Adult Patients Undergoing Liver Transplantation Research Articles

A-355 Comparison of Arterial and Venous Whole Blood Samples Analyzed on the QuantraSystem With the QPlusand QStatCartridges

Abstract Background The Quantra Hemostasis System (HemoSonics, LLC) is a cartridge-based viscoelastic testing system used to monitor the coagulation status of whole blood samples. The clinical performance of the System with the QPlus and QStat Cartridges was demonstrated in patients undergoing surgical procedures using venous blood samples. However, depending on the nature of the surgical procedure, arterial or venous samples may be more accessible for testing. It is currently unknown if differences exist between the two samples for the Quantra System. This study compared QPlus and QStat parameters measurements in venous and arterial blood samples collected in parallel from patients undergoing cardiac or liver transplant surgery. Methods Two studies were conducted according to CLSI EP09. The cardiac study enrolled 50 adult patients undergoing cardiac surgery utilizing cardiopulmonary bypass to evaluate QPlus parameters. Matching arterial and venous samples were obtained at two time points: during bypass and post-protamine. The liver study enrolled 25 adult patients undergoing liver transplantation to evaluate QStat parameters. Matching arterial and venous samples from were obtained at three time points: baseline, anhepatic and reperfusion phases. All arterial samples were drawn from an existing arterial catheter whereas venous samples were drawn from the venous side of the bypass circuit or from the central venous catheter (proximal port to minimize infusion contamination). Linear regression analysis and means comparison (paired t-test) were used to assess whether the two sample types provided equivalent results, Results Table 1 provides the mean values for each parameter determined for venous and arterial samples. None of the parameters showed a significant difference between sample types (P > 0.05). Additionally, the linear regression analysis show strong correlation between the results for each parameter. Conclusions Both studies demonstrated that venous and arterial whole blood samples provide equivalent results on the Quantra System with the QPlus and QStat Cartridges.

Patient-Reported Outcome Screens for Cognitive Dysfunction and Predicts Admissions in Cirrhosis

IntroductionHepatic encephalopathy (HE) is a frequent complication of cirrhosis, leading to preventable hospitalizations and increased mortality. Despite the availability of validated neuro-psychometric tests to diagnose HE, only 10% of clinicians regularly screen for HE due to lack of time, equipment, and trained personnel. Materials and MethodsWe studied the association between patient-reported cognitive function and the National Institutes of Health Toolbox Cognition Battery (a validated measure of HE) in patients with cirrhosis. A single-center prospective study of adult patients undergoing liver transplantation evaluation was performed from 10/2020 to 12/2021. Cognition was assessed using the National Institutes of Health Toolbox Cognition Battery and a brief Patient-Reported Outcomes Measurement Information System (PROMIS) survey. ResultsTwenty-three liver transplantation candidates were enrolled; the mean age was 56.4 (±9.7) years, 39% were female and the most common etiologies of cirrhosis were primary biliary cirrhosis/primary sclerosing cholangitis/overlap syndrome (30%), hepatitis C (22%) and alcohol-associated liver disease (22%). The mean MELD-Na was 14.9 (±6.4). The mean PROMIS Cognitive Function T-score (PROMISCF) was 49.2 (±9.6). The mean T-scores for the List Sort Working Memory test, Flanker Inhibitory Control and Attention test, and Pattern Comparison Processing Speed test were 46.4 (±9.9), 37.8 (±6.2), and 50.22 (±16.4), respectively. PROMISCF correlated with the List Sort Working Memory test (r = 0.45, P = .03). The mean hospitalization rate was 1.6 days admitted per month. On adjusted multivariate analysis, PROMISCF predicted total hospitalization days (P < .001), hospital admissions (P = .01), and hospitalization rate (P < .001). ConclusionsA brief survey can screen for HE and predict hospitalizations in patients with cirrhosis.

Donor Atheromatous Disease is a Risk Factor for Hepatic Artery Thrombosis After Liver Transplantation.

