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Braat AE, Blok JJ, Putter H, Adam R, Burroughs AK, Rahmel AO, Porte RJ, Rogiers X, Ringers J. The Eurotransplant donor risk index in liver transplantation: ET-DRI. Am J Transplant 2012; 12:2789-96. [PMID: 22823098 DOI: 10.1111/j.1600-6143.2012.04195.x] [Citation(s) in RCA: 214] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Recently we validated the donor risk index (DRI) as conducted by Feng et al. for the Eurotransplant region. Although this scoring system is a valid tool for scoring donor liver quality, for allocation purposes a scoring system tailored for the Eurotransplant region may be more appropriate. Objective of our study was to investigate various donor and transplant risk factors and design a risk model for the Eurotransplant region. This study is a database analysis of all 5939 liver transplantations from deceased donors into adult recipients from the 1st of January 2003 until the 31st of December 2007 in Eurotransplant. Data were analyzed with Kaplan-Meier and Cox regression models. From 5723 patients follow-up data were available with a mean of 2.5 years. After multivariate analysis the DRI (p < 0.0001), latest lab GGT (p = 0.005) and rescue allocation (p = 0.007) remained significant. These factors were used to create the Eurotransplant Donor Risk Index (ET-DRI). Concordance-index calculation shows this ET-DRI to have high predictive value for outcome after liver transplantation. Therefore, we advise the use of this ET-DRI for risk indication and possibly for allocation purposes within the Eurotrans-plant region.
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Affiliation(s)
- A E Braat
- Department of Transplant Surgery, Leiden University Medical Center, Leiden, the Netherlands.
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202
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Lisman T, Pittau G, Leite FJT, De Boer MT, Meijer K, Kluin-Nelemans HC, Huls G, Te Boome LCJ, Kuball J, Nowak G, Fan ST, Azoulay D, Porte RJ. The circulating platelet count is not dictated by the liver, but may be determined in part by the bone marrow: analyses from human liver and stem cell transplantations. J Thromb Haemost 2012; 10:1624-30. [PMID: 22642442 DOI: 10.1111/j.1538-7836.2012.04800.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The platelet count varies considerably between individuals, but within an individual the platelet count is remarkably stable over time. Mechanisms controlling the platelet count are not yet established. OBJECTIVE In the present study, we tested the hypothesis that the liver is important in controlling the circulating platelet count, as the liver is the main producer of thrombopoietin. METHODS We compared the platelet count prior to and after liver transplantation in >250 patients transplanted for familial amyloidotic polyneuropathy (FAP). In contrast to most patients undergoing liver transplantation, patients with FAP have normal liver function before transplantation. Furthermore, we compared platelet counts in 89 living liver donors with the platelet count in the recipients of these grafts. Finally we compared platelet counts in donor-recipient pairs of hematopoietic stem cells. RESULTS AND CONCLUSIONS The platelet count prior to transplantation correlated with the platelet count at 3 or 12 months after transplantation in patients with FAP (r=0.48, P<0.0001 at 3 months, r=0.39, P<0.0001 at 12 months), whereas the platelet count in a living liver donor did not correlate with the platelet count in the recipient at 3 or 12 months after transplantation (r=0.16, P=0.26 at 3 months, r=0.11, P=0.30 at 12 months). The platelet count of related donors of hematopoietic stem cells correlated with the platelet count in the recipient after transplantation (r=0.25, P=0.011). CONCLUSIONS These results suggest that the liver, in spite of being the prime producer of thrombopoietin, does not dictate the circulating platelet count, whereas the bone marrow does appear to play a role.
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Affiliation(s)
- T Lisman
- Section of Hepatobiliairy Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
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Mergental H, Adam R, Ericzon BG, Kalicinski P, Mühlbacher F, Höckerstedt K, Klempnauer JL, Friman S, Broelsch CE, Mantion G, Fernandez-Sellez C, van Hoek B, Fangmann J, Pirenne J, Muiesan P, Königsrainer A, Mirza DF, Lerut J, Detry O, Le Treut YP, Mazzaferro V, Löhe F, Berenguer M, Clavien PA, Rogiers X, Belghiti J, Kóbori L, Burra P, Wolf P, Schareck W, Pisarski P, Foss A, Filipponi F, Krawczyk M, Wolff M, Langrehr JM, Rolles K, Jamieson N, Hop WCJ, Porte RJ. Liver transplantation for unresectable hepatocellular carcinoma in normal livers. J Hepatol 2012; 57:297-305. [PMID: 22521348 DOI: 10.1016/j.jhep.2012.03.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Revised: 03/21/2012] [Accepted: 03/22/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS The role of liver transplantation in the treatment of hepatocellular carcinoma in livers without fibrosis/cirrhosis (NC-HCC) is unclear. We aimed to determine selection criteria for liver transplantation in patients with NC-HCC. METHODS Using the European Liver Transplant Registry, we identified 105 patients who underwent liver transplantation for unresectable NC-HCC. Detailed information about patient, tumor characteristics, and survival was obtained from the transplant centers. Variables associated with survival were identified using univariate and multivariate statistical analyses. RESULTS Liver transplantation was primary treatment in 62 patients and rescue therapy for intrahepatic recurrences after liver resection in 43. Median number of tumors was 3 (range 1-7) and median tumor size 8 cm (range 0.5-30). One- and 5-year overall and tumor-free survival rates were 84% and 49% and 76% and 43%, respectively. Macrovascular invasion (HR 2.55, 95% CI 1.34 to 4.86), lymph node involvement (HR 2.60, 95% CI 1.28 to 5.28), and time interval between liver resection and transplantation < 12 months (HR 2.12, 95% CI 0.96 to 4.67) were independently associated with survival. Five-year survival in patients without macrovascular invasion or lymph node involvement was 59% (95% CI 47-70%). Tumor size was not associated with survival. CONCLUSIONS This is the largest reported series of patients transplanted for NC-HCC. Selection of patients without macrovascular invasion or lymph node involvement, or patients ≥ 12months after previous liver resection, can result in 5-year survival rates of 59%. In contrast to HCC in cirrhosis, tumor size is not a predictor of post-transplant survival in NC-HCC.
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204
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Kist A, Wakkie J, Madu M, Versteeg R, ten Berge J, Nikolic A, Nieuwenhuijs VB, Porte RJ, Padbury RT, Barritt GJ. Rapamycin Induces Heme Oxygenase-1 in Liver but Inhibits Bile Flow Recovery after Ischemia. J Surg Res 2012; 176:468-75. [DOI: 10.1016/j.jss.2011.10.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2011] [Revised: 10/14/2011] [Accepted: 10/25/2011] [Indexed: 01/15/2023]
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205
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Lisman T, Bakhtiari K, Adelmeijer J, Meijers JCM, Porte RJ, Stravitz RT. Intact thrombin generation and decreased fibrinolytic capacity in patients with acute liver injury or acute liver failure. J Thromb Haemost 2012; 10:1312-9. [PMID: 22568491 DOI: 10.1111/j.1538-7836.2012.04770.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND It has been well established that hemostatic potential in patients with chronic liver disease is in a rebalanced status due to a concomitant decrease in pro- and antihemostatic drivers. The hemostatic changes in patients with acute liver injury/failure (ALI/ALF) are similar but not identical to the changes in patients with chronic liver disease and have not been studied in great detail. OBJECTIVE To assess thrombin generation and fibrinolytic potential in patients with ALI/ALF. METHODS We performed thrombin generation tests and clot lysis assays in platelet-poor plasma from 50 patients with ALI/ALF. Results were compared with values obtained in plasma from 40 healthy volunteers. RESULTS AND CONCLUSION The thrombin generation capacity of plasma from patients with ALI/ALF sampled on the day of admission to hospital was indistinguishable from that of healthy controls, provided thrombomodulin was added to the test mixture. Fibrinolytic capacity was profoundly impaired in patients with ALI/ALF on admission (no lysis in 73.5% of patients, compared with 2.5% of the healthy controls), which was associated with decreased levels of the plasminogen and increased levels of plasminogen activator inhibitor type 1. The intact thrombin generating capacity and the hypofibrinolytic status persisted during the first week of admission. Patients with ALI/ALF have a normal thrombin generating capacity and a decreased capacity to remove fibrin clots. These results contrast with routine laboratory tests such as the PT/INR, which are by definition prolonged in patients with ALI/ALF and suggest a bleeding tendency.
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Affiliation(s)
- T Lisman
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
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Affiliation(s)
| | - Robert J. Porte
- Department of Surgery; Section Hepatobiliairy Surgery and Liver Transplantation; University Medical Center Groningen; University of Groningen; Groningen; The Netherlands
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207
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Kele PG, de Boer M, van der Jagt EJ, Lisman T, Porte RJ. Early hepatic regeneration index and completeness of regeneration at 6 months after partial hepatectomy. Br J Surg 2012; 99:1113-9. [DOI: 10.1002/bjs.8807] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2012] [Indexed: 11/08/2022]
Abstract
Abstract
Background
The liver is known to regenerate following partial hepatectomy (PH), but little is known about the timing and completeness of regeneration relative to the resected volume. This study examined whether liver volume regeneration following PH and its completeness 6 months after surgery is related to the resected volume.
Methods
A consecutive series of patients undergoing PH were included. All patients underwent preoperative computed tomography (CT) before and 7 days after surgery. Additional scans were performed 6 months after operation. Preoperative total liver volume (TLV), resected volume, future liver remnant (FLR) and liver remnant (LR) volumes were measured on CT images by freehand drawing of regions of interest in the portal venous phase on 2-mm thick slices. Regeneration indices were calculated at 7 days (RIearly) and 6 months (RItotal) using the formula 100 × (LR volume—FLR volume)/FLR volume. Patients were classified into five groups based on resected volume as a percentage of TLV: 0–19, 20–39, 40–59, 60–69 and at least 70 per cent in groups 1–5 respectively.
