Anhepatic Phase Research Articles

An Observational Study of Hemostatic Profile during Different Stages of Liver Transplant Surgery Using Laboratory-Based Tests and Thromboelastography.

Background:Liver produces most of the blood coagulation factors, so it is not surprising to see a deranged coagulation profile in patients receiving liver transplants. Besides standard laboratory methods to evaluate coagulation profile, point-of-care assays are being used regularly since their results are rapidly available. However, sparse information is available on the comparability of point-of-care coagulation assays with laboratory coagulation assays in this special setting. In this study, our aim is to observe the changing hemostatic profile during different stages of liver transplant surgery using laboratory-based tests and thromboelastography (TEG).Methods:Fifty patients undergoing living donor liver transplantation surgery were selected. Coagulation tests (prothrombin time [PT], activated partial thromboplastin time [APTT], platelet count, and fibrinogen) and TEG were performed at various intervals during liver transplant surgeries – before induction of anesthesia, 2 h into dissection phase, 30 min into anhepatic phase, 30 min after reperfusion of homograft, postoperative – at closure of surgery, 12 h postoperative, and 24 h postoperative. Statistical analysis and Pearson correlation were performed between laboratory-based coagulation tests and TEG, and their pattern through various stages of the surgery analyzed.Results:Platelet count and fibrinogen have a significant positive correlation with TEG in almost all phases of liver transplant. PT and APTT have a positive correlation with TEG until uptake of new liver and predominantly negative correlation after that. However, this correlation is significant only before induction of anesthesia and anhepatic phase.Conclusions:TEG can be used to estimate platelet count and fibrinogen concentrations in all phases but PT and APTT only before induction and anhepatic phase of liver transplant surgery. The decision regarding transfusion of blood products should be based on a combination of the clinical assessment of surgeon and anesthesia personnel combined with results from laboratory and TEG.

Thromboelastometry-based algorithm and transfusion management during orthotopic liver transplantations

Thromboelastometry-based algorithm and transfusion management during orthotopic liver transplantations

Organ Ischemia-Reperfusion Injury by Simulating Hemodynamic Changes in Rat Liver Transplant Model.

Orthotopic liver transplantation (OLT) in rats is a tried and proven animal model used for preoperative, intraoperative, and postoperative studies, including ischemia-reperfusion injury (IRI) of extrahepatic organs. This model requires numerous experiments and devices. The duration of anhepatic phase is closely related to the time to develop IRI after transplantation. In this experiment, we used hemodynamic changes to induce extrahepatic organ damage in rats and determined the maximum tolerance time. The time until the most severe organ injury varied for different organs. This method can easily be replicated and can also be used to study IRI of the extrahepatic organs after liver transplantation.

In-hospital mortality of liver transplantation and risk factors: a single-center experience.

BackgroundLiver transplantation (LT) is a life-saving treatment for patients with end-stage liver disease and acute liver failure. However, in-hospital death cannot be avoided. We designed this study to analyze patients’ in-hospital mortality rate after LT and the factors correlated with in-hospital death.MethodsThe data of patients who received LT in our hospital between January 11, 2015, and November 19, 2019, were obtained from the China Liver Transplant Registry and medical records. The in-hospital mortality rate was calculated, and factors related to mortality, cause of death, and factors related to cause of death were analyzed by reviewing patients’ data.ResultsA total of 529 patients who underwent cadaveric LT were enrolled in this study. Modified piggyback orthotopic LT was performed for all patients. Seventy patients died in the hospital after LT, and the in-hospital mortality rate was 13.2%. Factors including model for end-stage liver disease (MELD) score, Child-Pugh grading, intraoperative blood loss, and anhepatic phase were correlated with in-hospital death. MELD score and intraoperative blood loss were determined as the two independent risk factors of in-hospital death. The first two causes of death were infection (34.3%) and primary non-function (15.7%). Pulmonary fungal infection was the main cause of infectious death. MELD score was the independent risk factor for infectious death, and both body mass index of donors and cold ischemic time were independent risk factors of primary non-function.ConclusionsIn-hospital death poses a threat to certain patients undergoing LT. Our study suggests that the main cause of in-hospital death is an infection, followed by primary non-function.