The increasing age of liver donors and transplant candidates, together with the growing prevalence of metabolic comorbidities, could impact the risk of vascular complications after liver transplantation. We enrolled a consecutive cohort of adult patients undergoing liver transplantation from 2012 to 2021 who had a blinded pathological assessment of atherosclerosis in the donor and recipient hepatic arteries (HA). Patients receiving partial or reduced grafts, retransplantation, or combined organ transplantation were excluded. The relationship between HA atherosclerosis and HA thrombosis after liver transplantation was evaluated using logistic regression in the whole study cohort and in a propensity score-matched subpopulation. Among 443 eligible patients, 272 had a full pathological evaluation of the donor and recipient HA and were included in the study. HA atheroma was present in 51.5% of donors and in 11.4% of recipients. HA thrombosis occurred in 16 patients (5.9%), being more likely in patients who received a donor with HA atherosclerosis than in those without (10.7%vs. 0.8%; p<0.001). Donor HA atherosclerosis was an independent risk factor of HA thrombosis (OR=17.79; p=0.008), and this finding was consistent in the propensity score-matched analysis according to age, sex, complex arterial anastomosis, and alcoholic liver disease (OR=19.29; p=0.007). Atheromatous disease in the recipient had no influence on the risk of HA thrombosis (OR=1.70; p=0.55). In conclusion, patients receiving donors with HA atherosclerosis are at increased risk for HA thrombosis after liver transplantation. The evaluation of the donor graft vasculature could guide antiplatelet therapy in the postoperative period.

Gammagrafía de perfusión miocárdica en la evaluación del riesgo cardiovascular en el trasplante hepático de adultos

IntroductionThe non-invasive diagnostic study of cardiovascular risk in patients who are going to undergo liver transplantation is not clear, especially in asymptomatic patients. Regarding myocardial perfusion scintigraphy (MPS), it has been thought that the impaired vasodilator reserve in these patients may reduce its performance. The objective is to assess the role of the MPS in the pre-surgical evaluation of patients who are going to undergo liver transplantation. Material and methodsRetrospective, descriptive and observational study was designed. All adult patients undergoing liver transplantation between 2017 and 2021 who had previous MPS were included. The findings of MPS were described and correlated with the findings of invasive angiography and with the appearance or not of peri- and post-transplant cardiovascular events. ResultsThere were a total of 188 transplanted patients (mean age: 57 years, SD: 12), 178 had previous myocardial perfusion, 82 (46%) patients had no cardiovascular risk factors, and 5 (2.8%) had a history of coronary disease.Of the MPS, 177 were with dipyridamole stress performed on average 10 months before transplantation. Only 17/178 (9.5%) studies were abnormal. The mean follow-up was 38 months (SD: 10). Of the patients with normal MPS, only 2 (1.2%) presented cardiovascular events, both with studies performed more than 2years before the procedure. There were no deaths of cardiovascular origin. ConclusionsMPS is a safe and reliable technique for cardiovascular assessment of patients who are candidates for liver transplantation, given the low rate of false negatives during follow-up.

Myocardial perfusion scintigraphy in the assessment of cardiovascular risk in adult liver transplantation

IntroductionThe non-invasive diagnostic study of cardiovascular risk in patients who are going to undergo liver transplantation is not clear, especially in asymptomatic patients. Regarding myocardial perfusion scintigraphy (MPS), it has been thought that the impaired vasodilator reserve in these patients may reduce its performance. The objective is to assess the role of the MPS in the pre-surgical evaluation of patients who are going to undergo liver transplantation. Material and methodsRetrospective, descriptive and observational study was designed. All adult patients undergoing liver transplantation between 2017 and 2021 who had previous MPS were included. The findings of MPS were described and correlated with the findings of invasive angiography and with the appearance or not of peri- and post-transplant cardiovascular events. ResultsThere were a total of 188 transplanted patients (mean age: 57 years, SD: 12), 178 had previous myocardial perfusion, 82 (46%) patients had no cardiovascular risk factors, and 5 (2.8%) had a history of coronary disease.Of the MPS, 177 were with dipyridamole stress performed on average 10 months before transplantation. Only 17/178 (9.5%) studies were abnormal. The mean follow-up was 38 months (SD: 10). Of the patients with normal MPS, only 2 (1.2%) presented cardiovascular events, both with studies performed more than 2 years before the procedure. There were no deaths of cardiovascular origin. ConclusionsMPS is a safe and reliable technique for cardiovascular assessment of patients who are candidates for liver transplantation, given the low rate of false negatives during follow-up.

