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Pagano D, Toniutto P, Burra P, Gruttadauria S, Vella R, Martini S, Morelli MC, Svegliati-Baroni G, Marrone G, Ponziani FR, Caraceni P, Angeli P, Calvaruso V, Giannelli V. Perioperative administration of albumin in adult patients undergoing liver transplantation: A systematic review. Dig Liver Dis 2025; 57:819-826. [PMID: 39645428 DOI: 10.1016/j.dld.2024.11.006] [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: 06/12/2024] [Revised: 11/08/2024] [Accepted: 11/14/2024] [Indexed: 12/09/2024]
Abstract
Hypoalbuminemia is a risk factor for mortality in patients with end-stage liver disease (ESLD) and in those undergoing orthotopic liver transplantation (OLT), since it represents a biomarker of post-operative delayed functional recovery of the graft. Despite albumin infusion during and after OLT is frequently adopted in recipients with hypoalbuminemia, it remains unclear whether this procedure could improve post OLT clinical outcomes. Observational studies indicated that treatment with albumin after OLT might be beneficial in reducing ascites and acute kidney injury (AKI) development. However, considering potential complications and the cost of albumin therapy, the decision to use albumin after OLT should be based on careful consideration of patient's individual needs and risks. In addition, the threshold plasma value of albumin below which it could be clinically useful to infuse albumin has not been clearly defined. This systematic review, prepared in accordance with the PRISMA 2020 guidelines, aimed to assess the efficacy of albumin infusion in patients undergoing OLT, in the prevention or treatment of ascites, AKI, and ischemia reperfusion syndrome, as well as its potential impact on patient survival. Furthermore, this review aimed to illustrate the pathophysiological bases justifying the use of albumin infusion in a subset of patients receiving OLT.
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Affiliation(s)
- Duilio Pagano
- Department for the Treatment and the Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneoper i Trapianti e Terapie ad alta specializzazione), UPMCI (University of Pittsburgh Medical Center Italy), Palermo, Italy
| | - Pierluigi Toniutto
- Hepatology and Liver Transplantation Unit, Azienda Ospedaliero Universitaria, University of Udine 33100, Udine, Italy.
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale-Università Padova, Department of Surgery, Oncology and Gastroenterology, University of Padova 35122, Padova, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and the Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneoper i Trapianti e Terapie ad alta specializzazione), UPMCI (University of Pittsburgh Medical Center Italy) Palermo, Italy; University of Catania, Catania, Italy
| | - Roberta Vella
- Department for the Treatment and the Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneoper i Trapianti e Terapie ad alta specializzazione), UPMCI (University of Pittsburgh Medical Center Italy) Palermo, Italy; Department of Precision Medicine in the Medical, Surgical and Critical Care Area University of Palermo, Palermo, Italy
| | - Silvia Martini
- Gastrohepatology Unit, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Maria Cristina Morelli
- RCCS Azienda Ospedaliero-Universitaria di Bologna, Internal Medicine Unit for the treatment of Severe Organ Failure, Bologna, Italy
| | | | - Giuseppe Marrone
- Liver Transplant Medicine Unit, Fondazione Policlinico Universitario Gemelli, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesca Romana Ponziani
- Hepatology Unit, CEMAD Centro Malattie dell'Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy; Unit of Semeiotics, IRCCS AOU Bologna, Bologna, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Vincenza Calvaruso
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo 90127 Palermo, Italy
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2
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Uasuwannakul A, Lertudomphonwanit C, Anantasit N, Tanpowpong P, Getsuwan S, Thirapattaraphan C, Treepongkaruna S. Postoperative hypoalbuminemia and outcomes of pediatric liver transplantation. BMC Pediatr 2024; 24:392. [PMID: 38867183 PMCID: PMC11167898 DOI: 10.1186/s12887-024-04831-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 05/13/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND Hypoalbuminemia after liver transplantation (LT) is associated with acute kidney injury (AKI) and poor outcomes in adult LT recipients. This study was performed to examine the association between the postoperative serum albumin level and early postoperative outcomes of LT in children. METHODS This single-center retrospective review involved pediatric LT recipients (0-18 years old) treated from January 2013 to June 2020. All patients were admitted to PICU and received standard post-LT care protocol. We divided patients into low (< 30 g/L) and normal (> 30 g/L) groups based on postoperative albumin day 1 to 3. RESULTS Among 108 LT recipients, most had biliary atresia. The median age at the time of LT was 1.8 years [interquartile range (IQR), 1.5-5.7]. There were 18 patients in low albumin group [median albumin level, 27.9 g/L (IQR, 25.8-29.6) and 90 patients in normal albumin group [median albumin level, 34.5 g/L (IQR, 32.4-36.9). The low albumin group had significantly higher incidence of AKI, occurring in 20% of patients with a median onset of 2.5 days following LT (IQR, 1-5). Postoperative hypoalbuminemia (OR, 4.94; 95% CI, 1.32-18.47; p = 0.01) and a longer operative time (OR, 1.37; 95% CI, 1.01-1.47; p = 0.02) were independent risk factors for AKI by multivariable analysis. No significant differences between the two groups were found in other early postoperative outcomes. CONCLUSION Postoperative hypoalbuminemia was associated with early postoperative AKI following LT in children but not with other worsening outcomes.
