Evolution of the plasma concentration of norepinephrine in cirrhotic patients during liver transplantation

Hepatic artery vasospasm masquerading as early hepatic artery thrombosis in progressive familial intrahepatic cholestasis 3: a case report

Post-liver transplant (LT) hepatic artery vasospasm is a vascular complication that is not well recognized and its incidence is not known. As a possible sequela to vasospasm, hepatic artery thrombosis is the second major cause of allograft failure after primary nonfunction and its reported incidence is 2.9% in adults and 8.3% in pediatric LT. Lacuna in knowledge regarding early hepatic artery vasospasm post-LT makes it a difficult condition to diagnose and treat, as the initial ischemic insult on graft can have devastating consequences. We report a case of pediatric progressive familial intrahepatic cholestasis type 3-related chronic liver disease who underwent cadaveric orthotopic LT and postoperatively developed fever, worsening hypotension, and elevated liver enzymes with an absence of arterial flow in intrahepatic branches on Doppler ultrasound. Suspecting early hepatic artery thrombosis, the patient was re-explored and the graft hepatic artery was found to be in a state of vasospasm. Following the infusion of intra-arterial papaverine, urokinase, and intravenous nicorandil, there was an improvement in blood flow. The patient responded well and was discharged on postoperative day 23 with normal liver enzymes.

Prognostic value of ultrasound in early arterial complications post liver transplant

Liver transplantation is the primary therapeutic intervention for end-stage liver disease. However, vascular complications, particularly those involving the hepatic artery, pose significant risks to patients. The clinical manifestations associated with early arterial complications following liver transplantation are often nonspecific. Without timely intervention, these complications can result in graft failure or patient mortality. Therefore, early diagnosis and the formulation of an optimal treatment plan are imperative. Ultrasound examination remains the predominant imaging modality for detecting complications post liver transplantation. This article comprehensively reviews common causes and clinical presentations of early hepatic artery complications in the post-transplantation period and delineates abnormal sonographic findings for accurate diagnosis of these conditions. Overall, ultrasound offers the advantages of convenience, safety, effectiveness, and non-invasiveness. It enables real-time, dynamic, and precise evaluation, making it the preferred diagnostic method for post-liver transplantation assessments.

Hepatic Artery Vasospasm Masquerading as Hepatic Artery Thrombosis in a Case of Deceased Donor Liver Transplant

Hepatic arterial vasospasm can be a potential vascular complication after liver transplantation and can manifest as hepatic artery thrombosis. Due to the scarcity of literature on this pathology, its incidence, mechanism, relevance, diagnosis, and prognosis remain to be investigated. Our index case, a 64-year-old man with decompensated alcohol-related cirrhosis, underwent a cadaveric orthotopic liver transplant and was having a normal postoperative course. On postoperative day 12, liver enzymes were elevated, and Doppler ultrasound performed showed hepatic arterial occlusion. In view of hepatic artery thrombosis digital subtraction angiography (DSA) was done, which showed a string bead appearance of graft hepatic artery, with no thrombosis or stenosis of hepatic artery anastomosis. It was managed by oral administration of vasodilator, as well as intra-arterial administration of vasodilators through DSA catheter tip placed in the hepatic artery. He responded well to the management and was discharged on postoperative day 24 with normal liver enzymes.

Perioperative Evolution of Sodium Levels in Cirrhotic Patients Undergoing Liver Transplantation: An Observational Cohort and Literature Review

Background & Aims

Hyponatremia is an important predictor of early death among cirrhotic patients in the orthotopic liver transplantation (OLT) waiting list. Evidence exists that prioritizing OLT waiting list according to the MELD score combined with plasma sodium concentration might prevent pre transplantation death. However, the evolution of plasma sodium concentrations during the perioperative period of OLT is not well known. We aimed to describe the evolution of perioperative sodium concentration during OLT and its relation to perioperative neurohormonal responses.

Methods

Twenty-seven consecutive cirrhotic patients who underwent OLT were prospectively included in the study over a period of 27 months. We studied the evolution of plasma sodium levels, the hemodynamics, the neurohormonal response and other biological markers during the perioperative period of OLT.

