Undergoing Liver Transplant Surgery Research Articles

The Effect of Fear of Covid-19 on Immunosuppressive Treatment Compliance in Patients with Liver Transplantation

Objective: In this study, we aimed to examine the effect of fear of Covid-19 on immunosuppressive treatment compliance in patients who underwent liver transplantation surgery. Method: This descriptive study was conducted at the liver transplant center of a university hospital with the participation of 169 patients. Data; It was collected face to face and online by researchers between February and March 2024. Data were collected using the Personal Information Form, Coronavirus (Covid-19) Fear Scale and Compliance with Immunosuppressive Medication Use scales. Data analysis was done with IBM SPSS (Statistical Package for the Social Sciences) Statistics 25 program. Results: 58.6% of the patients were male, 80.5% were married, 72% of the patients used tacrolimus as the immunosuppressive drug after the transplant, 63.3% did not catch Covid-19, 15.4% were diagnosed with Covid-19. It was determined that he lost a relative. Simple linear regression analysis was performed to determine the relationship between the scales used and no statistically significant relationship was found between the two scales (p>0.05). Conclusion: It is recommended to create support programs that will include the normalization processes of liver transplant patients who are afraid of Covid-19 in order to become more compatible with their daily lives.

A nomogram incorporating Psoas muscle index for predicting tumor recurrence after liver transplantation: A retrospective study in an Eastern Asian population

Background and aimsTumor recurrence significantly affects the prognostic outcomes for liver cancer patients following liver transplantation. However, existing predictive models often neglect the inclusion of body composition indicators. Hence, this research aimed to investigate the significance of the psoas muscle index (PMI) in evaluating the post-transplant prognosis of liver cancer. MethodsA retrospective analysis was conducted on liver cancer patients who underwent liver transplantation surgery. Imaging analysis was performed using CT data to calculate PMI based on the left and right psoas muscle areas. Subsequently, the patients were categorized into PMI-Low and PMI-High groups using the established cut-off values. Univariate and multivariate analyses were performed using Cox proportional hazards regression to assess the correlation between PMI and clinical outcomes, and a nomogram was constructed accordingly. ResultsAmong the 225 patients included in the analysis, the PMI-High group exhibited significantly improved overall survival (P < 0.001) and disease-free survival (DFS, P < 0.001) rates compared to the PMI-Low group. PMI exhibited a positive correlation with body mass index (R = 0.25, P < 0.001), but no significant correlations were observed. In the multivariate analysis, PMI (HR = 4.596, P < 0.001), MELD score (HR = 1.591, P = 0.038), and Hangzhou criteria (HR = 2.557, P < 0.001) emerged as significant predictors of DFS. The constructed nomogram, incorporating these predictors, demonstrated outstanding predictive performance. Decision curve analysis revealed the superiority of the nomogram over conventional methods. ConclusionsPMI serves as a valuable prognostic factor for tumor recurrence in liver cancer patients after liver transplantation. The established nomogram is pivotal in delivering personalized predictions of DFS.

Effectiveness of Nutritional Supplementation in Liver Transplant Recipients during Early Postoperative Course: A Systematic Review and Meta-Analysis

Abstract Background Nutrition is an integral part of health maintenance. The liver is the largest and most important metabolic organ, playing a pivotal role in integrating several biochemical pathways of carbohydrate, fat, protein, and vitamin metabolism. Malnutrition is a common complication of end- stage liver disease (ESLD). Progressive deterioration of nutritional status has been associated with poor outcome in cirrhotic patients. Liver transplantation (LT) revolutionized the management of liver disease. Nutritional therapy is an integral part of liver transplant care. Objective To identity the efficacy of different dietary nutritional supplements as zinc, vit D and immunonutrients (glutamine, omega 3, arginine and ribonucleic acid) for recipient at early post operative course. Material and Methods In this systematic review and meta-analysis we enrolled a total of 7 studies for assessing the clinical outcomes of ICU patients underwent liver transplantation surgery and supplied with dietary supplements during early postoperative period. The studies also assessed the laboratory assessment of patients postoperatively during ICU admission period. Results Regarding postoperative dietary supplementations with HMB, we found significant difference for appendicular skeletal muscle mass (ASMI) regarding the baseline and the postoperative ASMI in the intervention group with HMB. But we did not report significant difference regarding the baseline and the postoperative Fat-free mass index (FFMI) in both intervention and control group with HMB. Also we did not find significant difference between base line and postoperative in both groups for Mid-arm muscle-circumference (MAMC), Fat mass index (FMI), 6-minute walk test (6MWT), and Handgrip (HG). Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available in the Internet till 2021. Conclusion BCAA as dietary supplementation showing a significant favorable effect regarding the baseline and the postoperative BTR levels, also for BCAA levels, Tyrosine levels, prealbumin levels, retinol binding protein and PTINR levels in both intervention and control groups. For HMB, we found significant difference for appendicular skeletal muscle mass (ASMI) regarding the baseline and the postoperative ASMI in the intervention group with HMB. But we did not report significant difference regarding the baseline and the postoperative Fat-free mass index (FFMI) in both intervention and control group with HMB.