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Affiliation(s)
- Alina Uasuwannakul
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chatmanee Lertudomphonwanit
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Bangkok, 10400, Thailand.
- Ramathibodi Excellence Center for Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Nattachai Anantasit
- Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pornthep Tanpowpong
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Bangkok, 10400, Thailand
- Ramathibodi Excellence Center for Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Songpon Getsuwan
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Bangkok, 10400, Thailand
- Ramathibodi Excellence Center for Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chollasak Thirapattaraphan
- Ramathibodi Excellence Center for Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suporn Treepongkaruna
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Bangkok, 10400, Thailand
- Ramathibodi Excellence Center for Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Fiala A, Breitkopf R, Sinner B, Mathis S, Martini J. [Anesthesia for organ transplant patients]. DIE ANAESTHESIOLOGIE 2023; 72:773-783. [PMID: 37874343 PMCID: PMC10615924 DOI: 10.1007/s00101-023-01332-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/27/2023] [Indexed: 10/25/2023]
Abstract
Organ transplant patients who must undergo nontransplant surgical interventions can be challenging for the anesthesiologists in charge. On the one hand, it is important to carefully monitor the graft function in the perioperative period with respect to the occurrence of a possible rejection reaction. On the other hand, the ongoing immunosuppression may have to be adapted to the perioperative requirements in terms of the active substance and the route of administration, the resulting increased risk of infection and possible side effects (e.g., myelosuppression, nephrotoxicity and impairment of wound healing) must be included in the perioperative treatment concept. Furthermore, possible persistent comorbidities of the underlying disease and physiological peculiarities as a result of the organ transplantation must be taken into account. Support can be obtained from the expertise of the respective transplantation center.
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Affiliation(s)
- Anna Fiala
- Universitätsklinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - Robert Breitkopf
- Universitätsklinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
| | - Barbara Sinner
- Universitätsklinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - Simon Mathis
- Universitätsklinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - Judith Martini
- Universitätsklinik für Anästhesie und Intensivmedizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
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Mendoza Quevedo MD, Vaca-Espinosa MC, Marín Zuluaga JI, Amell Baron BC, Sierra Vargas AK. Refractory Ascites After Liver Transplantation Treated With Splenic Artery Embolization: A Case Report and Literature Review. Cureus 2023; 15:e43910. [PMID: 37746399 PMCID: PMC10512432 DOI: 10.7759/cureus.43910] [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: 08/21/2023] [Indexed: 09/26/2023] Open
Abstract
After orthotopic liver transplantation, several complications can arise, such as arterial or venous thrombosis, stenosis, biliary leakage, ischemia, or ascites. Although refractory ascites are not a common complication, they can have a significant impact on patients' prognosis and quality of life. This condition can be caused by multiple mechanisms, both intrahepatic and extrahepatic, and one of them is the splenic artery steal syndrome. In this article, we present the case of a patient with advanced cirrhosis who developed refractory ascites following liver transplantation. Despite management with diuretics and paracentesis, the ascites did not respond to conventional treatment. The diagnosis of splenic artery steal syndrome was confirmed through angiography, and subsequent embolization of the splenic artery resulted in symptom resolution.
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Patel BH, Melamed KH, Wilhalme H, Day GL, Wang T, DiNorcia J, Farmer D, Agopian V, Kaldas F, Barjaktarevic I. Implications of Pleural Fluid Composition in Persistent Pleural Effusion following Orthotopic Liver Transplant. Med Sci (Basel) 2023; 11:medsci11010024. [PMID: 36976532 PMCID: PMC10058754 DOI: 10.3390/medsci11010024] [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: 02/02/2023] [Revised: 03/03/2023] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
Persistent pleural effusions (PPEf) represent a known complication of orthotopic liver transplant (OLT). However, their clinical relevance is not well described. We evaluated the clinical, biochemical, and cellular characteristics of post-OLT PPEf and assessed their relationship with longitudinal outcomes. We performed a retrospective cohort study of OLT recipients between 2006 and 2015. Included patients had post-OLT PPEf, defined by effusion persisting >30 days after OLT and available pleural fluid analysis. PPEf were classified as transudates or exudates (ExudLight) by Light's criteria. Exudates were subclassified as those with elevated lactate dehydrogenase (ExudLDH) or elevated protein (ExudProt). Cellular composition was classified as neutrophil- or lymphocyte-predominant. Of 1602 OLT patients, 124 (7.7%) had PPEf, of which 90.2% were ExudLight. Compared to all OLT recipients, PPEf patients had lower two-year survival (HR 1.63; p = 0.002). Among PPEf patients, one-year mortality was associated with pleural fluid RBC count (p = 0.03). While ExudLight and ExudProt showed no association with outcomes, ExudLDH were associated with increased ventilator dependence (p = 0.03) and postoperative length of stay (p = 0.03). Neutrophil-predominant effusions were associated with increased postoperative ventilator dependence (p = 0.03), vasopressor dependence (p = 0.02), and surgical pleural intervention (p = 0.02). In summary, post-OLT PPEf were associated with increased mortality. Ninety percent of these effusions were exudates by Light's criteria. Defining exudates using LDH only and incorporating cellular analysis, including neutrophils and RBCs, was useful in predicting morbidity.
