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Puchany AJ, Hilmi I. Post-reperfusion syndrome in liver transplant recipients: What is new in prevention and management? World J Crit Care Med 2025; 14:101777. [DOI: 10.5492/wjccm.v14.i2.101777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2024] [Revised: 11/22/2024] [Accepted: 12/19/2024] [Indexed: 02/27/2025] Open
Abstract
Post-reperfusion syndrome (PRS) in liver transplant recipients remains one of the most dreaded complications in liver transplant surgery. PRS can impact the short-term and long-term patient and graft outcomes. The definition of PRS has evolved over the years, from changes in arterial blood pressures and heart and/or decreases in the systemic vascular resistance and cardiac output to including the fibrinolysis and grading the severity of PRS. However, all that did not reflect on the management of PRS or its impact on the outcomes. In recent years, new scientific techniques and new technology have been in the pipeline to better understand, manage and maybe prevent PRS. These new methods and techniques are still in the infancy, and they have to be proven not in prevention and management of PRS but their effects in the patient and graft outcomes. In this article, we will review the long history of PRS, its definition, etiology, management and most importantly the new advances in science and technology to prevent and properly manage PRS.
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Affiliation(s)
- Austin James Puchany
- Department of Anesthesiology & Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, United States
| | - Ibtesam Hilmi
- School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, United States
- Department of Anesthesiology and Perioperative Medicine, Clinical and Translational Science Institute, University of Pittsburgh, School of Medicine, Pittsburgh, PA 15213, United States
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Wu Y, Xue J, Li T, Jiang L, Che L, Huang X, Sheng M, Li H, Yu W, Weng Y. The pretransplant neutrophil-lymphocyte ratio is associated with postreperfusion syndrome and short-term outcomes after paediatric living-donor liver transplantation. Scand J Gastroenterol 2025:1-9. [PMID: 40219660 DOI: 10.1080/00365521.2025.2490622] [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: 10/07/2024] [Revised: 04/01/2025] [Accepted: 04/03/2025] [Indexed: 04/14/2025]
Abstract
OBJECTIVE The aim of this study was to evaluate whether the pretransplant neutrophil-lymphocyte ratio (NLR) is associated with postreperfusion syndrome (PRS) after paediatric living-donor liver transplantation (LDLT) and the impact of different pretransplant NLR values on short-term outcomes. METHODS Clinical data from paediatric patients who underwent LDLT for biliary atresia were retrospectively analysed. Receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive value of the pretransplant NLR for PRS. The paediatric patients were stratified into two cohorts according to the optimal cut-off value, and their perioperative clinical indices were subsequently compared. RESULTS This retrospective study included 313 paediatric patients who had been diagnosed with biliary atresia. Based on ROC analysis, the area under the curve (AUC) of the NLR was 0.738, with a sensitivity of 73.1% and a specificity of 68.2% when predicting PRS. Paediatric patients were split into two groups according to the optimal NLR cut-off: NLR-Low (n = 158) and NLR-High (n = 155). Compared with the NLR-Low group, the NLR-High group had significantly more postoperative intensive care unit and hospitalisation days (p < 0.05). Furthermore, patients in the NLR-High group demonstrated a notably lower 1-year survival rate than their counterparts in the NLR-Low group did. An elevated NLR, a prolonged graft cold ischaemic time, and the occurrence of hypothermia before reperfusion are independent risk factors for PRS. CONCLUSION The pretransplant NLR is associated with postreperfusion syndrome in paediatric LDLT patients, and an elevated NLR is correlated with unfavourable short-term postoperative outcomes in paediatric patients after LDLT.
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Affiliation(s)
- Yuli Wu
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin, China
| | - Jingyi Xue
- School of Medicine, Nankai University, Tianjin, China
| | - Tianying Li
- School of Medicine, Nankai University, Tianjin, China
| | - Lei Jiang
- School of Medicine, Nankai University, Tianjin, China
| | - Lu Che
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin, China
| | - Xiaoyu Huang
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin, China
| | - Mingwei Sheng
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin, China
| | - Hongxia Li
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin, China
| | - Wenli Yu
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin, China
| | - Yiqi Weng
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin, China
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Stoker AD, Gorlin AW, Rosenfeld DM, Nguyen MC, Mathur AK, Buckner-Petty SA, Lizaola-Mayo BC, Frasco PE. Donation After Circulatory Death Liver Transplantation: Impact of Normothermic Machine Perfusion on Key Variables. Anesth Analg 2025; 140:687-696. [PMID: 39808582 PMCID: PMC11805485 DOI: 10.1213/ane.0000000000007093] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2024] [Indexed: 01/16/2025]
Abstract
BACKGROUND During orthotopic liver transplantation, allograft reperfusion is a dynamic point in the operation and often requires vasoactive medications and blood transfusions. Normothermic machine perfusion (NMP) of liver allografts has emerged to increase the number of transplantable organs and may have utility during donation after circulatory death (DCD) liver transplantation in reducing transfusion burden and vasoactive medication requirements. METHODS This is a single-center retrospective study involving 226 DCD liver transplant recipients who received an allograft transported with NMP (DCD-NMP group) or with static cold storage (DCD-SCS group). Veno-venous bypass was not used in any patients. Infusion doses of norepinephrine, epinephrine, and vasopressin as well as bolus doses of vasoactive medications during reperfusion were recorded. Blood component therapy was recorded according to phase of liver transplantation and during the first 24 hours postprocedure. RESULTS A total of 103 recipients in the DCD-NMP group and 123 patients in the DCD-SCS group were included. Post-reperfusion syndrome (PRS) incidence was reduced in the DCD-NMP group compared to the DCD-SCS group (10.7% [95% confidence interval, CI, 5.5%-18.3%] vs 42.3% [95% CI, 33.4%-51.5%]; P < .001). During the reperfusion period, patients in the DCD-SCS group required increased bolus doses of epinephrine and vasopressin compared to the DCD-NMP group (24.6 vs 7.5 µg; P < .001) and (5.4 vs 2.4 units; P < .001), respectively. The DCD-SCS group received a higher infusion dose of epinephrine during anhepatic phase, at reperfusion, and up to 90 minutes after reperfusion. In the postreperfusion period, there were significant increases in the transfusion of red blood cells (RBCs; 5.3 vs 3.7 units; P = .006), fresh frozen plasma (FFP; 3.4 vs 1.9 units; P < .001), cryoprecipitate (2.7 vs 1.8 pooled units; P = .015) and platelets (0.9 vs 0.4 units; P = .008) in the DCD-SCS group compared to the DCD-NMP group. During the first 24 hours postprocedure, transfusion of RBCs, FFP, and cryoprecipitate in the DCD-SCS group was increased compared to the DCD-NMP group ([2.6 vs 1.7 units; P = .028], [1.6 vs 0.8 units; P < .001], [1.5 vs 0.9 pooled units; P = .031]) respectively. Administration of tranexamic acid was more frequent in the DCD-SCS group during the post-reperfusion period compared to the DCD-NMP group (13% [95% CI, 5.7%-17.4%] vs 3.9% [95% CI, 1.1%-9.6% 95%]; P = .018). CONCLUSIONS In DCD liver transplantation, use of NMP was associated with reduced incidence of PRS and decreased vasopressor and inotrope requirements at the time of allograft reperfusion compared to using SCS. Additionally, NMP was associated with reduced transfusion of all blood product components as well as antifibrinolytic agent administration in the post-reperfusion period. Reduced transfusion burden in the DCD-NMP group also occurred during the first 24 hours posttransplant.
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Affiliation(s)
- Alexander D. Stoker
- From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
| | - Andrew W. Gorlin
- From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
| | - David M. Rosenfeld
- From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
| | | | - Amit K. Mathur
- Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona
| | | | | | - Peter E. Frasco
- From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
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Puttappa A, Gaurav R, Kakhandki V, Swift L, Fear C, Webster R, Radwan A, Mohammed M, Butler A, Klinck J, Watson C. Normothermic regional and ex situ perfusion reduces postreperfusion syndrome in donation after circulatory death liver transplantation: A retrospective comparative study. Am J Transplant 2025:S1600-6135(25)00007-3. [PMID: 39826893 DOI: 10.1016/j.ajt.2025.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 12/13/2024] [Accepted: 01/06/2025] [Indexed: 01/22/2025]
Abstract
In controlled donation after circulatory death (DCD) liver transplantation, ischemia-reperfusion injury is linked to postreperfusion syndrome (PRS), acute kidney injury (AKI), and early allograft dysfunction. Normothermic regional perfusion (NRP) and normothermic machine perfusion (NMP) are techniques that mitigate ischemic injury and associated complications. In this single-center retrospective study, we compared early transplant outcomes of DCD livers undergoing direct procurement (DP) and static cold storage (SCS) (DCD-DP-SCS), NRP procurement with SCS (DCD-NRP-SCS), or DP with NMP (DCD-DP-NMP). Two hundred thirty-eight DCD liver recipients were evaluated, comprising 59 DCD-DP-SCS, 101 DCD-NRP-SCS, and 78 DCD-DP-NMP. Overall, the PRS incidence was 19%. DCD-DP-SCS had a higher incidence of PRS (37%; P < .001), AKI stage ≥2 (47%; P = .033), and an increased model for early allograft function score (P < .001). In adjusted multivariate analysis, recipient age (odds ratio [OR] 1.10, 95% CI 1.05-1.17; P < 0.001), and normothermic perfusion (DCD-NRP-SCS: OR 0.16, 95% CI 0.06-0.39; P < .001; DCD-DP-NMP: OR 0.38, 95% CI 0.15-0.91; P = .032) were significant predictors of PRS, which itself was associated with worse 5-year transplant survival (graft survival non-censored-to-death; Hazard ratio (HR) 2.9, 95% CI 1.3-6.7; P = .012). Compared to SCS alone, the use of either NRP or NMP significantly reduced the incidence of PRS and AKI with better early graft function.
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Affiliation(s)
- Anand Puttappa
- Division of Anaesthesia and Perioperative care, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Rohit Gaurav
- Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK; University of Cambridge Department of Surgery, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), UK.
| | - Vibhay Kakhandki
- Division of Anaesthesia and Perioperative care, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Lisa Swift
- Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Corrina Fear
- Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Rachel Webster
- Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Ahmed Radwan
- Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Musab Mohammed
- Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Andrew Butler
- Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK; University of Cambridge Department of Surgery, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), UK
| | - John Klinck
- Division of Anaesthesia and Perioperative care, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Christopher Watson
- Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK; University of Cambridge Department of Surgery, Cambridge, UK; National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), UK
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Gao Q, Cai JZ, Dong H. A Review of the Risk Factors and Approaches to Prevention of Post-Reperfusion Syndrome During Liver Transplantation. Organogenesis 2024; 20:2386730. [PMID: 39097866 PMCID: PMC11299628 DOI: 10.1080/15476278.2024.2386730] [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: 12/09/2023] [Revised: 06/22/2024] [Accepted: 07/26/2024] [Indexed: 08/05/2024] Open
Abstract
Post-reperfusion syndrome (PRS) is a severe and highly lethal syndrome that occurs after declamping the portal vein forceps during liver transplantation. It is marked by severe hemodynamic disturbances manifested by decreased mean arterial pressure, increased heart rate and elevated pulmonary artery pressure. The complex pathogenesis of PRS remains understudied. It is generally believed to be related to the large amount of acidic, cold blood that enters the circulation after release of the portal clamp. This blood is rich in oxygen-free radicals and metabolic toxins, which not only aggravate the ischemia-reperfusion injury of the liver but also further attack the systemic organs indiscriminately. Considering the range of possible adverse prognoses including acute kidney injury, delirium and graft nonfunction, it is imperative that clinicians increase their awareness and prevention of PRS. The aim of this article is to review the current risk factors, pathophysiological mechanisms and prevention strategies for PRS.
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Affiliation(s)
- Qian Gao
- Department of Anesthesiology, Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Jin-Zhen Cai
- Organ Transplant Center, Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - He Dong
- Department of Anesthesiology, Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
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Khampitak N, Pongpruksa C, Cheng D, Bui CM, Poorsattar S, Wray C, Xia VW. High Postreperfusion Pulmonary Artery Pressure Is Associated With Increased 30-Day Mortality in Liver Transplantation. J Cardiothorac Vasc Anesth 2024; 38:3150-3156. [PMID: 39341760 DOI: 10.1053/j.jvca.2024.08.041] [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: 06/30/2024] [Revised: 08/23/2024] [Accepted: 08/30/2024] [Indexed: 10/01/2024]
Abstract
OBJECTIVES To explore the incidence, risk factors, and impact of elevated mean pulmonary artery pressure (mPAP) on 30-day mortality in liver transplantation (LT). DESIGN A retrospective study. SETTING University tertiary medical center. PARTICIPANTS Adult patients who underwent between 2013 and 2023. INTERVENTION No intervention. MEASUREMENTS AND MAIN RESULTS Data for consecutive adults who underwent LT (n = 1243) between 2013 and 2023 were extracted from our institutional Discovery Data Repository. Elevated mPAP was defined as ≥40 mmHg or a ≥20% increase from baseline during the first hour following reperfusion. The 30-day mortality rate was recorded. Risk factors were identified using multivariable logistic regression. The study cohort had a mean age of 55.2 ± 11.9 years and a mean model for end-stage liver disease sodium (MELD-Na) score of 34.8 ± 6.1. Ninety-one patients (7.3%) developed an elevated postreperfusion mPAP. Multivariable logistic regression revealed that preoperative elevated PAP estimated by echocardiogram, preoperative serum creatinine, and the use of epinephrine during LT were significant risk factors. Thirty-two patients (1.9%) died within 30 days after LT. Elevated postreperfusion mPAP was significantly associated with 30-day mortality (odds ratio, 6.056; 95% confidence interval, 2.349-15.611; p < 0.001). CONCLUSIONS mPAP is frequently elevated after graft reperfusion during LT, but its influence on clinical outcomes remains unclear. This retrospective study found a 7.3% rate of high PAP following reperfusion in LT, and high postreperfusion PAP was associated with 30-day mortality.
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Affiliation(s)
- Nutchanok Khampitak
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Anesthesiology, Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Chinnarat Pongpruksa
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Drew Cheng
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Christine Myo Bui
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Sophia Poorsattar
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Christopher Wray
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Victor W Xia
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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Huh J, Chae MS. Impact of Paired Remote Ischemic Preconditioning on Postreperfusion Syndrome in Living-Donor Liver Transplantation: A Propensity-Score Matching Analysis. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1830. [PMID: 39597016 PMCID: PMC11596776 DOI: 10.3390/medicina60111830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2024] [Revised: 11/05/2024] [Accepted: 11/06/2024] [Indexed: 11/29/2024]
Abstract
Background and Objectives: Postreperfusion syndrome (PRS) is a significant challenge in liver transplantation (LT), leading to severe circulatory and metabolic complications. Ischemic preconditioning (IPC), including remote IPC (RIPC), can mitigate ischemia-reperfusion injury, although its efficacy in LT remains unclear. This study evaluated the impact of paired RIPC, involving the application of RIPC to both the recipient and the living donor, on the incidence of PRS and the need for rescue epinephrine during living-donor LT (LDLT). Materials and Methods: This retrospective observational cohort analysis included 676 adult patients who had undergone elective LDLT between September 2012 and September 2022. After applying exclusion criteria and propensity score matching (PSM), 664 patients were categorized into the paired RIPC and non-RIPC groups. The primary outcomes were the occurrence of PRS and the need for rescue epinephrine during reperfusion. Results: The incidence of PRS and the need for rescue epinephrine were significantly lower in the paired RIPC group than in the non-RIPC group. Furthermore, the incidence of postoperative acute kidney injury was lower in the paired RIPC group. Multivariable logistic regression adjusted for propensity scores indicated that paired RIPC was significantly associated with a reduced occurrence of PRS (odds ratio: 0.672, 95% confidence interval: 0.479-0.953, p = 0.021). Conclusions: Paired RIPC, involving both the recipient and the living donor, effectively reduces the occurrence of PRS and the need for rescue epinephrine during LDLT. These findings suggest that paired RIPC protects against ischemia-reperfusion injury in LDLT. Future randomized controlled trials are needed to verify our results and to explore the underlying mechanisms of the protective effects of RIPC.