Prospective population pharmacokinetic study of tacrolimus in adult recipients early after liver transplantation: A comparison of Michaelis-Menten and theory-based pharmacokinetic models.

Background and Objective: Tacrolimus, a calcineurin inhibitor widely used as a potent immunosuppressant to prevent graft rejection, exhibits nonlinear kinetics in patients with kidney transplantation and nephrotic syndrome. However, whether nonlinear drug metabolism occurs in adult patients undergoing liver transplantation remains unclear, as do the main underlying mechanisms. Therefore, here we aimed to further confirm the characteristics of nonlinearity through a large sample size, and determine the potential influence of nonlinearity and its possible mechanisms. Methods: In total, 906 trough concentrations from 176 adult patients (150 men/26 women; average age: 50.68 ± 9.71 years, average weight: 64.54 ± 11.85kg after first liver transplantation) were included in this study. Population pharmacokinetic analysis was performed using NONMEM®. Two modeling strategies, theory-based linear compartmental and nonlinear Michaelis-Menten (MM) models, were evaluated and compared. Potential covariates were screened using a stepwise approach. Bootstrap, prediction-, and simulation-based diagnostics (prediction-corrected visual predictive checks) were performed to determine model stability and predictive performance. Finally, Monte Carlo simulations based on the superior model were conducted to design dosing regimens. Results: Postoperative days (POD), Aspartate aminotransferase (AST), daily tacrolimus dose, triazole antifungal agent (TAF) co-therapy, and recipient CYP3A5*3 genotype constituted the main factors in the theory-based compartmental final model, whereas POD, Total serum bilirubin (TBIL), Haematocrit (HCT), TAF co-therapy, and recipient CYP3A5*3 genotype were important in the nonlinear MM model. The theory-based final model exhibited 234Lh-1 apparent plasma clearance and 11,000L plasma distribution volume. The maximum dose rate (V max ) of the nonlinear MM model was 6.62 mgday-1; the average concentration at steady state at half-V max (K m ) was 6.46ngml-1. The nonlinear MM final model was superior to the theory-based final model and used to propose dosing regimens based on simulations. Conclusion: Our findings demonstrate that saturated tacrolimus concentration-dependent binding to erythrocytes and the influence of daily tacrolimus dose on metabolism may partly contribute to nonlinearity. Further investigation is needed is need to explore the causes of nonlinear pharmacokinetic of tacrolimus. The nonlinear MM model can provide reliable support for tacrolimus dosing optimization and adjustment in adult patients undergoing liver transplantation.

Renal function after liver transplantation: Real-world experience with basiliximab induction and delayed reduced-dose tacrolimus.

Routine use of delayed reduced-dose calcineurin-inhibitor treatment with induction immunosuppression in liver transplantation to minimize post-operative kidney injury is still scarce. To evaluate real-world experience of basiliximab induction with delayed reduced-dose tacrolimus. In a retrospective cohort study, kidney function was evaluated pre- and postoperatively by measured glomerular filtration rate (mGFR). Adult patients undergoing liver transplantation between 2000 and 2017 were divided into a conventional treatment group (immediate-introduction of tacrolimus, target trough levels 10-15ng/mL, and corticosteroids, n=203) and a revised treatment group (basiliximab induction, reduced-dose tacrolimus, target through levels 5-8ng/mL, delayed until day three, and mycophenolate mofetil 2000mg/day, n=343). Mean mGFR was similar between groups at wait-listing (85.3vs 84.1ml/min/1.73m², p=0.60), but higher in the revised treatment group at 3 (56.8vs 63.4ml/min/1.73m², p=0.004) and 12 months post-transplant (60.9vs 69.7ml/min/1.73m², p<0.001); this difference remained after correcting for multiple confounders and was independent of pre-transplant mGFR. In the revised treatment group, biopsy proven acute rejection rate was lower (38% vs. 21%, p<0.001), and graft-survival better (p=0.01). Basiliximab induction with delayed reduced-dose tacrolimus is associated with less kidney injury when compared to standard-dose tacrolimus, without increased risk of rejection, graft loss or death.