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Affiliation(s)
- Bhavesh H Patel
- David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Kathryn H Melamed
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Holly Wilhalme
- Department of Medicine Statistics Core, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Gwenyth L Day
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Tisha Wang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Joseph DiNorcia
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Douglas Farmer
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Vatche Agopian
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Fady Kaldas
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
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Jiang JG, Ferrell T, Sauaia A, Rodriguez IE, Yoeli D, Nydam TL, Kennealey PT, Pomposelli JJ, Pomfret EA, Moore HB. Low viscoelastic clot strength, platelet transfusions, and graft dysfunction are associated with persistent postoperative ascites following liver transplantation. Am J Surg 2022; 224:1432-1437. [PMID: 36216610 PMCID: PMC10366940 DOI: 10.1016/j.amjsurg.2022.09.054] [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: 03/25/2022] [Revised: 08/25/2022] [Accepted: 09/28/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION High output, persistent ascites (PA) is a common complication following liver transplant (LT). Recent work has identified that platelets help maintain endothelial integrity and can decrease leakage in pathological states. We sought to assess the association of PA following LT with platelet count and platelet function. METHODS Clot strength (MA) is a measure of platelet function and was quantified using thrombelastography (TEG). Total drain output following surgery was recorded in 24-h intervals during the same time frame as TEG. PA was considered >1 L on POD7, as that much output prohibits drain removal. RESULTS 105 LT recipients with moderate or high volume preoperative ascites were prospectively enrolled. PA occurred in 28%. Platelet transfusions before and after surgery were associated with PA, in addition to POD5 TEG MA and POD5 MELD score. Patients with PA had a longer hospital length of stay and an increased rate of intraabdominal infections. CONCLUSION Persistent ascites following liver transplant is relatively common and associated with platelet transfusions, low clot strength, and graft dysfunction.
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Affiliation(s)
- Jessie G Jiang
- University of Colorado School of Medicine, CU Anschutz Fitzsimons Building, 13001 East 17th Place, C290, Aurora, CO, 80045, USA; University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA.
| | - Tanner Ferrell
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
| | - Angela Sauaia
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA; University of Colorado Denver School of Public Health, Department of Health Systems, Management and Policy, Fitzsimons Building, 3rd Floor, 13001 E. 17th Place, Mail Stop B119, Aurora, CO, 80045, USA
| | - Ivan E Rodriguez
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA; Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
| | - Dor Yoeli
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA; Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
| | - Trevor L Nydam
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA; Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
| | - Peter T Kennealey
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA; Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
| | - James J Pomposelli
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA; Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
| | - Elizabeth A Pomfret
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA; Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA
| | - Hunter B Moore
- University of Colorado Denver School of Medicine, Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA; Colorado Center for Transplantation Care, Research, and Education (CCTCARE). Department of Surgery, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, C-318, Aurora, CO, 80045, USA.
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7
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Ebada HE, Montasser MF, Abdelghaffar MF, Bahaa MM, Elbaset HSA, Sakr MA, Dabbous HM, Montasser IF, Hassan MS, Aboelmaaty ME, Elmeteini MS. Ascites post-living donor liver transplantation: Risk factors and outcome. JOURNAL OF LIVER TRANSPLANTATION 2022. [DOI: 10.1016/j.liver.2022.100112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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8
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Ostojic A, Petrovic I, Silovski H, Kosuta I, Sremac M, Mrzljak A. Approach to persistent ascites after liver transplantation. World J Hepatol 2022; 14:1739-1746. [PMID: 36185723 PMCID: PMC9521448 DOI: 10.4254/wjh.v14.i9.1739] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/08/2022] [Accepted: 09/02/2022] [Indexed: 02/06/2023] Open
Abstract
Persistent ascites (PA) after liver transplantation (LT), commonly defined as ascites lasting more than 4 wk after LT, can be expected in up to 7% of patients. Despite being relatively rare, it is associated with worse clinical outcomes, including higher 1-year mortality. The cause of PA can be divided into vascular, hepatic, or extrahepatic. Vascular causes of PA include hepatic outflow and inflow obstructions, which are usually successfully treated. Regarding modifiable hepatic causes, recurrent hepatitis C and acute cellular rejection are the leading ones. Considering predictors for PA, the presence of ascites, refractory ascites, hepato-renal syndrome type 1, spontaneous bacterial peritonitis, hepatic encephalopathy, and prolonged ischemic time significantly influence the development of PA after LT. The initial approach to patients with PA should be to diagnose the treatable cause of PA. The stepwise approach in evaluating PA includes diagnostic paracentesis, ultrasound with Doppler, and an echocardiogram when a cardiac cause is suspected. Finally, a percutaneous or transjugular liver biopsy should be performed in cases where the diagnosis is unclear. PA of unknown cause should be treated with diuretics and paracentesis, while transjugular intrahepatic portosystemic shunt and splenic artery embolization are treatment methods in patients with refractory ascites after LT.
