High-volume Liver Transplantation Center Research Articles

A comparison between patients with various etiologies of cirrhosis and examination of cardiac risk factors limiting survival to liver transplantation.

Objectives of this retrospective cohort study were to assess differences in patient survival between etiologies of cirrhosis while on the waitlist for liver transplantation (LT), and to identify cardiac risk factors that predict survival failure while on the waitlist for LT. This single-center retrospective cohort design included adult patients who were listed for LT at a tertiary academic hospital with a high-volume liver transplant center. Of the 653 patients listed for LT during the study period, 507 (77.6%) survived to transplant and 146 (22.4%) died or clinically deteriorated prior to transplant. Cumulative incidence of death or clinical deterioration did not differ statistically between patient groups (log rank p=.11). In multivariate analysis, compared to patients with NAFLD, there were no significant differences between patients with alcoholic cirrhosis (HR .95, 95%, CI, .62-1.45), cryptogenic cirrhosis (HR 1.31, 95%, CI, .77-2.23), or hepatitis C cirrhosis (HR 1.12, 95%, CI, .66-1.90). However, higher MELD scores (HR=1.52, 95% CI, 1.12-1.19), severe coronary artery disease (HR=2.09 95% CI, 1.23-3.55), and tricuspid regurgitation (HR=2.62, 95% CI, 1.31-5.26) were independently associated with increased risk for survival failure to LT. The presence of severe coronary artery disease and tricuspid regurgitation at the time of listing for transplant are associated with survival failure while on the LT waitlist across etiologies of liver disease. Diagnostic assessment of coronary and valvular disease should be considered in all patients undergoing evaluation for LT, such as cardiac catheterization and/or stress echocardiogram.

Safety of laparoscopic repair of incisional hernias in liver transplant recipients.

Incisional hernia is a common complication following liver transplantation occurring in 5%-34% of patients. Traditionally, open repair was standard due to fear of abdominal adhesions, postoperative complications and lack of experience with laparoscopic techniques. Laparoscopic incisional hernia repair (LIHR) has now become routine in non-transplant patients, with improved postoperative outcomes. In this study, we compared outcomes after laparoscopic and open incisional hernia repair after liver transplantation at a high-volume liver transplant center. We performed a retrospective cohort study including all incisional hernia repairs performed on post-liver transplant patients at a major liver transplant center in Australia from 2010 to 2021. Donor, recipient, intraoperative and postoperative variables were collected from the electronic medical record focusing on laparoscopic and open repairs. Between January 2010 and March 2021, 138 patients underwent incisional hernia repair: 40 laparoscopic (29%) and 98 open (71%). No difference in wound infection (2.5%vs. 7.7%, p=.243); wound dehiscence (.00%vs. 2.3%, p=.332) or hernia recurrence (16.3%vs. 23.0%, p=.352) was seen between treatment groups. For larger incisional hernias (>5cm) we found that a laparoscopic repair reduced length of stay compared to open-repair (3.89vs. 4.57 days, p=.026). Laparoscopic repair of larger incisional hernias reduced postoperative length of hospital stay, whilst potential advantages may include reduced wound complications and hernia recurrence. Importantly, laparoscopic repair did not increase postoperative complication rates and represents a safe technique for repair in this demographic.

Incidental Hepatocellular Carcinoma after Liver Transplantation: Clinicopathologic Features and Prognosis.

