Postreperfusion Syndrome Research Articles

The impact of postreperfusion syndrome during liver transplantation using livers with significant macrosteatosis.

The impact of postreperfusion syndrome (PRS) during liver transplantation (LT) using donor livers with significant macrosteatosis is largely unknown. Clinical outcomes of all patients undergoing LT with donor livers with moderate macrosteatosis (30%-60%) (N=96) between 2000 and 2017 were compared to propensity score matched cohorts of patients undergoing LT with donor livers with mild macrosteatosis (10%-29%) (N=96) and no steatosis (N=96). Cardiac arrest at the time of reperfusion was seen in eight (8.3%) of the patients in the moderate macrosteatosis group compared to one (1.0%) of the patients in the mild macrosteatosis group (P=.02) and zero (0%) of the patients in the no steatosis group (P=.004). Patients in the moderate macrosteatosis group had a higher rate of PRS (37.5% vs 18.8%; P=.004), early allograft dysfunction (EAD) (76.4% vs 25.8%; P<.001), renal dysfunction requiring continuous renal replacement therapy following transplant (18.8% vs 8.3%; P=.03) and return to the OR within 30days (24.0% vs 7.3%; P=.002), than the no steatosis group. Both long-term patient (P=.30 and P=.08) and graft survival (P=.15 and P=.12) were not statistically when comparing the moderate macrosteatosis group to the mild macrosteatosis and no steatosis groups. Recipients of LT using livers with moderate macrosteatosis are at a significant increased risk of PRS. If patients are able to overcome the initial increased perioperative risk of using these donor livers, long-term graft survival does not appear to be different than matched recipients receiving grafts with no steatosis.

Intraoperative Management to Prevent Cardiac Collapse in a Patient With a Recurrent, Large-volume Pericardial Effusion and Paroxysmal Atrial Fibrillation During Liver Transplantation: A Case Report

BackgroundPericardial effusion is a common feature of end-stage liver disease. In this case report we describe the intraoperative management of recurrent pericardial effusion, without re-pericardiocentesis, to prevent circulatory collapse during a critical surgical time-point; that is, during manipulation of the major vessels and graft reperfusion. MethodsA 47-year-old woman with hepatitis B was scheduled to undergo deceased donor liver transplantation (LT). A large pericardial effusion was preoperatively identified using transthoracic echocardiography (TTE). The patient also had paroxysmal atrial fibrillation. Two days before surgery, preemptive pericardiocentesis was performed and the 1150-mL effusion was drained. Intraoperatively, recurrence of the large pericardial effusion was identified using transesophageal echocardiography (TEE). During inferior vena cava manipulation, the surgeon consulted the anesthesiologist to evaluate the hemodynamic changes in the patient. After 3 attempts, the transplant team was able to determine the most appropriate anastomosis site, defined as that with the least impact on cardiac function. To prevent the development of severe postreperfusion syndrome, 10% MgSO4 (2 g) was gradually infused 20 minutes before portal vein declamping, and immediately before graft reperfusion a 100-μg bolus of epinephrine was administered. ResultsDuring graft reperfusion, there was no evidence of heart chamber collapse or flow disturbance, as seen on the TEE findings. Postoperatively, the patient recovered completely and was discharged from the hospital. Six months after surgery, there was no sign of pericardial effusion on follow-up TTE. ConclusionOur intraoperative strategy may prevent cardiac collapse in patients with pericardial effusion detected during LT. Intraoperative TEE plays an important role in guiding hemodynamic management.

Is the Institute Georges Lopez-1 solution an equally effective, cheaper alternative to the University of Wisconsin solution in liver transplantation?

Aim: To compare the outcomes of deceased donor liver transplantation (DDLT) using either the University of Wisconsin solution (UW) or the Institute Georges Lopez-1 (IGL-1) solution. Materials and Methods: Adult patients who underwent DDLT between November 2015 and March 2018 were included in the study. All patients received grafts from brain-dead donors. In 30 patients, the UW solution was used to preserve the liver and in 53 patients, the IGL-1 solution was used. The data of these two groups of the patients were analyzed and compared. Results: Between the two groups of patients, donor and recipient demographics and surgery-related variables were found to be similar. No difference was observed in the incidence of postreperfusion syndrome, number of days of hospitalization, and in the 30-day mortality. Early graft dysfunction was observed in 9 (16.98%) patients in the IGL-1 group and in 7 (23.33%) patients in the UW group (P = 0.48). One patient had primary nonfunction in each group. The postoperative levels of the liver transaminases were also not found to be significantly different. Conclusions: The efficacies of liver preservation by the IGL-1 and UW solutions were found to be comparable.

