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1
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Gunt C, Çekmen N. Perioperative Variation of Plasma Copeptin and Its Association With Vasopressor Need During Liver Transplantation. Transplant Proc 2025; 57:277-283. [PMID: 39848860 DOI: 10.1016/j.transproceed.2024.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 10/25/2024] [Accepted: 11/19/2024] [Indexed: 01/25/2025]
Abstract
BACKGROUND Vasopressor usage during liver transplant is related to decreased hepatic flow, graft failure, and mortality. We measured plasma Copeptin levels in liver transplant patients based on vasopressor requirements. We hypothesize that preoperative plasma copeptin measurement helps predict the vasopressor infusion requirement during liver transplantation in preoperative evaluation. METHODS The plasma Copeptin of 40 patients was measured 5 times: before the operation, 15 minutes before and after reperfusion, and postoperative 12th and 24th hours. Patients were categorized into 2 groups based on vasopressor infusion for comparison. RESULTS There was a statistically significant rise in median serum Copeptin concentration between the preoperative phase and before reperfusion (11.2 [7.3-20.9] vs 178.5 [121.5-243.0], P < .001), as well as a statistically substantial decline between after reperfusion and postoperative 12th hours (190.6 [127-276.3] vs 74.7 [42.0-124.9], P < .001). The vasopressor-taking group had significantly higher plasma copeptin at postoperative 12th hours (96.6 [71.4-191.7] vs 55.0 [31.8-82.5], P = .030) and 24th (133.7 [72.2-175.5] vs 51.1 [24.8-85.8], P = .037). A tendency above 11.85 pmol/L of plasma Copeptine level was observed between increasing preoperative plasma Copeptin and the odds of vasopressor use. CONCLUSION High preoperative plasma Copeptin levels may be an indicator of vasopressor need during liver transplantation. Further studies with more samples, including a higher range of preoperative plasma Copeptin levels, are required to provide more generalizable findings and to determine thresholds applicable to LT candidates.
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Affiliation(s)
- Ceren Gunt
- Ankara Güven Hospital, Department of Anaesthesiology and Reanimation Çankaya/Ankara, Turkey.
| | - Nedim Çekmen
- Nişantaşı University Health Services Vocational School, Department of Anesthesia, Turkey
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2
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Cassese G, Montalti R, Giglio MC, Rompianesi G, Troisi RI. Graft inflow modulation in recipients with portal hypertension. Updates Surg 2024:10.1007/s13304-024-02048-2. [PMID: 39680320 DOI: 10.1007/s13304-024-02048-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 11/25/2024] [Indexed: 12/17/2024]
Abstract
The extended application of living donor liver transplantation (LDLT) has revealed the problem of graft size mismatching, potentially leading to the "small-for-size syndrome" (SFSS). SFSS is a rare dysfunction that may affect a partial liver graft, characterized by coagulopathy, cholestasis, ascites, and encephalopathy. A key role in the physiopathology of SFSS is played by portal hypertension (PHT) to which a small allograft is submitted after reperfusion, resulting in sinusoidal congestion and hemorrhage. Portal overflow injures the liver directly through nutrient excess, endothelial activation, and sinusoidal shear stress, and indirectly through arterial vasoconstriction. Thus, SFSS prevention relies not only on increasing graft volume (implementing the use of larger grafts or auxiliary/dual liver transplantation), but also on the control of the increased portal vein pressure (PVP) and portal vein flow (PVF). To this aim, surgical graft inflow modulation techniques (GIM) such as splenic artery ligation (SAL), splenectomy and hemiportocaval shunts, can be considered when an imbalance between the PVP and the hepatic arterial flow (HAF) is acknowledged. However, such strategies have their pros and cons, and a deep knowledge of the indications and complications is needed. Furthermore, pharmacological modulation has also been proposed. This review is aimed to update available literature on the current knowledge and strategies for modulating portal vein flow in LDLT.
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Affiliation(s)
- Gianluca Cassese
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Transplantation Service, Federico II University Hospital, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Roberto Montalti
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Transplantation Service, Federico II University Hospital, Via Sergio Pansini 5, 80131, Naples, Italy
- Department of Public Health, Federico II University, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Mariano Cesare Giglio
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Transplantation Service, Federico II University Hospital, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Gianluca Rompianesi
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Transplantation Service, Federico II University Hospital, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Roberto Ivan Troisi
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Transplantation Service, Federico II University Hospital, Via Sergio Pansini 5, 80131, Naples, Italy.
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3
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Sodoma AM, Pellegrini JR, Greenberg S, Sodoma A, Munshi R, Pellegrini RG, Singh J. Outcomes of Coronary Artery Bypass Grafting (CABG) Patients With and Without a History of Liver Transplant. Cureus 2024; 16:e75820. [PMID: 39822448 PMCID: PMC11737807 DOI: 10.7759/cureus.75820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2024] [Indexed: 01/19/2025] Open
Abstract
BACKGROUND Liver transplant (LT) patients face various challenges, including an increased risk of coronary artery disease (CAD) for a variety of reasons, with 70% of LT recipients having one cardiovascular event. Coronary artery bypass grafting (CABG) remains one of the most commonly performed major surgical procedures in the United States, with 20-30% of LT patients requiring a CABG. Many studies have analyzed when to perform a CABG and CAD workup pre-LT, but this population remains a problem. The patient population is challenging to study due to their rarity and complexity. Our study aimed to compile many patients through the National Inpatient Sample (NIS) database to gauge the outcomes of CABG in patients with and without a history of LT. Methods: Patients who underwent CABG with or without a history of LT were selected from the NIS from 2008 to 2020. The International Classification of Diseases (ICD) 9 and 10 codes were used to identify suitable records. Primary outcomes of interest were all-cause hospital mortality, shock, acute myocardial infarction, acute kidney injury (AKI), and a composite of these. Secondary outcomes included length of stay and total charges. Results: A weighted total of 2,407,349 CABG hospitalizations were included in this study. Of these, 1,833 had a history of LT. Overall, patients with a history of LT were more likely to be younger (65.16 vs. 66.16; p<0.001), male (81.6% vs. 73.66%; p<0.001), and more complex (Charlson Comorbidity Index (CCI) 5.89 vs. 4.16; p<0.001) than patients without a history of LT. Patients with a history of LT also had higher rates of diabetes mellitus type 2 (57.02% vs. 43.39%; p<0.001), end-stage renal disease (11.21% vs. 2.95%; p<0.001), and gastroesophageal reflux disease (GERD) (28.39% vs. 21.26%; p<0.001). CABG patients with a history of LT were less likely, however, to have hyperlipidemia (56.72% vs. 74.26%; p<0.001), hypertension (25.95% vs. 58.45%; p<0.001), obesity (19% vs. 23.42%; p=0.046), a history of smoking (12.06% vs. 18.66%; p<0.01), or alcohol use disorder (9.04% vs. 13.44%; p=0.017). We found that patients admitted for CABG with a history of LT had significantly higher adjusted odds of mortality (OR 1.84; p<0.01), AKI (OR 2.65; p<0.001), and composite outcome (OR 2.04; p<0.001). They also experienced a longer length of stay (1.7 days; p=0.02) and greater hospital charges ($26,761; p=0.029). CONCLUSION We found that CABG patients with a history of LT had nearly twofold higher odds of mortality, nearly threefold higher odds of AKI, and twofold higher odds of composite outcomes than CABG patients without LT. This corresponded to longer lengths of stay and increased hospital charges. Patients should require lower thresholds for left heart catheterization and more strict CAD testing before an LT due to the increased risk of adverse outcomes with the current standard of care.
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Affiliation(s)
- Andrej M Sodoma
- Internal Medicine, South Shore University Hospital, Bay Shore, USA
| | | | - Samuel Greenberg
- Anesthesia and Critical Care, Renaissance School of Medicine at Stony Brook University, Stony Brook, USA
| | - Andrej Sodoma
- Chemistry Faculty, College of Natural Sciences, Grand Canyon University, Phoenix, USA
| | - Rezwan Munshi
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
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4
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Piano S, Reiberger T, Bosch J. Mechanisms and implications of recompensation in cirrhosis. JHEP Rep 2024; 6:101233. [PMID: 39640222 PMCID: PMC11617229 DOI: 10.1016/j.jhepr.2024.101233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 09/02/2024] [Accepted: 09/26/2024] [Indexed: 12/07/2024] Open
Abstract
Decompensated cirrhosis has long been considered the irreversible end stage of liver disease, characterised by further decompensating events until death or liver transplantation. However, the observed clinical improvements after effective antiviral treatments for HBV and HCV and after sustained alcohol abstinence have changed this paradigm, leading to the concept of "recompensation" of cirrhosis. Recompensation of cirrhosis was recently defined by Baveno VII as (i) cure of the primary liver disease aetiology; (ii) disappearance of signs of decompensation (ascites, encephalopathy and portal hypertensive bleeding) off therapy; and (iii) stable improvement of liver function tests (bilirubin, international normalised ratio and albumin). Achieving these recompensation criteria is linked to a significant survival benefit. However, apart from aetiological therapies, no interventions/treatments that facilitate recompensation are available, the molecular mechanisms underlying recompensation remain incompletely understood, and early predictors of recompensation are lacking. Moreover, current recompensation criteria are based on expert opinion and may be refined in the future. Herein, we review the available evidence on cirrhosis recompensation, provide guidance on the clinical management of recompensated patients and discuss future challenges related to cirrhosis recompensation.
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Affiliation(s)
- Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine – DIMED, University and Hospital of Padova, Italy
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna Austria
| | - Jaime Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
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5
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Fernández J, Blasi A, Hidalgo E, Karvellas CJ. Bridging the critically ill patient with acute to chronic liver failure to liver transplantation. Am J Transplant 2024; 24:1348-1361. [PMID: 38548058 DOI: 10.1016/j.ajt.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 04/14/2024]
Abstract
Liver transplantation (LT) has emerged as an effective therapy for severe forms of acute-on-chronic liver failure (ACLF), an entity characterized by the development of multiorgan failure and high short-term mortality. The aim of critical care management of ACLF patients is to rapidly treat precipitating events and aggressively support failing organs to ensure that patients may successfully undergo LT or, less frequently, recover. Malnutrition and sarcopenia are frequently present, adversely impacting the prognosis of these patients. Management of critical care patients with ACLF is complex and requires the participation of different specialties. Once the patient is stabilized, a rapid evaluation for salvage LT should be performed because the time window for LT is often narrow. The development of sepsis and prolonged organ support may preclude LT or diminish its chances of success. The current review describes strategies to bridge severe ACLF patients to LT, highlights the minimal evaluation required for listing and the currently suggested contraindications to proceed with LT, and addresses different aspects of management during the perioperative and early posttransplant period.