Transplant Hepatectomy With Portacaval Shunt and MARS Therapy for Perioperative Catastrophe: A Series of Four Liver Transplant Cases.

Background.Increased worldwide focus on maximal donor utilization and transplantation of patients once considered too ill to survive liver transplantation may increase the otherwise rare frequency of catastrophic graft failure. Although the deleterious effects of an acutely failing allograft have been established for decades, the optimal strategy in this patient population in the perioperative period remains ill-defined.Methods.A retrospective review of all liver transplant recipients with perioperative failure leading to transplant hepatectomy between January 1, 2014 and June 30, 2017 was performed. All patients were supported with MARS therapy while awaiting retransplantation.Results.Four patients experienced catastrophic graft failure from massive exsanguination and liver fracture (1), portal vein and hepatic artery thrombosis (1), idiopathic necrosis (1), and necrosis from inadequate donor flushing/primary nonfunction (1). All patients improved following transplant hepatectomy with portacaval shunting. Patients were supported with intubation, vasopressors, renal replacement therapy, and Molecular Adsorbent Recirculating System therapy. All patients underwent retransplantation after a mean anhepatic phase of 48.8 (± 5.13) h. Survival to discharge was 75%.Conclusions.Although catastrophic liver failure is highly challenging, acceptable outcomes can be achieved with timely hepatectomy with portacaval shunt and retransplantation, particularly in patients supported with the Molecular Adsorbent Recirculating System device.

An Alternative Surgical Technique of Native Hepatectomy in Liver Transplantation

BackgroundOrthotopic liver transplantation has become the procedure of choice for end-stage liver disease. There are 3 commonly used methods of vena cava anastomosis. Here, we report a new technique for native hepatectomy.Material/MethodsThe data of 12 patients who underwent orthotopic liver transplantation using a new surgical technique were retrospectively collected for analysis. The new separation and reconstruction surgical technique mainly involved the second portal isolation and hepatectomy that followed. We performed recipient liver resection without the occlusion of the inferior vena cava, which was then followed by classic, piggyback, modified piggyback, or side-to-side orthotopic liver transplantation. The graft function index and complications were collected after transplantation.ResultsThe length of the anhepatic phase was 30.92±9.1 min. Alanine transaminase (ALT) levels were 138 to 2027 U/L, with a median of 361.5 U/L. The ALT levels of all patients gradually decreased to normal levels 7 to 10 days after surgery. Only 2 recipients had elevated levels of ALT higher than 1000 U/L. Four of 12 patients did not require red blood cell transfusion during surgery. Four patients appeared to have early allograft dysfunction, while others recovered smoothly.ConclusionsThis new surgical technique may shorten the anhepatic phase and decrease blood loss volume, aiding the success of liver transplant surgery. It can be used for most patients and does not increase the risk of complications or impair prognosis.

Kidney Function After Liver Transplantation in a Single Center.

BackgroundRenal dysfunction in the peri-transplant period appears to complicate both short- and long-term outcome of liver transplantation (LT). The aim of this study was to analyze the impact of selected clinical features in the peri-liver transplant period, as well calcineurin inhibitor, particularly tacrolimus given after LT, on kidney function in a single liver transplant center’s experience.Material/MethodsA total 125 consecutive liver-grafted individuals (82 M, 43 F), mean age 50±13 y (with alcohol-related liver disease in 48 (38%) patients) were included into the study. Their clinical data were collected in the database until 46 months of follow-up, and the Python packages Pandas (version 0.22.0) and scikit-learn (version 0.21.3) were used for data analysis.ResultsMore advanced liver disease as judged by Child-Pugh class and MELD score differed significantly patients with preserved (serum creatinine SCr <1.5 mg/dL) and impaired (SCr ≥1.5 mg/dL) kidney function before LT. Older age and higher SCr pre-LT were associated with higher levels of SCr after LT in 2 time-points. SCr before LT was correlated with delta SCr for the highest and last recorded value (P<0.0001). Higher amounts of transfused colloids during surgery were associated with increased delta SCr for the highest value (P=0.019) after grafting in logistic regression analysis. There were no associations between SCr after LT and duration of anhepatic phase, urine output ≤100 mL/h, or post-reperfusion syndrome during transplantation (all P>0.05). There were no associations between SCr after LT and tacrolimus trough levels in analyses of correlations and linear regression analyses (all P>0.05).ConclusionsWe found that pretransplant serum creatinine was the only factor affecting kidney function after LT in our liver transplant center. The restricted fluid policy was safe and effective in terms of long-term renal function. The role of kidney-saving immunosuppressive protocols in preserving renal function long-term after LT was also confirmed.