Impact of Albumin Infusion Compared With Crystalloid Infusion on Organ Function After Liver Transplantation in Adult Patients

ObjectivesTo compare the clinical benefit of using albumin versus crystalloids for volume resuscitation on organ function in adult patients after liver transplantation. DesignA retrospective cohort study SettingData from a tertiary care facility electronic medical record, (EMR) on liver transplantation patients admitted to the intensive care unit (ICU) PatientsAdults admitted to the ICU after liver transplantation InterventionsCrystalloid fluid resuscitation compared to albumin 5% in the immediate postoperative period after liver transplant. Measurements and main resultsAdults who underwent liver transplantation surgery and received a 5% albumin solution were compared with adults who received a crystalloid solution. Demographic, etiology, clinical variables, perioperative, and outcome variables were collected. The data were analyzed using a t-test, two-way ANOVA, and multivariate analysis. After applying all the exclusion criteria, a conservative population of 57 adult patients who underwent liver transplantation was included in this study. The crystalloid group had 27 patients (47.4%), while the albumin group had 30 patients (52.6%). The total mean age of the population was 52.2 years; males constituted most of the population (52.6%). Patients in the crystalloid group had similar characteristics to those in the albumin group. Daily SOFA scores gradually decreased during the postoperative period in both groups. The trend of the SOFA score was not different between the two groups. A two-way ANOVA shows no statistical difference in SOFA Score between the two groups postoperatively; the p-value is 0.84. A multivariate linear regression analysis shows that the MELD score was a predictor of the 7-day postoperative SOFA score in this population. ConclusionsIn our study, the use of albumin compared to crystalloids in patients undergoing liver transplantation appeared to have no significant difference in terms of the risk of organ dysfunction. However, further research is needed to confirm these findings and fully understand the potential benefits and risks of using either type of fluid.

Risk Factors for Unplanned Readmission in Adult Liver Transplant Patients: A Retrospective Study

IntroductionUnplanned readmission is an important indicator for evaluating medical care quality. Adult liver transplant patients have high risk for readmission, which seriously affects their recovery. As there is currently a lack of research on risk factors for unplanned readmission of adult liver transplant patients in China, the purpose of this study was to elucidate such risk factors. MethodsData for patients undergoing liver transplantation surgery at a tertiary hospital in Zhejiang Province from March 2018 to July 2022 were retrospectively collected. Patients were divided into readmission and nonreadmission groups based on whether unplanned readmission occurred within 90 days. Univariate analysis and logistic regression were used to analyze risk factors for unplanned readmission. ResultsIn total, 123 adult liver transplant patients were included; 38 had unplanned readmission, for a rate of 30.8%. There was a statistically significant difference between the groups in terms of age, educational level, operation time, intraoperative bleeding volume, number of complications, postoperative hospital stay, and hemoglobin (P < .05). Logistic regression analysis showed that age [OR = 1.085, 95% CI (1.022, 1.152)], operation time [OR = 1.010, 95% CI (1.001, 1.020)], postoperative hospital stay [OR = 1.124, 95% CI (1.023, 1.235)], and number of complications [OR = 4.487, 95% CI (1.234, 16.319)] were independent risk factors for unplanned readmission in adult liver transplant patients (P < .05). ConclusionsThe current situation of unplanned readmission for adult liver transplant patients cannot be ignored, indicating that staff should identify risk factors for unplanned readmission as soon as possible and take targeted personalized measures and health education to reduce readmission risk.