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Affiliation(s)
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
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Fernández J, Blasi A, Hidalgo E, Karvellas CJ. Bridging the critically ill patient with acute to chronic liver failure to liver transplantation. Am J Transplant 2024; 24:1348-1361. [PMID: 38548058 DOI: 10.1016/j.ajt.2024.03.026] [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: 12/21/2023] [Revised: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 04/14/2024]
Abstract
Liver transplantation (LT) has emerged as an effective therapy for severe forms of acute-on-chronic liver failure (ACLF), an entity characterized by the development of multiorgan failure and high short-term mortality. The aim of critical care management of ACLF patients is to rapidly treat precipitating events and aggressively support failing organs to ensure that patients may successfully undergo LT or, less frequently, recover. Malnutrition and sarcopenia are frequently present, adversely impacting the prognosis of these patients. Management of critical care patients with ACLF is complex and requires the participation of different specialties. Once the patient is stabilized, a rapid evaluation for salvage LT should be performed because the time window for LT is often narrow. The development of sepsis and prolonged organ support may preclude LT or diminish its chances of success. The current review describes strategies to bridge severe ACLF patients to LT, highlights the minimal evaluation required for listing and the currently suggested contraindications to proceed with LT, and addresses different aspects of management during the perioperative and early posttransplant period.
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Affiliation(s)
- Javier Fernández
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain; EF Clif, EASL-CLIF Consortium, Barcelona, Spain.
| | - Annabel Blasi
- Anesthesiology Department, Hospital Clínic, and University of Barcelona, Spain
| | - Ernest Hidalgo
- Hepatolobiliary Surgery Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Constantine J Karvellas
- Department of Critical Care Medicine, University of Alberta, Edmonton, Canada; Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
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Kwon HM, Kang SJ, Han SB, Kim JH, Kim SH, Jun IG, Song JG, Hwang GS. Effect of dexmedetomidine on the incidence of postoperative acute kidney injury in living donor liver transplantation recipients: a randomized controlled trial. Int J Surg 2024; 110:4161-4169. [PMID: 38537086 PMCID: PMC11254204 DOI: 10.1097/js9.0000000000001331] [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: 12/19/2023] [Accepted: 03/03/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND Acute kidney injury (AKI) is one of the most common complications after living-donor liver transplantation (LDLT) that has great impact on recipient and graft outcomes. Dexmedetomidine is reported to decrease the incidence of AKI. In the current study, the authors investigated whether intraoperative dexmedetomidine infusion would reduce the AKI following LDLT. MATERIAL AND METHODS In total, 205 adult patients undergoing elective LDLT were randomly assigned to the dexmedetomidine group ( n =103) or the control group ( n =102). Dexmedetomidine group received continuous dexmedetomidine infusion at a rate of 0.4 mcg/kg/h after the anesthesia induction until 2 h after graft reperfusion. The primary outcome was to compare the incidence of AKI. Secondary outcomes included serial lactate levels during surgery, chronic kidney disease, major adverse cardiovascular events, early allograft dysfunction, graft failure, overall mortality, duration of mechanical ventilation, intensive care unit, and hospital length of stay. Intraoperative hemodynamic parameters were also collected. RESULTS Of 205 recipients, 42.4% ( n =87) developed AKI. The incidence of AKI was lower in the dexmedetomidine group (35.0%, n =36/103) compared with the control (50.0%, n =51/102) ( P =0.042). There were significantly lower lactate levels in the dexmedetomidine group after reperfusion [4.39 (3.99-4.8) vs 5.02 (4.62-5.42), P =0.031] until the end of surgery [4.23 (3.73-4.74) vs 5.35 (4.84-5.85), P =0.002]. There were no significant differences in the other secondary outcomes besides lactate. Also, intraoperative mean blood pressure, cardiac output, and systemic vascular resistance did not show any difference. CONCLUSION Our study suggests that intraoperative dexmedetomidine administration was associated with significantly decreased AKI incidence and lower intraoperative serum lactate levels in LDLT recipients, without untoward hemodynamic effects.
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Affiliation(s)
| | | | | | | | | | | | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul 05505, Republic of Korea
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10
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Raja K, Panackel C. Post Liver Transplant Renal Dysfunction-Evaluation, Management and Immunosuppressive Practice. J Clin Exp Hepatol 2024; 14:101306. [PMID: 38274509 PMCID: PMC10806298 DOI: 10.1016/j.jceh.2023.101306] [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: 01/10/2023] [Accepted: 11/21/2023] [Indexed: 01/27/2024] Open
Abstract
Liver transplantation (LT) is an effective and lifesaving treatment for patients with end-stage liver disease and hepatocellular carcinoma. Significant improvement in intermediate and long-term survival has been possible due to advancements in immunosuppressive therapy, perioperative care, and surgical techniques. Despite these advances, metabolic complications, including diabetes mellitus, cardiovascular diseases, malignancies, and renal dysfunction, are challenging issues after LT. Acute kidney injury (AKI) and chronic kidney disease (CKD) after LT are common and result in significant morbidity and mortality. Early diagnosis of kidney injury after LT is challenging, and no technique has yet proven effective in prediction of renal dysfunction. The methods for assessing renal function range from formulas that predict glomerular filtration rate to non-invasive biomarkers. The universal adoption of the model for end-stage liver disease has a direct impact on the incidence of peri-transplant AKI and development of CKD in the long-term. Post-LT renal dysfunction is multifactorial and is usually a result of pre-transplantation comorbidities, occurrence of renal dysfunction on the waiting list, perioperative events, and post-transplant nephrotoxic immunosuppressive medication use. Early identification of patients at risk for renal dysfunction and adoption of preventive measures are crucial in the pre-transplant period. No data are currently available to suggest a surgical technique that reliably demonstrates renal protection. Nephroprotective strategies during LT follow accepted surgical practice guidelines, such as maintenance of intravascular volume and mean arterial pressure. The management of kidney disease following LT is challenging, as by the time the serum creatinine is significantly elevated, few interventions impact the course of progression. Early nephroprotective measures are strongly advised and they mostly center on delaying the administration of calcineurin inhibitors (CNIs) during the initial postoperative period, lowering CNI dosage and combining CNI with mycophenolate mofetil and everolimus. The reasons for renal failure following LT, the techniques used to diagnose it, and the therapies designed to preserve renal function both immediately and late after LT are all critically evaluated in this review.
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Affiliation(s)
- Kaiser Raja
- Department of Gastroenterology and Hepatology, King's College Hospital London, Dubai, United Arab Emirates
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11
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Lee EJ, Hwang HJ, Ko JS, Park M. Effects of Extracellular Calcium Concentration on Hepatic Ischemia-Reperfusion Injury in a Rat Model. EXP CLIN TRANSPLANT 2024; 22:120-128. [PMID: 38511983 DOI: 10.6002/ect.2023.0307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
OBJECTIVES Hypocalcemia is frequently identified during liver transplant. However, supplementation of extracellular calcium could induce increased intracellular calcium concentration, as a potential factor for injury to the liver graft. We evaluated the effects of regulating extracellular calcium concentrations on hepatic ischemia-reperfusion injury. MATERIALS AND METHODS We randomly divided 24 Sprague-Dawley rats into 3 groups: group C received normal saline (n = 8), group L received citrate to induce hypocalcemia (n = 8), and group L-Co received citrate followed by calcium gluconate to ameliorate hypocalcemia (n = 8). Liver enzyme levels and extracellular calcium were measured before surgery, 1 hour after ischemia, and 2 hours after reperfusion. The primary outcome was liver enzyme levels measured 2 hours after reperfusion. In addition, we evaluated intracellular calcium levels, lactate dehydrogenase activity, and histopathological results in liver tissue. RESULTS Three groups demonstrated significant differences in extracellular calcium concentrations, but intracellular calcium concentrations in liver tissue were not significantly different. Group L showed significantly lower mean arterial pressure than other groups at 1 hour after ischemia (93.6 ± 20.8 vs 69.4 ± 14.2 vs 86.6 ± 10.4 mmHg; P = .02, for group C vs L vs L-Co, respectively). At 2 hours after reperfusion, group L showed significantly higher liver enzymes than other groups (aspartate aminotransferase 443.0 ± 353.2 vs 952.3 ± 94.8 vs 502.4 ± 327.3 U/L, P = .01; and alanine aminotransferase 407.9 ± 406.5 vs 860.6 ± 210.9 vs 333.9 ± 304.2 U/L, P = .02; for group C vs L vs L-Co, respectively). However, no significant difference was shown in lactate dehydrogenase and histological liver injury grade. CONCLUSIONS Administering calcium to rats with hypocalcemia did not increase intracellular calcium accumulation but instead resulted in less hepatic injury compared with rats with low extracellular calcium concentrations in this rat model study.
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Affiliation(s)
- Eun Ji Lee
- From the Department of Anesthesiology and Pain Medicine, Sungkyunkwan University School of Medicine, Seoul, South Korea
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12
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Arcas-Bellas JJ, Siljeström R, Sánchez C, González A, García-Fernández J. Use of Transesophageal Echocardiography During Orthotopic Liver Transplantation: Simplifying the Procedure. Transplant Direct 2024; 10:e1564. [PMID: 38274476 PMCID: PMC10810591 DOI: 10.1097/txd.0000000000001564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/21/2023] [Accepted: 09/25/2023] [Indexed: 01/27/2024] Open
Abstract
The intraoperative management of patients undergoing orthotopic liver transplantation (OLT) is influenced by the cardiovascular manifestations typically found in the context of end-stage liver disease, by the presence of concomitant cardiovascular disease, and by the significant hemodynamic changes that occur during surgery. Hypotension and intraoperative blood pressure fluctuations during OLT are associated with liver graft dysfunction, acute kidney failure, and increased risk of 30-d mortality. Patients also frequently present hemodynamic instability due to various causes, including cardiac arrest. Recent evidence has shown transesophageal echocardiography (TEE) to be a useful minimally invasive monitoring tool in patients undergoing OLT that gives valuable real-time information on biventricular function and volume status and can help to detect OLT-specific complications or situations. TEE also facilitates rapid diagnosis of life-threatening conditions in each stage of OLT, which is difficult to identify with other types of monitoring commonly used. Although there is no consensus on the best approach to intraoperative monitoring in these patients, intraoperative TEE is safe and useful and should be recommended during OLT, according to experts, for assessing hemodynamic changes, identifying possible complications, and guiding treatment with fluids and inotropes to achieve optimal patient care.
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Affiliation(s)
- José J. Arcas-Bellas
- Department of Anesthesia and Critical Care, Puerta de Hierro-Majadahonda University Hospital, Madrid, Spain
| | - Roberto Siljeström
- Department of Anesthesia and Critical Care, Puerta de Hierro-Majadahonda University Hospital, Madrid, Spain
| | - Cristina Sánchez
- Department of Anesthesia and Critical Care, Puerta de Hierro-Majadahonda University Hospital, Madrid, Spain
| | - Ana González
- Department of Anesthesia and Critical Care, Puerta de Hierro-Majadahonda University Hospital, Madrid, Spain
| | - Javier García-Fernández
- Department of Anesthesia and Critical Care, Puerta de Hierro-Majadahonda University Hospital, Madrid, Spain
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13
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González-Suárez S, Serrano HA, Chocron IZ, Tormos P, Cano E, Galán P, de Nadal M, Matarín S, Cabeza M, Rodríguez-Tesouro AB. Postreperfusion Syndrome in Patients Receiving Vasoactive Drugs During Liver Graft Reperfusion. EXP CLIN TRANSPLANT 2024; 22:43-51. [PMID: 38284374 DOI: 10.6002/ect.2023.0146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
OBJECTIVES The most widely used definition of postreperfusion syndrome in liver transplant is a 30% decrease in mean arterial pressure during the first 5 minutes after vascular unclamping. With these criteria, increased postoperative morbidity has been reported. Vasoactivedrugs couldpreventthis syndrome.Themain objective of our study was to determine the incidence and complications associated with postreperfusion syndrome inpatientswho receivedvasoactive support. MATERIALS AND METHODS We studied 246 patients who received norepinephrine infusions to maintain mean arterial pressure ≥60 mm Hg and who were monitored with a Swan-Ganz catheter. Patients received a bolus of adrenaline after vascular unclamping in cases of insufficient response to norepinephrine. RESULTS Among the study patients, 57 (23.17%) developed postreperfusion syndrome. Patients who developed postreperfusion syndrome did not present with morepostoperative complications interms ofrenal dysfunction (P = .69), repeat surgery (P = .15), graft rejection (P = .69), transplant replacement surgery (P = .76), hospital stay (P = .70), or survival (P = .17) compared with patients without postreperfusion syndrome. CONCLUSIONS In patients who underwent orthotopic liver transplant, in whom vasoactive drugs were administered, a diagnosis of self-limited postreperfusion syndrome during the first 5 minutes after unclamping may not be associated with postoperative complications. The administration of vasoconstrictors may have a preventive effect on the postoperative complications associated with postreperfusion syndrome or they may mask the real incidence of postreperfusion syndrome. A broader definition of postreperfusion syndrome should be accepted.