Background: The prognostic impact and clinicopathologic features of incidental hepatocellular carcinoma (iHCC) detected in explanted livers of patients undergoing liver transplantation (LT) has been a controversial issue in previous studies when compared with patients who are diagnosed with hepatocellular carcinoma (pdHCC) before LT. We aimed to review and compare these patient groups in a high-volume LT center. Methods: The present study involves a retrospective analysis of 406 HCC patients who received LT between January 2002 and April 2022. Among these patients, demographic data, histopathologic features and prognosis for iHCC and pdHCC were evaluated. Results: In our series, 406 patients' final diagnosis was HCC after they had received LT, nevertheless 54 patients in this HCC group were diagnosed incidentally after the pathological evaluation of the explanted livers. The etiology of the underlying liver disease between pdHCC (n = 352) and iHCC (n = 54) groups had some differences in our study population. Most of the patients in the pdHCC group had moderately differentiated tumors (45.7%). On the other hand, most of the patients in the iHCC group had well differentiated tumors (79.6%). There were 158 (44%) patients who met the Milan criteria in the pdHCC group while there were 48 (92%) patients in the iHCC group (p < 0.001). IHCC patients had statistically better 1, 3, 5 and 10 years disease-free and overall survival rates when compared with pdHCC patients. There was only 1 (1.8%) patient who had tumor recurrence in the iHCC group while 76 (21%) patients had tumor recurrence in the pdHCC group (p = 0.001). There is no disease free and overall survival difference when iHCC patients are compared with pdHCC patients who met the Milan criteria. Conclusion: It is the first study to show that iHCC patients may differ from pdHCC patients in terms of etiological features. IHCC tumors show better histopathologic features than pdHCC with low recurrence rate and iHCC patients have better survival rates than pdHCC patients.

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Viability assessment and transplantation of fatty liver grafts using end-ischemic normothermic machine perfusion.

End-ischemic viability testing by normothermic machine perfusion (NMP) represents an effective strategy to recover liver grafts having initially been discarded for liver transplantation (LT). However, its results in the setting of significant (≥30%) macrovesicular steatosis (MaS) have not been specifically assessed. Prospectively maintained databases at two high-volume LT centers in Northern Italy were searched to identify cases of end-ischemic NMP performed to test the viability of livers with MaS ≥ 30% in the period from January 2019 to January 2022. A total of 14 cases were retrieved, representing 57.9% of NMP and 5.7% of all machine perfusion procedures. Of those patients, 10 (71%) received transplants. Two patients developed primary nonfunction (PNF) and required urgent re-LT, and both were characterized by incomplete or suboptimal lactate clearance during NMP. PNF cases were also characterized by higher perfusate transaminases, lower hepatic artery and portal vein flows at 2 h, and a lack of glucose metabolism in one case. The remaining eight patients showed good liver function (Liver Graft Assessment Following Transplantation risk score, -1.9 [risk, 13.6%]; Early Allograft Failure Simplified Estimation score, -3.7 [risk, 2.6%]) and had a favorable postoperative course. Overall, NMP allowed successful transplantation of 57% of livers with moderate-to-severe MaS. Our findings suggest that prolonged observation (≥6 h) might be required for steatotic livers and that stable lactate clearance is a fundamental prerequisite for their use.

313.6: Early Graft Disfunction After Hypothermic Oxygenated Machine Perfusion of ECD Criteria Liver Grafts: No Longer A Clinical Issue?

Introduction: Early allograft disfunction (EAD) continues to be an important issue in liver transplantation, varying from 15 to 30%. This rate is particularly high in case of extended criteria donor (ECD) grafts due to significant ischemia-reperfusion injury leading to EAD. This injury is substantially reduced by thermoregulated oxygenated machine perfusion. The aim of the paper was to assess the use of hypothermic oxygenated machine perfusion (HOPE) in ECD liver grafts in a high-volume liver transplantation center using a specific protocol. Method: Grafts with >30% macrosteatosis and with multiple ECD (at least 2 criteria) were perfused using dual HOPE (hepatic artery and portal vein perfusion), while HOPE (portal vein perfusion only) was used for the remaining ECD grafts. The main criteria to establish graft improvement were the improvement of arterial and portal perfusion flows, with lactate under 3 mmol/L throughout the procedure. Results: Between February 2016 and February 2022, 26 ECD liver grafts were harvested from DBD (donation after brain death) donors and benefitted from HOPE. Dual HOPE was used in 8 grafts (30.7%). Criteria for graft improvement were met in all grafts except 5 (19.2%), where lactate was over 3 mmol/L, with a median of 3.6 (range 3.5-6.1). The median follow-up was 5 months (range 2-44). No EAD was encountered. Conclusion: By using a combined protocol of HOPE and dual HOPE, ECD liver grafts may be safely used by avoiding early graft dysfunction.