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Affiliation(s)
- Javier Fernández
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain; EF Clif, EASL-CLIF Consortium, Barcelona, Spain.
| | - Annabel Blasi
- Anesthesiology Department, Hospital Clínic, and University of Barcelona, Spain
| | - Ernest Hidalgo
- Hepatolobiliary Surgery Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Constantine J Karvellas
- Department of Critical Care Medicine, University of Alberta, Edmonton, Canada; Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
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6
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Ebada HE, Montasser MF, Abdelghaffar MF, Bahaa MM, Elbaset HSA, Sakr MA, Dabbous HM, Montasser IF, Hassan MS, Aboelmaaty ME, Elmeteini MS. Ascites post-living donor liver transplantation: Risk factors and outcome. JOURNAL OF LIVER TRANSPLANTATION 2022; 8:100112. [DOI: 10.1016/j.liver.2022.100112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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7
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Shekhtman L, Navasa M, Sansone N, Crespo G, Subramanya G, Chung TL, Cardozo-Ojeda EF, Pérez-Del-Pulgar S, Perelson AS, Cotler SJ, Forns X, Uprichard SL, Dahari H. Modeling hepatitis C virus kinetics during liver transplantation reveals the role of the liver in virus clearance. eLife 2021; 10:65297. [PMID: 34730511 PMCID: PMC8608386 DOI: 10.7554/elife.65297] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 11/01/2021] [Indexed: 12/15/2022] Open
Abstract
While the liver, specifically hepatocytes, are widely accepted as the main source of hepatitis C virus (HCV) production, the role of the liver/hepatocytes in clearance of circulating HCV remains unknown. Frequent HCV kinetic data were recorded and mathematically modeled from five liver transplant patients throughout the anhepatic (absence of liver) phase and for 4 hr post-reperfusion. During the anhepatic phase, HCV remained at pre-anhepatic levels (n = 3) or declined (n = 2) with t1/2~1 hr. Immediately post-reperfusion, virus declined in a biphasic manner in four patients consisting of a rapid decline (t1/2 = 5 min) followed by a slower decline (t1/2 = 67 min). Consistent with the majority of patients in the anhepatic phase, when we monitored HCV clearance at 37°C from culture medium in the absence/presence of chronically infected hepatoma cells that were inhibited from secreting HCV, the HCV t1/2 in cell culture was longer in the absence of chronically HCV-infected cells. The results suggest that the liver plays a major role in the clearance of circulating HCV and that hepatocytes may be involved.
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Affiliation(s)
- Louis Shekhtman
- The Program for Experimental & Theoretical Modeling, Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, United States.,Network Science Institute, Northeastern University, Boston, MA, United States
| | - Miquel Navasa
- Liver Unit, Hospital Clínic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Natasha Sansone
- The Program for Experimental & Theoretical Modeling, Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, United States.,Department of Microbiology & Immunology, University of Illinois Chicago, Chicago, IL, United States
| | - Gonzalo Crespo
- Liver Unit, Hospital Clínic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Gitanjali Subramanya
- The Program for Experimental & Theoretical Modeling, Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, United States
| | - Tje Lin Chung
- The Program for Experimental & Theoretical Modeling, Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, United States.,Institute for Biostatistics and Mathematical Modeling, Department of Medicine, Goethe Universität Frankfurt, Frankfurt, Germany
| | - E Fabian Cardozo-Ojeda
- The Program for Experimental & Theoretical Modeling, Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, United States.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Sofía Pérez-Del-Pulgar
- Liver Unit, Hospital Clínic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Alan S Perelson
- Theoretical Biology and Biophysics, Los Alamos National Laboratory, Los Alamos, NM, United States
| | - Scott J Cotler
- The Program for Experimental & Theoretical Modeling, Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, United States
| | - Xavier Forns
- Liver Unit, Hospital Clínic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Susan L Uprichard
- The Program for Experimental & Theoretical Modeling, Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, United States.,The Infectious Disease and Immunology Research Institute, Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, United States
| | - Harel Dahari
- The Program for Experimental & Theoretical Modeling, Division of Hepatology, Department of Medicine, Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, United States
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8
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Splenectomy with Portoazygous Disconnection for Correction of Systemic Hemodynamic Disorders in Hepatic Cirrhosis Patients with Portal Hypertension: A Prospective Single-Center Cohort Study. Can J Gastroenterol Hepatol 2020; 2020:8893119. [PMID: 33415086 PMCID: PMC7769657 DOI: 10.1155/2020/8893119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/21/2020] [Accepted: 12/08/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To investigate the effect of splenectomy for correction of systemic hemodynamic disorders in hepatic cirrhosis patients with portal hypertension. METHODS Hepatic cirrhosis patients with portal hypertension were enrolled from April 2015 to July 2018. Systemic hemodynamic parameters (heart rate, mean arterial pressure (MAP), cardiac output, and total peripheral vascular resistance (TPR)) were prospectively measured at baseline and 1 week, 1, 3, and 6 months, and 1, 2, and 3 years postoperatively. Paired analysis was conducted. RESULTS Sixty-nine patients were eligible, and 55 (79.7%) cases had a history of upper gastrointestinal bleeding. Child-Pugh classification was grade A in 41 (59.4%) cases, grade B in 26 (37.7%) cases, and grade C in 2 (2.9%) cases. The heart rate was significantly higher at 1 week postoperatively versus the baseline (P < 0.001). Meanwhile, the heart rate was significantly lower from 3 months to 2 years postoperatively versus the baseline (P < 0.05). The MAP was significantly higher at 6 months to 2 years postoperatively versus the baseline (P < 0.05). At 1 month postoperatively and 6 months to 2 years, the cardiac output was significantly lower versus the baseline (P < 0.05). At 1 month postoperatively and 6 months to 2 years, the TPR was significantly higher versus the baseline (P < 0.05). CONCLUSION Splenectomy corrects systemic hemodynamic disorder in hepatic cirrhosis patients with portal hypertension, and the effect is rapid and durable.
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9
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Chang WC, M Yeh B, Chu L, Kim SY, Wen KW, Chiu SH, Ding CKC, Wu EH, Roberts JP, Huang GS, Hsu HH. Post-operative assessment in patients after liver transplantation: imaging parameters associated with 1-year graft failure. Eur Radiol 2020; 31:764-774. [PMID: 32862291 DOI: 10.1007/s00330-020-07124-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/08/2020] [Accepted: 07/30/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To identify post-liver transplant CT findings which predict graft failure within 1 year. MATERIALS AND METHODS We evaluated the CT scans of 202 adult liver transplants performed in our institution who underwent CT within 3 months after transplantation. We recorded CT findings of liver perfusion defect (LPD), parenchymal homogeneity, and the diameters and attenuations of the hepatic vessels. Findings were correlated to 1-year graft failure, and interobserver variability was assessed. RESULTS Forty-one (20.3%) of the 202 liver grafts failed within 1 year. Graft failure was highly associated with LPD (n = 18/25, or 67%, versus 15/98, or 15%, p < 0.001), parenchymal hypoattenuation (n = 20/41, or 48.8% versus 17/161, or 10.6%, p < 0.001), and smaller diameter of portal veins (right portal vein [RPV], 10.7 ± 2.7 mm versus 14.7 ± 2.2 mm, and left portal vein [LPV], 9.8 ± 3.0 mm versus 12.4 ± 2.2 mm, p < 0.001, respectively). Of these findings, LPD (hazard ratio [HR], 5.43, p < 0.001) and small portal vein diameters (HR, RPV, 3.33, p < 0.001, and LPV, 3.13, p < 0.05) independently predicted graft failure. All the measurements showed fair to moderate interobserver agreement (0.233~0.597). CONCLUSION For patients who have CT scan within the first 3 months of liver transplantation, findings of LPD and small portal vein diameters predict 1-year graft failure. KEY POINTS •Failed grafts are highly associated with liver perfusion defect, hypoattenuation, and small portal vein. •Right portal vein < 11.5 mm and left portal vein < 10.0 mm were associated with poor graft outcome. •Liver perfusion defect and small portal vein diameter independently predicted graft failure.
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Affiliation(s)
- Wei-Chou Chang
- Department of Radiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan.
| | - Benjamin M Yeh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Lisa Chu
- Department of Radiology, Palo Alto Medical Foundation, Palo Alto, CA, USA
| | - So Yeon Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kwun Wah Wen
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Sung-Hua Chiu
- Department of Radiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
| | | | - En-Haw Wu
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - John P Roberts
- Division of Transplant Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Guo-Shu Huang
- Department of Radiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
| | - Hsian-He Hsu
- Department of Radiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
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10
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Trivedi PS, Brown MA, Rochon PJ, Ryu RK, Johnson DT. Gender Disparity in Inpatient Mortality After Transjugular Intrahepatic Portosystemic Shunt Creation in Patients Admitted With Hepatorenal Syndrome: A Nationwide Study. J Am Coll Radiol 2020; 17:231-237. [DOI: 10.1016/j.jacr.2019.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/19/2019] [Accepted: 08/21/2019] [Indexed: 12/30/2022]
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Liver Transplantation. THE CRITICALLY ILL CIRRHOTIC PATIENT 2020. [PMCID: PMC7122092 DOI: 10.1007/978-3-030-24490-3_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The field of liver transplantation has changed since the MELD scoring system became the most widely used donor allocation tool. Due to the MELD-based allocation system, sicker patients with higher MELD scores are being transplanted. Persistent organ donor shortages remain a challenging issue, and as a result, the wait-list mortality is a persistent problem for most of the regions. This chapter focuses on deceased donor and live donor liver transplantation in patients with complications of portal hypertension. Special attention will also be placed on donor-recipient matching, perioperative management of transplant patients, and the impact of hepatic hemodynamics on transplantation.
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12
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Feltracco P, Barbieri S, Carollo C, Bortolato A, Michieletto E, Bertacco A, Gringeri E, Cillo U. Early circulatory complications in liver transplant patients. Transplant Rev (Orlando) 2019; 33:219-230. [PMID: 31327573 DOI: 10.1016/j.trre.2019.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/28/2019] [Accepted: 06/30/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Paolo Feltracco
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy.
| | - Stefania Barbieri
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Cristiana Carollo
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Andrea Bortolato
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Elisa Michieletto
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Alessandra Bertacco
- Hepatobiliary Surgery and Liver Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
| | - Enrico Gringeri
- Hepatobiliary Surgery and Liver Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
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13
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Lam E, Bashir B, Chaballa M, Kraft WK. Drug interactions between direct-acting oral anticoagulants and calcineurin inhibitors during solid organ transplantation: considerations for therapy. Expert Rev Clin Pharmacol 2019; 12:781-790. [PMID: 31242782 DOI: 10.1080/17512433.2019.1637733] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Introduction: There is a high incidence of venous thromboembolism (VTE) in solid organ transplant recipients. The safety and efficacy of direct-acting oral anticoagulants (DOAC) have been well established in clinical practice for the prevention and treatment of VTE in broad populations. However, the management of VTE in the setting of solid organ transplantation remains a challenge to clinicians due to limited evidence of DOAC usage with calcineurin inhibitors. Areas covered: The current literature available on the pharmacokinetic-pharmacodynamic interaction between DOACs and calcineurin inhibitors is presented. A comprehensive review was undertaken using PubMed, Embase, drug product labeling, and drug product review conducted by the US Food and Drug Administration using Drugs@FDA. The potential for mitigation strategies and clinical management using extant knowledge is explored. Expert opinion: Immunosuppression therapy is necessary to prevent graft rejection by the host. The sparsity of data together with the lack of well-designed prospective studies of DOAC use in solid organ transplant recipients presents a unique challenge to clinicians in determining the clinical relevance of possible drug interactions. Existing evidence suggests that with attention to concomitant drug use and renal function, the co-administration of DOACs and calcineurin inhibitors is safe and effective.