Impact of prolonged clamping of the portal vein during liver transplantation in infants with biliary atresia: renewed interest in a long-standing issue.

Various approaches to portal vein (PV) reconstruction have been described; however, there is still scope to improve the safety and efficiency of how PV anastomosis is performed in infants. We analyzed, retrospectively, the predictive factors for PV reanastomosis during living donor liver transplantation (LDLT) in 117 infants (< 1year old) with biliary atresia (BA). Twenty-six infants required PV reanastomosis because of intraoperative PV thrombosis in 21 and insufficient PV flow in 5. Univariate analysis identified multiple previous laparotomies and a prolonged anhepatic phase (AHP) as significant risk factors for repeated PV anastomosis. The AHP cutoff value for identifying patients requiring PV reanastomosis was 134min. Multivariate analysis revealed prolonged AHP > 134min (odds ratio, 15.98; 95% confidence interval, 5.05-50.6; P < 0.001) as an independent risk factor for repeated PV anastomosis. The plasma D-dimer and fibrinogen degradation product concentration just after reperfusion were significantly higher in patients requiring PV reanastomosis (P < 0.001). Patients requiring reanastomosis of the PV had a higher incidence of PV complications after LDLT than those who did not need PV reanastomosis (P = 0.01). Attempting to minimize the AHP is indispensable for successful LDLT in infants with BA.

Combined B-type Natriuretic Peptide as strong predictor of short-term mortality in patients after Liver Transplantation.

Background: B-type natriuretic peptide (BNP) is a well-known predictor for prognosis in patients with cardiac and renal diseases. However, there is a lack of studies in patients with advanced hepatic disease, especially patients who underwent liver transplantation (LT). We evaluated whether BNP could predict the prognosis of patients who underwent LT.Material and Methods: The data from a total of 187 patients who underwent LT were collected retrospectively. The serum levels of BNP were acquired at four time points, the pre-anhepatic (T1), anhepatic (T2), and neohepatic phases (T3), and on postoperative day 1 (T4). The patients were dichotomized into survival and non-survival groups for 1-month mortality after LT. Combined BNP (cBNP) was calculated based on conditional logistic regression analysis of pairwise serum BNP measurements at two time points, T2 and T4. The area under the receiver operating characteristic curve (AUROC) was analyzed to determine the diagnostic accuracy and cut-off value of the predictive models, including cBNP.Results: Fourteen patients (7.5 %) expired within one month after LT. The leading cause of death was sepsis (N = 9, 64.3 %). The MELD and MELD-Na scores had an acceptable predictive ability for 1-month mortality (AUROC = 0.714, and 0.690, respectively). The BNPs at each time point (T1 - T4) showed excellent predictive ability (AUROC = 0.864, 0.962, 0.913, and 0.963, respectively). The cBNP value had an outstanding predictive ability for 1-month mortality after LT (AUROC = 0.976). The optimal cutoff values for cBNP at T2 and T4 were 137 and 187, respectively.Conclusions: The cBNP model showed the improved predictive ability for mortality within 1-month of LT. It could help clinicians stratify mortality risk and be a useful biomarker in patients undergoing LT.

Fast Vascular Reconstruction With Magnetic Devices in Liver Transplant: A Novel Surgical Technique.

