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Kim MJ, Lee DE, Kim JK, Yeo IH, Jung H, Kim JH, Jang TC, Lee SH, Park J, Kim D, Ryoo HW. Impact of the life-sustaining treatment decision act on organ donation in out-of-hospital cardiac arrests in South Korea: a multi-centre retrospective study. BMC Med Ethics 2024; 25:93. [PMID: 39223644 PMCID: PMC11367808 DOI: 10.1186/s12910-024-01090-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 08/20/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND The demand for organ transplants, both globally and in South Korea, substantially exceeds the supply, a situation that might have been aggravated by the enactment of the Life-Sustaining Treatment Decision Act (LSTDA) in February 2018. This legislation may influence emergency medical procedures and the availability of organs from brain-dead donors. This study aimed to assess LSTDA's impact, introduced in February 2018, on organ donation status in out-of-hospital cardiac arrest (OHCA) patients in a metropolitan city and identified related factors. METHODS We conducted a retrospective analysis of a regional cardiac arrest registry. This study included patients aged 16 or older with cardiac arrest and a cerebral performance category (CPC) score of 5 from January 2015 to December 2022. The exclusion criteria were CPC scores of 1-4, patients under 16 years, and patients declared dead or transferred from emergency departments. Logistic regression analysis was used to analyse factors affecting organ donation. RESULTS Of the 751 patients included in this study, 47 were organ donors, with a median age of 47 years. Before the LSTDA, there were 30 organ donations, which declined to 17 after its implementation. In the organ donation group, the causes of cardiac arrest included medical (34%), hanging (46.8%), and trauma (19.2%). The adjusted odds ratio for organ donation before the LSTDA implementation was 6.12 (95% CI 3.09-12.12), with non-medical aetiology as associated factors. CONCLUSION The enactment of the LSTDA in 2018 in South Korea may be linked to reduced organ donations among patients with OHCA, underscoring the need to re-evaluate the medical and legal aspects of organ donation, especially considering end-of-life care decisions.
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Affiliation(s)
- Min Jae Kim
- Department of Emergency Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Dong Eun Lee
- Department of Emergency Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea.
| | - Jong Kun Kim
- Department of Emergency Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - In Hwan Yeo
- Department of Emergency Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Haewon Jung
- Department of Emergency Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jung Ho Kim
- Department of Emergency Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Tae Chang Jang
- Department of Emergency Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Sang-Hun Lee
- Department of Emergency Medicine, Keimyung University Dongsan Medical Center School of Medicine, Daegu, Korea
| | - Jinwook Park
- Department of Emergency Medicine, Daegu Fatima hospital, Daegu, Korea
| | - Deokhyeon Kim
- Daegu Emergency Medicine Collaboration Committee, Daegu, Korea
| | - Hyun Wook Ryoo
- Department of Emergency Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
- Daegu Emergency Medicine Collaboration Committee, Daegu, Korea
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Yoon JA, You Y, Park JS, Min JH, Jeong W, Ahn HJ, Jeon SY, Kim D, Kang C. Checkpoint for Considering Interleukin-6 as a Potential Target to Mitigate Secondary Brain Injury after Cardiac Arrest. Brain Sci 2024; 14:779. [PMID: 39199472 PMCID: PMC11353038 DOI: 10.3390/brainsci14080779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 07/19/2024] [Accepted: 07/26/2024] [Indexed: 09/01/2024] Open
Abstract
Interleukin-6 (IL-6) was suggested as a potential target for intervention to mitigate brain injury. However, its neuro-protective effect in post-resuscitation care has not been proven. We investigated the time-course of changes in IL-6 and its association with other markers (systemic inflammation and myocardial and neuronal injury), according to the injury severity of the cardiac arrest. This retrospective study analyzed IL-6 and other markers at baseline and 24, 48, and 72 h after the return of spontaneous circulation. The primary outcome was the association of IL-6 with injury severity as assessed using the revised Post-Cardiac Arrest Syndrome for Therapeutic Hypothermia scoring system (low, moderate, and high severity). Of 111 patients, 22 (19.8%), 61 (55.0%), and 28 (25.2%) had low-, moderate-, and high-severity scores, respectively. IL-6 levels were significantly lower in the low-severity group than in the moderate- and high-severity groups at baseline and at 24 h and 72 h (p < 0.005). While IL-6 was not independently associated with neuronal injury markers in the low-severity group, it was demonstrated to be associated with it in the moderate-severity (β [95% CI] = 4.3 [0.1-8.6], R2 = 0.11) and high-severity (β [95% CI] = 7.9 [3.4-12.5], R2 = 0.14) groups. IL-6 exhibits distinct patterns across severity and shows differential associations with systemic inflammation or neuronal injury.