Results
Ninety-one patients were enrolled. RIearly varied from 11 to 66 per cent in groups 1–5 (P < 0·001). RIearly did not increase linearly with increasing resection volume and a plateau was seen from group 3 and above. In contrast, RItotal was related linearly to resected volume; values ranged from 21 to 233 per cent in groups 1–5 (P < 0·001). At 7 days, LR volume represented 97, 87, 70, 58 and 41 per cent of TLV in groups 1–5. At 6 months, respective values were 102, 99, 87, 82 and 91 per cent.
Conclusion
Early postoperative liver volume regeneration was not related linearly to resected volume. At 6 months after surgery, RI was related linearly to resected volume, but LRs had not yet regenerated to preoperative TLV.
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Affiliation(s)
- P G Kele
- Department of Radiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - M de Boer
- Department of Surgery, Section of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - E J van der Jagt
- Department of Radiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - T Lisman
- Department of Surgery, Section of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - R J Porte
- Department of Surgery, Section of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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208
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Potgieser ARE, de Vries W, Sze YK, Sieders E, Verkade HJ, Porte RJ, Hoekstra-Weebers JEHM, Hulscher JBF, Aronson DC, Damen G, Escher JH, van Heurn LWE, Houwen RHJ, Heij HA, Hulscher JBF, Kneepkens CMF, Koot BG, de Langen ZJ, Madern G, van den Neucker AM, Peeters PMJG, Verkade HJ, de Vries W, van der Zee DC. Course of life into adulthood of patients with biliary atresia: the achievement of developmental milestones in a nationwide cohort. J Adolesc Health 2012; 50:641-4. [PMID: 22626493 DOI: 10.1016/j.jadohealth.2011.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2011] [Revised: 10/08/2011] [Accepted: 10/11/2011] [Indexed: 11/28/2022]
Abstract
PURPOSE To investigate the course of life of young adults diagnosed with biliary atresia (BA) in infancy by comparing patients who did and did not underwent transplantation with an age-matched Dutch reference group. METHODS All patients from the Dutch BA registry, aged >18 years, were invited to complete the course of life questionnaire. RESULTS Forty patients participated (response = 74%). Twenty-five had not undergone transplantation; 15 had undergone orthotopic liver transplantation. One significant between-group difference was found, namely in substance use and gambling. BA patients who underwent transplantation reported less use than the reference group (p = .01, moderate effect size). Additional moderate effect sizes were found for differences in psychosexual and social development and antisocial behavior. Patients who underwent transplantation had lower scores than one or both other groups. CONCLUSIONS Development of BA survivors who did not undergo transplantation seems not delayed, whereas that of transplanted patients does seem somewhat delayed. However, patients who underwent transplantation display less risk behavior. Larger samples are necessary to confirm these findings.
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Affiliation(s)
- Adriaan R E Potgieser
- Department of Pediatric Surgery, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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209
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210
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Sutton ME, op den Dries S, Koster MH, Lisman T, Gouw ASH, Porte RJ. Regeneration of human extrahepatic biliary epithelium: the peribiliary glands as progenitor cell compartment. Liver Int 2012; 32:554-9. [PMID: 22171992 DOI: 10.1111/j.1478-3231.2011.02721.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 11/13/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Although regeneration of intrahepatic bile ducts has been extensively studied and intrahepatic progenitor cells have been identified, few studies have focussed on the extrahepatic bile duct (EHBD). We hypothesized that local progenitor cells are present within the EHBD of humans. Human EHBD specimens (n = 17) were included in this study. METHODS Specimens of normal EHBD tissue were obtained from healthy donor livers (n = 6), mildly injured EHBD from patients with cholangitis (n = 6) and severely injured EHBD from patients with ischaemic type biliary lesions (n = 5). Double immunostaining for K19 and the proliferation marker Ki-67 was performed to identify and localize proliferating cells. In addition, immunofluorescent doublestaining using antibodies against K19 and c-Kit was performed to identify and localize cholangiocytes co-expressing putative progenitor cell markers. RESULTS In normal EHBD, few Ki-67(+) cells were detected, whereas large numbers of Ki-67(+) were found in the diseased EHBD. In EHBD affected by cholangitis, Ki-67(+) cells were mainly located in the basal layer of the lumen. EHBD specimens from patients with ischaemic type biliary lesions displayed histological signs of epithelial cell loss and large numbers of Ki-67(+) cells were observed in the peribiliary glands. C-Kit expression was localized throughout the EHBD wall and immunofluorescent doublestaining identified a few K19(+) /c-Kit(+) cells in the luminal epithelium of the EHBD as well as in the peribiliary glands. CONCLUSIONS These findings support the hypothesis that progenitor cells exist in the EHBD and that the peribiliary glands can be considered a local progenitor cell niche in the human EHBD.
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Affiliation(s)
- Michael E Sutton
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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211
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Abstract
BACKGROUND Fibrin sealants are widely used in liver surgery. The aim of this article is to review the literature on evidence of hemostatic and biliostatic capacities of different fibrin sealants in liver surgery. METHODS In PubMed, a literature search was done with the search terms 'fibrin sealant' or 'fibrin glue' combined with 'liver resection' or 'bile leakage'. Thirteen comparative fibrin sealant studies were selected. RESULTS In general, these studies have shown a reduced time to hemostasis when fibrin sealants were used. So far, only a few studies have been published that have focused on postoperative resection surface-related complications. There is no strong evidence that fibrin sealants reduce the incidence of bile leakage after liver resection. Important new evidence shows that bile contains profibrinolytic activity that causes lysis of the clot formed by the fibrin sealant at least in vitro. CONCLUSIONS Fibrin sealants can be effective as an adjunct to achieve hemostasis during liver resections. However, considering lack of evidence on the efficacy of fibrin sealants in reducing postoperative resection surface-related complications, routine use of fibrin sealants in liver surgery cannot be recommended.
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Affiliation(s)
- Marieke T de Boer
- Division of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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212
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Abstract
Surgical procedures of the liver, such as partial liver resections and liver transplantation, are major types of abdominal surgery. Liver surgery can be associated with excessive intraoperative blood loss, not only because the liver is a highly vascularized organ, but also because it plays a central role in the hemostatic system. Intraoperative blood loss and transfusion of blood products have been shown to be negatively associated with postoperative outcome after liver surgery. Dysfunction of the liver is frequently accompanied with a dysfunctional hemostatic system. However, in general, there is a poor correlation between preoperative coagulation tests and the intraoperative bleeding risk in patients undergoing liver surgery. Strategies to avoid excessive blood loss in liver surgery have been an active field of research and include three different areas: surgical methods, anesthesiological methods, and pharmacological agents.Surgeons can minimize blood loss by clamping the hepatic vasculature, by using specific dissection devices, and by using topical hemostatic agents. Anesthesiologists play an important role in minimizing blood loss by avoiding intravascular fluid overload. Maintaining a low central venous pressure has shown to be very effective in reducing blood loss during partial liver resections. Prophylactic transfusion of blood products such as fresh frozen plasma (FFP) has not been shown to reduce intraoperative bleeding and even seems counterproductive as it results in an increase of the intravascular filling status, which may enhance the bleeding risk. In patients with liver cirrhosis, there is increasing evidence that factors such as portal hypertension and the hyperdynamic circulation play a more important role in the bleeding tendency than changes in the coagulation system. Therefore, intravenous fluid restriction rather than prophylactic administration of large volumes of blood products (i.e., FFP) is recommended in patients undergoing major liver surgery. Pharmacological agents such as antifibrinolytic drugs or recombinant factor VIIa may be indicated in selected individual patients, but these agents do not have a routine role in the management of patients undergoing liver surgery.
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Affiliation(s)
- Menno Stellingwerff
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, The University of Groningen, Groningen, The Netherlands
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213
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de Wilde RF, Besselink MGH, van der Tweel I, de Hingh IHJT, van Eijck CHJ, Dejong CHC, Porte RJ, Gouma DJ, Busch ORC, Molenaar IQ. Impact of nationwide centralization of pancreaticoduodenectomy on hospital mortality. Br J Surg 2012; 99:404-10. [PMID: 22237731 DOI: 10.1002/bjs.8664] [Citation(s) in RCA: 235] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2011] [Indexed: 12/31/2022]
Abstract
BACKGROUND The impact of nationwide centralization of pancreaticoduodenectomy (PD) on mortality is largely unknown. The aim of this study was to analyse changes in hospital volumes and in-hospital mortality after PD in the Netherlands between 2004 and 2009. METHODS Nationwide data on International Classification of Diseases, ninth revision (ICD-9) code 5-526 (PD, including Whipple), patient age, sex and mortality were retrieved from the independent nationwide KiwaPrismant registry. Based on established cut-off points of annually performed PDs, hospitals were categorized as very low (fewer than 5), low (5-10), medium (11-19) or high (at least 20) volume. A subgroup analysis based on a cut-off age of 70 years was also performed. RESULTS Some 2155 PDs were included. The number of hospitals performing PD decreased from 48 in 2004 to 30 in 2009 (P = 0·011). In these specific years, the proportion of patients undergoing PD in a medium- or high-volume centre increased from 52·9 to 91·2 per cent (P < 0·001). Nationwide mortality rates after PD decreased from 9·8 to 5·1 per cent (P = 0·044). The mortality rate during the 6-year period was 14·7, 9·8, 6·3 and 3·3 per cent in very low-, low-, medium- and high-volume hospitals respectively (P < 0·001). The difference in mortality between medium- and high-volume centres was statistically significant (P = 0·004). The volume-outcome relationship was not influenced by age (P = 0·467). The mortality rate after PD in patients aged at least 70 years was 10·4 per cent compared with 4·4 per cent in younger patients (P < 0·001). CONCLUSION With nationwide centralization of PD, the in-hospital mortality rate after this procedure decreased. Further centralization of PD is likely to decrease mortality further, especially in the elderly.