Minimizing the anhepatic period is critical to reduce allograft dysfunction, intestinal bacterial translocation, and acute liver failure among liver transplant (LT) recipients. The current study introduced a new surgical technique for fast major vascular reconstruction by utilization of magnetic devices in recipients. A prospective study was conducted among patients who underwent orthotopic LT using Donation after Cardiac Death (DCD) between November 2018 and December 2019. The procedures of magnetic-assisted LT was clinically performed and introduced. In brief, three pairs of C-shaped magnetic rings and matched base members were placed and fixed in the stump of supra- and infra-hepatic inferior vena cava, as well as portal vein of the donors and recipients. The donor liver was implanted, and the magnet rings at the donor and recipient vessels attached immediately for a rapid reconstruction. Final continuous suture of the vessels was then performed under restoration of the blood flow. A total of six patients were finally enrolled in magnetic-assisted LT. The median age of the recipients was 40.0 (IQR 37.0-49.3) years, and all were male patients as well. The median anhepatic time of patients undergoing magnetic-assisted LT was 10.3 min (IQR 9.5-13.2 min). With a median follow-up of 10.5 (range 7.2-19.8) months, all patients recovered well with normal liver function. Two patients had experienced partial portal vein thrombosis or acute rejection, respectively, which were unrelated to the surgical techniques, and treated successfully. The magnetic-assisted vascular anastomosis shortened the anhepatic phase to only about 10 min during LT. Fast revascularization of the donor liver by using the novel magnetic technique is safe and feasible in LT.

Study of factors affecting Small for Size Syndrome Post-Adult living donor liver transplantation

Recently, increasing evidence showed that small-for-size syndrome (SFSS) is a multifactorial disease which is precipitated by various perioperative factors other than graft size. We conducted the current work to evaluate perioperative effectors, which can increase the risk of SFSS following adult living-donor liver transplantation (LDLT). This is a retrospective study on 110 adult cirrhotic cases (mean age of 48.4±6.9 years old) who underwent adult LDLT. Most cases were males (89%). Cases were categorized into two groups based on the occurrence of SFSS. The groups were compared regarding preoperative (gender, age, comorbidities, baseline investigations), intraoperative (mean blood pressure and glucose; mean operation time; number of packed red cells, plasma, platelets, and cryoprecipitate units; time of cold and warm ischemia, and anhepatic phase; preclamping and post-reperfusion portal pressures), and postoperative factors (relevant investigations, hospital stay). Postoperatively, 23 patients developed SFSS (20.9%). SFSS group had significantly lower preoperative graft recipient weight ratio (GRWR) (0.76±0.1% versus 1.03±0.15, respectively; p<0.001), and elevated MELD scores (19±2.1 versus 17.9±4; p=0.024). Preclamping and post-reperfusion portal pressures of ≥22.5 and 17.5mmHg, exhibited a sensitivity of 95.7% and 91.3% and specificity of 87.4% and 88.9% respectively, for SFSS prediction. SFSS risk is significantly linked to GRWR, MELD score, and intraoperative portal haemodynamics. Intraoperative portal haemodynamics exhibited good diagnostic accuracy for SFSS prediction and represented promising indicators for the prediction of SFSS.

Intraoperative systemic biomarkers predict post-liver transplantation acute kidney injury.

Liver transplant (LT) is a definitive therapeutic option for patients with chronic liver disease. However, acute kidney injury after LT (post-LT AKI) is a frequent complication that may lead to graft dysfunction and decrease life expectancy. Delay in AKI detection by traditional biomarkers boosted research with new biomarkers for post-LT AKI as neutrophil gelatinase-associated lipocalin (NGAL) and syndecan-1. We aim to evaluate associations of intraoperative systemic NGAL and syndecan-1 levels with post-LT AKI. This is a prospective study conducted in 46 patients selected for LT. Patients were evaluated preoperatively and blood samples were collected intraoperatively: T1 (after induction of anesthesia), T2 (anhepatic phase) and T3 (2 h after reperfusion of the graft). The mean age was 54 ± 12 years and 60% were male. Post-LT AKI was observed in 24 (52%) patients of which 12% needed dialysis. Serum NGAL and syndecan-1 increased along surgical phases. Mostly, increment values of serum NGAL of T2 to T3 and syndecan-1 at T3 were importantly associated with post-LT AKI. Into a multivariate model with model for end-stage liver disease score, age, gender, warm ischemia, cold ischemia and surgery time, syndecan-1 levels at T3 remains capable to predict post-LT AKI. Serum NGAL had significance only with increment values calculated by the ratio of 'T3/T2'. Finally, serum syndecan-1 at T3 had a better diagnostic performance in receiver operating characteristic curve analysis. Serum syndecan-1 levels in 2 h after reperfusion were most useful in early post-LT AKI diagnosis and may be used to construct new risk groups in this context.