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Affiliation(s)
- Ana Ostojic
- Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, Zagreb 10000, Croatia
| | - Igor Petrovic
- Department of Hepatobiliary Surgery and Transplantation, University Hospital Center Zagreb, Zagreb 10000, Croatia
| | - Hrvoje Silovski
- Department of Hepatobiliary Surgery and Transplantation, University Hospital Center Zagreb, Zagreb 10000, Croatia
| | - Iva Kosuta
- Department of Intensive Care Medicine, University Hospital Center Zagreb, Zagreb 10000, Croatia
| | - Maja Sremac
- Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, Zagreb 10000, Croatia
| | - Anna Mrzljak
- Department of Gastroenterology and Hepatology, University Hospital Center Zagreb, Zagreb 10000, Croatia
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9
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Management of Ascites Following Deceased Donor Liver Transplantation: A Case Series. Transplant Direct 2022; 8:e1350. [PMID: 35923811 PMCID: PMC9298478 DOI: 10.1097/txd.0000000000001350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/31/2022] [Accepted: 02/05/2022] [Indexed: 11/26/2022] Open
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10
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Janwadkar A, Nagral A, Marar S, Sonavane A, Raut V, Vasanth S, Mirza D. Positional outflow obstruction as a cause of early refractory ascites post-pediatric living donor liver transplantation. Pediatr Transplant 2021; 25:e13969. [PMID: 33502075 DOI: 10.1111/petr.13969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 12/01/2020] [Accepted: 12/27/2020] [Indexed: 11/28/2022]
Abstract
Refractory ascites post-liver transplantation can be a challenging problem. Causes of refractory ascites include venous outflow anastomotic stenosis, vessel kinking by the regenerating liver, pre-existing graft disease, and positional outflow obstruction. We present a case report of a child presenting with high drain output and refractory ascites post-LDLT secondary to a positional kinking. Repeating the Doppler studies with patients both supine and sitting may be helpful.
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Affiliation(s)
| | - Aabha Nagral
- Apollo Hospital, Navi Mumbai, India.,Jaslok Hospital and Research Centre, Mumbai, India
| | - Shaji Marar
- Apollo Hospital, Navi Mumbai, India.,Jaslok Hospital and Research Centre, Mumbai, India
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11
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Constrictive pericarditis diagnosed following liver transplantation. MARMARA MEDICAL JOURNAL 2021. [DOI: 10.5472/marumj.1012634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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12
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Wu S, Li X. Platelets level variability during the first year after liver transplantation in the risk prediction model for recipients mortality. Ann Hepatol 2021; 23:100287. [PMID: 33189911 DOI: 10.1016/j.aohep.2020.100287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/12/2020] [Accepted: 11/02/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Shuang Wu
- Department of Infectious Diseases, YiWu Central Hospital, Zhejiang 322000, China
| | - Xiaofei Li
- Department of Infectious Diseases, YiWu Central Hospital, Zhejiang 322000, China.
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13
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Jenkins M, Satoskar R. Ascites After Liver Transplantation. Clin Liver Dis (Hoboken) 2021; 17:317-319. [PMID: 33968396 PMCID: PMC8087930 DOI: 10.1002/cld.1050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/22/2020] [Accepted: 10/11/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Michelle Jenkins
- Transplant InstituteMedStar Georgetown University HospitalWashingtonDC
| | - Rohit Satoskar
- Transplant InstituteMedStar Georgetown University HospitalWashingtonDC
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14
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Bianco G, Pascale MM, Frongillo F, Nure E, Agnes S, Spoletini G. Transjugular portosystemic shunt for early-onset refractory ascites after liver transplantation. Hepatobiliary Pancreat Dis Int 2021; 20:90-93. [PMID: 32967815 DOI: 10.1016/j.hbpd.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/04/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Giuseppe Bianco
- General Surgery and Liver Transplant Unit, Fondazione IRCCS - Policlinico Universitario "A. Gemelli", Rome 00168, Italy
| | - Marco Maria Pascale
- General Surgery and Liver Transplant Unit, Fondazione IRCCS - Policlinico Universitario "A. Gemelli", Rome 00168, Italy.
| | - Francesco Frongillo
- General Surgery and Liver Transplant Unit, Fondazione IRCCS - Policlinico Universitario "A. Gemelli", Rome 00168, Italy
| | - Erida Nure
- General Surgery and Liver Transplant Unit, Fondazione IRCCS - Policlinico Universitario "A. Gemelli", Rome 00168, Italy
| | - Salvatore Agnes
- General Surgery and Liver Transplant Unit, Fondazione IRCCS - Policlinico Universitario "A. Gemelli", Rome 00168, Italy
| | - Gabriele Spoletini
- General Surgery and Liver Transplant Unit, Fondazione IRCCS - Policlinico Universitario "A. Gemelli", Rome 00168, Italy
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15
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Yamamoto M, Doi K, Hayase N, Asada T, Akamatsu N, Kaneko J, Hasegawa K, Morimura N. Pulse oximetry-based capillary refilling evaluation predicts postoperative outcomes in liver transplantation: a prospective observational cohort study. BMC Anesthesiol 2020; 20:251. [PMID: 32993506 PMCID: PMC7523076 DOI: 10.1186/s12871-020-01171-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/22/2020] [Indexed: 12/21/2022] Open
Abstract
Background Capillary refill time (CRT) is a non-invasive technique to evaluate tissue perfusion, and quantitative CRT (Q-CRT) adapted to pulse oximetry was developed with patients with sepsis and compared to blood lactate and sepsis scores. In post liver transplantation, large amounts of fluid administration are necessary for maintaining tissue perfusion to grafted liver against intravascular hypovolemia. This study aimed to evaluate whether Q-CRT can predict poor outcomes by detecting peripheral tissue perfusion abnormality in patients with liver transplantations who were treated with massive fluid administration. Methods In this single-center prospective cohort study, we enrolled adult patients with liver transplantations between June 2018 and July 2019. Measurement of Q-CRT was conducted at intensive care units (ICU) admission and postoperative day 1 (POD1). Results A total of 33 patients with liver transplantations were enrolled. Significant correlations of Q-CRT and ΔAb, a tissue oxygen delivery parameter calculated by pulse oximetry data, at ICU admission with the postoperative outcomes such as length of ICU and hospital stay and total amount of ascitic fluid discharge were observed. Quantitative CRT and ΔAb at ICU admission were significantly associated with these postoperative outcomes, even after adjusting preoperative and operative factors (MELD score and bleeding volume, respectively). However, quantitative CRT and ΔAb at POD1 and changes from ICU admission to POD1 failed to show significant associations. Conclusions Q-CRT values were significantly associated with postoperative outcomes in liver transplantation. Although the mechanisms of this association need to be clarified further, Q-CRT may enable identification of high-risk patients that need intensive postoperative managements.
