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Tal N, Waisbourd-Zinman O, Kaplan E, Kadmon G, Gendler Y, Gurevich M, Nahum E, Weissbach A. Early post-liver transplant thrombocytopenia in children: Clinical characteristics and significance. Pediatr Transplant 2022; 26:e14326. [PMID: 35599548 DOI: 10.1111/petr.14326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 04/10/2022] [Accepted: 05/02/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Post-liver transplant thrombocytopenia is common and associated with worse outcome in adults. In children, however, the prevalence, course, and significance of post-liver transplantation thrombocytopenia are not described. Therefore, we aimed to assess this phenomenon in children. METHODS A retrospective chart review of children who underwent liver transplantation at a single tertiary center between 2004 and 2021. RESULTS Overall, 130 pediatric liver transplantations were reviewed. During the first 28 POD, thrombocytopenia was evident in 116 (89%, 95% CI 83%-94%). The median nadir platelet count was 54 K/μl (IQR: 37-99). Nadir platelet count was reached in half the patients by the third POD (IQR: 1-6). In multivariate analysis, preoperative platelet count (p = .024), volume of intraoperative packed cell transfusion (p = .045), and hypersplenism (p = .007) were associated with lower postoperative platelet counts. Patients with platelet count lower than the 50th centile on the first POD suffered from a more complicated course leading to a longer PICU admission (p = .039). CONCLUSIONS Early post-liver transplant thrombocytopenia appears to be common in children and associated with preoperative thrombocytopenia, hypersplenism, and higher intraoperative blood transfusion volumes. A low first POD platelet count (<86 K/μl) was found to be independently associated with a more complicated postoperative course, suggesting the need for heightened surveillance.
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Affiliation(s)
- Noa Tal
- Department of Pediatrics C, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orith Waisbourd-Zinman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Eytan Kaplan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Gili Kadmon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Yulia Gendler
- The Department of Nursing, School of Health Sciences, Ariel University, Ariel, Israel
| | - Michael Gurevich
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Liver Kidney Transplant Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Elhanan Nahum
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Avichai Weissbach
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
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2
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Zhou GP, Qu W, Zeng ZG, Sun LY, Liu Y, Wei L, Zhu ZJ. Successful Simultaneous Subtotal Splenectomy During Left Lobe Auxiliary Liver Transplantation for Portal Inflow Modulation and Severe Hypersplenism Correction: A Case Report. Front Med (Lausanne) 2022; 8:818825. [PMID: 35174187 PMCID: PMC8842677 DOI: 10.3389/fmed.2021.818825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 12/28/2021] [Indexed: 01/10/2023] Open
Abstract
Adult-to-adult living donor liver transplantation with small partial liver grafts often requires intraoperative portal inflow modulation to prevent portal hyperperfusion and subsequent small-for-size syndrome (SFSS). However, there are concerns about the specific morbidity of these modulation techniques. This study aims to lower post-perfusion portal venous pressure and correct severe hypersplenism in a patient with end-stage liver cirrhosis by simultaneous subtotal splenectomy during auxiliary partial orthotopic liver transplantation (APOLT). A 29-year-old man was diagnosed with cryptogenic cirrhosis and severe portal hypertension suffered recurrent acute variceal bleeding, severe thrombocytopenia, and massive ascites before admission to our hospital. After the recipient's left liver was resected, we performed APOLT using his 51-year-old father's left lobe graft with a graft-to-recipient weight ratio of 0.55%. Intraoperatively, simultaneous subtotal splenectomy was performed to lower graft post-perfusion portal vein pressure below 15 mmHg and correct severe hypersplenism-related pancytopenia. The recipient's postoperative hospital course was uneventful with no occurrence of SFSS and procedure-related complications. Platelet and leukocyte counts remained in the normal ranges postoperatively. The living donor was discharged 6 days after the operation and recovered well-with no complications. After a follow-up period of 35.3 months, both the recipient and donor live with good liver function and overall condition. This is the first case report of simultaneous subtotal splenectomy during APOLT using small-for-size living-donated left liver lobes, which is demonstrated to be a viable procedure for modulating portal inflow and correcting severe hypersplenism in selected adult patients with end-stage liver cirrhosis. APOLT using a small-for-size liver graft may be a safe and feasible treatment option for selected adult patients with end-stage liver cirrhosis.
