, e.g. sleep quality and walking ability. CONCLUSION We report a case of multi-organ ischemic symptoms in a post LT patient. EECP treatment can significantly improve the quality of life via the systematic promotion of hemodynamics.
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Affiliation(s)
- Xinchen Zeng
- Department of Liver Surgery, The Third People's Hospital of Shenzhen, Shenzhen, 518112, China
| | - Xin Jin
- Department of Liver Surgery, The Third People's Hospital of Shenzhen, Shenzhen, 518112, China
| | - Zi'an Wu
- Medical Research Center, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, 518033, China
- School of Biomedical Engineering, Sun Yat-sen University, Shenzhen, 518107, China
| | - Jun Hu
- Medical Research Center, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, 518033, China
- School of Biomedical Engineering, Sun Yat-sen University, Shenzhen, 518107, China
| | - Wenjuan Zhou
- Department of Cardiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, 518003, China
| | - Xuelian Shen
- Department of Ultrasound Medicine, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, 518003, China
| | - Jianhang Du
- Medical Research Center, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, 518033, China.
- National Health Commission (NHC), Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, 510080, China.
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2
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Che L, Wu Y, Sheng M, Xu J, Yu W, Weng Y. Intraoperative management during liver transplantation in the child with mitochondrial depletion syndrome: A case report. Int J Surg Case Rep 2024; 116:109432. [PMID: 38432165 PMCID: PMC10944120 DOI: 10.1016/j.ijscr.2024.109432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/17/2024] [Accepted: 02/19/2024] [Indexed: 03/05/2024] Open
Abstract
INTRODUCTION Mitochondrial DNA depletion syndrome (MDS) is a kind of autosomal recessive genetic disorder associated with a reduction in mitochondrial DNA (mtDNA) copy number caused by mutations in nuclear genes during nucleotide synthesis, which affects the energy production of tissues and organs. Changes in hemodynamics during liver transplantation may lead to high energy-demanding organs and tissues being vulnerable. This report described the intraoperative management during liver transplantation in a child with MDS. Ultimately, the child was discharged smoothly without any complications. PRESENTATION OF THE CASE A five-year-old boy was diagnosed with mitochondrial depletion syndrome preoperatively and scheduled for living donor liver transplantation. The incidence of postreperfusion syndrome (PRS) could not be avoided for 30 min after opening, despite our best efforts to aggressively prevent it before opening. While ensuring hemodynamic stability, we actively prevented and adopted high-energy-demand organ protection strategies to reduce the incidence of postoperative complications. Finally, the child was discharged 28 days after the operation, and no other complications were found. DISCUSSION Liver transplantation can be performed for liver failure in this disease to improve the quality of life and prolong the life of patients. As this child has mitochondrial DNA depletion syndrome, the disruption of cellular energy generation caused by mitochondrial malfunction puts high-energy-demanding organs and tissues at risk during surgery. It motivates us to pay closer attention to the prevention and treatment of PRS in anesthetic management to minimize damage to the child's organs and tissues with high energy demands. CONCLUSIONS This report describes the intraoperative management during liver transplantation in a child with mitochondrial depletion syndrome. To increase the safety of perioperative anesthesia and reduce mortality in patients with mitochondrial disease, for such patients, maintaining an acid-base balance and a stable internal environment is essential. We should also pay attention to protecting body temperature, using vasoactive drugs beforehand to lessen the incidence of PRS, and protecting high-energy-demanding organs afterward.
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Affiliation(s)
- Lu Che
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin, China
| | - Yuli Wu
- Tianjin Medical University First Central Clinical College, Tianjin, China
| | - Mingwei Sheng
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin, China
| | - Jiangang Xu
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin, China.
| | - Wenli Yu
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin, China.
| | - Yiqi Weng
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin, China.
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3
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Wu WK, Siegrist KK, Ziogas IA, Mishra KL, Matsuoka LK, Menachem JN, Izzy M, Shingina A, Do NL, Bacchetta M, Shah AS, Alexopoulos SP. Perioperative Characteristics and Outcomes of Fontan Versus Non-Fontan Patients Undergoing Combined Heart-Liver Transplantation: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2024; 38:745-754. [PMID: 38172029 DOI: 10.1053/j.jvca.2023.11.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/24/2023] [Accepted: 11/29/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES Combined heart-liver transplantation (CHLT) is becoming increasingly frequent as a maturing population of patients with Fontan-palliated congenital heart disease develop advanced liver fibrosis or cirrhosis. The authors present their experience with CHLT for congenital and noncongenital indications, and identify characteristics associated with poor outcomes that may guide intervention in high-risk patients. DESIGN This was a single-center retrospective cohort study. SETTING This study was conducted at Vanderbilt University Medical Center in Nashville, Tennessee. PARTICIPANTS The study included 16 consecutive adult recipients of CHLT at the authors' institution between April 2017 and February 2022. INTERVENTIONS Eleven patients underwent transplantation for Fontan indications, and 5 were transplanted for non-Fontan indications. MEASUREMENTS AND MAIN RESULTS Compared with non-Fontan patients, Fontan recipients had longer cardiopulmonary bypass duration (199 v 119 minutes, p =m0.002), operative times (786 v 599 minutes, p = 0.01), and larger blood product transfusions (15.4 v 6.3 L, p = 0.18). Six of 16 patients required extracorporeal membrane oxygenation (ECMO), of whom 4 were Fontan patients who subsequently died. Patients who required ECMO had lower 5-hour lactate clearance (0.0 v 3.5 mmol/L, p = 0.001), higher number of vasoactive infusions, lower pulmonary artery pulsatility indices (0.58 v 1.77, p = 0.03), and higher peak inspiratory pressures (28.0 v 18.5 mmHg, p = 0.01) after liver reperfusion. CONCLUSIONS Combined heart-liver transplantation in patients with Fontan-associated end-organ disease is particularly challenging and associated with higher recipient morbidity compared with non-Fontan-related CHLT. Early hemodynamic intervention for signs of ventricular dysfunction may improve outcomes in this growing high-risk population.
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Affiliation(s)
- Wei Kelly Wu
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN; Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Kara K Siegrist
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
| | - Ioannis A Ziogas
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN
| | - Kelly L Mishra
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Lea K Matsuoka
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN; Transplant Center, University of California Davis Medical Center, Sacramento, CA
| | - Jonathan N Menachem
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Manhal Izzy
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Alexandra Shingina
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Nhue L Do
- Division of Pediatric Cardiac Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Matthew Bacchetta
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Sophoclis P Alexopoulos
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN; Transplant Center, University of California Davis Medical Center, Sacramento, CA.
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4
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Ruan W, Galvan NTN, Dike P, Koci M, Faraone M, Fuller K, Koomaraie S, Cerminara D, Fishman DS, Deray KV, Munoz F, Schackman J, Leung D, Akcan-Arikan A, Virk M, Lam FW, Chau A, Desai MS, Hernandez JA, Goss JA. The Multidisciplinary Pediatric Liver Transplant. Curr Probl Surg 2023; 60:101377. [PMID: 37993242 DOI: 10.1016/j.cpsurg.2023.101377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 08/29/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Nhu Thao N Galvan
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Peace Dike
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Melissa Koci
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Marielle Faraone
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Kelby Fuller
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | | | - Dana Cerminara
- Department of Pharmacy, Texas Children's Hospital, Houston, TX
| | - Douglas S Fishman
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Kristen Valencia Deray
- Department of Pediatrics, Department of Pharmacy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Flor Munoz
- Department of Pediatrics, Department of Pharmacy, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Julie Schackman
- Division of Anesthesiology, Perioperative, & Pain Medicine, Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Daniel Leung
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Ayse Akcan-Arikan
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Manpreet Virk
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Fong W Lam
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Alex Chau
- Division of Interventional Radiology, Department of Radiology, Edward B. Singleton Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Moreshwar S Desai
- Division of Critical Care, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Jose A Hernandez
- Division of Interventional Radiology, Department of Radiology, Edward B. Singleton Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - John A Goss
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Department of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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5
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Mitchell J, Alnemer A, Deiparine S, Stein E, Gorelik L. Anesthetic Considerations for Patients With Mitral Stenosis Undergoing Orthotopic Liver Transplant. Cureus 2023; 15:e47751. [PMID: 38021530 PMCID: PMC10676281 DOI: 10.7759/cureus.47751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
A 70-year-old male presented for an orthotopic liver transplant (OLT) with co-existing moderate-severe mitral valve stenosis. The hemodynamic goals of managing mitral stenosis posed a significant additional challenge to this patient's care. Intraoperative transesophageal echocardiography (TEE) was critical in guiding volume status and resuscitation. In addition, the patient's valvulopathy guided our vasoactive medication selection and arrhythmia prevention. In this article, we describe the multidisciplinary discussions regarding preoperative valvular intervention as well as the intraoperative techniques used to preserve cardiac output while avoiding coagulopathy and arrhythmias. We discuss the pathophysiology of valvular disease in the context of liver failure and the guidelines by which this disease process is classified. In addition, we discuss the benefits and limitations of intraoperative TEE in evaluating this unique physiology.
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Affiliation(s)
- Justin Mitchell
- Anesthesiology, University of California, Los Angeles (UCLA) Medical Center, Los Angeles, USA
| | - Amar Alnemer
- Anesthesiology, The Ohio State University College of Medicine, Columbus, USA
| | | | - Erica Stein
- Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Leonid Gorelik
- Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, USA
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6
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Ueda Y, Kawaji T, Komura H, Hara Y, Kuriyama N, Nakamura T, Nishida O. Usefulness of intraoperative transesophageal echocardiography for hemodynamic management of liver transplantation in a patient with massive polycystic liver disease: a case report. JA Clin Rep 2023; 9:54. [PMID: 37626229 PMCID: PMC10457252 DOI: 10.1186/s40981-023-00646-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/15/2023] [Accepted: 08/18/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Hemodynamic management during anesthesia in liver transplantation for patients with polycystic liver disease (PLD) can be more challenging because of the bleeding and hemodynamic alterations due to the markedly enlarged liver. We hereby report a case of PLD wherein transesophageal echocardiography (TEE) was employed for optimal hemodynamic monitoring during liver transplantation. CASE PRESENTATION A 61-year-old man was scheduled to undergo liver transplantation for massive PLD. Hemodynamic instability was associated with mechanical displacement of the giant cystic liver. TEE results revealed the collapse of the inferior vena cava due to liver displacement. TEE also detected intrathoracic hemorrhage triggered by detachment from the markedly enlarged liver. CONCLUSION TEE is a valuable monitoring tool for sharing information with surgeons and diagnostic modality for finding the source of bleeding in liver transplantation for PLD and may contribute majorly to the quality of perioperative management.
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Affiliation(s)
- Yudai Ueda
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Takahiro Kawaji
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan.
| | - Hidefumi Komura
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Yoshitaka Hara
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Naohide Kuriyama
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Tomoyuki Nakamura
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
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7
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DeMaria S, Nolasco L, Igwe D, Jules RS, Bekki Y, Smith NK. Prediction, prevention, and treatment of post reperfusion syndrome in adult orthotopic liver transplant patients. Clin Transplant 2023:e15014. [PMID: 37178452 DOI: 10.1111/ctr.15014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 03/27/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023]
Abstract
IMPORTANCE This review explores proposed predictors, preventative measures, and treatment options for post-reperfusion syndrome (PRS) in liver transplantation and provides updated data for clinicians. OBJECTIVES The review aims to understand the status and progress made regarding PRS during orthotopic liver transplantation. Moreover, the predictors of PRS will be analyzed to highlight risk factors. Mediators of PRS and the modes of action of the currently available preventative and management agents that target particular PRS factors will be investigated. DATA SOURCES Data is drawn from secondary sources from databases of peer-reviewed journals. The bibliographies of select sources were also used to obtain additional data studies using the 'snowball' method. STUDY SELECTION The initial data search provided 1394 studies analyzed using PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. After applying the eligibility criteria, 18 studies were fit for inclusion. RESULTS The study identified that in addition to the severity of underlying medical conditions, other significant PRS predictors included patient age, sex, duration of cold ischemia, and the surgical technique. While the use of epinephrine and norepinephrine is well-established, further preventative measures commonly involve specifically targeting known mediators of the syndrome, such as antioxidants, vasodilators, free radical scavengers, and anticoagulants. Current management strategies involve supportive therapy. Machine Perfusion may ultimately decrease the risk of PRS. CONCLUSION PRS still holds unknowns, including the underlying pathophysiology, controllable factors, and ideal management practices. There is a need for further study, particularly prospective trials since liver transplantation is the gold standard for treating end-stage liver disease and the incidence of PRS remains high.