Twenty-year longitudinal follow-up after liver transplantation: a single-center experience with 251 consecutive patients.

BackgroundThe outcomes of liver transplantation (LT) have improved, but actual 20-year survival data have rarely been presented.MethodsLongitudinal follow-up data of 20-year LT survivors were retrospectively analyzed. The LT database of our institution was searched to identify patients who underwent primary LT from January 2000 to December 2001. The study cohort of 251 patients was divided into three groups 207 adults who underwent living donor LT (LDLT), 22 adults who underwent deceased donor LT (DDLT), and 22 pediatric patients who underwent LT.ResultsHepatitis B virus–associated liver cirrhosis and biliary atresia were the most common indications for adult and pediatric LT, respectively. Seven patients required retransplantation, including six who underwent DDLT and one who underwent LDLT. Twenty-two patients died within 3 months after LT and 69 died at later intervals. The overall survival rates at 1, 3, 5, 10, and 20 years were 86.4%, 79.6%, 77.7%, 72.8%, and 62.6%, respectively, in the adult LDLT group; 86.4%, 72.7%, 72.7%, 72.7%, and 68.2%, respectively, in the adult DDLT group; and 86.4%, 86.4%, 81.8%, 81.8%, and 77.3%, respectively, in the pediatric LT group (P=0.545). Common immunosuppressive regimens at 20 years included tacrolimus monotherapy, tacrolimus–mycophenolate dual therapy, cyclosporine monotherapy, and mycophenolate monotherapy.ConclusionsThe present study is the first report of actual 20-year survival data from a Korean high-volume LT center. The graft and patient survival outcomes reflected the early experiences of LT in our institution, with long-term outcomes being similar regardless of graft type and patient age.

Coronavirus Precautions: Experience of High Volume Liver Transplant Institute.

To present the struggle of a high volume liver transplant center against coronavirus infectious disease-2019 pandemic. Between March 2020 and December 2020, the demographic and clinical data of staff and liver transplant candidates diagnosed with coronavirus infectious disease-2019 in our Liver Transplant Institute were prospectively analyzed. First, 32 healthcare staff were diagnosed with coronavirus infectious disease-2019, and 6 of them were surgeons. Six staff were asymptomatic, while 24 staff had mild or moderate and 2 staff had severe coronavirus infectious disease-2019. All the staff recovered from the disease without any permanent sequela and returned to duty after 2 consecutive negative polymerase chain reaction results within 24-hour intervals. Second, during the preoperative investigation, 6 living liver donor candidates and 13 recipients were tested positive for coronavirus infectious disease-2019 (son = 6, unrelated = 3, cousin = 3, daughter = 2, cadaveric = 1). Eleven patients received favipiravir and 8 did not receive any treatment because they were asymptomatic. Only one recipient who had severe coronavirus infectious disease-2019 died due to multiple organ failure syndrome. One recipient died in the early postoperative period. The median duration from the initial diagnosis of the patients till the transplant procedure was 21 days (min-max: 14-105 days). During the time of operation, the polymerase chain reaction tests of the donors and the recipients were negative, and the thorax tomography images showed no signs of viral pneumonia. Meticulous precautions, multidisciplinary approach, team effort, and organization of facilities can increase the quality of care of these patients in the coronavirus infectious disease-2019 era. Healthcare workers have shown tremendous effort and are the true heroes of this era.

Institutional standard framework and experience of living donor liver transplantation for overseas non-Korean patients at Asan Medical Center.