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Affiliation(s)
- R F de Wilde
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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214
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Blok JJ, Braat AE, Adam R, Burroughs AK, Putter H, Kooreman NG, Rahmel AO, Porte RJ, Rogiers X, Ringers J. Validation of the donor risk index in orthotopic liver transplantation within the Eurotransplant region. Liver Transpl 2012; 18:112-9. [PMID: 21987454 DOI: 10.1002/lt.22447] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In Eurotransplant, more than 50% of liver allografts come from extended criteria donors (ECDs). However, not every ECD is the same. The limits of their use are being explored. A continuous scoring system for analyzing donor risk has been developed within the Organ Procurement and Transplantation Network (OPTN), the Donor Risk Index (DRI). The objective of this study was the validation of this donor risk index (DRI) in Eurotransplant. The study was a database analysis of all 5939 liver transplants involving deceased donors and adult recipients from January 1, 2003 to December 31, 2007 in Eurotransplant. Data were analyzed with Kaplan-Meier and Cox regression models. Follow-up data were available for 5723 patients with a median follow up of 2.5 years. The mean DRI was remarkably higher in the Eurotransplant region versus OPTN (1.71 versus 1.45), and this indicated different donor populations. Nevertheless, we were able to validate the DRI for the Eurotransplant region. Kaplan-Meier curves per DRI category showed a significant correlation between the DRI and outcomes (P < 0.001). A multivariate analysis demonstrated that the DRI was the most significant factor influencing outcomes (P < 0.001). Among all donor, transplant, and recipient variables, the DRI was the strongest predictor of outcomes.
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Affiliation(s)
- Joris J Blok
- Departments of Surgery, Leiden University Medical Center, Albinusdreef 2, Leiden, the Netherlands
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215
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Boonstra EA, de Boer MT, Sieders E, Peeters PMJG, de Jong KP, Slooff MJH, Porte RJ. Risk factors for central bile duct injury complicating partial liver resection. Br J Surg 2011; 99:256-62. [PMID: 22190220 DOI: 10.1002/bjs.7802] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2011] [Indexed: 01/10/2023]
Abstract
BACKGROUND Bile duct injury is a serious complication following liver resection. Few studies have differentiated between leakage from small peripheral bile ducts and central bile duct injury (CBDI), defined as an injury leading to leakage or stenosis of the common bile duct, common hepatic duct, right or left hepatic duct. This study analysed the incidence, risk factors and consequences of CBDI in liver resection. METHODS Patients undergoing liver resection between 1990 and 2007 were included in this study. Those having resection for bile duct-related pathology or trauma, or after liver transplantation were excluded. Characteristics and outcome variables were collected prospectively and analysed retrospectively. RESULTS There were 19 instances of CBDI in 462 liver resections (4·1 per cent). One-third of patients with CBDI required surgical reintervention and construction of a hepaticojejunostomy. Resection type (P < 0·001), previous liver resection (P = 0·039) and intraoperative blood loss (P = 0·002) were associated with an increased risk of CBDI. Of all resection types, extended left hemihepatectomy was associated with the highest incidence of CBDI (2 of 9 procedures). CONCLUSION Patients undergoing extended left hemihepatectomy or repeat hepatectomy were at increased risk of CBDI.
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Affiliation(s)
- E A Boonstra
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, University Medical Centre Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
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Lerut J, Mergental H, Kahn D, Albuquerque L, Marrero J, Vauthey JN, Porte RJ. Place of liver transplantation in the treatment of hepatocellular carcinoma in the normal liver. Liver Transpl 2011; 17 Suppl 2:S90-7. [PMID: 21796760 DOI: 10.1002/lt.22393] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Jan Lerut
- Starzl Abdominal Transplant Unit, St. Luc University Hospital, Catholic University of Louvain, Brussels, Belgium.
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217
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Abstract
BACKGROUND Brain death is associated with a systemic inflammatory response resulting in diminished organ function in individuals transplanted with organs from brain dead donors. As inflammation is accompanied by activation of coagulation, we hypothesized that activation of hemostasis occurs in brain dead organ donors. OBJECTIVES To assess the hemostatic status in brain dead organ donors. PATIENTS AND METHODS In this study, we systematically assessed the hemostatic system in samples taken from 30 brain dead donors. As controls, blood samples from 30 living kidney donors were included. RESULTS AND CONCLUSIONS Compared with the living donors, brain dead donors showed significant platelet activation (assessed by glycocalicin plasma levels), and a profound dysbalance in the von Willebrand factor/ADAMTS13 axis, which is key in platelet attachment to damaged vasculature. Furthermore, compared with the living donors, brain dead donors showed a significantly increased activation of secondary hemostasis with formation of fibrin (assessed by plasma levels of prothrombin fragment 1 + 2, fibrinopeptide A and D-dimer). Finally, brain dead donors showed profound hypofibrinolysis as assessed by a global clot lysis assay, which was attributed to substantially elevated plasma levels of plasminogen activator inhibitor type 1. Collectively, our results show activation of hemostasis and dysregulated fibrinolysis in brain dead organ donors. This prothrombotic state may contribute to formation of microthrombi in transplantable organs, which potentially contributes to deterioration of organ function.
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Affiliation(s)
- T Lisman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
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de Rooij BJF, van der Beek MT, van Hoek B, Vossen ACTM, Rogier Ten Hove W, Roos A, Schaapherder AF, Porte RJ, van der Reijden JJ, Coenraad MJ, Hommes DW, Verspaget HW. Mannose-binding lectin and ficolin-2 gene polymorphisms predispose to cytomegalovirus (re)infection after orthotopic liver transplantation. J Hepatol 2011; 55:800-7. [PMID: 21334396 DOI: 10.1016/j.jhep.2011.01.039] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 12/20/2010] [Accepted: 01/10/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS The lectin pathway of complement activation is a crucial effector cascade of the innate immune response to pathogens. Cytomegalovirus (CMV) infection occurs frequently in immunocompromised patients after orthotopic liver transplantation (OLT). Single-nucleotide polymorphisms (SNPs) in the lectin pathway genes determine their liver-derived protein level and functional activity. We examined the association between these SNPs and the risk for CMV infection in OLT. METHODS OLT patients (n = 295) were genotyped for recipient and donor SNPs in mannose-binding lectin (MBL2), Ficolin-2 (FCN2) and MBL-associated serine protease (MASP2) genes. RESULTS Combined analysis of independently associated variant MBL2 [HR 1.65, p<0.02] and wild-type FCN2 [1.85; p<0.02] SNPs in the donor liver showed an increased risk of CMV infection for either and both risk genotypes [HR 2.02 and HR 3.26, respectively, p = 0.004], especially in CMV Donor-/Recipient+ (D-/R+) patients [HR 4.7 and HR 10.0, respectively, p = 0.01]. A genetic donor-recipient mismatch for MBL2 and FCN2 increased the CMV risk independently, also combined [HR 5.35; p<0.001], particularly in CMV D-/R+ patients [HR 16.6; p = 0.009]. Multivariate Cox analysis showed a consistent stepwise increase in CMV infection risk with the gene profile of the donor [up to HR 2.77; p<0.005] and the combined MBL2 and FCN2 donor-recipient mismatch profile [up to HR 4.57; p<0.001], independent from donor-recipient CMV serostatus, also at higher CMV (re)infection cut-off values. CONCLUSIONS MBL2 and FCN2 risk alleles of donor liver and recipient constitute independent risk factors for CMV infection after OLT. Patients with these risk genes probably need intensified CMV monitoring and anti-viral therapy.
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Affiliation(s)
- Bert-Jan F de Rooij
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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van Keimpema L, Nevens F, Adam R, Porte RJ, Fikatas P, Becker T, Kirkegaard P, Metselaar HJ, Drenth JPH. Excellent survival after liver transplantation for isolated polycystic liver disease: an European Liver Transplant Registry study. Transpl Int 2011; 24:1239-45. [PMID: 21955068 DOI: 10.1111/j.1432-2277.2011.01360.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patients with end-stage isolated polycystic liver disease (PCLD) suffer from incapacitating symptoms because of very large liver volumes. Liver transplantation (LT) is the only curative option. This study assesses the feasibility of LT in PCLD. We used the European Liver Transplant Registry (ELTR) database to extract demographics and outcomes of 58 PCLD patients. We used Kaplan-Meier survival analysis for survival rates. Severe abdominal pain (75%) was the most prominent symptom, while portal hypertension (35%) was the most common complication in PCLD. The explantation of the polycystic liver was extremely difficult in 38% of patients, because of presence of adhesions from prior therapy (17%). Karnofsky score following LT was 90%. The 1- and 5-year graft survival rate was 94.3% and 87.5%, while patient survival rate was 94.8% and 92.3%, respectively. Survival rates after LT for PCLD are good.
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Affiliation(s)
- Loes van Keimpema
- Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
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Verdonk RC, Haagsma EB, Jongsma T, Porte RJ, Roozendaal C, van den Berg AP, Hepkema BG. A prospective analysis of the natural course of donor chimerism including the natural killer cell fraction after liver transplantation. Transplantation 2011; 92:e22-4. [PMID: 21814126 DOI: 10.1097/tp.0b013e318225283e] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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221
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Ten Hove WR, Korkmaz KS, op den Dries S, de Rooij BJF, van Hoek B, Porte RJ, van der Reijden JJ, Coenraad MJ, Dubbeld J, Hommes DW, Verspaget HW. Matrix metalloproteinase 2 genotype is associated with nonanastomotic biliary strictures after orthotopic liver transplantation. Liver Int 2011; 31:1110-7. [PMID: 21745270 DOI: 10.1111/j.1478-3231.2011.02459.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
BACKGROUND Nonanastomotic biliary strictures (NAS) are a serious complication after orthotopic liver transplantation (OLT). Matrix metalloproteinases (MMPs) are involved in connective tissue remodelling in chronic liver disease and complications after OLT. AIM To evaluate the relationship between MMP-2 and MMP-9 gene polymorphisms and NAS. METHODS MMP-2 (-1306 C/T) and MMP-9 (-1562 C/T) gene promoter polymorphisms were analysed in 314 recipient-donor combinations. Serum levels of these MMPs were determined in subgroups of patients as well. NAS were identified with various radiological imaging studies performed within 4 years after OLT and defined as any stricture, dilation or irregularity of the intra- or extrahepatic bile ducts of the liver graft followed by an intervention, after exclusion of hepatic artery thrombosis and anastomotic strictures. RESULTS The average incidence of NAS was 15%. The major clinical risk factor for the development of NAS was PSC in the recipient. The presence of the MMP-2 CT genotype in donor and/or recipient was associated with a significantly higher incidence of NAS, up to 29% when both donor and recipient had the MMP-2 CT genotype (P=0.003). In the multivariate analyses, pre-OLT PSC (hazard ratio 2.1, P=0.02) and MMP-2 CT genotype (hazard ratio 3.5, P=0.003) were found to be independent risk factors for the development of NAS after OLT. No obvious association was found between NAS and the MMP-9 genotype and serum levels of the MMPs. CONCLUSION MMP-2 CT genotype of donor and recipient is an independent risk factor, in addition to PSC, for the development of NAS after OLT.