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Affiliation(s)
- Susana González-Suárez
- From the Department of Surgery, Universitat Autònoma de Barcelona, Unitat Docent Vall d'Hebron, Barcelona, Spain; and the Department of Anesthesiology and Intensive Care, Vall d'Hebron University Hospital, Barcelona, Spain
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14
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Abdou AH, Abdalla W, Ammar MA. Effect of mannitol on postreperfusion syndrome during living donor liver transplant: A randomized clinical trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2023. [DOI: 10.1080/11101849.2023.2196112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Affiliation(s)
- Amr Hilal Abdou
- Department of Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Waleed Abdalla
- Department of Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mona Ahmed Ammar
- Department of Anesthesia, Intensive Care, and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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15
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Gajate L, de la Hoz I, Espiño M, Martin Gonzalez MDC, Fernandez Martin C, Martín-Grande A, Parise Roux D, Pastor O, Villahoz J, Rodriguez-Gandía MÁ, Nuño Vazquez J. Intravenous Ascorbic Acid for the Prevention of Postreperfusion Syndrome in Orthotopic Liver Transplantation: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e50091. [PMID: 38100226 PMCID: PMC10757222 DOI: 10.2196/50091] [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: 06/29/2023] [Revised: 11/23/2023] [Accepted: 11/27/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Liver transplantation is the last therapeutic option for patients with end-stage liver disease. Postreperfusion syndrome (PRS), defined as a fall in mean arterial pressure of more than 30% within the first 5 minutes after reperfusion of at least 1 minute, can occur in liver transplantation as a deep hemodynamic instability with associated hyperfibrinolysis immediately after reperfusion of the new graft. Its incidence has remained unchanged since it was first described in 1987. PRS is related to ischemia-reperfusion (I/R) injury, whose pathophysiology involves the release of several mediators from both the donor and the recipient. The antioxidant effect of ascorbic acid has been studied in resuscitating patients with septic shock and burns. Even today, there are publications with conflicting results, and there is a need for further studies to confirm or rule out the usefulness of this drug in this group of patients. The addition of ascorbic acid to preservation solutions used in solid organ transplantation is under investigation to harness its antioxidant effect and mitigate I/R injury. Since PRS could be considered a manifestation of I/R injury, we believe that the possible beneficial effect of ascorbic acid on the occurrence of PRS should be investigated. OBJECTIVE The aim of this randomized controlled trial is to assess the benefits of ascorbic acid over saline in the development of PRS in adult liver transplantation. METHODS We plan to conduct a single-center randomized controlled trial at the Hospital Universitario Ramón y Cajal in Spain. A total of 70 participants aged 18 years or older undergoing liver transplantation will be randomized to receive either ascorbic acid or saline. The primary outcome will be the difference between groups in the incidence of PRS. The randomized controlled trial will be conducted under conditions of respect for fundamental human rights and ethical principles governing biomedical research involving human participants and in accordance with the international recommendations contained in the Declaration of Helsinki and its subsequent revisions. RESULTS The enrollment process began in 2020. A total of 35 patients have been recruited so far. Data cleaning and analysis are expected to occur in the first months of 2024. Results are expected around the middle of 2024. CONCLUSIONS We believe that this study could be particularly relevant because it will be the first to analyze the clinical effect of ascorbic acid in liver transplantation. Moreover, we believe that this study fills an important gap in the knowledge of the potential benefits of ascorbic acid in the field of liver transplantation, particularly in relation to PRS. TRIAL REGISTRATION European Union Drug Regulating Authorities Clinical Trials Database 2020-000123-39; https://tinyurl.com/2cfzddw8; ClinicalTrials.gov NCT05754242; https://tinyurl.com/346vw7sm. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/50091.
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Affiliation(s)
- Luis Gajate
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Inés de la Hoz
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Mercedes Espiño
- Department of Immunology, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Maria Del Carmen Martin Gonzalez
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Cristina Fernandez Martin
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Ascensión Martín-Grande
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Diego Parise Roux
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Oscar Pastor
- Department of Biochemistry, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Judith Villahoz
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Miguel Ángel Rodriguez-Gandía
- Department of Digestive Diseases, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Javier Nuño Vazquez
- Department of Liver Surgery, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
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16
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Emara MM, Elsedeiq M, Abdelkhalek M, Yassen AM, Elmorshedi MA. Norepinephrine boluses for the prevention of post-reperfusion syndrome in living donor liver transplantation: A prospective, open-label, single-arm feasibility trial. Indian J Anaesth 2023; 67:991-998. [PMID: 38213689 PMCID: PMC10779968 DOI: 10.4103/ija.ija_539_23] [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: 06/07/2023] [Revised: 07/15/2023] [Accepted: 09/06/2023] [Indexed: 01/13/2024] Open
Abstract
Background and Aims Post-reperfusion syndrome (PRS) is a serious haemodynamic event during liver transplantation (LT), which increases early graft dysfunction and mortality. This study aimed to test the efficacy and safety of norepinephrine (NE) boluses to prevent PRS during orthotopic LT. Methods This feasibility phase II trial prospectively recruited a single arm of 40 patients undergoing living donor LT. The intervention was an escalated protocol of NE boluses starting at 20 µg. The primary outcome was the incidence of PRS. The secondary outcomes were arrhythmia, electrocardiographic (EKG) ischaemic changes, mean pulmonary pressure after reperfusion, 3-month survival and 1-year survival. Results PRS occurred in 28 (70%) cases [95% confidence interval (CI) 54% to 83%, P < 0.001], with a relative risk reduction of 0.22 when compared to our previous results (90%). Twelve cases developed transient EKG ischaemic changes. All EKG ischaemic changes returned to baseline after correction of hypotension. There was no significant arrhythmia or bradycardia (95% CI 0 to 0.9). After reperfusion, the mean pulmonary artery pressure was not significantly higher than the normal limit (20 mmHg) (P = 0.88). The 3-month survival was 0.95 (95% CI 0.83 to 0.99), and the 1-year survival was 0.93 (95% CI 0.8 to 0.98). Conclusion Our findings suggest that NE boluses starting with 20 μg is feasible and effective in lowering the risk of PRS during living donor LT. Additionally, NE boluses were not associated with significant myocardial ischaemic events, arrhythmia or a rise in pulmonary pressure.
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Affiliation(s)
- Moataz Maher Emara
- Department of Anesthesiology and Intensive Care and Pain Medicine, Mansoura University, Mansoura, Egypt
- Liver Transplantation Program, Mansoura University - Gastrointestinal Surgery Centre, Mansoura, Egypt
| | - Mahmoud Elsedeiq
- Department of Anesthesiology and Intensive Care and Pain Medicine, Mansoura University, Mansoura, Egypt
- Liver Transplantation Program, Mansoura University - Gastrointestinal Surgery Centre, Mansoura, Egypt
| | - Mostafa Abdelkhalek
- Department of Anesthesiology and Intensive Care and Pain Medicine, Mansoura University, Mansoura, Egypt
- Liver Transplantation Program, Mansoura University - Gastrointestinal Surgery Centre, Mansoura, Egypt
| | - Amr M. Yassen
- Department of Anesthesiology and Intensive Care and Pain Medicine, Mansoura University, Mansoura, Egypt
- Liver Transplantation Program, Mansoura University - Gastrointestinal Surgery Centre, Mansoura, Egypt
| | - Mohamed A. Elmorshedi
- Department of Anesthesiology and Intensive Care and Pain Medicine, Mansoura University, Mansoura, Egypt
- Liver Transplantation Program, Mansoura University - Gastrointestinal Surgery Centre, Mansoura, Egypt
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17
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Mouratidou C, Pavlidis ET, Katsanos G, Kotoulas SC, Mouloudi E, Tsoulfas G, Galanis IN, Pavlidis TE. Hepatic ischemia-reperfusion syndrome and its effect on the cardiovascular system: The role of treprostinil, a synthetic prostacyclin analog. World J Gastrointest Surg 2023; 15:1858-1870. [PMID: 37901735 PMCID: PMC10600776 DOI: 10.4240/wjgs.v15.i9.1858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/20/2023] [Accepted: 07/25/2023] [Indexed: 09/21/2023] Open
Abstract
Hepatic ischemia-reperfusion syndrome has been the subject of intensive study and experimentation in recent decades since it is responsible for the outcome of several clinical entities, such as major hepatic resections and liver transplantation. In addition to the organ's post reperfusion injury, this syndrome appears to play a central role in the dysfunction of distant tissues and systems. Thus, continuous research should be directed toward finding effective therapeutic options to improve the outcome and reduce the postoperative morbidity and mortality rates. Treprostinil is a synthetic analog of prostaglandin I2, and its experimental administration has shown encouraging results. It has already been approved by the Food and Drug Administration in the United States for pulmonary arterial hypertension and has been used in liver transplantation, where preliminary encouraging results showed its safety and feasibility by using continuous intravenous administration at a dose of 5 ng/kg/min. Treprostinil improves renal and hepatic function, diminishes hepatic oxidative stress and lipid peroxidation, reduces hepatictoll-like receptor 9 and inflammation, inhibits hepatic apoptosis and restores hepatic adenosine triphosphate (ATP) levels and ATP synthases, which is necessary for functional maintenance of mitochondria. Treprostinil exhibits vasodilatory properties and antiplatelet activity and regulates proinflammatory cytokines; therefore, it can potentially minimize ischemia-reperfusion injury. Additionally, it may have beneficial effects on cardiovascular parameters, and much current research interest is concentrated on this compound.
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Affiliation(s)
| | - Efstathios T Pavlidis
- 2nd Propedeutic Department of Surgery, Hippokration General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Georgios Katsanos
- Department of Transplantation, Hippokration General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | | | - Eleni Mouloudi
- Intensive Care Unit, Hippokration General Hospital, Thessaloniki 54642, Greece
| | - Georgios Tsoulfas
- Department of Transplantation, Hippokration General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Ioannis N Galanis
- 2nd Propedeutic Department of Surgery, Hippokration General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Theodoros E Pavlidis
- 2nd Propedeutic Department of Surgery, Hippokration General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
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18
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Carrier FM, Vincelette C, Trottier H, Amzallag É, Carr A, Chaudhury P, Dajani K, Fugère R, Giard JM, Gonzalez-Valencia N, Joosten A, Kandelman S, Karvellas C, McCluskey SA, Özelsel T, Park J, Simoneau È, Chassé M. Perioperative clinical practice in liver transplantation: a cross-sectional survey. Can J Anaesth 2023; 70:1155-1166. [PMID: 37266852 DOI: 10.1007/s12630-023-02499-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/07/2022] [Accepted: 11/02/2022] [Indexed: 06/03/2023] Open
Abstract
PURPOSE The objective of this study was to describe some components of the perioperative practice in liver transplantation as reported by clinicians. METHODS We conducted a cross-sectional clinical practice survey using an online instrument containing questions on selected themes related to the perioperative care of liver transplant recipients. We sent email invitations to Canadian anesthesiologists, Canadian surgeons, and French anesthesiologists specialized in liver transplantation. We used five-point Likert-type scales (from "never" to "always") and numerical or categorical answers. Results are presented as medians or proportions. RESULTS We obtained answers from 130 participants (estimated response rate of 71% in Canada and 26% in France). Respondents reported rarely using transesophageal echocardiography routinely but often using it for hemodynamic instability, often using an intraoperative goal-directed hemodynamic management strategy, and never using a phlebotomy (medians from ordinal scales). Fifty-nine percent of respondents reported using a restrictive fluid management strategy to manage hemodynamic instability during the dissection phase. Forty-two percent and 15% of respondents reported using viscoelastic tests to guide intraoperative and postoperative transfusions, respectively. Fifty-four percent of respondents reported not pre-emptively treating preoperative coagulations disturbances, and 91% reported treating them intraoperatively only when bleeding was significant. Most respondents (48-64%) did not have an opinion on the maximal graft ischemic times. Forty-seven percent of respondents reported that a piggyback technique was the preferred vena cava anastomosis approach. CONCLUSION Different interventions were reported to be used regarding most components of perioperative care in liver transplantation. Our results suggest that significant equipoise exists on the optimal perioperative management of this population.
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Affiliation(s)
- François M Carrier
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada.
- Critical Care Division, Department of Medicine, Centre hospitalier de l'Université de Montréal, Montreal, Canada.
- Health Innovation and Evaluation Hub, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), 900, rue St-Denis, porte S03-434, Montreal, QC, H2X 0A9, Canada.
- Department of Anesthesiology and Pain Medicine, Université de Montréal, Montreal, QC, Canada.
| | - Christian Vincelette
- School of Nursing, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Longueuil, QC, Canada
| | - Helen Trottier
- Department of Social and Preventive Medicine, École de santé publique de l'Université de Montréal, Montreal, QC, Canada
| | - Éva Amzallag
- Health Innovation and Evaluation Hub, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), 900, rue St-Denis, porte S03-434, Montreal, QC, H2X 0A9, Canada
| | - Adrienne Carr
- Department of Anesthesiology, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Prosanto Chaudhury
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Khaled Dajani
- Department of Surgery, University Health Centre, University of Alberta, Edmonton, AB, Canada
| | - René Fugère
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Jeanne-Marie Giard
- Department of Medicine, Liver Disease Division, Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | | | - Alexandre Joosten
- Department of Anesthesiology, Paris Saclay University, Paul Brousse Hospital, Villejuif, France
| | - Stanislas Kandelman
- Department of Anesthesiology, McGill University Health Centre, Montreal, QC, Canada
| | - Constantine Karvellas
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Stuart A McCluskey
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Timur Özelsel
- Department of Anesthesiology & Pain Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jeieung Park
- Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Colombia, Vancouver, BC, Canada
| | - Ève Simoneau
- Hepatobiliary Division, Department of Surgery, Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Michaël Chassé
- Critical Care Division, Department of Medicine, Centre hospitalier de l'Université de Montréal, Montreal, Canada
- Health Innovation and Evaluation Hub, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), 900, rue St-Denis, porte S03-434, Montreal, QC, H2X 0A9, Canada
- Department of Medicine, Université de Montréal, Montreal, QC, Canada
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19
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Li T, Wu Y, Gong X, Che L, Sheng M, Jia L, Li H, Yu W, Weng Y. Risk factors for postreperfusion syndrome during living donor liver transplantation in paediatric patients with biliary atresia: a retrospective analysis. BMJ Paediatr Open 2023; 7:e001934. [PMID: 37407250 DOI: 10.1136/bmjpo-2023-001934] [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: 02/24/2023] [Accepted: 06/09/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Living donor liver transplantation (LT) is the main treatment for paediatric biliary atresia (BA) in Asia. During LT, a series of haemodynamic changes often occur during LT reperfusion, which is called postreperfusion syndrome (PRS), and PRS is related to a prolonged postoperative hospital stay, delayed recovery of graft function and increased mortality. To reduce adverse reactions after paediatric living donor LT (LDLT), our study's objectives were to ascertain the incidence of PRS and analyse possible risk factors for PRS. METHODS With the approval of the Ethics Committee of our hospital, the clinical data of 304 paediatric patients who underwent LDLT from January 2020 to December 2021 were analysed retrospectively. According to the presence or absence of PRS, the paediatric patients were divided into the non-PRS group and the PRS group. Independent risk factors of PRS were analysed using logistic regression analysis. RESULTS PRS occurred in 132 recipients (43.4%). The peak values of AST (816 (507-1625) vs 678 (449-1107), p=0.016) and ALT (675 (415-1402) vs 545 (389-885), p=0.015) during the first 5 days after LDLT in paediatric patients with PRS were significantly higher than those in the non-PRS group. Meanwhile, the paediatric patients in the PRS group had longer intensive care unit stays and hospital stays, as well as lower 1-year survival rates. Graft cold ischaemic time (CIT) ≥90 min (OR (95% CI)=5.205 (3.094 to 8.754)) and a temperature <36°C immediately before reperfusion (OR (95% CI)=2.973 (1.669 to 5.295)) are independent risk factors for PRS. CONCLUSIONS The occurrence of hypothermia (<36.0℃) in children immediately before reperfusion and graft CIT≥90 min are independent risk factors for PRS. PRS was closely related to the postoperative adverse outcomes of paediatric patients.