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Affiliation(s)
- Miyuki Yamamoto
- Department of Acute Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kent Doi
- Department of Acute Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Naoki Hayase
- Department of Acute Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Toshifumi Asada
- Department of Acute Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Transplantation Division, Department of Surgery, The University of Tokyo, Tokyo, Japan
| | - Junichi Kaneko
- Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Transplantation Division, Department of Surgery, The University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Transplantation Division, Department of Surgery, The University of Tokyo, Tokyo, Japan
| | - Naoto Morimura
- Department of Acute Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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16
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Bezjak M, Kocman B, Jadrijević S, Gašparović H, Mrzljak A, Kanižaj TF, Vujanić D, Bubalo T, Mikulić D. Constrictive pericarditis as a cause of refractory ascites after liver transplantation: A case report. World J Clin Cases 2019; 7:3266-3270. [PMID: 31667177 PMCID: PMC6819289 DOI: 10.12998/wjcc.v7.i20.3266] [Citation(s) in RCA: 3] [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: 05/27/2019] [Revised: 08/23/2019] [Accepted: 10/05/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Refractory ascites is a rare complication following orthotopic liver transplantation (OLT). The broad spectrum of differential diagnosis often leads to delay in diagnosis. Therapy depends on recognition and treatment of the underlying cause. Constrictive pericarditis is a condition characterized by clinical signs of right-sided heart failure. In the advanced stages of the disease, hepatic congestion leads to formation of ascites. In patients after OLT, cardiac etiology of ascites is easily overlooked and it requires a high degree of clinical suspicion.
CASE SUMMARY We report a case of a 55-year-old man who presented with a refractory ascites three months after liver transplantation for alcoholic cirrhosis. Prior to transplantation the patient had a minimal amount of ascites. The transplant procedure and the early postoperative course were uneventful. Standard post-transplant work up failed to reveal any typical cause of refractory post-transplant ascites. The function of the graft was good. Apart from atrial fibrillation, cardiac status was normal. Eighteen months post transplantation the patient developed dyspnea and severe fatigue with peripheral edema. Ascites was still prominent. The presenting signs of right-sided heart failure were highly suggestive of cardiac etiology. Diagnostic paracentesis was suggestive of cardiac ascites, and further cardiac evaluation showed typical signs of constrictive pericarditis. Pericardiectomy was performed followed by complete resolution of ascites. On the follow-up the patient remained symptom-free with no signs of recurrent ascites and with normal function of the liver graft.
CONCLUSION Refractory ascites following liver transplantation is a rare complication with many possible causes. Broad differential diagnosis needs to be considered.
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Affiliation(s)
- Miran Bezjak
- Division of Abdominal Surgery and Organ Transplantation, Department of Surgery, University Hospital Merkur, Zagreb 10000, Croatia
| | - Branislav Kocman
- Division of Abdominal Surgery and Organ Transplantation, Department of Surgery, University Hospital Merkur, Zagreb 10000, Croatia
| | - Stipislav Jadrijević
- Division of Abdominal Surgery and Organ Transplantation, Department of Surgery, University Hospital Merkur, Zagreb 10000, Croatia
| | - Hrvoje Gašparović
- Division of Cardiology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb 10000, Croatia
| | - Anna Mrzljak
- Division of Gastroenterology, Department of Internal Medicine, University Hospital Merkur, Zagreb 10000, Croatia
| | - Tajana Filipec Kanižaj
- Division of Gastroenterology, Department of Internal Medicine, University Hospital Merkur, Zagreb 10000, Croatia
| | - Darko Vujanić
- Division of Cardiology, Department of Internal Medicine, University Hospital Merkur, Zagreb 10000, Croatia
| | - Tomislav Bubalo
- Division of Abdominal Surgery and Organ Transplantation, Department of Surgery, University Hospital Merkur, Zagreb 10000, Croatia
| | - Danko Mikulić
- Division of Abdominal Surgery and Organ Transplantation, Department of Surgery, University Hospital Merkur, Zagreb 10000, Croatia
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17
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Bezjak M, Kocman B, Jadrijević S, Gašparović H, Mrzljak A, Kanižaj TF, Vujanić D, Bubalo T, Mikulić D. Constrictive pericarditis as a cause of refractory ascites after liver transplantation: A case report. World J Clin Cases 2019. [DOI: 10.12998/wjcc.v7.i20.3267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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18
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Nutu OA, Manrique Municio A, Marcacuzco Quinto A, Calvo Pulido J, Jiménez Romero C. Using octreotide for refractory ascites after liver transplantation. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:882-884. [PMID: 31595758 DOI: 10.17235/reed.2019.6316/2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Refractory ascites is a condition associated with a reduced survival and a poorer quality of life. Portal hyperflow after liver transplantation is one of the main causes. We report the case of a female patient with refractory ascites after liver transplantation who was treated with splenic embolization. Ascites persisted despite embolization due to splenic revascularization by short gastric vessels and repeat embolization was technically unfeasible. Based on pathophysiology data, she was treated with octreotide, a somatostatin octapeptide analog, which resulted in splanchnic vasoconstriction and a reduction of the portal flow and venous pressure. After four months of treatment with octreotide, the patient had a good clinical status without ascites.