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Affiliation(s)
- W Rogier Ten Hove
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
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op den Dries S, Buis CI, Adelmeijer J, Van der Jagt EJ, Haagsma EB, Lisman T, Porte RJ. The combination of primary sclerosing cholangitis and CCR5-Δ32 in recipients is strongly associated with the development of nonanastomotic biliary strictures after liver transplantation. Liver Int 2011; 31:1102-9. [PMID: 21134114 DOI: 10.1111/j.1478-3231.2010.02422.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
BACKGROUND The role of the immune system in the pathogenesis of nonanastomotic biliary strictures (NAS) after orthotopic liver transplantation (OLT) is unclear. A loss-of-function mutation in the CC chemokine receptor 5 (CCR5-Δ32) leads to changes in the immune system, including impaired chemotaxis of regulatory T cells. AIM To investigate the impact of the CCR5-Δ32 mutation on the development of NAS. METHODS In 384 OLTs, we assessed the CCR5 genotype in donors and recipients and correlated this with the occurrence of NAS. RESULTS The CCR5-Δ32 allele was found in 65 (16.9%) recipients. The cumulative incidence of NAS at 5 years was 6.5% in wild-type (Wt) recipients vs 17.2% for carriers of the CCR5-Δ32 allele (P<0.01). In recipients with CCR5-Δ32, 50% of all NAS occurred >2 years after OLT, compared with 10% in the Wt group. In multivariate regression analysis, the adjusted risk of developing NAS was four-fold higher in recipients with CCR5-Δ32 (P<0.01). The highest risk of NAS was seen in patients transplanted for primary sclerosing cholangitis (PSC), who also carried CCR5-Δ32 (relative risk 5.4, 95% confidence interval 2.2-12.9; P<0.01). Donor CCR5 genotype had no impact on the occurrence of NAS. CONCLUSIONS Patients with the CCR5-Δ32 mutation have a four-fold higher risk of developing NAS, compared with Wt recipients. This risk is even higher in patients with CCR5-Δ32 transplanted for PSC. Late development of NAS is significantly more present in patients with CCR5-Δ32. These data suggest that the immune system plays a critical role in the development of NAS after OLT.
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Affiliation(s)
- Sanna op den Dries
- Department of Surgery, University of Groningen, Groningen, the Netherlands
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Janse M, Lamberts LE, Franke L, Raychaudhuri S, Ellinghaus E, MuriBoberg K, Melum E, Folseraas T, Schrumpf E, Bergquist A, Bjornsson E, Fu J, Westra HJ, Groen HJM, Fehrmann RSN, Smolonska J, van den Berg LH, Ophoff RA, Porte RJ, Weismuller TJ, Wedemeyer J, Schramm C, Sterneck M, Gunther R, Braun F, Vermeire S, Henckaerts L, Wijmenga C, Ponsioen CY, Schreiber S, HKarlsen T, Franke A, Weersma RK. Three ulcerative colitis susceptibility loci are associated with primary sclerosing cholangitis and indicate a role for IL2, REL, and CARD9. Hepatology 2011; 53:1977-85. [PMID: 21425313 PMCID: PMC3121050 DOI: 10.1002/hep.24307] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Accepted: 03/09/2011] [Indexed: 12/13/2022]
Abstract
UNLABELLED Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease characterized by inflammation and fibrosis of the bile ducts. Both environmental and genetic factors contribute to its pathogenesis. To further clarify its genetic background, we investigated susceptibility loci recently identified for ulcerative colitis (UC) in a large cohort of 1,186 PSC patients and 1,748 controls. Single nucleotide polymorphisms (SNPs) tagging 13 UC susceptibility loci were initially genotyped in 854 PSC patients and 1,491 controls from Benelux (331 cases, 735 controls), Germany (265 cases, 368 controls), and Scandinavia (258 cases, 388 controls). Subsequently, a joint analysis was performed with an independent second Scandinavian cohort (332 cases, 257 controls). SNPs at chromosomes 2p16 (P-value 4.12 × 10(-4) ), 4q27 (P-value 4.10 × 10(-5) ), and 9q34 (P-value 8.41 × 10(-4) ) were associated with PSC in the joint analysis after correcting for multiple testing. In PSC patients without inflammatory bowel disease (IBD), SNPs at 4q27 and 9q34 were nominally associated (P < 0.05). We applied additional in silico analyses to identify likely candidate genes at PSC susceptibility loci. To identify nonrandom, evidence-based links we used GRAIL (Gene Relationships Across Implicated Loci) analysis showing interconnectivity between genes in six out of in total nine PSC-associated regions. Expression quantitative trait analysis from 1,469 Dutch and UK individuals demonstrated that five out of nine SNPs had an effect on cis-gene expression. These analyses prioritized IL2, CARD9, and REL as novel candidates. CONCLUSION We have identified three UC susceptibility loci to be associated with PSC, harboring the putative candidate genes REL, IL2, and CARD9. These results add to the scarce knowledge on the genetic background of PSC and imply an important role for both innate and adaptive immunological factors.
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Affiliation(s)
- Marcel Janse
- Department of Gastroenterology and Hepatology, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands
| | - Laetitia E Lamberts
- Department of Gastroenterology and Hepatology, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands
| | - Lude Franke
- Department of Genetics, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands
| | - Soumya Raychaudhuri
- Division of Genetics, Brigham and Women’s Hospital, Boston, Massachusetts, 02115, USA, Division of Rheumatology, Immunology, and Allergy, Brigham and Women’s Hospital, Boston, Massachusetts, 02115, USA, Broad Institute, Cambridge, Massachusetts, 02142 USA
| | - Eva Ellinghaus
- Institute of Clinical Molecular Biology, Christian-Albrechts-University, Kiel, Germany
| | - Kirsten MuriBoberg
- Norwegian PSC Research Center, Clinic for Specialized Surgery and Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Espen Melum
- Norwegian PSC Research Center, Clinic for Specialized Surgery and Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Trine Folseraas
- Norwegian PSC Research Center, Clinic for Specialized Surgery and Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Erik Schrumpf
- Norwegian PSC Research Center, Clinic for Specialized Surgery and Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Annika Bergquist
- Department of Gastroenterology and Hepatology, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Einar Bjornsson
- Section of Gastroenterology and Hepatology, Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jingyuan Fu
- Department of Genetics, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands
| | - Harm Jan Westra
- Department of Genetics, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands
| | - Harry JM Groen
- Department of Pulmonology, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands
| | - Rudolf SN Fehrmann
- Department of Genetics, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands
| | - Joanna Smolonska
- Department of Genetics, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands
| | - Leonard H van den Berg
- Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Roel A Ophoff
- Department of Medical Genetics and Rolf Magnus Institute, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Robert J Porte
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands
| | - Tobias J Weismuller
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Jochen Wedemeyer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Christoph Schramm
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martina Sterneck
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rainer Gunther
- 1st Department of Medicine, University Medical Centre Schleswig-Holstein (UK S-H), Campus Kiel, Germany
| | - Felix Braun
- Department of General and Thoracic Surgery, University Medical Centre Schleswig-Holstein (UK S-H), Campus Kiel, Germany
| | - Severine Vermeire
- Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Liesbet Henckaerts
- Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Cisca Wijmenga
- Department of Genetics, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands
| | - Cyriel Y. Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Stefan Schreiber
- Institute of Clinical Molecular Biology, Christian-Albrechts-University, Kiel, Germany
| | - Tom HKarlsen
- Norwegian PSC Research Center, Clinic for Specialized Surgery and Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Andre Franke
- Institute of Clinical Molecular Biology, Christian-Albrechts-University, Kiel, Germany
| | - Rinse K Weersma
- Department of Gastroenterology and Hepatology, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands
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Ruys AT, Tanis PJ, Nagtegaal ID, Iris ND, van Duijvendijk P, Verhoef C, Porte RJ, van Gulik TM. Surgical treatment of renal cell cancer liver metastases: a population-based study. Ann Surg Oncol 2011; 18:1932-8. [PMID: 21347794 PMCID: PMC3115064 DOI: 10.1245/s10434-010-1526-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Indexed: 12/12/2022]
Abstract
BACKGROUND To evaluate outcomes of surgical treatment in patients with hepatic metastases from renal-cell carcinoma in the Netherlands, and to identify prognostic factors for survival after resection. Renal-cell carcinoma has an incidence of 2,000 new patients in the Netherlands each year (12.5/100,000 inhabitants). According to literature, half of these patients ultimately develop distant metastases with 20% involvement of the liver. Resection of renal-cell carcinoma liver metastases (RCCLM) is performed in only a minority of patients. Hence, little is known about outcome of resectable RCCLM. METHODS Patients were retrieved from local databases of the Netherlands Task Force for Liver Surgery (14 centers) and from the Dutch collective pathology database. Survival and prognostic factors were determined by Kaplan-Meier analysis and log rank test. RESULTS Thirty-three patients were identified who underwent resection (n = 29) or local ablation (n = 4) of RCCLM in the Netherlands between 1990 and 2008. These patients comprise 0.5% to 1% of the total population of patients diagnosed with RCCLM in that period. There was no operative mortality. The overall survival at 1, 3, and 5 years was 79, 47, and 43%, respectively. Metachronous metastases (n = 23, P = 0.03) and radical resection (n = 19, P < 0.001) were statistically significant prognosticators of overall survival. Size < 50 mm (n = 18, P = 0,54), solitary metastases (n = 19, P = 0.93), and presence of extrahepatic metastases (n = 11, P = 0.28) did not have a statistically significant impact on survival. CONCLUSIONS The favorable 5-year survival rate of 43% without operative mortality as found in this nationwide study indicates that selected patients with RCCLM can benefit from surgical treatment.
