Initial Poor Function Research Articles

Sevoflurane preconditioning in living liver donation is associated with better initial graft function after pediatric transplantation: a retrospective study

IntroductionInitial allograft function determines the patient’s immediate prognosis in pediatric liver transplantation. Ischemia-reperfusion injuries play a role in initial poor graft function (IPGF). In animal studies, preconditioning with inhaled anesthetic agents has demonstrated a protective effect on the liver. In humans, the few available studies are conflicting. This study assesses the association between the hypnotic agent used to maintain anesthesia during hepatectomy in living donors and the occurrence of IPGF after pediatric transplantation.MethodsWe conducted a single-center retrospective analysis of children who received a living donor liver transplant (LDLT) between 2010 and 2019. We analyzed the incidence of EAD according to the hypnotic agent used to maintain general anesthesia during donor hepatectomy.ResultsWe included 183 pairs of patients (living donors-recipients). The anesthetics used in the donor were propofol (n = 85), sevoflurane (n = 69), or propofol with sevoflurane started 30 min before clamping (n = 29). Forty-two children (23%) developed IPGF. After multivariate logistic regression analysis, factors significantly associated with the occurrence of IPGF were the anesthesia maintenance agent used in the donor (p = 0.004), age of the donor (p = 0.03), duration of transplant surgery (p = 0.009), preoperative receiver neutrophil to lymphocyte ratio (p = 0.02), and albumin (p = 0.05).ConclusionSignificantly fewer children who received a graft from a donor in whom only sevoflurane was used to maintain anesthesia developed IPGF. Although additional research is needed, this preconditioning strategy may provide an option to prevent IPGF after living liver donation.

Renal outcomes in IgA nephropathy following inactivated SARS-CoV-2 vaccination.

There are increasing case reports on de novo or relapsing IgA nephropathy (IgAN) following SARS-CoV-2 vaccines, although the follow-up information on renal outcomes in IgAN patients post-SARS-CoV-2 vaccination is limited. In this study, we evaluated the renal outcomes of IgAN patients following inactivated vaccines. We investigated the change in eGFR, proteinuria and hematuria in 113 primary IgAN patients post-vaccination. Worsening proteinuria was defined as an increase in proteinuria by more than 0.5 times and proteinuria > 1g/d. Univariate and multivariable logistic regression analysis were used to evaluate possible predictors of worsening proteinuria. We then compared the renal outcomes of vaccinated patients after 6months with 101 unvaccinated patients who were followed during the same period. A 2.54% (0.64, 8.61) decrease in renal function was observed in post-vaccination patients. Subgroup analysis revealed a significant decrease in eGFR in patients with 30 ≤ eGFR < 60 (mL/min/1.73m2) post second SARS-CoV-2 dose (n = 18, p = 0.01). In addition, 10 individuals displayed worsening proteinuria post-vaccination, with the proteinuria subsequently ameliorating significantly after 6-month. Multivariate analysis showed that higher eGFR levels was an independent protective factor for worsening proteinuria. The renal outcome tended towards a decrease in eGFR in vaccinated patients after 6months follow-up, although the difference was not significant (p = 0.06). Kidney function in IgAN patients tended to worsen after SARS-CoV-2 vaccination, particularly those with initial poor kidney function. This pattern of disease flare appears to be clinically mild, and further research is needed to determine whether the impact on kidney function is long-term.

Banff consensus recommendations for steatosis assessment in donor livers.

Background and AimsNo consensus criteria or approaches exist regarding assessment of steatosis in the setting of human donor liver suitability for transplantation. The Banff Working Group on Liver Allograft Pathology undertook a study to determine the consistency with which steatosis is assessed and reported in frozen sections of potential donor livers.Approach and ResultsA panel of 59 pathologists from 16 countries completed a questionnaire covering criteria used to assess steatosis in donor liver biopsies, including droplet size and magnification used; subsequently, steatosis severity was assessed in 18 whole slide images of donor liver frozen sections (n = 59). Survey results (from 56/59) indicated a wide variation in definitions and approaches used to assess and report steatosis. Whole slide image assessment led to a broad range in the scores. Findings were discussed at a workshop held at the 15th Banff Conference on Allograft Pathology, September 2019. The aims of discussions were to (i) establish consensus criteria for defining “large droplet fat” (LDF) that predisposes to increased risk of initial poor graft function and (ii) develop an algorithmic approach to determine fat droplet size and the percentage of hepatocytes involved. LDF was defined as typically a single fat droplet that expands the involved hepatocyte and is larger than adjacent nonsteatotic hepatocytes. Estimating severity of steatosis involves (i) low magnification estimate of the approximate surface area of the biopsy occupied by fat, (ii) higher magnification determination of the percentage of hepatocytes within the fatty area with LDF, and (iii) final score calculation.ConclusionsThe proposed guidelines herein are intended to improve standardization in steatosis assessment of donor liver biopsies. The calculated percent LDF should be provided to the surgeon.