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Affiliation(s)
- Oana-Anisa Nutu
- Unidad de Cirugía HBP y Trasplante de Órganos Abdo, Hospital Universitario 12 de Octubre
| | | | | | - Jorge Calvo Pulido
- Unidad de Cirugía HBP y Trasplante de Órganos Abdo, Hospital Universitario 12 de Octubre
| | - Carlos Jiménez Romero
- Unidad de Cirugía HBP y Trasplante de Órganos Abdo, Hospital Universitario 12 de Octubre
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19
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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: 0.5] [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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20
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Sato K, Ohira M, Shimizu S, Imaoka Y, Hashimoto S, Tahara H, Kobayashi T, Kuroda S, Ide K, Tanaka Y, Ohdan H. Risk Factors for Refractory Ascites After Living Donor Liver Transplant. Transplant Proc 2019; 51:1516-1519. [PMID: 31155185 DOI: 10.1016/j.transproceed.2019.01.120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 01/28/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Refractory ascites after liver transplant commonly occurs in living donor liver transplant (LDLT). Refractory ascites is associated with postoperative complications and poor prognosis. This study sought to determine the risk factors of refractory ascites and discuss their perioperative management. METHODS A retrospective study of 122 living donor liver transplant recipients between 2008 and 2017 was performed to analyze the risk factors, incidence, and characteristics of refractory ascites. Refractory ascites post LDLT was defined as the production of ascites fluid >1000 mL/d on postoperative day 14 or required repeated drainage. RESULTS A total of 24 patients (19.6%) developed refractory ascites. The 1-year survival rate was significantly worse in the refractory ascites group compared with the nonrefractory ascites group (P < .001). In a univariate analysis, patients with refractory ascites had a higher Model for End-Stage Liver Disease (MELD) score, donor age, presence of left lobe graft, ascites at laparotomy, portal venous pressure just after surgery, cold ischemia time, and absence of hepatocellular carcinoma compared with patients without refractory ascites. Multivariate proportional regression analyses revealed that MELD score ≥20, left lobe graft, donor age 50 years or older, and ascites at laparotomy ≥350 mL were independently associated with refractory ascites. Postoperative complications, such as bleeding (P < .001), sepsis (P < .001), and bloodstream infection within 30 days after LDLT (P < .00), were significantly higher in the refractory ascites group. CONCLUSION Refractory ascites is associated with reduced 1-year survival and increased postoperative complications. Four factors including MELD score ≥20, donor age 50 years or older, presence of left graft, and ascites at laparotomy ≥350 mL were independent predictors for refractory ascites.
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Affiliation(s)
- Koki Sato
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masahiro Ohira
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Seiichi Shimizu
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuki Imaoka
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinji Hashimoto
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroyuki Tahara
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tsuyoshi Kobayashi
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shintaro Kuroda
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kentaro Ide
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuka Tanaka
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan
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21
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Nutu OA, Justo Alonso I, Marcacuzco Quinto AA, Calvo Pulido J, Jiménez Romero LC. Complete splenic embolization for the treatment of refractory ascites after liver transplantation. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:257-259. [PMID: 29411988 DOI: 10.17235/reed.2018.5338/2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Refractory ascites is an uncommon complication that may develop postoperatively after liver transplantation. The diagnosis and treatment of this condition is a real challenge. We report two cases of patients who underwent a transplant due to cryptogenic cirrhosis and developed refractory ascites during the immediate postoperative period. This is a serious complication associated with decreased survival by up to one year and a reduced quality of life. After ruling out the main causes of ascites, a portal hyperflow was a potential etiology. This condition perpetuates itself with splenic circulation and brings about a reduction in the hepatic arterial flow. Therefore, if arterial blood flow to the spleen is diminished, venous return and portal circulation will be reduced and arterial blood flow will improve. Splenic artery embolization is a procedure introduced many years ago for the management of splenic artery steal syndrome and small-for-size living donor liver transplantation. This procedure is performed in order to reduce portal hyperflow and consequently, ascites. In conclusion, splenic artery embolization is a therapeutic option for the treatment of refractory ascites after liver transplantation.