Results

Among study's population, four patients had hyponatremia before OLT, all with Child cirrhosis. In patients with hyponatremia, plasmatic sodium reached normal levels during surgery, and sodium levels remained within normal ranges 1 day, 7 days, as well as 6 months after surgery for all patients. Creatinine clearance was decreased significantly during the perioperative period, while creatinine and cystatin C levels increased significantly. Neutrophil gelatinase-associated lipocalin (NGAL) and vasopressin levels did not change significantly in this period. Plasma renin activity, concentrations of norepinephrine and brain natriuretic peptide varied significantly during the perioperative period.

Conclusion

In our study, plasmatic sodium concentrations among hyponatremic cirrhotic patients undergoing OLT seem to reach normal levels after OLT and remain stable six months after surgery providing more evidence for the importance of sodium levels in prioritization of liver transplant candidates. Further investigation of rapid correction and stabilization of sodium levels after OLT, as observed in our study, would be of interest in order to fully understand the mechanisms involved in cirrhosis-related hyponatremia, its prognostic value and clinical implications.

Pretransplant increases in left ventricular volume and mass are associated with QT prolongation during pediatric liver transplantation

Structural alterations in the cirrhotic heart may contribute to electromechanical abnormalities, represented by QT prolongation. The aim of this study was to investigate the changes in QTc according to the operative stage during pediatric LT and to identify which baseline echocardiographic parameters were associated with intraoperative QTc prolongation. Data were evaluated from 39 children undergoing LT for chronic liver disease (median age 9 months). In 19 patients (48.7%), baseline QTc was prolonged ≥440 ms (462 ± 19 ms). Through the period of post-reperfusion, QTI, QTc, and JTI progressively increased, although values partially recovered toward the end of surgery. High LVMI (≥82.51 g/m2 ) was associated with baseline QTc ≥ 440 ms (OR = 1.034, P = .032). In the 5 minutes post-reperfusion stage, marked QTc prolongation (defined as QTc ≥ 500 ms; n = 24, 61.5%) was significantly associated with high EDVI (OR = 1.060, P = .027) and SVI (OR = 1.075, P = .026). In children with chronic liver disease, increased ventricular volumes and mass may increase the risk of QTc prolongation during LT, suggesting that repolarization abnormalities might be contributed by structural changes characteristic of cirrhotic cardiomyopathy.

The Relationship between QT Interval Dispersion and End-Stage Liver Disease Score in the Patients Undergoing Orthotopic Liver Transplantation

BACKGROUND

This study was performed to determine the changes in corrected QT (QTc) and QT dispersion and their relationship with end-stage liver disease score in the children undergoing orthotopic liver transplantation.

METHODS

This case-control study was performed in a 2-year period from February 2009 to March 2011 in Department of Organ Transplantation of Nemazee Hospital. We consecutively included all the 22 pediatric patients undergoing orthotopic liver transplantation and 22 healthy age- and sex-matched controls. Electrocardiogram (ECG) was performed for all the patients and controls before and 6 months after the transplantation and the QTc was calculated according to Bazett's formula in lead I, aVF, andV1. Besides, QT dispersion was calculated by the difference between maximum and minimum QTc in the three leads. The data were statistically analyzed using independent sample t-test, chi-square test, paired t-test, and Pearson correlation analysis. In addition, P value < 0.05 was considered as statistically significant.

RESULTS

The patients with end-stage liver disease had significantly longer QTc dispersion (P = 0.002) compared to the controls. The post-transplantation QTc dispersion (P = 0.003) was also significantly longer compared to the healthy controls. Moreover, pretransplant QTc dispersion was negatively correlated with weight (r = ‒0.589, P = 0.004) and Child-Pugh score (r = ‒0.549, P = 0.008).

CONCLUSIONS

The patients with ESLD awaiting liver transplantation suffer from prolonged QTc interval predisposing them to ventricular tachycardia. The QTc prolongation in these patients does not response to liver transplantation. This study revealed a fine negative correlation between the Child- Pugh score and QTc.

Alterations in QT interval in patients undergoing living donor liver transplantation

BACKGROUND

QT interval prolongation, predisposing to ventricular tachyarrhythmia, has frequently been observed in patients with liver cirrhosis. During liver transplantation (LT) surgery, electrolyte imbalance and hemodynamic instability may affect QT interval changes. We evaluated the alterations in QT parameters at each stage of LT surgery.