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Affiliation(s)
- Jung A Yoon
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea; (J.A.Y.); (Y.Y.); (J.S.P.); (W.J.); (H.J.A.); (S.Y.J.)
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea; (J.A.Y.); (Y.Y.); (J.S.P.); (W.J.); (H.J.A.); (S.Y.J.)
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Republic of Korea;
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea; (J.A.Y.); (Y.Y.); (J.S.P.); (W.J.); (H.J.A.); (S.Y.J.)
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Republic of Korea;
| | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Republic of Korea;
- Department of Emergency Medicine, Chungnam National University Sejong Hospital, 20, Bodeum 7-ro, Sejong 30099, Republic of Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea; (J.A.Y.); (Y.Y.); (J.S.P.); (W.J.); (H.J.A.); (S.Y.J.)
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Republic of Korea;
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea; (J.A.Y.); (Y.Y.); (J.S.P.); (W.J.); (H.J.A.); (S.Y.J.)
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Republic of Korea;
| | - So Young Jeon
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea; (J.A.Y.); (Y.Y.); (J.S.P.); (W.J.); (H.J.A.); (S.Y.J.)
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Republic of Korea;
| | - Dongha Kim
- Department of Statistics, Sungshin Women’s University, 2, Bomun-ro, Seongbuk-gu, Seoul 02844, Republic of Korea;
| | - Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea; (J.A.Y.); (Y.Y.); (J.S.P.); (W.J.); (H.J.A.); (S.Y.J.)
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Republic of Korea;
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Jeon J, Song Y, Yu JY, Jung W, Lee K, Lee JE, Huh W, Cha WC, Jang HR. Prediction of post-donation renal function using machine learning techniques and conventional regression models in living kidney donors. J Nephrol 2024:10.1007/s40620-024-02027-1. [PMID: 39073700 DOI: 10.1007/s40620-024-02027-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 06/30/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Accurate prediction of renal function following kidney donation and careful selection of living donors are essential for living-kidney donation programs. We aimed to develop a prediction model for post-donation renal function following living kidney donation using machine learning. METHODS This retrospective cohort study was conducted with 823 living kidney donors between 2009 and 2020. The dataset was randomly split into training (80%) and test sets (20%). The main outcome was the post-donation estimated glomerular filtration rate (eGFR) 12 months after nephrectomy. We compared the performance of machine learning techniques, traditional regression models, and models from previous studies. The best-performing model was selected based on the mean absolute error (MAE) and root mean square error (RMSE). RESULTS The mean age of the participants was 45.2 ± 12.3 years, and 48.4% were males. The mean pre-donation and post-donation eGFRs were 101.3 ± 13.0 and 68.8 ± 12.7 mL/min/1.73 m2, respectively. The XGBoost model with the eGFR, age, serum creatinine, 24-h urine creatinine, 24-h urine sodium, creatinine clearance, cystatin C, cystatin C-based eGFR, computed tomography volume of the remaining kidney/body weight, normalized GFR of the remaining kidney measured through a diethylenetriaminepentaacetic acid scan, and sex, showed the best performance with a mean absolute error of 6.23 and root mean square error of 8.06. An easy-to-use web application titled Kidney Donation with Nephrologic Intelligence (KDNI) was developed. CONCLUSIONS The prediction model using XGBoost accurately predicted the post-donation eGFR after living kidney donation. This model can be applied in clinical practice using KDNI, the developed web application.
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Affiliation(s)
- Junseok Jeon
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yeejun Song
- Department of Digital Health, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, South Korea
- Smart Health Lab, Research Institute of Future Medicine, Samsung Medical Center, Seoul, South Korea
| | - Jae Yong Yu
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, South Korea
| | - Weon Jung
- Smart Health Lab, Research Institute of Future Medicine, Samsung Medical Center, Seoul, South Korea
| | - Kyungho Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jung Eun Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Wooseong Huh
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Won Chul Cha
- Department of Digital Health, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, South Korea.