Association of Preoperative Red Cell Distribution Width with Postoperative Outcomes in Liver Transplantation Recipients

Background: The 1-year mortality rate after liver transplantation is approximately 8%-20%. It is important to explore risk factors associated with postoperative outcomes in liver transplantation recipients (LTRs). Red cell distribution width (RDW) is an indicator that assesses the variability in the volume of red blood cells in circulation. RDW is not only related to inflammatory levels and nutritional status but also associated with postoperative outcomes in surgical patients. However, the relationship between preoperative RDW and postoperative outcomes in LTRs remains unclear. Therefore, we designed a retrospective observational study to investigate the impact of preoperative RDW levels on postoperative outcomes in LTRs. Methods: We retrospectively collected clinical data of patients who underwent allogeneic liver transplantation at West China Hospital, Sichuan University, from January 2016 to December 2020. The primary outcome was 1-year mortality. Secondary outcomes included 30-day mortality, long-term survival, early postoperative graft dysfunction, acute kidney injury, renal replacement therapy, pulmonary complications, duration of postoperative mechanical ventilation, length of ICU stay, and length of hospital stay. Patients were divided into two groups: RDW ≤ 14.5% and RDW &gt; 14.5%. We selected 14 covariates and used propensity score matching (PSM) to adjust for baseline characteristics. Postoperative outcomes and long-term survival were analyzed after PSM. Receiver operating characteristics (ROC) curves and subgroup analyses were also performed. Results: A total of 661 patients who underwent liver transplantation surgery were screened for this study. Finally, 438 patients were included in the statistical analysis. After PSM, there were no statistically significant differences in postoperative mortality and complications between the RDW ≤ 14.5% group and the RDW &gt; 14.5% group (P &gt; 0.05). The comparison of long-term survival between the two groups also showed no statistical difference (hazard ratio = 0.67, 95% confidence interval: 0.28-1.61, P = 0.358). Subgroup analyses showed consistent results. The ROC curve indicated that the predictive ability of preoperative RDW levels for 1-year mortality is moderate (area under the ROC curve 0.661). Conclusion: Preoperative RDW levels do not affect postoperative mortality and the incidence of complications in LTRs. However, these results still need further research for verification.

Prolonged Tracheal Intubation in the ICU as a Possible Risk Factor for Arytenoid Dislocation After Liver Transplant Surgery: A Retrospective Case-Control Study.

BACKGROUND Arytenoid dislocation (AD) is a rare complication of general anesthesia with tracheal intubation, with a published incidence of 0.009-0.097%. This retrospective case-control study aimed to identify risk factors associated with AD in patients who underwent liver transplantation. MATERIAL AND METHODS This study included 476 patients who underwent liver transplantation between January 2013 and December 2022. Patients with AD who underwent surgery were included in the AD group. For each case of AD, 4 patients matched by anesthesia type and anesthetist were randomly selected as the non-AD group. Data on patient characteristics, anesthetic factors, and surgical factors were collected and compared between patients with and without AD. Logistic regression analysis was performed to determine the risk factors for AD after liver transplantation. RESULTS Of the 476 patients who underwent liver transplantation, 17 (3.57%) had AD. AD occurred on the left side in 13 patients and on the right side in 4 patients. The 17 patients who experienced AD and 68 matched non-AD patients were enrolled. Patients in the AD group had a greater intubation depth (24 [23-24] vs 24 [24-24], P=0.043), a higher level of hemoglobin (134.5 [118-147.5] vs 112 [96.25-125], P=0.014), and prolonged tracheal intubation in the ICU (19.75 [15.87-31.87] vs 13 [10.62-15], P<0.001) compared to those in the non-dislocation group. Multivariate logistic regression analysis showed that prolonged tracheal intubation in the ICU was independently associated with the occurrence of AD in patients who underwent liver transplantation (P=0.013). CONCLUSIONS This study showed that the incidence of AD was 3.57% in patients undergoing liver transplant surgery and that prolonged tracheal intubation in the ICU was a possible risk factor for AD.