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Affiliation(s)
- Edwin Lam
- a Department of Pharmacology & Experimental Therapeutics, Thomas Jefferson University , Philadelphia , PA , USA
| | - Babar Bashir
- b Department of Medical Oncology, Thomas Jefferson University Hospital , Philadelphia , PA , USA
| | - Mark Chaballa
- c Department of Pharmacy, Thomas Jefferson University Hospital , Philadelphia , PA , USA
| | - Walter K Kraft
- a Department of Pharmacology & Experimental Therapeutics, Thomas Jefferson University , Philadelphia , PA , USA
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Hessheimer AJ, Martínez de la Maza L, Adel Al Shwely F, Espinoza AS, Ausania F, Fondevila C. Somatostatin and the "Small-For-Size" Liver. Int J Mol Sci 2019; 20:2512. [PMID: 31121844 PMCID: PMC6566601 DOI: 10.3390/ijms20102512] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 05/07/2019] [Accepted: 05/14/2019] [Indexed: 02/07/2023] Open
Abstract
"Small-for-size" livers arising in the context of liver resection and transplantation are vulnerable to the effects of increased portal flow in the immediate postoperative period. Increased portal flow is an essential stimulus for liver regeneration. If the rise in flow and stimulus for regeneration are excessive; however, liver failure and patient death may result. Somatostatin is an endogenous peptide hormone that may be administered exogenously to not only reduce portal blood flow but also offer direct protection to different cells in the liver. In this review article, we describe key changes that transpire in the liver following a relative size reduction occurring in the context of resection and transplantation and the largely beneficial effects that peri-operative somatostatin therapy may help achieve in this setting.
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Affiliation(s)
- Amelia J Hessheimer
- Hepatopancreatobiliary Surgery and Transplantation, General & Digestive Surgery, Metabolic & Digestive Diseases Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain.
| | - Lilia Martínez de la Maza
- Hepatopancreatobiliary Surgery and Transplantation, General & Digestive Surgery, Metabolic & Digestive Diseases Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain.
| | - Farah Adel Al Shwely
- Hepatopancreatobiliary Surgery and Transplantation, General & Digestive Surgery, Metabolic & Digestive Diseases Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain.
| | - Arlena Sofía Espinoza
- Hepatopancreatobiliary Surgery and Transplantation, General & Digestive Surgery, Metabolic & Digestive Diseases Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain.
| | - Fabio Ausania
- Hepatopancreatobiliary Surgery and Transplantation, General & Digestive Surgery, Metabolic & Digestive Diseases Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain.
| | - Constantino Fondevila
- Hepatopancreatobiliary Surgery and Transplantation, General & Digestive Surgery, Metabolic & Digestive Diseases Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain.
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Activation of the Alternate Renin-Angiotensin System Correlates with the Clinical Status in Human Cirrhosis and Corrects Post Liver Transplantation. J Clin Med 2019; 8:jcm8040419. [PMID: 30934723 PMCID: PMC6518205 DOI: 10.3390/jcm8040419] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 03/16/2019] [Accepted: 03/21/2019] [Indexed: 12/11/2022] Open
Abstract
Introduction: Recent animal studies have shown that the alternate renin-angiotensin system (RAS) consisting of angiotensin-converting enzyme 2 (ACE2), angiotensin-(1–7) (Ang-(1–7)) and the Mas receptor is upregulated in cirrhosis and contributes to splanchnic vasodilatation and portal hypertension. To determine the potential relevance of these findings to human liver disease, we evaluated its expression and relationship to the patients’ clinical status in subjects with cirrhosis. Methods: Blood sampling from peripheral and central vascular beds was performed intra-operatively for cirrhotic patients at the time of liver transplantation (LT) or trans-jugular intra-hepatic portosystemic shunt (TIPS) procedures to measure angiotensin II (Ang II) and Ang-(1–7) peptide levels and ACE and ACE2 enzyme activity. Relevant clinical and hemodynamic data were recorded pre-operatively for all subjects and peripheral blood sampling was repeated 3 months or later post-operatively. Results: Ang-(1–-7) and ACE2 activity were up-regulated more than twofold in cirrhotic subjects both at the time of LT and TIPS and levels returned to comparable levels as control subjects post-transplantation. Ang-(1–7) levels correlated positively with the degree of liver disease severity, as measured by the model for an end-stage liver disease (MELD) and also with clinical parameters of pathological vasodilatation including cardiac output (CO). There were strong correlations found between the ACE2:ACE and the Ang-(1–7):Ang II ratio highlighting the inter-dependence of the alternate and classical arms of the RAS and thus their potential impact on vascular tone. Conclusions: In human cirrhosis, the alternate RAS is markedly upregulated and the activation of this system is associated strongly with features of the hyperdynamic circulation in advanced human cirrhosis.
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Patterns of splenic arterial enhancement on computed tomography are related to changes in portal venous pressure. Eur J Gastroenterol Hepatol 2019; 31:352-356. [PMID: 30334908 DOI: 10.1097/meg.0000000000001286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES One of the striking features of splenic imaging is variable heterogeneous gyriform arterial enhancement on dynamic computed tomography (CT). We speculated that these patterns of arterial enhancement may reflect changes in splenic micro-circulation related to changes in portal venous pressure. PATIENTS AND METHODS To test this hypothesis, we evaluated arterial phase CT scans performed before and after liver transplantation (n=91), as this is the most effective way of alleviating portal hypertension. We developed novel grading systems to assess heterogeneity. Two control groups were used: patients with cirrhosis undergoing transarterial chemoembolization (TACE) (n=28) and patients with cirrhosis on the liver transplant waiting list who had repeated CT scans (n=28). RESULTS Splenic arterial heterogeneity increased in 55% of transplant patients compared with 14% in the TACE patients and 4% in the waiting list patients (P<0.0001). Mean Hounsfield units in areas of splenic enhancement were 71.7±2 before transplant and 90.1±2.5 after transplant (P<0.01). In contrast, there were no significant changes following TACE (86.3±4.2 vs. 83.5±4.5; P=NS) or in waiting list patients (80.9±4.6 vs. 73.8±3.7; P=NS). CONCLUSION We have shown the heterogeneous gyriform enhancement patterns significantly increase following liver transplantation but not after TACE or in waiting list patients. We suggest that these changes are due to the reduction in portal venous pressure and likely reflect changes in splenic micro-circulation. These changes may be important in the pathophysiology of hypersplenism.
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Incidence and Risk Factors of Intracranial Hemorrhage in Liver Transplant Recipients. Transplantation 2018; 102:448-453. [PMID: 29189631 DOI: 10.1097/tp.0000000000002005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Intracranial hemorrhage after liver transplantation is an infrequently reported complication but one which can have devastating consequences. METHODS We performed a retrospective cross-sectional analysis of all liver transplants performed between January 2010 and June 2015 at a single high-volume institution using a prospectively maintained electronic database and query of the electronic medical record. Cases of intracranial hemorrhage were adjudicated as either spontaneous intraparenchymal hemorrhage(IPH) or extra-axial hemorrhage (EAH). Patients with confirmed intracranial hemorrhage were compared with all other liver transplant recipients. Risk factors were identified by univariate analysis and logistic regression models for IPH and EAH. RESULTS Thirty-one (5.2%) of 595 liver transplant recipients developed an intracranial hemorrhage within 12 months of transplantation, 15 IPH and 16 EAH. The majority of intracranial hemorrhages were diagnosed within 1 month of transplantation. Eight (26%) intracranial hemorrhage patients died during hospitalization. Fourteen (45%) intracranial hemorrhage patients died within 1 year of transplantation and 1-year mortality was greater than in patients without intracranial hemorrhage (11.2%, P < 0.01). Female sex (adjusted odds ratio [OR], 3.291; 95% confidence interval [CI], 1.092-9.924; P = 0.034), higher pretransplant bilirubin (adjusted OR, 1.037; 95% CI, 1.006-1.070; P = 0.020), and greater increase in pretransplant to posttransplant systolic blood pressure (adjusted OR, 1.029; 95% CI, 1.006-1.052; P = 0.012) were associated with posttransplant IPH. Lower pretransplant serum fibrinogen level (adjusted OR, 0.988; 95% CI, 0.979-0.998; P = 0.017) was associated with posttransplant EAH. CONCLUSIONS Postoperative blood pressure control and pretransplant fibrinogen levels may be modifiable risk factors for preventing posttransplant intracranial hemorrhage.
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18
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Cirrhosis regression: extrahepatic angiogenesis and liver hyperarterialization persist. Clin Sci (Lond) 2018; 132:1341-1343. [PMID: 29954952 DOI: 10.1042/cs20180129] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 05/19/2018] [Accepted: 05/22/2018] [Indexed: 12/21/2022]
Abstract
Data on the consequences of cirrhosis regression on portal hypertension and on splanchnic and systemic hemodynamic are scarce. Previous studies have reported a decrease in hepatic venous pressure gradient following antiviral treatment in patients with hepatitis B or C related cirrhosis. However, these studies did not investigate splanchnic and systemic hemodynamic changes associated with virus control. To fill this gap in knowledge, in a recent issue of Clinical Science, Hsu et al. (vol. 132, issue 6, 669-683) used rat models of cirrhosis induced by thioacetamide and by bile duct ligation and provided a comprehensive analysis of the effects of cirrhosis regression on splanchnic and systemic hemodynamics. They observed a significant reduction in portal pressure accompanied by a normalization of systemic hemodynamic (normal cardiac index and systemic vascular resistance) and a decrease in intrahepatic vascular resistance. No change in extrahepatic vascular structures were observed despite normalization of collateral shunting, meaning that portosystemic collaterals persist but are not perfused. One intriguing part of their results is the only marginal effect of cirrhosis regression on liver hyperarterialisation. This result suggests that changes in splanchnic hemodynamic features induced by cirrhosis remain when hepatic vascular resistance decreases, raising the hypothesis of an autonomous mechanism persisting despite regression of intrahepatic vascular resistance. Microbiota changes and bacterial translocation might account for this effect. In conclusion cirrhosis regression normalizes systemic hemodynamics, but some splanchnic hemodynamic changes persist including extrahepatic angiogenesis and liver hyperarterialization.