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Affiliation(s)
- Tianying Li
- School of Medicine, Nankai University, Tianjin, China
| | - Yuli Wu
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin, China
| | - Xinyuan Gong
- Department of Science and Education, Tianjin First Central Hospital, Tianjin, China
| | - Lu Che
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin, China
| | - Mingwei Sheng
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin, China
| | - Lili Jia
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin, China
| | - Hongxia Li
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin, China
| | - Wenli Yu
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin, China
| | - Yiqi Weng
- Department of Anesthesiology, Tianjin First Central Hospital, Tianjin, China
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20
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DeMaria S, Nolasco L, Igwe D, Jules RS, Bekki Y, Smith NK. Prediction, prevention, and treatment of post reperfusion syndrome in adult orthotopic liver transplant patients. Clin Transplant 2023:e15014. [PMID: 37178452 DOI: 10.1111/ctr.15014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 03/27/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023]
Abstract
IMPORTANCE This review explores proposed predictors, preventative measures, and treatment options for post-reperfusion syndrome (PRS) in liver transplantation and provides updated data for clinicians. OBJECTIVES The review aims to understand the status and progress made regarding PRS during orthotopic liver transplantation. Moreover, the predictors of PRS will be analyzed to highlight risk factors. Mediators of PRS and the modes of action of the currently available preventative and management agents that target particular PRS factors will be investigated. DATA SOURCES Data is drawn from secondary sources from databases of peer-reviewed journals. The bibliographies of select sources were also used to obtain additional data studies using the 'snowball' method. STUDY SELECTION The initial data search provided 1394 studies analyzed using PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. After applying the eligibility criteria, 18 studies were fit for inclusion. RESULTS The study identified that in addition to the severity of underlying medical conditions, other significant PRS predictors included patient age, sex, duration of cold ischemia, and the surgical technique. While the use of epinephrine and norepinephrine is well-established, further preventative measures commonly involve specifically targeting known mediators of the syndrome, such as antioxidants, vasodilators, free radical scavengers, and anticoagulants. Current management strategies involve supportive therapy. Machine Perfusion may ultimately decrease the risk of PRS. CONCLUSION PRS still holds unknowns, including the underlying pathophysiology, controllable factors, and ideal management practices. There is a need for further study, particularly prospective trials since liver transplantation is the gold standard for treating end-stage liver disease and the incidence of PRS remains high.
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Affiliation(s)
- Samuel DeMaria
- The Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lyle Nolasco
- The Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Divya Igwe
- The Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robert St Jules
- The Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Yuki Bekki
- The Department of Transplant Surgery, Recanati/Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Natalie K Smith
- The Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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21
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Reydellet L, Le Saux A, Blasco V, Nafati C, Harti-Souab K, Armand R, Lannelongue A, Gregoire E, Hardwigsen J, Albanese J, Chopinet S. Impact of Hyperoxia after Graft Reperfusion on Lactate Level and Outcomes in Adults Undergoing Orthotopic Liver Transplantation. J Clin Med 2023; 12:jcm12082940. [PMID: 37109276 PMCID: PMC10145037 DOI: 10.3390/jcm12082940] [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: 02/05/2023] [Revised: 04/06/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Hyperoxia is common during liver transplantation (LT), without being supported by any guidelines. Recent studies have shown the potential deleterious effect of hyperoxia in similar models of ischemia-reperfusion. Hyperoxia after graft reperfusion during orthotopic LT could increase lactate levels and worsen patient outcomes. METHODS We conducted a retrospective and monocentric pilot study. All adult patients who underwent LT from 26 July 2013 to 26 December 2017 were considered for inclusion. Patients were classified into two groups according to oxygen levels before graft reperfusion: the hyperoxic group (PaO2 > 200 mmHg) and the nonhyperoxic group (PaO2 < 200 mmHg). The primary endpoint was arterial lactatemia 15 min after graft revascularization. Secondary endpoints included postoperative clinical outcomes and laboratory data. RESULTS A total of 222 liver transplant recipients were included. Arterial lactatemia after graft revascularization was significantly higher in the hyperoxic group (6.03 ± 4 mmol/L) than in the nonhyperoxic group (4.81 ± 2 mmol/L), p < 0.01. The postoperative hepatic cytolysis peak, duration of mechanical ventilation and duration of ileus were significantly increased in the hyperoxic group. CONCLUSIONS In the hyperoxic group, the arterial lactatemia, the hepatic cytolysis peak, the mechanical ventilation and the postoperative ileus were higher than in the nonhyperoxic group, suggesting that hyperoxia worsens short-term outcomes and could lead to increase ischemia-reperfusion injury after liver transplantation. A multicenter prospective study should be performed to confirm these results.
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Affiliation(s)
- Laurent Reydellet
- Department of Anaesthesia and Intensive Care, Hôpital la Timone, 13005 Marseille, France
| | - Audrey Le Saux
- Department of Anaesthesia and Intensive Care, Hôpital la Timone, 13005 Marseille, France
| | - Valery Blasco
- Department of Anaesthesia and Intensive Care, Hôpital la Timone, 13005 Marseille, France
| | - Cyril Nafati
- Department of Anaesthesia and Intensive Care, Hôpital la Timone, 13005 Marseille, France
| | - Karim Harti-Souab
- Department of Anaesthesia and Intensive Care, Hôpital la Timone, 13005 Marseille, France
| | - Romain Armand
- Department of Anaesthesia and Intensive Care, Hôpital la Timone, 13005 Marseille, France
| | - Ariane Lannelongue
- Department of Anaesthesia and Intensive Care, Carémeau Hospital, 30029 Nîmes, France
| | - Emilie Gregoire
- Department of Digestive Surgery and Liver Transplantation, Hôpital la Timone, 13005 Marseille, France
- European Center for Medical Imaging Research CERIMED/LIIE, Aix-Marseille Université, 13385 Marseille, France
| | - Jean Hardwigsen
- Department of Digestive Surgery and Liver Transplantation, Hôpital la Timone, 13005 Marseille, France
- École de Médecine, Faculté des Sciences Médicales et Paramédicales, Aix-Marseille Université, 27 Boulevard Jean Moulin, 13385 Marseille, France
| | - Jacques Albanese
- Department of Anaesthesia and Intensive Care, Hôpital la Timone, 13005 Marseille, France
- École de Médecine, Faculté des Sciences Médicales et Paramédicales, Aix-Marseille Université, 27 Boulevard Jean Moulin, 13385 Marseille, France
| | - Sophie Chopinet
- Department of Digestive Surgery and Liver Transplantation, Hôpital la Timone, 13005 Marseille, France
- European Center for Medical Imaging Research CERIMED/LIIE, Aix-Marseille Université, 13385 Marseille, France
- École de Médecine, Faculté des Sciences Médicales et Paramédicales, Aix-Marseille Université, 27 Boulevard Jean Moulin, 13385 Marseille, France
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22
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Picard B, Sigaut S, Roux O, Abback PS, Choinier PM, Hachouf M, Giabicani M, Kavafyan J, Francoz C, Dondero F, Lesurtel M, Durand F, Cauchy F, Paugam-Burtz C, Dahmani S, Weiss E. Evaluation of transcranial Doppler use in patients with acute liver failure listed for emergency liver transplantation. Clin Transplant 2023:e14975. [PMID: 36964926 DOI: 10.1111/ctr.14975] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/27/2022] [Accepted: 03/08/2023] [Indexed: 03/27/2023]
Abstract
PURPOSE Acute liver failure (ALF) is characterized by hepatic encephalopathy (HE) often due to intracranial hypertension (ICH). The risk/benefit-balance of intraparenchymal pressure catheter monitoring is controversial during ALF. AIMS Perform an evaluation of transcranial Doppler (TCD) use in patients with ALF listed for emergency liver transplantation. MATERIAL AND METHODS Single center retrospective cohort study including all patients registered on high emergency LT list between 2012 and 2018. All TCD measurements performed during ICU stay after listing and after LT (when performed) were recorded. TCD was considered abnormal when pulsatility index (PI) was >1.2. RESULTS Among 106 patients with ALF, forty-seven (44%) had a TCD while on list. They had more severe liver and extrahepatic organ failure. When performed, TCD was abnormal in 51% of patients. These patients more frequently developed ICH events (45% vs. 13%, p = .02) and more frequently required increase in sedative drugs and vasopressors. While 22% of patients with normal TCD spontaneously survived, all of those with abnormal TCD died or were transplanted (p = .02). All transplanted patients who had abnormal exams normalized their TCD within 2 (1-2) days after LT. CONCLUSION TCD may be a useful non-invasive tool for ICH detection and management, then guide sedation withdrawal.
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Affiliation(s)
- Benjamin Picard
- Department of Anesthesiology and Intensive Care, CHU Beaujon, DMU Parabol APHP.Nord - Clichy, Paris, France
| | - Stéphanie Sigaut
- Department of Anesthesiology and Intensive Care, CHU Beaujon, DMU Parabol APHP.Nord - Clichy, Paris, France
| | | | - Paër-Selim Abback
- Department of Anesthesiology and Intensive Care, CHU Beaujon, DMU Parabol APHP.Nord - Clichy, Paris, France
| | - Pierre-Marie Choinier
- Department of Anesthesiology and Intensive Care, CHU Beaujon, DMU Parabol APHP.Nord - Clichy, Paris, France
| | - Marina Hachouf
- Department of Anesthesiology and Intensive Care, CHU Beaujon, DMU Parabol APHP.Nord - Clichy, Paris, France
| | - Mikhael Giabicani
- Department of Anesthesiology and Intensive Care, CHU Beaujon, DMU Parabol APHP.Nord - Clichy, Paris, France
| | - Juliette Kavafyan
- Department of Anesthesiology and Intensive Care, CHU Beaujon, DMU Parabol APHP.Nord - Clichy, Paris, France
| | | | - Federica Dondero
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, CHU Beaujon - Clichy, Paris, France
| | - Mickaël Lesurtel
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, CHU Beaujon - Clichy, Paris, France
- Université Paris Cité, Paris, France
| | - François Durand
- Liver Unit, CHU Beaujon - Clichy, Paris, France
- Université Paris Cité, Paris, France
| | - François Cauchy
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, CHU Beaujon - Clichy, Paris, France
- Université Paris Cité, Paris, France
| | - Catherine Paugam-Burtz
- Department of Anesthesiology and Intensive Care, CHU Beaujon, DMU Parabol APHP.Nord - Clichy, Paris, France
- Université Paris Cité, Paris, France
- UMR_S1149, Centre de recherche sur l'inflammation, Paris, France
| | - Souhayl Dahmani
- Department of Anesthesiology and Intensive Care, CHU Robert Debré, Paris, France
- UMR_S1149, Centre de recherche sur l'inflammation, Paris, France
| | - Emmanuel Weiss
- Department of Anesthesiology and Intensive Care, CHU Beaujon, DMU Parabol APHP.Nord - Clichy, Paris, France
- Université Paris Cité, Paris, France
- UMR_S1149, Centre de recherche sur l'inflammation, Paris, France
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23
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Pescarissi C, Penzo B, Ghinolfi D, Lai Q, Bindi L, DeCarlis R, Melandro F, Balzano E, DeSimone P, DeCarlis L, DeGasperi A, Biancofiore GL. The perioperative period of liver transplantation from unconventional extended criteria donors: data from two high-volume centres. BMC Anesthesiol 2022; 22:390. [PMID: 36522695 PMCID: PMC9753359 DOI: 10.1186/s12871-022-01932-x] [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: 08/03/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND As literature largely focuses on long-term outcomes, this study aimed at elucidating the perioperative outcomes of liver transplant patients receiving a graft from two groups of unconventional expanded criteria donors: brain dead aged > 80 years and cardiac dead. METHODS Data of 247 cirrhotic patients transplanted at two high volume liver transplant centers were analysed. Confounders were balanced using a stabilized inverse probability therapy weighting and a propensity score for each patient on the original population was generated. The score was created using a multivariate logistic regression model considering a Comprehensive Complication Index ≥ 42 (no versus yes) as the dependent variable and 11 possible clinically relevant confounders as covariate. RESULTS Forty-four patients received the graft from a cardiac-dead donor and 203 from a brain-dead donor aged > 80 years. Intraoperatively, cardiac-dead donors liver transplant cases required more fresh frozen plasma units (P < 0.0001) with similar reduced need of fibrinogen to old brain-dead donors cases. The incidence of reperfusion syndrome was similar (P = 0.80). In the Intensive Care Unit, both the groups presented a comparable low need for blood transfusions, renal replacement therapy and inotropes. Cardiac-dead donors liver transplantations required more time to tracheal extubation (P < 0.0001) and scored higher Comprehensive Complication Index (P < 0.0001) however the incidence of a severe complication status (Comprehensive Complication Index ≥ 42) was similar (P = 0.52). ICU stay (P = 0.97), total hospital stay (P = 0.57), in hospital (P = 1.00) and 6 months (P = 1.00) death were similar. CONCLUSION Selected octogenarian and cardiac-dead donors can be used safely for liver transplantation.
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Affiliation(s)
- Claudia Pescarissi
- grid.5395.a0000 0004 1757 3729Transplant Anesthesia and Critical Care, University of Pisa Medical School Hospital, Via Paradisa 2 – 56124, Pisa, Italy
| | - Beatrice Penzo
- Department of Anesthesia, ASST GOM Niguarda, Milan, Italy
| | - Davide Ghinolfi
- grid.5395.a0000 0004 1757 3729Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Quirino Lai
- grid.7841.aSapienza University of Rome, AOU Umberto I Policlinico of Rome, Rome, Italy
| | - Lucia Bindi
- grid.5395.a0000 0004 1757 3729Transplant Anesthesia and Critical Care, University of Pisa Medical School Hospital, Via Paradisa 2 – 56124, Pisa, Italy
| | | | - Fabio Melandro
- grid.5395.a0000 0004 1757 3729Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Emanuele Balzano
- grid.5395.a0000 0004 1757 3729Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Paolo DeSimone
- grid.5395.a0000 0004 1757 3729Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Luciano DeCarlis
- grid.7563.70000 0001 2174 1754School of Medicine, University of Milano-Bicocca, Milano, Italy
| | | | | | - Giandomenico L. Biancofiore
- grid.5395.a0000 0004 1757 3729Transplant Anesthesia and Critical Care, University of Pisa Medical School Hospital, Via Paradisa 2 – 56124, Pisa, Italy
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24
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Hypothermic Oxygenated Machine Perfusion (HOPE) Prior to Liver Transplantation Mitigates Post-Reperfusion Syndrome and Perioperative Electrolyte Shifts. J Clin Med 2022; 11:jcm11247381. [PMID: 36555997 PMCID: PMC9786550 DOI: 10.3390/jcm11247381] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
(1) Background: Post-reperfusion syndrome (PRS) and electrolyte shifts (ES) represent considerable challenges during liver transplantation (LT) being associated with significant morbidity. We aimed to investigate the impact of hypothermic oxygenated machine perfusion (HOPE) on PRS and ES in LT. (2) Methods: In this retrospective study, we compared intraoperative parameters of 100 LTs, with 50 HOPE preconditioned liver grafts and 50 grafts stored in static cold storage (SCS). During reperfusion phase, prospectively registered serum parameters and vasopressor administration were analyzed. (3) Results: Twelve percent of patients developed PRS in the HOPE cohort vs. 42% in the SCS group (p = 0.0013). Total vasopressor demand in the first hour after reperfusion was lower after HOPE pretreatment, with reduced usage of norepinephrine (−26%; p = 0.122) and significant reduction of epinephrine consumption (−52%; p = 0.018). Serum potassium concentration dropped by a mean of 14.1% in transplantations after HOPE, compared to a slight decrease of 1% (p < 0.001) after SCS. The overall incidence of early allograft dysfunction (EAD) was reduced by 44% in the HOPE group (p = 0.04). (4) Conclusions: Pre-transplant graft preconditioning with HOPE results in higher hemodynamic stability during reperfusion and lower incidence of PRS and EAD. HOPE has the potential to mitigate ES by preventing hyperpotassemic complications that need to be addressed in LT with HOPE-pre-treated grafts.