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Affiliation(s)
- Anthony T Ruys
- Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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226
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Franssen CFM, Kema IP, Eleveld DJ, Porte RJ, Homan van der Heide JJ. Intra-operative continuous renal replacement therapy during combined liver-kidney transplantation in two patients with primary hyperoxaluria type 1. NDT Plus 2011; 4:113-6. [PMID: 25984128 PMCID: PMC4421572 DOI: 10.1093/ndtplus/sfq216] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 12/20/2010] [Indexed: 11/25/2022] Open
Abstract
Liver–kidney transplantation in patients with primary hyperoxaluria type 1 (PH1) and a high systemic oxalate load is often complicated by oxalate deposition in the renal allograft and loss of renal function. Intensive pre- and post-operative haemodialysis (HD) cannot completely prevent rises in plasma oxalate levels during transplantation because of rebound from saturated oxalate stores. Continuous renal replacement therapy may overcome this problem. In two PH1 patients with extensive oxalate accumulation, we found that intra-operative continuous venovenous haemodiafiltration effectively cleared oxalate and kept oxalate at relatively low levels following preoperative HD.
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Affiliation(s)
- Casper F M Franssen
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ido P Kema
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Douglas J Eleveld
- Department of Anaesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Department of Surgery, Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jaap J Homan van der Heide
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Eguchi S, Soyama A, Mergental H, van den Berg AP, Scheenstra R, Porte RJ, Slooff MJH. Honoring the contract with our patients: outcome after repeated re-transplantation of the liver. Clin Transplant 2010; 25:E211-8. [PMID: 21198856 DOI: 10.1111/j.1399-0012.2010.01389.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The aim of this study was to describe the outcome after repeated orthotopic liver re-transplantations (re-OLT) in a population of adults and children, and to determine whether such repeated re-transplantations are an effective treatment or should be considered futile. In a consecutive series of 867 patients, 628 adults and 239 children, who underwent OLT at the University Medical Center Groningen, 23 patients (2.7%), 10 adults and 13 children, underwent more than two re-transplantations of the liver between March 1979 and October 2008. All 23 patients had a second re-transplantation, and seven of them received a third transplant. The overall actuarial patient survival at 1, 5, and 10 yr after primary OLT was 96%, 87%, and 71%, respectively. The overall actuarial patient survival after the second re-OLT was 78%, 73%, and 67%, respectively. Sixteen patients (70%) survived long term. However, for the 23 repeated re-transplantation patients, 76 grafts were used. In a simulation calculation, it was shown that honoring the initial commitment to the 23 patients ultimately led to more surviving patients and less death than if treatment of the original patients was stopped after the first re-transplantation and the remaining grafts were allocated to other primary graft recipients.
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Affiliation(s)
- Susumu Eguchi
- Division of Hepatopancreatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands.
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Khan AA, Chow ECY, Porte RJ, Pang KS, Groothuis GMM. The role of lithocholic acid in the regulation of bile acid detoxication, synthesis, and transport proteins in rat and human intestine and liver slices. Toxicol In Vitro 2010; 25:80-90. [PMID: 20888898 DOI: 10.1016/j.tiv.2010.09.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Revised: 07/25/2010] [Accepted: 09/26/2010] [Indexed: 10/19/2022]
Abstract
The effects of the secondary bile acid, lithocholic acid (LCA), a VDR, FXR and PXR ligand, on the regulation of bile acid metabolism (CYP3A isozymes), synthesis (CYP7A1), and transporter proteins (MRP3, MRP2, BSEP, NTCP) as well as nuclear receptors (FXR, PXR, LXRα, HNF1α, HNF4α and SHP) were studied in rat and human precision-cut intestine and liver slices at the mRNA level. Changes due to 5 to 10 μM of LCA were compared to those of other prototype ligands for VDR, FXR, PXR and GR. LCA induced rCYP3A1 and rCYP3A9 in the rat jejunum, ileum and colon, rCYP3A2 only in the ileum, rCYP3A9 expression in the liver, and CYP3A4 in the human ileum but not in liver. LCA induced the expression of rMRP2 in the colon but not in the jejunum and ileum but did not affect rMRP3 expression along the length of the rat intestine. In human ileum slices, LCA induced hMRP3 and hMRP2 expression. In rat liver slices, LCA decreased rCYP7A1, rLXRα and rHNF4α expression, induced rSHP expression, but did not affect rBSEP or rNTCP expression; whereas in the human liver, a small but significant decrease was found for hHNF1α expression. These data suggests profound species differences in the effects of LCA on bile acid transport, synthesis and detoxification. An examination of the effects of prototype VDR, PXR, GR and FXR ligands showed that these pathways are all intact in precision cut slices and that LCA exerted VDR, PXR and FXR effects. The LCA-induced altered enzymes and transporter expressions in the intestine and liver would affect the disposition of drugs.
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Affiliation(s)
- Ansar A Khan
- Department of Pharmacy, University of Groningen, Groningen, The Netherlands
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229
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de Rooij BJF, van Hoek B, ten Hove WR, Roos A, Bouwman LH, Schaapherder AF, Porte RJ, Daha MR, van der Reijden JJ, Coenraad MJ, Ringers J, Baranski AG, Hepkema BG, Hommes DW, Verspaget HW. Lectin complement pathway gene profile of donor and recipient determine the risk of bacterial infections after orthotopic liver transplantation. Hepatology 2010; 52:1100-10. [PMID: 20593422 DOI: 10.1002/hep.23782] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
UNLABELLED Infectious complications after orthotopic liver transplantation (OLT) are a major clinical problem. The lectin pathway of complement activation is liver-derived and a crucial effector of the innate immune defense against pathogens. Polymorphisms in lectin pathway genes determine their functional activity. We assessed the relationship between these polymorphic genes and clinically significant bacterial infections, i.e., sepsis, pneumonia, and intra-abdominal infection, and mortality within the first year after OLT, in relation to major risk factors in two cohorts from different transplant centers. Single-nucleotide polymorphisms in the mannose-binding lectin gene (MBL2), the ficolin-2 gene (FCN2), and the MBL-associated serine protease gene (MASP2) of recipients and donors were determined. Recipients receiving a donor liver in the principal cohort with polymorphisms in all three components i.e., MBL2 (XA/O; O/O), FCN2+6359T, and MASP2+371A, had a cumulative risk of an infection of 75% as compared to 18% with wild-type donor livers (P = 0.002), an observation confirmed in the second cohort (P = 0.04). In addition, a genetic (mis)match between donor and recipient conferred a two-fold higher infection risk for each separate gene. Multivariate Cox analysis revealed a stepwise increase in infection risk with the lectin pathway gene profile of the donor (hazard ratio = 4.52; P = 8.1 x 10(-6)) and the donor-recipient (mis)match genotype (hazard ratio = 6.41; P = 1.9 x 10(-7)), independent from the other risk factors sex and antibiotic prophylaxis (hazard ratio > 1.7 and P < 0.02). Moreover, patients with a lectin pathway gene polymorphism and infection had a six-fold higher mortality (P = 0.9 x 10(-8)), of which 80% was infection-related. CONCLUSION Donor and recipient gene polymorphisms in the lectin complement pathway are major determinants of the risk of clinically significant bacterial infection and mortality after OLT.
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Affiliation(s)
- Bert-Jan F de Rooij
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Lisman T, Caldwell SH, Burroughs AK, Northup PG, Senzolo M, Stravitz RT, Tripodi A, Trotter JF, Valla DC, Porte RJ. Hemostasis and thrombosis in patients with liver disease: the ups and downs. J Hepatol 2010; 53:362-71. [PMID: 20546962 DOI: 10.1016/j.jhep.2010.01.042] [Citation(s) in RCA: 218] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Revised: 01/28/2010] [Accepted: 01/29/2010] [Indexed: 12/13/2022]
Abstract
Patients with chronic or acute liver failure frequently show profound abnormalities in their hemostatic system. Whereas routine laboratory tests of hemostasis suggest these hemostatic alterations result in a bleeding diathesis, accumulating evidence from both clinical and laboratory studies suggest that the situation is more complex. The average patient with liver failure may be in hemostatic balance despite prolonged routine coagulation tests, since both pro- and antihemostatic factors are affected, the latter of which are not well reflected in routine coagulation testing. However, this balance may easily tip towards a hypo- or hypercoagulable situation. Indeed, patients with liver disease may encounter both hemostasis-related bleeding episodes as well as thrombotic events. During the 3rd International Symposium on Coagulopathy and Liver disease, held in Groningen, The Netherlands (18-19 September 2009), a multidisciplinary panel of experts critically reviewed the current data concerning pathophysiology and clinical consequences of hemostatic disorders in patients with liver disease. Highlights of this symposium are summarized in this review.
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Affiliation(s)
- Ton Lisman
- Section Hepatobiliairy Surgery and Liver Transplantation, The Netherlands.