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Affiliation(s)
- Samuel DeMaria
- The Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lyle Nolasco
- The Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Divya Igwe
- The Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robert St Jules
- The Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Yuki Bekki
- The Department of Transplant Surgery, Recanati/Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Natalie K Smith
- The Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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8
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Kawaji T, Toyama H, Yoshida N, Moteki S, Sasaki A, Sasaki K, Fujio A, Tokodai K, Miyagi S, Yamauchi M. Postreperfusion Syndrome Presenting as Posttransplant Portal Hypertension due to Prolonged Elevation of Pulmonary Vascular Resistance and the Role of Nitroglycerin in Diagnosis and Treatment: A Case Report of Budd-Chiari Syndrome. TOHOKU J EXP MED 2023; 259:121-126. [PMID: 36476584 DOI: 10.1620/tjem.2022.j105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Postreperfusion syndrome is one of the responsible mechanisms of portal hypertension in patients undergoing liver transplantation. And post-transplant portal hypertension causes graft dysfunction. Postreperfusion syndrome is characterized by a decrease in arterial pressure and cardiac output, and an increase in central venous pressure, pulmonary artery pressure, and pulmonary vascular resistance that occurs after the release of the portal vein clamp. Although early recovery from postreperfusion syndrome is desired, there is a little medication therapy such as the administration of calcium chloride, sodium bicarbonate, and beta-agonist for postreperfusion syndrome. We present a case of postreperfusion syndrome manifested as post-transplant portal hypertension and reversed after nitroglycerin administration. A 49-year-old Asian woman was scheduled for liver transplantation because of Budd-Chiari syndrome. After portal vein reperfusion, she experienced severe postreperfusion syndrome. Administration of ephedrine and calcium restored arterial pressure; however, pulmonary artery pressure, pulmonary vascular resistance, and central venous pressure elevations were sustained, causing right ventricular overload. This condition did not improve after hepatic artery reperfusion, and caused post-transplant portal hypertension. After nitroglycerin administration, pulmonary vascular resistance and central venous pressure decreased, mean arterial pressure increased, right heart contractility recovered, and portal hypertension disappeared. Hemodynamic improvement by nitroglycerin administration helped in diagnosing postreperfusion syndrome and avoiding unnecessary splenectomy. If portal vein pressure increases after liver transplantation, the change in hemodynamic parameters by nitroglycerin administration should be assessed, which will lead to accurate diagnosis and appropriate treatment. Furthermore, postreperfusion syndrome should be listed as a differential diagnosis of post-transplant portal hypertension.
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Affiliation(s)
- Takahiro Kawaji
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine
| | - Hiroaki Toyama
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine
| | - Norifumi Yoshida
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine
| | - Shoichiro Moteki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine
| | - Ayaka Sasaki
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine
| | - Kengo Sasaki
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Atsushi Fujio
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Kazuaki Tokodai
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Shigehito Miyagi
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Masanori Yamauchi
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine
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9
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Hypothermic Oxygenated Machine Perfusion (HOPE) Prior to Liver Transplantation Mitigates Post-Reperfusion Syndrome and Perioperative Electrolyte Shifts. J Clin Med 2022; 11:jcm11247381. [PMID: 36555997 PMCID: PMC9786550 DOI: 10.3390/jcm11247381] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
(1) Background: Post-reperfusion syndrome (PRS) and electrolyte shifts (ES) represent considerable challenges during liver transplantation (LT) being associated with significant morbidity. We aimed to investigate the impact of hypothermic oxygenated machine perfusion (HOPE) on PRS and ES in LT. (2) Methods: In this retrospective study, we compared intraoperative parameters of 100 LTs, with 50 HOPE preconditioned liver grafts and 50 grafts stored in static cold storage (SCS). During reperfusion phase, prospectively registered serum parameters and vasopressor administration were analyzed. (3) Results: Twelve percent of patients developed PRS in the HOPE cohort vs. 42% in the SCS group (p = 0.0013). Total vasopressor demand in the first hour after reperfusion was lower after HOPE pretreatment, with reduced usage of norepinephrine (−26%; p = 0.122) and significant reduction of epinephrine consumption (−52%; p = 0.018). Serum potassium concentration dropped by a mean of 14.1% in transplantations after HOPE, compared to a slight decrease of 1% (p < 0.001) after SCS. The overall incidence of early allograft dysfunction (EAD) was reduced by 44% in the HOPE group (p = 0.04). (4) Conclusions: Pre-transplant graft preconditioning with HOPE results in higher hemodynamic stability during reperfusion and lower incidence of PRS and EAD. HOPE has the potential to mitigate ES by preventing hyperpotassemic complications that need to be addressed in LT with HOPE-pre-treated grafts.
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10
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Misra AC, Emamaullee J. CAQ Corner: Surgical evaluation for liver transplantation. Liver Transpl 2022; 28:1936-1943. [PMID: 35575000 PMCID: PMC9666671 DOI: 10.1002/lt.26505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 04/12/2022] [Accepted: 05/11/2022] [Indexed: 01/07/2023]
Abstract
The evaluation of a liver transplantation candidate is a complex and detailed process that in many cases must be done in an expedited manner because of the critically ill status of some patients with end-stage liver disease. It involves great effort from and the collaboration of multiple disciplines, and during the evaluation several studies and interventions are performed to assess and potentially prepare a patient for liver transplant. Here we review the liver transplantation evaluation from a surgical perspective.
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Affiliation(s)
- Asish C. Misra
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of SurgeryUniversity of Southern CaliforniaLos AngelesCaliforniaUSA,Division of Hepatobiliary and Abdominal Organ Transplantation SurgeryChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
| | - Juliet Emamaullee
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of SurgeryUniversity of Southern CaliforniaLos AngelesCaliforniaUSA,Division of Hepatobiliary and Abdominal Organ Transplantation SurgeryChildren's Hospital Los AngelesLos AngelesCaliforniaUSA
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11
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Sáez de la Fuente I, Sáez de la Fuente J, Martín-Arriscado C, Sánchez-Izquierdo Riera JÁ, García de Lorenzo Y Mateos A, Montejo González JC. Utility of the central venous-to-arterial CO 2 difference to predict adverse outcomes after liver transplantation. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:526-535. [PMID: 36280569 DOI: 10.1016/j.redare.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 11/10/2021] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Test whether the development of abnormal venous-to arterial CO2 difference (ΔPCO2) during the early phases of postoperative care after a liver transplantation (LT) is related to multi-organ dysfunction and outcomes. MATERIALS AND METHODS Prospective cohort study accomplished in a mixed intensive care unit (ICU) at a university hospital. We included 150 eligible patients after a LT between 2015 and 2018. Patients were classified in four predefined groups according to the ΔPCO2 evolution during the first 6 h of resuscitation: (1) persistently normal ΔPCO2 (normal at T0 and T6); (2) decreasing ΔPCO2 (high at T0, normal at T6); (3) increasing ΔPCO2 (normal at T0, high at T6); and (4) persistently high ΔPCO2 (high at T0 and T6). Multiorgan dysfunction at day-3 was compared for predefined groups and a Kaplan Meier curve was constructed to show the survival probabilities using a log-rank test to evaluate differences between groups. A Spearman-Rho was used to test the agreement between cardiac output and ΔPCO2. RESULTS There were no significant differences between the study groups regarding higher SOFA scores at day-3 (P = .86), Δ-SOFA (P = .088), as well as global mortality rates (χ² = 5.72; P = .126) and mortality rates at day-30 (χ² = 2.23; P = .5252). A significantly poor inverse agreement between cardiac output and ΔPCO2 was observed (r2 -0,17; P = ,002) at different points of resuscitation. CONCLUSIONS After a LT, central venous-to-arterial CO2 difference was not associated with survival or postoperative adverse outcomes in a critical care patients population.
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Affiliation(s)
- I Sáez de la Fuente
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - J Sáez de la Fuente
- Servicio de Farmacia Hospitalaria, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - C Martín-Arriscado
- Unidad de Investigación y Soporte Científico, Hospital Universitario 12, Madrid, Spain
| | | | | | - J C Montejo González
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
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12
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DCD Liver Grafts Can Safely Be Used for Recipients With Grade I–II Portal Vein Thrombosis: A Multicenter Analysis. Transplant Direct 2022; 8:e1392. [PMID: 36246002 PMCID: PMC9553382 DOI: 10.1097/txd.0000000000001392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 11/25/2022] Open
Abstract
With donation after circulatory death (DCD) liver transplantation (LT), the goal of the recipient implantation procedure is to minimize surgical complexity to avoid a tenuous environment for an already marginal graft. The presence of portal vein thrombosis (PVT) at the time of LT adds surgical complexity, yet‚ to date, no studies have investigated the utilization of DCD liver grafts for patients with PVT.
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13
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Dou XJ, Wang QP, Liu WH, Weng YQ, Sun Y, Yu WL. Effect of cardiac output - guided hemodynamic management on acute lung injury in pediatric living donor liver transplantation. World J Gastrointest Surg 2022; 14:1037-1048. [PMID: 36185553 PMCID: PMC9521467 DOI: 10.4240/wjgs.v14.i9.1037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/25/2022] [Accepted: 08/18/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute lung injury (ALI) after liver transplantation (LT) may lead to acute respiratory distress syndrome, which is associated with adverse postoperative outcomes, such as prolonged hospital stay, high morbidity, and mortality. Therefore, it is vital to maintain hemodynamic stability and optimize fluid management. However, few studies have reported cardiac output-guided (CO-G) management in pediatric LT.
AIM To investigate the effect of CO-G hemodynamic management on early postoperative ALI and hemodynamic stability during pediatric living donor LT.
METHODS A total of 130 pediatric patients scheduled for elective living donor LT were enrolled as study participants and were assigned to the control group (65 cases) and CO-G group (65 cases). In the CO-G group, CO was considered the target for hemodynamic management. In the control group, hemodynamic management was based on usual perioperative care guided by central venous pressure, continuous invasive arterial pressure, urinary volume, etc. The primary outcome was early postoperative ALI. Secondary outcomes included other early postoperative pulmonary complications, readmission to the intense care unit (ICU) for pulmonary complications, ICU stay, hospital stay, and in-hospital mortality.
RESULTS The incidence of early postoperative ALI was 27.7% in the CO-G group, which was significantly lower than that in the control group (44.6%) (P < 0.05). During the surgery, the incidence of postreperfusion syndrome was lower in the CO-G group (P < 0.05). The level of intraoperative positive fluid transfusions was lower and the rate of dobutamine use before portal vein opening was higher, while the usage and dosage of epinephrine during portal vein opening and vasoactive inotropic score after portal vein opening were lower in the CO-G group (P < 0.05). Compared to the control group, serum inflammatory factors (interleukin-6 and tumor necrosis factor-α), cardiac troponin I, and N-terminal pro-brain natriuretic peptide were lower in the CO-G group after the operation (P < 0.05).
CONCLUSION CO-G hemodynamic management in pediatric living-donor LT decreases the incidence of early postoperative ALI due to hemodynamic stability through optimized fluid management and appropriate administration of vasopressors and inotropes.