Post-Liver Transplant Inferior Vena Cava Stenosis in a Large Volume UK Centre

Background: Inferior vena cava stenosis (IVCS) is a rare complication following liver transplantation. Limited consensus exists on management of IVCS. We report the management and outcomes of patients with IVCS at our centre. Methods: Data were collected from adult patients undergoing liver transplantation at our centre between October 2014 and August 2020. Data included demographics, investigation and management regarding IVCS. Values presented as % of total and median with interquartile range (IQR). Results: 636 liver transplants were performed during the study period, with 48 (7.6%) investigated for possible IVCS, and 14 of those (2.2% of total) were found to have IVCS. 85.7% (n=12) were female and 2/14 were re-transplants. 10 livers (71.4%) were from DBD donors. Normothermic machine perfusion was used in 4/14 patients. All 14 recipients found to have IVCS had implantation using a modified piggyback cavocavostomy technique. IVCS was identified at a median of 25.5 days (19.7-30.8 days) following transplantation within the suprahepatic IVC in 92.9% (n=13). 8/14 recipients underwent intervention for IVCS; 6 patients underwent balloon venoplasty, 1 required IVC stenting and 1 was managed surgically. Six recipients with IVCS died, 4 of whom had an intervention for their stenosis. 3 of these were within 90 days of transplant. Pressures measured at the anastomotic stricture were higher in those who succumbed (median of 21 Vs 12.5 mmHg; p=.017). Conclusions: At our centre, cava-replacement technique was not associated with IVCS. Patients with significant strictures (evidenced by higher pressures at anastomotic stenosis) may have increased mortality risk.

Strategies for a successful hepatic artery anastomosis in liver transplantation: A review of 51 cases

Hepatic artery reconstruction is a critical aspect of liver transplantation. The microsurgeon faces several challenges when reconstructing the hepatic artery-the donor hepatic artery stalk is short and often a poor match for the usually hypertrophic recipient vessels. Previous inflammation impedes vessel dissection, and recipient vessels have a tendency to delaminate with manipulation. We review 51 consecutive liver transplantations to highlight these problems and propose strategies for a successful reconstruction of the hepatic artery. A prospective study involving all adult patients undergoing liver transplantation at the Singapore General Hospital from January 2015 to December 2018 was undertaken. All hepatic artery anastomoses were performed by 2 microsurgeons at 10x magnification. Patients were started on a standard immunosuppressive regimen. Postoperative ultrasound scans on days 1, 3, 5, 7, 9 and 14 were used to confirm arterial patency. There were 51 patients who underwent liver transplantation during the study period. Of this number, 31 patients received deceased donor grafts and 20 received living donor grafts. A total of 61 anastomoses were performed (5 dual anastomosis, 4 radial artery interposition grafts) with 1 case of hepatic artery thrombosis that was successfully salvaged. The mean (range) postoperative resistive index and hepatic artery peak systolic velocity were 0.69 (0.68-0.69) and 1.0m/s (0.88-1.10m/s), respectively. Hepatic artery thrombosis after liver transplantation is poorly tolerated. The challenges of hepatic artery reconstruction in liver transplantation are related to vessel quality and length. The use of microsurgical technique, appropriate recipient vessel selection, minimisation of vessel manipulation with modified instruments, variation in anastomosis techniques, and use of radial artery interpositional grafts are useful strategies to maximise the chances of success.