- Smart Health Lab, Research Institute of Future Medicine, Samsung Medical Center, Seoul, South Korea.
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Hye Ryoun Jang
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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Park JS, Kim EY, You Y, Min JH, Jeong W, Ahn HJ, In YN, Lee IH, Kim JM, Kang C. Combination strategy for prognostication in patients undergoing post-resuscitation care after cardiac arrest. Sci Rep 2023; 13:21880. [PMID: 38072906 PMCID: PMC10711008 DOI: 10.1038/s41598-023-49345-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 12/07/2023] [Indexed: 12/18/2023] Open
Abstract
This study investigated the prognostic performance of combination strategies using a multimodal approach in patients treated after cardiac arrest. Prospectively collected registry data were used for this retrospective analysis. Poor outcome was defined as a cerebral performance category of 3-5 at 6 months. Predictors of poor outcome were absence of ocular reflexes (PR/CR) without confounding factors, a highly malignant pattern on the most recent electroencephalography, defined as suppressed background with or without periodic discharges and burst-suppression, high neuron-specific enolase (NSE) after 48 h, and diffuse injury on imaging studies (computed tomography or diffusion-weighted imaging [DWI]) at 72-96 h. The prognostic performances for poor outcomes were analyzed for sensitivity and specificity. A total of 130 patients were included in the analysis. Of these, 68 (52.3%) patients had poor outcomes. The best prognostic performance was observed with the combination of absent PR/CR, high NSE, and diffuse injury on DWI [91.2%, 95% confidence interval (CI) 80.7-97.1], whereas the combination strategy of all available predictors did not improve prognostic performance (87.8%, 95% CI 73.8-95.9). Combining three of the predictors may improve prognostic performance and be more efficient than adding all tests indiscriminately, given limited medical resources.
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Affiliation(s)
- Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Eun Young Kim
- Department of Neurology, Chungnam National University Sejong Hospital, 20, Bodeum 7-ro, Sejong, Republic of Korea
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Yong Nam In
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - In Ho Lee
- Department of Radiology, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
- Department of Radiology, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Jae Moon Kim
- Department of Neurology, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea.
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea.
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Jeon J, Yu JY, Song Y, Jung W, Lee K, Lee JE, Huh W, Cha WC, Jang HR. Prediction tool for renal adaptation after living kidney donation using interpretable machine learning. Front Med (Lausanne) 2023; 10:1222973. [PMID: 37521345 PMCID: PMC10375292 DOI: 10.3389/fmed.2023.1222973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/22/2023] [Indexed: 08/01/2023] Open
Abstract
Introduction Post-donation renal outcomes are a crucial issue for living kidney donors considering young donors' high life expectancy and elderly donors' comorbidities that affect kidney function. We developed a prediction model for renal adaptation after living kidney donation using interpretable machine learning. Methods The study included 823 living kidney donors who underwent nephrectomy in 2009-2020. AutoScore, a machine learning-based score generator, was used to develop a prediction model. Fair and good renal adaptation were defined as post-donation estimated glomerular filtration rate (eGFR) of ≥ 60 mL/min/1.73 m2 and ≥ 65% of the pre-donation values, respectively. Results The mean age was 45.2 years; 51.6% were female. The model included pre-donation demographic and laboratory variables, GFR measured by diethylenetriamine pentaacetate scan, and computed tomography kidney volume/body weight of both kidneys and the remaining kidney. The areas under the receiver operating characteristic curve were 0.846 (95% confidence interval, 0.762-0.930) and 0.626 (0.541-0.712), while the areas under the precision-recall curve were 0.965 (0.944-0.978) and 0.709 (0.647-0.788) for fair and good renal adaptation, respectively. An interactive clinical decision support system was developed. Conclusion The prediction tool for post-donation renal adaptation showed good predictive capability and may help clinical decisions through an easy-to-use web-based application.