Presentation, management and outcomes of pediatric urogenital tuberculosis: 20 years’ experience from a tertiary center

Urogenital tuberculosis (UGTB) has traditionally being a diagnosis of adulthood and is supposed to be rare in children, as it is believed that the symptoms of renal tuberculosis do not appear for 10 or more years after the primary infection. While this may be true in developed countries, where childhood pulmonary tuberculosis is a rarity nowadays. In developing countries, childhood pulmonary tuberculosis is still a major issue and hence, UGTB is not an uncommon diagnosis in younger children and adolescents in these countries. Considering this dearth of data on childhood UGTB, we retrospectively evaluated our series of children with this disease, with special emphasis on the role of surgery. To analyze the clinical presentation, management strategies and outcomes of pediatric UGTB managed in a tertiary care center. Case records of children and adolescents ≤18 years diagnosed with UGTB during the period July 1998 to June 2018at our center were reviewed. Clinical features, organ involvement, investigations, treatment and outcome of therapy were studied. There were 41 children and adolescents (M: F=22:19) identified, with a mean age of 14.8±3.9 years who fulfilled the inclusion criteria. The most common presentation was flank pain and irritative storage symptoms. Mycobacterium tuberculosis was identified on urinary examination in only 17 (41.5%) cases. Six patients were lost to follow up after initial diagnosis. A total of 45 procedures (35 primary and 10 secondary) were performed in 35 children. Initial diversion in the form of PCN and DJS were done in 11 and 12 patients respectively, of which 8 were managed with stenting alone. Surgical management was done mostly in the form of nephrectomy (15), nephrectomy along with reconstruction (5) and reconstruction only (6). On univariate analysis, factors associated with nephrectomy were poor initial function and nephrostomy as initial diversion. Overall median follow-up was 25 (IQR 15.5-74.25) months. During follow up, chronic renal failure developed in nearly 53.8% of patients who underwent major reconstruction. Urogenital tuberculosis presents with a wide spectrum of clinical features and pathological lesions. Diagnosis is often delayed because of late presentation and many children present with cicatrization sequelae. Antitubercular drug therapy and judicious application of minimally invasive diversions and surgery (both ablative and reconstructive) achieve satisfactory results in the majority of cases. Children undergoing major surgical reconstruction in particular need to be followed up rigorously and counselled about possibility of development of renal failure.

Outcomes of liver transplantation using moderately steatotic liver from donation after cardiac death (DCD).

BackgroundLiver grafts from donation after cardiac death (DCD) with moderate steatosis (MS) are generally considered unsui for liver transplantation (LT) because DCD and MS are independent risk factors of poor prognosis of LT. Many centers have begun to accept this type of liver graft. However, the clinical outcomes are indeed controversial. This study aimed to examine the outcomes after LT of using such liver grafts.MethodsThis study retrospectively reviewed our experiences in 80 allografts from May 2015 to September 2019. A total of 16 allografts using MS liver grafts from DCD (MS-DCD group) were compared with a matched control group of 64 allografts using a nonsteatotic liver graft (NS group) (1:4 ratio). Postoperative outcomes, including primary nonfunction (PNF), initial poor function (IPF), postoperative complications, and graft/patient survival rates, were extracted for pooled analysis.ResultsRecipient and surgical characteristics of patients and clinical data of donors between MS-DCD group and NS group were balanced. No significant differences were observed in hepatitis B virus (HBV) infection, model for end-stage liver disease (MELD) score, cold ischemia time (CIT), donor risk index, warm ischemia time (WIT). A significant difference was detected in the incidence of initial poor function (IPF) (11/16 vs. 26/64; P=0.02), and the average peak value of aspartate transaminase (AST) (3,469 vs. 1,295; P<0.01) was significantly higher in the steatosis group. Meanwhile, alanine transaminase (ALT) was only higher on day 1, and international normalized ratio (INR) level was only higher on days 1 and 3 and disappeared on day 7. The serum total bilirubin (TB) was the same between the two groups. Postoperative complications were similar between the two groups. The 90-day, 1-year, and 3-year survival rates in patients and grafts between the two groups were similar (patient survival(MS-DCD group vs. NS group): 75% vs. 85.9%, 75% vs. 78.1%, 68.8% vs. 71.9%, log-rank test, P=0.77; graft survival(MS-DCD group vs. NS group): 75% vs. 84.4%, 75% vs. 75%, 68.8% vs. 68.8%, log-rank test, P=0.79).ConclusionsAfter rigorous evaluation, it was found that moderately steatotic liver from DCD is an effective means to expand the source of liver supply.