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Affiliation(s)
- Xiao-Jing Dou
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin 300192, China
| | - Qing-Ping Wang
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin 300192, China
| | - Wei-Hua Liu
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin 300192, China
| | - Yi-Qi Weng
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin 300192, China
| | - Ying Sun
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin 300192, China
| | - Wen-Li Yu
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin 300192, China
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14
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Scalera I, De Carlis R, Patrono D, Gringeri E, Olivieri T, Pagano D, Lai Q, Rossi M, Gruttadauria S, Di Benedetto F, Cillo U, Romagnoli R, Lupo LG, De Carlis L. How useful is the machine perfusion in liver transplantation? An answer from a national survey. Front Surg 2022; 9:975150. [PMID: 36211259 PMCID: PMC9535084 DOI: 10.3389/fsurg.2022.975150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Machine perfusion (MP) has been shown worldwide to offer many advantages in liver transplantation, but it still has some gray areas. The purpose of the study is to evaluate the donor risk factors of grafts, perfused with any MP, that might predict an ineffective MP setting and those would trigger post-transplant early allograft dysfunction (EAD). Data from donors of all MP-perfused grafts at six liver transplant centers have been analyzed, whether implanted or discarded after perfusion. The first endpoint was the negative events after perfusion (NegE), which is the number of grafts discarded plus those that were implanted but lost after the transplant. A risk factor analysis for NegE was performed and marginal grafts for MP were identified. Finally, the risk of EAD was analyzed, considering only implanted grafts. From 2015 to September 2019, 158 grafts were perfused with MP: 151 grafts were implanted and 7 were discarded after the MP phase because they did not reach viability criteria. Of 151, 15 grafts were lost after transplant, so the NegE group consisted of 22 donors. In univariate analysis, the donor risk index >1.7, the presence of hypertension in the medical history, static cold ischemia time, and the moderate or severe macrovesicular steatosis were the significant factors for NegE. Multivariate analysis confirmed that macrosteatosis >30% was an independent risk factor for NegE (odd ratio 5.643, p = 0.023, 95% confidence interval, 1.27–24.98). Of 151 transplanted patients, 34% experienced EAD and had worse 1- and 3-year-survival, compared with those who did not face EAD (NoEAD), 96% and 96% for EAD vs. 89% and 71% for NoEAD, respectively (p = 0.03). None of the donor/graft characteristics was associated with EAD even if the graft was moderately steatotic or fibrotic or from an aged donor. For the first time, this study shows that macrovesicular steatosis >30% might be a warning factor involved in the risk of graft loss or a cause of graft discard after the MP treatment. On the other hand, the MP seems to be useful in reducing the donor and graft weight in the development of EAD.
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Affiliation(s)
- Irene Scalera
- Hepatobiliary and Liver Transplant Unit, Department of Emergency and Organ Transplantation, University Hospital Policlinic of Bari, Bari, Italy
- Correspondence: Irene Scalera
| | - R. De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - D. Patrono
- General Surgery 2U-Liver Transplant Centre, A.O.U. “Città della Salute e della Scienza”, Turin, Italy
| | - E. Gringeri
- Hepatobiliary Surgery and Liver Transplantation Unit, University Hospital of Padua, Padua, Italy
| | - T. Olivieri
- Hepato-Pancreato-Biliary Surgery and Liver Transplant Center, University of Modena and Reggio Emilia, Modena, Italy
| | - D. Pagano
- Department for the Treatment and the Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT, UPMC, Palermo, Italy
- Department of Surgery and Medical and Surgical Specialties, University of Catania, Catania, Italy
| | - Q. Lai
- Liver Transplant Unit, Sapienza University of Rome, Rome, Italy
| | - M. Rossi
- Liver Transplant Unit, Sapienza University of Rome, Rome, Italy
| | - S. Gruttadauria
- Department for the Treatment and the Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT, UPMC, Palermo, Italy
- Department of Surgery and Medical and Surgical Specialties, University of Catania, Catania, Italy
| | - F. Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplant Center, University of Modena and Reggio Emilia, Modena, Italy
| | - U. Cillo
- Hepatobiliary Surgery and Liver Transplantation Unit, University Hospital of Padua, Padua, Italy
| | - R. Romagnoli
- General Surgery 2U-Liver Transplant Centre, A.O.U. “Città della Salute e della Scienza”, Turin, Italy
| | - L. G. Lupo
- Hepatobiliary and Liver Transplant Unit, Department of Emergency and Organ Transplantation, University Hospital Policlinic of Bari, Bari, Italy
| | - L. De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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15
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Krüger M, Ruppelt A, Kappler B, Van Soest E, Samsom RA, Grinwis GCM, Geijsen N, Helms JB, Stijnen M, Kock LM, Rasponi M, Kooistra HS, Spee B. Normothermic Ex Vivo Liver Platform Using Porcine Slaughterhouse Livers for Disease Modeling. Bioengineering (Basel) 2022; 9:bioengineering9090471. [PMID: 36135018 PMCID: PMC9495507 DOI: 10.3390/bioengineering9090471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/25/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
Metabolic and toxic liver disorders, such as fatty liver disease (steatosis) and drug-induced liver injury, are highly prevalent and potentially life-threatening. To allow for the study of these disorders from the early stages onward, without using experimental animals, we collected porcine livers in a slaughterhouse and perfused these livers normothermically. With our simplified protocol, the perfused slaughterhouse livers remained viable and functional over five hours of perfusion, as shown by hemodynamics, bile production, indocyanine green clearance, ammonia metabolism, gene expression and histology. As a proof-of-concept to study liver disorders, we show that an infusion of free fatty acids and acetaminophen results in early biochemical signs of liver damage, including reduced functionality. In conclusion, the present platform offers an accessible system to perform research in a functional, relevant large animal model while avoiding using experimental animals. With further improvements to the model, prolonged exposure could make this model a versatile tool for studying liver diseases and potential treatments.
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Affiliation(s)
- Melanie Krüger
- LifeTec Group BV, 5611 ZS Eindhoven, The Netherlands
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CT Utrecht, The Netherlands
| | - Alicia Ruppelt
- LifeTec Group BV, 5611 ZS Eindhoven, The Netherlands
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, 20133 Milan, Italy
- Correspondence:
| | | | | | - Roos Anne Samsom
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CT Utrecht, The Netherlands
| | - Guy C. M. Grinwis
- Veterinary Pathology Diagnostic Centre, Department of Biomedical Health Sciences, Faculty of Veterinary Medicine, Utrecht University, 3508 TD Utrecht, The Netherlands
| | - Niels Geijsen
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CT Utrecht, The Netherlands
| | - J. Bernd Helms
- Department of Biomolecular Health Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CL Utrecht, The Netherlands
| | - Marco Stijnen
- LifeTec Group BV, 5611 ZS Eindhoven, The Netherlands
| | - Linda M. Kock
- LifeTec Group BV, 5611 ZS Eindhoven, The Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, 5600 MB Eindhoven, The Netherlands
| | - Marco Rasponi
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, 20133 Milan, Italy
| | - Hans S. Kooistra
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CT Utrecht, The Netherlands
| | - Bart Spee
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CT Utrecht, The Netherlands
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16
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Shamaa TM, Shamaa O, Crombez C, Konel JM, Kitajima T, Shimada S, Ivanics T, Mohamed A, Collins K, Nagai S, Yoshida A, Abouljoud M, Rizzari M. The use of normothermic liver preservation in combined liver and lung transplantation: A single-center experience. Am J Transplant 2022; 22:2261-2264. [PMID: 35384271 DOI: 10.1111/ajt.17053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 01/25/2023]
Abstract
Combined liver and lung transplantation (CLLT) is indicated in patients with both end-stage liver and lung disease. Ex-situ normothermic machine perfusion (NMP) has been previously used for extended normothermic lung preservation in CLLT. We aim to describe our single-center experience using ex-situ NMP for extended normothermic liver preservation in CLLT. Four CLLTs were performed from 2019 to 2020 with the lung transplanted first for all patients. Median ex-situ pump time for the liver was 413 min (IQR 400-424). Over a median follow-up of 15 months (IQR 14-19), all patients were alive and doing well. Normothermic extended liver preservation is a safe method to allow prolonged cold ischemia using normothermic perfusion of the liver during CLLT.
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Affiliation(s)
- Tayseer M Shamaa
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Omar Shamaa
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Catherine Crombez
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | | | - Toshihiro Kitajima
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Shingo Shimada
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Tommy Ivanics
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Adhnan Mohamed
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Kelly Collins
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Shunji Nagai
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Atsushi Yoshida
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Marwan Abouljoud
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Michael Rizzari
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
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17
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Ma Y, Jiao Z, Liu X, Zhang Q, Piao C, Xu J, Wang H. Protective effect of adipose-derived stromal cell-secretome attenuate autophagy induced by liver ischemia–reperfusion and partial hepatectomy. STEM CELL RESEARCH & THERAPY 2022; 13:427. [PMID: 35987696 PMCID: PMC9392224 DOI: 10.1186/s13287-022-03109-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 05/03/2022] [Indexed: 11/25/2022]
Abstract
Background The therapeutic effects of adipose-derived mesenchymal stromal cells (ADSCs) may be mainly mediated by their paracrine effects. The ADSC-secretome can ameliorate hepatic ischemia–reperfusion injury (IRI). We explored the therapeutic effect of the ADSC-secretome from the perspective of excessive hepatocyte autophagy induced by hepatic IRI. Methods We established a miniature pig model of hepatic ischemia–reperfusion (I/R) and hepatectomy using a laparoscopic technique and transplanted ADSCs and the ADSC-secretome into the liver parenchyma immediately after surgery. Liver injury and hepatocyte autophagy were evaluated by histopathological examination and assessment of relevant cytokines and other factors. Results The results showed that the ADSC-secretome alleviated the pathological changes of liver tissue and the microstructural damage of hepatocytes after IRI. Moreover, the expression levels of autophagy-related markers including Beclin-1, ATG5, ATG12, and LC3II/LC3I decreased, whereas those of p62 increased during phagophore expansion. Furthermore, the expression levels of markers related to the autophagy inhibition pathway phosphatidylinositol-3-kinase/Akt/mammalian target of rapamycin (PI3K/Akt/mTOR), including PI3K, Akt, and mTOR, increased. Conclusion The ADSC-secretome attenuates hepatic I/R and hepatectomy-induced liver damage by inhibiting autophagy, which is possibly mediated by activation of the PI3K/Akt/mTOR signaling pathway. In addition, there was no significant difference between ADSCs and the ADSC-secretome in the regulation of hepatocyte autophagy. Therefore, ADSCs may improve the excessive autophagy-induced injury of hepatocytes in hepatic I/R and hepatectomy through paracrine effect. Our findings provide new insight into the therapeutic potential of cell-free products, which could replace cell therapy in liver diseases. Supplementary Information The online version contains supplementary material available at 10.1186/s13287-022-03109-2.
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18
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Livingstone J, Raveh Y, Souki F, Shatz V, Shah R, Ibrahim T, Shuman M, Beduschi T, Vianna R, Alvarez R, Nicolau-Raducu R. Multivisceral Transplant in a Patient With Portopulmonary Hypertension: A Case Report. Transplant Proc 2022; 54:1664-1670. [PMID: 35914967 DOI: 10.1016/j.transproceed.2022.03.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/14/2022] [Indexed: 11/18/2022]
Abstract
Portopulmonary hypertension, a type of pulmonary arterial hypertension in the setting of cirrhotic or noncirrhotic portal hypertension, is associated with elevated morbidity and mortality during and after transplantation. Uncontrolled portopulmonary hypertension may prevent or delay listing for transplant candidates, and the prognosis without treatment and ultimately transplant is extremely poor. We present a 29-year-old White woman, who had a post-liver transplant at infancy due to biliary atresia. Later on, she developed extensive portal vein thrombosis and portopulmonary hypertension and underwent a multivisceral transplant (liver, stomach, pancreaticoduodenal complex, and small and large intestine). Preoperative mean pulmonary artery pressure was <30 mm Hg with a pulmonary vascular resistance of <300 dynes.s/cm5 on oral sildenafil and intravenous epoprostenol. Intraoperatively, management required comprehensive transfusion protocols, a careful balance between correcting blood loss and preventing thrombosis. Intravenous epoprostenol, sildenafil, milrinone, and inhaled nitric oxide were used to reduce elevated mean pulmonary artery pressure and right ventricular strain associated with vascular clamping, reperfusion, and massive fluid shifts. Nitric oxide and epoprostenol use unleashed antiplatelet effects on a patient already susceptible to coagulopathy. A multimodal and multidisciplinary approach continued throughout the surgery and in the postoperative period, which led to a successful outcome.
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Affiliation(s)
- J Livingstone
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Y Raveh
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - F Souki
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - V Shatz
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - R Shah
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida; Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - T Ibrahim
- Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - M Shuman
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - T Beduschi
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida; Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - R Vianna
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida; Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - R Alvarez
- Department of Medicine, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - R Nicolau-Raducu
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida.
