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Ghazaly M, Tiwari N, Sethi P, Surendrakumar V, Duckworth A. Use of Steatotic Donor Livers for Transplantation: Do They Affect Outcome? SURGICAL PRACTICE 2022. [DOI: 10.1111/1744-1633.12563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Mohamed Ghazaly
- Department of Transplant Surgery Addenbrookes Hospital Cambridge United Kingdom
- Department of Surgery Tanta University Tanta Gharbia Egypt
| | - Navneet Tiwari
- Department of Transplant Surgery Addenbrookes Hospital Cambridge United Kingdom
| | - Pulkit Sethi
- Department of Transplant Surgery Addenbrookes Hospital Cambridge United Kingdom
| | - Veena Surendrakumar
- Department of Transplant Surgery Addenbrookes Hospital Cambridge United Kingdom
| | - Adam Duckworth
- Department of Pathology Addenbrookes Hospital Cambridge United Kingdom
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Diaz-Nieto R, Lykoudis P, Robertson F, Sharma D, Moore K, Malago M, Davidson BR. A simple scoring model for predicting early graft failure and postoperative mortality after liver transplantation. Ann Hepatol 2020; 18:902-912. [PMID: 31405576 DOI: 10.1016/j.aohep.2019.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/15/2019] [Accepted: 06/25/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Graft failure and postoperative mortality are the most serious complications after liver transplantation. The aim of this study is to establish a prognostic scoring system to predict graft and patient survival based on serum transaminases levels that are routinely used during the postoperative period in human cadaveric liver transplants. PATIENTS AND METHODS Postoperative graft failure and patient mortality after liver transplant were analyzed from a consecutive series of 1299 patients undergoing cadaveric liver transplantation. This was correlated with serum liver function tests and the rate of reduction in transaminase levels over the first postoperative week. A cut-off transaminase level correlating with graft and patient survival was calculated and incorporated into a scoring system. RESULTS Aspartate-aminotransferase (AST) on postoperative day one showed significant correlation with early graft failure for levels above 723U/dl and early postoperative mortality for levels above 750U/dl. AST reduction rate (day 1 to 3) greater than 1.8 correlated with reduced graft failure and greater than 2 with mortality. Alanine-aminotransferase (ALT) reduction in the first 48h post transplantation also correlated with outcomes. CONCLUSION A scoring system with these three variables allowed us to classify our patients into three groups of risk for early graft failure and mortality.
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Affiliation(s)
- Rafael Diaz-Nieto
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom; Royal Free Campus, University College London, London, United Kingdom.
| | - Panagis Lykoudis
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom; Royal Free Campus, University College London, London, United Kingdom
| | - Francis Robertson
- Royal Free Campus, University College London, London, United Kingdom
| | - Dinesh Sharma
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom
| | - Kevin Moore
- Royal Free Campus, University College London, London, United Kingdom
| | - Massimo Malago
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom
| | - Brian R Davidson
- HPB and Liver Transplant Unit, Royal Free Hospital, London, United Kingdom; Royal Free Campus, University College London, London, United Kingdom
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Chen L, Shi X, Lv G, Sun X, Sun C, Cai Y, Niu J, Jin J, Liu N, Li W. The long-term outcomes of deceased-donor liver transplantation for primary biliary cirrhosis: a two-center study in China. PeerJ 2020; 8:e9563. [PMID: 32879788 PMCID: PMC7443077 DOI: 10.7717/peerj.9563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/26/2020] [Indexed: 12/13/2022] Open
Abstract
Background & Aims Factors that influence the outcomes after deceased-donor liver transplantation (DDLT) for primary biliary cirrhosis (PBC) are not well known. We aimed to clarify these effects on the outcomes after DDLT. Methods We retrospectively analyzed patients with PBC who underwent DDLT from March 2006 to July 2018 at the organ transplantation center of the First Hospital of Jilin University and the First Central Hospital of Tianjin. Changes in liver function were assessed posttransplantation. Recurrence, survival rate, and complications were recorded at follow-up. The effect of liver transplantation on survival and recurrence was evaluated using univariate and/or multivariate Cox regression analyses. Results In total, 69 patients with PBC undergoing DDLT were included in this study. At 4 weeks posttransplant, all liver function tests were normal. During a median follow-up time of 32 months, 5-year overall survival and recurrence rates were estimated as 95.1% and 21.8%, respectively. A recipient aspartate aminotransferase-to-platelet ratio index (APRI) greater than 2 was negatively associated with survival (P = 0.0018). Multivariate regression analysis demonstrated that age younger than 48 years was an independent risk factor for recurrent PBC in recipients undergoing liver transplantation (hazard ratio 0.028, 95% confidence interval 0.01-0.71, P = 0.03). Posttransplant infections (62%) and biliary tract complications (26%) were the most common complications. Conclusion Liver transplantation is an effective treatment for patients with PBC. Liver function normalizes by 4 weeks posttransplant. Although posttransplant survival rate is high, recurrence is possible. To some extent, survival rate and recurrence rate can be predicted by APRI and age, respectively.