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Affiliation(s)
- Oana Anisa Nutu
- Unidad de Cirugía Hepatobiliopancreática, Hospital Universitario 12 de Octubre, ESPAÑA
| | - Iago Justo Alonso
- Unidad de Cirugía Hepatobiliopancreática, Hospital Universitario 12 de Octubre, ESPAÑA
| | | | - Jorge Calvo Pulido
- Unidad de Cirugía Hepatobiliopancreática, Hospital Universitario 12 de Octubre, ESPAÑA
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22
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Cost Effectiveness of Early Insertion of Transjugular Intrahepatic Portosystemic Shunts for Recurrent Ascites. Clin Gastroenterol Hepatol 2018; 16:1503-1510.e3. [PMID: 29609068 DOI: 10.1016/j.cgh.2018.03.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 03/12/2018] [Accepted: 03/24/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Treatment options for recurrent ascites resulting from decompensated cirrhosis include serial large-volume paracentesis and albumin infusion (LVP+A) or insertion of a transjugular intrahepatic portosystemic shunt (TIPS). Insertion of TIPSs with covered stents during early stages of ascites (early TIPS, defined as 2 LVPs within the past 3 weeks and <6 LVPs in the prior 3 months) significantly improves chances of survival and reduces complications of cirrhosis compared with LVP+A. However, it is not clear if TIPS insertion is cost effective in these patients. METHODS We developed a Markov model using the payer perspective for a hypothetical cohort of patients with cirrhosis with recurrent ascites receiving early TIPSs or LVP+A using data from publications and national databases collected from 2012 to 2018. Projected outcomes included quality-adjusted life-year (QALY), costs (2017 US dollars), and incremental cost-effectiveness ratios (ICERs; $/QALY). Sensitivity analyses (1-way, 2-way, and probabilistic) were conducted. ICERs less than $100,000 per QALY were considered cost effective. RESULTS In base-case analysis, early insertion of TIPS had a higher cost ($22,770) than LVP+A ($19,180), but also increased QALY (0.73 for early TIPSs and 0.65 for LVP+A), resulting in an ICER of $46,310/QALY. Results were sensitive to cost of uncomplicated TIPS insertion and transplant, need for LVP+A, probability of transplant, and decompensated QALY. In probabilistic sensitivity analysis, TIPS insertion was the optimal strategy in 59.1% of simulations. CONCLUSIONS Based on Markov model analysis, early placement of TIPSs appears to be a cost-effective strategy for management of specific patients with cirrhosis and recurrent ascites. TIPS placement should be considered early and as a first-line treatment option for select patients.
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23
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Prediction of the Development of Persistent Massive Ascites After Living Donor Liver Transplantation Using a Perioperative Risk Score. Transplantation 2018; 102:e275-e281. [DOI: 10.1097/tp.0000000000002174] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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24
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Ito D, Akamatsu N, Togashi J, Kaneko J, Arita J, Hasegawa K, Sakamoto Y, Kokudo N. Behavior and clinical impact of ascites after living donor liver transplantation: risk factors associated with massive ascites. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:688-696. [PMID: 27474897 DOI: 10.1002/jhbp.390] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Affiliation(s)
- Daisuke Ito
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo, Bunkyo-ku Tokyo 113-8655 Japan
| | - Nobuhisa Akamatsu
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo, Bunkyo-ku Tokyo 113-8655 Japan
| | - Junichi Togashi
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo, Bunkyo-ku Tokyo 113-8655 Japan
| | - Junichi Kaneko
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo, Bunkyo-ku Tokyo 113-8655 Japan
| | - Junichi Arita
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo, Bunkyo-ku Tokyo 113-8655 Japan
| | - Kiyoshi Hasegawa
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo, Bunkyo-ku Tokyo 113-8655 Japan
| | - Yoshihiro Sakamoto
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo, Bunkyo-ku Tokyo 113-8655 Japan
| | - Norihiro Kokudo
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine; The University of Tokyo; 7-3-1 Hongo, Bunkyo-ku Tokyo 113-8655 Japan
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25
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Pravisani R, Baccarani U, Adani G, Lorenzin D, Vit A, Cherchi V, Calandra S, Rispoli I, Toniutto P, Sponza M, Risaliti A. Splenic Artery Syndrome as a Possible Cause of Late Onset Refractory Ascites After Liver Transplantation: Management With Proximal Splenic Artery Embolization. Transplant Proc 2016; 48:377-9. [PMID: 27109959 DOI: 10.1016/j.transproceed.2016.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 01/03/2016] [Accepted: 01/12/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Portal hyperperfusion (PHP) is a hemodynamic condition which may develop after liver transplantation and cause refractory ascites (RA). The diagnosis is established by exclusion of other causes of increased sinusoidal pressure/resistance such as cellular rejection or toxicity and outflow obstruction. PHP as part of the pathogenesis of the splenic artery syndrome (SAS) can be treated with splenic artery embolization (SAE). METHODS This is a retrospective study on a cohort of first-time whole-size liver transplant recipients diagnosed with RA due to PHP and treated by proximal SAE (pSAE) at the Liver Transplant Unit of the University Hospital of Udine between 2004 and 2014. RESULTS For this study, 23 patients were identified (prevalence 8%) and treated. Preliminary clinical workup to diagnose SAS was based on exclusion of other possible causes of RA with graft biopsy, cavogram with hepatic venous pressure measurement, computed tomography scan, and angiography. The pSAE was performed 110 ± 61 days after transplantation, and no procedure-related complications occurred. pSAE resulted in a significant decrease of portal vein velocity (P = .01) and wedge hepatic venous pressure (P = .03). The diameter of the spleen showed a slightly significant reduction (P = .047); no modification of hepatic artery resistive index were encountered (P = .34). Moreover, pSAE determined the resolution of RA in all cases. CONCLUSIONS pSAE is a safe and effective procedure to modulate the hepatic inflow and thus to treat RA secondary to SAS, with a low incidence of complications and a high rate of clinical response.