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19
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Intraoperative dialysis with the use of a mobile dialysis system during liver transplantation. Adv Med Sci 2022; 67:208-215. [PMID: 35568010 DOI: 10.1016/j.advms.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 03/22/2022] [Accepted: 04/29/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE Over the last few years, transplant centers have started to use various intraoperative renal replacement therapy (ioRRT) modalities during liver transplantation (LT) in patients with pre-existing renal impairment. Here, we present a study on the safety and clinical outcomes of intraoperative hemodialysis (ioHD) performed using a mobile dialysis system during LT. PATIENTS AND METHODS We retrospectively analyzed 102 adult patients undergoing LT with ioHD; pre-existing renal failure and/or intraoperative metabolic derangement were ioHD treatment indications. RESULTS Our study cohort consisted of three groups: LT with preoperative serum creatinine (sCr) < 2 mg/dL (Group 1:n = 22), LT with preoperative sCr ≥2 mg/dL (Group 2:n = 73), and simultaneous liver-kidney transplantation (Group 3:n = 7). Among the procedures, 30% were re-transplantations. The mean calculated Model for End-stage Liver Disease score in Group 2 was 39.2, and 67% of patients were hospitalized in the intensive care unit. Patients in Group 1 were less acutely ill but developed severe intraoperative derangements and, therefore, underwent urgent ioHD intraoperatively. However, it was delayed when compared to Group 2. All groups achieved post-reperfusion potassium levels <4 mmol/L and a decrease in central venous pressure. No serious procedural complications occurred. Post-reperfusion syndrome occurred in 12.7% of patients. Elevated mortality was likely due to the high illness severity in the cohort. CONCLUSIONS Performing ioHD with a mobile dialysis system during LT was safe and effective, while being easier to perform than continuous techniques. Its effect on intra- and postoperative outcomes should be addressed in a study with a control group.
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20
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Cho HY, Lee HJ, Kim WH, Lee HC, Jung CW, Hong SK, Yang SM. Influence of anesthesia type on post-reperfusion syndrome during liver transplantation: a single-center retrospective study. Anesth Pain Med (Seoul) 2022; 17:304-311. [PMID: 35918864 PMCID: PMC9346196 DOI: 10.17085/apm.21104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 03/03/2022] [Indexed: 11/23/2022] Open
Abstract
Background Post-reperfusion syndrome (PRS) results in sudden hemodynamic instability following graft reperfusion. Although PRS is known to influence outcomes following liver transplantation, little is known regarding the effects of anesthetics on PRS. This study investigated the association between the type of anesthetic agent and PRS in liver transplantation. Methods This single-center retrospective cohort study included patients who underwent liver transplantation between June 2016 and December 2019. Patients were divided into sevoflurane and propofol groups according to the anesthetic agent used. Stabilized inverse probability of treatment weighting (IPTW) analysis was performed to investigate the association between PRS identified based on blood pressure recordings and the type of anesthesia. Associations between the anesthetic agent and the duration of hypotension as well as early postoperative outcomes were also investigated. Results Data were analyzed for 398 patients, 304 (76.4%) and 94 (23.6%) of whom were anesthetized with propofol and sevoflurane, respectively. PRS developed in 40.7% of the 398 patients. Following stabilized IPTW analysis, the association with PRS was lower in the sevoflurane group than in the propofol group (odds ratio, 0.47; P = 0.018). However, there was no association between the type of anesthetic used and early postoperative outcomes. Conclusions The association of PRS was lower in the sevoflurane group than in the propofol group. However, there was no association between the type of anesthetic and the early postoperative outcomes. Further studies are required to determine the optimal anesthetic for liver transplantation.
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Affiliation(s)
- Hye-Yeon Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Chul-Woo Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seong-Mi Yang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
- Corresponding Author: Seong-Mi Yang, M.D. Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: +82-2-2072-2467, Fax: +82-2-747-8363 E-mail:
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Sahmeddini MA, Tehran SG, Khosravi MB, Eghbal MH, Asmarian N, Khalili F, Vatankhah P, Izadi S. Risk factors of the post-reperfusion syndrome during orthotopic liver transplantation: a clinical observational study. BMC Anesthesiol 2022; 22:89. [PMID: 35366808 PMCID: PMC8976299 DOI: 10.1186/s12871-022-01635-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 03/28/2022] [Indexed: 02/07/2023] Open
Abstract
Background Post reperfusion syndrome (PRS) is a relatively common and life-threatening complication during orthotopic liver transplantation (OLT). It is associated with poor patient and transplanted liver outcomes. Objective This study aimed to compare the risk factors of PRS during OLT. Design Clinical-epidemiological observational retrospective study. Setting We gathered the records of patients who underwent OLT in 3 years, from May 22, 2016, to May 22, 2019, in Namazi and Bu-Ali Sina organ transplantation hospitals. Patients In this study, we assessed 1182 patients who underwent OLT. Patients were divided into two groups based on the presence or absence of PRS. Main outcome measures Diagnosing the predictors of PRS was the primary outcome of this study. Results Results showed that age > 60 years, Child-Pugh scores C, higher Model End Stage liver disease score, and preoperative sodium < 130 mmol/l (parameters of the liver recipient), increase in cold ischemic time (the donors’ parameters), and the classical technique (the surgical parameters) were the strong predictors of PRS. Conclusions The results indicated that underlying liver disease was not the predictor of PRS in the presence of other risk factors; therefore, clinicians have to consider these risk factors in patients undergoing OLT. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01635-3.
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22
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Wu WK, Tumen A, Stokes JW, Ukita R, Hozain A, Pinezich M, O'Neill JD, Lee MJ, Reimer JA, Flynn CR, Talackine JR, Cardwell NL, Benson C, Vunjak-Novakovic G, Alexopoulos SP, Bacchetta M. Cross-Circulation for Extracorporeal Liver Support in a Swine Model. ASAIO J 2022; 68:561-570. [PMID: 34352819 PMCID: PMC9984766 DOI: 10.1097/mat.0000000000001543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Although machine perfusion has gained momentum as an organ preservation technique in liver transplantation, persistent organ shortages and high waitlist mortality highlight unmet needs for improved organ salvage strategies. Beyond preservation, extracorporeal organ support platforms can also aid the development and evaluation of novel therapeutics. Here, we report the use of veno-arterial-venous (V-AV) cross-circulation (XC) with a swine host to provide normothermic support to extracorporeal livers. Functional, biochemical, and morphological analyses of the extracorporeal livers and swine hosts were performed over 12 hours of support. Extracorporeal livers maintained synthetic function through alkaline bile production and metabolic activity through lactate clearance and oxygen consumption. Beyond initial reperfusion, no biochemical evidence of hepatocellular injury was observed. Histopathologic injury scoring showed improvements in sinusoidal dilatation and composite acute injury scores after 12 hours. Swine hosts remained hemodynamically stable throughout XC support. Altogether, these outcomes demonstrate the feasibility of using a novel V-AV XC technique to provide support for extracorporeal livers in a swine model. V-AV XC has potential applications as a translational research platform and clinical biotechnology for donor organ salvage.
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Affiliation(s)
- Wei Kelly Wu
- From the Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew Tumen
- From the Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John W Stokes
- From the Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rei Ukita
- From the Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ahmed Hozain
- Department of Surgery, Columbia University Medical Center, New York, New York
- Department of Biomedical Engineering, Columbia University, New York, New York
| | - Meghan Pinezich
- Department of Biomedical Engineering, Columbia University, New York, New York
| | - John D O'Neill
- Department of Biomedical Engineering, Columbia University, New York, New York
- Department of Cell Biology, State University of New York Downstate Medical Center, Brooklyn, New York City
| | - Michael J Lee
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Jonathan A Reimer
- Department of Surgery, Columbia University Medical Center, New York, New York
- Department of Biomedical Engineering, Columbia University, New York, New York
| | - Charles R Flynn
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jennifer R Talackine
- From the Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nancy L Cardwell
- From the Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Clayne Benson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gordana Vunjak-Novakovic
- Department of Biomedical Engineering, Columbia University, New York, New York
- Department of Medicine, Columbia University, New York, New York
| | - Sophoclis P Alexopoulos
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew Bacchetta
- From the Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee
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23
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Simultaneous Liver-Kidney Transplantation and the Use of Intraoperative Dialysis: A Monocenter Study. Transplant Proc 2022; 54:1002-1006. [DOI: 10.1016/j.transproceed.2022.02.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/18/2022] [Indexed: 11/19/2022]
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24
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Dewitte A, Defaye M, Dahmi A, Ouattara A, Joannes-Boyau O, Chermak F, Chiche L, Laurent C, Battelier M, Sigaut S, Khoy-Ear L, Grigoresco B, Cauchy F, Francoz C, Paugam Burtz C, Janny S, Weiss E. Prognostic Impact of Early Recovering Acute Kidney Injury Following Liver Transplantation: A Multicenter Retrospective Study. Transplantation 2022; 106:781-791. [PMID: 34172644 DOI: 10.1097/tp.0000000000003865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication after liver transplantation (LT), but the specific impact of rapidly resolving AKI is not elucidated. This study investigates the factors associated with early recovery from AKI and its association with post-LT outcomes. METHODS Retrospective analysis of 441 liver transplant recipients with end-stage liver disease without pretransplant renal impairment. AKI was defined according to Kidney Disease Improving Global Outcomes criteria and early renal recovery by its disappearance within 7 d post-LT. RESULTS One hundred forty-six patients (32%) developed a post-LT AKI, of whom 99 (69%) recovered early and 45 (31%) did not. Factors associated with early recovery were Kidney Disease Improving Global Outcomes stage 1 (odds ratio [OR],14.11; 95% confidence interval [CI], 5.59-40.22; P < 0.0001), minimum prothrombin time >50 % (OR, 4.50; 95% CI, 1.67-13.46; P = 0.003) and aspartate aminotransferase peak value <1000 U/L (OR, 4.07; 95% CI, 1.64-10.75; P = 0.002) within 48 h post-LT. Patients with early recovery had a renal prognosis similar to that of patients without AKI with no difference in estimated glomerular filtration rate between day 7 and 1 y. Their relative risk of developing chronic kidney disease was 0.88 (95% CI, 0.55-1.41; P = 0.6) with survival identical to patients without AKI and better than patients without early recovery (P < 0.0001). CONCLUSIONS Most patients with post-LT AKI recover early and have a similar renal prognosis and survival to those without post-LT AKI. Factors associated with early renal recovery are related to the stage of AKI, the extent of liver injury, and the early graft function. Patients at risk of not recovering may benefit the most from perioperative protective strategies, particularly those aimed at minimizing the adverse effects of calcineurin inhibitors.