BackgroundLiver transplantation (LT) for foreign patients is a sensitive issue because of possibility of transplant tourism and difficulty in posttransplant follow-up. This study describes the institutional standard framework and experience of living donor LT (LDLT) for overseas non-Korean patients in a Korean high-volume LDLT center.MethodsThe framework and experience of LDLT for 105 non-Korean patients from 2010 to 2019 were retrospectively investigated.ResultsOnly 3.1% of patients who underwent LDLT were overseas non-Koreans; of these, 83.8% were from the United Arab Emirates and Mongolia. Selection criteria for recipients and donors were the same as for Korean citizens. Of the 105 recipients, 95 (90.5%) were adults. The most common reasons for transplantation were hepatitis B or C virus-associated liver cirrhosis. Of the 95 adults, 78 (82.1%) received right liver grafts, and 16 (16.8%) received dual grafts. The most frequent donors for adult recipients were sons and daughters, whereas the most frequent donors for pediatric recipients were parents. Of the 10 pediatric patients, eight were from the United Arab Emirates; their common primary diseases were biliary atresia, acute liver failure, hepatoblastoma, and genetic metabolic diseases. The 1-, 3-, and 5-year posttransplant overall patient survival rates in all patients were 96.2%, 92.4%, and 92.4%, respectively. The 5-year overall patient survival rates were 91.8% in adult recipients and 100% in pediatric recipients (P=0.47).ConclusionsLDLT at Korean high-volume LT centers including our institution is safe and effective for non-Korean patients with end-stage liver disease seeking alternatives not available in their own countries.

Hypothermic Oxygenated Machine Perfusion of Liver Grafts: Preliminary Experience in a Single Center.

Background: The need to maximize the use of donor organs and the issue of ischemia-reperfusion injury led to the use of thermoregulated oxygenated machine perfusion that improves the function of liver graft prior to transplantation. Among these methods, the HOPE (hypothermic oxygenated perfusion) protocol shows significant benefits. The aim of the paper is to analyze the early experience in using such procedure in a high-volume liver transplantation center. Methods: Normal liver grafts with cold ischemia time â?¥6 hours, marginal grafts and discarded (beyond ECD criteria) grafts were perfused using HOPE. Our selection criteria for dual HOPE (hepatic artery and portal perfusion) were steatosis, at least 3 associated ECD criteria, and discarded grafts. The main criteria to establish graft improvement were the progressive increase of arterial and portal flows, with lactate under 3 mmol/L or, even if over this value, with a decreasing trend during perfusion. Results: Whole liver grafts harvested from 28 donors between February 2016 and June 2021 benefitted from HOPE: 9 otherwise discarded grafts were assessed and considered not fit for transplantation, while the other 19 were ECD or standard grafts that were subsequently transplanted. Dual HOPE was used in 8 out of the 19 procedures (42.1%). We obtained a significant increase of arterial and portal flow (p=0.005 and p=0.001, respectively). In recipients, significant improvement of AST, ALT, INR and lactate values were recorded (p 0.001, p 0.001, p 0.001, and p=0.05, respectively). The rate of major postoperative complications (Dindo-Clavien grade 3) after LT was 26.3%, while the rate of early graft dysfunction was 15.8%. No PRS or acute rejection was recorded. The postoperative mortality rate was 15.8%. After a median follow-up of 9.3 months (range 2-44), the late major complication rate was 15.8%, without mortality. Conclusion: Machine perfusion is nowadays part of current clinical practice. This way, marginal liver grafts (DCD, ECD-DBD) may be safely used for transplantation improving the outcome, thus effectively enhance the use of a persistent scarce pool of donors. For best results, we believe that both techniques of HOPE (mono and dual HOPE) should be used based on specific selection criteria.

Standard framework and experience of living donor liver transplantation for overseas non-Korean patients at Asan Medical Center