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Affiliation(s)
- Lin Chen
- Department of Hepatology, First Hospital, Jilin University, Changchun, China
| | - Xiaodong Shi
- Department of Rheumatology, First Hospital, Jilin University, Changchun, China
| | - Guoyue Lv
- Department of Hepatobiliary Pancreatic Surgery, First Hospital, Jilin University, Changchun, China
| | - Xiaodong Sun
- Department of Hepatobiliary Pancreatic Surgery, First Hospital, Jilin University, Changchun, China
| | - Chao Sun
- Department of Transplant Center, First Central Hospital, Tianjin, Tianjin, China
| | - Yanjun Cai
- Department of Hepatology, First Hospital, Jilin University, Changchun, China
| | - Junqi Niu
- Department of Hepatology, First Hospital, Jilin University, Changchun, China
| | - Jinglan Jin
- Department of Hepatology, First Hospital, Jilin University, Changchun, China
| | - Ning Liu
- Department of Cardiology, First Hospital, Jilin University, Changchun, China
| | - Wanyu Li
- Department of Hepatology, First Hospital, Jilin University, Changchun, China
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Early graft dysfunction after liver transplant: Comparison of different diagnostic criteria in a single-center prospective cohort. Med Intensiva 2018; 44:150-159. [PMID: 30528954 DOI: 10.1016/j.medin.2018.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 08/23/2018] [Accepted: 09/05/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Comparison of different diagnostic criteria for early liver allograft dysfunction (EAD) and their capability to predict mortality. DESIGN Single-center, prospective, cohort study. SETTINGS ICU in a Regional Hospital with a liver transplant program since 1997. PATIENTS 253 consecutive patients admitted to our ICU immediately after liver transplantation between 2009 and 2015. VARIABLES OF INTEREST Differences in the incidence of EAD and its relation with ICU, Hospital and 2-year mortality depending on the definition applied using as comparator the UNOS (United Network for Organ Sharing) primary non-function criterion. RESULTS The incidence of early liver allograft dysfunction according to UNOS was 13.8%, to Makowka 6.3%, to Ardite 10.7%, to Nanashima 20.6%, to Dhillon 30.8% and to MEAF 13.4%. Kappa test did not show a good correlation among these criteria. EAD was related with ICU mortality for all diagnostic criteria except Dhillon but only UNOS, Makowka and MEAF were associated with 2-year mortality. Hospital mortality was poorly predicted by all criteria except for the MEAF score. CONCLUSION We found a poor agreement between different criteria analyzed for the diagnosis of EAD. In our population, the MEAF score showed the best relationship with short- and long-term mortality.
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Zanchet MV, Silva LLGD, Matias JEF, Coelho JCU. POST-REPERFUSION LIVER BIOPSY AND ITS VALUE IN PREDICTING MORTALITY AND GRAFT DYSFUNCTION AFTER LIVER TRANSPLANTATION. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2017; 29:189-193. [PMID: 27759784 PMCID: PMC5074672 DOI: 10.1590/0102-6720201600030014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 05/20/2016] [Indexed: 12/11/2022]
Abstract
Background: The outcome of the patients after liver transplant is complex and to characterize the risk for complications is not always easy. In this context, the hepatic post-reperfusion biopsy is capable of portraying alterations of prognostic importance. Aim: To compare the results of liver transplantation, correlating the different histologic features of the hepatic post-reperfusion biopsy with graft dysfunction, primary non-function and patient survival in the first year after transplantation. Method: From the 377 transplants performed from 1996 to 2008, 164 patients were selected. Medical records were reviewed and the following clinical outcomes were registered: mortality in 1, 3, 6 and 12 months, graft dysfunction in varied degrees and primary graft non-function. The post-reperfusion biopsies had been examined by a blinded pathologist for the outcomes. The following histological variables had been evaluated: ischemic alterations, congestion, steatosis, neutrophilic exudate, monomorphonuclear infiltrate and necrosis. Results: The variables associated with increased mortality were: steatosis (p=0.02209), monomorphonuclear infiltrate (p=0.03935) and necrosis (p<0.00001). The neutrophilic exudate reduced mortality in this study (p=0.00659). The primary non-function showed significant association (p<0.05) with the necrosis, steatosis and the monomorphonuclear infiltrate. Conclusion: Post-reperfusion biopsy is useful tool to foresee complications after liver transplant.
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Affiliation(s)
- Marcos Vinícius Zanchet
- Postgraduate Program im Sugical clinics, Healtu Sciences Sector, Federal University of Paraná, Curitiba, PR, Brazil
| | | | - Jorge Eduardo Fouto Matias
- Postgraduate Program im Sugical clinics, Healtu Sciences Sector, Federal University of Paraná, Curitiba, PR, Brazil
| | - Júlio Cezar Uili Coelho
- Postgraduate Program im Sugical clinics, Healtu Sciences Sector, Federal University of Paraná, Curitiba, PR, Brazil
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Huang Y, MacQuillan G, Adams LA, Garas G, Collins M, Nwaba A, Mou L, Bulsara MK, Delriviere L, Jeffrey GP. Effect of airplane transport of donor livers on post-liver transplantation survival. World J Gastroenterol 2016; 22:9154-9161. [PMID: 27895402 PMCID: PMC5107596 DOI: 10.3748/wjg.v22.i41.9154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 07/26/2016] [Accepted: 08/23/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the effect of long haul airplane transport of donor livers on post-transplant outcomes.