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Affiliation(s)
- Antoine Dewitte
- Department of Anaesthesia and Critical Care, CHU de Bordeaux, Pessac, France
- University of Bordeaux, CNRS, Immunoconcept, U5164, Bordeaux, France
| | - Mylène Defaye
- Department of Anaesthesia and Critical Care, CHU de Bordeaux, Pessac, France
| | - Anissa Dahmi
- Department of Anaesthesia and Critical Care, CHU de Bordeaux, Pessac, France
| | - Alexandre Ouattara
- Department of Anaesthesia and Critical Care, CHU de Bordeaux, Pessac, France
- University of Bordeaux, INSERM, Biology of Cardiovascular Diseases, U1034, Bordeaux, France
| | | | - Faiza Chermak
- Department of Hepatology, CHU de Bordeaux, Pessac, France
| | | | | | - Mathieu Battelier
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Stéphanie Sigaut
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Linda Khoy-Ear
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Bénédicte Grigoresco
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - François Cauchy
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, DMU Digest, AP-HP.Nord, Clichy, France
- Inserm UMR_S 1149, Centre de Recherche Sur L'inflammation, Paris, France
| | - Claire Francoz
- Inserm UMR_S 1149, Centre de Recherche Sur L'inflammation, Paris, France
- Liver Unit, Beaujon Hospital, Clichy, France
| | - Catherine Paugam Burtz
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Clichy, France
- Inserm UMR_S 1149, Centre de Recherche Sur L'inflammation, Paris, France
- University of Paris, Paris, France
| | - Sylvie Janny
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Clichy, France
- Inserm UMR_S 1149, Centre de Recherche Sur L'inflammation, Paris, France
- University of Paris, Paris, France
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25
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Umehara K, Karashima Y, Yoshizumi T, Yamaura K. Factors Associated With Postreperfusion Syndrome in Living Donor Liver Transplantation: A Retrospective Study. Anesth Analg 2022; 135:354-361. [PMID: 35343925 DOI: 10.1213/ane.0000000000006002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postreperfusion syndrome (PRS) after portal vein reperfusion during liver transplantation (LT) has been reported to cause rapid hemodynamic changes and is associated with a prolonged postoperative hospital stay, renal failure, and increased mortality. Although there are some reports on risk factors for PRS in brain-dead donor LT, there are a few reports on those in living donor LT. Therefore, we retrospectively reviewed the factors associated with PRS to contribute to the anesthetic management so as to reduce PRS during living donor LT. METHODS After approval by the ethics committee of our institution, 250 patients aged ≥20 years who underwent living donor LT at our institution between January 2013 and September 2018 were included in the study. A decrease in mean arterial pressure of ≥30% within 5 minutes after portal vein reperfusion was defined as PRS, and estimates and odds ratio (OR) for PRS were calculated using logistic regression. The backward method was used for variable selection in the multivariable analysis. RESULTS Serum calcium ion concentration before reperfusion (per 0.1 mmol/L increase; OR, 0.74; 95% confidence interval (CI), 0.60-0.95; P < .001), preoperative echocardiographic left ventricular end-diastolic diameter (per 1-mm increase: OR, 0.90; 95% CI, 0.85-0.95; P < .001, men [versus women: OR, 2.45; 95% CI, 1.26-4.75; P = .008]), mean pulmonary artery pressure before reperfusion (restricted cubic spline, P = .003), anhepatic period (restricted cubic spline, P = .02), and graft volume to standard liver volume ratio (restricted cubic spline, P = .03) were significantly associated with PRS. CONCLUSIONS In living donor LT, male sex and presence of small left ventricular end-diastolic diameter, large graft volume, and long anhepatic period are associated with PRS, and a high calcium ion concentration and low pulmonary artery pressure before reperfusion are negatively associated with PRS.
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Affiliation(s)
- Kaoru Umehara
- From the Operating Rooms, Kyushu University Hospital, Fukuoka, Japan
| | - Yuji Karashima
- From the Operating Rooms, Kyushu University Hospital, Fukuoka, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ken Yamaura
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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26
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Miles LF, Couture EJ, Potes C, Makar T, Fernando MC, Hungenahally A, Mathieson MD, Perlman H, Perini MV, Thind D, Weinberg L, Denault AY. Preliminary experience with continuous right ventricular pressure and transesophageal echocardiography monitoring in orthotopic liver transplantation. PLoS One 2022; 17:e0263386. [PMID: 35120144 PMCID: PMC8815904 DOI: 10.1371/journal.pone.0263386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/19/2022] [Indexed: 11/19/2022] Open
Abstract
Background Despite increasing attention in the cardiac anesthesiology literature, continuous measurement of right ventricular pressure using a pulmonary artery catheter has not been described in orthotopic liver transplantation, despite similarities in the anesthetic approach to the two populations. We describe our preliminary experience with this technique in orthotopic liver transplantation, and by combining various derived measures with trans-esophageal echocardiography, make some early observations regarding the response of these measures of right ventricular function during the procedure. Methods In this case series, ten patients (five men and five women) undergoing orthotopic liver transplantation in our institution had their surgeries performed while monitored with a pulmonary artery catheter with continuous right ventricular port transduction and trans-esophageal echocardiography. We recorded various right ventricular waveform (early-to-end diastolic pressure difference, right ventricular outflow tract gradient, right ventricular dP/dT and right ventricular end-diastolic pressure) and echocardiographic (right ventricular fractional area change, tricuspid annular plane systolic excursion, right ventricular lateral wall strain) and described their change relative to baseline at timepoints five minutes before and after portal vein reperfusion, immediately after hepatic artery reperfusion and on abdominal closure. Results Except for tricuspid annular plane systolic excursion at five minutes prior to reperfusion (mean −0.8 cm; 95% CI−1.4, –0.3; p = 0.007), no echocardiographic metric was statistically significantly different at any timepoint relative to baseline. In contrast, changes in right ventricular outflow tract gradient and right ventricular dP/dt were highly significant at multiple timepoints, generally peaking immediately before or after reperfusion before reducing, but not returning to baseline in the neohepatic phase. Nine of 10 participants in this series demonstrated a degree of dynamic right ventricular outflow tract obstruction, which met criteria for hemodynamic significance (> 25 mmHg) in two participants. These changes were not materially affected by cardiac index. Conclusions Dynamic right ventricular outflow tract obstruction of varying severity appears common in patients undergoing orthotopic liver transplantation. These results are hypothesis generating and will form the basis of future prospective research.
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Affiliation(s)
- Lachlan F. Miles
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Department of Anaesthesia, Austin Health, Melbourne, Australia
- * E-mail:
| | - Etienne J. Couture
- Division of Intensive Care Medicine, Department of Anesthesiology and Department of Medicine, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Cristhian Potes
- Edwards LifeSciences Pty. Ltd., Irvine, California, United States of America
| | - Timothy Makar
- Department of Anaesthesia, Austin Health, Melbourne, Australia
| | | | | | | | - Hannah Perlman
- Department of Anaesthesia, Austin Health, Melbourne, Australia
| | - Marcos V. Perini
- Department of Surgery, The University of Melbourne, Melbourne, Australia
- Victorian Liver and Intestinal Transplant Unit, Austin Health, Melbourne, Australia
| | - Dilraj Thind
- Department of Anaesthesia, Austin Health, Melbourne, Australia
| | - Laurence Weinberg
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Department of Anaesthesia, Austin Health, Melbourne, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - André Y. Denault
- Department of Anesthesiology and Critical Care Division, Montreal Heart Institute, Université de Montréal, Montréal, Canada
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27
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Park J, Jung S, Na S, Choi HJ, Shim JW, Lee HM, Hong SH, Chae MS. Clinical application of intraoperative somatic tissue oxygen saturation for detecting postoperative early kidney dysfunction patients undergoing living donor liver transplantation: A propensity score matching analysis. PLoS One 2022; 17:e0262847. [PMID: 35061855 PMCID: PMC8782411 DOI: 10.1371/journal.pone.0262847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/06/2022] [Indexed: 01/17/2023] Open
Abstract
Background Somatic tissue oxygen saturation (SstO2) is associated with systemic hypoperfusion. Kidney dysfunction may lead to increased mortality and morbidity in patients who undergo living donor liver transplantation (LDLT). We investigated the clinical utility of SstO2 during LDLT for identifying postoperative kidney dysfunction. Patients and methods Data from 304 adults undergoing elective LDLT between January 2015 and February 2020 at Seoul St. Mary’s Hospital were retrospectively collected. Thirty-six patients were excluded based on the exclusion criteria. In total, 268 adults were analyzed, and 200 patients were 1:1 propensity score (PS)-matched. Results Patients with early kidney dysfunction had significantly lower intraoperative SstO2 values than those with normal kidney function. Low SstO2 (< 66%) 1 h after graft reperfusion was more highly predictive of early kidney dysfunction than the values measured in other intraoperative phases. A decline in the SstO2 was also related to kidney dysfunction. Conclusions Kidney dysfunction after LDLT is associated with patient morbidity and mortality. Our results may assist in the detection of early kidney dysfunction by providing a basis for analyzing SstO2 in patients undergoing LDLT. A low SstO2 (< 66%), particularly 1 h after graft reperfusion, was significantly associated with early kidney dysfunction after surgery. SstO2 monitoring may facilitate the identification of early kidney dysfunction and enable early management of patients.
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Affiliation(s)
- Jaesik Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sangmin Jung
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sanghoon Na
- Department of Anesthesiology and Pain Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jung-Woo Shim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyung Mook Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- * E-mail:
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What's New in Cirrhotic Cardiomyopathy?-Review Article. J Pers Med 2021; 11:jpm11121285. [PMID: 34945757 PMCID: PMC8705028 DOI: 10.3390/jpm11121285] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/21/2021] [Accepted: 11/25/2021] [Indexed: 01/16/2023] Open
Abstract
Cirrhotic cardiomyopathy (CCM) is a relatively new medical term. The constant development of novel diagnostic and clinical tools continuously delivers new data and findings about this broad disorder. The purpose of this review is to summarize current facts about CCM, identify gaps of knowledge, and indicate the direction in which to prepare an updated definition of CCM. We performed a review of the literature using scientific data sources with an emphasis on the latest findings. CCM is a clinical manifestation of disorders in the circulatory system in the course of portal hypertension. It is characterized by impaired left ventricular systolic and diastolic dysfunction, and electrophysiological abnormalities, especially QT interval prolongation. However, signs and symptoms reported by patients are non-specific and include reduced exercise tolerance, fatigue, peripheral oedema, and ascites. The disease usually remains asymptomatic with almost normal heart function, unless patients are exposed to stress or exertion. Unfortunately, due to the subclinical course, CCM is rarely recognized. Orthotopic liver transplantation (OLTx) seems to improve circulatory function although there is no consensus about its positive effect, with reported cases of heart failure onset after transplantation. Researchers indicate a careful pre-, peri-, and post-transplant cardiac assessment as a crucial point in detecting CCM and improving patients’ prognosis. There is also an urgent need to update the CCM definition and establish a diagnostic algorithm for early diagnosis of CCM as well as a specific treatment of this condition.
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29
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Hussain B, Kasinath V, Madsen JC, Bromberg J, Tullius SG, Abdi R. Intra-Organ Delivery of Nanotherapeutics for Organ Transplantation. ACS NANO 2021; 15:17124-17136. [PMID: 34714050 PMCID: PMC9050969 DOI: 10.1021/acsnano.1c04707] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Targeted delivery of therapeutics through the use of nanoparticles (NPs) has emerged as a promising method that increases their efficacy and reduces their side effects. NPs can be tailored to localize to selective tissues through conjugation to ligands that bind cell-specific receptors. Although the vast majority of nanodelivery platforms have focused on cancer therapy, efforts have begun to introduce nanotherapeutics to the fields of immunology as well as transplantation. In this review, we provide an overview from a clinician's perspective of current nanotherapeutic strategies to treat solid organ transplants with NPs during the time interval between organ harvest from the donor and placement into the recipient, an innovative technology that can provide major benefits to transplant patients. The use of ex vivo normothermic machine perfusion (NMP), which is associated with preserving the function of the organ following transplantation, also provides an ideal opportunity for a localized, sustained, and controlled delivery of nanotherapeutics to the organ during this critical time period. Here, we summarize previous endeavors to improve transplantation outcomes by treating the organ with NPs prior to placement in the recipient. Investigations in this burgeoning field of research are promising, but more extensive studies are needed to overcome the physiological challenges to achieving effective nanotherapeutic delivery to transplanted organs discussed in this review.