Metabonomic Profile of Macrosteatotic Allografts for Orthotopic Liver Transplantation in Patients With Initial Poor Function: Mechanistic Investigation and Prognostic Prediction.

BackgroundOur previous study revealled amplified hazardous effects of macrosteatosis (MaS) on graft failure (GF) in recipients with severe liver damage in short post-operative days, with vague mechanism inside.AimWe aimed to uncover the molecular mechanism of donor MaS on GF, and construct the predictive model to monitor post-transplant prognosis based on “omics” perspective.MethodsUltra-performance liquid chromatography coupled to mass spectrometry metabolomic analysis was performed in allograft tissues from 82 patients with initial poor function (IPF) from multi-liver transplant (LT) centers. Pathway analysis was performed by on-line toolkit Metaboanalyst (v 3.0). Predictive model was constructed based on combinative metabonomic and clinical data extracted by stepwised cox proportional analysis.ResultsPrinciple component analysis (PCA) analysis revealled stratification on metabolic feature in organs classified by MaS status. Differential metabolits both associated with MaS and GF were significantly enriched on pathway of glycerophospholipid metabolism (P < 0.05). Phosphatidylcholine (PC) and phosphatidylethanolamine (PE) involved in glycerophospholipid metabolism was significantly decreased in cases with MaS donors and GF (P < 0.05). Better prediction was observed on graft survival by combinative model (area under the curve = 0.91) and confirmed by internal validation.ConclusionMetabonomic features of allografts can be clearly distinguished by MaS status in patients with IPF. Dysfunction on glycerophospholipid metabolism was culprit to link donor MaS and final GF. Decrement on PC and PE exerted the fatal effects of MaS on organ failure. Metabonomic data might help for monitoring long-term graft survival after LT.

Long-Term Outcomes of Ante-Situm Resection and Auto-Transplantation in Conventionally Unresectable Hepatocellular Carcinoma: A Single-Center Experience.

BackgroundAnte-situm resection and auto-transplantation (ante-situm for short) provides a more aggressive approach to conventionally unresectable hepatocellular carcinoma (HCC). We described the long-term outcomes of patients with HCCs who underwent this technique.Material/MethodsBetween October 2005 and December 2016, we performed 23 ante-situm liver resections. We evaluated postoperative complications, 90-day mortality, recurrence, and long-term survival rates, and reviewed the literature on this topic.ResultsFive types of complications associated with six patients were observed.: 1) primary nonfunctioning liver, thus receiving a liver transplantation; 2) initial poor liver function with recovery two weeks after treatment; 3) diagnoses of portal vein tumor thrombosis, biliary fistula, and small-for-size syndrome, respectively. The median follow-up was 3.6 years; 12 out of 23 patients were alive at the end of the study. One patient who had hepatic recurrence was lost to follow-up after three months. One patient died of multiple organ dysfunction syndrome after the operation, nine patients died due to hepatic recurrence and/or extrahepatic metastasis of HCC. The one-year, three-year, five-year, and 10-year survival rates were 65.2%, 56.5%, 50.9%, and 20.3%, respectively. The one-year, three-year, five-year, and 10-year recurrence rates were 60.9%, 50.7%, 50.7%, and 50.7%, respectively. The chi-square test revealed the patients with recurrence after ante-situm technique were more likely to have poor prognosis (mortality of patients with recurrence versus no-recurrence: 88.9% versus 14.3%, p<0.05) and a strong association was evidenced by Cramer’s V statistic (Cramer’s V=0.734).ConclusionsAnte-situm procedure showed benefits in select patients with HCCs who had contraindications for conventional resection operations. In our case series, the ante-situm technique resulted in lower mortality compared to other ex-vivo hepatic resection techniques reported in the literature and similar long-term efficacy compared to cases of HCCs suitable for conventional resections. HCCs recurrence was a major risk factor associated with the survival rate of ante-situm technique.