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Affiliation(s)
- Guang-Peng Zhou
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Wei Qu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Zhi-Gui Zeng
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Li-Ying Sun
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China.,Department of Critical Liver Diseases, Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ying Liu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China.,Department of Critical Liver Diseases, Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lin Wei
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Zhi-Jun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
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3
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Zhou GP, Wei L, Zhu ZJ, Qu W, Zeng ZG, Sun LY, Liu Y. Successful Simultaneous Anatomic Subtotal Splenectomy During Pediatric Living-Donor Liver Transplantation: A Case Report. Transplant Proc 2020; 52:2767-2772. [DOI: 10.1016/j.transproceed.2020.01.170] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 12/16/2019] [Accepted: 01/10/2020] [Indexed: 12/24/2022]
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4
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DuBois B, Mobley D, Chick JFB, Srinivasa RN, Wilcox C, Weintraub J. Efficacy and safety of partial splenic embolization for hypersplenism in pre- and post-liver transplant patients: A 16-year comparative analysis. Clin Imaging 2018; 54:71-77. [PMID: 30553121 DOI: 10.1016/j.clinimag.2018.11.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 09/28/2018] [Accepted: 11/26/2018] [Indexed: 12/22/2022]
Abstract
PURPOSE To report the effect of partial splenic embolization (PSE) on hematological indices and the procedure's safety in pre- and post-liver transplant (LT) patients. MATERIALS AND METHODS A single-center retrospective study evaluating all patients who underwent PSE over a 16-year period was performed. Inclusion criteria were splenomegaly confirmed by imaging and at least one of the following cytopenias: hemoglobin ≤10 g/dL, WBC count ≤1500 μL-1, or platelet count ≤100,000 μL-1. 38 of 102 patients (37%) met criteria (24 pre- and 14 post-LT) for a total of 40 PSEs. RESULTS No effect was seen on median hemoglobin beyond 2 weeks post-PSE. There was a significant and sustained increase in median WBC counts (from 3400 μL-1 to 5400 μL-1 at 2 years) and platelet count (from 65,000 μL-1 to 117,000 μL-1 at 3.5 years). In 6 out of 40 PSEs (15%) a major complication occurred which included pleural effusion, ascites, spontaneous bacterial peritonitis, pneumonia, and inferior vena cava thrombus. Similar efficacy was observed in pre- and post-LT cohorts, with a trend toward higher complication rate in pre-LT patients. CONCLUSIONS PSE is efficacious in increasing WBC count out to 2 years and platelet count out to 3.5 years in patients with hypersplenism. Efficacy and safety appeared independent of pre- or post-LT status. The intervention is associated with major complications and special care should be taken when selecting patients for PSE.
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Affiliation(s)
- Byron DuBois
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109, United States of America; Department of Radiology, Division of Vascular and Interventional Radiology, Columbia University Medical Center, 177 Fort Washington Ave, Milstein Hospital - 4 Hudson North, New York, NY 10032, United States of America.
| | - David Mobley
- Department of Radiology, Division of Vascular and Interventional Radiology, Columbia University Medical Center, 177 Fort Washington Ave, Milstein Hospital - 4 Hudson North, New York, NY 10032, United States of America
| | - Jeffrey F B Chick
- Cardiovascular and Interventional Radiology, Inova Alexandria Hospital, 4320 Seminary Road, Alexandria, VA 22304, United States of America
| | - Ravi N Srinivasa
- Department of Radiology, Division of Interventional Radiology, University of California Los Angeles, 757 Western Plaza, Los Angeles, CA 90095, United States of America
| | - Chad Wilcox
- Department of Radiology, Division of Interventional Radiology, University of California Los Angeles, 757 Western Plaza, Los Angeles, CA 90095, United States of America
| | - Joshua Weintraub
- Department of Radiology, Division of Vascular and Interventional Radiology, Columbia University Medical Center, 177 Fort Washington Ave, Milstein Hospital - 4 Hudson North, New York, NY 10032, United States of America
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5
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Gemery JM, Forauer AR, Silas AM, Hoffer EK. Hypersplenism in liver disease and SLE revisited: current evidence supports an active rather than passive process. BMC HEMATOLOGY 2016; 16:3. [PMID: 26865982 PMCID: PMC4748462 DOI: 10.1186/s12878-016-0042-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 01/20/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Active and passive theories have been advanced to explain splenomegaly and cytopenias in liver disease. Dameshek proposed active downregulation of hematopoiesis. Doan proposed passive trapping of blood components in a spleen enlarged by portal hypertension. Recent findings do not support a passive process. DISCUSSION Cytopenias and splenomegaly in both liver disease and systemic lupus erythematosus (SLE) poorly correlate with portal hypertension, and likely reflect an active process allocating stem cell resources in response to injury. Organ injury is repaired partly by bone-marrow-derived stem cells. Signaling would thus be needed to allocate resources between repair and routine marrow activities, hematologic and bone production. Granulocyte-colony stimulating factor (G-CSF) may play a central role: mobilizing stem cells, increasing spleen size and downregulating bone production. Serum G-CSF rises with liver injury, and is elevated in chronic liver disease and SLE. Signaling, not sequestration, likely accounts for splenomegaly and osteopenia in liver disease and SLE. The downregulation of a non-repair use of stem cells, bone production, suggests that repair efforts are prioritized. Other non-repair uses might be downregulated, namely hematologic production, as Dameshek proposed. SUMMARY Recognition that an active process may exist to allocate stem-cell resources would provide new approaches to diagnosis and treatment of cytopenias in liver disease, SLE and potentially other illnesses.