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Affiliation(s)
- Junseok Jeon
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Yong Yu
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yeejun Song
- Department of Digital Health, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea
- Smart Health Lab, Research Institute of Future Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Weon Jung
- Smart Health Lab, Research Institute of Future Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Kyungho Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung Eun Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Wooseong Huh
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Won Chul Cha
- Department of Digital Health, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hye Ryoun Jang
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Park SY, Kim H, Park KH, Park SM, Lee DE, Jung YH, Jeong W, Park KH. Exploring the experiences and perspectives of emergency physicians on brain death organ tissue donation after the Life-Sustaining Treatment Decision Act. KOREAN JOURNAL OF TRANSPLANTATION 2022; 36:29-36. [PMID: 35769432 PMCID: PMC9235530 DOI: 10.4285/kjt.22.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/03/2022] [Accepted: 03/22/2022] [Indexed: 12/03/2022] Open
Abstract
Background This study explored emergency physicians' experiences and perspectives related to brain death organ tissue donation (OTD) after the enforcement of the Life-Sustaining Treatment (LST) Decision Act in Korea. Methods Using the Braun and Clarke thematic analysis method, this qualitative study analyzed interview data-comprising experiences and perspectives of brain death OTD since the LST Decision Act-of 10 emergency physicians who specialized in targeted temperature management (TTM) and cared for post-cardiac arrest patients. Results Data analysis revealed 13 subthemes and 5 themes the LST Decision Act is easier to explain to family members than brain death OTD, but it does not fit well in an emergency medical setting; many family members decide to stop LST even before physicians mention brain death or OTD; family members view stopping LST as being about comforting patients without bothering them, and decision-makers are therefore no longer willing to choose OTD; stopping LST does not always result in brain death, but cases of brain death are preceded by stopping LST; and since the LST Decision Act, the number of TTM cases and potential brain death donors has decreased. Conclusions Unless a supplementary policy that connects stopping LST to brain death OTD is prepared, the withdrawal of LST in patients resuscitated after cardiac arrest is expected to continue, and brain death OTD is expected to decrease.
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Affiliation(s)
- Song Yi Park
- Department of Emergency Medicine, Dong-A University College of Medicine, Busan, Korea
- Department of Medical Education, Dong-A University College of Medicine, Busan, Korea
| | - Hyun Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kwi Hwa Park
- Department of Medical Education, Gachon University College of Medicine, Incheon, Korea
| | - Seung Min Park
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Dong Eun Lee
- Department of Emergency Medicine, Kyungpook National University Chilgok Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yong Hun Jung
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Kyung Hye Park
- Department of Medical Education, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Emergency Medicine, Wonju Severance Christian Hospital, Wonju, Korea
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Yang G, Hwang S, Ahn CS, Ha TY, Jung DH. Clinical sequence of an adult recipient undergone split liver transplantation using a right liver graft with erroneous deprivation of the middle hepatic vein trunk: a case report. KOREAN JOURNAL OF TRANSPLANTATION 2021; 35:189-194. [PMID: 35769249 PMCID: PMC9235449 DOI: 10.4285/kjt.21.0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 11/23/2022] Open
Abstract
The anatomy of middle hepatic vein (MHV) varies widely, and some individuals have aberrant MHV anatomy, thus there is risk of iatrogenic damage to graft MHV during liver splitting. We present the clinical sequences of an adult recipient who received a split right liver graft with erroneous deprivation of the MHV trunk. This is the case was a 58-year-old male patient with hepatitis B virus-associated liver cirrhosis who suffered from hepatic encephalopathy. The split right liver graft had a graft-to-recipient weight ratio of 2.1%. Soon after graft reperfusion, large-sized hepatic venous congestion (HVC) appeared at the graft liver surface, indicating lack of MHV drainage. The amount of HVC was approximately 20% of the right liver graft mass at day 1, which had gradually reduced on follow-up computed tomography (CT) scans. Although liver function recovered progressively, the patient remained bed-ridden because of pre-existing hypoxic brain damage. The patient passed away 4 years after transplantation because of pneumonia and multi-organ failure. The present case implies that there is some possibility of unrecognized damage to the graft MHV during liver splitting, suggesting the necessity of preoperative donor abdomen CT scan and preparation of intraoperative ultrasonography for easy evaluation of graft liver MHV anatomy.