Recent insights into mitochondrial targeting strategies in liver transplantation.

Ischemia/reperfusion (I/R) injury in liver transplantation can disrupt the normal activity of mitochondria in the hepatic parenchyma. This potential dysfunction of mitochondria after I/R injury could be responsible for the initial poor graft function or primary nonfunction observed after liver transplantation. Thus, determining the mechanisms that lead to human hepatic mitochondrial dysfunction might contribute to improving the outcome of liver transplantation. Furthermore, early identification of novel prognostic factors involved in I/R injury could serve as a key endpoint to predict the outcome of liver grafts and also to promote the early adoption of novel strategies that protect against I/R injury. Here, we briefly review recent advances in the study of mitochondrial dysfunction and I/R injury, particularly in relation to liver transplantation. Next, we highlight various pharmacological therapeutic strategies that could be applied, and discuss their relationship to relevant mitochondrion-related processes and targets. Lastly, we note that although considerable progress has been made in our understanding of I/R injury and mitochondrial dysfunction, further investigation is required to elucidate the cellular and molecular mechanisms underlying these processes, thereby identifying biomarkers that can help in evaluating donor organs.

Low Graft Attenuation at Unenhanced CT: Association with 1-Month Mortality or Graft Failure after Liver Transplantation.

Purpose To investigate whether low graft attenuation at unenhanced computed tomography (CT) is associated with 1-month mortality or graft failure after liver transplant and determine its diagnostic performance. Materials and Methods Included were 663 recipients who underwent CT imaging within 7 days after liver transplant between December 2014 and August 2016. Initial poor function (IPF) was diagnosed by using a combination of laboratory values within 7 days after liver transplant and subdivided patients into primary and secondary IPF. At 1 month after the operation, mortality and graft failure or survival in recipients was categorized. Two radiologists who were blinded to clinical data retrospectively and independently evaluated graft attenuation on unenhanced CT images (high or isoattenuation, graft attenuation greater than or equal to that of spleen; low, graft attenuation less than that of spleen). The interobserver agreement was evaluated by using intraclass correlation coefficient and κ statics. Incidence of low graft attenuation between recipients with IPF and those with normal function was compared by using χ2 test. The relationship between graft attenuation and outcome in primary and secondary IPF was evaluated by using log-rank test. Results Of 663 recipients, 114 had IPF (80 primary; 34 secondary). After 1 month, 11 had graft failure or died, whereas 652 survived. Low graft attenuation was more common in patients with IPF than in normal-function patients (P < .001). In the primary group (those without identifiable cause), 15 patients had low graft attenuation, which led to mortality or graft failure within 1 month in seven of those patients. No recipient with high or isoattenuation had 1-month mortality or graft failure (P < .001). The secondary group (those with identifiable cause) showed no significant association between graft attenuation and 1-month mortality and graft failure (P = .181). Values of low graft attenuation for 1-month mortality and graft failure in primary IPF were positive predictive value, 46.7%; negative predictive value, 100%; sensitivity, 100%; specificity, 89.0%; and accuracy, 90.0%. There was excellent interobserver agreement in the assessment of graft attenuation (intraclass correlation coefficient, 0.957; κ = 1.00). Conclusion Low graft attenuation can be associated with 1-month mortality or graft failure in liver graft recipients with primary IPF. © RSNA, 2017.