METHODS A retrospective cohort study of patients who received a liver transplantation was performed in Perth, Australia from 1992 to 2012. Donor and recipient characteristics information were extracted from Western Australian liver transplantation service database. Patients were followed up for a mean of six years. Patient and graft survival were evaluated and compared between patients who received a local donor liver and those who received an airplane transported donor liver. Predictors of survival were determined by univariate and multivariate analysis using cox regression.
RESULTS One hundred and ninety-three patients received a local donor liver and 93 patients received an airplane transported donor liver. Airplane transported livers had a significantly lower alanine transaminase (mean: 45 U/L vs 84 U/L, P = 0.035), higher donor risk index (mean: 1.88 vs 1.42, P < 0.001) and longer cold ischemic time (CIT) (mean: 10.1 h vs 6.4 h, P < 0.001). There was a weak correlation between CIT and transport distance (r2 = 0.29, P < 0.001). Mean follow up was six years and 93 patients had graft failure. Multivariate analysis found only airplane transport retained significance for graft loss (HR = 1.92, 95%CI: 1.16-3.17). One year graft survival was 0.88 for those with a local liver and was 0.71 for those with an airplane transported liver. One year graft loss was due to primary graft non-function or associated with preservation injury in 20.8% of recipients of an airplane transported liver compared with 4.6% in those with a local liver (P = 0.027).
CONCLUSION Airplane transport of donor livers was independently associated with reduced graft survival following liver transplantation.
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Kim JS, Kwon JH, Kim KW, Kim J, Kim SY, Jeong WK, Park SH, Yu E, Lee J, Lee SJ, Lee JS, Kim HJ, Song GW, Lee SG. CT Features of Primary Graft Nonfunction after Liver Transplantation. Radiology 2016; 281:465-473. [PMID: 27152552 DOI: 10.1148/radiol.2016152157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Purpose To determine computed tomographic (CT) features of primary graft nonfunction (PNF) after liver transplantation in comparison with those of early graft failure or death by identifiable causes. Materials and Methods Institutional review board approval was obtained and informed consent was waived. Among 3947 adult liver transplantations performed in one institution between May 2002 and May 2015, 72 patients died or had graft failure within 10 days, and 38 of them were evaluated with CT. PNF was diagnosed in 21 patients. The other 17 patients who died or had early graft failure were considered the non-PNF control group. On unenhanced CT images, graft attenuation was compared qualitatively. Graft attenuation was measured quantitatively and, if available, the difference between preoperative and postoperative CT (interval change) attenuation was evaluated. Unenhanced CT was evaluated for relative parenchymal enhancement. Statistical analyses included the Fisher exact and χ2 tests with Yates correction and the Student t test. Results On unenhanced CT images, grafts with PNF more commonly showed low (eight of 26 [31%]) or extremely low (18 of 26 [69%]) qualitative attenuation compared with grafts in the non-PNF group (three of 21 [14%], one of 21 [5%]; P < .001). The mean attenuation value (30.5 HU ± 10.8) was significantly lower and the mean interval change (24.7 HU ± 12.5) was significantly higher in the PNF group than in the non-PNF group (49.7 HU ± 8.0 and 9.7 HU ± 10.1, respectively; P < .001 and P = .001). There was no significant difference in the proportion of grafts that showed poor enhancement on postcontrast CT images between the PNF group and the non-PNF group (nine of 24 [38%] vs two of 20 [10%], respectively; P = .08). Conclusion Recipients with PNF after liver transplantation tended to show low or extremely low attenuation on unenhanced CT images, and this finding was seen more frequently in patients with PNF than in those who died of identifiable causes and in those with early graft failure. © RSNA, 2016 Online supplemental material is available for this article.
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Affiliation(s)
- Jin Sil Kim
- From the Department of Radiology (J.S.K., K.W.K., S.Y.K., S.H.P., S.J.L., J.S.L., H.J.K.), Division of Liver Transplantation and Hepatobiliary Surgery, and Departments of Surgery (J.H.K., G.W.S., S.G.L.) and Pathology (J.K., E.Y.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (W.K.J.); and School of Computer Science and Engineering, Soongsil University, Seoul, Korea (J.L.)
| | - Jae Hyun Kwon
- From the Department of Radiology (J.S.K., K.W.K., S.Y.K., S.H.P., S.J.L., J.S.L., H.J.K.), Division of Liver Transplantation and Hepatobiliary Surgery, and Departments of Surgery (J.H.K., G.W.S., S.G.L.) and Pathology (J.K., E.Y.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (W.K.J.); and School of Computer Science and Engineering, Soongsil University, Seoul, Korea (J.L.)
| | - Kyoung Won Kim
- From the Department of Radiology (J.S.K., K.W.K., S.Y.K., S.H.P., S.J.L., J.S.L., H.J.K.), Division of Liver Transplantation and Hepatobiliary Surgery, and Departments of Surgery (J.H.K., G.W.S., S.G.L.) and Pathology (J.K., E.Y.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (W.K.J.); and School of Computer Science and Engineering, Soongsil University, Seoul, Korea (J.L.)