Safety evaluation of curative gastrectomy for gastric cancer patients who underwent liver transplantation: a comparative study with conventional gastrectomy for gastric cancer patients

BackgroundWe aimed to examine the technical and oncological safety of curative gastrectomy for gastric cancer patients who underwent liver transplantation.MethodsIn this study, we compared the surgical and oncological outcomes of two groups. The first group consisted of 32 consecutive patients who underwent curative gastrectomy for gastric cancer after liver transplantation (LT), while the other group consisted of 127 patients who underwent conventional gastrectomy (CG). In addition, a subgroup analysis was performed to evaluate the impact of the background differences and the surgical outcomes on the involvement of a specialized liver transplant surgery team.ResultsThe mean operative time was significantly longer in the LT group (p < 0.05). Furthermore, there were more frequent cases of postoperative transfusion in the LT group compared to the CG group (p < 0.05). However, there were no significant differences in the overall complications between the groups (25.00 vs 23.62%, p = 0.874). The 5-year overall survival rates of the LT and CG groups were 76.7% and 90.1%, respectively (p < 0.05). The results of the subgroup analysis demonstrated no statistically significant difference in various early surgical outcomes, such as time to transfusion during surgery, first flatus, time to first soft diet, postoperative complications, hospital stay after surgery, and the number of harvested lymph nodes except for operation time.ConclusionsDespite one’s medical history of undergoing LT, our study demonstrated that curative gastrectomy could be a surgically safe treatment for gastric cancer. However, further study should be conducted to identify the reason gastric cancer patients who underwent liver transplant surgery have lower overall survival rate.

Arterial Lactate Concentration at the End of Liver Transplantation is Independently Associated With One-Year Mortality

Liver transplant patients who develop hyperlactatemia are at increased risk of postoperative morbidity and short-term mortality, but there are few data on longer-term outcomes. We therefore investigated if arterial lactate concentration obtained immediately after surgery, at the time of admission to the intensive care unit (ICU), was associated with 1-year mortality. In this retrospective cohort study, all patients who underwent liver transplant surgery from a deceased donor between September 2013 and December 2019 were screened for inclusion. Patients who underwent combined transplantation surgery and those with a history of previous liver transplantation (ie, redo surgery) were not included. Logistic regression modeling included univariate and multivariate analyses. Receiver operating characteristic curves and areas under the curves were calculated. Lactate thresholds and association with outcome were analyzed for specificity, sensitivity, and Youden's index. Of 226 patients included, 18.4% died within 1 year of liver transplantation. Immediate postoperative lactate concentration was independently associated with 1-year mortality with an adjusted odds ratio of 1.35 (95% CI 1.16-1.59; P < .001) per mmol/L increase in lactate and an area under the curve of 0.80 (95% CI 0.72-0.87; P < .001). A lactate concentration of 2.25 mmol/L (cutoff determined using Youden's index) was associated with increased 1-year mortality with a sensitivity of 0.71 and a specificity of 0.72. Increased arterial lactate concentration on admission to the intensive care unit immediately after orthotopic liver transplantation is independently associated with increased 1-year mortality.

Central Versus Peripheral Invasive Arterial Blood Pressure Monitoring in Liver Transplant Surgery.

Introduction Invasive blood pressure monitoring is essential in liver transplant surgery due to expected major hemodynamic shifts.The use of central versusperipheral arterial access, however, is institution-dependent, which can affect clinical decisions regarding vasopressor therapy.Although there are studies that demonstrate inconsistencies based on arterial cannulation sites, few studies have compared femoral and radial artery blood pressures in patients undergoing liver transplant surgery.To our knowledge, there are no studies investigating the differences between continuous minute-to-minute femoral and radial artery measurements during all three phases of liver transplant surgery. Objective The main objective of this study was to evaluate for any differences between central and peripheral blood pressure measurements in liver transplant surgeryand to assess for any correlation between vasopressor infusion dose and femoral-arterial pressure differences. Methods In this retrospective study, we reviewed and studied the data of 61 patientswith American Society of Anesthesiologists (ASA) grade 4who underwent liver transplant surgery at Loma Linda University Medical Center between January and December of 2019.All patients had both femoral and radial arterial lines placed for liver transplant surgery.Femoral and radial arterial blood pressure values were obtained continuously over 60 minutes in the pre-anhepatic phase, 45 minutes during the anhepatic phase, and 60 minutes into the neo-hepatic phase. Vasopressor infusion doses were also recorded for each patient during these time frames. Results This pilot study found statistically significant differences between the mean femoral and radial systolic blood pressure (SBP; p < 0.0001), diastolic blood pressure (DBP; p < 0.0001), and mean arterial pressure (MAP; p < 0.0001)during all phases of liver transplantation.The meanSBP and MAP differences between femoral and radial arteries were highest (femoral blood pressure reading higher than radial blood pressure measurements) in the late anhepatic and early neo-hepatic phases with SBP differences of 20.8 ± 0.8 mmHg and 22.8 ± 0.8 mmHg, respectively, and MAP differences of 10.0 ± 0.4 mmHg and 9.8 ± 0.4 mmHg, respectively. Higher vasopressor infusion doses were strongly associated with greater differences in femoral-radial SBP and MAP measurements (r = 0.69 for vasopressin, 0.68 for norepinephrine, and 0.68 for epinephrine; p < 0.0001) during the anhepatic phase. Conclusions Peripheral invasive blood pressure monitoring may result in underestimation of the central blood pressure, as was seen in all phases of liver transplantation. This may lead to excessive vasopressor use with potentially adverse effects. Although the cause for the difference between femoral and radial artery measurements is unclear, increasing vasopressor infusion dosages appears to contribute. Femoral artery blood pressure monitoring allows clinicians to interpret hemodynamic status and administer appropriate vasopressors more accurately.

