Abstract
Introduction: This case describes the successful re-LTx (with 18 hours anhepatic period) performed due to severe AMR on the 10th POD. On the 7th day after re-LTx ischemic necrotizing pancreatitis developed. The patient died 20 days after the re-LTx due to the septic shock. Method: The patient S., aged 58, was transplanted due to NASH-related cirrhosis (MELD 23, hepatorenal syndrome). LTx was performed from non-marginal DBD. Result: First four postoperative days (PODs) were uneventful. From 5th till 10th PODs liver graft function progressively deteriorated with the level of AST/ALT of 5500 / 5300 U/l and INR of 3.6 on the 10th POD. Despite the sequential steroid pulse therapy, IVIG infusion and plasmapheresis, performed from the 6th to the 9th PODs, liver graft failure with multi-organ failure was developed on the 10th POD. The recipient was transferred to the operation theatre: the total graft necrosis was revealed (histologically C4d-positive antibody mediated rejection); hepatectomy and temporary portacaval shunt were performed. After this the patient condition was stabilized and the patient has been waiting for the liver graft in the operating theatre. Liver retransplantation from marginal DBD (graft steatosis - 60 %) was performed after 18 hours of anhepatic period. Early postoperative period was complicated by Enterococcus spp serous peritonitis, successfully treated by planned relaparotomies and antibiotic treatment. The second liver graft function was adequate. On the 7th day after re-LTx pancreonecrosis with necrosis of the mesentery of the descending colon was revealed. Despite provided intensive care the patient died 30 days after the 1st LTx. Conclusion: The aim - to verify on what step incorrect tactics was applied (if it was): 1. a) Classic technique vs Piggy-back in patients with severe HRS? b) Should we avoid Tac in patients with RRT in early postoperative period? c) Could we save that sort of patient?
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