Surgical Procedures in Patients Awaiting Liver Transplantation: Complications and Impact on the Liver Function

BACKGROUND

Potential indications for surgery frequently arise in patients awaiting liver transplantation. There is a risk of hepatic decompensation and death triggered by surgical trauma, but this has not been studied in detail in this unique population. We aimed to quantify the impact of surgical interventions in patients awaiting liver transplantation on hepatic function and identify risk factors for decompensation.

METHODS

All surgeries between 2000 and 2018 in patients awaiting liver transplantation in a highvolume German liver transplant center were analyzed retrospectively. Change in liver function measured as indicated by MELD score was assessed and complication rates recorded. The primary endpoint was a composite of an increase in MELD score by > 5 points or death. A logistic regression model was used for multivariate analysis to identify risk factors.

RESULTS

In total, 177 surgical procedures in 148 patients were analyzed. The primary endpoint was reached in 42 cases (23.7%). The overall in-hospital complication rate (including death) was 44.1%. Multivariate analysis identified elevated leukocyte count, perioperative blood transfusion, preoperative presence of ascites, and preoperative circulatory support as independent risk factors for a decline in liver function or death.

CONCLUSION

Surgery in patients awaiting liver transplantation carries a relevant risk of hepatic decompensation and death that needs to be considered when deciding whether to perform elective surgery prior to or defer until after liver transplantation.

COVID-19 and stroke: A review

COVID-19 patients have presented with a wide range of neurological disorders, among which stroke is the most devastating. We have reviewed current studies, case series, and case reports with a focus on COVID-19 patients complicated with stroke, and presented the current understanding of stroke in this patient population. As evidenced by increased D-dimer, fibrinogen, factor VIII and von Willebrand factor, SARS-CoV-2 infection induces coagulopathy, disrupts endothelial function, and promotes hypercoagulative state. Collectively, it predisposes patients to cerebrovascular events. Additionally, due to the unprecedented strain on the healthcare system, stroke care has been inevitably compromised. The underlying mechanism between COVID-19 and stroke warrants further study, so does the development of an effective therapeutic or preventive intervention.

A comprehensive multi-directional exploration of phytochemicals and bioactivities of flower extracts from Delonix regia (Bojer ex Hook.) Raf., Cassia fistula L. and Lagerstroemia speciosa L

Delonix regia (Bojer ex Hook.) Raf., Cassia fistula L. and Lagerstroemia speciosa L. are three ornamental plants that produce colorful flowers. The present study aimed to evaluate the phytochemicals and bioactivities of methanolic extracts of flowers from Delonix regia (DrFME), Cassia fistula (CfFME), and Lagerstroemia speciosa (LsFME). The presence of ten different chemical classes in varying degrees was confirmed while qualitatively screened. During quantitative determination, LsFME possesses the highest amount of total phenolic (418.0 mg/g), flavonoid (50.8 mg/g), and tannin (256.3 mg/g) contents. The extracts showed excellent antioxidant capacity in a concentration-dependent manner with the lowest IC50 value (41.51 μg/mL) displayed by LsFME. LsFME paralyzed the experimental worms at 2.95 min and killed at 3.96 min. DrFME was found to be more effective in thrombolytic (35.5% clot lysis) and anticoagulant activities. Negligible hemolytic activity (IC50 > 200 μg/mL) found for all extracts which suggest their less potential toxicity. The in vivo experiments revealed that the CfFME has the highest analgesic (64.34% pain inhibition) activity while LsFME has the highest antidiarrheal (70.27% inhibition) and antihyperglycemic (46.94% inhibition) activities at 400 mg/kg of body weight doses. This study has shown the presence of phytochemicals and potential bioactivities which indicates the possibility of these flowers to be used as a source of phytochemicals as well as safe and effective natural medicine.

Performance of 6 routine coagulation assays on the new Roche Cobas t711 analyzer

Objectives

For new analyzers or tests, analytical evaluation is required before implementation in the clinical laboratory. We evaluated the novel Roche Cobas t711 analyzer with six newly developed coagulation assays: the activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalized ratio (INR), fibrinogen, d-dimer and anti-Xa. The evaluation included imprecision experiments, method comparison with the currently used Stago STA-R Evolution, monitoring of unfractionated heparin (UFH) with aPTT, a fast centrifugation protocol to improve turn-around time, and determination of sample stability in whole blood and plasma.

Design and methods

Imprecision and method comparison were assessed using commercial quality control samples and patient samples, respectively. For dose monitoring of UFH with the aPTT, samples from patients treated with UFH were used. Samples from healthy volunteers were collected for evaluation of the fast centrifugation protocol (5’ 2750×g) and for investigating sample stability over 6–8 h.

Results

Results for between-run precision were within the desirable specification. Method comparison showed an excellent agreement for fibrinogen, d-dimer and anti-Xa. For aPTT, PT and INR, a good correlation was found, but results were significantly lower on the t711 compared to the STA-R Evolution, which is caused by different coagulation activators. Results from the fast centrifugation protocol differed not significantly from the standard protocol (15’ 2500×g). Blood and plasma samples were stable at room temperature up to 6 and 8 h, respectively.

Conclusions

The t711 coagulation analyzer with 6 novel tests is suitable for routine use in clinical laboratories.

Sudden onset abdominal wall swellings in patient of liver cirrhosis

Spontaneous hematomas in cirrhotic patients are uncommon. Severe coagulopathy in advanced hepatic disease is characterized by both coagulation factor deficiencies and accelerated fibrinolysis. Hyperfibrinolysis in cirrhosis is a result of excess fibrin breakdown leading to defective hemostasis. We present a case of spontaneous hematomas with an acute drop in hemoglobin level, in a patient with cirrhosis which was due to primary hyperfibrinolysis.