Background: Liver transplantation (LT) for foreign patients is a sensitive issue because of the possibility of transplant tourism and the difficulty in follow-up. This study describes the standard framework and experience of living donor LT (LDLT) for over seas non-Korean patients in a Korean high-volume LDLT center. Methods: The framework and experience of LDLT for 105 non-Korean patients from 2010 to 2019 were retrospectively investigated. Results: Only 3.1% of patients who underwent LDLT were overseas non-Koreans; of these, 83.8% were from the United Arab Emir ates and Mongolia. Selection criteria for recipients and donors were the same as for Korean citizens. Of the 105 recipients, 95 (90.5%) were adults. The most common reasons for transplantation were hepatitis B or C virus-associated liver cirrhosis. Of the 95 adults, 78 (82.1%) received right liver grafts, and 16 (16.8%) received dual grafts. The most frequent donors for adult recipients were sons and daughters, whereas the most frequent donors for pediatric recipients were parents. Of the 10 pediatric patients, eight were from the United Arab Emirates; their common primary diseases were biliary atresia, acute liver failure, hepatoblasto ma, and genetic metabolic diseases. The 1-, 3-, and 5-year posttransplant overall patient survival rates in all patients were 96.2%, 92.4%, and 92.4%, respectively. The 5-year overall patient survival rates were 91.8% in adult recipients and 100% in pediatric re cipients (P=0.47). Conclusions: LDLT at Korean high-volume LT centers including our institution is safe and effective for non-Korean patients with end-stage liver disease seeking alternatives not available in their own countries.

S0622 Upper Endoscopic Outcomes in High MELD Patients Undergoing Inpatient Transplant Evaluation

INTRODUCTION: Patients with cirrhosis have increased risks of bleeding related to portal hypertension (including esophageal varices, and portal hypertensive gastropathy), as well coagulopathy from hepatic dysfunction, thrombocytopenia, and impaired INR. There is limited data evaluating the upper endoscopy outcomes of interventions in patient with increased MELD scores, or those undergoing transplant evaluation. Our aims were to determine upper endoscopy outcomes of intra-procedure bleeding, post-procedure bleeding, and IR intervention in patients undergoing inpatient liver transplant evaluations at a single high-volume liver transplant center. METHODS: Retrospective review of patients who underwent inpatient liver transplant evaluation at a single high-volume center were evaluated between January 2017 and July 2019, with 235 patients identified. 62 of those required an inpatient upper endoscopy as a part of their transplant evaluation. Univariate analysis with Pearson Chi-squared or ANOVA was performed. Multivariate logistic model selection was performed using AIC. The final logistic model utilized MELD, INR, platelets, and banding to predict the probability of intra or post-procedure bleeding after endoscopies during urgent liver transplant evaluation. The model was tested using the Hosmer-Lemeshow goodness of fit test. A P-value of 0.05 was considered statistically significant. RESULTS: Of sixty-two patients who underwent upper endoscopy, 9 were noted to have intra-procedure or post-procedure bleeding. Of those 9 patients that bled, 6 were related to varices, and 1 patient required an interventional radiology procedure for hemostasis. While not statistically significant, 7 of the patients with procedure-related bleeding had underlying alcoholic cirrhosis (P = 0.089). Univariate MELD differences between the two groups were not significant (P = 0.40) with group means of 23.39 for the outcome group and 20.33 for the non-outcome group. On multivariate analysis (Table 1), a platelet count > 100 demonstrated a statistically significant 0.10 times decreased odds of bleeding (P = 0.035). MELD, INR, and banding were not significant on multivariate analysis. CONCLUSION: Based on our single center results, we have demonstrated that performing upper endoscopies in patients with a high MELD can be done safely. Those with a platelet count below 100 may have a slightly increased risk of bleeding based on multivariate analysis. A larger sample size is needed to evaluate these findings along with external validation.Table 1

Perioperative Pleural Drainage in Liver Transplantation: A Retrospective Analysis from a High-Volume Liver Transplant Center.

BackgroundPleural effusions represent a common complication after liver transplantation (LT) and chest drain (CD) placement is frequently necessary.Material/MethodsIn this retrospective cohort study, adult LT recipients between 2009 and 2016 were analyzed for pleural effusion formation and its treatment within the first 10 postoperative days. The aim of the study was to compare different settings of CD placement with regard to intervention-related complications.ResultsOverall, 597 patients met the inclusion criteria, of which 361 patients (60.5%) received at least 1 CD within the study period. Patients with a MELD >25 were more frequently affected (75.7% versus 56.0%, P<0.001). Typically, CDs were placed in the intensive care unit (ICU) (66.8%) or in the operating room (14.1% during LT, 11.5% in the context of reoperations). In total, 97.0% of the patients received a right-sided CD, presumably caused by local irritations. Approximately one-third (35.4%) of ICU-patients required pre-interventional optimization of coagulation. Of the 361 patients receiving a CD, 15 patients (4.2%) suffered a post-interventional hemorrhage and 6 patients (1.4%) had a pneumothorax requiring further treatment. Less complications were observed when the CD was performed in the operating room compared to the ICU: 1 out 127 patients (0.8%) versus 20 out of 332 patients (6.0%); P=0.016.ConclusionsCD placement occurring in the operating room was associated with fewer complications in contrast to placement occurring in the ICU. Planned CD placement in the course of surgery might be favorable in high-risk patients.