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Affiliation(s)
- Bilal Hussain
- Transplantation Research Center and Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Vivek Kasinath
- Transplantation Research Center and Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Joren C. Madsen
- Department of Surgery and Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jonathan Bromberg
- Departments of Surgery and Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Stefan G. Tullius
- Transplant Surgery Research Laboratory and Division of Transplant Surgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Reza Abdi
- Transplantation Research Center and Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
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30
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Fiorelli S, Biancofiore G, Feltracco P, Lavezzo B, DE Gasperi A, Pompei L, Masiero L, Testa S, Ricci A, Della Rocca G. Acute kidney injury after liver transplantation, perioperative risk factors, and outcome: prospective observational study of 1681 patients (OLTx Study). Minerva Anestesiol 2021; 88:248-258. [PMID: 34709014 DOI: 10.23736/s0375-9393.21.15860-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) represents a frequent complication after orthotopic liver transplantation (OLT). This study aimed to evaluate early postoperative AKI incidence during the first 72 h after OLT, perioperative risk factors, and AKI impact on survival. METHODS From January 2011 to December 2013) 1681 patients underwent OLT in 19 centers and were enrolled in this prospective cohort study. RESULTS According to RIFLE criteria, AKI occurred in 367 patients, 21.8% (R: 5.8%, I: 6.4%, F: 4.8%, L: 4.8%). Based on multivariate analysis, intraoperative risk factors for AKI were: administration of 5-10 RBCs (OR 1.8, 95%CI 1.3-2.7), dopamine use (OR 1.6, 95%CI 1.2-2.3), post-reperfusion syndrome (OR 1.5, 95%CI 1.0-2.3), surgical complications (OR 2.0, 95% CI 1.3-3.0), and cardiological complications (OR 2.2, 95%CI 1.2-4.0). Postoperative risk factors were: norepinephrine (OR 1.4, 95%CI 1.0-2.0), furosemide (OR 4.2, 95% CI 3.0-5.9), more than 10 RBCs transfusion, (OR 3.7, 95%CI 1.4-10.5), platelets administration (OR 1.6, 95% CI 1.1-2.4), fibrinogen administration (OR 3.0, 95%CI, 1.5-6.2), hepatic complications (OR 4.6, 95%CI 2.9-7.5), neurological complications (OR 2.4, 95%CI 1.5-3.7), and infectious complications (OR 2.7, 95%CI 1.8-4.3). NO-AKI patients' 5 years survival rate was higher than AKI patients (68.06, 95% CI 62.7-72.7 and 81.2, 95% CI 78.9-83.3, p< 0.001). CONCLUSIONS AKI still remains an important risk factor for morbidity and mortality after OLT. Further researches to develop new strategies aimed at preventing or minimizing post-OLT AKI are needed.
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Affiliation(s)
- Silvia Fiorelli
- Department of Anesthesiology and Intensive care, Sapienza University of Rome, Rome, Italy -
| | | | | | - Bruna Lavezzo
- AOU Città della Salute e della Scienza, presidio Molinette, Turin, Italy
| | | | - Livia Pompei
- Department of Medical Area, University of Udine, Udine, Italy
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31
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Haga S, Kanno A, Morita N, Jin S, Matoba K, Ozawa T, Ozaki M. Poly(ADP-ribose) Polymerase (PARP) is Critically Involved in Liver Ischemia/reperfusion-injury. J Surg Res 2021; 270:124-138. [PMID: 34656890 DOI: 10.1016/j.jss.2021.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 08/27/2021] [Accepted: 09/14/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Poly(ADP-ribose) polymerase (PARP) is a DNA-repairing enzyme activated by extreme genomic stress, and therefore is potently activated in the remnant liver suffering from ischemia after surgical resection. However, the impact of PARP on post-ischemic liver injury has not been elucidated yet. MATERIALS AND METHODS We investigated the impact of PARP on murine hepatocyte/liver injury induced by hypoxia/ischemia, respectively. RESULTS PJ34, a specific inhibitor of PARP, markedly protected against hypoxia/reoxygenation (H/R)-induced cell death, though z-VAD-fmk, a pan-caspase inhibitor similarly showed the protective effect. PJ34 did not affect H/R-induced caspase activity or caspase-mediated cell death. z-VAD-fmk also did not affect the production of PAR (i.e., PARP activity). Therefore, PARP- and caspase-mediated cell death occurred in a mechanism independent of each other in H/R. H/R immediately induced activation of PARP and cell death afterwards, both of which were suppressed by PJ34 or Trolox, an antioxidant. This suggests that H/R-induced cell death occurred redox-dependently through PARP activation. H/R and OS induced nuclear translocation of apoptosis inducing factor (AIF, a marker of parthanatos) and RIP1-RIP3 interaction (a marker of necroptosis), both of which were suppressed by PJ34. H/R induced PARP-mediated parthanatos and necroptosis redox-dependently. In mouse experiments, PJ34 significantly reduced serum levels of AST, ALT & LDH and areas of hepatic necrosis after liver ischemia/reperfusion, similar to z-VAD-fmk or Trolox. CONCLUSION PARP, activated by ischemic damage and/or oxidative stress, may play a critical role in post-ischemic liver injury by inducing programmed necrosis (parthanatos and necroptosis). PARP inhibition may be one of the promising strategies against post-ischemic liver injury.
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Affiliation(s)
- Sanae Haga
- Department of Biological Response and Regulation, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Akira Kanno
- Department of Environmental Applied Chemistry, University of Toyama, Toyama, Toyama, Japan
| | - Naoki Morita
- Bioproduction Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Sapporo, Hokkaido, Japan
| | - Shigeki Jin
- Department of Forensic Medicine, Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Kotaro Matoba
- Department of Forensic Medicine, Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Takeaki Ozawa
- Department of Chemistry, School of Science, The University of Tokyo, Tokyo, Japan
| | - Michitaka Ozaki
- Department of Biological Response and Regulation, Hokkaido University, Sapporo, Hokkaido, Japan; Laboratory of Molecular and Functional Bio-Imaging, Hokkaido University, Sapporo, Hokkaido, Japan.
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Bezinover D, Mukhtar A, Wagener G, Wray C, Blasi A, Kronish K, Zerillo J, Tomescu D, Pustavoitau A, Gitman M, Singh A, Saner FH. Hemodynamic Instability During Liver Transplantation in Patients With End-stage Liver Disease: A Consensus Document from ILTS, LICAGE, and SATA. Transplantation 2021; 105:2184-2200. [PMID: 33534523 DOI: 10.1097/tp.0000000000003642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemodynamic instability (HDI) during liver transplantation (LT) can be difficult to manage and increases postoperative morbidity and mortality. In addition to surgical causes of HDI, patient- and graft-related factors are also important. Nitric oxide-mediated vasodilatation is a common denominator associated with end-stage liver disease related to HDI. Despite intense investigation, optimal management strategies remain elusive. In this consensus article, experts from the International Liver Transplantation Society, the Liver Intensive Care Group of Europe, and the Society for the Advancement of Transplant Anesthesia performed a rigorous review of the most current literature regarding the epidemiology, causes, and management of HDI during LT. Special attention has been paid to unique LT-associated conditions including the causes and management of vasoplegic syndrome, cardiomyopathies, LT-related arrhythmias, right and left ventricular dysfunction, and the specifics of medical and fluid management in end-stage liver disease as well as problems specifically related to portal circulation. When possible, management recommendations are made.
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Affiliation(s)
- Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Pennsylvania State University, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA. Represents ILTS and LICAGE
| | - Ahmed Mukhtar
- Department of Anesthesia and Surgical Intensive Care, Cairo University, Almanyal, Cairo, Egypt. Represents LICAGE
| | - Gebhard Wagener
- Department of Anesthesiology, Columbia University Medical Center, New York, NY. Represents SATA and ILTS
| | - Christopher Wray
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA. Represents SATA
| | - Annabel Blasi
- Department of Anesthesia, IDIBAPS (Institut d´investigació biomèdica Agustí Pi i Sunyé) Hospital Clinic, Villaroel, Barcelona, Spain. Represents LICAGE and ILTS
| | - Kate Kronish
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA. Represents SATA
| | - Jeron Zerillo
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY. Represents SATA and ILTS
| | - Dana Tomescu
- Department of Anesthesiology and Intensive Care, Carol Davila University of Medicine and Pharmacy, Fundeni Clinical Institute, Bucharest, Romania. Represents LICAGE
| | - Aliaksei Pustavoitau
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Johns Hopkins School of Medicine, Baltimore, MD. Represents ILTS
| | - Marina Gitman
- Department of Anesthesiology, University of Illinois Hospital, Chicago, IL. Represents SATA and ILTS
| | - Anil Singh
- Department of Liver Transplant and GI Critical Care, Sir HN Reliance Foundation Hospital, Cirgaon, Mumbai, India. Represents ILTS
| | - Fuat H Saner
- Department of General, Visceral and Transplant Surgery, Essen University Medical Center, Essen, Germany. Represents LICAGE
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Sáez de la Fuente I, Sáez de la Fuente J, Molina Collado Z, Chacón Alves S, Sánchez-Bayton Griffith M, Lesmes González de Aledo A, Barea Mendoza J, Sánchez-Izquierdo Riera JÁ, García de Lorenzo A, Montejo González JC. Combination of arterial lactate levels and Cv-aCO2/Da-vO2 ratio to predict early allograft dysfunction after liver transplantation. Clin Transplant 2021; 35:e14482. [PMID: 34545961 DOI: 10.1111/ctr.14482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/30/2021] [Accepted: 09/08/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE We examined the ability of the P(v-a)CO2/Da-vO2 ratio combined with elevated lactate levels to predict early allograft dysfunction (EAD). MATERIALS AND METHODS Patients were classified into four groups according to lactate levels and P(v-a)CO2/Da-vO2 ratio: Group 1; lactate >2.0 mmol/L and P(v-a)CO2/Da-vO2 ratio >1.0; Group 2; lactate >2.0 mmol/L and P(v-a)CO2/Da-vO2 ratio <1.0; group 3; lactate<2.0 mmol/L and P(v-a)CO2/Da-vO2 ratio >1.0; group 4; lactate<2.0 mmol/L and P(v-a)CO2/Da-vO2 ratio <1.0. We defined EAD according to Olthoff criteria. RESULTS One-hundred and fifty patients were included. EAD occurred in 41 patients (27.3%), and was associated with worse graft survival at 1 year (92% vs. 73%; P = ,003) as well as a higher re-transplantation rate (4,6% vs. 17,1%; P = ,019). The multivariate analysis revealed that P(v-a)CO2/Da-vO2 ratio at T6 [OR 7.05(CI95% 2.77-19.01, P<.001)] was an independent predictor for EAD. Belonging to group 1 at 6 h was associated with worse clinical outcomes but no association was found with 1-year graft survival or 1-year patient survival. CONCLUSIONS In this single center, prospective, observational study in patients who received an OLT, we found that elevated lactate levels combined with a high Cv-aCO2/Da-vO2 after 6 h was associated with the development of EAD and worse clinical outcomes in the early postoperative period.
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Affiliation(s)
| | | | | | - Silvia Chacón Alves
- Hospital Universitario 12 de Octubre, Critical Care Department, Madrid, Spain
| | | | | | - Jesús Barea Mendoza
- Hospital Universitario 12 de Octubre, Critical Care Department, Madrid, Spain
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Larivière J, Giard JM, Zuo RM, Massicotte L, Chassé M, Carrier FM. Association between intraoperative fluid balance, vasopressors and graft complications in liver transplantation: A cohort study. PLoS One 2021; 16:e0254455. [PMID: 34242370 PMCID: PMC8270449 DOI: 10.1371/journal.pone.0254455] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 06/26/2021] [Indexed: 01/08/2023] Open
Abstract
Introduction Biliary complications following liver transplantation are common. The effect of intraoperative fluid balance and vasopressors on these complications is unknown. Materials and methods We conducted a cohort study between July 2008 and December 2017. Our exposure variables were the total intraoperative fluid balance and the use of vasopressors on ICU admission. Our primary outcome was any biliary complication (anastomotic and non-anastomotic strictures) up to one year after transplantation. Our secondary outcomes were vascular complications, primary graft non-function and survival. Results We included 562 consecutive liver transplantations. 192 (34%) transplants had a biliary complication, 167 (30%) had an anastomotic stricture and 56 had a non-anastomotic stricture (10%). We did not observe any effect of intraoperative fluid balance or vasopressor on biliary complications (HR = 0.97; 95% CI, 0.93 to 1.02). A higher intraoperative fluid balance was associated with an increased risk of primary graft non-function (non-linear) and a lower survival (HR = 1.40, 95% CI, 1.14 to 1.71) in multivariable analyses. Conclusion Intraoperative fluid balance and vasopressors upon ICU admission were not associated with biliary complications after liver transplantation but may be associated with other adverse events. Intraoperative hemodynamic management must be prospectively studied to further assess their impact on liver recipients’ outcomes.