Effects of retrograde reperfusion on the intraoperative internal environment and hemodynamics in classic orthotopic liver transplantation

BackgroundTo investigate the effects of retrograde reperfusion on the intraoperative internal environment and hemodynamics in classic orthotopic liver transplantation (OLT).MethodsThirty patients were undergone classic OLT using retrograde reperfusion in our center. Blood sampling was done at different time points including: Before blood venting via the portal vein (PV), 10 mL of blood was collected from the inferior vena cava (T0); During retrograde reperfusion through the inferior vena cava (IVC), 10 mL of blood was collected when the volume of blood venting reached 10 mL (T1), 100 mL (T2), and 200 mL (T3), respectively. 5 mL of blood was analyzed using a NOVA-f–type Blood Gas Analyzer. The remaining 5 mL was measured to determine the level of IL-1β using an enzyme-linked immunosobent assay.ResultsAll operations were completed successfully, and postreperfusion syndrome (PRS) occurred in 6 patients (20%). The most notable findings were significant changes at T1, T2 and T3, including pH value, PvO2, SvO2, BEecf, HCO3−, Lac, K+, Ca2+ and IL-1β, compared with T0 (P < 0.05). Yet their levels at T3 were not back to the level at T0 (P < 0.05).ConclusionThis retrograde perfusion could eliminate some harmful metabolites inside the donor liver in time and reduce acid-base and electrolyte disorders as well as drastic hemodynamic fluctuations after recirculation during classic OLT.

Preoperative beta blockade and severe intraoperative bradycardia in liver transplantation.

Nonselective Beta blockade (NSBB) is commonly prescribed for liver transplantation (LT) candidates, but its impact on intraoperative hemodynamics is not well understood. In this study, we investigated if preoperative NSBB was associated with severe bradycardia during LT and if severe intraoperative bradycardia was associated with 30-day mortality. Adult patients undergoing LT between 2005 and 2014 were included. Propensity matching was used to control selection bias. Intraoperative hemodynamics were compared between patients with and without preoperative NSBB. Univariate and multivariate methods were used in statistical analysis. Of 1452 patients, 370 who received preoperative NSBB were matched in a 1:1 ratio with those who did not. Propensity matching eliminated all significant differences between the two groups. Patients who received preoperative NSBB had a significantly higher incidence of severe intraoperative bradycardia compared with the non-BB group (9.6% vs 3.2%, P=0.001, OR 2.95, 95% CI 1.42-6.12, P=0.004). Intraoperative hypotension and postreperfusion syndrome were not significantly different between the two groups. Severe intraoperative bradycardia was associated with increased 30-day mortality. In conclusion, preoperative NSBB was associated with severe intraoperative bradycardia in LT. In patients who receive preoperative NSBB, severe intraoperative bradycardia should be closely monitored in LT. Further studies assessing safety of preoperative NSBB and intraoperative bradycardia in LT are warranted.

The Impact of Postreperfusion Syndrome on Acute Kidney Injury in Living Donor Liver Transplantation: A Propensity Score Analysis.