Effect of preoperative hypoalbuminemia on postoperative mortality and morbidity in liver transplant surgery

Aim: In this study, it isaimed to retrospectively evaluatethe effect of serum albumin levels on postoperative mortality and morbidity in patients with end-stage liver failure with hypoalbuminemia who underwent follow-up liver transplant surgery.&#x0D; Material and Method: After the approval of the ethics committee, the patients who underwent liver transplant surgery between April 2011 and September 2016 were divided into two groups as with preoperative albumin values

Experimental Clinical Model of Liver Transplantation in Large White Pigs Without Venovenous Bypass: Pre-, Intra-, and Maintenance Care

Liver transplantation in an animal model is challenging due to hemodynamics and intraoperative anesthetic care. Several models are described in the literature employing different techniques such as venovenous bypass or aortic cross-clamping to maintain hemodynamic stability, although few groups keep the animal alive in the postoperative period. This study aims to evaluate a liver transplantation clinical model in pigs without venovenous bypass or aortic cross-clamping. Male pigs weighing 20 to 35 kg underwent liver transplantation surgery without using venovenous bypass or aorta cross-clamping. Protocols were approved by the Animal Care and Use Committee of the University of São Paulo, Brazil. Ten LTs were performed. Cold ischemia and warm ischemia were 119 ± 33.28 minutes and 26 ± 9.6 minutes, respectively. Hemodynamic changes were significantly higher after the postrevasculazation phase: heart rate (P < .001), medium arterial pressure (P < .001), and cardiac output (P=.03). Hypotension was treated with intravenous fluids and, in some cases, with vasoactive drugs especially during the post-reperfusion period. No animals died during the procedure and almost survival until the first postoperative day. Serum aspartate aminotransferase and lactate increased their values in the post-reperfusion phase. Practice-based on laboratory animals improves surgical skills and the development of experimental models aimed at new advances in this field. Perfecting our technique on the swine model, we could move forward to create a small-for-size model, test new therapeutic strategies, and define the boundaries for safely performing an enlarged liver resection or a partial liver graft transplant.

Advancing Prediction of Risk of Intraoperative Massive Blood Transfusion in Liver Transplantation With Machine Learning Models. A Multicenter Retrospective Study.

BackgroundLiver transplantation surgery is often accompanied by massive blood loss and massive transfusion (MT), while MT can cause many serious complications related to high mortality. Therefore, there is an urgent need for a model that can predict the demand for MT to reduce the waste of blood resources and improve the prognosis of patients.ObjectiveTo develop a model for predicting intraoperative massive blood transfusion in liver transplantation surgery based on machine learning algorithms.MethodsA total of 1,239 patients who underwent liver transplantation surgery in three large grade lll-A general hospitals of China from March 2014 to November 2021 were included and analyzed. A total of 1193 cases were randomly divided into the training set (70%) and test set (30%), and 46 cases were prospectively collected as a validation set. The outcome of this study was an intraoperative massive blood transfusion. A total of 27 candidate risk factors were collected, and recursive feature elimination (RFE) was used to select key features based on the Categorical Boosting (CatBoost) model. A total of ten machine learning models were built, among which the three best performing models and the traditional logistic regression (LR) method were prospectively verified in the validation set. The Area Under the Receiver Operating Characteristic Curve (AUROC) was used for model performance evaluation. The Shapley additive explanation value was applied to explain the complex ensemble learning models.ResultsFifteen key variables were screened out, including age, weight, hemoglobin, platelets, white blood cells count, activated partial thromboplastin time, prothrombin time, thrombin time, direct bilirubin, aspartate aminotransferase, total protein, albumin, globulin, creatinine, urea. Among all algorithms, the predictive performance of the CatBoost model (AUROC: 0.810) was the best. In the prospective validation cohort, LR performed far less well than other algorithms.ConclusionA prediction model for massive blood transfusion in liver transplantation surgery was successfully established based on the CatBoost algorithm, and a certain degree of generalization verification is carried out in the validation set. The model may be superior to the traditional LR model and other algorithms, and it can more accurately predict the risk of massive blood transfusions and guide clinical decision-making.