Anatomía patológica del trasplante renal

In order to make an objective assessment of the histopathology of a renal biopsy during a kidney transplant, all the various elements involved in the process must be understood. It is important to know the characteristics of the donor organ, especially if the donor is older than 65. The histopathological features of the donor biopsy, especially its vascular status, are often related to an initial poor function of the transplanted kidney. The T lymphocyte inflammatory response is characteristic in acute cellular rejection; the degree of tubulitis, together with the amount of affected parenchyme, are important factors. The proportion of cellular sub-populations, such as plasma cells and macrophages, is also important, as they can be related to antibody-mediated humoral rejection. Immunofluorescent or immunohistochemical studies are necessary to rule out C4d deposits or immunogloblulins. The presence of abundant deposits of C4d in tubular basement membranes supports a diagnosis of humoral rejection, as does the presence of capillaritis, glomerulitis which, together with vasculitis, are typical diagnostic findings in C4d negative cases. Interstitial fibrosis, tubular atrophy and glomerular sclerosis, although non-specific, imply a chronic phase. Transplant glomerulopathy and multilamination in more than 6 layers of the tubular and glomerular basement membranes are quasi-specific characteristics of chronic humoral rejection. Electron microscopy is essential to identify of these pathologies as well as to demonstrate the presence of other glomerular renal diseases.

Initial Poor Function and Primary Nonfunction in Deceased-Donor Orthotopic Liver Transplantation Maintaining Short Cold Ischemic Time.

Nations with emerging deceased-donor liver transplantation programs, such as India, face problems associated with poor donor maintenance. Cold ischemic time (CIT) is typically maintained short by matching donor organ recovery and recipient hepatectomy to achieve maximum favorable outcome. We analyzed different extended criteria donor factors including donor acidosis, which may act as a surrogate marker of poor donor maintenance, to quantify the risk of primary nonfunction (PNF) or initial poor function (IPF). A single-center retrospective outcome analysis of prospectively collected data of patients undergoing deceased-donor liver transplantation over 2 years to determine the impact of different extended criteria donor factors on IPF and PNF. From March 2013 to February 2015, a total of 84 patients underwent deceased-donor liver transplantation. None developed PNF. Thirteen (15.5%) patients developed IPF. Graft macrosteatosis and donor acidosis were only related to IPF ( P = .002 and P = .032, respectively). Cold ischemic time was maintained short (81 cases ≤8 hours, maximum 11 hours) in all cases. Poor donor maintenance as evidenced by donor acidosis and graft macrosteatosis had significant impact in developing IPF when CIT is kept short. Similar study with larger sample size is required to establish extended criteria cutoff values.

Clinical efficacy of liver transplantation using aged liver grafts from donation after citizen′s death

Objective : To explore the clinical efficacy of liver transplantation using aged liver grafts from donation after citizen′s death (DCD). Methods The retrospective case-control study was adopted. The clinico-pathological data of 146 patients who underwent liver transplatation using liver grafts from DCD at the Tongji Hospital of Huazhong University of Science and Technology from January 2011 to December 2015 were collected. Of 146 patients, forty-six recipients who received liver grafts from donors≥60 years were allocated into the donor age≥60 years group and 100 who received liver grafts from donor age<60 years were allocated into the donor age<60 years group. Observed indicators included: (1) the incidence of primary liver graft nonfunction (PNF) and initial poor function (IPF) of transplanted liver, (2) liver function recovery in the first postoperative month, (3) the postoperative complications, including reoperation because of bleeding, acute rejection, thrombosis of hepatic artery, thrombosis of portal vein, biliary complications, neurological complications, bacterial infection, cytomegalovirus infection and adverse reaction of calcineurin inhibitors, (4) postoperative survival rate in liver transplant recipients. The regular follow-up using outpatient examination was performed to detect indexes of laboratory examination and postoperative complications and survival of patients till January 2016. Measurement data with normal distribution were represented as ±s and comparison between groups was evaluated with the independent t test. Measurement data with skewed distribution were represented as M(Qn) and analyzed by Mann-Whitney test. Count data were analyzed using the chi-square test. Results (1) The incidences of PNF and IPF of transplanted liver: two patients in the donor age≥60 years group and 1 patient in the donor age 0.05). Eight patients in the donor age≥60 years group and 6 patients in the donor age 0.05). Nine patients had adverse reaction of calcineurin inhibitors in the donor age≥60 years group and 6 patients in the donor age 0.05). Conclusion Using liver grafts from donor age≥60 years after strict selection can achieve good therapeutic effects in liver transplantation. Key words: Liver diseases; Aged liver graft; Donation after citizen′s death; Liver transplantation

The impact of donor liver graft quality on postoperative outcome in liver transplant recipients. A single centre experience.