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Affiliation(s)
- Geunhyeok Yang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Chung YK, Hwang S, Ahn CS, Kim KH, Moon DB, Ha TY, Song GW, Jung DH, Park GC, Yoon YI, Kang WH, Cho HD, Choi JU, Kim M, Kim SH, Na BG, Lee SG. Fates of retained hepatic segment IV and its prognostic impact in adult split liver transplantation using an extended right liver graft. Ann Surg Treat Res 2021; 101:37-48. [PMID: 34235115 PMCID: PMC8255581 DOI: 10.4174/astr.2021.101.1.37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 03/30/2021] [Accepted: 04/18/2021] [Indexed: 12/16/2022] Open
Abstract
PURPOSE When splitting a liver for adult and pediatric graft recipients, the retained left medial section (S4) will undergo ischemic necrosis and the right trisection graft becomes an extended right liver (ERL) graft. We investigated the fates of the retained S4 and its prognostic impact in adult split liver transplantation (SLT) using an ERL graft. METHODS This was a retrospective analysis of 25 adult SLT recipients who received split ERL grafts. RESULTS The mean model for end-stage liver disease (MELD) score was 27.3 ± 10.9 and graft-recipient weight ratio (GRWR) was 1.98 ± 0.44. The mean donor age was 26.5 ± 7.7 years. The split ERL graft weight was 1,181.5 ± 252.8 g, which resulted in a mean GRWR of 1.98 ± 0.44. Computed tomography of the retained S4 parenchyma revealed small ischemic necrosis in 16 patients (64.0%) and large ischemic necrosis in the remaining 9 patients (36.0%). No S4-associated biliary complications were developed. The mean GRWR was 1.87 ± 0.43 in the 9 patients with large ischemic necrosis and 2.10 ± 0.44 in the 15 cases with small ischemic necrosis (P = 0.283). The retained S4 parenchyma showed gradual atrophy on follow-up imaging studies. The amount of S4 ischemic necrosis was not associated with graft (P = 0.592) or patient (P = 0.243) survival. A MELD score of >30 and pretransplant ventilator support were associated with inferior outcomes. CONCLUSION The amount of S4 ischemic necrosis is not a prognostic factor in adult SLT recipients, probably due to a sufficiently large GRWR.
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Affiliation(s)
- Yong-Kyu Chung
- Department of Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-In Yoon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo-Hyoung Kang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwui-Dong Cho
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Uk Choi
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Minjae Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Hoon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byeong-Gon Na
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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9
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Park B, Yoon J, Kim HJ, Jung YK, Lee KG, Choi D. Transfusion Status in Liver and Kidney Transplantation Recipients-Results from Nationwide Claims Database. J Clin Med 2020; 9:E3613. [PMID: 33182639 PMCID: PMC7697733 DOI: 10.3390/jcm9113613] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND This study analyzed the status and trends of transfusion and its associated factors among liver and kidney transplantation recipients. METHODS A total of 10,858 and 16,191 naïve liver or kidney transplantation recipients from 2008 to 2017 were identified through the National Health Insurance Service database. The prescription code for transfusion and the presence, number, and amount of each type of transfusion were noted. The odds ratios and 95% confidence intervals were determined to identify significant differences in transfusion and blood components by liver and kidney transplantation recipient characteristics. RESULTS In this study, 96.4% of liver recipients and 59.7% of kidney recipients received transfusions related to the transplantation operation, mostly platelet and fresh frozen plasma. Higher perioperative transfusion in women and declining transfusion rates from 2008 to 2017 were observed in both liver and kidney recipients. In liver recipients, the transfusion rate in those who received organs from deceased donors was much higher than that in those who received organs from living donors; however, the mortality rate according to transfusion was higher only in recipients of deceased donor organs. In kidney recipients, a higher mortality rate was observed in those receiving transfusion than that in patients without transfusion. CONCLUSIONS In Korea, the transfusion rates in liver and kidney recipients were relatively higher than those in other countries. Sociodemographic factors, especially sex and year of transplantation, were associated with transfusion in solid organ recipients, possibly as surrogates for other causal clinical factors.
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Affiliation(s)
- Boyoung Park
- Department of Medicine, College of Medicine, Hanyang University, Seoul 04763, Korea;
| | - Junghyun Yoon
- Graduate School of Public Health, Hanyang University, Seoul 04763, Korea;
| | - Han Joon Kim
- Department of Surgery, College of Medicine, Hanyang University, Seoul 04763, Korea; (H.J.K.); (Y.K.J.); (K.G.L.)
| | - Yun Kyung Jung
- Department of Surgery, College of Medicine, Hanyang University, Seoul 04763, Korea; (H.J.K.); (Y.K.J.); (K.G.L.)