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19
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Shimazu M, Kato Y, Kawachi S, Tanabe M, Hoshino K, Wakabayashi G, Kitagawa Y, Kitajima M. Impact of Portal Hemodynamic Changes in Partial Liver Grafts on Short-Term Graft Regeneration in Living Donor Liver Transplantation. Transplant Proc 2017; 48:2747-2755. [PMID: 27788812 DOI: 10.1016/j.transproceed.2016.06.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 05/20/2016] [Accepted: 06/22/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Regeneration of partial liver grafts is critical for successful living donor liver transplantation (LDLT), especially in adult recipients. The purpose of this study was to investigate the intraoperative hemodynamic changes in partial liver grafts and characterize their potential impact on post-transplant liver regeneration in LDLT. METHODS We examined the portal venous flow (PVF) and hepatic arterial flow (HAF) to partial liver grafts by means of ultrasonic transit time flowmeter of donors immediately before graft retrieval and of the corresponding recipients after vascular reconstruction in 48 LDLT cases. We evaluated post-transplant liver regeneration according to the changes in graft liver volume between the time of transplantation and the 7th post-transplant day. RESULTS There was a significant increase in PVF to the partial liver grafts in recipients (rPVF) compared with that in donors. In contrast, graft HAF in recipients significantly decreased compared with that in donors. The rPVF inversely correlated with graft weight (GW)-recipient body weight ratio (GRWR), whereas HAF volume showed no significant correlation. The rPVF/GW positively correlated with the rate of liver regeneration (GRR), which inversely correlated with GRWR. The rPVF/GW was significantly higher, and GRR tended to be larger in the small graft group than in the non-small graft group. CONCLUSIONS Intraoperative portal hemodynamic changes in partial liver grafts strongly affect their post-transplant regeneration. In particular, in small liver grafts, an immediate and remarkable increase in graft PVF may contribute to rapid liver regeneration after LDLT if the increased PVF remains within a safe range.
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Affiliation(s)
- M Shimazu
- Department of Surgery, School of Medicine, Keio University, Tokyo, Japan; Department of Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan.
| | - Y Kato
- Department of Surgery, Fujita Health University, Aichi, Japan
| | - S Kawachi
- Department of Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - M Tanabe
- Department of Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - K Hoshino
- Department of Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - G Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Y Kitagawa
- Department of Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - M Kitajima
- International University of Health and Welfare, Tokyo, Japan
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20
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Troisi RI, Berardi G, Tomassini F, Sainz-Barriga M. Graft inflow modulation in adult-to-adult living donor liver transplantation: A systematic review. Transplant Rev (Orlando) 2017; 31:127-135. [PMID: 27989547 DOI: 10.1016/j.trre.2016.11.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 11/29/2016] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Small-for-size syndrome (SFSS) has an incidence between 0 and 43% in small-for-size graft (SFSG) adult living donor liver transplantation (LDLT). Portal hypertension following reperfusion and the hyperdynamic splanchnic state are reported as the major triggering factors of SFSS. Intra- and postoperative strategies to prevent or to reduce its onset are still under debate. We analyzed graft inflow modulation (GIM) during adult LDLT considering the indications, efficacy of the available techniques, changes in hemodynamics and outcomes. MATERIALS AND METHODS A systematic literature search was performed using PubMed, EMBASE, Scopus and the Cochrane Library Central. Treatment outcomes including in-hospital mortality and morbidity, re-transplantation rate, 1-, 3-, and 5-year patient overall survival and 1-, 3-, and 5-year graft survival rates, hepatic artery and portal vein flows and pressures before and after inflow modulation were analyzed. RESULTS From 563 articles, 12 studies dated between 2003 and 2014 fulfilled the selection criteria and were therefore included in the study. These comprised a total of 449 adult patients who underwent inflow modulation during adult-to-adult LDLT. Types of GIM described were splenic artery ligation, splenectomy, meso-caval shunt, spleno-renal shunt, portocaval shunt, and splenic artery embolization. Mortality and morbidity ranged between 0 and 33% and 17% and 70%, respectively. Re-transplantation rates ranged between 0% and 25%. GIM was associated with good survival for both graft and recipients, reaching an 84% actuarial rate at 5 years. Through the use of GIM, irrespective of the technique, a statistically significant reduction of PVF and PVP was obtained. CONCLUSIONS GIM is a safe and efficient technique to avoid or limit portal hyperperfusion, especially in cases of SFSG, decreasing overall morbidity and improving outcomes.
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Affiliation(s)
- Roberto I Troisi
- Deparment of General, Hepatobiliary and Liver Transplantation Surgery, UZ Ghent, Ghent, Belgium.
| | - Giammauro Berardi
- Deparment of General, Hepatobiliary and Liver Transplantation Surgery, UZ Ghent, Ghent, Belgium
| | - Federico Tomassini
- Deparment of General, Hepatobiliary and Liver Transplantation Surgery, UZ Ghent, Ghent, Belgium
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21
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Gifford FJ, Morling JR, Fallowfield JA. Systematic review with meta-analysis: vasoactive drugs for the treatment of hepatorenal syndrome type 1. Aliment Pharmacol Ther 2017; 45:593-603. [PMID: 28052382 DOI: 10.1111/apt.13912] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 11/13/2016] [Accepted: 12/02/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatorenal syndrome type 1 (HRS1) is a functional, rapidly progressive, potentially reversible form of acute kidney injury occurring in patients with cirrhosis. Characterised by intense renal arterial vasoconstriction, it carries a very poor prognosis. There is a significant unmet need for a widely approved, safe and effective pharmacological treatment. AIM To re-evaluate efficacy and safety of pharmacological treatments for HRS1, in the light of recently published randomised controlled trials (RCTs). METHODS MEDLINE (OvidSP), EMBASE, PubMed and Cochrane registers were searched for RCTs reporting efficacy and adverse events related to pharmacological treatment of HRS1. Search terms included: 'hepatorenal syndrome', 'terlipressin', 'noradrenaline', 'octreotide', 'midodrine', 'vasopressin', 'dopamine', 'albumin' and synonyms. Comparison of vasoactive drugs vs. placebo/no treatment, and two active drugs were included. Meta-analysis was performed for HRS1 reversal, creatinine improvement, mortality and adverse events. RESULTS Twelve RCTs enrolling 700 HRS1 patients were included. Treatment with terlipressin and albumin led to HRS1 reversal more frequently than albumin alone or placebo (RR: 2.54, 95% CI: 1.51-4.26). Noradrenaline was effective in reversing HRS1, but trials were small and nonblinded. Overall, there was mortality benefit with terlipressin (RR: 0.79, 95% CI: 0.63-1.01), but sensitivity analysis including only trials with low risk of selection bias weakened this relationship (RR: 0.87, 95% CI: 0.71-1.06). Notably, there was a significant risk of adverse events with terlipressin therapy (RR: 4.32, 95% CI: 0.75-24.86). CONCLUSIONS Terlipressin treatment is superior to placebo for achieving HRS1 reversal, but mortality benefit is less clear. Terlipressin is associated with significant adverse events, but infusion regimens may be better tolerated. There is continued need for safe and effective treatment options for hepatorenal syndrome.
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Affiliation(s)
- F J Gifford
- Department of Hepatology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - J R Morling
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - J A Fallowfield
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
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22
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Hogan BJ, Gonsalkorala E, Heneghan MA. Evaluation of coronary artery disease in potential liver transplant recipients. Liver Transpl 2017; 23:386-395. [PMID: 27875636 DOI: 10.1002/lt.24679] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 11/08/2016] [Indexed: 12/12/2022]
Abstract
Improvements in the management of patients undergoing liver transplantation (LT) have resulted in a significant increase in survival in recent years. Cardiac disease is now the leading cause of early mortality, and the stress of major surgery, hemodynamic shifts, and the possibilities of hemorrhage or reperfusion syndrome require the recipient to have good baseline cardiac function. The prevalence of coronary artery disease (CAD) is increasing in LT candidates, especially in those with nonalcoholic fatty liver disease. In assessing LT recipients, we suggest a management paradigm of "quadruple assessment" to include (1) history, examination, and electrocardiogram; (2) transthoracic echocardiogram; (3) functional testing; and (4) where appropriate, direct assessment of CAD. The added value of functional testing, such as cardiopulmonary exercise testing, has been shown to be able to predict posttransplant complications independently of the presence of CV disease. This approach gives the assessment team the greatest chance of detecting and preventing complications related to CAD. Liver Transplantation 23 386-395 2017 AASLD.
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Affiliation(s)
- Brian J Hogan
- Institute of Liver Studies, King's College Hospital, National Health Service Foundation Trust, London, UK
| | - Enoka Gonsalkorala
- Institute of Liver Studies, King's College Hospital, National Health Service Foundation Trust, London, UK
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, National Health Service Foundation Trust, London, UK
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23
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Goldaracena N, Echeverri J, Selzner M. Small-for-size syndrome in live donor liver transplantation-Pathways of injury and therapeutic strategies. Clin Transplant 2017; 31. [PMID: 27935645 DOI: 10.1111/ctr.12885] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2016] [Indexed: 12/14/2022]
Abstract
Due to the severe organ shortage and the increasing gap between the supply and demand for donor grafts, live donor liver transplantation (LDLT) has become an accepted and alternative technique for the expansion of the donor pool. However, donor safety and good recipient outcomes must be balanced regarding risk stratification and decision-making within this patient population. Small-for-size syndrome (SFSS) is one of the complications encountered after LDLT, thus increasing the burden of optimizing donor graft selection and effective treatments during its occurrence. A graft-to-recipient weight ratio (GRWR) <0.8 predisposes the graft to SFSS. However, other factors may induce this complication even without a graft-to-patient size mismatch. Several strategies to prevent this complication include portal vein flow and liver outflow modulation, as well as pharmacological treatment. Also, as an entity with a multifactorial etiology, outcomes vary between right-lobe, left-lobe, and posterior-lobe donation among series encountered in the literature. In this review, we analyze the pathophysiology and classification of this complication, the state-of-the-art on management of SFSS, and the outcomes regarding the best treatment strategy on this patient population.