The Donor Risk Index (DRI) has become a universal score for organ allocation in liver transplantation (LT) worldwide. The aim of this study was to evaluate the impact of liver graft quality measured by DRI, CIT, WIT and donor age on intraoperative hemodynamics (reperfusion syndrome) and early postoperative outcome, defined as initial graft poor function (within 3 days of LT), of deceased donor liver transplant (DDLT) recipients. Secondary end-points were the assessment of the impact of graft quality on the intraoperative and postoperative day 1 hemostasis (evaluated using ROTEM assay). We retrospectively analyzed 135 patients who underwent deceased-donor LT between January 2013 and December 2014. Patient demographic data (age, sex, cause of End-Stage Liver Disease), preoperative paraclinical data (total bilirubin, creatinine, serum sodium), severity of liver disease scores (Model for End-Stage Liver Disease - MELD and MELD-sodium), intraoperative blood loss and blood products transfusion, incidence of post reperfusion syndrome, postoperative biochemical data (including total bilirubin, hepatic transaminases, lactate levels) and outcome (initial graft poor function diagnosis) were noted. Donor characteristics including DRI, CIT, WIT and donor age were noted. Coagulation was assessed by rotational thromboelastometry (ROTEM) after reperfusion of the graft and on postoperative day 1 in order to determine the effects of liver graft quality on hemostasis. Donor age has significantly correlated with decreased derived ROTEM parameters time to the maximum velocity of clot formation - MaxVt (p = 0.000), area under the curve (AUC) (p = 0.008) and maximum clot elasticity (MCE) (p = 0.018) although no difference in transfusion requirements has been observed. A longer CIT was associated with an increase in AST and ALT observed during the early postoperative period: day 1 ALT (p = 0.032) and AST (p = 0.008), day 2 ALT (p = 0.001) and AST (p = 0.001) and day 3 AST (p = 0.010) and ALT (p = 0.001). Higher DRI correlated with higher bilirubin levels measured on postoperative day 1 (p = 0.027) and 2 (p = 0.001). Patients who developed initial graft poor function received liver grafts from older donors (p = 0.05) with a higher DRI (p = 0.002). Our results suggest a significant impact of donor age and DRI on perioperative coagulation kinetics that may be a result of initial graft poor function. Although CIT and DRI correlated with a more severe cholestasis and hepatocitolysis during the early postoperative period these seems to be short-lived.

Early allograft dysfunction after liver transplantation: an intermediate outcome measure for targeted improvements

Background. The term early allograft dysfunction (EAD) identifies liver transplant (LT) allografts with initial poor function and portends poor allograft and patient survival. Aims of this study are to use EAD as an intermediate outcome measure in a large single center cohort and identify donor, recipient and peri-operative risk factors.Material and methods. In 1950 consecutive primary LT, donor, recipient and peri-operative data were collected. EAD was defined by the presence of one or more of the following: total bilirubin ≥ 10 mg/dL (171 μmol/L) or, INR ≥ 1.6 on day 7, and ALT/AST > 2,000 IU/L within the first 7 days.Results. The incidence of EAD was 26.5%. 1-, 3-, and 5-year allograft and patient survival for patients who developed EAD were significantly inferior to those who did not (P < 0.01 at all time points). Multivariate analysis demonstrated associations in the development of EAD with recipient pre-operative ventilator status, donation after cardiac death allografts, donor age, allograft size, degree of steatosis, operative time and intra-operative transfusion requirements (all P < 0.01). Patients with EAD had a significantly longer hospitalization at 20.9 ± 38.9 days (median: 9; range: 4-446) compared with 10.7 ± 13.5 days (median: 7; range: 3-231) in patients with no EAD (P < 0.01).Conclusions. This is the largest single center experience demonstrating incidence of EAD and identifying factors associated with development of EAD. EAD is a useful intermediate outcome measure for allograft and patient survival. Balancing recipient pretransplant conditions, donor risk factors and intra-operative conditions are necessary for avoiding EAD.