| | - Jihun Kim
- From the Department of Radiology (J.S.K., K.W.K., S.Y.K., S.H.P., S.J.L., J.S.L., H.J.K.), Division of Liver Transplantation and Hepatobiliary Surgery, and Departments of Surgery (J.H.K., G.W.S., S.G.L.) and Pathology (J.K., E.Y.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (W.K.J.); and School of Computer Science and Engineering, Soongsil University, Seoul, Korea (J.L.)
| | - So Yeon Kim
- From the Department of Radiology (J.S.K., K.W.K., S.Y.K., S.H.P., S.J.L., J.S.L., H.J.K.), Division of Liver Transplantation and Hepatobiliary Surgery, and Departments of Surgery (J.H.K., G.W.S., S.G.L.) and Pathology (J.K., E.Y.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (W.K.J.); and School of Computer Science and Engineering, Soongsil University, Seoul, Korea (J.L.)
| | - Woo Kyoung Jeong
- From the Department of Radiology (J.S.K., K.W.K., S.Y.K., S.H.P., S.J.L., J.S.L., H.J.K.), Division of Liver Transplantation and Hepatobiliary Surgery, and Departments of Surgery (J.H.K., G.W.S., S.G.L.) and Pathology (J.K., E.Y.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (W.K.J.); and School of Computer Science and Engineering, Soongsil University, Seoul, Korea (J.L.)
| | - So Hyun Park
- From the Department of Radiology (J.S.K., K.W.K., S.Y.K., S.H.P., S.J.L., J.S.L., H.J.K.), Division of Liver Transplantation and Hepatobiliary Surgery, and Departments of Surgery (J.H.K., G.W.S., S.G.L.) and Pathology (J.K., E.Y.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (W.K.J.); and School of Computer Science and Engineering, Soongsil University, Seoul, Korea (J.L.)
| | - Eunsil Yu
- From the Department of Radiology (J.S.K., K.W.K., S.Y.K., S.H.P., S.J.L., J.S.L., H.J.K.), Division of Liver Transplantation and Hepatobiliary Surgery, and Departments of Surgery (J.H.K., G.W.S., S.G.L.) and Pathology (J.K., E.Y.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (W.K.J.); and School of Computer Science and Engineering, Soongsil University, Seoul, Korea (J.L.)
| | - Jeongjin Lee
- From the Department of Radiology (J.S.K., K.W.K., S.Y.K., S.H.P., S.J.L., J.S.L., H.J.K.), Division of Liver Transplantation and Hepatobiliary Surgery, and Departments of Surgery (J.H.K., G.W.S., S.G.L.) and Pathology (J.K., E.Y.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (W.K.J.); and School of Computer Science and Engineering, Soongsil University, Seoul, Korea (J.L.)
| | - So Jung Lee
- From the Department of Radiology (J.S.K., K.W.K., S.Y.K., S.H.P., S.J.L., J.S.L., H.J.K.), Division of Liver Transplantation and Hepatobiliary Surgery, and Departments of Surgery (J.H.K., G.W.S., S.G.L.) and Pathology (J.K., E.Y.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (W.K.J.); and School of Computer Science and Engineering, Soongsil University, Seoul, Korea (J.L.)
| | - Jong Seok Lee
- From the Department of Radiology (J.S.K., K.W.K., S.Y.K., S.H.P., S.J.L., J.S.L., H.J.K.), Division of Liver Transplantation and Hepatobiliary Surgery, and Departments of Surgery (J.H.K., G.W.S., S.G.L.) and Pathology (J.K., E.Y.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (W.K.J.); and School of Computer Science and Engineering, Soongsil University, Seoul, Korea (J.L.)
| | - Hyoung Jung Kim
- From the Department of Radiology (J.S.K., K.W.K., S.Y.K., S.H.P., S.J.L., J.S.L., H.J.K.), Division of Liver Transplantation and Hepatobiliary Surgery, and Departments of Surgery (J.H.K., G.W.S., S.G.L.) and Pathology (J.K., E.Y.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (W.K.J.); and School of Computer Science and Engineering, Soongsil University, Seoul, Korea (J.L.)
| | - Gi Won Song
- From the Department of Radiology (J.S.K., K.W.K., S.Y.K., S.H.P., S.J.L., J.S.L., H.J.K.), Division of Liver Transplantation and Hepatobiliary Surgery, and Departments of Surgery (J.H.K., G.W.S., S.G.L.) and Pathology (J.K., E.Y.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (W.K.J.); and School of Computer Science and Engineering, Soongsil University, Seoul, Korea (J.L.)
| | - Sung Gyu Lee
- From the Department of Radiology (J.S.K., K.W.K., S.Y.K., S.H.P., S.J.L., J.S.L., H.J.K.), Division of Liver Transplantation and Hepatobiliary Surgery, and Departments of Surgery (J.H.K., G.W.S., S.G.L.) and Pathology (J.K., E.Y.), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea; Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (W.K.J.); and School of Computer Science and Engineering, Soongsil University, Seoul, Korea (J.L.)