New-onset diabetes mellitus after liver transplantation in the patients with acute liver failure

To detect the frequency and possible risk factors of new-onset diabetes after liver transplantation in the patients with acute liver failure. The frequency of new-onset diabetes after transplant (NODAT) is 5–30% in liver transplant recipients. We aimed to analyze the frequency and predictors of NODAT in the patients undergoing liver transplantation due to acute liver failure. Adult patients undergoing liver transplantation due to acute liver failure were analyzed retrospectively. The patients with chronic liver failure or diabetes were excluded. We measured pretransplant random blood glucose and posttransplant fasting blood glucose. NODAT was diagnosed according to principally 1st month fasting blood glucose (group 1 125 mg/dL). The participants were subgrouped according to age, gender, body mass index, etiology, antiviral medication, thyroid function, pretransplant random blood glucose, donor type, immunosuppressive drug, common infection, and surgical complication. Mean age of total 91 patients was 33.48 (± 13.35), and 52.7% (n = 48) of them was female. The ratio of NODAT was 26.98% on the 1st month. NODAT group had a higher pretransplant random blood glucose than the others. Pretransplant hyperglycemia increased the risk of NODAT by 4.065 times (p = 0.018). We showed that pretransplant hyperglycemia increased NODAT risk by 4 times, but hypoglycemia did not affect. So, pretransplant hyperglycemia should be controlled also in the patients with acute liver failure as in the patients with chronic liver failure.

Good Practices in Transitional Care: continuity of care for patients undergoing liver transplantation.

to develop a guide of care recommendations for good practices in care transition for adult patients undergoing liver transplantation. a methodological study, based on the Appraisal of Guidelines for Research & Evaluation in the updated version, II. Care recommendations were sustained by conducting an integrative literature review and qualitative research. from evidence, three topics emerged: Care Transition Planning; Health Education for Self-Care; Care Management. Each of the central topics has respective subtopics, totaling six, giving rise to 30 care recommendations. Concerning evaluators' scores, in all domains the scores were higher than 90%. the proposed guide assists professionals in conducting care transition in liver transplantation, ensuring greater safety for patients in continuity of home care.

Medicines management in adult patients undergoing liver transplantation

Since the first successful human liver transplant was performed by surgeon Thomas Starzl in 1967, liver transplantation (LT) has evolved to become a life-saving treatment​[1]​. The service is currently provided by seven adult and three paediatric centres in the UK. Waiting times are around four months; although, as demand continues to exceed supply of grafts, […]

S0983 Coronary Artery Calcium Score and All-Cause Mortality in Liver Transplant Recipients: A Retrospective Analysis