Outcomes of Liver Transplant With Donors Over 70 Years of Age

Organ shortage has forced transplant teams to progressively expand the acceptance of marginal donors. MethodsWe performed a comparative analysis of the post-transplant evolution depending on donor age (group I: less than 70 years old (n=474) vs group II: 70 or more years old [n=105]) over a 10 year period (2002–2011). ResultsDonors over 70 years old were similar to donors less than 70 years old in terms of ICU stay, gender, weight, laboratory results, and use of vasoactive drugs. However, the younger donor group presented with cardiac arrest more often (GI: 14 vs GII: 3%, P=.005). There were no differences in initial poor function (GI: 6% vs GII: 7.7%; P=.71), ICU stay (GI: 2.7±2 vs GII: 3.3±3.8, P=.46), hospital stay (GI: 13.5±10 vs GII: 15.5±11, P=.1), or hospital mortality (GI: 5.3 vs GII: 5.8%, P=.66) between receptors of more or less than 70 year old grafts. After a median follow up of 32 months, no differences were found in the incidence of biliary tract complications (GI: 17 vs GII: 20%, P=.4) or vascular complications (GI: 11 vs GII: 9%, P=.69). The actuarial 5 year survival was similar for both study groups (GI: 70 vs GII: 76%, P=.54). ConclusionsIn our experience, the use of grafts from donors older than 70 years, when other risk factors are avoided (cold ischaemia, steatosis, sodium levels), does not worsen the results of liver transplantation on the short or long term.

Bakteriális infekciók májátültetés után

The authors reviewed the prevalence of postoperative infections, the results of bacterium cultures, and the incidence of multidrug resistance in their liver transplanted patients during a period between 2003 and 2012. The aim of this study was to analyse risk factors and colonisations of bacterial infections. The files of 408 patients (281 bacterium cultures) were reviewed. Of the 408 patients 70 had a postoperative infection (17%); 58 patients (14.2%) had positive and 12 patients (2.9%) negative bacterial culture results. Cholangitis was found in 7 cases (12.1%), abdominal infection in 17 cases (29.3%), and pulmonary infection in 28 cases (48.3%). Postoperative infection was more frequent in patients with initial poor graft function, acute renal insufficiency, biliary complication, and in those with intraabdominal bleeding. The 1-, 3- and 5-year cumulative survival of patients who had infection was 70%, 56% and 56%, respectively, whereas the cumulative survival data of patients without infection was 94%, 87% and 85%, respectively (p<0.001). Multidrug resistance was found in 56% of the positive cultures, however, the one-year survival was not different in patients who had multidrug resistance positive and negative bacterial infection (both 70.2%). Infection control must target the management of multidrug resistance microbes through encouraging prevention, hygienic, and isolation rules, improving the operative, transfusion, and antimicrobial policy in a teamwork setting.

Resultados del trasplante hepático con donantes de más de 70 años

Organ shortage has forced transplant teams to progressively expand the acceptance of marginal donors. MethodsWe performed a comparative analysis of the post-transplant evolution depending on donor age (group I: less than 70 years old (n=474) vs. group II: 70 or more years old [n=105]) over a 10 year period (2002-2011). ResultsDonors over 70 years old were similar to donors less than 70 years old in terms of ICU stay, gender, weight, laboratory results, and use of vasoactive drugs. However, the younger donor group presented with cardiac arrest more often (GI: 14 vs. GII: 3%, P=.005). There were no differences in initial poor function (GI: 6% vs. GII: 7,7%; P=.71), ICU stay (GI: 2.7±2 vs. GII: 3.3±3.8, P=.46), hospital stay (GI: 13.5±10 vs. GII: 15.5±11, P=.1), or hospital mortality (GI: 5.3 vs. GII: 5.8%, P=.66) between receptors of more or less than 70 year old grafts. After a median follow up of 32 months, no differences were found in the incidence of biliary tract complications (GI: 17 vs. GII: 20%, P=.4) or vascular complications (GI: 11 vs. GII: 9%, P=.69). The actuarial 5 year survival was similar for both study groups (GI: 70 vs. GII: 76%, P=.54). ConclusionsIn our experience, the use of grafts from donors older than 70 years, when other risk factors are avoided (cold ischemia, steatosis, sodium levels), does not worsen the results of liver transplantation on the short or long term.

Risk factors of metabolic disorders after liver transplantation: an analysis of data from fasted patients.