Postreperfusion syndrome (PRS) has been shown to be related to postoperative morbidity and graft failure in orthotopic liver transplantation. To date, little is known about the impact of PRS on the prevalence of postoperative acute kidney injury (AKI) and the postoperative outcomes after living donor liver transplantation (LDLT). The purpose of our study was to determine the impact of PRS on AKI and postoperative outcomes after LDLT surgery. Between January 2008 and October 2015, we retrospectively collected and evaluated the records of 1865 patients who underwent LDLT surgery. We divided the patients into 2 groups according to the development of PRS: PRS group (n = 715) versus no PRS group (n = 1150). Risk factors for AKI and mortality were investigated by multivariable logistic and Cox proportional hazards regression model analysis. Propensity score (PS) analysis (PS matching and inverse probability of treatment weighting analysis) was designed to compare the outcomes between the 2 groups. The prevalence of PRS and the mortality rate were 38% and 7%, respectively. In unadjusted analyses, the PRS group showed more frequent development of AKI (P < .001), longer hospital stay (P = .010), and higher incidence of intensive care unit stay over 7 days (P < .001) than the no PRS group. After PS matching and inverse probability of treatment weighting analysis, the PRS group showed a higher prevalence of postoperative AKI (P = .023 and P = .017, respectively) and renal dysfunction 3 months after LDLT (P = .036 and P = .006, respectively), and a higher incidence of intensive care unit stay over 7 days (P = .014 and P = .032, respectively). We demonstrated that the magnitude and duration of hypotension caused by PRS is a factor contributing to the development of AKI and residual renal dysfunction 3 months after LDLT.

Intraoperative venesection and isosorbide dinitrate for postreperfusion syndrome during liver transplantation

Rationale:Postreperfusion syndrome is the most severe cardiovascular and metabolic alteration which typically occurs after the declamping of the portal vein of the grafted liver during liver transplantation, and it could affect the mortality and morbidity of the patient.Patient concerns:We report the case of ischemic change in electrocardiogram with substantial increase of central venous pressure, from 6 to 16 mmHg, that developed immediately after reperfusion.Diagnoses:Based on his hemodynamic parameters, it was suspected that this event was caused by sudden volume overload in the right ventricle after reperfusion rather than hypovolemic status, thromboembolism, or any other possibilities.Interventions:He was treated with active venesection of 300 mL and isosorbide dinitrates infusion at the rate of 30 μg/min.Outcomes:The parameter values were restored to normal within 15 to 20 minutes after treatment, and the patient was discharged postoperatively without any significant cardiac sequelae.Lessons:Although ischemic ST change during reperfusion reported without any previous cardiac complication is limited, the patient could recover rapidly with careful identification of the cause of PRS and immediate treatment.

α-lipoic acid reduces postreperfusion syndrome in human liver transplantation - a pilot study.

A double-blind randomized controlled trial was performed to compare the safety and efficacy of α-lipoic acid (ALA) in liver transplantation (LT). The grafts were randomized to receive ALA or placebo before the cold ischemia time. Furthermore, patients transplanted with the ALA-perfused graft received 600 mg of intravenous ALA, while patients with the nonperfused graft received the placebo just before graft reperfusion. Hepatic biopsy was performed 2 h postreperfusion. Blood samples were collected before, during and 1 and 2 days after reperfusion. Quantitative polymerase chain reaction (qPCR) analysis was performed on biopsies to assess genes involved in the response to hypoxia, apoptosis, cell growth, survival and proliferation, cytokine production and tissue damage protection. Nine of 40 patients developed postreperfusion syndrome (PRS), but seven of them belonged to the control group. There was a decrease in PHD2 and an increase in alpha subunit of hypoxia-inducible factor-1 (HIF-1α) and baculoviral IAP repeat containing 2 (Birc2) transcript levels in the biopsies from the ALA-treated versus the control group of patients. Additionally, plasma levels of alarmins were lower in ALA-treated patients than control patients, which suggests that ALA-treated grafts are less inflammatory than untreated grafts. These results showed that ALA is safe for use in LT, induces gene changes that protect against hypoxia and oxidative stress and reduces the appearance of PRS.

Liver Transplantation in Patient with Hereditary Hemorrhagic Telangiectasia or Rendu-Osler-Weber Disease