INTRODUCTION: Cardiovascular disease is a major cause of death after liver transplantation. Pre-transplant cardiac risk stratification generally involves pharmacologic stress testing, as well as coronary artery angiography in high-risk patients. Coronary artery calcium (CAC) score is a non-invasive estimation of total calcified plaque in coronary arteries. CAC score has been shown to be associated with 1-month post-transplant mortality; however, it has not been studied as a predictor of long-term outcomes in liver transplant recipients. METHODS: We retrospectively studied patients who underwent liver transplantation at Johns Hopkins Hospital between 1/1/2015 and 12/31/2018 who had a pre-transplant CAC score measured. Patients were divided into 3 groups: CAC score 0 (group 1), CAC score 1–400 (group 2) and CAC score >400 (group 3). All-cause mortality in the 3 groups was compared using Kaplan-Meier curves and the log-rank test, with statistical significance defined as P < 0.05. RESULTS: A total of 412 adult patients underwent liver transplantation, of which 155 patients had a CAC score measured as part of pre-transplant cardiovascular evaluation. CAC group 1, 2, and 3 and 37, 82, and 36 patients, respectively. The median age was 60, median body mass index (BMI) was 28.6, and median model for end-stage liver disease (MELD) score was 19, with no significant difference between groups (Table 1). The cohort was 38.1% female, with significantly lower proportion of females in higher CAC score groups (P = 004). At 1 year, death occurred in 3 (8.1%), 7 (8.5%) and 2 (5.6%) patients in groups 1, 2, and 3, respectively (Table 2). At 2 years, there were 5 (15.2%), 12 (16.9%), and 6 (20.7%) deaths in the three groups, respectively. At 3 years, there were 6 (23.1%), 13 (24.5%), and 8 (32.0%) deaths in the 3 groups, respectively. There was no significant difference in all-cause mortality between CAC score groups (Figure 1). CONCLUSION: CAC score may be useful in cardiac risk stratification prior to liver transplantation. In this study, there was no significant difference in 1-, 2-, or 3-year all-cause mortality between CAC score groups. However, there was a non-significant trend towards increased all-cause mortality with higher calcium scores at 2 and 3 years of follow up. Further research is needed with a larger sample size and examination of cardiac risk factors to better evaluate the prognostic utility of CAC score in this population.Table 1.: Baseline characteristics by coronary artery calcium score groups. Continuous variables in this table were assumed to be skewed in the population, thus nonparametric k-test for equality of medians was used to compare medians between groups. Fisher’s exact test was used to compare categorical variables. a. body mass index (BMI) b. model for end-stage liver disease (MELD) c. coronary artery calcium (CAC)Table 2.: All-cause mortality at 1, 2, and 3 years after liver transplant, stratified by coronary artery calcium score groups. a. coronary artery calcium (CAC)Figure 1.: Three-year Kaplan-Meier survival curves stratified by coronary artery calcium score groups. No significant difference between groups (P = 0.71). Abbreviations: coronary artery calcium (CAC).

Neuropraxia: An Underappreciated Morbidity of Liver Transplantation

BackgroundPeripheral nerve injuries can be devastating complications of surgery, potentially resulting in severe functional disability and decreased quality of life. Long surgeries with considerable tissue manipulation, for example, liver transplantation, may present increased risk; however, neuropraxia in transplantation has not been well investigated. Materials and methodsThis is a retrospective study of all adult patients undergoing liver transplantation at a large academic center between January 2013 and December 2015. Descriptive analyses, logistic regressions, and forward selection procedures were used to determine the odds of developing neuropraxia and associated factors. ResultsOf the 283 liver recipients, the mean age was 55.8 y, 35.1% were female, 65.6% were Caucasian, 8.9% were African American, 16.7% were Hispanic, and mean model for end-stage liver disease sodium score at transplant was 24.2 ± 10.9. The underlying etiology was alcohol (26.2%), hepatitis C (34.8%), nonalcoholic steatohepatitis (13.1%), and other (14.2%). The incidence of neuropraxia after liver transplantation was 8.3% (n = 25), with 60% (n = 16) upper extremities, 82% left sided, and 84% male. There was no difference in age, race, body mass index, hypertension, diabetes, hyperlipidemia, or smoking in those with neuropraxia versus those without. In multivariate analysis, neuropraxia was significantly associated with male gender, lower model for end-stage liver disease score, and longer duration of surgery (P < 0.05). Symptoms lasted median 5 d, with a wide range up to 187 d. Neuropraxia-specific treatment (physical therapy or medications) was required in 32% (n = 9). ConclusionsPeripheral nerve injuries are an unexplored complication of liver transplantation. Although transient, a high number (8.2%) of patients developed neuropraxia, negatively affecting their ability for recovery. Exploration of mechanisms for minimizing risk and intraoperative detection and prevention should be considered to mitigate this complication.

Pretransplant left ventricular hypertrophy in association with postoperative myocardial injury in liver transplantation