- Hanyang ICT Fusion Medical Research Center, Seoul 04763, Korea
| | - Kyeong Geun Lee
- Department of Surgery, College of Medicine, Hanyang University, Seoul 04763, Korea; (H.J.K.); (Y.K.J.); (K.G.L.)
| | - Dongho Choi
- Department of Surgery, College of Medicine, Hanyang University, Seoul 04763, Korea; (H.J.K.); (Y.K.J.); (K.G.L.)
- Hanyang ICT Fusion Medical Research Center, Seoul 04763, Korea
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10
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Kim IC, Youn JC, Lee SE, Jung SH, Kim JJ. Donor Heart Utilization in Korea. INTERNATIONAL JOURNAL OF HEART FAILURE 2020; 2:254-263. [PMID: 36262172 PMCID: PMC9536728 DOI: 10.36628/ijhf.2020.0011] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/18/2020] [Accepted: 04/21/2020] [Indexed: 11/23/2022]
Abstract
Background and Objectives Donor heart utilization patterns in Korea are not well known. We aimed to analyze the current utilization rate of donor heart and to evaluate the reason for non-utilization in Korea. Methods Brain death donors were identified from the Korean Network for Organ Sharing registry from November 2009 to December 2019. Baseline characteristics and heart transplant related parameters were compared between transplanted and discarded donor hearts. Results Among 4,401 donors, 1,383 (31.4%) hearts were utilized. Hearts from younger, male donors without history of hypertension or diabetes mellitus were utilized more frequently. The most common blood type in the transplanted group was O, while blood type A was the most common blood type in the discarded group. The ejection fraction in the discarded group were significantly lower (57.0 ± 13.5% vs. 61.7 ± 7.0%, p<0.001). Reasons for non-utilization were as follows: medical condition (34.4%), old age (31.8%), refused by all candidates (22.5%), refused to donate (11.0%), and others (0.2%). The most common cause of brain death was cerebrovascular disease in both the transplanted and discarded groups, but the incidence was significantly higher in the discarded group (46.8% vs. 37.5%, p<0.001). In multivariate analysis, old age, small body surface area, rapid heart rate, blood type other than O, abnormal echocardiography findings were independent predictors for non-utilization. Conclusions Average donor heart utilization rate was 31.4% and it improved to 42.9% in 2019. However, substantial numbers of donor hearts are still discarded. A strategic approach to improve donor heart utilization is necessary.
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Affiliation(s)
- In-Cheol Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University College of Medicine, Daegu, Korea
| | - Jong-Chan Youn
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Eun Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Joong Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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11
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Kim YS, Kim DH, Yang TW, Kim M, Lee J, Cho W, Kwon OY. Factors Affecting the Time Taken to Determine Brain Death in Patients with Impending Brain Death. J Clin Neurol 2020; 16:668-673. [PMID: 33029974 PMCID: PMC7541988 DOI: 10.3988/jcn.2020.16.4.668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND PURPOSE The increased demand for donor organs has made it crucial to keep the organs of patients with impending brain death (PWIBDs) suitable for transplantation during the process of determining brain death. This study aimed to identify the time taken to determine brain death (TT-BD) in PWIBDs and the associated influencing factors. METHODS This study analyzed data collected by the Korean Organ Donation Agency from 15 hospitals in the Yeongnam region of South Korea. There were 414 PWIBDs eligible for inclusion in this study. The data consisted of the TT-BD for PWIBDs and the potential variables influencing the TT-BD. RESULTS The mean age of the 414 PWIBDs was 48.9 years, and 120 of them were female (29.0%). The mean TT-BD was 8.5 days. The presence of spontaneous movements (SMs) and craniotomy significantly affected the TT-BD. The mean TT-BDs were 13.9 and 8.2 days in the PWIBDs with and without SMs, respectively, and 9.8 and 8.0 days in the PWIBDs with and without craniotomy, respectively. CONCLUSIONS The SMs in PWIBDs and a craniotomy performed immediately before starting the process of determining brain death seem to be related to lengthening the TT-BD.
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Affiliation(s)
- Young Soo Kim
- Department of Neurology, Gyeongsang National University Hospital, Jinju, Korea
| | - Do Hyung Kim
- Department of Neurology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Tae Won Yang
- Department of Neurology, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Minhwa Kim
- Korea Organ Donation Agency, Seoul, Korea
| | | | | | - Oh Young Kwon
- Department of Neurology, Gyeongsang National University Hospital, Jinju, Korea
- Department of Neurology, Gyeongsang National University College of Medicine, Jinju, Korea
- Gyeongsang Institute of Health Science, Gyeongsang National University College of Medicine, Jinju, Korea.