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Affiliation(s)
- Nicolas Goldaracena
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Juan Echeverri
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Markus Selzner
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
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Hori T, Ogura Y, Onishi Y, Kamei H, Kurata N, Kainuma M, Takahashi H, Suzuki S, Ichikawa T, Mizuno S, Aoyama T, Ishida Y, Hirai T, Hayashi T, Hasegawa K, Takeichi H, Ota A, Kodera Y, Sugimoto H, Iida T, Yagi S, Taniguchi K, Uemoto S. Systemic hemodynamics in advanced cirrhosis: Concerns during perioperative period of liver transplantation. World J Hepatol 2016; 8:1047-1060. [PMID: 27660671 PMCID: PMC5026996 DOI: 10.4254/wjh.v8.i25.1047] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 05/16/2016] [Accepted: 07/14/2016] [Indexed: 02/06/2023] Open
Abstract
Advanced liver cirrhosis is usually accompanied by portal hypertension. Long-term portal hypertension results in various vascular alterations. The systemic hemodynamic state in patients with cirrhosis is termed a hyperdynamic state. This peculiar hemodynamic state is characterized by an expanded blood volume, high cardiac output, and low total peripheral resistance. Vascular alterations do not disappear even long after liver transplantation (LT), and recipients with cirrhosis exhibit a persistent systemic hyperdynamic state even after LT. Stability of optimal systemic hemodynamics is indispensable for adequate portal venous flow (PVF) and successful LT, and reliable parameters for optimal systemic hemodynamics and adequate PVF are required. Even a subtle disorder in systemic hemodynamics is precisely indicated by the balance between cardiac output and blood volume. The indocyanine green (ICG) kinetics reflect the patient's functional hepatocytes and effective PVF, and PVF is a major determinant of the ICG elimination constant (kICG) in the well-preserved allograft. The kICG value is useful to set the optimal PVF during living-donor LT and to evaluate adequate PVF after LT. Perioperative management has a large influence on the postoperative course and outcome; therefore, key points and unexpected pitfalls for intensive management are herein summarized. Transplant physicians should fully understand the peculiar systemic hemodynamic behavior in LT recipients with cirrhosis and recognize the critical importance of PVF after LT.
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Affiliation(s)
- Tomohide Hori
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Yasuhiro Ogura
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Yasuharu Onishi
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Hideya Kamei
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Nobuhiko Kurata
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Motoshi Kainuma
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Hideo Takahashi
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Shogo Suzuki
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Takashi Ichikawa
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Shoko Mizuno
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Tadashi Aoyama
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Yuki Ishida
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Takahiro Hirai
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Tomoko Hayashi
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Kazuko Hasegawa
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Hiromu Takeichi
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Atsunobu Ota
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Yasuhiro Kodera
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Hiroyuki Sugimoto
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Taku Iida
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Shintaro Yagi
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Kentaro Taniguchi
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
| | - Shinji Uemoto
- Tomohide Hori, Yasuhiro Ogura, Yasuharu Onishi, Hideya Kamei, Nobuhiko Kurata, Department of Transplant Surgery, Nagoya University Hospital, Nagoya 466-8550, Japan
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Baraldi O, Valentini C, Donati G, Comai G, Cuna V, Capelli I, Angelini ML, Moretti MI, Angeletti A, Piscaglia F, Manna GL. Hepatorenal syndrome: Update on diagnosis and treatment. World J Nephrol 2015; 4:511-520. [PMID: 26558188 PMCID: PMC4635371 DOI: 10.5527/wjn.v4.i5.511] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 08/13/2015] [Accepted: 09/18/2015] [Indexed: 02/06/2023] Open
Abstract
Acute kidney injury (AKI) is a common complication in patients with end-stage liver disease and advanced cirrhosis regardless of the underlying cause. Hepatorenal syndrome (HRS), a functional form of kidney failure, is one of the many possible causes of AKI. HRS is potentially reversible but involves highly complex pathogenetic mechanisms and equally complex clinical and therapeutic management. Once HRS has developed, it has a very poor prognosis. This review focuses on the diagnostic approach to HRS and discusses the therapeutic protocols currently adopted in clinical practice.
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Zardi EM, Zardi DM, Chin D, Sonnino C, Dobrina A, Abbate A. Cirrhotic cardiomyopathy in the pre- and post-liver transplantation phase. J Cardiol 2015; 67:125-30. [PMID: 26074443 DOI: 10.1016/j.jjcc.2015.04.016] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 03/24/2015] [Accepted: 04/16/2015] [Indexed: 12/23/2022]
Abstract
Patients with advanced liver cirrhosis may develop a clinical syndrome characterized by a blunted contractile responsiveness to stress and/or altered diastolic relaxation, called "cirrhotic cardiomyopathy." This syndrome, which is initially asymptomatic, is often misdiagnosed due to the presence of symptoms that characterize other disorders present in patients with advanced liver cirrhosis, such as exercise intolerance, fatigue, and dyspnea. Stress and other conditions such as liver transplantation and transjugular intrahepatic portosystemic shunt (TIPS) may unmask this syndrome. Liver transplantation in this group of patients results in a clinical improvement and can be a cure for the cardiomyopathy. However, post-transplant prognosis depends on the identification of cirrhotics with cardiomyopathy in the pre-transplant phase; an early diagnosis of cirrhotic cardiomyopathy in the pre-transplant phase may avoid an acute onset or worsening of cardiac failure after liver transplantation. Since a preserved left ventricular ejection fraction may mask the presence of cirrhotic cardiomyopathy, the use of newer noninvasive diagnostic techniques (i.e. tissue Doppler, myocardial strain) is necessary to identify cirrhotics with this syndrome, in the pre-transplant phase. A pre-transplant treatment of heart failure in cirrhotics with cardiomyopathy improves the quality of life in this phase and reduces the complications during and immediately after liver transplantation. Since specific therapies for cirrhotic cardiomyopathy are lacking, due to the absence of a clear understanding of the pathophysiology of the cardiomyopathy, further research in this field is required.
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Affiliation(s)
- Enrico Maria Zardi
- Department of Clinical Medicine, University Campus Bio-Medico, Rome, Italy.
| | - Domenico Maria Zardi
- Department of Cardiology, II School of Medicine, University La Sapienza, Ospedale Sant'Andrea, Rome, Italy
| | - Diana Chin
- Department of Cardiology, II School of Medicine, University La Sapienza, Ospedale Sant'Andrea, Rome, Italy
| | - Chiara Sonnino
- Virginia Commonwealth University-VCU Pauley Heart Center, Richmond, VA, USA
| | - Aldo Dobrina
- Department of Physiology and Pathology, University of Trieste, Trieste, Italy
| | - Antonio Abbate
- Virginia Commonwealth University-VCU Pauley Heart Center, Richmond, VA, USA
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DuBrock HM, Bankier AA, Silva M, Litmanovich DE, Curry MP, Washko GR. Pulmonary Vessel Cross-sectional Area before and after Liver Transplantation: Quantification with Computed Tomography. Acad Radiol 2015; 22:752-9. [PMID: 25770631 DOI: 10.1016/j.acra.2015.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 01/23/2015] [Accepted: 01/25/2015] [Indexed: 10/23/2022]
Abstract
RATIONALE AND OBJECTIVES Pulmonary vascular complications of liver disease have a substantial impact on morbidity and mortality in patients who undergo liver transplant. The effect of liver transplantation on the pulmonary vasculature in patients without pulmonary vascular disease, however, has not been described. This study was undertaken to characterize the regional effect of liver transplant on the cross-sectional area (CSA) of pulmonary vessels. MATERIALS AND METHODS We performed a single-center, retrospective, cohort study of patients who had a liver transplant between 2002 and 2012 and who had chest computed tomography scans within 1 year before and after transplant. Using ImageJ software, we measured the CSA of small pulmonary vessels (0-5 mm(2)) and the total lung CSA to calculate the percent CSA of pulmonary vessels <5 mm (%CSA<5) at the level of the aortic arch, carina, and right inferior pulmonary vein (RIPV). Pretransplant and posttransplant, %CSA<5 were compared, and associations of pretransplant %CSA<5 with clinical parameters were measured. RESULTS There was a significant decrease in %CSA<5 at the level of the RIPV (0.19% [interquartile range {IQR}, 0.15-0.26] before vs. 0.15% [IQR, 0.12-0.21] after; P = .0003), with a median change of -16.2% (IQR, -39.3 to 3.9) posttransplant. Changes at the level of the aortic arch and carina were not significant. Pretransplant RIPV %CSA<5 was not significantly correlated with severity of liver disease or oxygenation but was inversely correlated with percent change in %CSA<5 (r = -0.39; P = .0039). CONCLUSIONS This is the first study to describe a significant regional change in the pulmonary vessels of patients without known pulmonary vascular disease who undergo liver transplant.
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Karagiannakis DS, Papatheodoridis G, Vlachogiannakos J. Recent advances in cirrhotic cardiomyopathy. Dig Dis Sci 2015; 60:1141-1151. [PMID: 25404411 DOI: 10.1007/s10620-014-3432-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 11/08/2014] [Indexed: 12/15/2022]
Abstract
Cirrhotic cardiomyopathy, a cardiac dysfunction presented in patients with cirrhosis, represents a recently recognized clinical entity. It is characterized by altered diastolic relaxation, impaired contractility, and electrophysiological abnormalities, in particular prolongation of the QT interval. Several mechanisms seem to be involved in the pathogenesis of cirrhotic cardiomyopathy, including impaired function of beta-receptors, altered transmembrane currents, and overproduction of cardiodepressant factors, like nitric oxide, tumor necrosis factor α, and endogenous cannabinoids. Diastolic dysfunction is the first manifestation of cirrhotic cardiomyopathy and reflects the increased stiffness of the cardiac mass, which leads to delayed left ventricular filling. On the other hand, systolic incompetence is presented later, is usually unmasked during pharmacological or physical stress, and predisposes to the development of hepatorenal syndrome. The prolongation of QT is found in about 50 % of cirrhotic patients, but rarely leads to fatal arrhythmias. Cirrhotics with blunted cardiac function seem to have poorer survival rates compared to those without, and the risk is particularly increased during the insertion of transjugular intrahepatic portosystemic shunt or liver transplantation. Till now, there is no specific treatment for the management of cirrhotic cardiomyopathy. New agents, targeting to its pathogenetical mechanisms, may play some role as future therapeutic options.
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Affiliation(s)
- Dimitrios S Karagiannakis
- Department of Gastroenterology, Medical School of Athens University, Laiko General Hospital, 17 Agiou Thoma Street, 11527, Athens, Greece,
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Bargehr J, Trejo-Gutierrez JF, Patel T, Rosser B, Aranda-Michel J, Yataco ML, Taner CB. Preexisting atrial fibrillation and cardiac complications after liver transplantation. Liver Transpl 2015; 21:314-20. [PMID: 25488693 DOI: 10.1002/lt.24060] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 10/14/2014] [Accepted: 11/23/2014] [Indexed: 12/12/2022]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia, and it is associated with increased cardiovascular morbidity and all-cause mortality. Our aim was to determine the impact of preexisting AF on patients undergoing liver transplantation (LT). A retrospective case-control study was performed. Records from patients who underwent LT between January 2005 and December 2008 at Mayo Clinic Florida were reviewed. Patients with preexisting AF were identified and matched to patients who did not have a diagnosis of AF. Thirty-two of 717 LT recipients (4.5%) had AF before LT. These patients were compared to a control group of 63 LT recipients. Pre-LT left ventricular hypertrophy (P = 0.03), a history of congestive heart failure (P = 0.04), and a history of stroke or transient ischemic attack (P = 0.03) were significantly more prevalent in patients with AF versus controls. Intraoperative adverse cardiac events (P = 0.02) and AF-related adverse postoperative events (P < 0.001) were more common in the recipients with known AF. Six patients with paroxysmal AF (19%) developed chronic/persistent AF postoperatively. Graft survival and patient survival were similar in the groups. Although patients with AF had a higher incidence of intraoperative cardiac events, a higher cardiovascular morbidity rate, and a complicated postoperative course, this did not affect overall graft and patient survival.