Feasibility of Retrohepatic Inferior Vena Cava Resection Without Reconstruction for Hepatic Alveolar Echinococcosis.

This study evaluates the feasibility of retrohepatic inferior vena cava (RHIVC) resection without reconstruction in patients with end-stage hepatic alveolar echinococcosis (AE). Four hundred and fifty-seven patients diagnosed with hepatic AE and who underwent surgical resections between January 2010 and October 2018 were retrospectively analyzed. Nine patients receiving RHIVC resection without reconstruction were included in this study. Among the patients, 5 were male and 4 female. Mean follow-up time was 64.4 months (18-95). In this series, adequate collateral circulation was formed before operation in all patients, and 7 cases underwent ex vivo liver resection and autotransplantation (ELRA) and 2 cases underwent extended right hemi-hepatectomy. Average standard liver volume, graft volume, surgical time, and anhepatic phase in ELRA group patients was 1144 ± 127 cm3, 740 ± 235 cm3, 16.8 ± 4.1 hours, and 337.4 ± 108.65 minutes respectively. Average hospital stay time for all patients was 45 ± 36.4 days. There were no intraoperative deaths. The 30-day mortality rate was 11.1%, and total mortality rate was 22.2%. Postoperative complications occurred in 4 patients. During follow-up, no relapsed AE lesions were found. RHIVC resection without reconstruction is a feasible way for hepatic AE patients with adequate collateral circulation. Careful protection of collateral venous is the key factor for successful operation.

Detection of early allograft dysfunction at 30 min of reperfusion in liver transplantation: An intraoperative diagnostic tool with real time assessment of graft function

IntroductionDuring the anhepatic phase of liver transplantation (LT), fibrinolytic activity increases, since the liver clears tissue plasminogen activator (tPA). We hypothesize that patients who fail to reduce fibrinolytic activity following graft reperfusion will have an increased rate of early allograft dysfunction (EAD). MethodsAssessment of fibrinolysis in liver transplant recipients was quantified with thrombelastography (TEG) LY30. Changes in LY30 were assessed after graft reperfusion. The 30-min post-reperfusion LY30 was subtracted from the anhepatic LY30 quantifying fibrinolytic changes (delta-LY30). ResultsSeventy-three primary LT patients were included in the analysis. Receiver operating characteristic curve (ROC) analysis identified an inflection point of delta-LY30–5.3% as a risk factor for EAD. EAD occurred in 44% of these patients compared to 5% in high delta-LY30 (p = 0.002). ConclusionLT recipients that develop hyperfibrinolysis who fail to reduce fibrinolytic activity 30 min after graft reperfusion had an EAD rate 8-fold higher than patients who had a large reduction in LY30 following reperfusion.

Single Orifice Outflow Reconstruction: Refining the Venous Outflow in Modified Right Lobe Live Donor Liver Transplantation