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25
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Brennan KA, Bhutiani M, Kingeter MA, McEvoy MD. Updates in the Management of Perioperative Vasoplegic Syndrome. Adv Anesth 2022; 40:71-92. [PMID: 36333053 DOI: 10.1016/j.aan.2022.07.010] [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] [Indexed: 06/16/2023]
Abstract
Vasoplegic syndrome occurs relatively frequently in cardiac surgery, liver transplant, major noncardiac surgery, in post-return of spontaneous circulation situations, and in pateints with sepsis. It is paramount for the anesthesiologist to understand both the pathophysiology of vasoplegia and the different treatment strategies available for rescuing a patient from life-threatening hypotension.
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Affiliation(s)
- Kaitlyn A Brennan
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, MAB 422, Nashville, TN 37212, USA
| | - Monica Bhutiani
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue South, VUH 4107, Nashville, TN 37212, USA
| | - Meredith A Kingeter
- Anesthesia Residency, Vanderbilt University Medical Center, 1215 21st Avenue South, Suite 5160 MCE NT, Nashville, TN 37212, USA
| | - Matthew D McEvoy
- VUMC Enhanced Recovery Programs, Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, TVC 4648, Nashville, TN 37232, USA.
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26
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Sharma S, Saner FH, Bezinover D. A brief history of liver transplantation and transplant anesthesia. BMC Anesthesiol 2022; 22:363. [PMID: 36435747 PMCID: PMC9701388 DOI: 10.1186/s12871-022-01904-1] [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: 09/06/2022] [Accepted: 11/13/2022] [Indexed: 11/28/2022] Open
Abstract
In this review, we describe the major milestones in the development of organ transplantation with a specific focus on hepatic transplantation. For many years, the barriers preventing successful organ transplantation in humans seemed insurmountable. Although advances in surgical technique provided the technical ability to perform organ transplantation, limited understanding of immunology prevented successful organ transplantation. The breakthrough to success was the result of several significant discoveries between 1950 and 1980 involving improved surgical techniques, the development of effective preservative solutions, and the suppression of cellular immunity to prevent graft rejection. After that, technical innovations and laboratory and clinical research developed rapidly. However, these advances alone could not have led to improved transplant outcomes without parallel advances in anesthesia and critical care. With increasing organ demand, it proved necessary to expand the donor pool, which has been achieved with the use of living donors, split grafts, extended criteria organs, and organs obtained through donation after cardiac death. Given this increased access to organs and organ resources, the number of transplantations performed every year has increased dramatically. New regulatory organizations and transplant societies provide critical oversight to ensure equitable organ distribution and a high standard of care and also perform outcome analyses. Establishing dedicated transplant anesthesia teams results in improved organ transplantation outcomes and provides a foundation for developing new standards for other subspecialties in anesthesiology, critical care, and medicine overall. Through a century of discovery, the success we enjoy at the present time is the result of the work of well-organized multidisciplinary teams following standardized protocols and thereby saving thousands of lives worldwide each year. With continuing innovation, the future is bright.
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Affiliation(s)
- Sonal Sharma
- Department of Anesthesiology and Perioperative Medicine, Pennsylvania State University, Milton S. Hershey Medical Center, 500 University Dr, Hershey, PA, 17033, USA
| | - Fuat H Saner
- Department of General, Visceral, and Transplant Surgery, Medical Center University Essen, Hufeland 55, 45147, Essen, Germany
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.
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27
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Martín LG, Vázquez-Garza JN, Grande AM, González MCM, Martín CF, Polo IDLH, Roux DP, Rojo MG, García FL. Postreperfusion Syndrome in Liver Transplant: A Risk Factor for Acute Kidney Failure: A Retrospective Analysis. Transplant Proc 2022; 54:2277-2284. [PMID: 36192211 DOI: 10.1016/j.transproceed.2022.08.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 07/29/2022] [Accepted: 08/26/2022] [Indexed: 10/07/2022]
Abstract
The maximum expression of hemodynamic instability during liver transplant is the so-called postreperfusion syndrome (PRS) that increases both overall mortality and postoperative complications. It was first defined by Aggarwal et al in 1987, but the results are still conflicting when establishing the relationship between PRS and acute kidney failure (AKF). We conducted a retrospective observational study of transplant recipients with deceased-donor liver grafts between January 2002 and December 2018. We analyzed the incidence of PRS and its potential negative impact over kidney function. A total of 551 transplants were analyzed. PRS was recorded in 130 patients (23.6%). The incidence of AKF was 61.5%. A total of 111 patients required kidney replacement therapy (32.7%). Regarding the severity of AKF, 128 patients were classified as acute kidney injury (AKI) 1 (23.2%), 76 as AKI 2 (13.8%), and 135 as AKI 3 (24.5%). In the group with PRS, 75.4% (n = 98) developed AKF vs 57.2% (n = 241) in the group without PRS. In the multivariate analysis we found a relationship between PRS and AKF with an odds ratio of 2.18 (95% CI, 1.30-3.64; P = .003), once adjusted by the length of the anhepatic phase, donor age, Model for End-Stage Liver Disease score, history of ascites, and need for early surgical reintervention. The incidence of AKF decreased (44.5%) ever since the implementation of delayed calcineurin inhibitors therapy and piggyback surgical technique, but a clear influence of the occurrence of PRS on the development of AKF is still observed, with an OR of 3.78 (95% CI, 1.92-7.43; P < .001), once adjusted by albumin and hemoglobin levels, Model for End-Stage Liver Disease score, and Child classification.
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Affiliation(s)
- L Gajate Martín
- Department of Anesthesiology and Critical Care, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | | | - A Martín Grande
- Department of Anesthesiology and Critical Care, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - M C Martín González
- Department of Anesthesiology and Critical Care, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - C Fernández Martín
- Department of Anesthesiology and Critical Care, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - I De la Hoz Polo
- Department of Anesthesiology and Critical Care, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - D Parise Roux
- Department of Anesthesiology and Critical Care, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - M Gómez Rojo
- Department of Anesthesiology and Critical Care, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - F Liaño García
- Department of Anesthesiology and Critical Care, Hospital Universitario Ramón y Cajal, Madrid, Spain; Department of Nephrology, Hospital Universitario Ramón y Cajal, Madrid, Spain
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28
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Scalera I, De Carlis R, Patrono D, Gringeri E, Olivieri T, Pagano D, Lai Q, Rossi M, Gruttadauria S, Di Benedetto F, Cillo U, Romagnoli R, Lupo LG, De Carlis L. How useful is the machine perfusion in liver transplantation? An answer from a national survey. Front Surg 2022; 9:975150. [PMID: 36211259 PMCID: PMC9535084 DOI: 10.3389/fsurg.2022.975150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Machine perfusion (MP) has been shown worldwide to offer many advantages in liver transplantation, but it still has some gray areas. The purpose of the study is to evaluate the donor risk factors of grafts, perfused with any MP, that might predict an ineffective MP setting and those would trigger post-transplant early allograft dysfunction (EAD). Data from donors of all MP-perfused grafts at six liver transplant centers have been analyzed, whether implanted or discarded after perfusion. The first endpoint was the negative events after perfusion (NegE), which is the number of grafts discarded plus those that were implanted but lost after the transplant. A risk factor analysis for NegE was performed and marginal grafts for MP were identified. Finally, the risk of EAD was analyzed, considering only implanted grafts. From 2015 to September 2019, 158 grafts were perfused with MP: 151 grafts were implanted and 7 were discarded after the MP phase because they did not reach viability criteria. Of 151, 15 grafts were lost after transplant, so the NegE group consisted of 22 donors. In univariate analysis, the donor risk index >1.7, the presence of hypertension in the medical history, static cold ischemia time, and the moderate or severe macrovesicular steatosis were the significant factors for NegE. Multivariate analysis confirmed that macrosteatosis >30% was an independent risk factor for NegE (odd ratio 5.643, p = 0.023, 95% confidence interval, 1.27–24.98). Of 151 transplanted patients, 34% experienced EAD and had worse 1- and 3-year-survival, compared with those who did not face EAD (NoEAD), 96% and 96% for EAD vs. 89% and 71% for NoEAD, respectively (p = 0.03). None of the donor/graft characteristics was associated with EAD even if the graft was moderately steatotic or fibrotic or from an aged donor. For the first time, this study shows that macrovesicular steatosis >30% might be a warning factor involved in the risk of graft loss or a cause of graft discard after the MP treatment. On the other hand, the MP seems to be useful in reducing the donor and graft weight in the development of EAD.
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Affiliation(s)
- Irene Scalera
- Hepatobiliary and Liver Transplant Unit, Department of Emergency and Organ Transplantation, University Hospital Policlinic of Bari, Bari, Italy
- Correspondence: Irene Scalera
| | - R. De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - D. Patrono
- General Surgery 2U-Liver Transplant Centre, A.O.U. “Città della Salute e della Scienza”, Turin, Italy
| | - E. Gringeri
- Hepatobiliary Surgery and Liver Transplantation Unit, University Hospital of Padua, Padua, Italy
| | - T. Olivieri
- Hepato-Pancreato-Biliary Surgery and Liver Transplant Center, University of Modena and Reggio Emilia, Modena, Italy
| | - D. Pagano
- Department for the Treatment and the Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT, UPMC, Palermo, Italy
- Department of Surgery and Medical and Surgical Specialties, University of Catania, Catania, Italy
| | - Q. Lai
- Liver Transplant Unit, Sapienza University of Rome, Rome, Italy
| | - M. Rossi
- Liver Transplant Unit, Sapienza University of Rome, Rome, Italy
| | - S. Gruttadauria
- Department for the Treatment and the Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT, UPMC, Palermo, Italy
- Department of Surgery and Medical and Surgical Specialties, University of Catania, Catania, Italy
| | - F. Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplant Center, University of Modena and Reggio Emilia, Modena, Italy
| | - U. Cillo
- Hepatobiliary Surgery and Liver Transplantation Unit, University Hospital of Padua, Padua, Italy
| | - R. Romagnoli
- General Surgery 2U-Liver Transplant Centre, A.O.U. “Città della Salute e della Scienza”, Turin, Italy
| | - L. G. Lupo
- Hepatobiliary and Liver Transplant Unit, Department of Emergency and Organ Transplantation, University Hospital Policlinic of Bari, Bari, Italy
| | - L. De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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29
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Ausania F, Borin A, Martinez-Perez A, Blasi A, Landi F, Colmenero J, Fuster J, Garcia-Valdecasas JC. Development of a preoperative score to predict surgical difficulty in liver transplantation. Surgery 2022; 172:1529-1536. [PMID: 36055816 DOI: 10.1016/j.surg.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/13/2022] [Accepted: 07/05/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND A difficulty score to predict intraoperative surgical complexity in liver transplantation has never been developed. The aim of this study was to assess factors associated with a difficult liver transplant and develop a score to predict difficult surgery. METHODS All patients undergoing deceased donor whole liver transplantation from 2012 to 2019 at a single center were included. Estimated intraoperative blood loss (mL/kg) and surgery duration (skin-to-arterial reperfusion time) were used as surrogates of difficulty. Based on these variables, the study population was divided into 2 groups: high risk and standard risk of difficulty. Univariate and multivariate analyses were performed to identify predictors associated with a demanding liver transplantation and develop a difficulty score. RESULTS A total of 515 patients were included in the study population, and 101 (20%) were considered difficult operations. Patients with a higher risk of difficulty showed a significantly higher rate of Clavien-Dindo ≥III complications (50.5% vs 24.4%, P = .001) and a longer hospital stay (19 vs 16 days, P = .001). Preoperative factors associated with difficulty were retransplantation (odds ratio 4.34, P = .001), preoperative portal vein thrombosis (odds ratio 3.419, P = .001), previous upper abdominal surgery (odds ratio 2.161, P = .003), spontaneous bacterial peritonitis (odds ratio 1.985, P < .02), and prior variceal bleeding (odds ratio 1.401, P = .051). A 10-point difficulty score was created, showing a negative predictive value of 84% at 4 points. CONCLUSION Difficult liver transplantation surgery, as assessed by skin-to-arterial reperfusion time and estimated blood loss, is associated with worse perioperative outcomes. We developed a simple score with clinical preoperative variables that predicts difficult surgery, and therefore, it may help to optimize allocation policies and perioperative logistics.
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Affiliation(s)
- Fabio Ausania
- Department of HPB and Transplant Surgery, Hospital Clinic, IDIBAPS, University of Barcelona, Spain. https://twitter.com/fabio_ausania
| | - Alex Borin
- Department of HPB and Transplant Surgery, Hospital Clinic, IDIBAPS, University of Barcelona, Spain; Department of General Surgery and Dentistry, Liver Transplant Unit, University and Hospital Trust of Verona, Italy.
| | | | - Anabel Blasi
- Department of Anesthesia, Hospital Clinic, IDIBAPS, University of Barcelona, Spain
| | - Filippo Landi
- Department of HPB and Transplant Surgery, Hospital Clinic, IDIBAPS, University of Barcelona, Spain
| | - Jordi Colmenero
- Liver Unit, Hospital Clinic, IDIBAPS, CIBERehd, University of Barcelona, Spain
| | - Josep Fuster
- Department of HPB and Transplant Surgery, Hospital Clinic, IDIBAPS, University of Barcelona, Spain
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30
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Sim J, Kwon H, Jun I, Kim S, Kim B, Kim S, Song J, Hwang G. Association between red blood cell distribution width and blood transfusion in patients undergoing living donor liver transplantation: propensity score analysis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:983-993. [DOI: 10.1002/jhbp.1163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/26/2022] [Accepted: 03/27/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Ji‐Hoon Sim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Hye‐Mee Kwon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - In‐Gu Jun
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Sung‐Hoon Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Bomi Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Sehee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Jun‐Gol Song
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Gyu‐Sam Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
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31
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Cho HY, Lee HJ, Kim WH, Lee HC, Jung CW, Hong SK, Yang SM. Influence of anesthesia type on post-reperfusion syndrome during liver transplantation: a single-center retrospective study. Anesth Pain Med (Seoul) 2022; 17:304-311. [PMID: 35918864 PMCID: PMC9346196 DOI: 10.17085/apm.21104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 03/03/2022] [Indexed: 11/23/2022] Open
Abstract
Background Post-reperfusion syndrome (PRS) results in sudden hemodynamic instability following graft reperfusion. Although PRS is known to influence outcomes following liver transplantation, little is known regarding the effects of anesthetics on PRS. This study investigated the association between the type of anesthetic agent and PRS in liver transplantation. Methods This single-center retrospective cohort study included patients who underwent liver transplantation between June 2016 and December 2019. Patients were divided into sevoflurane and propofol groups according to the anesthetic agent used. Stabilized inverse probability of treatment weighting (IPTW) analysis was performed to investigate the association between PRS identified based on blood pressure recordings and the type of anesthesia. Associations between the anesthetic agent and the duration of hypotension as well as early postoperative outcomes were also investigated. Results Data were analyzed for 398 patients, 304 (76.4%) and 94 (23.6%) of whom were anesthetized with propofol and sevoflurane, respectively. PRS developed in 40.7% of the 398 patients. Following stabilized IPTW analysis, the association with PRS was lower in the sevoflurane group than in the propofol group (odds ratio, 0.47; P = 0.018). However, there was no association between the type of anesthetic used and early postoperative outcomes. Conclusions The association of PRS was lower in the sevoflurane group than in the propofol group. However, there was no association between the type of anesthetic and the early postoperative outcomes. Further studies are required to determine the optimal anesthetic for liver transplantation.