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Affiliation(s)
- R Pravisani
- General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - U Baccarani
- General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy.
| | - G Adani
- General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - D Lorenzin
- General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - A Vit
- Division of Interventional Radiology, University Hospital of Udine, Udine, Italy
| | - V Cherchi
- General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - S Calandra
- General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - I Rispoli
- General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | - P Toniutto
- Department of Medicine and Pathology Clinical and Experimental, Medical Liver Transplantation Unit, Internal Medicine, University of Udine, Udine, Italy
| | - M Sponza
- Division of Interventional Radiology, University Hospital of Udine, Udine, Italy
| | - A Risaliti
- General Surgery and Transplantation Unit, Department of Medical and Biological Sciences, University of Udine, Udine, Italy
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26
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Splenic Artery Embolization for Treatment of Refractory Ascites After Liver Transplantation. ACG Case Rep J 2016; 3:136-8. [PMID: 26958571 PMCID: PMC4748207 DOI: 10.14309/crj.2016.25] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 11/03/2015] [Indexed: 12/11/2022] Open
Abstract
Post-transplantation refractory ascites is uncommon; however, it can be a serious problem, increasing both morbidity and mortality in patients. Despite scant literature available, splenic artery embolization (SAE) has been shown to be an effective treatment for refractory ascites after cadaveric orthotopic liver transplantation (OLT). We report a successful use of therapeutic SAE for refractory ascites post-OLT.
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27
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Novelli PM, Shields J, Krishnamurthy V, Cho K. Two Unusual but Treatable Causes of Refractory Ascites After Liver Transplantation. Cardiovasc Intervent Radiol 2015; 38:1663-9. [PMID: 26017456 DOI: 10.1007/s00270-015-1120-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
Abstract
Refractory ascites (RA) is thought to complicate the postoperative course of 5-7% (Nishida et al. in Am J Transplant. 6: 140-149, 2006; Gotthardt et al. in Ann Transplant. 18: 378-383, 2013) of liver transplant recipients. RA after liver transplantation is often a frustrating diagnostic dilemma with few good management options unless an obvious mechanical factor is identified. Supportive therapies often fail until a treatable precipitating cause is identified and removed. We describe two patients who developed RA following liver transplantation for primary sclerosing cholangitis, and hepatitis C and alcoholic liver disease, respectively. The cause for RA was hyperkinetic portal hypertension secondary to splenomegaly in the first case and a pancreatic AVM in the 2nd case. After failure of other interventions, surgical splenectomy resulted in immediate and durable resolution of the previously intractable ascites.
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Affiliation(s)
- P M Novelli
- Department of Radiology, University of Michigan Medical Center, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA.
| | - J Shields
- Department of Radiology, University of Michigan Medical Center, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - V Krishnamurthy
- Department of Radiology, University of Michigan Medical Center, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - K Cho
- Department of Radiology, University of Michigan Medical Center, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
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Yuksel I, Karaahmet F, Coskun Y, Kılıncalp S, Hamamci M, Akinci H, Ustun Y, Simsek Z, Erarslan E, Coban S. Significance of serum and ascitic fluid C-reactive protein in differential diagnosis of benign and malignant ascites. Dig Dis Sci 2014; 59:2588-93. [PMID: 24838501 DOI: 10.1007/s10620-014-3205-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 05/03/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND The values of C-reactive protein (CRP) can prove useful in determining disease progress. Because of synthesis by the liver, production of CRP in response to inflammation may be attenuated in patients with liver dysfunction. This may result in differences interpreting CRP levels in patient with portal and non-portal hypertension ascites. AIM The aim of the present study is to assess discriminant value of serum and ascitic fluid CRP, which is easily accessible and inexpensive laboratory marker of inflammation, concentrations for diagnosis of underlying cause of ascites. METHODS This prospective study was conducted at Dıskapı Yıldırım Beyazıt Educational and Research Hospital Department of Gastroenterology. Patients with ascites were further divided into two subgroups based on underlying cause of ascites: Group 1, patient with ascites due to portal hypertensive etiology (high-gradient ascites); Group 2, patient with ascites due to non-portal hypertensive etiology (low-gradient ascites). RESULTS A total of 91 patients fulfilling the criteria for a diagnosis of ascites were enrolled in the study. Of these patients, 50 had proven (Group 1) ascites due to portal hypertensive etiology (high-gradient ascites) and 41 had clinical (Group 2) ascites due to non-portal hypertensive etiology (low-gradient ascites). Mean baseline serum and ascites levels of CRP were significantly higher in Group 2 compared to those in Group 1 (p = 0.021, p = <0.0001, respectively). CONCLUSIONS Increased levels of serum and ascitic fluid CRP were associated with malignant ascites.
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Affiliation(s)
- Ilhami Yuksel
- Department of Gastroenterology, Dıskapı Yıldırım Beyazıt Educational and Research Hospital, 06080, Altındag, Ankara, Turkey
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