Metabolic disorders are common complications after orthotopic liver transplantation (OLT) and may lead to increased morbidity and mortality. Fasting glucose and lipid metabolism, and body weight of 81 patients undergoing primary OLT were prospectively analyzed. Patients were investigated preoperatively, on postoperative days 1, 3, 5, 10, 14, 28 as well as 6 months and 1 year after OLT. Data of nonfasted patients were excluded from the analysis. Standardized definitions and classifications for diabetes mellitus (DM), body mass index (BMI), and dyslipidemia were used. Prevalence of new-onset diabetes after transplantation was 9.3%, and obesity was its only independent risk factor (odds ratio [OR], 16.5). Preoperative impaired glucose homeostasis (OR, 10.8) and initial poor graft function (OR, 6.89) were independent risk factors for postoperative DM. Maximum prevalence of hypertriglyceridemia and hypercholesterolemia was found on postoperative day 10 and 6 months post-OLT, respectively. Risk factors for hypercholesterolemia at 1 year were patient age (OR, 1.17) and postoperative renal dysfunction (OR, 16.33). Higher preoperative BMI was a risk factor for postoperative hypertriglyceridemia (OR, 1.17). Overall body weight and BMI significantly decreased over 1 year (P < 0.05). Prevalence of obesity was 22.2% before and 20.9% after OLT. For the first time, initial poor graft function was identified as a risk factor for post-OLT DM. By ruling out any exogenous factors influencing metabolism, we believe we were able to show the true prevalence of metabolic disorders and therefore provided a valuable contribution to the identification of potential risk factors.

Brain death and marginal grafts in liver transplantation.

It is well known that most organs for transplantation are currently procured from brain-dead donors; however, the presence of brain death is an important risk factor in liver transplantation. In addition, one of the mechanisms to avoid the shortage of liver grafts for transplant is the use of marginal livers, which may show higher risk of primary non-function or initial poor function. To our knowledge, very few reviews have focused in the field of liver transplantation using brain-dead donors; moreover, reviews that focused on both brain death and marginal grafts in liver transplantation, both being key risk factors in clinical practice, have not been published elsewhere. The present review aims to describe the recent findings and the state-of-the-art knowledge regarding the pathophysiological changes occurring during brain death, their effects on marginal liver grafts and summarize the more controversial topics of this pathology. We also review the therapeutic strategies designed to date to reduce the detrimental effects of brain death in both marginal and optimal livers, attempting to explain why such strategies have not solved the clinical problem of liver transplantation.

The unreliability of continuous postoperative lactate monitoring after extended hepatectomies: single center experience.

Postoperative plasma lactate clearance has been established as an important prognostic factor for liver resection morbidity and mortality. The aim of this study was to analyse continuous monitoring of plasma lactate in patients submitted to extended hepatectomy (EH) with special attention to those who received preoperative portal vein branch embolization (PVE) to augment the future remnant liver. In this single center retrospective study, a full revision of 45 medical records was performed from patients who underwent EH at ISMETT from October 1999 to August 2013. Plasma lactates from admission to ICU to day 5 were recorded. Postoperative lactate clearance (ΔLAC) was defined as lactate at postoperative day 5 minus lactate at ICU presentation (hour 0). ΔLAC was analysed in relation to total hospital stay and 90 days' perioperative morbidity and mortality, using Clavien-Dindo classification, and by presence or absence of PVE. Forty-one right and four left EH were performed. 17 patients underwent previous PVE with a mean of 44 ± 28.9 days-to-surgery time and a 24 ± 8.3% degree of hypertrophy. In 39 cases (86.7%), a malignant etiology was the indication for EH, length of surgery was 486 ± 122 min with a median of 300 ml of blood transfusion. In 25 patients, a Clavien grade IIIa or worst complication has been experienced, and in three cases the death occurred during the first 3 months after EH. The median length of hospitalization was 11 days. In patients with preoperative PVE a significative association with an early post-resectional lactate clearance was obtained (p 0.01). Conversely, the univariate analysis measured by t test did not show any significative associations between ΔLAC and a median time of hospital stay longer than 11 days (p 0.08), or the onset of any complications (p 0.67) and of a Clavien's grade of complications ≥IIIa patients (p 0.48). After adjusting for co-variables, results of the multivariate logistic regression analyses confirmed that ΔLAC is not independent or significant predictor for initial poor liver function following EH. In our single center experience, the continuous monitoring of postoperative lactate clearance did not work as an early marker of postoperative liver dysfunction following EH. Although lactate clearance, worked as guide having a clinical utility in the ICU statement for hemodynamic optimization and systemic fluid balance management.