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Affiliation(s)
- Johannes Bargehr
- Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL; Division of Cardiovascular Diseases, Mayo Clinic Florida, Jacksonville, FL
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Nicolau-Raducu R, Gitman M, Ganier D, Loss GE, Cohen AJ, Patel H, Girgrah N, Sekar K, Nossaman B. Adverse cardiac events after orthotopic liver transplantation: a cross-sectional study in 389 consecutive patients. Liver Transpl 2015; 21:13-21. [PMID: 25213120 DOI: 10.1002/lt.23997] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 09/02/2014] [Accepted: 09/08/2014] [Indexed: 12/18/2022]
Abstract
Current American College of Cardiology/American Heart Association guidelines caution that preoperative noninvasive cardiac tests may have poor predictive value for detecting coronary artery disease in liver transplant candidates. The purpose of our study was to evaluate the role of clinical predictor variables for early and late cardiac morbidity and mortality and the predictive values of noninvasive cardiac tests for perioperative cardiac events in a high-risk liver transplant population. In all, 389 adult recipients were retrospectively analyzed for a median follow-up time of 3.4 years (range = 2.3-4.4 years). Overall survival was 83%. During the first year after transplantation, cardiovascular morbidity and mortality rates were 15.2% and 2.8%. In patients who survived the first year, cardiovascular morbidity and mortality rates were 3.9% and 2%, with cardiovascular etiology as the third leading cause of death. Dobutamine stress echocardiography (DSE) and single-photon emission computed tomography had respective sensitivities of 9% and 57%, specificities of 98% and 75%, positive predictive values of 33% and 28%, and negative predictive values of 89% and 91% for predicting early cardiac events. A rate blood pressure product less than 12,000 with DSE was associated with an increased risk for postoperative atrial fibrillation. Correspondence analysis identified a statistical association between nonalcoholic steatohepatitis/cryptogenic cirrhosis and postoperative myocardial ischemia. Logistic regression identified 3 risk factors for postoperative acute coronary syndrome: age, history of coronary artery disease, and pretransplant requirement for vasopressors. Multivariable analysis showed statistical associations of the Model for End-Stage Liver Disease score and the development of acute kidney injury as risk factors for overall cardiac-related mortality. These findings may help in identifying high-risk patients and may lead to the development of better cardiac tests.
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Gassanov N, Caglayan E, Semmo N, Massenkeil G, Er F. Cirrhotic cardiomyopathy: A cardiologist’s perspective. World J Gastroenterol 2014; 20:15492-15498. [PMID: 25400434 PMCID: PMC4229515 DOI: 10.3748/wjg.v20.i42.15492] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 04/01/2014] [Accepted: 06/13/2014] [Indexed: 02/06/2023] Open
Abstract
Cardiac dysfunction is frequently observed in patients with cirrhosis, and has long been linked to the direct toxic effect of alcohol. Cirrhotic cardiomyopathy (CCM) has recently been identified as an entity regardless of the cirrhosis etiology. Increased cardiac output due to hyperdynamic circulation is a pathophysiological hallmark of the disease. The underlying mechanisms involved in pathogenesis of CCM are complex and involve various neurohumoral and cellular pathways, including the impaired β-receptor and calcium signaling, altered cardiomyocyte membrane physiology, elevated sympathetic nervous tone and increased activity of vasodilatory pathways predominantly through the actions of nitric oxide, carbon monoxide and endocannabinoids. The main clinical features of CCM include attenuated systolic contractility in response to physiologic or pharmacologic strain, diastolic dysfunction, electrical conductance abnormalities and chronotropic incompetence. Particularly the diastolic dysfunction with impaired ventricular relaxation and ventricular filling is a prominent feature of CCM. The underlying mechanism of diastolic dysfunction in cirrhosis is likely due to the increased myocardial wall stiffness caused by myocardial hypertrophy, fibrosis and subendothelial edema, subsequently resulting in high filling pressures of the left ventricle and atrium. Currently, no specific treatment exists for CCM. The liver transplantation is the only established effective therapy for patients with end-stage liver disease and associated cardiac failure. Liver transplantation has been shown to reverse systolic and diastolic dysfunction and the prolonged QT interval after transplantation. Here, we review the pathophysiological basis and clinical features of cirrhotic cardiomyopathy, and discuss currently available limited therapeutic options.
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33
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Early Graft Dysfunction in Living Donor Liver Transplantation and the Small for Size Syndrome. CURRENT TRANSPLANTATION REPORTS 2014; 1:43-52. [PMID: 27280080 DOI: 10.1007/s40472-013-0006-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
LDLT has arisen as a viable means to reduce waitlist mortality. However, its widespread embrace by the liver transplant community has been met with frustration centered on donor morbidity and small-for-size-syndrome. Focusing on the later entity, we describe the initial recognition of this early graft dysfunction, the theorized pathophysiology and solutions to remedy its emergence.
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Review of the surgical approach to prevent small-for-size syndrome in recipients after left lobe adult LDLT. Surg Today 2013; 44:1189-96. [PMID: 23904045 DOI: 10.1007/s00595-013-0658-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 05/13/2013] [Indexed: 02/06/2023]
Abstract
Left lobe liver grafts increase the donor safety in adult-to-adult living-donor liver transplantation (ALDLT). However, the left lobe graft provides about 30-50 % of the required liver volume to adult recipients, which is insufficient to sustain their metabolic demands, which can lead to small-for-size syndrome (SFSS). Transient portal hypertension and microcirculatory hemodynamic derangement, apart from outflow obstruction, during the first week after reperfusion are the critical events associated with small-for-size graft transplantation. The incidence of SFSS in left lobe ALDLT can be decreased by increasing the left lobe graft volume by effective utilization of the caudate lobe with preserved vascular supply, by modulating the portal pressure with splenectomy or a porto-systemic shunt or by hepatic venous outflow reconstruction to prevent the development of venous congestion. In this review, we discuss the pathophysiology of SFSS and the various surgical strategies that can be performed to prevent SFSS in an effort to enhance the donor safety during living-donor liver transplantation.
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Schepis F, Vukotic R, Berzigotti A, Carrión JA, Forns X, Abraldes JG, García-Valdecasas JC, Navasa M, García-Pagán JC, Bosch J. Hemodynamic response to propranolol in patients with recurrent hepatitis C virus-related cirrhosis after liver transplantation: a case-control study. Liver Transpl 2013; 19:450-6. [PMID: 23408436 DOI: 10.1002/lt.23614] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Accepted: 01/13/2013] [Indexed: 02/07/2023]
Abstract
Cirrhosis recurrence is frequent after orthotopic liver transplantation for hepatitis C virus (HCV). Because transplantation causes liver denervation, we hypothesized that the response to propranolol might differ in transplant patients versus nontransplant patients with cirrhosis and portal hypertension. Twenty-one patients with cirrhosis recurrence after orthotopic liver transplantation with portal hypertension were compared to 20 nontransplant patients with cirrhosis, HCV, and portal hypertension, and they were matched by sex, age, presence of varices, and Child-Pugh score. The patients underwent systemic and hepatic hemodynamic measurements at the baseline and 20 minutes after intravenous propranolol (0.15 mg/kg). At the baseline, the transplant patients with cirrhosis had a lower hepatic venous pressure gradient (HVPG) than the nontransplant patients with cirrhosis (14.8 ± 2.9 versus 17.3 ± 4.4 mm Hg, P = 0.03) but a higher mean arterial pressure (MAP; 100.3 ± 12.3 versus 91.8 ± 11.6 mm Hg, P = 0.04) and higher systemic vascular resistance (2253 ± 573 versus 1883 ± 525 dyn/second/cm(-5) , P = 0.03). There were no differences in the cardiac index (CI). Propranolol significantly decreased HVPG to similar extents in transplant patients and nontransplant patients with cirrhosis (-14.1% ± 8.0% versus -16.9% ± 9.5%, P > 0.99). MAP tended to increase in transplant patients with cirrhosis, whereas it slightly decreased in nontransplant patients (5.1% ± 14.2% versus -4.8% ± 6.4%, P = 0.007); however, the reduction in CI was less marked in transplant patients with cirrhosis (-18.6% ± 7.6% versus -26.9% ± 9.0%, P = 0.005). In conclusion, patients with HCV-related cirrhosis and portal hypertension after orthotopic liver transplantation have lower baseline HVPG values but similar HVPG responses to propranolol infusions in comparison with nontransplant patients with cirrhosis. In contrast to nontransplant patients, propranolol increases the systemic vascular resistance and arterial pressure in transplant patients with cirrhosis and attenuates the fall in CI.
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Affiliation(s)
- Filippo Schepis
- Hepatic Hemodynamic Laboratory and Liver Transplantation Section, Barcelona, Spain
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Sánchez-Cabús S, Fondevila C, Calatayud D, Ferrer J, Taurá P, Fuster J, García-Valdecasas JC. Importance of the temporary portocaval shunt during adult living donor liver transplantation. Liver Transpl 2013; 19:174-83. [PMID: 23055401 DOI: 10.1002/lt.23558] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 09/28/2012] [Indexed: 02/07/2023]
Abstract
Adult living donor liver transplantation (aLDLT) is associated with surgical risks for the donor and with the possibility of small-for-size syndrome (SFSS) for the recipient, with both events being of great importance. An excessively small liver graft entails a relative increase in the portal blood flow during reperfusion, and this factor predisposes the recipient to an increased risk of SFSS in the postoperative period, although other causes related to recipient, graft, and technical factors have also been reported. A hemodynamic monitoring protocol was used for 45 consecutive aLDLT recipients. After various hemodynamic parameters before reperfusion were analyzed, a significant correlation between the temporary portocaval shunt flow during the anhepatic phase and the portal vein flow (PVF) after reperfusion of the graft (R(2) = 0.3, P < 0.001) was found, and so was a correlation between the native liver portal pressure and PVF after reperfusion (R(2) = 0.21, P = 0.007). The identification of patients at risk for excessive portal hyperflow will allow its modulation before reperfusion. This could favor the use of smaller grafts and ultimately lead to a reduction in donor complications because it would allow more limited hepatectomies to be performed.