Pretransplant left ventricular hypertrophy (LVH) is a common finding during preoperative cardiac evaluation. We hypothesized that patients with pretransplant LVH were associated with a higher risk of postoperative myocardial injury (PMI) in adult patients undergoing liver transplantation (LT). A retrospective cohort analysis was performed by reviewing the medical records of adult patients who underwent LT between January 2006 and October 2013. Of 893 patients, the incidences of mild, moderate, and severe LVH were 7.8%, 5.6%, and 2.5%, respectively. Propensity match was used to eliminate the pretransplant imbalance between the LVH and non-LVH groups. In after-match patients, 23.5% of LVH patients developed PMI compared to 11.8% in the control group (P=.011). The incidence of PMI in patients with moderate-severe degrees of LVH was significantly higher compared with that in patients with mild LVH (27.9% vs 19.1%, P=.016). When controlling intraoperative variables, patients with LVH had 4.5 higher odds of developing PMI (95% CI1.18-17.19, P=.028). Patients experiencing PMI had significantly higher 1-year mortality (37.5% vs 15.7%, log-rank test P<.001). Our results suggest that patients with pretransplant LVH were at a high risk of developing PMI and should be monitored closely in the perioperative period. More studies are warranted.

Persistent acidosis after reperfusion-A prognostic indicator of increased 30-day and in-hospital postoperative mortality in liver transplant recipients.

During liver transplantation, the patient is at risk of developing progressive lactic acidosis. Following reperfusion, correction of acidosis may occur. In some patients, acidosis will worsen, a phenomenon referred to as persistent acidosis after reperfusion (PAAR). We compared postoperative outcomes in patients who manifested PAAR vs those that did not. All adult patients undergoing liver transplantation from 2002 to 2015 were included. PAAR is defined by the presence of a significant negative slope coefficient for base excess values measured after hepatic artery anastomosis through 72hours postoperatively. Primary outcome was a composite of 30-day and in-hospital mortality. Secondary outcomes included: ICU LOS, total hospital LOS, and re-transplantation rate within 7days. PAAR occurred in 10% of the transplant recipients. Patients with PAAR had higher MELD, BMI, and eGFR and demonstrated a longer median ICU LOS and hospital median LOS with a trend toward mortality difference. But, after propensity matching, the mortality rate difference became significantly higher in patients with PAAR compared with matched controls while the ICU LOS differences disappeared. The re-transplantation rates were similar also between the PAAR and no PAAR groups. The cohort with PAAR had a significant 30-day and in-hospital increase in mortality after propensity score matching.

Outcome of the use of paediatric donor livers in adult recipients: A single Chinese centre experience

Paediatric liver allografts sometimes are allocated to adult recipients when there are no suitable paediatric recipients on the waiting list. However, debate exits regarding the reported outcomes of liver transplants using such small grafts. Records from adult patients undergoing liver transplantation between February 2010 and January 2016 who received whole grafts from paediatric (≤ 13 years) donors or ideal deceased adult (18-35 years) donors were reviewed. Patient and graft survival, post-transplant liver function, and complications between the two groups were compared. The baseline characteristics were comparable, except that the paediatric donor allografts had smaller size. The 3-month, 1-year, and 3-year rates of patient survival were 91.3%, 85.2%, and 85.2% in the paediatric donor group and 93.4%, 88.9%, and 85.0% in the adult donor group (P = 0.947), respectively. One patient receiving a paediatric allograft developed small-for-size liver syndrome post-transplantation. There was no difference in primary non-function, early allograft dysfunction, biliary complications, vascular complications, or infection between the two groups. Our study indicates that using paediatric donor livers in well-selected adult recipients is a safe procedure, considering there was no suitable paediatric recipient. However, the risk of portal hyperperfusion should be considered in clinical cases such as size-mismatched transplants.

Risk factors and outcomes of pyogenic liver abscess in adult liver recipients: a matched case-control study