Introduction Hereditary hemorrhagic telangiectasia(HHT) is characterized by a disorder in vascular endothelium that presents angiodysplastic lesions in variuos organs. Their presence in the liver can cause serious and possibly mortal complications such as biliary ischemia, portal hypertension or cardiac insufficiency. The only definite cure for HHT with liver involvement is orthotopic liver transplantation(OLT) Materials and Methods 40y old woman is diagnosed with HHT type 2 in 2014. She presents with epistaxis, mucocutaneous telangiectasias, liver arteriovenous malformations(AVM), chronic hyperbilirubinemia and elevated cardiac output(12L/min) with hyperdynamic systolic function and pulmonary hypertension(PH). OLT is suggested as curative treatment. Before OLT her condition worsens and is unresponsive to medical treatment leading to numerous admissions due to decompensated heart failure(HF), GIT bleeding, respiratory infections and hepatic encephalopathy For OLT basic monitorization is carried out and pulmonary artery catheter is inserted before induction. The initial data shows moderate PH and hyperdynamic state. After the general anesthesia induction a transesophagel ultrasound is performed that shows moderate dilation of right cardiac chambers and hyperdynamic contraction function. During the hepatectomy there is moderate bleeding with signs of portal hypertension. During clamping of portal and suprahepatic veins there is no need for vasopressor medication. The hemodynamic changes and metabolic acidosis that occur in reperfusion phase are treated with epinephrine, ephedrine, calcium chloride and sodium bicarbonate. There was no postreperfusion syndrome. In the neohepatic phase norepinephrine infusion(up to 0.2mcg/kg/min) was initiated. The treatment with blood products was guided by ROTEM®. Lactic acid peaked at 8mmol/L and reached 6.9mmol/L at the time of transfer to the ICU.Results and discussion The worst complication in HHT patients with liver involvement is development of HF. That is due to presence of mayor shunts generated by AMV and that augment cardiac output by 25-58%. It is necessary to perform right cardiac catheterization preoperatively to assess pulmonary and right cardiac pressures and to evaluate the shunt and the contractile function. Possible treatments for the cardiopulmonary involvement are embolization or ligature of the hepatic artery, but with serious side effects such as liver necrosis or failure. The OLT should be considered at an early stage in patients with HHT with liver involvement to improve the cardiopulmonary function and avoid the risk for hepatobiliary sepsis and offer a better life quality. Conclusions The OLT is considered to be the only curative treatment for patients with HHT and liver involvement, especially when it is severe. It is important to perform an invasive cardiopulmonary assessment due to high possibility of secondary PH that will dictate the intraoperative anesthetic management.

Donation After Cardiac Death in Liver Transplantation: An Additional Source of Organs With Similar Results to Donation After Brain Death

BackgroundAs new sources of organs are needed, liver transplantation using donors after cardiac death (DCD) is progressively increasing, but outcomes with this method are still questioned. This study was accomplished to verify that DCD outcomes are comparable to those seen in donation after brain death (DBD). MethodsThis was a prospective cohort study including 100 liver transplantation performed between 2014 and 2017, divided according to donor type in 75 DBD and 25 DCD. ResultsDCD donors were younger (mean age: DCD 56 years, DBD 59 years; P = .009). Mean Modified End-stage Liver Disease (MELD) score was lower for DCD (DCD 16, DBD 19; P < .001). No differences were found regarding ischemia times and development of postreperfusion syndrome or coagulopathy. Primary graft dysfunction was more frequent in DCD (60%, DCD 29.3%; P = .006). Rates of primary graft nonfunction (DCD 0%, DBD 1.3%; P = .562) and acute rejection (DCD 20%, DBD 16.4%; P = .685) were similar. Acute kidney injury occurred more often in DBD (DCD 32%, DBD 12%; P = .051). Length of stay was comparable. Rates of biliary complications (DCD 20%, DBD 26.7%; P = .505) were similar, unlike ischemic cholangiopathy (DCD 12%, DBD 1.3%; P = .018). Retransplantation rates were also similar (DCD 8%, DBD 4%; P = .427) as was survival rate after 3 years (DCD 84%, DBD 86.7%; P = .739). ConclusionDCD represents an additional graft source with results that are encouraging and may be comparable to DBD with a careful donor and recipient selection.

Diagnosis, Incidence, Predictors and Management of Postreperfusion Syndrome in Pediatric Deceased Donor Liver Transplantation: A Single-Center Study.