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12
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Park GC, Hwang S, Song GW, Jung DH, Ha TY, Ahn CS, Moon DB, Kim KH, Yoon YI, Kang WH, Cho HD, Choi JU, Kim M, Na BG, Kim SH, Lee SG. Prognosis of Split Liver Transplantation Compared with Whole Liver Transplantation in Adult Patients: Single-center Results under the Korean MELD Score-based Allocation Policy. J Korean Med Sci 2020; 35:e304. [PMID: 32959541 PMCID: PMC7505731 DOI: 10.3346/jkms.2020.35.e304] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 07/21/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Split liver transplantation (SLT) has been occasionally performed in Korea. This study compared the incidence and prognosis of SLT with whole liver transplantation (WLT) in adult patients. METHODS Between June 2016 and November 2019, 242 adult patients underwent a total of 256 deceased donor liver transplantation operations. SLT was performed in 7 patients (2.9%). RESULTS The mean age of SLT donors was 29.7 ± 7.4 years, and the mean age of recipients was 55.7 ± 10.6 years, with the latter having a mean model for end-stage liver disease score of 34.6 ± 3.1. Mean split right liver graft weight was 1,228.6 ± 149.7 g and mean graft-recipient weight ratio was 1.97 ± 0.39. Of the seven SLT recipients, Korean Network for Organ Sharing (KONOS) status was one in status 1, one in status 2 and five in status 3. The graft (P = 0.72) and patient (P = 0.84) survival rates were comparable in the SLT and WLT groups. Following propensity score matching, graft (P = 0.61) and patient (P = 0.91) survival rates remained comparable in the two groups. Univariate analysis showed that pretransplant ventilator support and renal replacement therapy were significantly associated with patient survival, whereas KONOS status category and primary liver diseases were not. Multivariate analysis showed that pretransplant ventilator support was an independent risk factor for patient survival. CONCLUSION Survival outcomes were similar in adult SLT and WLT recipients, probably due to selection of high-quality grafts and low-risk recipients. Prudent selection of donors and adult recipients for SLT may expand the liver graft pool for pediatric patients without affecting outcomes in adults undergoing SLT.
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Affiliation(s)
- Gil Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Gi Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Yong Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul Soo Ahn
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo Hyoung Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwui Dong Cho
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Uk Choi
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Minjae Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byeong Gon Na
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Hoon Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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13
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Kim MJ, Hwang S, Jung DH, Park GC, Song GW, Cho HD, Lee SG. Reuse of liver allograft from a brain-dead recipient: A case report. Ann Hepatobiliary Pancreat Surg 2020; 24:192-197. [PMID: 32457266 PMCID: PMC7271115 DOI: 10.14701/ahbps.2020.24.2.192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 03/24/2020] [Accepted: 03/25/2020] [Indexed: 11/25/2022] Open
Abstract
We report our first case of deceased-donor liver transplantation (LT) using a reuse liver graft after the first LT. The recipient was a 38-year-old female with fulminant hepatic failure from toxic hepatitis. She had a history of herb intake and her liver function deteriorated progressively. She was enrolled as the Korean Network for Organ Sharing (KONOS) status 1 and the model for end-stage liver disease score was 34. The donor was a 42-year-old male patient who fell into brain death after LT for alcoholic liver cirrhosis. Donation of multiple organs including the transplanted liver graft was performed 10 days after the first LT operation. Since the liver graft appeared to be normal and frozen-section liver biopsy showed only mild fatty changes, we decided to reuse the liver graft. A modified piggy-back technique of the suprahepatic inferior vena cava reconstruction was used. Other surgical procedures were comparable to the standard deceased-donor LT procedures. The explant liver pathology revealed submassive hepatic necrosis, which was compatible with toxic hepatitis. The peak of serum liver enzyme levels were aspartate transaminase 1,063 IU/L and alanine transaminase 512 IU/L at posttransplant day 3. Since the pretransplant general condition of the recipient was very poor, hospital stay was prolonged and she was discharged 51 days after LT operation. She is currently doing well for 3 years to date. Experience in our case and the literature review suggest that a reuse liver graft can be regarded as one of the marginal grafts which can be transplantable to the LT candidates requiring urgent LT.
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Affiliation(s)
- Min-Jae Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwui-Dong Cho
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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