Is renal replacement therapy necessary in deceased donor liver transplantation candidates with hepatorenal syndrome?: a 2-year experience at a high-volume center.

PurposeHepatorenal syndrome (HRS) is a fatal complication in patients with end-stage liver disease awaiting liver transplantation (LT). HRS often develops in patients with high model for end-stage liver disease (MELD) score. This study investigated the outcomes of peritransplant management of HRS in a high-volume LT center in Korea for 2 years.MethodsA total of 157 recipients that deceased donor liver transplantation (DDLT) from January 2017 to December 2018 were included. In-hospital mortality (IHM) was analyzed in relation to pre- and posttransplant application of renal replacement therapy (RRT).ResultsPrimary diagnoses for DDLT were alcoholic liver disease (n = 61), HBV-associated liver cirrhosis (n = 48), retransplantation for chronic graft failure (n = 24), and others (n = 24). Mean MELD score was 34.6 ± 6.2 with 72 patients at Korean Network for Organ Sharing MELD status 2 (45.9%), 43 at status 3 (27.4%), 36 at status 4 (22.9%), and 6 at status 5 (3.8%). Pretransplant RRT was performed in 16 patients (10.2%) that did not show IHM. Posttransplant RRT was performed in 69 patients (44.0%), for whom IHM incidence was 15.9%. In 53 patients that had undergone de novo posttransplant RRT, IHM incidence increased to 20.8%. IHM in the 88 patients not requiring RRT was 2.3%.ConclusionThe majority of adult DDLT recipients in Korean MELD score-based allocation system have very high MELD scores, which is often associated with HRS. Pretransplant RRT appears to improve posttransplant survival outcomes. We thereby recommend that, if indicated, pretransplant RRT be performed while awaiting DDLT.

Living Donor Liver Transplantation for Hepatocellular Carcinoma: An Asian Perspective.

Despite advancements in early diagnosis and medico-surgical treatment, hepatocellular carcinoma (HCC) is still a major cancer that causes substantial mortality in Asian countries. Liver transplantation (LT) has been accepted worldwide as the most effective treatment modality for patients with HCC; however, with the high incidence of HCC and low organ donation rate, Asia has developed distinctive features of indications and strategies for the application of LT. Unlike Western countries, living donor liver transplantation (LDLT) accounts for most LT cases for HCC in Asian countries, and most major transplantation centers perform LDLT for HCC patients with extended criteria. This article reviewed the current practice and outcome of LDLT for HCC from an Asian perspective and summarized the strategies that the high-volume LT centers in Asia use to obtain satisfactory oncologic results.

Assessment of patient safety and the efficiency of facility utilization following simplified ultra-rapid intravenous infusion of hepatitis B immunoglobulin in a high-volume liver transplantation center.