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Affiliation(s)
- Hye-Yeon Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Chul-Woo Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seong-Mi Yang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
- Corresponding Author: Seong-Mi Yang, M.D. Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: +82-2-2072-2467, Fax: +82-2-747-8363 E-mail:
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Dewitte A, Defaye M, Dahmi A, Ouattara A, Joannes-Boyau O, Chermak F, Chiche L, Laurent C, Battelier M, Sigaut S, Khoy-Ear L, Grigoresco B, Cauchy F, Francoz C, Paugam Burtz C, Janny S, Weiss E. Prognostic Impact of Early Recovering Acute Kidney Injury Following Liver Transplantation: A Multicenter Retrospective Study. Transplantation 2022; 106:781-791. [PMID: 34172644 DOI: 10.1097/tp.0000000000003865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication after liver transplantation (LT), but the specific impact of rapidly resolving AKI is not elucidated. This study investigates the factors associated with early recovery from AKI and its association with post-LT outcomes. METHODS Retrospective analysis of 441 liver transplant recipients with end-stage liver disease without pretransplant renal impairment. AKI was defined according to Kidney Disease Improving Global Outcomes criteria and early renal recovery by its disappearance within 7 d post-LT. RESULTS One hundred forty-six patients (32%) developed a post-LT AKI, of whom 99 (69%) recovered early and 45 (31%) did not. Factors associated with early recovery were Kidney Disease Improving Global Outcomes stage 1 (odds ratio [OR],14.11; 95% confidence interval [CI], 5.59-40.22; P < 0.0001), minimum prothrombin time >50 % (OR, 4.50; 95% CI, 1.67-13.46; P = 0.003) and aspartate aminotransferase peak value <1000 U/L (OR, 4.07; 95% CI, 1.64-10.75; P = 0.002) within 48 h post-LT. Patients with early recovery had a renal prognosis similar to that of patients without AKI with no difference in estimated glomerular filtration rate between day 7 and 1 y. Their relative risk of developing chronic kidney disease was 0.88 (95% CI, 0.55-1.41; P = 0.6) with survival identical to patients without AKI and better than patients without early recovery (P < 0.0001). CONCLUSIONS Most patients with post-LT AKI recover early and have a similar renal prognosis and survival to those without post-LT AKI. Factors associated with early renal recovery are related to the stage of AKI, the extent of liver injury, and the early graft function. Patients at risk of not recovering may benefit the most from perioperative protective strategies, particularly those aimed at minimizing the adverse effects of calcineurin inhibitors.
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Affiliation(s)
- Antoine Dewitte
- Department of Anaesthesia and Critical Care, CHU de Bordeaux, Pessac, France
- University of Bordeaux, CNRS, Immunoconcept, U5164, Bordeaux, France
| | - Mylène Defaye
- Department of Anaesthesia and Critical Care, CHU de Bordeaux, Pessac, France
| | - Anissa Dahmi
- Department of Anaesthesia and Critical Care, CHU de Bordeaux, Pessac, France
| | - Alexandre Ouattara
- Department of Anaesthesia and Critical Care, CHU de Bordeaux, Pessac, France
- University of Bordeaux, INSERM, Biology of Cardiovascular Diseases, U1034, Bordeaux, France
| | | | - Faiza Chermak
- Department of Hepatology, CHU de Bordeaux, Pessac, France
| | | | | | - Mathieu Battelier
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Stéphanie Sigaut
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Linda Khoy-Ear
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Bénédicte Grigoresco
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - François Cauchy
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, DMU Digest, AP-HP.Nord, Clichy, France
- Inserm UMR_S 1149, Centre de Recherche Sur L'inflammation, Paris, France
| | - Claire Francoz
- Inserm UMR_S 1149, Centre de Recherche Sur L'inflammation, Paris, France
- Liver Unit, Beaujon Hospital, Clichy, France
| | - Catherine Paugam Burtz
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Clichy, France
- Inserm UMR_S 1149, Centre de Recherche Sur L'inflammation, Paris, France
- University of Paris, Paris, France
| | - Sylvie Janny
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Clichy, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP.Nord, Clichy, France
- Inserm UMR_S 1149, Centre de Recherche Sur L'inflammation, Paris, France
- University of Paris, Paris, France
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[Kidney failure after liver transplantation]. Nephrol Ther 2022; 18:89-103. [PMID: 35151596 DOI: 10.1016/j.nephro.2021.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/11/2021] [Accepted: 11/06/2021] [Indexed: 02/06/2023]
Abstract
One third of cirrhotic patients present impaired kidney function. It has multifactorial causes and has a harmful effect on patients' morbi-mortality before and after liver transplant. Kidney function does not improve in all patients after liver transplantation and liver-transplant recipients are at high risk of developing chronic kidney disease. Causes for renal dysfunction can be divided in three groups: preoperative, peroperative and postoperative factors. To date, there is no consensus for the modality of evaluation the risk for chronic kidney disease after liver transplantation, and for its prevention. In the present review, we describe the outcome of kidney function after liver transplantation, and the prognostic factors of chronic kidney disease to determine a risk stratification for each patient. Furthermore, we discuss therapeutic options to prevent kidney dysfunction in this setting, and highlight the indications of combined liver-kidney transplantation.
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Umehara K, Karashima Y, Yoshizumi T, Yamaura K. Factors Associated With Postreperfusion Syndrome in Living Donor Liver Transplantation: A Retrospective Study. Anesth Analg 2022; 135:354-361. [PMID: 35343925 DOI: 10.1213/ane.0000000000006002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postreperfusion syndrome (PRS) after portal vein reperfusion during liver transplantation (LT) has been reported to cause rapid hemodynamic changes and is associated with a prolonged postoperative hospital stay, renal failure, and increased mortality. Although there are some reports on risk factors for PRS in brain-dead donor LT, there are a few reports on those in living donor LT. Therefore, we retrospectively reviewed the factors associated with PRS to contribute to the anesthetic management so as to reduce PRS during living donor LT. METHODS After approval by the ethics committee of our institution, 250 patients aged ≥20 years who underwent living donor LT at our institution between January 2013 and September 2018 were included in the study. A decrease in mean arterial pressure of ≥30% within 5 minutes after portal vein reperfusion was defined as PRS, and estimates and odds ratio (OR) for PRS were calculated using logistic regression. The backward method was used for variable selection in the multivariable analysis. RESULTS Serum calcium ion concentration before reperfusion (per 0.1 mmol/L increase; OR, 0.74; 95% confidence interval (CI), 0.60-0.95; P < .001), preoperative echocardiographic left ventricular end-diastolic diameter (per 1-mm increase: OR, 0.90; 95% CI, 0.85-0.95; P < .001, men [versus women: OR, 2.45; 95% CI, 1.26-4.75; P = .008]), mean pulmonary artery pressure before reperfusion (restricted cubic spline, P = .003), anhepatic period (restricted cubic spline, P = .02), and graft volume to standard liver volume ratio (restricted cubic spline, P = .03) were significantly associated with PRS. CONCLUSIONS In living donor LT, male sex and presence of small left ventricular end-diastolic diameter, large graft volume, and long anhepatic period are associated with PRS, and a high calcium ion concentration and low pulmonary artery pressure before reperfusion are negatively associated with PRS.
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Affiliation(s)
- Kaoru Umehara
- From the Operating Rooms, Kyushu University Hospital, Fukuoka, Japan
| | - Yuji Karashima
- From the Operating Rooms, Kyushu University Hospital, Fukuoka, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ken Yamaura
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Park M, Park IH, Kim GS. The Requirement of Isoflurane and Remifentanil During Liver Transplantation Using Bispectral Index and Surgical Pleth Index: An Observational Study. Transplant Proc 2022; 54:726-730. [PMID: 35241299 DOI: 10.1016/j.transproceed.2021.12.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/07/2021] [Accepted: 12/27/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND During liver transplantation (LT), patients and surgical factors potentially influence the pharmacokinetics of the anesthetic agents. The aim of this study was to investigate the requirement of isoflurane and remifentanil according to severity of liver disease during LT under balanced anesthesia. METHODS We enrolled 44 patients undergoing LT. Anesthetic depth was maintained within the bispectral index score of 40 to 60 and Surgical Pleth Index of 20 to 60. Patients were divided into 2 groups according to their median Model for End-Stage Liver Disease (MELD) score: low MELD group and high MELD group. We compared end-tidal inhaled anesthetics and remifentanil consumption. RESULTS Patients were divided into 2 groups according to median value of MELD score: MELD score <16 (low MELD group; n = 20) or MELD ≥16 (high MELD group; n = 20). There was no significant difference between the 2 groups in end-tidal concentration of isoflurane during 3 phases. However, the remifentanil requirement was lower in the high MELD group during the dissection and anhepatic phases (mean (SD), 0.105 (0.067) vs 0.064 (0.055) µg/kg/min; P = .037, and 0.167 (0.096) vs 0.108 (0.079) µg/kg/min; P = .039, respectively; low MELD group vs high MELD group) with no significant difference during the neohepatic phase. CONCLUSIONS The severity of liver dysfunction based on MELD score affected the intraoperative remifentanil requirement during LT. Patients with cirrhosis are required to use analgesics appropriate to their individual patient characteristics in clinical practice.
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Affiliation(s)
- MiHye Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - I Hyun Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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Bekki Y, Myers B, Wang R, Smith N, Zerillo J, Rocha C, Tabrizian P, Moon J, Arvelakis A, Facciuto ME, DeMaria S, Florman S. Postreperfusion syndrome in liver transplantation: Outcomes, predictors, and application for recipient selection. Clin Transplant 2022; 36:e14587. [PMID: 34997798 DOI: 10.1111/ctr.14587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/07/2021] [Accepted: 01/04/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND This study aimed to identify risk factors for postreperfusion syndrome (PRS) and its impact on LT outcomes. METHODS Data analysis was performed in 1021 adult patients undergoing donation after brain death (DBD) LT to identify PRS incidence, the risk factors for PRS development, and its impact on LT outcomes. RESULTS The overall incidence of PRS was 16.1%. Independent risk factors for PRS included donor age (odds ratio (OR) 1.01, p = 0.02), donor body mass index (BMI) (OR 1.04, p = 0.003), moderate macrosteatosis (OR 2.48, p = 0.02), and cold ischemia time (CIT) (OR 1.06, p = 0.02). On multivariable analysis for 30-day graft failure, PRS (hazard ratio (HR) 3.49; p<0.001) and Model for End-stage Liver Disease (MELD) score (HR 1.01; p = 0.05) were independent risk factors. Patients were categorized into 4 distinct groups based on PRS risk groups and MELD groups, which showed different 1-year graft survival (p<0.001). There were comparable outcomes between low PRS risk - high MELD and high PRS risk - low MELD group (p = 0.33). CONCLUSIONS donor age, donor BMI, moderate macrosteatosis, and CIT were identified as risk factors for the development of PRS in LT using DBD grafts. PRS risk evaluation may improve donor-to-recipient matching based on their MELD scores. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Yuki Bekki
- Recanati-Miller Transplantation Institute, the Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Bryan Myers
- Division of General Surgery, Department of Surgery, Mount Sinai School of Medicine, New York City, New York, USA
| | - Ryan Wang
- Department of Anesthesiology, Perioperative and Pain Medicine, the Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Natalie Smith
- Department of Anesthesiology, Perioperative and Pain Medicine, the Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Jeron Zerillo
- Department of Anesthesiology, Perioperative and Pain Medicine, the Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Chiara Rocha
- Recanati-Miller Transplantation Institute, the Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Parissa Tabrizian
- Recanati-Miller Transplantation Institute, the Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Jang Moon
- Recanati-Miller Transplantation Institute, the Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Antonios Arvelakis
- Recanati-Miller Transplantation Institute, the Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Marcelo E Facciuto
- Recanati-Miller Transplantation Institute, the Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Samuel DeMaria
- Department of Anesthesiology, Perioperative and Pain Medicine, the Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Sander Florman
- Recanati-Miller Transplantation Institute, the Icahn School of Medicine at Mount Sinai, New York City, New York, USA
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37
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Lee S, Kim HY, Kim GS. Comparison of the Incidence of Postreperfusion Syndrome During Liver Transplantation Between Radial and Femoral Artery. Transplant Proc 2022; 54:409-411. [DOI: 10.1016/j.transproceed.2021.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/23/2021] [Accepted: 12/27/2021] [Indexed: 10/19/2022]
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38
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Lapisatepun W, Agopian VG, Xia VW, Lapisatepun W. Impact of the Share 35 Policy on Perioperative Management and Mortality in Liver Transplantation Recipients. Ann Transplant 2021; 26:e932895. [PMID: 34711796 PMCID: PMC8562012 DOI: 10.12659/aot.932895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background The Share 35 policy was introduced in 2013 by the Organ Procurement and Transplantation Network (OPTN) to increase opportunities of sicker patients to access liver transplantation. However, it has the disadvantage of higher MELD score associated with adverse postoperative transplant outcomes. Early data after implementation of the Share 35 policy showed significantly poorer post-transplantation survival in some UNOS regions. We aimed to analyze the impact of Share 35 on demographics of patients, perioperative management, and perioperative mortality. Material/Methods A retrospective analysis of data was performed from an institutional liver transplantation cohort from 1 January 2008 to 31 December 2017. Adult patients who underwent liver transplantation before 2013 were defined as the pre-Share 35 group and the other group was defined as the post-Share 35 group. The MELD score of each patient was calculated at the time of transplantation. Perioperative mortality was defined as death within 30 days after the operation. Results A total of 1596 patients underwent liver transplantation. Of those, 895 recipients underwent OLT in the pre-Share 35 era and 737 in the post-Share 35 era. The median MELD score was significantly higher in the post-Share 35 group (30 vs 26, P<0.001) and 45.7% of the post-Share 35 group had MELD scores ≥35. In intraoperative management, patients required significantly more blood component transfusion, intraoperative vasopressor, and fluid replacement. Veno-venous bypass (VVB) usage was significantly higher in the post-Share 35 era (47.2% vs 38.1%, P<0.001). In the subgroup of patients with MELD scores ≥35, the median waiting time was significantly shorter (18.5 vs 14.5 days, P=0.045). Overall perioperative mortality was not significantly difference between groups (P=0.435). Conclusions After implementation of the Share 35 policy, we performed liver transplantation in significantly higher medical acuity patients, which required more medical resources to obtain a result comparable to that of the pre-Share 35 era.