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Di Martino M, Rossi M, Mennini G, Melandro F, Anzidei M, De Vizio S, Koryukova K, Catalano C. Imaging follow-up after liver transplantation. Br J Radiol 2016; 89:20151025. [PMID: 27188846 DOI: 10.1259/bjr.20151025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Liver transplantation (LT) represents the best treatment for end-stage chronic liver disease, acute liver failure and early stages of hepatocellular carcinoma. Radiologists should be aware of surgical techniques to distinguish a normal appearance from pathological findings. Imaging modalities, such as ultrasound, CT and MR, provide for rapid and reliable detection of vascular and biliary complications after LT. The role of imaging in the evaluation of rejection and primary graft dysfunction is less defined. This article illustrates the main surgical anastomoses during LT, the normal appearance and complications of the liver parenchyma and vascular and biliary structures.
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Affiliation(s)
- Michele Di Martino
- 1 Department of Radiological Sciences, Oncology and Anatomical Pathology, University of Rome "Sapienza", Rome, Italy
| | - Massimo Rossi
- 2 Department of General Surgery, Division of Organ Transplantation, University of Rome "Sapienza", Rome, Italy
| | - Gianluca Mennini
- 2 Department of General Surgery, Division of Organ Transplantation, University of Rome "Sapienza", Rome, Italy
| | - Fabio Melandro
- 2 Department of General Surgery, Division of Organ Transplantation, University of Rome "Sapienza", Rome, Italy
| | - Michele Anzidei
- 1 Department of Radiological Sciences, Oncology and Anatomical Pathology, University of Rome "Sapienza", Rome, Italy
| | - Silvia De Vizio
- 1 Department of Radiological Sciences, Oncology and Anatomical Pathology, University of Rome "Sapienza", Rome, Italy
| | - Kameliya Koryukova
- 1 Department of Radiological Sciences, Oncology and Anatomical Pathology, University of Rome "Sapienza", Rome, Italy
| | - Carlo Catalano
- 1 Department of Radiological Sciences, Oncology and Anatomical Pathology, University of Rome "Sapienza", Rome, Italy
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9
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Ali JM, Davies SE, Brais RJ, Randle LV, Klinck JR, Allison MED, Chen Y, Pasea L, Harper SFJ, Pettigrew GJ. Analysis of ischemia/reperfusion injury in time-zero biopsies predicts liver allograft outcomes. Liver Transpl 2015; 21:487-99. [PMID: 25545865 DOI: 10.1002/lt.24072] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Revised: 12/04/2014] [Accepted: 12/14/2014] [Indexed: 12/12/2022]
Abstract
Ischemia/reperfusion injury (IRI) that develops after liver implantation may prejudice long-term graft survival, but it remains poorly understood. Here we correlate the severity of IRIs that were determined by histological grading of time-zero biopsies sampled after graft revascularization with patient and graft outcomes. Time-zero biopsies of 476 liver transplants performed at our center between 2000 and 2010 were graded as follows: nil (10.5%), mild (58.8%), moderate (26.1%), and severe (4.6%). Severe IRI was associated with donor age, donation after circulatory death, prolonged cold ischemia time, and liver steatosis, but it was also associated with increased rates of primary nonfunction (9.1%) and retransplantation within 90 days (22.7%). Longer term outcomes in the severe IRI group were also poor, with 1-year graft and patient survival rates of only 55% and 68%, respectively (cf. 90% and 93% for the remainder). Severe IRI on the time-zero biopsy was, in a multivariate analysis, an independent determinant of 1-year graft survival and was a better predictor of 1-year graft loss than liver steatosis, early graft dysfunction syndrome, and high first-week alanine aminotransferase with a positive predictive value of 45%. Time-zero biopsies predict adverse clinical outcomes after liver transplantation, and severe IRI upon biopsy signals the likely need for early retransplantation.
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Affiliation(s)
- Jason M Ali
- Departments of Surgery, Cambridge University Hospitals National Health Service Trust, Cambridge, United Kingdom
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10
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Abstract
BACKGROUND Primary graft dysfunction (PGD) causes complications in liver transplantation, which result in poor prognosis. Recipients who develop PGD usually experience a longer intensive care unit and hospital stay and have higher mortality and graft loss rates compared with those without graft dysfunction. However, because of the lack of universally accepted definition, early diagnosis of graft dysfunction is difficult. Additionally, numerous factors affect the allograft function after transplantation, making the prediction of PGD more difficult. The present review was to analyze the literature available on PGD and to propose a definition. DATA SOURCE A search of PubMed (up to the end of 2012) for English-language articles relevant to PGD was performed to clarify the characteristics, risk factors, and possible treatments or interventions for PGD. RESULTS There is no pathological diagnostic standard; many documented definitions of PGD are different. Many factors, such as donor status, procurement and transplant process and recipient illness may affect the function of graft, and ischemia-reperfusion injury is considered the direct cause. Potential managements which are helpful to improve graft function were investigated. Some of them are promising. CONCLUSIONS Our analyses suggested that the definition of PGD should include one or more of the following variables: (1) bilirubin ≥ 10 mg/dL on postoperative day 7; (2) international normalized ratio ≥ 1.6 on postoperative day 7; and (3) alanine aminotransferase or aspartate aminotransferase >2000 IU/L within 7 postoperative days. Reducing risk factors may decrease the incidence of PGD. A majority of the recipients could recover from PGD; however, when the graft progresses into primary non-function, the patients need to be treated with re-transplantation.
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Affiliation(s)
- Xiao-Bo Chen
- Department of Liver and Vascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, China.