Backgrounds/AimsThis study intended to evaluate patient safety and efficiency of facility utilization following simplified ultra-rapid intravenous infusion of hepatitis B immunoglobulin (HBIG) in recipients of hepatitis B virus-associated adult liver transplantation (LT), who visited our outpatient clinic.MethodsOur simplified ultra-rapid infusion protocol was to directly infuse 50 ml volume of 10,000 IU HBIG for 20–25 minutes on an ambulatory basis. The incidence of adverse side-effects and the efficiency of facility utilization were assessed retrospectively.ResultsA total of 1,513 patients received 12,472 sessions of HBIG infusion according to simplified ultra-rapid infusion method. Of these, 1,172 patients were converted from conventional ultra-rapid infusion method, and received 8,352 sessions of HBIG infusion for 18 months (mean 7.1 times; 4.8 times per year). The remaining 341 de novo patients received 4,120 sessions of HBIG infusion for 18 months (mean 12.1 times; 8.1 times per year). None of these patients experienced any adverse side-effects following the simplified ultra-rapid infusion. The maximal capacity of HBIG infusion sessions at the injection facility of our outpatient clinic was increased from 65–70 sessions to 80 sessions, after introduction of simplified ultra-rapid infusion method. Mean trough anti-HBs titer was lower, and mean interval of HBIG infusion was longer in the combination therapy group compared with HBIG monotherapy group.ConclusionsOur high-volume study indicates that in nearly all LT recipients, rapid infusion of highly purified HBIG within 30 minutes was well-tolerated. This suggests that it would be reasonable to perform simplified ultra-rapid infusion protocol widely for patient convenience.

Risk factors and outcomes of acute respiratory distress syndrome in critically ill patients with cirrhosis.

Prior randomized controlled trials of acute respiratory distress syndrome (ARDS) excluded critically ill patients with cirrhosis. Data regarding risk factors for ARDS development and outcomes from ARDS in patients with cirrhosis are scarce. We sought to characterize outcomes from ARDS in patients with cirrhosis. An observational cohort of patients with cirrhosis admitted to an intensive care unit at a high-volume liver transplant center between 1 January 2012 and 31 December 2014 were reviewed. ARDS cases were identified according to the Berlin definition. Potential risk factors were examined in multivariable logistic regression analysis for ARDS development. Outcomes including in-hospital mortality were compared between ARDS and non-ARDS patients. A total of 559 patients met the inclusion criteria and 45 (8.1%) developed ARDS. Differences between ARDS and non-ARDS patients included sepsis, Model for End-Stage Liver Disease - Sodium score, and Sequential Organ Failure Assessment score. In-hospital mortality was higher in cirrhotic patients with ARDS compared with those without ARDS (82.2% vs. 27.6%, P < 0.001). In multivariable analysis, acute-on-chronic liver failure (OR 8.69, 95% CI 2.28-33.18, P < 0.01) and shock on intensive care unit admission (OR 3.13, 95% CI 1.57-6.24, P = 0.001) were associated with ARDS development, whereas etiology of cirrhosis or alcohol use were not. Acute-on-chronic liver failure and shock on intensive care unit admission were risk factors for ARDS development, whereas etiology of cirrhosis and alcohol were not. Mortality from ARDS was markedly increased in patients with cirrhosis. Early recognition and treatment for infection might be important for improving the high mortality in this group of patients.

Usefulness for Predicting Cardiac Events After Orthotopic Liver Transplantation of Myocardial Perfusion Imaging and Dobutamine Stress Echocardiography Preoperatively

Patients undergoing orthotopic liver transplantation have high rates of cardiac morbidity and mortality. Although guidelines recommend noninvasive stress testing as part of the preoperative evaluation, little data have evaluated clinical outcomes following orthotopic liver transplantation. A retrospective study at 2 high-volume liver transplantation centers was performed. All patients undergoing noninvasive stress testing (myocardial perfusion imaging [MPI] or dobutamine stress echocardiography [DSE]) over a 5-year period were included. Descriptive analyses, including clinical outcomes and perioperative and postoperative ischemic events, were performed. Comparisons were made between subsets of patients within each stress modality based on abnormal versus normal results. A total of 506 patients were included, of which 343 underwent DSE and 163 MPI. Few patients had abnormal results, with 19 (5.5%) in the DSE group and 13 (8%) in the MPI group. Perioperative and postoperative cardiac complications were low (n= 20, 5.8% and n= 3, 0.9% in DSE group and n= 15, 9.2% and n= 3, 1.8% in MPI group). Comparisons between abnormal versus normal findings showed a trend toward periprocedural cardiac complications in the abnormal DSE group (n= 3, 15.8% vs n= 17, 5.25%; p= 0.09) with no difference in 6-month postprocedural complications (n= 0 vs n= 3, 0.9%; p= 1.0). In the MPI group, a trend toward periprocedural ischemic complications (n= 3, 23.1% vs n= 12, 8%; p= 0.1) was noted with no difference in 6-month postprocedural complications (n= 0 vs n= 3, 2%; p= 1.0). In conclusion, our study found a significantly lower than reported cardiac event rate. In addition, it demonstrated that ischemic cardiac events are uncommon in patients with normal stress testing.