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Affiliation(s)
- Jordan Larivière
- Department of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Jeanne-Marie Giard
- Department of Medicine—Liver Diseases Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Rui Min Zuo
- Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Luc Massicotte
- Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Michaël Chassé
- Department of Medicine–Intensive Care Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - François Martin Carrier
- Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
- Department of Medicine–Intensive Care Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
- Carrefour de l’innovation, Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montréal, Québec, Canada
- * E-mail:
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Robertson M, Chung W, Liu D, Seagar R, O'Halloran T, Koshy AN, Horrigan M, Farouque O, Gow P, Angus P. Cardiac Risk Stratification in Liver Transplantation: Results of a Tiered Assessment Protocol Based on Traditional Cardiovascular Risk Factors. Liver Transpl 2021; 27:1007-1018. [PMID: 33606328 DOI: 10.1002/lt.26025] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/14/2020] [Accepted: 12/17/2020] [Indexed: 01/13/2023]
Abstract
Coronary artery disease (CAD) confers increased perioperative risk in patients undergoing liver transplantation (LT). Although routine screening for CAD is recommended, there are limited data on the effectiveness of screening strategies. We evaluated the safety and efficacy of a 3-tiered cardiac risk-assessment protocol that stratifies patients based on age and traditional cardiac risk factors. We peformed a single-center, prospective, observational study of consecutive adult patients undergoing LT assessment (2010-2017). Patients were stratified into low-risk (LR), intermediate-risk (IR), or high-risk (HR) cardiac groups and received standardized investigations with selective use of transthoracic echocardiography (TTE), dobutamine stress echocardiography (DSE), computed tomography coronary angiography (CTCA), and coronary angiography (CA). Primary outcomes were cardiac events (CEs) and cardiovascular death up to 30 days after LT. Overall, 569 patients were included, with 76 patients identified as LR, 256 as IR, and 237 as HR. Cardiac risk factors included diabetes mellitus (26.0%), smoking history (47.3%), hypertension (17.8%), hypercholesterolemia (7.2%), family (17.0%) or prior history of heart disease (6.0%), and obesity (27.6%). Of the patients, 42.0% had ≥2 risk factors. Overall compliance with the protocol was 90.3%. Abnormal findings on TTE, DSE, and CTCA were documented in 3, 23, and 44 patients, respectively, and 12 patients were not listed for transplantation following cardiac assessment (1 LR, 2 IR, and 9 HR). Moderate or severe CAD was identified in 25.4% of HR patients on CTCA following a normal DSE. CEs were recorded in 7 patients (1.2%), with 2 cardiovascular deaths (0.4%). Cardiac risk stratification based on traditional cardiac risk factors with the selective use of DSE, CTCA, and CA is a safe and feasible approach that results in a low perioperative cardiac event rate.
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Affiliation(s)
- Marcus Robertson
- Liver Transplant Unit, Austin Hospital, Heidelberg, Victoria, Australia.,Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia
| | - William Chung
- Liver Transplant Unit, Austin Hospital, Heidelberg, Victoria, Australia
| | - Dorothy Liu
- Liver Transplant Unit, Austin Hospital, Heidelberg, Victoria, Australia
| | - Rosemary Seagar
- Liver Transplant Unit, Austin Hospital, Heidelberg, Victoria, Australia
| | - Tess O'Halloran
- Liver Transplant Unit, Austin Hospital, Heidelberg, Victoria, Australia
| | - Anoop N Koshy
- Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia.,Department of Cardiology, Austin Hospital, Heidelberg, Victoria, Australia
| | - Mark Horrigan
- Department of Cardiology, Austin Hospital, Heidelberg, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Hospital, Heidelberg, Victoria, Australia
| | - Paul Gow
- Liver Transplant Unit, Austin Hospital, Heidelberg, Victoria, Australia.,Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia
| | - Peter Angus
- Liver Transplant Unit, Austin Hospital, Heidelberg, Victoria, Australia.,Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia
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Thomas M, Kumar L, Jain P, Sarma C, Paul S, Surendran S. Correlation between radial and femoral arterial blood pressure during reperfusion in living donor liver transplantation. Indian J Anaesth 2021; 65:302-308. [PMID: 34103744 PMCID: PMC8174597 DOI: 10.4103/ija.ija_495_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/19/2020] [Accepted: 07/14/2020] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Accurate blood pressure measurements are the mainstay for the efficient management of abrupt cardiovascular changes during reperfusion in liver transplant. We sought to compare the femoral and radial pressures during reperfusion and at T1:baseline, T2: 1 h in dissection: T3:portosystemic shunt, T4:reperfusion, T5: at bile duct anastomosis. Methods A retrospective study was performed amongst 102 adult patients who underwent R lobe living donor liver transplantation. Mean arterial pressure (MAP) and systolic arterial pressure (SAP) at 10 s intervals at reperfusion and at five fixed time points were compared by intraclass correlation coefficient (ICC) and limits of agreement by Bland-Altman statistics. Results MAP by both routes had a good correlation at all time points during reperfusion (overall ICC: 0.946 [0.938, 0.949]) in comparison with SAP (overall ICC: 0.650 [0.6128, 0.684]). At the lowest reperfusion pressure (reperfusion point), MAP showed high levels of agreements (ICC: 0.833 [0.761, 0.885]), whereas SAP showed only a poor level of agreement (ICC 0.343 [0.153, 0.508]). The Bland-Altman analysis for MAP showed a bias of 7.18 (5.94) mmHg and limits of agreement of - 4.5 mmHg to + 18.8 mmHg and for SAP a bias of 25.2 (22.04) mmHg and limits of agreement of - 18.0 mmHg to + 68.4 mmHg at the reperfusion point. The incidence of post-reperfusion syndrome (PRS) was 52.94% by femoral and 57.84% by radial routes. Conclusions Radial MAP correlated well with femoral MAP during reperfusion and at predefined time points and can be used interchangeably for intraoperative monitoring. A high incidence of PRS was noted by our technique of measurement.
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Affiliation(s)
- Manu Thomas
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Lakshmi Kumar
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Priyanka Jain
- Department of Clinical Research, Institute of Liver and Biliary Sciences, Delhi, India
| | - Chitra Sarma
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Shabala Paul
- Department of Anaesthesiology and Critical Care, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Sudhindran Surendran
- Department of Gastro Intestinal Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
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Ricksten SE, Bragadottir G, Lannemyr L, Redfors B, Skytte J. Renal Hemodynamics, Function, and Oxygenation in Critically Ill Patients and after Major Surgery. KIDNEY360 2021; 2:894-904. [PMID: 35373068 PMCID: PMC8791344 DOI: 10.34067/kid.0007012020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/02/2021] [Indexed: 02/04/2023]
Abstract
This review outlines the available data from the work of our group on renal hemodynamics, function, and oxygenation in patients who are critically ill with acute renal dysfunction, such as those with postoperative AKI, those in early clinical septic shock, in patients undergoing cardiac surgery with cardiopulmonary bypass, or in patients undergoing liver transplantation. We also provide information on renal hemodynamics, function, and oxygenation in patients with chronic renal impairment due to congestive heart failure. This review will argue that, for all of these groups of patients, the common denominator is that renal oxygenation is impaired due to a lower renal oxygen delivery or a pronounced increase in renal oxygen consumption.
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Khalili F, Khosravi MB, Sahmeddini MA, Eghbal MH, Kazemi K, Nikeghbalian S, Ghazanfar Tehran S, Khosravi B. The Effect of Perioperative N-acetylcysteine on the Short and Long Term Outcomes in Pediatrics Undergoing Living-Donor Liver Transplantation. Int J Organ Transplant Med 2021; 12:12-20. [PMID: 34987729 PMCID: PMC8717878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Ischemia-reperfusion injury during transplantation can cause post-operative graft dysfunction. OBJECTIVE To assess the efficacy of N-acetylcysteine in preventing hepatic ischemia-reperfusion injury and post-transplant outcomes. METHODS In this retrospective study on pediatrics undergoing living-donor (from one of their parents) liver transplantation, N-acetylcysteine was administered to one group (n=20) after induction in the donors until graft harvest, and in the recipients during implantation, which was maintained for 19 hours. The second group (n=20) did not receive NAC. Early allograft dysfunction was determined in the presence of alanine aminotransferase or aspartate aminotransferase ≥2000 IU/L and bilirubin ≥10 mg/dL within the first 7 days, and an international normalized ratio ≥1.6 on day 7. Data were collected from a retrospectively maintained database. RESULTS The incidence of post-reperfusion syndrome was lower in N-acetylcysteine group compared with the other group (5% vs. 30%, p=0.037). Serum creatinine level was significantly (p=0.04) different in the N-acetylcysteine group during the second post-operative week (0.14 vs. 0.15 mg/dL). There was no significant difference in the incidence of early allograft dysfunction (21% vs. 14%, p=0.327), and the survival rate (p=0.409). CONCLUSION Peri-operative infusion of N-acetylcysteine in both donor and recipient would effectively prevent post-reperfusion syndrome and renal insufficiency. However, it might not affect the early allograft dysfunction, ICU stay, and mortality. NAC increases the chance of re-operation due to non-surgical bleeding in the first post-operative day.
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Affiliation(s)
- F. Khalili
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - M. B. Khosravi
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - M. A. Sahmeddini
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - M. H. Eghbal
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - K. Kazemi
- Shiraz Organ Transplant Center, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - S. Nikeghbalian
- Shiraz Organ Transplant Center, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - S. Ghazanfar Tehran
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - B. Khosravi
- Biostatistics Department, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Espindola SD, Nascimento KCD, Knihs NDS, Sebold LF, Girondi JBR, Alvarez AG. Safe surgery checklist: content validation proposal for liver transplantation. Rev Bras Enferm 2020; 73:e20190538. [PMID: 33338123 DOI: 10.1590/0034-7167-2019-0538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 05/11/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES to develop the safe surgery checklist for liver transplantation according to the original model of the World Health Organization and perform content validation. METHODS a methodological research developed in four stages: integrative review; expert participation; consensus among researchers; and content validation using the Delphi technique in two rounds, by five judges. For data analysis, the Content Validation Index was used. RESULTS the first version of the checklist consisted of four surgical moments with 64 items of verification, with an average Content Validation Index of 0.80. After adjustments, in the second round the checklist maintained four surgical moments with 76 items and a Content Validation Index of 0.87. CONCLUSIONS the checklist was validated and adequate for the safety of liver transplantation in the surgical environment, given that each item established must be mapped and managed for the success and effectiveness of the procedure.
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Kościelska M, Matuszkiewicz-Rowińska J, Zieniewicz K, Krawczyk M, Giercuszkiewicz D, Sierdziński J, Żebrowski P, Małyszko J. Intraoperative Dialysis During Liver Transplantation. Transplant Proc 2020; 52:2454-2458. [PMID: 32448654 DOI: 10.1016/j.transproceed.2020.01.129] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/26/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Orthotopic liver transplantation (LT) is a technically complex surgical procedure associated with a major risk of hemodynamic instability and metabolic derangement, especially in patients with coexisting renal dysfunction. Some centers have applied intraoperative renal replacement therapy (ioRRT) to support patients with preoperative renal failure and prevent critical complications. Although there is a strong theoretical rationale for this treatment, there remains a paucity of definite data demonstrating its benefits. METHODS This was a retrospective observational study of all adult patients undergoing intraoperative dialysis in our center from January 2010 till December 2016. RESULTS The study group consisted of 88 patients with a mean MELD score of 31.4. Six patients underwent simultaneous liver and kidney transplantation. Forty-four (50%) recipients were admitted to the intensive care unit before transplantation, and 19 (21.6%) needed mechanical ventilation. Twenty-eight (31.8%) of the procedures were retransplantations, and 40 (45.4%) patients had been undergoing renal replacement therapy before LT. The mean preoperative serum creatinine was 2.82 ± 1.13 mg/dL. The majority of patients (54.5%) was operated on using the veno-venous bypass technique. The mean arterial blood pH and potassium levels after reperfusion were 7.2 ± 0.12 and 4.04 ± 0.95 mmol/L, respectively. Postreperfusion syndrome (PRS) occurred in 11 (13.9%) patients in whom dialysis started at least 15 minutes before reperfusion. Dialysis circuit clotting occurred in 9.1% of cases. There were no other adverse events of ioRRT. CONCLUSION Our data suggests that intraoperative dialysis in severely ill patients with a high MELD score is safe and effective. Lower than expected PRS occurrence needs to be confirmed in a study with a control group.