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Affiliation(s)
- Santiago Sánchez-Cabús
- Hepatobiliary Surgery and Liver Transplantation Unit, Hospital Clinic of Barcelona, Barcelona, Spain
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Ogawa E, Hori T, Doi H, Segawa H, Uemoto S. Living-donor liver transplantation for moderate or severe porto-pulmonary hypertension accompanied by pulmonary arterial hypertension: a single-centre experience over 2 decades in Japan. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2012; 19:638-649. [PMID: 22086457 DOI: 10.1007/s00534-011-0453-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Candidates for orthotopic liver transplantation (OLT) often have porto-pulmonary hypertension (PPHTN) with pulmonary arterial hypertension (PAH). Poor outcomes of PPHTN contraindicate OLT. There are no guidelines for living-donor liver transplantation (LDLT) in PPHTN patients. METHODS We present our experiences of LDLT in six patients with moderate or severe PPHTN, along with our institutional guidelines. Three had liver cirrhosis and three were non-cirrhotic. Catheterization studies were undertaken before, during and after LDLT, and the mean pulmonary arterial pressure (mPAP), cardiac output (CO), pulmonary vascular resistance and total peripheral resistance (TPR) were monitored. RESULTS The results showed significant differences in CO and TPR between cirrhotic and non-cirrhotic patients before, during and after LDLT. Cirrhotic patients showed systemic hyperdynamic state. Two cirrhotic patients showed poor responses to pre-transplant treatment, and continued to have increased PAH and poor clinical courses after LDLT. LDLT has an advantage of flexible timing of LT. Currently in our institution, PPHTN patients with mPAP <40 mmHg are registered for LDLT after treatment and catheterization. However, LDLT is performed when mPAP is ≤35 mmHg, leading to improved outcomes. CONCLUSION PPHTN patients with well-controlled PAH, or secondary PAH resulting from porto-systemic shunts, may be appropriate candidates for LDLT after careful considerations.
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Affiliation(s)
- Eri Ogawa
- Divisions of Hepato-Pancreato-Biliary and Transplant Surgery, Department of Surgery, Kyoto University Hospital, 54 Shogoinkawara-cho Sakyo-ku, Kyoto, 606-8507, Japan
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Eyraud D, Granger B, Ionescu C, Fratéa S, Darnat S, Vaillant JC, Siksik JM, Hannoun L, Coriat P. Thrombocytopenia, splenomegaly, and portal blood flow in patients who have undergone liver transplantation for cirrhosis. Liver Transpl 2012; 18:340-6. [PMID: 22006447 DOI: 10.1002/lt.22456] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The platelet count (PC), the spleen size (SS), and the portal blood flow (PBF) have been independently studied in the perioperative period after orthotopic liver transplantation (OLT) for cirrhosis, but these parameters have not been described and analyzed in combination. We analyzed PC data and Doppler sonography measurements of SS and PBF from 125 adult patients before OLT and 1, 3, 6, 9, and 12 months after transplantation. A linear mixed model with fixed subject random intercepts was used. PCs increased significantly from 101.5 ± 68.5 × 10(9) /L before OLT to 162.4 ± 86 × 10(9) /L 1 month after OLT and remained stable for 1 year after the operation. PBF increased significantly from 619 ± 239 mL/minute before OLT to 1379 ± 491 mL/minute after OLT and remained stable during the first year. SS slowly decreased after OLT, but the decrease became significant only 9 months after the operation (13.8 ± 4.2 cm before OLT versus 11.7 ± 3.7 cm at 9 months, P < 0.05). The cirrhosis etiology did not influence the evolution of the parameters. With or without replication or interferon treatment before OLT, the hepatitis C group viruses did not influence PCs postoperatively. The evolution of SS was correlated to the evolution of PCs in the year after transplantation. In conclusion, PCs and PBF increase rapidly after OLT, whereas SS slowly decreases. The cirrhosis etiology does not influence the evolution of PCs. Thrombocytopenia and splenomegaly are 2 results of portal hypertension, but the rapid normalization of PBF does not completely or rapidly reverse these 2 phenomena.
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Affiliation(s)
- Daniel Eyraud
- Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Public Hospital System of Paris, Pierre and Marie Curie University, Paris, France.
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Wang K, Zhu ZJ, Zheng H, Deng YL, Pan C, Sun LY, Shen ZY. Protective hepatitis B surface antibodies in blood and ascites fluid in the early stage after liver transplantation for hepatitis B diseases. Hepatol Res 2012; 42:280-287. [PMID: 22176205 DOI: 10.1111/j.1872-034x.2011.00926.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study is to identify the titres of protective hepatitis B surface antibodies (anti-HBs) in the blood and their effective factors in the early stage after liver transplantation (LT) for hepatitis B virus (HBV) related diseases. The condition of anti-HBs lost in ascites fluid was also investigated. METHODS Twenty-six patients who received LT were administered prophylaxis of lamivudine combining intravenous hepatitis B immunoglobulin (HBIG) post-LT. The titres of anti-HBs were recorded and analyzed daily in blood and ascites fluid within the first week post-LT. RESULTS In the first 5 days post-LT, the titres of anti-HBs in HBV DNA positive groups, high hepatitis B surface antigen (HBsAg) groups, hepatitis B e antigen (HBeAg) positive groups were lower than that in the parallel HBV DNA negative groups, low HBsAg groups and HBeAg negative groups. The mean titre level of anti-HBs in ascites fluid is 224.89 IU/L and fluctuated from 0.00 IU/L to 968.50 IU/L, which is also correlated with anti-HBs titres in blood drawn at the same time (r = 0.927, P = 0.000). The level of anit-HBs in ascites fluid was very high; however, it fluctuated in a wide range (from 0.00 IU to 908.55 IU). CONCLUSIONS Patients in high risk groups should receive a higher level of HBIG to maintain sufficient amounts of anti-HBs in the early stage post-LT, while the patients in low risk groups need a lower level of HBIG administration. Furthermore, the lost amount of anti-HBs in ascitic fluid post-LT has minimum impact on the anti-HBs titres in blood.
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Affiliation(s)
- Kai Wang
- Department of Transplant Surgery, First Center Hospital Clinic Institute, Tianjin Medical University, Tianjin, China
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Abstract
Hepatorenal syndrome (HRS) is a functional form of acute kidney injury (AKI) associated with advanced liver cirrhosis or fulminant hepatic failure. Various new concepts have emerged since the initial diagnostic criteria and definition of HRS was initially published. These include better understanding of the pathophysiological mechanisms involved in HRS, identification of bacterial infection (especially spontaneous bacterial peritonitis) as the most important HRS-precipitating event, recognition that insufficient cardiac output plays a role in the occurrence of HRS, and evidence that renal failure reverses with pharmacotherapy. Patients with HRS are often critically ill and, by definition, have multiorgan failure. The purpose of this review is to provide an update on novel advances in HRS, with emphasis on the different aspects of management of these patients in the intensive care unit.
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Affiliation(s)
- Hani M Wadei
- Department of Transplantation, College of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA.
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Hessheimer AJ, Fondevila C, Taurá P, Muñoz J, Sánchez O, Fuster J, Rimola A, García-Valdecasas JC. Decompression of the portal bed and twice-baseline portal inflow are necessary for the functional recovery of a "small-for-size" graft. Ann Surg 2011; 253:1201-10. [PMID: 21587116 DOI: 10.1097/sla.0b013e3181ffb2d7] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND In partial liver transplant, a reduction in the intrahepatic vascular bed produces a rise in the portal vein flow and the portal venous pressure gradient, leading to endothelial and, thereby, hepatocellular injury and death in a process known as "small-for-size" (SFS) syndrome. OBJECTIVE To demonstrate that a calibrated portocaval shunt prevents superfluous inflow in a porcine model of SFS transplant. METHODS Donor pigs (15-20 kg) underwent 70% hepatectomy. In 2 groups, a 6 mm (S6) (n = 6) or 12 mm (S12) (n = 6) Gore-Tex shunt was placed between the portal vein and infrahepatic inferior vena cava. In a third group, no portocaval shunt was placed (SFS) (n = 17). Grafts were stored for 5 hours at 4°C and then transplanted into recipients (30-35 kg). RESULTS Five-day survival was 29% in SFS, 100% in S6, and 0 in S12. Postreperfusion portal vein flow was 4-, 2-, and 1-times flow at baseline in SFS, S6, and S12, respectively. With respect to portal venous pressure gradient, both the 6- and 12-mm shunts effectively decompressed the portal bed. Aspartate aminotransferase and bilirubin rose and the Quick prothrombin time fell in all animals after reperfusion but improved significantly by day 5 in S6. Serum levels of endothelin-1 remained elevated in SFS and S12 but returned to baseline by 12 hours in S6: 2.76 (2.05-4.08) and 2.04 (1.97-2.12) versus 0.43 (0.26-0.50) pg/mL, respectively (P < 0.05 for both comparisons). CONCLUSIONS A calibrated portocaval shunt that maintains portal vein flow about twice its baseline value produces a favorable outcome after SFS liver transplantation, avoiding endothelial injury due to portal hyperperfusion or to hypoperfusion because of excess shunting.
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Affiliation(s)
- Amelia J Hessheimer
- Department of Surgery, Institut de Malaties Digestives, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
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42
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Quintini C, D'Amico G, Brown C, Aucejo F, Hashimoto K, Kelly DM, Eghtesad B, Sands M, Fung JJ, Miller CM. Splenic artery embolization for the treatment of refractory ascites after liver transplantation. Liver Transpl 2011; 17:668-73. [PMID: 21618687 DOI: 10.1002/lt.22280] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Refractory ascites (RA) is a challenging complication after orthotopic liver transplantation. Its treatment consists of the removal of the precipitating factors. When the etiology is unknown, supportive treatment can be attempted. In severe cases, transjugular intrahepatic portosystemic shunts, portocaval shunts, and liver retransplantation have been used with marginal results. Recently, splenic artery embolization (SAE) has been described as an effective procedure for reducing portal hyperperfusion in patients undergoing partial or whole liver transplantation. Here we describe our experience with SAE for the treatment of RA. Between June 2004 and June 2010, 6 patients underwent proximal SAE for RA. Intraoperative flow measurements, graft characteristics, embolization portal vein (PV) velocities before and after SAE, and spleen/liver volume ratios were collected and analyzed. The response to treatment was assessed with imaging (ultrasound/computed tomography) and on the basis of clinical outcomes (weight changes, diuretic requirements, and the time to ascites resolution). The PV velocity decreased significantly for each patient after the embolization (median = 66.5 cm/second before SAE and median = 27.5 cm/second after SAE, P < 0.01). All patients experienced a significant postprocedural weight loss (mean = 88.1 ± 28.4 kg before SAE and mean = 75.8 ± 28.4 kg after SAE, P < 0.01) and a dramatic decrease in their diuretic requirements. All but 1 of the patients experienced a complete resolution of ascites after a median time of 49.5 days (range = 12-295 days). No patient presented with postembolization complications. In conclusion, SAE was effective in reducing the PV velocity immediately after the procedure. Clinically, this translated into a dramatic weight loss, a reduction of diuretic use, and a resolution of ascites. SAE appears to be a safe and effective treatment for RA.