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Affiliation(s)
- Warangkana Lapisatepun
- Department of Anesthesiology, Ronald Reagan University of California Los Angeles Medical Center, David Geffen School of Medicine, Los Angeles, CA, USA.,Department of Anesthesiology, Chiangmai University, Muang, Thailand
| | - Vatche G Agopian
- Department of Surgery, Ronald Reagan University of California Los Angeles Medical Center, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Victor W Xia
- Department of Anesthesiology, Ronald Reagan University of California Los Angeles Medical Center, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Worakitti Lapisatepun
- Department of Surgery, Ronald Reagan University of California Los Angeles Medical Center, David Geffen School of Medicine, Los Angeles, CA, USA.,Department of Surgery, Chiangmai University, Muang, Thailand
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Bezinover D, Mukhtar A, Wagener G, Wray C, Blasi A, Kronish K, Zerillo J, Tomescu D, Pustavoitau A, Gitman M, Singh A, Saner FH. Hemodynamic Instability During Liver Transplantation in Patients With End-stage Liver Disease: A Consensus Document from ILTS, LICAGE, and SATA. Transplantation 2021; 105:2184-2200. [PMID: 33534523 DOI: 10.1097/tp.0000000000003642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemodynamic instability (HDI) during liver transplantation (LT) can be difficult to manage and increases postoperative morbidity and mortality. In addition to surgical causes of HDI, patient- and graft-related factors are also important. Nitric oxide-mediated vasodilatation is a common denominator associated with end-stage liver disease related to HDI. Despite intense investigation, optimal management strategies remain elusive. In this consensus article, experts from the International Liver Transplantation Society, the Liver Intensive Care Group of Europe, and the Society for the Advancement of Transplant Anesthesia performed a rigorous review of the most current literature regarding the epidemiology, causes, and management of HDI during LT. Special attention has been paid to unique LT-associated conditions including the causes and management of vasoplegic syndrome, cardiomyopathies, LT-related arrhythmias, right and left ventricular dysfunction, and the specifics of medical and fluid management in end-stage liver disease as well as problems specifically related to portal circulation. When possible, management recommendations are made.
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Affiliation(s)
- Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Pennsylvania State University, Penn State Health, Milton S. Hershey Medical Center, Hershey, PA. Represents ILTS and LICAGE
| | - Ahmed Mukhtar
- Department of Anesthesia and Surgical Intensive Care, Cairo University, Almanyal, Cairo, Egypt. Represents LICAGE
| | - Gebhard Wagener
- Department of Anesthesiology, Columbia University Medical Center, New York, NY. Represents SATA and ILTS
| | - Christopher Wray
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA. Represents SATA
| | - Annabel Blasi
- Department of Anesthesia, IDIBAPS (Institut d´investigació biomèdica Agustí Pi i Sunyé) Hospital Clinic, Villaroel, Barcelona, Spain. Represents LICAGE and ILTS
| | - Kate Kronish
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA. Represents SATA
| | - Jeron Zerillo
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY. Represents SATA and ILTS
| | - Dana Tomescu
- Department of Anesthesiology and Intensive Care, Carol Davila University of Medicine and Pharmacy, Fundeni Clinical Institute, Bucharest, Romania. Represents LICAGE
| | - Aliaksei Pustavoitau
- Department of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Johns Hopkins School of Medicine, Baltimore, MD. Represents ILTS
| | - Marina Gitman
- Department of Anesthesiology, University of Illinois Hospital, Chicago, IL. Represents SATA and ILTS
| | - Anil Singh
- Department of Liver Transplant and GI Critical Care, Sir HN Reliance Foundation Hospital, Cirgaon, Mumbai, India. Represents ILTS
| | - Fuat H Saner
- Department of General, Visceral and Transplant Surgery, Essen University Medical Center, Essen, Germany. Represents LICAGE
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Abstract
One-third of patients with cirrhosis present kidney failure (AKI and CKD). It has multifactorial causes and a harmful effect on morbidity and mortality before and after liver transplantation. Kidney function does not improve in all patients after liver transplantation, and liver transplant recipients are at a high risk of developing chronic kidney disease. The causes of renal dysfunction can be divided into three groups: pre-operative, perioperative and post-operative factors. To date, there is no consensus on the modality to evaluate the risk of chronic kidney disease after liver transplantation, or for its prevention. In this narrative review, we describe the outcome of kidney function after liver transplantation, and the prognostic factors of chronic kidney disease in order to establish a risk categorization for each patient. Furthermore, we discuss therapeutic options to prevent kidney dysfunction in this context, and highlight the indications of combined liver–kidney transplantation.
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Milani S, Jafari M, Afzal Aghaee M, Sabzevari A. Correlation of Deceased Donor Factors to Postreperfusion Severe Hyperglycemia in Adult Patients Undergoing Liver Transplant. EXP CLIN TRANSPLANT 2021; 19:1058-1062. [PMID: 34387155 DOI: 10.6002/ect.2021.0140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES In this study, our objective was to identify perioperative factors associated with postreperfusion severe hyperglycemia, with a particular focus on deceased donor factors. MATERIALS AND METHODS Perioperative data from 100 patients without diabetes who were undergoing liver transplant from deceased donors were reviewed. Mean blood glucose levels were calculated at each liver transplant surgical phase, with a cutoff level of 12.7 mmol/L (230 mg/dL) during the neo-hepatic phase defined as postreperfusion severe hyperglycemia. Patients were divided into those with and without postreperfusion severe hyperglycemia. Selected perioperative variables were compared between the 2 groups. RESULTS Of 100 patients, 55 developed postreperfusion severe hyperglycemia. Among donor variables, a statistically significant difference between groups was only shown for graft-to-recipient liver weight ratio (P < .001). With regard to preoperative recipient variables, the 2 groups showed a significant difference in mean age (P = .001). Patients in the postreperfusion severe hyperglycemia group required significantly more packed red blood cell transfusions (P = .002), sodium bicarbonate (P = .054), and vasopressors (P = .002) during the operation. Moreover, in terms of laboratory findings, although the last arterial pH was acceptable in both groups, a last lower arterial pH was observed in patients with postreperfusion severe hyperglycemia (P = .011). Higher mean blood glucose levels were detected in the postre - perfusion hyperglycemia group during the preanhepatic and anhepatic phases (P = .024, P = .001, respectively). CONCLUSIONS In patients undergoing liver transplant, incidence of postreperfusion severe hyperglycemia was influenced by graft-to-recipient liver weight ratio. Furthermore, postreperfusion severe hyperglycemia was associated with intraoperative clinical and laboratory disturbances in liver transplant recipients.
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Affiliation(s)
- Soheila Milani
- From the Department of Anesthesia and Intensive Care, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Larivière J, Giard JM, Zuo RM, Massicotte L, Chassé M, Carrier FM. Association between intraoperative fluid balance, vasopressors and graft complications in liver transplantation: A cohort study. PLoS One 2021; 16:e0254455. [PMID: 34242370 PMCID: PMC8270449 DOI: 10.1371/journal.pone.0254455] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 06/26/2021] [Indexed: 01/08/2023] Open
Abstract
Introduction Biliary complications following liver transplantation are common. The effect of intraoperative fluid balance and vasopressors on these complications is unknown. Materials and methods We conducted a cohort study between July 2008 and December 2017. Our exposure variables were the total intraoperative fluid balance and the use of vasopressors on ICU admission. Our primary outcome was any biliary complication (anastomotic and non-anastomotic strictures) up to one year after transplantation. Our secondary outcomes were vascular complications, primary graft non-function and survival. Results We included 562 consecutive liver transplantations. 192 (34%) transplants had a biliary complication, 167 (30%) had an anastomotic stricture and 56 had a non-anastomotic stricture (10%). We did not observe any effect of intraoperative fluid balance or vasopressor on biliary complications (HR = 0.97; 95% CI, 0.93 to 1.02). A higher intraoperative fluid balance was associated with an increased risk of primary graft non-function (non-linear) and a lower survival (HR = 1.40, 95% CI, 1.14 to 1.71) in multivariable analyses. Conclusion Intraoperative fluid balance and vasopressors upon ICU admission were not associated with biliary complications after liver transplantation but may be associated with other adverse events. Intraoperative hemodynamic management must be prospectively studied to further assess their impact on liver recipients’ outcomes.
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Affiliation(s)
- Jordan Larivière
- Department of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Jeanne-Marie Giard
- Department of Medicine—Liver Diseases Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Rui Min Zuo
- Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Luc Massicotte
- Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Michaël Chassé
- Department of Medicine–Intensive Care Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - François Martin Carrier
- Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
- Department of Medicine–Intensive Care Division, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
- Carrefour de l’innovation, Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), Montréal, Québec, Canada
- * E-mail:
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Perioperative ABO Blood Group Isoagglutinin Titer and the Risk of Acute Kidney Injury after ABO-Incompatible Living Donor Liver Transplantation. J Clin Med 2021; 10:jcm10081679. [PMID: 33919744 PMCID: PMC8070732 DOI: 10.3390/jcm10081679] [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: 02/27/2021] [Revised: 04/04/2021] [Accepted: 04/10/2021] [Indexed: 01/28/2023] Open
Abstract
For ABO-incompatible liver transplantation (ABO-i LT), therapeutic plasma exchange (TPE) is performed preoperatively to reduce the isoagglutinin titer of anti-ABO blood type antibodies. We evaluated whether perioperative high isoagglutinin titer is associated with postoperative risk of acute kidney injury (AKI). In 130 cases of ABO-i LT, we collected immunoglobulin (Ig) G and Ig M isoagglutinin titers of baseline, pre-LT, and postoperative peak values. These values were compared between the patients with and without postoperative AKI. Multivariable logistic regression analysis was used to evaluate the association between perioperative isoagglutinin titers and postoperative AKI. Clinical and graft-related outcomes were compared between high and low baseline and postoperative peak isoagglutinin groups. The incidence of AKI was 42.3%. Preoperative baseline and postoperative peak isoagglutinin titers of both Ig M and Ig G were significantly higher in the patients with AKI than those without AKI. Multivariable logistic regression analysis showed that preoperative baseline and postoperative peak Ig M isoagglutinin titers were significantly associated with the risk of AKI (baseline: odds ratio 1.06, 95% confidence interval 1.02 to 1.09; postoperative peak: odds ratio 1.08, 95% confidence interval 1.04 to 1.13). Cubic spline function curves show a positive relationship between the baseline and postoperative peak isoagglutinin titers and the risk of AKI. Clinical outcomes other than AKI were not significantly different according to the baseline and postoperative peak isoagglutinin titers. Preoperative high initial and postoperative peak Ig M isoagglutinin titers were significantly associated with the development of AKI. As the causal relationship between high isoagglutinin titers and risk of AKI is unclear, the high baseline and postoperative isoagglutinin titers could be used simply as a warning sign for the risk of AKI after liver transplantation.
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Rayar M, Beaurepaire JM, Bajeux E, Hamonic S, Renard T, Locher C, Desfourneaux V, Merdrignac A, Bergeat D, Lakehal M, Sulpice L, Houssel-Debry P, Jezequel C, Camus C, Bardou-Jacquet E, Meunier B. Hypothermic Oxygenated Perfusion Improves Extended Criteria Donor Liver Graft Function and Reduces Duration of Hospitalization Without Extra Cost: The PERPHO Study. Liver Transpl 2021; 27:349-362. [PMID: 33237618 DOI: 10.1002/lt.25955] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/19/2020] [Accepted: 11/05/2020] [Indexed: 12/14/2022]
Abstract
Few studies have evaluated the efficacy or the cost of hypothermic oxygenated perfusion (HOPE) in the conservation of extended criteria donor (ECD) grafts from donation after brain death (DBD) donors during liver transplantation (LT). We performed a prospective, monocentric study (NCT03376074) designed to evaluate the interest of HOPE for ECD-DBD grafts. For comparison, a control group was selected after propensity score matching among patients who received transplants between 2010 and 2017. Between February and November 2018, the HOPE procedure was used in 25 LTs. Immediately after LT, the median aspartate aminotransferase (AST) level was significantly lower in the HOPE group (724UI versus 1284UI; P = 0.046) as were the alanine aminotransferase (ALT; 392UI versus 720UI; P = 0.01), lactate (2.2 versus 2.7; P = 0.01) There was a significant reduction in intensive care unit stay (3 versus 5 days; P = 0.01) and hospitalization (15 versus 20 days; P = 0.01). The incidence of early allograft dysfunction (EAD; 28% versus 42%; P = 0.22) was similar . A level of AST or ALT in perfusate >800UI was found to be highly predictive of EAD occurrence (areas under the curve, 0.92 and 0.91, respectively). The 12-month graft (88% versus 89.5%; P = 1.00) and patient survival rates (91% versus 91.3%; P = 1.00) were similar. The additional cost of HOPE was estimated at € 5298 per patient. The difference between costs and revenues, from the hospital's perspective, was not different between the HOPE and control groups (respectively, € 3023 versus € 4059]; IC, -€ 5470 and € 8652). HOPE may improve ECD graft function and reduce hospitalization stay without extra cost. These results must be confirmed in a randomized trial.