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11
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Novelli G, Morabito V, Lai Q, Levi Sandri G, Melandro F, Pugliese F, Novelli S, Rossi M, Berloco P. Glasgow Coma Score and Tumor Necrosis Factor α as Predictive Criteria for Initial Poor Graft Function. Transplant Proc 2012; 44:1820-5. [DOI: 10.1016/j.transproceed.2012.06.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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12
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Sirivatanauksorn Y, Taweerutchana V, Limsrichamrern S, Kositamongkol P, Mahawithitwong P, Asavakarn S, Tovikkai C. Recipient and perioperative risk factors associated with liver transplant graft outcomes. Transplant Proc 2012; 44:505-8. [PMID: 22410056 DOI: 10.1016/j.transproceed.2012.01.065] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Orthotopic liver transplantation (OLT) is currently considered to be the ultimate form of therapy for most patients with end-stage liver diseases. The identification of recipient and various perioperative factors that may affect the graft outcomes is critical. This study sought to analyze the preoperative and perioperative factors associated with graft outcomes in our institute. METHODS This retrospective study of liver transplanted patients from January 2002 to December 2009 determined the incidence of 2 forms of primary dysfunction (PDF): Primary nonfunction (PNF) and initial poor function (IPF). RESULTS The 97 posttransplant patients included in the study had an average age of 52.74 years. The majority of indications for OLT were hepatitis B and/or C cirrhosis, alcoholic cirrhosis, and hepatocellular carcinoma. The incidence of PDF was 31.9% (31/97) with 7.2% (7/97) PNF and 24.7% (24/97) IPF. Additionally, we observed 68.1% (66/97) to display immediate function (IF). Warm ischemic time (WIT) and operative time were significantly longer in the PDF compared with the IF group. The logistic regression model showed a WIT of >45 minutes to be a risk factor leading to PDF (odds ratio, 11.74; P<.05). An operative time of >6 hours and operative blood loss of >2 L were possible risk factors. CONCLUSION Prolonged WIT (>45 minutes) was the only significant risk factor among other established parameters for graft function. Nevertheless, reduced operative times and blood loss may improve the outcomes of OLT.
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Affiliation(s)
- Y Sirivatanauksorn
- Division of General Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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13
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Analysis of Donor Risk Factors Associated With Graft Outcomes in Orthotopic Liver Transplantation. Transplant Proc 2012; 44:320-3. [DOI: 10.1016/j.transproceed.2011.12.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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14
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Wu JF, Wu RY, Chen J, Ou-Yang B, Chen MY, Guan XD. Early lactate clearance as a reliable predictor of initial poor graft function after orthotopic liver transplantation. Hepatobiliary Pancreat Dis Int 2011; 10:587-92. [PMID: 22146621 DOI: 10.1016/s1499-3872(11)60100-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Initial poor graft function (IPGF) following orthotopic liver transplantation is a major determinant of postoperative survival and morbidity. Lactate clearance is a good marker of liver function. In this study, we investigated the clinical utility of early lactate clearance as an early and accurate predictor for IPGF following liver transplantation. METHODS This was a prospective observational study of 222 patients referred to the surgical intensive care unit (SICU) after orthotopic liver transplantation. The IPGF group consisted of patients with alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST) >1500 IU/L within 72 hours after orthotopic liver transplantation. Early lactate clearance was defined as lactate at SICU presentation (hour 0) minus lactate at hour 6, divided by lactate at SICU presentation. The model for end-stage liver disease (MELD) score, Child-Pugh score and laboratory data including AST, ALT, total bilirubin (TB) and prothrombin time (PT) were recorded at SICU presentation and compared between the non-IPGF and IPGF groups. Receiver operating characteristic (ROC) curves were plotted to measure the performance of early lactate clearance, MELD score, Child-Pugh score, TB and PT. RESULTS IPGF occurred in 45 of the 222 patients (20.3%). The early lactate clearance in the non-IPGF group was markedly higher than that in the IPGF group (43.2+/-13.8% vs 13.4+/-13.7% P<0.001). The optimum cut-off value for early lactate clearance predicting IPGF was 24.8% (sensitivity 95.5%, specificity 88.9%). The area under the curve of the ROC was 0.961, which was significantly superior to MELD score, Child-Pugh score, TB and PT. Patients with early lactate clearance ≤24.8% had a higher IPGF rate (OR=169) and a higher risk of in-hospital mortality (OR=3.625). CONCLUSIONS Early lactate clearance can serve as a prompt and accurate bedside predictor of IPGF. Patients with early lactate clearance less than 24.8% are associated with a higher incidence of IPGF.