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Affiliation(s)
- Cristiano Quintini
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH 44106, USA.
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43
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Ripoll C, Yotti R, Bermejo J, Bañares R. The heart in liver transplantation. J Hepatol 2011; 54:810-22. [PMID: 21145840 DOI: 10.1016/j.jhep.2010.11.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 09/27/2010] [Accepted: 11/04/2010] [Indexed: 02/08/2023]
Abstract
The heart and liver are organs that are closely related in both health and disease. Patients who undergo liver transplantation may suffer from heart disease that is: (a) related to the original cause of the liver disease such as hemochromatosis, (b) related to the liver disease itself, or (c) related to other associated conditions. Furthermore, liver transplantation is one of the most cardiovascular stressful events that a patient with cirrhosis may undergo. After liver transplantation, the progression of pre-existing or the development of new-onset cardiac disease may occur. This article reviews the relationship between the heart and liver transplantation in the pre-transplant, intra-operative, and post-transplant periods.
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Affiliation(s)
- Cristina Ripoll
- Department of Digestive Disease, Ciber EHD Hospital General Universitario Gregorio Marañón, Madrid 28007, Spain
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44
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Fleming JN, Abou Abbass A. Hepatorenal syndrome: a comprehensive overview for the critical care nurse. Crit Care Nurs Clin North Am 2010; 22:351-68. [PMID: 20691386 DOI: 10.1016/j.ccell.2010.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Over the past 50 years, the pathophysiology and features of the hepatorenal syndrome have been illuminated. The syndrome can be divided into 2 distinct clinical patterns: a rapidly progressive renal failure with an extremely poor prognosis (type 1) and a slow progressive renal failure that correlates with the degree of cirrhosis (type 2). Although our understanding of hepatorenal syndrome continues to grow, our current methods of treating this condition remain limited in their effectiveness. The only definitive therapy is liver transplantation. This is a review of the definition, pathophysiology, and current recommendations for management of hepatorenal syndrome with the critical care nurse in mind.
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Affiliation(s)
- James N Fleming
- Solid Organ Transplant, Department of Pharmacy Services, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202, USA.
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45
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Testa A, Baiocchini A, Comandini U, Falasca L, Nardacci R, Maritti M, Loiacono L, Bibbolino C, Rizzi E, Cristofaro M, Ettorre G, Vennarecci G, Antonucci G, Del Nonno F. Fatal Sclerosing Peritonitis Associated With Primary Effusion Lymphoma After Liver Transplantation: A Case Report. Transplant Proc 2010; 42:3849-53. [DOI: 10.1016/j.transproceed.2010.08.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2010] [Revised: 07/06/2010] [Accepted: 08/19/2010] [Indexed: 10/18/2022]
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Jiang SM, Zhang QS, Zhou GW, Huang SF, Lu HM, Peng CH. Differences in portal hemodynamics between whole liver transplantation and living donor liver transplantation. Liver Transpl 2010; 16:1236-41. [PMID: 21031538 DOI: 10.1002/lt.22138] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The aim of this study was to investigate the differences in portal hemodynamics between whole liver transplantation and living donor liver transplantation (LDLT). Twenty patients who underwent LDLT (the L group) and 42 patients who underwent whole liver transplantation (the W group) were enrolled, and colored Doppler ultrasonography was performed preoperatively and on postoperative days (PODs) 1, 3, 5, 7, 30, and 90. The changes in the portal blood flow velocity (PBV) and portal blood flow volume (PBF) were monitored. The graft and spleen sizes were measured with angiographic computed tomography, and upper endoscopy was used to measure esophageal varices on PODs 14, 30, and 90. Although the portal venous pressure (PVP) decreased after graft implantation, it was higher in the L group with a smaller graft size ratio (25.7 ± 5.1 cm H₂O for the L group and 18.5 ± 4.6 cm H₂O for the W group, P < 0.05). PBF and PBV increased in both the W and L groups on POD 1 after transplantation; however, the PBF and PBV peaks were significantly higher in the W group. The postoperative PVP and graft volume were greatly related to PBF on POD 1. Grafts in the L group regenerated rapidly after the operation, and the volume increased from 704 ± 115 to 1524 ± 281 mL as early as 1 month after transplantation. A rapid improvement in splenomegaly was observed in both groups. An improvement in esophageal varices was observed in the W group on POD 14 after transplantation, whereas no change was observed in the L group. The portal venous flow in patients with portal hypertension showed a high perfusion state after LDLT, but in contrast to whole liver transplantation, the PVP elevation after LDLT postponed the closing time of the collateral circulation and affected the recovery from splenomegaly.
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Affiliation(s)
- Shui-Ming Jiang
- Department of General Surgery, Fourth Affiliated Hospital, Guangxi Medical University, Liuzhou, China.
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47
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Sainz-Barriga M, Reyntjens K, Costa MG, Scudeller L, Rogiers X, Wouters P, de Hemptinne B, Troisi RI. Prospective evaluation of intraoperative hemodynamics in liver transplantation with whole, partial and DCD grafts. Am J Transplant 2010; 10:1850-60. [PMID: 20659091 DOI: 10.1111/j.1600-6143.2010.03207.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The interaction of systemic hemodynamics with hepatic flows at the time of liver transplantation (LT) has not been studied in a prospective uniform way for different types of grafts. We prospectively evaluated intraoperative hemodynamics of 103 whole and partial LT. Liver graft hemodynamics were measured using the ultrasound transit time method to obtain portal (PVF) and arterial (HAF) hepatic flow. Measurements were recorded on the native liver, the portocaval shunt, following reperfusion and after biliary anastomosis. After LT HAF and PVF do not immediately return to normal values. Increased PVF was observed after graft implantation. Living donor LT showed the highest compliance to portal hyperperfusion. The amount of liver perfusion seemed to be related to the quality of the graft. A positive correlation for HAF, PVF and total hepatic blood flow with cardiac output was found (p = 0.001). Portal hypertension, macrosteatosis >30%, warm ischemia time and cardiac output, independently influence the hepatic flows. These results highlight the role of systemic hemodynamic management in LT to optimize hepatic perfusion, particularly in LDLT and split LT, where the highest flows were registered.
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Affiliation(s)
- M Sainz-Barriga
- Department of General & Hepatobiliary Surgery, Ghent University Hospital and Medical School, Belgium
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48
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Møller S, Henriksen JH. Cirrhotic cardiomyopathy. J Hepatol 2010; 53:179-90. [PMID: 20462649 DOI: 10.1016/j.jhep.2010.02.023] [Citation(s) in RCA: 230] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Revised: 01/26/2010] [Accepted: 02/04/2010] [Indexed: 12/13/2022]
Abstract
Increased cardiac output was first described in patients with cirrhosis more than fifty years ago. Later, various observations have indicated the presence of a latent cardiac dysfunction, which includes a combination of reduced cardiac contractility with systolic and diastolic dysfunction and electrophysiological abnormalities. This syndrome is termed cirrhotic cardiomyopathy. Results of experimental studies indicate the involvement of several mechanisms in the pathophysiology, such as reduced beta-adrenergic receptor signal transduction, altered transmembrane currents and electromechanical coupling, nitric oxide overproduction, and cannabinoid receptor activation. Systolic incompetence in patients can be revealed by pharmacological or physical strain and during stressful procedures, such as transjugular intrahepatic portosystemic shunt insertion and liver transplantation. Systolic dysfunction has recently been implicated in development of renal failure in advanced disease. Diastolic dysfunction reflects delayed left ventricular filling and is partly attributed to ventricular hypertrophy, subendocardial oedema, and altered collagen structure. The QT interval is prolonged in about half of the cirrhotic patients and it may be normalised by beta-blockers. No specific therapy for cirrhotic cardiomyopathy can be recommended, but treatment should be supportive and directed against the cardiac dysfunction. Future research should better describe the prevalence, impact on morbidity and survival, and look for potential treatments.
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Affiliation(s)
- Søren Møller
- Department of Clinical Physiology and Nuclear Medicine, Hvidovre Hospital, Faculty of Health Sciences, University of Copenhagen, Denmark.
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49
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Oksenberg D. Cirrosis hepática: manejo moderno de antiguas complicaciones. Medwave 2010. [DOI: 10.5867/medwave.2010.05.4518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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50
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Fondevila C, Hessheimer AJ, Taurá P, Sánchez O, Calatayud D, de Riva N, Muñoz J, Fuster J, Rimola A, García-Valdecasas JC. Portal hyperperfusion: mechanism of injury and stimulus for regeneration in porcine small-for-size transplantation. Liver Transpl 2010; 16:364-74. [PMID: 20209596 DOI: 10.1002/lt.21989] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Understanding the pathogenesis of small-for-size (SFS) syndrome is critical to expanding the applicability of partial liver transplantation. We aimed to characterize its acute presentation and association with alterations in hepatic hemodynamics, microstructure, and regeneration in a porcine model. Eighteen SFS liver transplants were performed. Donors underwent 70% hepatectomy. Partial grafts were implanted into larger recipients. Whole liver transplants were also performed (n = 6). Recipients were followed until death or for 5 days. Hemodynamics were measured, and tissue was sampled intraoperatively and at the study end. Serum was sampled regularly during follow-up. Seventeen SFS transplants and 6 whole liver transplants were included. SFS grafts represented 23.2% (19.3%-25.3%) of the recipients' standard liver volume. The survival rate was 29% and 100% in the SFS and whole liver groups, respectively. The portal venous flow, pressure gradient, and resistance were significantly higher in recipients of SFS grafts versus whole livers after portal and arterial reperfusion. Arterial flow as a percentage of the total liver blood flow was significantly lower after reperfusion in SFS grafts and remained so when measured again after 5 days. Markers of endothelial cell injury increased soon after reperfusion, and those of hepatocellular injury increased later; both predicted the appearance of either graft failure or histological recovery. Proliferative activity peaked earlier and higher among nonsurvivors in the SFS group. Surviving grafts demonstrated a slower but maintained rise in regenerative activity, although metabolic activity failed to improve. In SFS transplantation in the acute setting, portal hyperperfusion is a stimulus for regeneration but may simultaneously cause irreparable endothelial injury. This porcine model not only helps to elucidate the inciting factors in SFS pathogenesis but also offers a clinically relevant means to study its prevention.
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Affiliation(s)
- Constantino Fondevila
- Liver Transplant Unit, Department of Surgery, Hospital Clinic, University of Barcelona, C/Villarroel 170, 08036 Barcelona, Spain.
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