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Affiliation(s)
- Michel Rayar
- Service de Chirurgie Hépato-Biliaire et DigestiveCHU RennesRennesFrance
- Faculté de MédecineUniversité Rennes 1RennesFrance
- INSERM, CIC 1414RennesFrance
| | | | - Emma Bajeux
- Service d'Epidémiologie et de Santé PubliqueCHU RennesRennesFrance
| | | | - Thomas Renard
- Service de Chirurgie Hépato-Biliaire et DigestiveCHU RennesRennesFrance
| | - Clara Locher
- Faculté de MédecineUniversité Rennes 1RennesFrance
- Service de Pharmacologie Clinique, Centre Hospitalo- Universitaire RennesRennesFrance
| | | | - Aude Merdrignac
- Service de Chirurgie Hépato-Biliaire et DigestiveCHU RennesRennesFrance
- Faculté de MédecineUniversité Rennes 1RennesFrance
| | - Damien Bergeat
- Service de Chirurgie Hépato-Biliaire et DigestiveCHU RennesRennesFrance
| | - Mohamed Lakehal
- Service de Chirurgie Hépato-Biliaire et DigestiveCHU RennesRennesFrance
| | - Laurent Sulpice
- Service de Chirurgie Hépato-Biliaire et DigestiveCHU RennesRennesFrance
- Faculté de MédecineUniversité Rennes 1RennesFrance
| | | | - Caroline Jezequel
- Service des Maladies du FoieCentre Hospitalo-Universitaire RennesRennesFrance
| | - Christophe Camus
- Service de Maladies Infectieuses et Réanimation MédicaleCHU RennesRennesFrance
| | - Edouard Bardou-Jacquet
- Faculté de MédecineUniversité Rennes 1RennesFrance
- INSERM, CIC 1414RennesFrance
- Service des Maladies du FoieCentre Hospitalo-Universitaire RennesRennesFrance
| | - Bernard Meunier
- Service de Chirurgie Hépato-Biliaire et DigestiveCHU RennesRennesFrance
- Faculté de MédecineUniversité Rennes 1RennesFrance
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Smith NK, Zerillo J, Kim SJ, Efune GE, Wang C, Pai SL, Chadha R, Kor TM, Wetzel DR, Hall MA, Burton KK, Fukazawa K, Hill B, Spad MA, Wax DB, Lin HM, Liu X, Odeh J, Torsher L, Kindscher JD, Mandell MS, Sakai T, DeMaria S. Intraoperative Cardiac Arrest During Adult Liver Transplantation: Incidence and Risk Factor Analysis From 7 Academic Centers in the United States. Anesth Analg 2021; 132:130-139. [PMID: 32167977 DOI: 10.1213/ane.0000000000004734] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intraoperative cardiac arrest (ICA) has a reported frequency of 1 in 10,000 anesthetics but has a much higher estimated incidence in orthotopic liver transplantation (OLT). Single-center studies of ICA in OLT are limited by small sample size that prohibits multivariable regression analysis of risks. METHODS Utilizing data from 7 academic medical centers, we performed a retrospective, observational study of 5296 adult liver transplant recipients (18-80 years old) between 2000 and 2017 to identify the rate of ICA, associated risk factors, and outcomes. RESULTS ICA occurred in 196 cases (3.7% 95% confidence interval [CI], 3.2-4.2) and mortality occurred in 62 patients (1.2%). The intraoperative mortality rate was 31.6% in patients who experienced ICA. In a multivariable generalized linear mixed model, ICA was associated with body mass index (BMI) <20 (odds ratio [OR]: 2.04, 95% CI, 1.05-3.98; P = .0386), BMI ≥40 (2.16 [1.12-4.19]; P = .022), Model for End-Stage Liver Disease (MELD) score: (MELD 30-39: 1.75 [1.09-2.79], P = .02; MELD ≥40: 2.73 [1.53-4.85], P = .001), postreperfusion syndrome (PRS) (3.83 [2.75-5.34], P < .001), living donors (2.13 [1.16-3.89], P = .014), and reoperation (1.87 [1.13-3.11], P = .015). Overall 30-day and 1-year mortality were 4.18% and 11.0%, respectively. After ICA, 30-day and 1-year mortality were 43.9% and 52%, respectively, compared to 2.6% and 9.3% without ICA. CONCLUSIONS We established a 3.7% incidence of ICA and a 1.2% incidence of intraoperative mortality in liver transplantation and confirmed previously identified risk factors for ICA including BMI, MELD score, PRS, and reoperation and identified new risk factors including living donor and length of surgery in this multicenter retrospective cohort. ICA, while rare, is associated with high intraoperative mortality, and future research must focus on therapy to reduce the incidence of ICA.
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Affiliation(s)
- Natalie K Smith
- From the Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Jeron Zerillo
- From the Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Sang Jo Kim
- Department of Anesthesiology, Hospital for Special Surgery, New York City, New York
| | - Guy E Efune
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Cynthia Wang
- Department of Anesthesiology, Greater Los Angeles VA Healthcare System, Los Angeles, California
| | - Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Todd M Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - David R Wetzel
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael A Hall
- Department of Anesthesiology, Christiana Care Health System, Newark, Delaware
| | - Kristen K Burton
- Department of Anesthesiology and Critical Care, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kyota Fukazawa
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Bryan Hill
- Department of Anesthesiology, The Ohio State University, Columbus, Ohio
| | | | - David B Wax
- From the Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, The Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Xiaoyu Liu
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas
| | - Jaffer Odeh
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Laurence Torsher
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - James D Kindscher
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas
| | - M Susan Mandell
- Department of Anesthesiology, University of Colorado Hospital, Aurora, Colorado.,The Center for Perioperative & Pain Quality, Safety and Outcomes-PPQiSO, University of Washington Medical Center, Seattle, Washington
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Samuel DeMaria
- From the Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai, New York City, New York
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Addeo P, Schaaf C, Noblet V, Faitot F, Lebas B, Mahoudeau G, Besch C, Serfaty L, Bachellier P. The learning curve for piggyback liver transplantation: identifying factors challenging surgery. Surgery 2020; 169:974-982. [PMID: 33143932 DOI: 10.1016/j.surg.2020.09.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/05/2020] [Accepted: 09/26/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study aimed to quantify the learning curve of piggyback liver transplantation and to identify factors that impact the operative time and blood transfusion during the learning curve. METHODS A retrospective review was performed on consecutive cases of patients' first piggyback liver transplantations that were performed by a single surgeon. The learning curve for the operative time was evaluated using the cumulative sum method. RESULTS There were 181, consecutive, first-time piggyback liver transplantations. The median operative time was 345 minutes (range: 180-745 minutes) with a median transfusion rate of 4 packed red blood cell units (range: 0-23 units). The cumulative sum learning curve identified 3 phases: an initial phase (1-70 piggyback liver transplantations), a plateau phase (71-101 piggyback liver transplantations), and a stable phase (102-181 piggyback liver transplantations). Over the 3 phases, there were significant decreases in the median duration of the surgery (388.8 vs 344.8 vs 326.9 minutes; P = .004, P = .0004, P ≤ .0001) and the number of red blood cell units transfused (6.00 vs 3.90 vs 3.71; P = .02, P = .79, P = .0006). Multivariable analysis identified that the following factors impacted the operative time: surgeon experience (P = .00006), previous upper abdominal surgery (P = .01), portocaval shunt fashioning (P = .0003), early portal section (P = .00001), multiple arterial graft reconstruction (P = .03), and the length of the retrohepatic inferior vena covered by segment 1 (P = .0006). Independent risk factors for increased blood loss were surgeon experience (P = .0001), previous upper abdominal surgery (P = .002), the retrohepatic inferior vena cava encirclement by segment 1 (P = .0001), severe portal hypertension (P = .01), early portal section (P = .001), and low prothrombin time (P = .00001). CONCLUSION Easily identifiable factors related to recipients (segment 1 morphology, previous upper abdominal surgery, severe portal hypertension) and to surgeon (operative experience, portocaval shunt fashioning, early portal section, and multiple arterial reconstructions) impact operative time and blood loss during the learning curve of piggyback liver transplantation. These factors can be used for grading the difficulties of liver transplantation to tailor the surgical strategy.
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Affiliation(s)
- Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France; ICube, Université de Strasbourg, CNRS UMR 7357, Illkirch, France.
| | - Caroline Schaaf
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
| | - Vincent Noblet
- ICube, Université de Strasbourg, CNRS UMR 7357, Illkirch, France
| | - François Faitot
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France; ICube, Université de Strasbourg, CNRS UMR 7357, Illkirch, France
| | - Benjamin Lebas
- Department of Anesthesiology, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
| | - Gilles Mahoudeau
- Department of Anesthesiology, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
| | - Camille Besch
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France; Hepatology Department, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
| | - Lawrence Serfaty
- Hepatology Department, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
| | - Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
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Effects of Intraoperative Fluid Balance During Liver Transplantation on Postoperative Acute Kidney Injury: An Observational Cohort Study. Transplantation 2020; 104:1419-1428. [PMID: 31644490 DOI: 10.1097/tp.0000000000002998] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Liver transplant recipients suffer many postoperative complications. Few studies evaluated the effects of fluid management on these complications. We conducted an observational cohort study to evaluate the association between intraoperative fluid balance and postoperative acute kidney injury (AKI) and other postoperative complications. METHODS We included consecutive adult liver transplant recipients who had their surgery between July 2008 and December 2017. Our exposure was intraoperative fluid balance, and our primary outcome was the grade of AKI at 48 hours after surgery. Our secondary outcomes were the grade of AKI at 7 days, the need for postoperative renal replacement therapy, postoperative red blood cell transfusions, time to first extubation, time to discharge from the intensive care unit (ICU), and 1-year survival. Every analysis was adjusted for potential confounders. RESULTS We included 532 transplantations in 492 patients. We observed no effect of fluid balance on either 48-hour AKI, 7-day AKI, or on the need for postoperative renal replacement therapy after adjustments for confounders. A higher fluid balance increased the time to ICU discharge, and increased the risk of dying (hazard ratio = 1.21 [1.04,1.40]). CONCLUSIONS We observed no association between intraoperative fluid balance and postoperative AKI. Fluid balance was associated with longer time to ICU discharge and lower survival. This study provides insight that might inform the design of a clinical trial on fluid management strategies in this population.
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Effects of intraoperative hemodynamic management on postoperative acute kidney injury in liver transplantation: An observational cohort study. PLoS One 2020; 15:e0237503. [PMID: 32810154 PMCID: PMC7446917 DOI: 10.1371/journal.pone.0237503] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/23/2020] [Indexed: 12/28/2022] Open
Abstract
Background Intraoperative restrictive fluid management strategies might improve postoperative outcomes in liver transplantation. Effects of vasopressors within any hemodynamic management strategy are unclear. Methods We conducted an observational cohort study on adult liver transplant recipients between July 2008 and December 2017. We measured the effect of vasopressors infused at admission in the intensive care unit (ICU) and total intraoperative fluid balance. Our primary outcome was 48-hour acute kidney injury (AKI) and our secondary outcomes were 7-day AKI, need for postoperative renal replacement therapy (RRT), time to extubation in the ICU, time to ICU discharge and survival up to 1 year. We fitted models adjusted for confounders using generalized estimating equations or survival models using robust standard errors. We reported results with 95% confidence intervals. Results We included 532 patients. Vasopressors use was not associated with 48-hour or 7-day AKI but modified the effects of fluid balance on RRT and mortality. A higher fluid balance was associated with a higher need for RRT (OR = 1.52 [1.15, 2.01], p<0.001 for interaction) and lower survival (HR = 1.71 [1.26, 2.34], p<0.01 for interaction) only among patients without vasopressors. In patients with vasopressors, higher doses of vasopressors were associated with a higher mortality (HR = 1.29 [1.13, 1.49] per 10 μg/min of norepinephrine). Conclusion The presence of any vasopressor at the end of surgery was not associated with AKI or RRT. The use of vasopressors might modify the harmful association between fluid balance and other postoperative outcomes. The liberal use of vasopressors to implement a restrictive fluid management strategy deserves further investigation.
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Tokodai K, Lannsjö C, Kjaernet F, Romano A, Januszkiewicz A, Ericzon B, Nowak G. Association of post-reperfusion syndrome and ischemia-reperfusion injury with acute kidney injury after liver transplantation. Acta Anaesthesiol Scand 2020; 64:742-750. [PMID: 32020588 DOI: 10.1111/aas.13556] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is frequently observed after orthotopic liver transplantation (OLT) even in patients with previously normal renal function. In this study, we investigated the impact of factors such graft steatosis, post-reperfusion syndrome (PRS), and hepatic ischemia reperfusion injury (HIRI) on the development of AKI after OLT in adult patients. METHODS We retrospectively examined consecutive adult patients who underwent OLT at our institution between July 2011 and June 2017. AKI was diagnosed based on the criteria proposed by the International Kidney Disease Improving Global Outcomes (KDIGO) workgroup. Peak aspartate aminotransferase (AST) level within 72 hours after OLT was used as a surrogate marker for HIRI. Graft steatosis was diagnosed by histopathological examination using specimens biopsied intraoperatively at the end of transplantation procedure and categorized as <10%, 10%-20%, 20%-30%, and ≥30% of hepatic steatosis. RESULTS Out of 386 patients, 141 (37%) developed AKI (KDIGO stage 1:71 patients; stage 2:29 patients; stage 3:41 patients). Multivariable logistic regression analysis revealed that cold ischemic time (P = .012) and HIRI (P = .007) were independent risk factors for post-OLT AKI. Multivariable analysis also revealed that graft steatosis was associated with HIRI but not directly with AKI. PRS was not associated with HIRI or AKI in the multivariable analyses. CONCLUSION Our results indicate that greater severity of liver graft injury during transplantation negatively affects renal function after OLT. As expected, the severity of liver graft steatosis contributes to accelerated liver injury occurring during the transplantation procedure.
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Affiliation(s)
- Kazuaki Tokodai
- Department of Clinical Science, Intervention and Technology Division of Transplantation Surgery Karolinska Institutet Huddinge Sweden
| | - Claudia Lannsjö
- Perioperative Medicine and Intensive Care Karolinska University Hospital Huddinge Sweden
| | - Felicia Kjaernet
- Department of Clinical Science, Intervention and Technology Division of Transplantation Surgery Karolinska Institutet Huddinge Sweden
| | - Antonio Romano
- Department of Clinical Science, Intervention and Technology Division of Transplantation Surgery Karolinska Institutet Huddinge Sweden
| | - Anna Januszkiewicz
- Perioperative Medicine and Intensive Care Karolinska University Hospital Huddinge Sweden
| | - Bo‐Göran Ericzon
- Department of Clinical Science, Intervention and Technology Division of Transplantation Surgery Karolinska Institutet Huddinge Sweden
| | - Greg Nowak
- Department of Clinical Science, Intervention and Technology Division of Transplantation Surgery Karolinska Institutet Huddinge Sweden
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Intraoperative Hemodynamic Parameters and Acute Kidney Injury After Living Donor Liver Transplantation. Transplantation 2020; 103:1877-1886. [PMID: 30720690 DOI: 10.1097/tp.0000000000002584] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) after living donor liver transplantation (LDLT) is associated with increased mortality. We sought to identify associations between intraoperative hemodynamic variables and postoperative AKI. METHODS We retrospectively reviewed 734 cases of LDLT. Intraoperative hemodynamic variables of systemic and pulmonary arterial pressure, central venous pressure (CVP), and pulmonary artery catheter-derived parameters including mixed venous oxygen saturation (SvO2), right ventricular end-diastolic volume (RVEDV), stroke volume, systemic vascular resistance, right ventricular ejection fraction, and stroke work index were collected. Propensity score matching analysis was performed between patients with (n = 265) and without (n = 265) postoperative AKI. Hemodynamic variables were compared between patients with AKI, defined by Kidney Disease Improving Global Outcomes criteria, and those without AKI in the matched sample. RESULTS The incidence of AKI was 36.1% (265/734). Baseline CVP, baseline RVEDV, and SvO2 at 5 minutes before reperfusion were significantly different between patients with and without AKI in the matched sample of 265 pairs. Multivariable logistic regression analysis revealed that baseline CVP, baseline RVEDV, and SvO2 at 5 minutes before reperfusion were independent predictors of AKI (CVP per 5 cm H2O increase: odds ratio [OR], 1.20; 95% confidence interval [CI], 1.09-1.32; SvO2: OR, 1.45; 95% CI, 1.27-1.71; RVEDV: OR, 1.48; 95% CI, 1.24-1.78). CONCLUSIONS The elevated baseline CVP, elevated baseline RVEDV after anesthesia induction, and decreased SvO2 during anhepatic phase were associated with postoperative AKI. Prospective trials are required to evaluate whether the optimization of these variables may decrease the risk of AKI after LDLT.
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