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231
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Dubbeld J, Hoekstra H, Farid W, Ringers J, Porte RJ, Metselaar HJ, Baranski AG, Kazemier G, van den Berg AP, van Hoek B. Authors' reply: Similar liver transplantation survival with selected cardiac death donors and brain death donors ( Br J Surg 2010; 97; 744–753). Br J Surg 2010. [DOI: 10.1002/bjs.7208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- J Dubbeld
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - H Hoekstra
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - W Farid
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - J Ringers
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - R J Porte
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - H J Metselaar
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - A G Baranski
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - G Kazemier
- Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - A P van den Berg
- Department of Gastroenterology and Hepatology, University Medical Centre Groningen, Groningen, The Netherlands
| | - B van Hoek
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
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232
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Ruitenbeek K, Meijers JCM, Adelmeijer J, Hendriks HGD, Porte RJ, Lisman T. Intact thrombomodulin-mediated regulation of fibrinolysis during and after liver transplantation, despite a profoundly defective thrombomodulin-mediated regulation of coagulation. J Thromb Haemost 2010; 8:1646-9. [PMID: 20403095 DOI: 10.1111/j.1538-7836.2010.03886.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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233
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Warnaar N, Polak WG, de Jong KP, de Boer MT, Verkade HJ, Sieders E, Peeters PMJG, Porte RJ. Long-term results of urgent revascularization for hepatic artery thrombosis after pediatric liver transplantation. Liver Transpl 2010; 16:847-55. [PMID: 20583091 DOI: 10.1002/lt.22063] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Hepatic artery thrombosis (HAT) after pediatric orthotopic liver transplantation (OLT) is a serious complication resulting in bile duct necrosis and often requiring retransplantation. Immediate surgical thrombectomy/thrombolysis has been reported to be a potentially successful treatment for restoring blood flow and avoiding urgent retransplantation. The long-term results of this strategy remain to be determined. In 232 pediatric liver transplants, we analyzed long-term outcomes after urgent revascularization for early HAT. HAT developed in 32 patients (13.7%). In 16 children (50%), immediate surgical thrombectomy was performed in an attempt to salvage the graft. Fourteen patients (44%) underwent urgent retransplantation, and 2 (6%) died before further intervention. Immediate thrombectomy resulted in long-term restoration of the hepatic artery flow in 6 of 16 patients (38%) and in 1- and 5-year graft and patient survival rates of 83% and 67%, respectively. In 10 patients, revascularization was unsuccessful, and retransplantation was inevitable. The 1- and 5-year patient survival rates in this group decreased to 50% and 40%, respectively. After immediate retransplantation, the 5-year patient survival rate was 71%. In conclusion, immediate surgical thrombectomy for HAT after pediatric OLT results in long-term graft salvage in about one-third of patients. However, when thrombectomy is unsuccessful, long-term patient survival is lower than the survival of patients who underwent immediate retransplantation.
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Affiliation(s)
- Nienke Warnaar
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, Groningen, the Netherlands
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234
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Abstract
The Model for End-Stage Liver Disease (MELD) score is widely used to prioritize patients for liver transplantation. One of the pitfalls of the MELD score is the interlaboratory variability in all three components of the score (INR, bilirubin, creatinine). The interlaboratory variability in the INR has the largest impact on the MELD score, with a mean difference of around 5 MELD points in most studies. During the 3rd conference on Coagulopathy and Liver disease, a multidisciplinary group of scientists and physicians discussed possible solutions for the INR problem in the MELD score with the intention to provide a constructive contribution to the international debate on this issue. Here we will discuss possible solutions and highlight advantages and disadvantages.
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Affiliation(s)
- R J Porte
- Section Hepatobiliairy Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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235
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Dubbeld J, Hoekstra H, Farid W, Ringers J, Porte RJ, Metselaar HJ, Baranski AG, Kazemier G, van den Berg AP, van Hoek B. Similar liver transplantation survival with selected cardiac death donors and brain death donors. Br J Surg 2010; 97:744-53. [PMID: 20393979 DOI: 10.1002/bjs.7043] [Citation(s) in RCA: 164] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The outcome of orthotopic liver transplantation (OLT) with controlled graft donation after cardiac death (DCD) is usually inferior to that with graft donation after brain death (DBD). This study compared outcomes from OLT with DBD versus controlled DCD donors with predefined restrictive acceptance criteria. METHODS All adult recipients in the Netherlands in 2001-2006 with full-size OLT from DCD (n = 55) and DBD (n = 471) donors were included. Kaplan-Meier, log rank and Cox regression analyses were used. RESULTS One- and 3-year patient survival rates were similar for DCD (85 and 80 per cent) and DBD (86.3 and 80.8 per cent) transplants (P = 0.763), as were graft survival rates (74 and 68 per cent versus 80.4 and 74.5 per cent; P = 0.212). The 3-year cumulative percentage of surviving grafts developing non-anastomotic biliary strictures was 31 per cent after DCD and 9.7 per cent after DBD transplantation (P < 0.001). The retransplantation rate was similar overall (P = 0.081), but that for biliary stricture was higher in the DCD group (P < 0.001). Risk factors for 1-year graft loss after DBD OLT were transplant centre, recipient warm ischaemia time and donor with severe head trauma. After DCD OLT they were transplant centre, donor warm ischaemia time and cold ischaemia time. DCD graft was a risk factor for non-anastomotic biliary stricture. CONCLUSION OLT using controlled DCD grafts and restrictive criteria can result in patient and graft survival rates similar to those of DBD OLT, despite a higher risk of biliary stricture.
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Affiliation(s)
- J Dubbeld
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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236
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Haagsma EB, Riezebos-Brilman A, van den Berg AP, Porte RJ, Niesters HGM. Treatment of chronic hepatitis E in liver transplant recipients with pegylated interferon alpha-2b. Liver Transpl 2010; 16:474-7. [PMID: 20373458 DOI: 10.1002/lt.22014] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Hepatitis E virus (HEV) infections are known to run a self-limiting course. Recently, chronic hepatitis E has been described in immunosuppressed patients after solid-organ transplantation. Besides the general recommendation to lower the immunosuppressive medication in these patients, there is currently no specific treatment. We here describe the successful use of pegylated interferon alpha-2b in the treatment of 2 liver transplant recipients who suffered a chronic HEV infection for 9 years (case A) or 9 months (case B). After 4 weeks of therapy, a 2-log decrease (case A) and a 3-log decrease (case B) in the viral load were observed. In case A, who received treatment for 1 year, serum viral RNA became undetectable from week 20 onward, and serum liver enzymes normalized completely. In case B, interferon was discontinued at week 16 because of a lack of a further decline in the viral load. However, 4 weeks after the cessation of therapy, viral RNA was no longer detectable in the serum, and this was probably related to a further decline in the immunosuppressive medication. Liver tests normalized completely. In both cases, no relapse has been noted so far. We conclude that pegylated interferon alpha-2b may be useful in the treatment of chronic HEV infections in patients in whom the reduction of the immunosuppressive medication alone is not sufficient.
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Affiliation(s)
- Elizabeth B Haagsma
- Department of Gastroenterology and Hepatology,University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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237
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Abstract
Hepatocellular carcinoma (HCC) arising in noncirrhotic and nonfibrotic liver (NC-HCC) is a rare type of malignancy frequently found in healthy young individuals. Partial liver resection is the treatment of choice with expected 5-year survival rates between 40% and 70%. As a result of absence of any symptom, a considerable number of patients are diagnosed when the malignancy has progressed to an advanced stage and the tumor has turned already unresectable. Some other patients suffer from intrahepatic recurrence after previous liver resection that cannot be re-resected or locally ablated. In these situations, liver transplantation (LT) may be the only potentially curative treatment. The indication for LT in NC-HCC patients, however, is not well established. The preliminary results of recent analysis of the European Liver Transplant Registry (ELTR) together with a literature review identified over 150 patients transplanted for NC-HCC during the last 15 years. In contrast to the historical data, these studies showed 5-year survival rates at 50-70% in well-selected patients. Important determinants of poor outcome are macrovascular invasion, lymph node involvement, and time interval of <12 months when LT is used as rescue therapy for intrahepatic recurrence after a previous partial liver resection. Interestingly, outcomes after both liver resection and LT for NC-HCC are much less influenced by tumor size than is the case with cirrhotic HCC. A large tumor size per se should, therefore, not to be seen as a strict contraindication for performing LT in patients with NC-HCC.
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Affiliation(s)
- Hynek Mergental
- Oxford Transplant Centre and Department of Hepato-Pancreato-Biliary Surgery, Oxford Radcliffe Hospitals NHS Trust, Churchill Hospital, Oxford, UK
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238
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Abstract
Hepatocellular carcinoma (HCC) arising in noncirrhotic and nonfibrotic liver (NC-HCC) is a rare type of malignancy frequently found in healthy young individuals. Partial liver resection is the treatment of choice with expected 5-year survival rates between 40% and 70%. As a result of absence of any symptom, a considerable number of patients are diagnosed when the malignancy has progressed to an advanced stage and the tumor has turned already unresectable. Some other patients suffer from intrahepatic recurrence after previous liver resection that cannot be re-resected or locally ablated. In these situations, liver transplantation (LT) may be the only potentially curative treatment. The indication for LT in NC-HCC patients, however, is not well established. The preliminary results of recent analysis of the European Liver Transplant Registry (ELTR) together with a literature review identified over 150 patients transplanted for NC-HCC during the last 15 years. In contrast to the historical data, these studies showed 5-year survival rates at 50-70% in well-selected patients. Important determinants of poor outcome are macrovascular invasion, lymph node involvement, and time interval of <12 months when LT is used as rescue therapy for intrahepatic recurrence after a previous partial liver resection. Interestingly, outcomes after both liver resection and LT for NC-HCC are much less influenced by tumor size than is the case with cirrhotic HCC. A large tumor size per se should, therefore, not to be seen as a strict contraindication for performing LT in patients with NC-HCC.