BackgroundMHV reconstruction is essential to avoid anterior sector congestion in adult live donor liver transplantation (LDLT) using a modified right lobe graft. AimsThe objective of this study is to evaluate the graft and patient outcomes with single orifice outflow reconstruction technique (SORT) (RHV + neo-MHV combined reconstruction on IVC) vs. dual outflow reconstruction technique (DORT) (RHV and neo-MHV separately reconstructed on IVC) in a modified right lobe LDLT. MethodsProspectively collected data of consecutive patients undergoing LDLT from June 2011 to August 2018 were analyzed. The patients were divided into two groups: SORT (n = 207) and DORT (n = 108). The perioperative morbidity and mortality were compared between two groups. ResultsThe two groups were comparable in baseline preoperative characteristics. Intraoperatively, warm ischemia time (27 vs. 45 min, p < 0.001), anhepatic phase (132 vs. 159 min, p < 0.001), and operative time (680 vs. 840 min, p < 0.001) were significantly shorter in SORT group. SORT group also had significantly lower GRWR (0.92 vs. 1.06, p < 0.001) and higher portal flow (2.4 vs. 2.7 L/min, p = 0.02). Postoperatively, SORT group had lower peak AST (177 vs. 209 IU/L, p < 0.001), ALT (163 vs. 189 IU/L, p = 0.004), creatinine levels (0.98 vs. 1.10, p = 0.01), rate of severe sepsis (13.7% vs. 22.9%, p = 0.03), major morbidity (50.7% vs. 62.6%, p = 0.03), shorter ICU (9 vs. 14 days, p < 0.001), and hospital stay (21 vs. 26 days, p = 0.03). Overall survival rates were comparable. ConclusionA SORT leads to improved early graft function and perioperative morbidity in modified right lobe LDLT in spite of having lower GRWR and higher portal flow.

Impact of Intraoperative Norepinephrine Support on Living Donor Liver Transplantation Outcomes: A Retrospective Cohort Study of 430 Children.

Norepinephrine (NE) is often administered during the perioperative period of liver transplantation to address hemodynamic instability and to improve organ perfusion and oxygen supply. However, its role and safety profile have yet to be evaluated in pediatric living donor liver transplantation (LDLT). We hypothesized that intraoperative NE infusion might affect pediatric LDLT outcomes. A retrospective study of 430 pediatric patients (median [interquartile range] age, 7 [6.10] months; 189 [43.9%] female) receiving LDLT between 2014 and 2016 at Renji Hospital was conducted. We evaluated patient survival among recipients who received intraoperative NE infusion (NE group, 85 recipients) and those that did not (non-NE group, 345 recipients). The number of children aged over 24 months and weighing more than 10 kg in NE group was more than that in non-NE group. And children in NE group had longer operative time, longer anhepatic phase time and more fluid infusion. After multivariate regression analysis and propensity score regression adjusting for confounding factors to determine the influence of intraoperative NE infusion on patient survival, the NE group had a 169% more probability of dying. Although there was no difference in mean arterial pressure changes relative to the baseline between the two groups, we did observe increased heart rates in NE group compared with those of the non-NE group at anhepatic phase (P=0.025), neohepatic phase (P=0.012) and operation end phase (P=0.017) of the operation. In conclusion, intraoperative NE infusion was associated with a poorer prognosis for pediatric LDLT recipients. Therefore, we recommend the application of NE during pediatric LDLT should be carefully re-considered.

Rescue Hepatectomy and Anhepatic Phase Management After Primary Nonfunction in a Liver Transplant

Primary nonfunction is a rare but lethal complication that occurs in a small number of liver transplants. When primary nonfunction occurs, the only definite treatment is retransplant; however, another liver might not be readily available at that time. Hence, a surgeon should be aware of the various options available at hand for patient care during the time interval between the primary nonfunction and retransplant. Here, we describe the management strategy that was devised to take care of an unstable anhepatic patient in the intensive care unit, care of the patient during anhepatic phase, and successful outcome with a second liver transplant. Our index patient was a recipient of a liver donated after cardiac death. While in the operating room, after reperfusion of the liver, the patient had right heart dysfunction leading to hemodynamic instability and congestion of the liver, which culminated in primary nonfunction. Graft hepatectomy had to be done on postoperative day 1 because of deteriorating condition of the patient, and the patient was maintained in anhepatic phase in the intensive care unit for 27 hours.