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Affiliation(s)
- John M. Gemery
- />Division of Interventional Radiology, Department of Radiology, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03766 USA
- />Geisel School of Medicine at Dartmouth, One Rope Ferry Road, Hanover, NH 03755 USA
| | - Andrew R. Forauer
- />Geisel School of Medicine at Dartmouth, One Rope Ferry Road, Hanover, NH 03755 USA
| | - Anne M. Silas
- />Geisel School of Medicine at Dartmouth, One Rope Ferry Road, Hanover, NH 03755 USA
| | - Eric K. Hoffer
- />Geisel School of Medicine at Dartmouth, One Rope Ferry Road, Hanover, NH 03755 USA
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Surgical Management of Large Spontaneous Portosystemic Splenorenal Shunts During Liver Transplantation: Splenectomy or Left Renal Vein Ligation? Transplant Proc 2015; 47:1866-76. [DOI: 10.1016/j.transproceed.2015.06.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 06/05/2015] [Accepted: 06/16/2015] [Indexed: 12/13/2022]
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7
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Li C, Zhao H, Zhao J, Li Z, Huang Z, Zhang Y, Bi X, Cai J. Prognosis of patients with hepatocellular carcinoma and hypersplenism after surgery: a single-center experience from the People's Republic of China. Onco Targets Ther 2014; 7:957-64. [PMID: 24959082 PMCID: PMC4061180 DOI: 10.2147/ott.s64921] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE As prognosis of patients with hepatocellular carcinoma (HCC) and hypersplenism is rarely reported, this study examined prognostic factors for patients who underwent surgery for this condition. PATIENTS AND METHODS This study retrospectively analyzed prognostic factors in 181 consecutive HCC patients using univariate and multivariate analyses, as well as subgroup analyses for disease-free survival (DFS) and overall survival (OS) of two groups: one group who received splenectomies (Sp) and one group who did not (non-Sp). RESULTS 1, 3, and 5 year OS rates were 88.4%, 67.1%, and 52.8%, respectively; corresponding DFS rates were 67.0%, 43.8%, and 31.6%, respectively. Age ≥55 years old, cigarette smoking, tumor size ≥5 cm, microvascular invasion, and Child-Pugh grade B (versus A) correlated significantly with OS (P<0.05). Interestingly, in patients with tumor lymph node metastasis (TNM) stage I disease, DFS of the Sp-group (median DFS, 24.1 months; n=34) was significantly lower than that of the non-Sp group (median DFS, 62.1 months; n=74), P=0.034; whereas at TNM stage II, OS of the Sp-group (median OS, 79.1 months; n=21) was significantly better than that of the non-Sp group (median OS, 23.3 months; n=30), P=0.018. CONCLUSION Hepatectomy without concomitant splenectomy can contribute to improved DFS of TNM stage I HCC patients with hypersplenism, whereas simultaneous hepatectomy and splenectomy can prolong OS for patients at TNM stage II.