Acute Graft-vs-Host Disease After Liver Transplantation: Experience at a High-volume Liver Transplantation Center in Korea

BackgroundAcute graft-vs-host disease (GVHD) is a rare but life-threatening complication of orthotopic liver transplantation (OLT). We present 6 cases of GVHD after OLT. MethodsAmong our 4294 OLT recipients, we identified 6 patients (0.14%) who were diagnosed with GVHD. Their medical records were reviewed retrospectively. ResultsLiver graft types included deceased donor whole liver graft (n = 3) and right liver graft from son (n = 3). Mean recipient and donor ages were 57.2 ± 6.6 years and 32.7 ± 10.8 years, respectively. Onset of GVHD symptoms occurred 14 to 32 days after OLT, and initial symptoms were skin rash (n = 5) and fever (n = 1). GVHD was pathologically confirmed by skin or rectal biopsy. Chimerism of donor lymphocytes was identified in all 3 patients who underwent the short tandem repeat polymerase chain reaction assay. Attempts were made to treat the GVHD in all 6 patients by corticosteroids with or without low-dose calcineurin inhibitor, but we had to stop early or reduce these agents due to aggravation of pancytopenia and septic complications. Ultimately, 5 patients died 6 to 106 days after the onset of GVHD, and only 1 patient recovered. This surviving patient was diagnosed earlier and had been administered the recommended dosage of corticosteroid for a longer period with aggressive infection prophylaxis compared to the other cases. ConclusionsBecause of very poor outcomes of GVHD after OLT, early diagnosis and vigorous treatment should be emphasized, although no effective treatment modality has been established yet. We strongly suggest performing aggressive infection prophylaxis during GVHD treatment.

Descriptive Analysis of Patients Undergoing Conventional Non-invasive Stress Testing as Part of the Pre-orthotopic Liver Transplant Evaluation

Introduction: Patients undergoing orthotopic liver transplantation (OLT) have high rates of cardiac morbidity and mortality. Although guidelines recommend non-invasive stress testing as part of the preoperative evaluation, little data has evaluated clinical outcomes following OLT. Methods: A retrospective study at two high volume liver transplantation centers was performed. All patients undergoing non-invasive stress testing (myocardial perfusion imaging [MPI] or dobutamine stress echocardiography [DSE]) over a 5-year period were included. Descriptive analyses, including clinical outcomes and peri- and post- operative ischemic events, were performed. Comparisons were made between subsets of patients within each stress modality based on abnormal versus normal results. Results: A total of 506 patients were included, of which 343 underwent DSE and 163 MPI. Few patients had abnormal results, with 19 (5.5%) in the DSE group and 13 (8%) in the MPI. Peri- and post-operative cardiac complications were low (n=20, 5.8% and n=3, 0.9% in DSE group and n=15, 9.2% and n=3, 1.8% in MPI group). Comparisons between abnormal versus normal findings showed a trend toward periprocedural cardiac complications in the abnormal DSE group (n=3, 15.8% versus n=17, 5.25%; p=0.09) with no difference in 6-month post-procedural complications (n=0 versus n=3, 0.9%; p=1.0). In the MPI group, no difference in peri-procedural ischemic complications (n=3, 23.1% versus n=12, 8%; p=0.1) or 6-month post-procedural complications (n=0 versus n=3, 2%; p=1.0) was noted. Conclusion: Our study found a significantly lower than reported cardiac event rate. Additionally, it demonstrated that ischemic cardiac events are uncommon in patients with normal non-invasive stress testing.