BackgroundPostreperfusion syndrome (PRS) is a dreadful and well-documented complication in adult liver transplantation (LT). However, information regarding PRS in pediatric LT is still scarce. We aimed to identify the incidence, risk factors and associated outcomes of pediatric LT in a single-center study.Material/MethodsThe medical records of 75 consecutive pediatric patients who underwent deceased donor liver transplantation (DDLT) from July 2015 to October 2017 were retrospectively reviewed. PRS was determined according to the Peking criteria when significant arrhythmia or refractory hypotension occurred following revascularization of the liver graft. Patients were divided into PRS and non-PRS groups. Preoperative, intraoperative, and postoperative data were collected and compared between the 2 groups. Independent risk factors for PRS were analyzed using binary logistic regression analysis.ResultsPRS occurred in 26 patients (34.7%). Univariate analysis showed that the graft-to-recipient weight ratio (P=0.023), donor warm ischemia time (P<0.001), and the use of an expanded criteria donor (ECD) liver graft (P<0.001) were significant predictors of PRS. Binary logistic regression showed that the use of an ECD liver graft (odds ratio [OR]: 18.668; 95% confidence interval [95% CI]: 4.866–71.622) and lower hematocrit (HCT) level before reperfusion (OR: 0.878; 95% CI: 0.782–0.985) were independent predictors of PRS. PRS was significantly associated with early allograft dysfunction (73.1% vs. 18.4%, P<0.001), primary nonfunction (11.5% vs. 0.0%, P=0.039), and a prolonged hospital stay (median: 30.5 vs. 21.0, P=0.007).ConclusionsThe use of an ECD liver graft and lower HCT level before reperfusion were independent risk factors for PRS in pediatric DDLT. Intraoperative PRS occurrence seems to be associated with poor liver allograft function and worsened patient postoperative outcomes.

Elevated High-Sensitivity Troponin I During Living Donor Liver Transplantation Is Associated With Postoperative Adverse Outcomes.

This study aimed to evaluate risk factors and postoperative clinical outcome associated with myocardial injury detected by an elevated high-sensitivity cardiac troponin I (hs-cTnI) immediately after living donor liver transplantation (LDLT). Between January 2011 and December 2016, 313 adult recipients undergoing LDLT, with normal preoperative hs-cTnI were selected. Hs-cTnI level above 0.04 ng/mL according to 99th percentile reference limit was defined as myocardial injury. The recipients were divided into 2 groups according to postoperative hs-cTnI measured immediately after LDLT and postoperative clinical outcome was compared. The primary outcome was composite of death or graft failure during hospital stay. Risk factors associated with myocardial injury during LDLT was also evaluated. Of the 313 recipients with normal preoperative hs-cTnI level, 159 (50.8%) had elevated hs-cTnI level and 154 (49.2%) had normal level after LDLT. The incidence of all-cause death or graft failure during hospital stay was significantly higher in recipients with myocardial injury (1.9% vs 7.6%; hazard ratio, 4.15; 95% confidence interval, 1.01-17.14; P = 0.049). The same result was shown in propensity-matched population (0.9% vs 9.0%; hazard ratio, 9.08; 95% confidence interval, 1.16-71.01; P = 0.04). The results during 1-year follow-up were not consistent. Female sex, ischemia time, and presence of postreperfusion syndrome were independent predictors of myocardial injury during LDLT. Myocardial injury detected by elevation of hs-cTnI level immediately after LDLT was independently associated with adverse outcome during hospital stay.

Post-reperfusion syndrome in patients with ischemic heart disease after coronary stenting.

Post-reperfusion syndrome is a chronic multi-factorial syndrome, caused by restoration of coronary blood flow of de novo in patients after coronary stenting. Pathophysiological processes occurring in stenting segment (incomplete endothelization of vessel, excessive regeneration of neointima, formation of neoatherosclerosis) the risk of partial or total stent thrombosis due to the low level of compliance of the patient, as well as local changes in blood flow to the myocardium and modification of hemodynamics in stented arteries have a significant impact on the clinical course and prognosis of the disease. In contrast to the syndrome of reperfusion occurring after restoration of blood flow in the infarct-dependent coronary artery syndrome and postischemic reperfusion syndrome in patients with acute myocardial infarction after spontaneous or therapeutic thrombolysis, post-reperfusion syndrome is characterized by prolonged course (months and years). Clinical symptoms depend of the localization of pathological process (in stented arteries or in other non-stented arteries of the heart), as well as the presence of comorbidity and the factors of risk of the coronary heart disease.