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Affiliation(s)
- Jian-Feng Wu
- Department of Surgical Intensive Care Unit, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510080, China
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15
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Cheng Q, Ng KT, Fan ST, Lim ZX, Guo DY, Liu XB, Liu Y, Poon RTP, Lo CM, Man K. Distinct mechanism of small-for-size fatty liver graft injury--Wnt4 signaling activates hepatic stellate cells. Am J Transplant 2010; 10:1178-88. [PMID: 20420630 DOI: 10.1111/j.1600-6143.2010.03102.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In this study, we aimed to investigate the significance of hepatic stellate cells (HSCs) activation in small-for-size fatty liver graft injury and to explore the underlying molecular mechanism in a rat liver transplantation model. A rat orthotopic liver transplantation model using fatty grafts (40% of fatty changes) and cirrhotic recipients was applied. Intragraft gene expression profiles, ultrastructure features and HSCs activation were compared among the rats received different types of grafts (whole vs. small-for-size, normal vs. fatty). The distinct molecular signature of small-for-size fatty graft injury was identified by cDNA microarray screening and confirmed by RT-PCR detection. In vitro functional studies were further conducted to investigate the direct effect of specific molecular signature on HSCs activation. HSCs activation was predominantly present in small-for-size fatty grafts during the first 2 weeks after transplantation, and was strongly correlated with progressive hepatic sinusoidal damage and significant upregulation of intragraft Wnt4 signaling pathway. In vitro suppression of Wnt4 expression could inhibit HSC activation directly. In conclusion, upregulation of Wnt4 signaling led to direct HSC activation and subsequently induced small-for-size fatty liver grafts injury. Discovery of this distinct mechanism may lay the foundation for prophylactic treatment for marginal graft injury in living donor liver transplantation.
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Affiliation(s)
- Q Cheng
- Department of Surgery and Centre for Cancer Research, LKS Faculty of Medicine, the University of Hong Kong, Hong Kong.
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16
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Northup PG, Abecassis MM, Englesbe MJ, Emond JC, Lee VD, Stukenborg GJ, Tong L, Berg CL. Addition of adult-to-adult living donation to liver transplant programs improves survival but at an increased cost. Liver Transpl 2009; 15:148-62. [PMID: 19177435 PMCID: PMC3222562 DOI: 10.1002/lt.21671] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Using outcomes data from the Adult-to-Adult Living Donor Liver Transplantation Cohort Study, we performed a cost-effectiveness analysis exploring the costs and benefits of living donor liver transplantation (LDLT). A multistage Markov decision analysis model was developed with treatment, including medical management only (strategy 1), waiting list with possible deceased donor liver transplantation (DDLT; strategy 2), and waiting list with possible LDLT or DDLT (strategy 3) over 10 years. Decompensated cirrhosis with medical management offered survival of 2.0 quality-adjusted life years (QALYs) while costing an average of $65,068, waiting list with possible DDLT offered 4.4-QALY survival and a mean cost of $151,613, and waiting list with possible DDLT or LDLT offered 4.9-QALY survival and a mean cost of $208,149. Strategy 2 had an incremental cost-effectiveness ratio (ICER) of $35,976 over strategy 1, whereas strategy 3 produced an ICER of $106,788 over strategy 2. On average, strategy 3 cost $47,693 more per QALY than strategy 1. Both DDLT and LDLT were cost-effective compared to medical management of cirrhosis over our 10-year study period. The addition of LDLT to a standard waiting list DDLT program is effective at improving recipient survival and preventing waiting list deaths but at a greater cost.
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Affiliation(s)
| | | | | | - Jean C. Emond
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Vanessa D. Lee
- Department of Medicine, University of Virginia, Charlottesville, VA
| | | | - Lan Tong
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Carl L. Berg
- Department of Medicine, University of Virginia, Charlottesville, VA
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Angele MK, Rentsch M, Hartl WH, Wittmann B, Graeb C, Jauch KW, Loehe F. Effect of graft steatosis on liver function and organ survival after liver transplantation. Am J Surg 2008; 195:214-20. [PMID: 18154767 DOI: 10.1016/j.amjsurg.2007.02.023] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2007] [Revised: 02/18/2007] [Accepted: 02/18/2007] [Indexed: 12/13/2022]
Abstract
BACKGROUND It was the aim to determine the effect of graft steatosis on intraoperative organ blood flow, postoperative liver function, and organ survival. METHODS A total of 225 consecutive liver transplants were reviewed. Liver blood flow, hepatic function (AST, ALT, prothrombin time), and organ survival were determined. Donor liver grafts were categorized into 2 subgroups: mild (<30%) (n = 175) and moderate to severe (>/=30%) (n = 50) macrovesicular steatosis. RESULTS Moderate to severe steatosis was associated with significantly increased AST and ALT levels and significantly diminished prothrombin time on the first and second postoperative day. By day 7 differences in liver function were no longer evident. Organ blood flow was not affected by steatosis. After adjustment for potential confounders, organ survival did not depend on the degree of donor steatosis (5-year-survival rates: 68% and 58% with steatosis <30%, or >/= 30%, respectively) (hazard ratio .754, confidence interval .458-1.242, P = .268). CONCLUSION Steatotic livers can be transplanted safely with good results for long-term organ survival if other contraindications are absent.