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Affiliation(s)
- Cong Li
- Department of Abdominal Surgery, Cancer Institute and Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Hong Zhao
- Department of Abdominal Surgery, Cancer Institute and Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Jianjun Zhao
- Department of Abdominal Surgery, Cancer Institute and Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Zhiyu Li
- Department of Abdominal Surgery, Cancer Institute and Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Zhen Huang
- Department of Abdominal Surgery, Cancer Institute and Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Yefan Zhang
- Department of Abdominal Surgery, Cancer Institute and Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Xinyu Bi
- Department of Abdominal Surgery, Cancer Institute and Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Jianqiang Cai
- Department of Abdominal Surgery, Cancer Institute and Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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Fayed NA, Abdallah AR, Khalil MK, Marwan IK. Therapeutic rather than prophylactic platelet transfusion policy for severe thrombocytopenia during liver transplantation. Platelets 2013; 25:576-86. [PMID: 24246132 DOI: 10.3109/09537104.2013.849335] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Platelet transfusion (PTx) has been identified as an important risk factor for morbidity and mortality after liver transplantation (LTx). Our aim was to evaluate the safety of therapeutic rather than prophylactic PTx policy in severe thrombocytopenic patients undergoing LTx. Recipients of LTx were divided into two groups: group I (GI) (n = 76) platelet count (PC) ≥ 50 × 10(9)/l and group II (GII) PC < 50 × 109/l (n = 76). Platelets were transfused following a thromboelastometry protocol and clinical signs of diffuse bleeding. Both groups were compared regarding hemoglobin (Hb), international normalized ratio (INR), fibrinogen level, blood loss (BL), blood products required, percentage of bloodless surgery, duration of mechanical ventilation, ICU stay, and vascular complications. Each group was further subdivided according to PTx into (GI NPTx and GII NPTx) with no platelet transfusion (NPTx) and (GI PTx and GII PTx) received PTx. These subgroups were further compared for some variables. Base line Hb was significantly higher while INR was significantly lower in GI.75% avoided PTx in GII. Comparisons of BL, packed red blood cells (PRBCs), and cryoprecipitate transfusion were insignificant. Fresh frozen plasma (FFP) transfusion was higher and the percentage of bloodless surgery was lower in GII. In GII, PC increased after start of surgery. Two cases of hepatic artery thrombosis in GI and one in GII were recorded. Recovery of platelets was quicker, and duration of mechanical ventilation and ICU stay was shorter in NPTx patients regardless the base line PC. Cut-off values of PC 30 × 10(9)/l (with sensitivity 73.7% and specificity 78.8%, p < 0.01), BL of 3750 ml in GI (sensitivity of 75% and specificity of 69%, p < 0.01) and of 3250 ml in GII (sensitivity of 84.2% and specificity of 87.7% (p < 0.01)) could indicate the need of PTx. With therapeutic approach, 75% of patients in GII could avoid unnecessary PTx with its hazards without excessive bleeding. PC in GII increased intraoperatively, PTx may lead to delayed recovery of platelets, increased duration of mechanical ventilation and ICU stay. The given cut-off values may help to guide PTx.
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Affiliation(s)
- Nirmeen A Fayed
- Department of Anesthesia, National Liver Institute, Menoufeya University , Shebeen El-Kom , Egypt
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9
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Chen TY, Chen CL, Huang TL, Tsang LC, Ou HY, Yu CY, Hsu HW, Cheng YF. Predictive Factors for Persistent Splenomegaly and Hypersplenism After Adult Living Donor Liver Transplantation. Transplant Proc 2012; 44:752-4. [DOI: 10.1016/j.transproceed.2012.01.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Buxbaum JL, Biggins SW, Bagatelos KC, Ostroff JW. Predictors of endoscopic treatment outcomes in the management of biliary problems after liver transplantation at a high-volume academic center. Gastrointest Endosc 2011; 73:37-44. [PMID: 21074761 DOI: 10.1016/j.gie.2010.09.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Accepted: 09/06/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Biliary tract problems are the most common complications after liver transplantation. ERCP is increasingly being used to address posttransplantation biliary problems. OBJECTIVE To identify predictors of endoscopic treatment outcomes in the management of post-liver transplantation complications. SETTING AND PATIENTS All adult patients who underwent liver transplantation at the University of California, San Francisco between January 1999 and December 2008 were reviewed. DESIGN A multivariate regression analysis. MAIN OUTCOME MEASUREMENTS Identification of donor and recipient factors as well as technical considerations that predicted success or failure in the endoscopic management of posttransplantation biliary complications. RESULTS In 1062 patients who underwent liver transplantation, there were 224 biliary complications. ERCP was the primary treatment modality and was successful in the majority of patients treated. Patients with biliary complications who had take-back surgery for a nonbiliary indication during the first month after liver transplantation (odds ratio [OR], 0.32; P = .03), particularly for bleeding (OR, 0.18; P = .02), were less likely to respond to endoscopic therapy. Those who received a graft from a donor after cardiac death (OR, 0.15; P = .02) or a living donor (OR, 0.11; P < .01) were also less likely to respond to endoscopic therapy. Take-back surgery for a nonbiliary indication in the first month after liver transplantation was also identified as a novel risk factor for the development of biliary complications (OR, 1.80; P = .02). LIMITATIONS Retrospective design. CONCLUSIONS ERCP can be used to treat the majority of posttransplantation biliary problems. However, endoscopic therapy is less efficacious in the treatment of complications associated with ischemia.
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Affiliation(s)
- James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Keck School of Medicine, Los Angeles, California, USA
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