Visual quality assessment of the liver graft by the transplanting surgeon predicts postreperfusion syndrome after liver transplantation: a retrospective cohort study

BackgroundThe discrepancy between demand and supply for liver transplants (LT) has led to an increased transplantation of organs from extended criteria donors (ECD).MethodsIn this single center retrospective analysis of 122 cadaveric LT recipients, we investigated predictors of postreperfusion syndrome (PRS) including transplant liver quality categorized by both histological assessment of steatosis and subjective visual assessment by the transplanting surgeon using multivariable regression analysis. Furthermore, we describe the relevance of PRS during the intraoperative and postoperative course of LT recipients.Results53.3% (n = 65) of the patients suffered from PRS. Risk factors for PRS were visually assessed organ quality of the liver grafts (acceptable: OR 12.2 [95% CI 2.43–61.59], P = 0.002; poor: OR 13.4 [95% CI 1.48–121.1], P = 0.02) as well as intraoperative norepinephrine dosage before reperfusion (OR 2.2 [95% CI 1.26–3.86] per 0.1 μg kg− 1 min− 1, P = 0.01). In contrast, histological assessment of the graft was not associated with PRS. LT recipients suffering from PRS were hemodynamically more instable after reperfusion compared to recipients not suffering from PRS. They had lower mean arterial pressures until the end of surgery (P < 0.001), received more epinephrine and norepinephrine before reperfusion (P = 0.02 and P < 0.001, respectively) as well as higher rates of continuous infusion of norepinephrine (P < 0.001) and vasopressin (P = 0.02) after reperfusion. Postoperative peak AST was significantly higher (P = 0.001) in LT recipients with PRS. LT recipients with intraoperative PRS had more postoperative adverse cardiac events (P = 0.05) and suffered more often from postoperative delirium (P = 0.04).ConclusionsPatients receiving ECD liver grafts are especially prone to PRS. Anesthesiologists should keep these newly described risk factors in mind when preparing for reperfusion in patients receiving high-risk organs.

Liver Grafts Flush and its Relation to Hemodynamic Status in Recipients of Living Donor Liver Transplantation: An Egyptian Experience

Background: There have been limited data towards the hemodynamic (HD) changes in recipients of living donor liver transplantation (LDLT) especially during the reperfusion phase. Purpose: Does surgical techniques affects the HD of the patients during reperfusion? We evaluated the differences between two surgical techniques done before the reperfusion phase of LDLT; one with liver graft flush and the other without flush. Methods: A retrospective observational study conducted at Ain Shams University Hospitals, Center of organ transplantation. Analysis of 50 recipients HD data, usage of vassopressors, ICU stay and mortality during reperfusion phase and 20 min after it, thus comparing two different methods; one with liver flush through the portal vein (PV) of 100 ml-200 ml (1.5 ml/kg-2.5 ml/kg) of blood and venting it from hepatic vein (HV), other group without liver flush technique. Results: Regarding the use of vassopressors; recipients underwent liver flush showed low initial and maintenance doses of nor-epinephrine compared to patients without flush (P ≤ 0.001), no differences detected regarding the HD state, intensive care unit (ICU) stay and blood products usage between the two techniques. Conclusion: In patients candidates for LDLT there is an increased risk of a complex and not completely understood pathology of postreperfusion syndrome (PRS), antegrade Portal vein (PV) flushing with HV venting is a surgical technique with reduced doses of vassopressors with minimal PRS hemodynamic instability.

Liver transplantation for acute liver failure due to hepatitis E in a pregnant patient.

Liver transplantation for acute liver failure due to hepatitis E in a pregnant patient.

Hypothermic Oxygenated Machine Perfusion for Liver Transplantation: An Initial Experience.

Due to widespread exploitation of extended criteria donors, machine perfusion is emerging as an alternative to static cold storage for organ preservation. Hypothermic oxygenated machine perfusion has been associated with improved outcomes after liver transplant, both in laboratory and clinical settings. Here, we present our initial experience with hypothermic oxygenated machine perfusion, evaluating incidence of postreperfusion syndrome, early allograft dysfunction, and long-term biliary complications. End-ischemic dual (hepatic artery and portal vein) hypothermic oxygenated machine perfusion was carried out for 150 to 200 minutes before organ implantation in 4 liver transplants considered at increased risk due to donor, recipient, or matching issues. No device malfunction occurred. Theatre logistics were minimally affected. Incidences of post-reperfusion syndrome and early allograft dysfunction were 25% and 50%. At 6-month follow-up, all patients were alive with normal hepatic function and no evidence of ischemic cholangiopathy. In our experience, hypothermic oxygenated machine perfusion appeared safe and logistically simple. Further studies are needed to assess the real value of this technique and to identify which subset of patients would benefit from its implementation.