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Affiliation(s)
- Martin K Angele
- Department of Surgery, Klinikum Grosshadern, Ludwig-Maximilians University Munich, Marchioninistr. 15, D-81377 Munich, Germany
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Hetz H, Hoetzenecker K, Hacker S, Faybik P, Pollreisz A, Moser B, Roth G, Hoetzenecker W, Lichtenauer M, Klinger M, Krenn CG, Ankersmit HJ. Caspase-cleaved cytokeratin 18 and 20 S proteasome in liver degeneration. J Clin Lab Anal 2007; 21:277-81. [PMID: 17847110 PMCID: PMC6648973 DOI: 10.1002/jcla.20180] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Apoptosis of epithelial hepatocytes plays a pivotal role in acute as well as in chronic liver diseases. The cleavage of cytokeratin-18 (CK-18) by caspases is an early event in the apoptotic process. We therefore sought to investigate serum levels of CK-18 and 20S proteasome in patients with liver cirrhosis, primary graft dysfunction (PDF), and acute liver failure (ALF), and in healthy volunteers. Enzyme-linked immunosorbent assay (ELISA) was utilized to measure the concentration of M30, a fragment of CK-18 cleaved at Asp396 (M30 neoantigen), and the concentration of 20S proteasome. Serum levels of the CK-18 neoepitope M30 were significantly increased in ALF, primary graft dysfunction, and liver cirrhosis vs. healthy controls (1,993.6+/-124.7 U/L, 2,238.1+/-235.9 U/L, and 673.6+/-86.5 U/L vs. 66.8+/-29.1 U/L, respectively, P<0.001). Similar results were detected with the evaluation of 20S proteasome (124,014.5+/-13,235.6 ng/mL, 76,993.2+/-15,720.1 ng/mL, and 2,395.9+/-1,098.2 ng/mL vs. 1,074.5+/-259.4 ng/mL, respectively; P<0.001). Detection of CK-18 neoepitope M30 and 20S proteasome may represent a novel marker of tracing apoptotic epithelium, respectively mirroring degenerative liver processes in affected patient population.
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Affiliation(s)
- Hubert Hetz
- Department of Anesthesiology and Intensive Care, General Hospital Vienna, Medical University of Vienna, Austria
| | - Konrad Hoetzenecker
- Department of CT‐Surgery, General Hospital Vienna, Medical University of Vienna, Austria
| | - Stefan Hacker
- Department of CT‐Surgery, General Hospital Vienna, Medical University of Vienna, Austria
| | - Peter Faybik
- Department of Anesthesiology and Intensive Care, General Hospital Vienna, Medical University of Vienna, Austria
| | - Andreas Pollreisz
- Department of CT‐Surgery, General Hospital Vienna, Medical University of Vienna, Austria
| | - Bernhard Moser
- Department of CT‐Surgery, General Hospital Vienna, Medical University of Vienna, Austria
| | - Georg Roth
- Department of Anesthesiology and Intensive Care, General Hospital Vienna, Medical University of Vienna, Austria
| | | | - Michael Lichtenauer
- Department of CT‐Surgery, General Hospital Vienna, Medical University of Vienna, Austria
| | - Markus Klinger
- Department of Surgery, General Hospital Vienna, Medical University of Vienna, Austria
| | - Claus Georg Krenn
- Department of Anesthesiology and Intensive Care, General Hospital Vienna, Medical University of Vienna, Austria
| | - Hendrik Jan Ankersmit
- Department of CT‐Surgery, General Hospital Vienna, Medical University of Vienna, Austria
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Feng L, Zhao N, Yao X, Sun X, Du L, Diao X, Li S, Li Y. Histidine-tryptophan-ketoglutarate solution vs. University of Wisconsin solution for liver transplantation: a systematic review. Liver Transpl 2007; 13:1125-36. [PMID: 17665493 DOI: 10.1002/lt.21208] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
University of Wisconsin (UW) solution has been recognized as the gold standard in liver preservation, but its limitations are becoming obvious, such as risk of biliary complications and its high cost. Alternatively, the effects of histidine-tryptophan-ketoglutarate (HTK), such as improved biliary protection and low cost, have been observed. This systematic review is conducted to compare the efficacy and safety of these 2 solutions. Databases from 1966 to June 2006 were searched. Randomized clinical trials (RCTs) and cohort studies comparing HTK and UW solutions for liver transplantation were included. Ten articles including 11 comparisons (1,200 patients) met the inclusion criteria, containing 2 RCTs and 9 cohort studies. No marked differences existed between the 2 groups in patient and graft survival rates, acute rejection, primary nonfunction, primary dysfunction, delayed graft function, and ALT and AST levels after transplantation. The only positive result was observed in the bile production after deceased donor liver transplantation (DDLT), which was statistically significantly higher in HTK group than that of UW group (95% confidence interval, 18.65-57.47; P=0.0001). Although the difference in biliary complications between the 2 groups did not reach statistical significance, HTK was thought to be more effective for biliary tract flush and prevention of biliary complications in some studies. There was no statistically significant difference of effects (except bile production) between HTK and UW. But trends were documented in some studies for the superiority of HTK in biliary tract flush, prevention of biliary complications, and cost saving. Adequately powered RCTs with longer follow-up periods are required to evaluate the long-term effect of these 2 solutions.
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Affiliation(s)
- Li Feng
- Key Laboratory of Transplant Engineering and Immunology, Ministry of Health, West China Hospital, Sichuan University, PR China.
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20
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21
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Mor E, Brown M, Michowiz R, Bar-Nathan N, Shaharabani E, Yussim A, Shapira Z, Tur-Kaspa R, Ben-Ari Z. Cholestasis and hypoalbuminemia as predictors of outcome after liver transplantation. Transplant Proc 2003; 35:617-8. [PMID: 12644069 DOI: 10.1016/s0041-1345(03)00011-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- E Mor
- Department of Transplantation, Petah-Tikwa, Israel.
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