METHODS

We assessed 50 living donor LT recipients without overt heart disease for the corrected QT (QTc) and the interval from peak to the end of the T wave (T(p-e)) automatically using Bazett's formula with LabChart software. QT parameters, laboratory and hemodynamic data were simultaneously collected in the following stages of LT: before anesthetic induction (baseline), pre-anhepatic, anhepatic, 1 hour postreperfusion, and after hepatic artery anastomosis. Recipients were allocated into 2 groups according to their baseline QTc: ≥440 versus <440 msec.

RESULTS

QTc progressively rose from the pre-anhepatic stage remaining prolonged in each stage of LT surgery compared with the baseline. In the anhepatic stage, 54% of recipients showed marked prolongation of QTc ≥500 msec (522 ± 14), which indicated the potential for a fatal ventricular dysrhythmia: 77% and 36% in groups with QTc ≥440 and <440 msec, respectively. As opposed to changes in QTc, T(p-e) in the anhepatic stage decreased significantly; however, it returned to the baseline level in the neohepatic stage.

CONCLUSION

A prolonged QTc interval (≥500 msec) was frequently observed throughout the procedure of LT, even among patients with baseline QTc <440 msec, emphasizing the importance of optimizing electrolyte balance and hemodynamic status to reduce greater risk of perioperative arrhythmias.

Norepinephrine in Small-For-Size Liver Grafts: An Experimental Study in Pigs

BACKGROUND

Norepinephrine plasma levels may play a role in small-for-size grafts dysfunction at the early posttransplant period.

MATERIALS AND METHODS

The 18 pigs used as recipients were assigned to group 1 (n = 6), group 2 (n = 6), and group 3 (n = 6) and given grafts with graft-to-recipient volume ratios of 1:1, 2:3, and 1:3, respectively. Blood serum norepinephrine was measured by high-performance liquid chromatography with electrochemical detection at the following time points: pre-anhepatic period (baseline); anhepatic period; and 30, 60, 180, and 360 min after reperfusion. Graft arterial and portal vein flows were obtained 30, 60, 180, and 360 min after reperfusion by the aid of an ultrasonic flowmeter. Aspartate transferase (AST) and international normalized ratio (INR) were measured before the procedure (baseline), and at 180 and 360 min after reperfusion.

RESULTS

Anhepatic phase was characterized by a significant increase (6- to 8-fold) of norepinephrine in all groups (P < 0.05). In groups 1 and 2 plasma norepinephrine returned to normal values 30 min after reperfusion. In group 3, plasma norepinephrine remained significantly increased at every time point of the study compared to groups 1 and 2 (P < 0.001). Hepatic artery and portal vein flows in group 3 were significantly (P < 0.05) reduced and increased, respectively, compared to groups 1 and 2 at all times measured. Liver function tests (AST and INR) 360 min after reperfusion were significantly higher in group 3 compared to groups 1 and 2.

CONCLUSIONS

Norepinephrine levels are increased in very small-for-size grafts and this increase may be associated with early graft dysfunction.

Doppler ultrasonographic findings on hepatic arterial vasospasm early after liver transplantation

OBJECTIVE

Hepatic arterial vasospasm has not been well recognized clinically as a post-liver transplant vascular complication because of the lack of sufficient data and diagnostic standards. The goal of this study was to provide new evidence and a diagnostic model for the clinical appreciation of hepatic arterial vasospasm and evaluate the role of ultrasonography in the diagnostic process.

METHODS

Nine post-orthotopic liver transplant cases were retrospectively reviewed. Multiple clinical measurements were analyzed. Routine Doppler ultrasonography was performed within 24 hours, and additional ultrasonographic examinations were conducted as indicated. Each of the 9 patients was given a single 10 mg dose of nifedipine sublingually and monitored by ultrasonography when vasospasm was suspected on the basis of the Doppler ultrasonographic results.

RESULTS

Doppler ultrasonography showed high-resistance hepatic arterial flow with absence of antegrade flow and even reversal of flow during diastole both extrahepatically and intrahepatically in all cases. Ten to 45 minutes after administration of the vasodilator, antegrade diastolic flow was observed along the course of the main hepatic artery and its intrahepatic branches with the resistive indices decreasing on average from 1.0 to 0.76. In addition, the peak systolic velocities increased from 57 cm/s before nifedipine administration to 77 cm/s after administration.

CONCLUSIONS

High-resistance hepatic arterial flow (resistive index = 1) early after liver transplantation is indicative of hepatic arterial vasospasm if it responds to vasodilators. Doppler ultrasonography is a useful tool for the diagnosis of this vascular complication.