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Affiliation(s)
- Małgorzata Kościelska
- Department of Nephrology, Dialysis, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland.
| | | | - Krzysztof Zieniewicz
- Department of General, Liver, and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Marek Krawczyk
- Department of General, Liver, and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Dorota Giercuszkiewicz
- Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Janusz Sierdziński
- Department of Medical Informatics and Telemedicine, Medical University of Warsaw, Warsaw, Poland
| | - Paweł Żebrowski
- Department of Nephrology, Dialysis, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
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Manning MW, Kumar PA, Maheshwari K, Arora H. Post-Reperfusion Syndrome in Liver Transplantation—An Overview. J Cardiothorac Vasc Anesth 2020; 34:501-511. [DOI: 10.1053/j.jvca.2019.02.050] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 02/15/2019] [Accepted: 02/28/2019] [Indexed: 01/13/2023]
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Liver Transplantation. THE CRITICALLY ILL CIRRHOTIC PATIENT 2020. [PMCID: PMC7122092 DOI: 10.1007/978-3-030-24490-3_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The field of liver transplantation has changed since the MELD scoring system became the most widely used donor allocation tool. Due to the MELD-based allocation system, sicker patients with higher MELD scores are being transplanted. Persistent organ donor shortages remain a challenging issue, and as a result, the wait-list mortality is a persistent problem for most of the regions. This chapter focuses on deceased donor and live donor liver transplantation in patients with complications of portal hypertension. Special attention will also be placed on donor-recipient matching, perioperative management of transplant patients, and the impact of hepatic hemodynamics on transplantation.
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Fakhar N, Chavoshi Khamneh A, Najafi A, Sharifi A, Hyder Z, Salimi J. Impact of reperfusion with blood venting on liver transplantation outcomes; a prospective case-control study. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2020; 13:50-56. [PMID: 32190225 PMCID: PMC7069539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
AIM This study aimed to evaluate the impact of two different reperfusion techniques on outcomes of LT patients. BACKGROUND Post-reperfusion syndrome (PRS) during liver transplantation (LT) remains a serious issue for both the surgeon and anesthetist. METHODS In this prospective study, all liver transplant recipients referred to the liver transplantation department of Imam Khomeini Hospital, Tehran, Iran, from January 2016 to June 2017 were enrolled in the study and were divided into two groups of vented (reperfusion with 300cc blood venting) and non-vented (reperfusion without blood venting) cases. Then, 30-minute intraoperative hemodynamic and biochemical changes, as well as 2-month complications and 6-month mortality, were compared between the groups. RESULTS 57 LT cases (31 vented and 26 non-vented) were studied (50.9% female). The two groups had a similar age (p = 0.107), sex (p = 0.885), MELD score (p = 0.61), donor warm ischemic time (p = 0.85), recipient warm ischemic time (p = 0.36), cold ischemic time (p = 0.99), comorbid disease (p = 0.502), and etiology of end-stage liver disease (p = 0.281). PRS occurred in 3 (11.5%) patients in the vented group and 4 (12.9%) in the non-vented group (p = 0.69). One (3.8%) patient in the non-vented group and 4 (12.9%) patients in vented group died (p = 0.229). CONCLUSION Reperfusion with and without blood venting had the same outcome regarding intraoperative hemodynamic and biochemical changes, PRS rate, and postoperative complications, as well as 6-month survival. Thus, it seems that blood venting is not a necessary method for decreasing post-reperfusion complications following LT.
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Affiliation(s)
- Nasir Fakhar
- Liver Transplantation Research Centre, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Abdolhamid Chavoshi Khamneh
- Liver Transplantation Research Centre, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Atabac Najafi
- Liver Transplantation Research Centre, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Sharifi
- Liver Transplantation Research Centre, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran,General Surgery Department, Hamadan University of Medical Sciences, Hamedan, Iran
| | - Zeeshan Hyder
- Liver Transplantation Research Centre, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Javad Salimi
- Liver Transplantation Research Centre, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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Rosenfeld DM, Smith ML, Seamans DP, Giorgakis E, Gaitan BD, Khurmi N, Aqel BA, Reddy KS. Fatal diffuse pulmonary fat microemboli following reperfusion in liver transplantation with the use of marginal steatotic allografts. Am J Transplant 2019; 19:2640-2645. [PMID: 31012531 DOI: 10.1111/ajt.15399] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/29/2019] [Accepted: 04/18/2019] [Indexed: 01/25/2023]
Abstract
Organ shortage is a major cause of delayed liver transplantation and increased waitlist time. The level of donor steatosis is a significant determinant in organ selection. Scarcity of organs has led some programs to expand their acceptable criteria for the percentage of steatosis. We report two cases of liver transplantation of steatotic donor organs that resulted in mortality within hours from transplantation. Postmortem analysis showed evidence of diffuse pulmonary fat microemboli likely originating from the donor organ, with marked preservation reperfusion injury. The mechanism of diffuse fat microemboli in this setting and possible relationship to other perioperative syndromes (transfusion-related lung injury, acute kidney injury, and postreperfusion syndrome) is discussed.
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Affiliation(s)
- David M Rosenfeld
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona
| | - Maxwell L Smith
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Phoenix, Arizona
| | - David P Seamans
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona
| | - Emmanouil Giorgakis
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Brantley D Gaitan
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona
| | - Narjeet Khurmi
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona
| | - Bashar A Aqel
- Department of Medicine, Division of Transplant Hepatology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Kunam S Reddy
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic Arizona, Phoenix, Arizona
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Feltracco P, Barbieri S, Carollo C, Bortolato A, Michieletto E, Bertacco A, Gringeri E, Cillo U. Early circulatory complications in liver transplant patients. Transplant Rev (Orlando) 2019; 33:219-230. [PMID: 31327573 DOI: 10.1016/j.trre.2019.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/28/2019] [Accepted: 06/30/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Paolo Feltracco
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy.
| | - Stefania Barbieri
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Cristiana Carollo
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Andrea Bortolato
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Elisa Michieletto
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Alessandra Bertacco
- Hepatobiliary Surgery and Liver Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
| | - Enrico Gringeri
- Hepatobiliary Surgery and Liver Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
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Abstract
Liver transplantation (LTPL) is the only curative option for patients with end stage liver disease (ESLD) or with hepatocellular carcinoma (HCC). Eurotransplant in Leiden, the Netherlands, is responsible for organ allocation. The model of end stage liver disease (MELD) score, which describes the severity of the liver disease, is decisive for organ allocation. The heterogeneous patient collective and hepatic-related comorbidities and their dynamics represent challenges. The anesthesiologist is responsible for evaluating the overall prognosis, whereby cardiac, pulmonary, renal and neurological comorbidities must be taken into consideration. During LTPL surgery is divided into several stages. Besides volume management, heat preservation and coagulation management, major challenges for the anesthesiologist are hemodynamic stabilization and regulation of the acid-base balance.
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Dar WA, Sullivan E, Bynon JS, Eltzschig H, Ju C. Ischaemia reperfusion injury in liver transplantation: Cellular and molecular mechanisms. Liver Int 2019; 39:788-801. [PMID: 30843314 PMCID: PMC6483869 DOI: 10.1111/liv.14091] [Citation(s) in RCA: 215] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 02/13/2019] [Accepted: 02/22/2019] [Indexed: 12/11/2022]
Abstract
Liver disease causing end organ failure is a growing cause of mortality. In most cases, the only therapy is liver transplantation. However, liver transplantation is a complex undertaking and its success is dependent on a number of factors. In particular, liver transplantation is subject to the risks of ischaemia-reperfusion injury (IRI). Liver IRI has significant effects on the function of a liver after transplantation. The cellular and molecular mechanisms governing IRI in liver transplantation are numerous. They involve multiple cells types such as liver sinusoidal endothelial cells, hepatocytes, Kupffer cells, neutrophils and platelets acting via an interconnected network of molecular pathways such as activation of toll-like receptor signalling, alterations in micro-RNA expression, production of ROS, regulation of autophagy and activation of hypoxia-inducible factors. Interestingly, the cellular and molecular events in liver IRI can be correlated with clinical risk factors for IRI in liver transplantation such as donor organ steatosis, ischaemic times, donor age, and donor and recipient coagulopathy. Thus, understanding the relationship of the clinical risk factors for liver IRI to the cellular and molecular mechanisms that govern it is critical to higher levels of success after liver transplantation. This in turn will help in the discovery of therapeutics for IRI in liver transplantation - a process that will lead to improved outcomes for patients suffering from end-stage liver disease.
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Affiliation(s)
- Wasim A. Dar
- Department of Surgery, McGovern Medical School at UT Health, Houston, TX
| | - Elise Sullivan
- Department of Anesthesia, McGovern Medical School at UT Health, Houston, TX
| | - John S. Bynon
- Department of Surgery, McGovern Medical School at UT Health, Houston, TX
| | - Holger Eltzschig
- Department of Anesthesia, McGovern Medical School at UT Health, Houston, TX
| | - Cynthia Ju
- Department of Anesthesia, McGovern Medical School at UT Health, Houston, TX
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48
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Intraoperative anesthetic management of the liver transplant recipient with portopulmonary hypertension. Curr Opin Organ Transplant 2019; 24:121-130. [DOI: 10.1097/mot.0000000000000613] [Citation(s) in RCA: 3] [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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49
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Han JL, Beal EW, Mumtaz K, Washburn K, Black SM. Combined liver-lung transplantation: Indications, outcomes, current experience and ethical Issues. Transplant Rev (Orlando) 2019; 33:99-106. [DOI: 10.1016/j.trre.2018.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/14/2018] [Accepted: 11/15/2018] [Indexed: 01/29/2023]
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50
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Burlage LC, Hessels L, van Rijn R, Matton APM, Fujiyoshi M, van den Berg AP, Reyntjens KM, Meyer P, de Boer MT, de Kleine RHJ, Nijsten MW, Porte RJ. Opposite acute potassium and sodium shifts during transplantation of hypothermic machine perfused donor livers. Am J Transplant 2019; 19:1061-1071. [PMID: 30411502 PMCID: PMC6587472 DOI: 10.1111/ajt.15173] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 10/08/2018] [Accepted: 10/30/2018] [Indexed: 01/25/2023]
Abstract
Liver transplantation is frequently associated with hyperkalemia, especially after graft reperfusion. Dual hypothermic oxygenated machine perfusion (DHOPE) reduces ischemia/reperfusion injury and improves graft function, compared to conventional static cold storage (SCS). We examined the effect of DHOPE on ex situ and in vivo shifts of potassium and sodium. Potassium and sodium shifts were derived from balance measurements in a preclinical study of livers that underwent DHOPE (n = 6) or SCS alone (n = 9), followed by ex situ normothermic reperfusion. Similar measurements were performed in a clinical study of DHOPE-preserved livers (n = 10) and control livers that were transplanted after SCS only (n = 9). During DHOPE, preclinical and clinical livers released a mean of 17 ± 2 and 34 ± 6 mmol potassium and took up 25 ± 9 and 24 ± 14 mmol sodium, respectively. After subsequent normothermic reperfusion, DHOPE-preserved livers took up a mean of 19 ± 3 mmol potassium, while controls released 8 ± 5 mmol potassium. During liver transplantation, blood potassium levels decreased upon reperfusion of DHOPE-preserved livers while levels increased after reperfusion of SCS-preserved liver, delta potassium levels were -0.77 ± 0.20 vs. +0.64 ± 0.37 mmol/L, respectively (P = .002). While hyperkalemia is generally anticipated during transplantation of SCS-preserved livers, reperfusion of hypothermic machine perfused livers can lead to decreased blood potassium or even hypokalemia in the recipient.
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Affiliation(s)
- Laura C. Burlage
- Section of HPB Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands,Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Lara Hessels
- Department of Critical CareUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Rianne van Rijn
- Section of HPB Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands,Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Alix P. M. Matton
- Section of HPB Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands,Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Masato Fujiyoshi
- Section of HPB Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Aad P. van den Berg
- Department of Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Koen M.E.M. Reyntjens
- Department of AnesthesiologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Peter Meyer
- Department of AnesthesiologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Marieke T. de Boer
- Section of HPB Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Ruben H. J. de Kleine
- Section of HPB Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Maarten W. Nijsten
- Department of Critical CareUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Robert J. Porte
- Section of HPB Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
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