Association of HLA-DPA1 polymorphism with prolonged mechanical ventilation in patients undergoing liver transplantation.

BackgroundProlonged mechanical ventilation (PMV) is a common complication after liver transplantation surgery. However, owing to the clinical and economic benefits of early extubation, many efforts have been used to assess the clinical predictors for PMV. The aim of our study was to explore the impact of perioperative risk factors, including candidate gene polymorphisms, for PMV in patients undergoing liver transplantation.MethodsOne hundred forty patients who underwent liver transplantation surgery were enrolled. The duration of mechanical ventilation after surgery was examined, along with the length of intensive care unit and hospital stay, and 30-day mortality. Patient-related clinical factors and single nucleotide polymorphisms of candidate genes were assessed with regard to PMV, which was defined as mechanical ventilation for > 48 h. ResultsTwenty-six (19%) patients continued to receive mechanical ventilation at 48 h after surgery. Intraoperative continuous renal replacement therapy (CRRT) and an elevated serum lactate level during the postoperative period were significantly associated with the PMV group, compared to the non-PMV group (odds ratio [OR] = 24.731 [1.077, 567.915] versus OR = 3.008 [1.497, 6.045]). A significant association existed between the HLA-DPA1 rs8486 polymorphism and the risk of PMV under the allele model (OR = 8.060 [1.451, 44.765]).ConclusionsThe rs8486 polymorphism in HLA-DPA1 can independently affect the risk of PMV in liver transplantation recipients, along with intraoperative CRRT application, and elevated lactate level during the postoperative period.

The Effect of Immunosuppressant Therapy Adherence on the Comfort of Liver Transplant Recipients.

Inadequate immunosuppressive therapy causes rejection, whereas an overdose may lead to infections or malignancy to affect a patient's life and comfort. This study used a descriptive correlational design to determine how compliance with immunosuppressive therapy affected the well-being of liver transplant patients. The study was conducted in the liver transplant unit of a university hospital with 103 patients who underwent liver transplant surgery. The target population included patients who received treatment in liver transplant clinics between July 2016 and August 2017. Mean age of the patients in the study was 44.66 ± 14.86 years and the time after transplant was 15.48 ± 16.90 months on the average. A significant difference was found between mean General Comfort Scale scores according to the variable of adherence status (t = 6.898, p < .05). Simple linear regression analysis showed a positive moderate, significant correlation between the adherence variable and mean General Comfort Scale scores (R = 0.543, p < .001). It was found that the patients who adhered to immunosuppressive therapy experienced higher levels of comfort. Therefore, arrangements to improve patient adherence to therapy, hence comfort, are recommended, as well as periodic evaluations of patient comfort levels.

Abstract No. 513 Endovascular interventions safely and effectively maintain long-term patency in patients with arterial complications of liver transplantation

To investigate the long-term safety and efficacy of endovascular interventions at treating transplant hepatic artery stenosis and thrombosis An IRB-approved, retrospective single-center cohort study was conducted on patients who underwent liver transplantation surgery from 1986 to 2020. Of the 1984 liver transplant patient records reviewed, 29 contained diagnoses of transplant hepatic artery stenosis (HAS) or thrombosis (HAT) necessitating a total of 50 endovascular interventions between 2005 and 2020. Median follow-up time from the initial intervention was 644 days (range, 5–4782 days) with follow-up time exceeding 2500 days in 11 cases. Complications were considered clinically significant if the Common Terminology Criteria for Adverse Events grade was 2 or greater. Two-sided, Wilcoxon signed-rank tests were performed to compare pre- and post-procedural duplex imaging measurements of resistive index and peak systolic velocity; P values less than 0.05 were considered statistically significant. Kaplan-Meier analyses were used to evaluate the primary patency and primary-assisted patency rates of the interventions. 94% (47/50) of interventions were performed for HAS, and 6% (3/50) were performed for HAT. Primary technical success was achieved in 92% (46/50) of cases. Clinically significant peri-procedural complications occurred in 6% (3/50) of cases. Pre- and post-procedural duplex imaging demonstrated improvements in both resistive index (mean difference, 0.10; P < 0.05) and peak systolic velocity (mean difference, -128 cm/s; P < 0.01). The primary patency rate of initial interventions was 90%, 63%, and 55% at 1, 6, and 12 months, respectively. The primary-assisted patency rate was maintained at 97% through 10 years of follow-up. Endovascular interventions used to treat transplant HAS and HAT demonstrate safety and efficacy on long-term follow-up. Although one-year primary patency is modest, additional interventions can be performed to maintain primary-assisted patency for a durable long-term result.