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Affiliation(s)
- Hynek Mergental
- Oxford Transplant Centre and Department of Hepato-Pancreato-Biliary Surgery, Oxford Radcliffe Hospitals NHS Trust, Churchill Hospital, Oxford, UK
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239
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Lisman T, Bakhtiari K, Pereboom ITA, Hendriks HGD, Meijers JCM, Porte RJ. Normal to increased thrombin generation in patients undergoing liver transplantation despite prolonged conventional coagulation tests. J Hepatol 2010; 52:355-61. [PMID: 20132999 DOI: 10.1016/j.jhep.2009.12.001] [Citation(s) in RCA: 163] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Revised: 08/25/2009] [Accepted: 10/21/2009] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Patients with liver disease often show substantial changes in their hemostatic system, which may aggravate further during liver transplantation. Recently, thrombin generation in patients with stable disease was shown to be indistinguishable from controls provided thrombomodulin, the natural activator of the anticoagulant protein C system, was added to the plasma. These results indicated that the hemostatic balance is preserved in patients with liver disease, despite conventional coagulation tests suggest otherwise. METHODS Here we examined thrombin generation profiles in serial plasma samples taken from ten consecutive patients undergoing liver transplantation. RESULTS At all time points, the endogenous thrombin potential (ETP) was slightly lower compared to healthy volunteers, despite substantially prolonged PT and APTT values. However, when thrombin generation was tested in the presence of thrombomodulin, the ETP was equal to or even higher than that in healthy subjects. In fact, thrombin generation was hardly affected by thrombomodulin, while thrombin generation in healthy subjects decreased profoundly upon the addition of thrombomodulin. In patients undergoing liver transplantation, efficient thrombin generation in the presence of thrombomodulin may be explained by decreased levels of protein C, S, and antithrombin, and by elevated levels of FVIII. CONCLUSIONS Thrombin generation in patients undergoing liver transplantation is equal or even superior to thrombin generation in healthy volunteers when tested in the presence of exogenous thrombomodulin. These results support the recently advocated restrictive use of plasma during liver transplantation and warrants further study of the prophylactic use of anticoagulants to reduce thromboembolic complications after transplantation.
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Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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240
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Abstract
INTRODUCTION Paediatric blunt hepatic trauma treatment is changing from operative treatment (OT) to non-operative treatment (NOT). In 2000 the American Pediatric Surgical Association has published guidelines for NOT of these injuries. Little is known about the treatment of paediatric liver trauma in the Netherlands. PATIENTS AND METHODS Data of all patients aged 18 years and younger admitted to our hospital for blunt hepatic trauma in the past 18 years were retrospectively analysed using a prospective trauma registry. The mechanism of injury, treatment, ICU admission time, total admission time, morbidity and mortality were assessed. Subsequently the group was divided into patients treated before and after 2000. RESULTS Eighty patients were identified: 52M, 28F with a mean age of 12 years (range 2-18). Thirty patients sustained isolated liver injury. Concomitant injuries were fractures of long bones (28), abdominal (25), chest (24) and head injuries (18). Mean ISS score was 18 (range 4-57). Mortality was 8%. Mechanisms of injury consisted of bicycle (25%), car (20%), and motorcycle accidents (15%), pedestrian hit by vehicle (15%), fall from height (14%) and accidents associated with animals (11%). Haemodynamically stable patients underwent NOT (55). 25 patients (31%) underwent a laparotomy, which in 20 cases (80%) was related to hepatic injury. Although the groups treated before and after 2000 did not differ haemodynamically on admission to hospital, a shift to NOT is evident: 24/37 (63%) patients underwent NOT before 2000 versus 38/45 (84%) after 2000 (p=0.04). Complications following NOT were rare. Late onset bleeding did not occur. Two patients developed an infected biloma, requiring a laparotomy. Mean ICU stay before 2000 was 4.2 days (range 0-25 days) and 2.6 days (range 0-17 days) after 2000. Total hospital time did not decrease: 14 days (range 1-39 days) before 2000 and 14 days (range 1-60 days) after 2000. The overall mortality was 8%. All deaths occurred in the operative group and were spread evenly over both periods. CONCLUSION In blunt paediatric liver trauma, the incidence and trauma mechanism seem age-related. A shift to NOT is found in the treatment of paediatric blunt hepatic trauma. NOT is the preferred treatment for the haemodynamically stable patient. Complications are rare and the success rate is 96%. The mean ICU stay has decreased but the total admission time could possibly be shortened.
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Affiliation(s)
- D Nellensteijn
- Surgery, subdivision Traumatology, University Medical Center Groningen, Groningen, Netherlands
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241
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Haagsma EB, Niesters HGM, van den Berg AP, Riezebos-Brilman A, Porte RJ, Vennema H, Reimerink JHJ, Koopmans MPG. Prevalence of hepatitis E virus infection in liver transplant recipients. Liver Transpl 2009; 15:1225-8. [PMID: 19790147 DOI: 10.1002/lt.21819] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Hepatitis E virus (HEV) infection is known to run a self-limited course. Recently, chronic hepatitis E has been described in several immunosuppressed patients after solid organ transplantation. The prevalence of HEV infection after transplantation, however, is unknown. We studied HEV parameters [HEV RNA, HEV immunoglobulin M (IgM), and HEV immunoglobulin G (IgG) by enzyme-linked immunosorbent assay and confirmatory immunoblotting] in a cohort of 285 adult liver transplant recipients. The most recent freeze-stored sera were investigated, and if they were positive, a retrospective analysis was performed. Samples from 274 patients (96.1%) tested negative for all HEV parameters. This included a patient described earlier as having experienced an episode of chronic HEV hepatitis in the past. One patient was found positive for HEV RNA without HEV antibodies. She presently suffers from chronic HEV hepatitis and has also been described before. Sera from 9 patients tested positive for HEV IgG without HEV IgM or HEV RNA. Six of these 9 patients (2.1% of the total) were found to have HEV IgG antibodies in retrospect related to an HEV infection at some time pre-transplant as they also tested positive in a pretransplant serum sample. One of these 9 patients suffered in retrospect from a chronic HEV infection with mild hepatitis between 2 and 5 years after liver transplantation on the basis of the course of HEV RNA, IgM, and IgG, aminotransferases, and liver histology. Overall, the prevalence of acquired HEV hepatitis after liver transplantation was 1% in this cohort. We conclude that liver transplant recipients have a risk for chronic HEV infection, but the prevalence is low.
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Affiliation(s)
- Elizabeth B Haagsma
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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242
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Yang H, Plösch T, Lisman T, Gouw ASH, Porte RJ, Verkade HJ, Hulscher JBF. Inflammation mediated down-regulation of hepatobiliary transporters contributes to intrahepatic cholestasis and liver damage in murine biliary atresia. Pediatr Res 2009; 66:380-5. [PMID: 19581828 DOI: 10.1203/pdr.0b013e3181b454a4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
To investigate the hypothesis that during the development of biliary atresia, early changes in hepatobiliary transport are mainly related to the inflammatory process and lead to intrahepatic cholestasis and subsequent liver injury, livers from mice with rhesus rotavirus-induced biliary atresia were analyzed for mRNA expression of hepatobiliary transporters, nuclear receptors, and inflammatory cytokines. Seven days after inoculation, despite high bile acid concentrations in the liver, gene expression of canalicular and basolateral hepatobiliary transporters and their regulatory nuclear receptors was down-regulated with concomitant increase in gene expression of inflammatory cytokines and rise in serum unconjugated bilirubin. At 14 d, hepatobiliary transporters and nuclear receptors remained down-regulated although the inflammatory response subsided. The percentage of conjugated bilirubin started to increase as extrahepatic biliary obstruction occurred. At 18 d, expression of hepatobiliary transporters remained low, expression of nuclear receptors returned to normal, while expression of inflammatory cytokines decreased further. Moreover, histology demonstrated progressive inflammation, bile duct damage, ductular proliferation, and hepatocyte necrosis. In conclusion, intrahepatic cholestasis due to inflammation-related down-regulation of basolateral and canalicular hepatobiliary transporters is an early event in the development of biliary atresia. Intrahepatic cholestasis contributes to the development of jaundice and liver injury.
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Affiliation(s)
- Huiqi Yang
- Department of Surgery, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen 9700 RB, The Netherlands
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243
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van der Werf J, Porte RJ, Lisman T. Hemostasis in patients with liver disease. Acta Gastroenterol Belg 2009; 72:433-440. [PMID: 20163038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
In patients with liver disease alterations in the hemostatic system frequently occur. Although it was generally believed that these changes result in a bleeding tendency, laboratory models and clinical data have shown evidence for a rebalanced hemostasis in liver disease, as a result of a concomitant decrease in both pro- and antihemostatic systems. The rebalanced system presumably has much narrower margins as compared to healthy individuals and therefore can more easily turn to either a hypo- or hypercoagulable state. Bleeding does occur in patients with liver disease but this is frequently related to non-hematological factors, for example bleeding from ruptured esophageal varices. Further clinical data supporting the concept of rebalanced hemostasis include the lack of major blood loss in a great proportion of patients during liver transplantation and the fact that patients with liver disease are not fully protected from thromboembolic complications including venous thrombosis and thrombosis of the hepatic vessels. It is still common practice to prophylactically treat patients with liver disease prior to invasive procedures to prevent bleeding. Because of a lack of data supporting the effectiveness of this management and the proven side-effects of transfusion of blood products, we believe transfusion of blood products can and should be restricted. The most important thrombotic problem after liver transplantation is hepatic artery thrombosis, a potentially devastating complication. Since the bleeding tendency in patients with liver disease may not be primarily caused by a deranged hemostatic system, the restricted use of anticoagulant drugs in the post-transplant setting should be reconsidered.
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Affiliation(s)
- J van der Werf
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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244
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Abstract
Patients with liver disease frequently have substantial changes in their haemostatic system. This is reflected in abnormal test results on routine coagulation screening assays such as the prothrombin time (PT), activated thromboplastin time (APTT) and platelet count. Traditionally, attempts were made to correct abnormalities in the haemostatic system as measured by routine coagulation assays prior to invasive procedures by infusion of platelets or fresh frozen plasma (FFP). Recent laboratory and clinical data have indicated that the haemostatic reserve in cirrhotic patients is relatively well maintained although the coagulation screening assays suggest otherwise. Pre-procedural correction of coagulation tests with blood products may therefore not be necessary, and may even have harmful side-effects. In particular, fluid overload resulting in exacerbation of portal hypertension by infusion of blood products may in fact promote bleeding. In recent years, it has become clear that reduction of the central and portal venous pressure by fluid restriction and avoidance of blood product transfusion is a beneficial strategy in minimizing bleeding during liver surgery in cirrhotic patients. Some investigators have even taken this a step further and suggested pre-procedural phlebotomy in liver transplant recipients. The aim of this review is to provide an overview of recent studies and developments which have changed our understanding of the clinical relevance of abnormal coagulation tests in patients with cirrhosis, and which have contributed to a reduction in blood loss and transfusion requirements when liver surgery is needed in these patients.