Association Between Flushed Fluid Potassium Concentration and Severe Postreperfusion Syndrome in Deceased Donor Liver Transplantation.

BackgroundsPredicting the occurrence of severe postreperfusion syndrome (PRS) is clinically challenging. We investigated whether the flushed fluid potassium concentration (FFK) was associated with severe PRS in deceased donor liver transplantation (DDLT).Material/MethodsForty adult DDLT recipients were enrolled in this retrospective study. Effluent solution samples were collected at the end of the portal vein flush, and the FFK was determined using a point-of-care blood gas analyzer. The risk factors associated with severe PRS and the clinical outcomes in 2 groups were compared.ResultsSevere PRS occurred in 22 out of 40 patients (55.0%). The FFK of the severe PRS group was significantly higher than that of the non-severe PRS group (median, 9.6 vs. 5.8, P<0.001). Other variables associated with severe PRS included the donor risk index (DRI), Child-Turcotte-Pugh score, donor type, donor warm ischemia time, and Model for End-stage Liver Disease score. The area under the receiver operator characteristic curve for the FFK was 0.982, and the best cut-off value of the FFK for predicting severe PRS was 6.75 mmol/L (100.0% sensitivity and 88.9% specificity). A significant positive correlation was observed between the FFK and DRI (R=0.714). Patients who experienced severe PRS had a higher early allograft dysfunction rate (63.6% vs. 22.2%, P=0.019) and a longer hospital stay (median, 33.0 vs. 24.0, P=0.034).ConclusionsBoth the severity of the recipient’s liver disease and the donor graft factors play an important role in the development of severe PRS in DDLT. An FFK of more than 6.75 mmol/L was associated with severe PRS after reperfusion.

Predictive model and risk factors associated with a revised definition of early allograft dysfunction in liver transplant recipients.

Early allograft dysfunction (EAD) is a well-defined clinical syndrome that reflects overall graft function within the first week after transplant. The aim of this study was to further refine the definition for EAD. In this study, 1124 patients were included for analysis. Logistic regression was performed to identify markers of liver injury associated with 6-month patient and graft failure. Recursive partitioning identified cut-points for ALT/AST>3000/6000IU/dL observed within first week, with bilirubin≥10mg/dL and INR≥1.6 on postoperative day 7 for the revised EAD model. The incidence of updated EAD was 15% (164/1124). Multivariable analysis identified eight risk factors associated with EAD: % macrosteatosis, donor location, donor weight, nonheart beating donors, type of organ transplanted, recipient-associated hepatocellular carcinoma, severity of postreperfusion syndrome, and the amount of transfused fresh frozen plasma. In the presence of EAD, the incidence of post-transplant renal replacement therapy and dialysis dependence increases. There was a significant association of the presence of EAD with 6-month mortality (12% vs 3%) and 6-month graft failure (8% vs 1%). Higher AST/ALT level needed as cutoff in comparison with the old EAD definition.

Anesthetic management for intestinal transplantation: A decade of experience.

Intestinal transplantation (ITx) is the definitive therapy for patients suffering from intestinal failure. Previously published reports suggest that these cases should be managed perioperatively with the same intensive monitors and techniques as in liver transplantation. We retrospectively reviewed the anesthetic management of 67 isolated intestinal, intestinal-pancreas, and intestinal-kidney transplants over the previous decade (2005-2015) in our tertiary care institution. Patients were typically managed with a single arterial line, a single central venous catheter, and rarely intensive modalities such as a pulmonary artery catheter, a transesophageal echocardiography, a second arterial catheter or central venous catheter, a rapid infusion system, a cell salvage device, or viscoelastic testing. Significant hemodynamic derangements were rare, and the rate of postreperfusion syndrome was 8.96%. Our fluid administration type and volume and transfusion type and volume were similar to previous reports in which more intensive anesthetic management was employed. We demonstrate that ITx can safely occur without utilizing the intensive resources requisite for a liver transplant.