Intraoperative hypotension during liver transplant surgery is associated with postoperative acute kidney injury: a historical cohort study

BackgroundAcute kidney injury (AKI) occurs frequently after liver transplant surgery and is associated with significant morbidity and mortality. While the impact of intraoperative hypotension (IOH) on postoperative AKI has been well demonstrated in patients undergoing a wide variety of non-cardiac surgeries, it remains poorly studied in liver transplant surgery. We tested the hypothesis that IOH is associated with AKI following liver transplant surgery.MethodsThis historical cohort study included all patients who underwent liver transplant surgery between 2014 and 2019 except those with a preoperative creatinine > 1.5 mg/dl and/or who had combined transplantation surgery. IOH was defined as any mean arterial pressure (MAP) < 65 mmHg and was classified according to the percentage of case time during which the MAP was < 65 mmHg into three groups, based on the interquartile range of the study cohort: “short” (Quartile 1, < 8.6% of case time), “intermediate” (Quartiles 2–3, 8.6–39.5%) and “long” (Quartile 4, > 39.5%) duration. AKI stages were classified according to a “modified” “Kidney Disease: Improving Global Outcomes” (KDIGO) criteria. Logistic regression modelling was conducted to assess the association between IOH and postoperative AKI. The model was run both as a univariate and with multiple perioperative covariates to test for robustness to confounders.ResultsOf the 205 patients who met our inclusion criteria, 117 (57.1%) developed AKI. Fifty-two (25%), 102 (50%) and 51 (25%) patients had short, intermediate and long duration of IOH respectively. In multivariate analysis, IOH was independently associated with an increased risk of AKI (adjusted odds ratio [OR] 1.05; 95%CI 1.02–1.09; P < 0.001). Compared to “short duration” of IOH, “intermediate duration” was associated with a 10-fold increased risk of developing AKI (OR 9.7; 95%CI 4.1–22.7; P < 0.001). “Long duration” was associated with an even greater risk of AKI compared to “short duration” (OR 34.6; 95%CI 11.5-108.6; P < 0.001).ConclusionsIntraoperative hypotension is independently associated with the development of AKI after liver transplant surgery. The longer the MAP is < 65 mmHg, the higher the risk the patient will develop AKI in the immediate postoperative period, and the greater the likely severity. Anesthesiologists and surgeons must therefore make every effort to avoid IOH during surgery.

Efficacy of albumin dialysis as a bridge to transplantation in children with end-stage liver disease

Liver transplantation is the only effective treatment modality for end-stage liver disease. However, donor organs are not always available. In some cases, the gravity of the patient’s condition makes transplantation impossible. In this regard, the use of artificial liver support systems helps in preparing a patient for transplant surgery. Objective: to conduct a retrospective study aimed at evaluating the efficiency of fractionated plasma separation and adsorption system. Materials and methods. From January 2019 to May 2020, 139 pediatric liver transplants were. We analyzed the data of 5 pediatric patients (2 girls and 3 boys, aged 12 to 17 years) who received fractionated plasma separation and adsorption (FPSA) sessions as a bridge to transplantation. The main clinical indication for FPSA was severe hepatic encephalopathy (grade 3 according to the West Haven Criteria), which was observed at 350–872 μmol/L (average 597 ± 98 μmol/L) serum bilirubin level. The FPSA sessions were conducted on a Prometheus device using AV-600 hemofilters as dialyzers (Fresenius Medical Care, Germany). Results. Depending on the extent of bilirubinemia in patients, it took from one (in one case) to three (in one case) daily FPSA sessions to restore clear consciousness, appetite and physical activity. Average bilirubin levels after treatment cycles decreased from 597 ± 98 to 236 ± 73 μmol/L. All patients successfully underwent liver transplant surgery within two to five days, two patients received a liver fragment from a living related donor. Conclusion. The FPSA system stabilizes the condition of potential recipients with acute liver failure. Further research is required to develop optimal regimens for albumin dialysis.