Five-lead Electrocardiography During Living Donor Liver Transplantation: Incidence and Clinical Significance of ST Segment Abnormality

ObjectivesFive-lead electrocardiography (ECG) is commonly used during liver transplantation, while 3-lead ECG is used during most noncardiac operations. This study aimed to evaluate the incidence and clinical significance of ST segment abnormality during living donor liver transplantation (LDLT) with 5-lead ECG. MethodsWe retrospectively reviewed medical records of patients who received LDLT between May 2018 and May 2019. A total of 109 adult recipients underwent LDLT, and 108 recipients were divided into 2 groups according to whether or not significant ST segment abnormality had occurred at 8 predetermined time points during the operation. ST segment change by more than 1 mm was regarded as significant. ResultsOf the 108 recipients, 21 recipients (19.4%) had significant ST segment depression during the operation. No case of significant ST segment elevation was noted. The significant ST segment depression was detected mostly in lead II and V5, and with 2 in combination we could detect 95.2% of significant ST segment change. The significant ST segment depression was frequently observed 1 hour after anhepatic phase and 2 hours after reperfusion. Patient characteristics were not different between the 2 groups. Moreover, the cardiac enzyme (troponin I) measurements, measured immediately after the operation, were not different between the 2 groups. ConclusionsAlthough significant ST segment change was frequently observed during LDLT, more studies are required to determine the clinical significance of 5-lead ECG ST segment abnormality during LDLT.

Prolonged Anhepatic Phase after Liver Transplantation Failure Followed by ABO Incompatible Liver Transplantation: A Case Report and Review of the Literature

Objective: To describe the experience with a multimodal therapeutic approach in a patient who developed toxic liver syndrome and fulminant hepatic failure following orthotopic liver transplantation (OLT) as a result of occlusion of the portal vein. Setting: Department of Intensive Care. Patient: A patient with liver cirrhosis secondary to autoimmune hepatitis and primary biliary cirrhosis who underwent orthotopic liver transplantation (OLT). Interventions: Transplant hepatectomy, plasmapheresis and retransplantation. Case Report: A 39-year-old man underwent an elective OLT. A routine postoperative doppler ultrasound examination a few hours after surgery revealed portal vein thrombosis. Attempts at recanalization failed, and the patient developed acute fulminant liver failure, which remained resistant to supportive therapy. A transplant hepatectomy was performed 9 hours later and plasmapheresis started. Following a 10-hour anhepatic period, the patient received a second liver, from an ABO-incompatible donor. The patient underwent column plasmapheresis and subsequent splenectomy to remove anti-B antibody to preserve the incompatible transplanted liver from immunogenic complications. The patient spent a total of 21 days in the Intensive Care Unit (ICU) before being discharged to a step-down ward. Conclusion: Our experience suggests that multimodal therapy, including transplant hepatectomy, plasmapheresis and retransplantation of an even non-ABO compatible liver may result in the successful outcome in patients with acute fulminant liver failure complicating OLT.

Ligation Of The Left Renal Vein In Liver Transplant Recipients Diagnosed With A Spontaneous Splenorenal Shunt – Case Report

IntroductionFor patients diagnosed with hepatic cirrhosis and portal hypertension, qualified for liver transplantation, the presence of portosystemic collateral circulation constitutes a typical phenomenon. One of its types is the spontaneous splenorenal shunt. Large or multiple ones may cause the steal syndrome and graft hypoperfusion. An attempt to remove such shunts directly is technically difficult and fraught with complications. An easier and safer method would involve ligating the left renal vein. The aim of this paper is to present a case where proper perfusion of a transplanted liver is ensured by the left renal vein ligation, performed in a recipient with a splenorenal shunt, and to review the scientific reports devoted to portosystemic shunts in liver transplant recipients. Case reportA 63-year-old female with alcoholic liver disease was qualified for liver transplantation. The CT-angiography showed numerous splenorenal shunts with diameter up to 13 mm. During the anhepatic phase of the liver transplantation a very weak effusion from the portal vein was observed, which improved significantly following clamping of the left renal vein. Thus renal vein orifice was ligated in order to achieve the correct graft reperfusion. Postoperative Doppler ultrasound showed a correct portal blood flow. The early liver and renal function was good. Finally, in the 7th month, the patient underwent a re-transplantation due to biliary necrosis caused by late hepatic artery thrombosis. ConclusionLigation of the left renal vein efficiently prevents the steal syndrome in the liver transplant recipients with splenorenal shunt and ensures good graft perfusion.