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Affiliation(s)
- Andrie C Westerkamp
- Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of GroningenGroningen, the Netherlands
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of GroningenGroningen, the Netherlands,Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of GroningenGroningen, the Netherlands
| | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of GroningenGroningen, the Netherlands
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245
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Ijtsma AJC, van der Hilst CS, de Boer MT, de Jong KP, Peeters PMJG, Porte RJ, Slooff MJH. The clinical relevance of the anhepatic phase during liver transplantation. Liver Transpl 2009; 15:1050-5. [PMID: 19718649 DOI: 10.1002/lt.21791] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This study assesses the relation between the anhepatic phase duration and the outcome after liver transplantation. Of 645 patients who underwent transplantation between 1994 and 2006, 194 were recipients of consecutive adult primary piggyback liver transplants using heart-beating donors. The anhepatic phase was defined as the time from the physical removal of the liver from the recipient to recirculation of the graft. Other noted study variables were the cold and warm ischemia times, donor and recipient age, donor and recipient body mass index, perioperative red blood cell (RBC) transfusion, indication for transplantation, and Model for End-Stage Liver Disease score. The primary outcome parameter was graft dysfunction, which was defined as either primary nonfunction or initial poor function according to the Ploeg-Maring criteria. The median anhepatic phase was 71 minutes (37-321 minutes). Graft dysfunction occurred in 27 patients (14%). Logistic regression analysis showed an anhepatic phase over 100 minutes [odds ratio (OR), 4.28], a recipient body mass index over 25 kg/m(2) (OR, 3.21), and perioperative RBC transfusion (OR, 3.04) to be independently significant predictive factors for graft dysfunction. One-year patient survival in patients with graft dysfunction was 67% versus 92% in patients without graft dysfunction (P < 0.001). A direct relation between the anhepatic phase duration and patient survival could, however, not be established. In conclusion, this study shows that liver transplant patients with an anhepatic phase over 100 minutes have a higher incidence of graft dysfunction. Patients with graft dysfunction have significantly worse 1-year patient survival.
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Affiliation(s)
- Alexander J C Ijtsma
- Division of Hepatopancreatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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246
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Pereboom ITA, de Boer MT, Haagsma EB, van der Heide F, Porcelijn L, Lisman T, Porte RJ. Transmission of idiopathic thrombocytopenic purpura during orthotopic liver transplantation. Transpl Int 2009; 23:236-8. [PMID: 19691662 DOI: 10.1111/j.1432-2277.2009.00936.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Hoekstra H, Buis CI, Verdonk RC, van der Hilst CS, van der Jagt EJ, Haagsma EB, Porte RJ. Is Roux-en-Y choledochojejunostomy an independent risk factor for nonanastomotic biliary strictures after liver transplantation? Liver Transpl 2009; 15:924-30. [PMID: 19642122 DOI: 10.1002/lt.21764] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Biliary reconstruction using Roux-en-Y choledochojejunostomy has been suggested as a risk factor for the development of nonanastomotic biliary strictures (NAS) after liver transplantation. Roux-en-Y reconstruction, however, is preferentially used in patients transplanted for primary sclerosing cholangitis (PSC), and the disease itself is also associated with a higher incidence of NAS. The aim of this study was to determine whether Roux-en-Y reconstruction is really an independent risk factor for NAS. A series of 486 consecutive adult liver transplants were studied. Biliary reconstruction in patients transplanted for PSC was either by Roux-en-Y choledochojejunostomy or by duct-to-duct anastomosis, depending on the quality of the recipient's extrahepatic bile duct. Univariate and multivariate statistical analyses were used to identify risk factors for the development of NAS. The overall incidence of NAS was 16.5% (80/486). In univariate analyses, the following variables were significantly associated with NAS: PSC as the indication for transplantation, type of biliary reconstruction (Roux-en-Y versus duct-to-duct), and postoperative cytomegalovirus infection. After multivariate logistic regression analysis, PSC as the indication for transplantation (odds ratio, 2.813; 95% confidence interval, 1.624-4.875; P < 0.001) and postoperative cytomegalovirus infection (odds ratio, 2.098; 95% confidence interval, 1.266-3.477; P = 0.004) remained as independent risk factors for NAS. Biliary reconstruction using Roux-en-Y choledochojejunostomy was not identified as an independent risk factor for NAS. In conclusion, the association between Roux-en-Y choledochojejunostomy and NAS observed in previous studies can be explained by the more frequent use of Roux-en-Y reconstruction in patients with PSC. Roux-en-Y reconstruction itself is not an independent risk factor for NAS. Liver Transpl 15:924-930, 2009. (c) 2009 AASLD.
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Affiliation(s)
- Harm Hoekstra
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, Groningen, The Netherlands
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Pereboom ITA, Adelmeijer J, van Leeuwen Y, Hendriks HGD, Porte RJ, Lisman T. No evidence for systemic platelet activation during or after orthotopic liver transplantation. Liver Transpl 2009; 15:956-62. [PMID: 19642138 DOI: 10.1002/lt.21776] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Platelet function is thought to deteriorate during liver transplantation as a result of platelet activation and proteolysis of platelet receptors by plasmin following reperfusion. However, this hypothesis has never been formally tested. Twenty patients undergoing a first or second liver transplant were included in the study. Blood samples were taken at standardized time points during transplantation and up to 10 days after transplantation. Platelet activation was assessed by detection of the activation markers P-selectin and activated integrin alphaIIbbeta3 with flow cytometry. Proteolytic cleavage of platelet receptors was assessed by flow cytometry measurement of the constitutively expressed platelet receptors glycoprotein Ibalpha and integrin alphaIIbbeta3. In addition, using enzyme-linked immunosorbent assay techniques, we measured plasma levels of platelet activation products beta-thromboglobulin and platelet factor 4 and plasma levels of cleaved fragments of glycoproteins Ibalpha and V. Flow cytometry analyses provided no evidence of substantial platelet activation during transplantation. In fact, the expression of activated integrin alphaIIbbeta3 decreased postoperatively; this indicated that platelets were in a slightly activated state prior to surgery. Plasma levels of beta-thromboglobulin and platelet factor 4 also substantially decreased after transplantation. In addition, no changes were observed in the constitutively expressed platelet receptors or in the plasma levels of platelet receptor fragments, and this indicated a lack of substantial receptor proteolysis. In conclusion, no evidence was found for significant activation of circulating blood platelets or the proteolysis of key platelet receptors during liver transplantation. These findings suggest that the platelet functional capacity does not decrease during liver transplantation. Liver Transpl 15:956-962, 2009. (c) 2009 AASLD.
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Affiliation(s)
- Ilona T A Pereboom
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Abstract
After liver transplantation, the prevalence of complications related to the biliary system is 6-35%. In recent years, the diagnosis and treatment of biliary problems has changed markedly. The two standard methods of biliary reconstruction in liver transplant recipients are the duct-to-duct choledochocholedochostomy and the Roux-en-Y-hepaticojejunostomy. Biliary leakage occurs in approximately 5-7% of transplant cases. Leakage from the site of anastomosis, the T-tube exit site and donor or recipient remnant cystic duct is well described. Symptomatic bile leakage should be treated by stenting of the duct by endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTCD). Biliary strictures can occur at the site of the anastomosis (anastomotic stricture; AS) or at other locations in the biliary tree (non-anastomotic strictures; NAS). AS occur in 5-10% of cases and are due to fibrotic healing. Treatment by ERCP or PTCD with dilatation and progressive stenting is successful in the majority of cases. NAS can occur in the context of a hepatic artery thrombosis, or with an open hepatic artery (ischaemic type biliary lesions or ITBL). The incidence is 5-10%. NAS has been associated with various types of injury, e.g. macrovascular, microvascular, immunological and cytotoxic injury by bile salts. Treatment can be attempted with multiple sessions of dilatation and stenting of stenotic areas by ERCP or PTCD. In cases of localized diseased and good graft function, biliary reconstructive surgery is useful. However, a significant number of patients will need a re-transplant. When biliary strictures or ischaemia of the graft are present, stones, casts and sludge can develop.
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Affiliation(s)
- Robert C Verdonk
- Department of Gastroenterology and Hepatology, University of Groningen and University Medical Center Groningen, The Netherlands.
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250
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Koornstra JJ, de Vries EGE, Porte RJ. Improvements in small bowel carcinoid diagnosis and staging: 18F-DOPA PET, capsule endoscopy and double balloon enteroscopy. Dig Liver Dis 2009; 41:e35-8. [PMID: 18606578 DOI: 10.1016/j.dld.2008.05.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2008] [Revised: 05/13/2008] [Accepted: 05/23/2008] [Indexed: 12/11/2022]
Abstract
Carcinoid tumours are rare, slow growing tumours, originating from cells of the neuroendocrine system. Staging of the disease is of paramount importance to determine the optimal treatment strategy but is notoriously difficult. A case of a 45-year-old male who presented with abdominal pain and flushes is presented. An abdominal computerised tomography-scan was performed which showed a solitary liver lesion, consisting of neuroendocrine tumour cells. Further staging with (18)F-DOPA PET, capsule endoscopy and double balloon enteroscopy revealed the localisation of the primary tumours in the small bowel, and the patient subsequently underwent surgery. The recent introduction of (18)F-DOPA PET, capsule endoscopy and double balloon enteroscopy in the diagnosis and staging of carcinoid tumours has made significant contributions to the management of this disease.
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Affiliation(s)
- J J Koornstra
- Department of Gastroenterology & Hepatology, University Medical Centre Groningen, University of Groningen, The Netherlands.
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