S2501 Cardiopulmonary Failure and Stroke in a Patient With PFO Following Liver Transplant: A Case Report

INTRODUCTION: Patent foramen ovale (PFO) is the most common congenital heart anomaly, and currently affects roughly 20–25% of adults worldwide. This defect allows direct blood flow between the right and left atria with interatrial shunting and increased risk of stroke due to paradoxical embolism. These potential complications are particularly concerning in patients undergoing liver transplant especially those with hepatopulmonary syndrome (HPS) and when using the piggyback operative technique. Two studies evaluated short-term outcomes including neurologic events in patients undergoing liver transplant surgery. Both reported no statistically significant difference in outcomes/neurologic events between patients with or without PFO undergoing transplant. The purpose of this case report is to discuss a patient with known PFO without closure who underwent liver transplantation, and suffered from an MRI-proven stroke and significant cardiopulmonary compromise. CASE DESCRIPTION/METHODS: A 60-year-old female with history of NASH cirrhosis, HPS, and atrial fibrillation with known, asymptomatic PFO as evidenced by interatrial shunting on transthoracic echocardiogram underwent liver transplant with uncomplicated surgery. However, her hospital course was complicated by pneumonia. She was difficult to wean from the ventilator, prompting initiation of extracorporeal membranous oxygenation (ECMO) ten days post-transplant. She remained on ECMO for eleven days, and due to her continued desaturation when weaning from ECMO, underwent percutaneous PFO closure. Roughly two-weeks post-PFO closure, she was noted to have right-sided weakness and right-sided facial droop when weaned from sedation. MR brain showed infarction in the anterior left medulla. DISCUSSION: The etiology of this patient's complicated post-operative course is multifactorial including pneumonia, underlying HPS and underlying PFO. This case questions the current standard of care for patients pre-transplant with known PFO. While the existing data suggests there is no indication for prophylactic PFO closure, some authors recommend considerations for closure in the presence of HPS. Some liver transplant centers recommend routine closure of PFO prior to liver transplant. Further studies are needed to define the population at high risk for paradoxical embolization and other complications of shunting that would benefit from PFO closure prior to liver transplant.

Evaluation of microRNA Gene Polymorphisms in Liver Transplant Patients with Hepatocellular Carcinoma

Background: Genetic polymorphism in the miRNA sequence might alter miRNA expression and/or maturation, which is associated with the development and progression of hepatocellular carcinoma (HCC) in liver transplant patients. Objectives: Therefore, the prevalence of miRNA-146a G &gt; C (rs2910164), miRNA-499A &gt; G (rs3746444), miRNA-149C &gt; T (rs2292832), and miRNA-196a-2 C &gt; T (rs11614913) gene polymorphisms was evaluated in liver recipients with HCC with or without experiencing graft rejection. Methods: In a cross-sectional study, tissue samples were collected from 60 HCC patients who underwent liver transplant surgery at Namazi Hospital, Shiraz, Iran, in 2013 - 2015. A control group consisting of 120 individuals was randomly selected, as well. The genomic DNA was extracted from collected tissues and blood samples. The miRNA-146a (rs2910164), miRNA-499 (rs3746444), miRNA-149 (rs2292832), and miRNA-196a-2 (rs11614913) gene polymorphisms were evaluated in patients with HCC using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. Results: The CC genotype and C allele of the miRNA-146a (rs2910164) polymorphism were significantly associated with the increased risk of transplant rejection in patients with HCC (P = 0.05 and P = 0.05, respectively). The CC genotype and C allele of the miRNA-146a (rs2910164) were also significantly more frequent in male liver transplant patients who experienced acute rejection than in non-rejected ones (P = 0.05 and P = 0.03, respectively). However, no significant association was found between the genotypes and alleles of miRNA-499 (rs3746444), miRNA-149 (rs2292832), and miRNA-196a-2 (rs11614913) polymorphisms and HCC outcomes in liver transplant recipients. Conclusions: The importance of the CC genotype and C allele of the miRNA-146a (rs2910164) polymorphism in increasing the risk of transplant rejection was confirmed, but it needs further studies in larger populations.