BackgroundAdult liver recipients (ALR) differ from the general population with pyogenic liver abscess (PLA) as they exhibit: reconstructed biliary anatomy, recurrent hospitalizations, poor clinical condition and are subjected to immunosuppression. The aim of this study was to identify risk factors associated with PLA in ALR and to analyze the management experience of these patients. MethodsBetween 1996 and 2016, 879 adult patients underwent liver transplantation (LT), 26 of whom developed PLA. Patients and controls were matched according to the time from transplant to abscess in a 1 to 5 relation. A logistic regression model was performed to establish PLA risk factors considering clusters for matched cases and controls. Risk factors were identified and a multivariate regression analysis performed. ResultsPatients with post-LT PLA were more likely to have lower BMI (p = 0.006), renal failure (p = 0.031) and to have undergone retransplantation (p = 0.002). A history of hepatic artery thrombosis (p = 0.010), the presence of Roux en-Y hepatojejunostomy (p < 0.001) and longer organ ischemia time (p = 0.009) were independent predictors for the development of post-LT PLA. Five-year survival was 49% (95%CI 28–67%) and 89% (95%CI 78%–94%) for post-LT PLA and no post-LT PLA, respectively (p < 0.001). Conclusionhistory of hepatic artery thrombosis, the presence of hepatojejunostomy and a longer ischemia time represent independent predictors for the development of post-LT PLA. There was a significantly poorer survival in patients who developed post-LT PLA compared with those who did not.

Liver transplantation for patients with hepatopulmonary syndrome: long-term follow-up and prognosis analysis

Objective To analyze the clinical efficacy of liver transplantation (OLT) for patients with hepatopulmonary syndrome (HPS). Methods From 2008 to 2013, 420 adult patients underwent liver transplantation in our hospital. There were 91 patients with, and 329 patients without, HPS. The 5-year survival and mortality rates after OLT for the two groups were retrospectively analyzed. Results There were no significant differences between patients without and with HPS in age, primary disease, Child-Pugh score, MELD score, cold ischemia time and warm ischemia time. However, the differences on serum albumin [(29.6±1.2) g/L vs. (26.4±1.6) g/L] and blood oxygen pressure [(61.0±9.0) mmHg (1 mmHg=0.133 kPa) vs. (87.0±6.0) mmHg] were significantly different (P<0.05). The 1-year cure rate was 65.9% (60/91) in 91 patients with HPS after liver transplantation. The 1, 3, 5-year cumulative survival rates for patients without HPS were 97.3%, 90.9% and 80.3%, respectively, and the main causes of death were primary graft dysfunction, recurrent cardiovascular events and primary disease recurrence or tumors. The 1, 3, 5-year cumulative survival rates for patients with HPS were 65.9%, 59.3% and 56.0%, and the main causes of death were multiple-organ failure, pulmonary infection and cerebrovascular events. Kaplan-Meier survival curve analysis showed that the survival of patients with HPS was significantly lower than that of patients without HPS (P<0.05). Conclusions Liver transplantation is the most effective treatment for patients with HPS, but the short-term mortality rate is relatively high. We still need to learn more about HPS to improve the survival rate of patients with HPS after liver transplantation. Key words: Hepatopulmonary syndrome; Liver transplantation; Prognosis

An Arterial Conduit is Not a Risk Factor for Survival Following Orthotopic Liver Transplantation: An Analysis of 20 Years of Liver Transplantation in Innsbruck

BACKGROUND In adult liver transplantation, arterial conduits have been associated with increased risk for vascular complications and inferior outcome. MATERIAL AND METHODS Complication rates and outcomes of adult patients undergoing liver transplantation in our center between 1990 and 2012 were analyzed retrospectively. Characteristics, transplantation-related factors, and survival rates of patients with conduit grafts (n=43) were compared to patients with a standard arterial anastomosis (n=904) by univariate and multivariate analysis. RESULTS Patients in the conduit group were younger but had a significantly higher proportion of high-urgency and re-transplantations. While patient survival was comparable between the groups, graft survival was inferior for patients with a conduit (1-year, 5-year, and 10-year survival, control vs. conduit group: 87.3%, 78.8% and 71.5% vs. 72.4%, 63.8%, and 41.8%, respectively, p=0.008). In univariate analysis, an arterial conduit was associated with more arterial and biliary complications. However, an arterial conduit was not an independent risk factor for graft or patient survival in a Cox regression analysis. CONCLUSIONS An arterial conduit is associated with more vascular complications, yet a conduit per se does not influence graft survival. The inferior outcome may reflect the complex situation of the sicker liver transplant patients needing a non-standard arterial anastomosis.