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Wang F, Gao J, Wang ZY, Yuan TB, Cai DW, Wan H, Qin J. Two Pathological Fractures in a Patient with Chronic Abnormalities in Serum Markers Following Two Liver Transplantations: A Case Report and Literature Review. J Clin Densitom 2024; 27:101463. [PMID: 38157729 DOI: 10.1016/j.jocd.2023.101463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/08/2023] [Indexed: 01/03/2024]
Abstract
Bone disease is a common complication following liver transplantation, often overlooked in clinical practice. Clinical diagnosis of post-liver transplantation bone disease is challenging, and there have been few case report in the literature. This case report presents a patient who underwent two liver transplant surgeries, exhibited good daily activity, and did not display typical clinical symptoms such as fatigue, bone pain, or spinal deformities associated with prolonged sitting or standing. However, within the fifth year after the second liver transplant, the patient experienced two consecutive fractures. In March 2023, the patient underwent the first bone density test, which revealed osteoporosis. This case highlights the fact that severe fractures after liver transplantation may not necessarily be accompanied by typical symptoms of bone disease. Without timely examination and early prevention, serious consequences may arise. Therefore, this condition requires attention, proactive prevention, early detection, and timely treatment. Additionally, a retrospective analysis of the patient's previous laboratory data revealed persistent abnormalities in serum markers such as hypocalcemia and elevated alkaline phosphatase levels after liver transplantation, emphasizing the importance of monitoring these serum markers.
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Affiliation(s)
- Feng Wang
- Department of Orthopedics, Sir Run Run Hospital, Nanjing Medical University, Nanjing, China
| | - Jia Gao
- Department of Orthopedics, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zheng-Ye Wang
- The Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
| | - Tang-Bo Yuan
- Department of Orthopedics, Sir Run Run Hospital, Nanjing Medical University, Nanjing, China
| | - Da-Wei Cai
- Department of Orthopedics, Sir Run Run Hospital, Nanjing Medical University, Nanjing, China
| | - Hua Wan
- Sir Run Run Hospital, Nanjing Medical University, Nanjing, China
| | - Jian Qin
- Department of Orthopedics, Sir Run Run Hospital, Nanjing Medical University, Nanjing, China.
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2
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Seong H, Jang Y, Ko E, Lee J, Kim T, Lim CH, Shin HJ, Kim YH, Kim DS. Impact of preoperative red blood cell transfusion on long-term mortality of liver transplantation: A retrospective cohort study. Medicine (Baltimore) 2023; 102:e34914. [PMID: 37713857 PMCID: PMC10508566 DOI: 10.1097/md.0000000000034914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 08/03/2023] [Indexed: 09/17/2023] Open
Abstract
Preoperative red blood cell (RBC) transfusion can induce immune modulation and alloimmunization; however, few studies have investigated the effect of preoperative transfusion and hemoglobin levels that need to be corrected before surgery, especially in critically ill patients such as those with end-stage liver disease who undergo liver transplantation (LT). This study aimed to investigate the effects of preoperative RBC transfusion on long-term mortality in LT recipients. A total of 249 patients who underwent LT at a single center between January 2012 and December 2021 were included in this study. The patients were divided into 2 groups: preoperative transfusion and preoperative non-transfusion. Since the baseline characteristics were significantly different between the 2 groups, we performed propensity score matching, including factors such as the Model for End-Stage Liver Disease score and intraoperative RBC transfusion, to exclude possible biases that could affect prognosis. We analyzed the 5-year mortality rate as the primary outcome. The preoperative transfusion group showed a 4.84-fold higher hazard ratio than that in the preoperative non-transfusion group. There were no differences in 30-day mortality, duration of intensive care unit stay, or graft rejection rate between the 2 groups. Preoperative transfusion could influence long-term mortality in LT, and clinicians should pay attention to RBC transfusion before LT unless the patient is hemodynamically unstable. A large-scale randomized controlled trial is needed to determine the possible mechanisms related to preoperative RBC transfusion, long-term mortality, and the level of anemia that should be corrected before surgery.
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Affiliation(s)
- Hyunyoung Seong
- Department of Anesthesiology and Pain Medicine, Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Yookyung Jang
- Department of Anesthesiology and Pain Medicine, Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Eunji Ko
- Department of Anesthesiology and Pain Medicine, Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Jaehee Lee
- Department of Anesthesiology and Pain Medicine, Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Taesan Kim
- Department of Anesthesiology and Pain Medicine, Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Choon Hak Lim
- Department of Anesthesiology and Pain Medicine, Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Hyeon Ju Shin
- Department of Anesthesiology and Pain Medicine, Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Yun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Changwon Hanmaeum Hospital, Changwon, South Korea
| | - Dong-Sik Kim
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery Anam Hospital, Korea University College of Medicine, Seoul, South Korea
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Pérez-Calatayud AA, Hofmann A, Pérez-Ferrer A, Escorza-Molina C, Torres-Pérez B, Zaccarias-Ezzat JR, Sanchez-Cedillo A, Manuel Paez-Zayas V, Carrillo-Esper R, Görlinger K. Patient Blood Management in Liver Transplant—A Concise Review. Biomedicines 2023; 11:biomedicines11041093. [PMID: 37189710 DOI: 10.3390/biomedicines11041093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/09/2023] [Accepted: 03/13/2023] [Indexed: 04/07/2023] Open
Abstract
Transfusion of blood products in orthotopic liver transplantation (OLT) significantly increases post-transplant morbidity and mortality and is associated with reduced graft survival. Based on these results, an active effort to prevent and minimize blood transfusion is required. Patient blood management is a revolutionary approach defined as a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient’s own blood while promoting patient safety and empowerment. This approach is based on three pillars of treatment: (1) detecting and correcting anemia and thrombocytopenia, (2) minimizing iatrogenic blood loss, detecting, and correcting coagulopathy, and (3) harnessing and increasing anemia tolerance. This review emphasizes the importance of the three-pillar nine-field matrix of patient blood management to improve patient outcomes in liver transplant recipients.
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Affiliation(s)
| | - Axel Hofmann
- Faculty of Health and Medical Sciences, Discipline of Surgery, The University of Western Australia, Perth 6907, WA, Australia
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, 8057 Zurich, Switzerland
| | - Antonio Pérez-Ferrer
- Department of Anesthesiology, Infanta Sofia University Hospital, 28700 San Sebastián de los Reyes, Spain
- Department of Anesthesiology, European University of Madrid, 28702 Madrid, Spain
| | - Carla Escorza-Molina
- Departmen of Anesthesiology, Hospital General de México Dr. Eduardo Liceaga, Mexico City 06720, Mexico
| | - Bettina Torres-Pérez
- Department of Anesthesiology, Pediatric Transplant, Centro Medico de Occidente, Instituto Mexicano del Seguro Social, Guadalajara 44329, Mexico
| | | | - Aczel Sanchez-Cedillo
- Transplant Department Hospital General de México Dr. Eduardo Liceaga, Mexico City 06720, Mexico
| | - Victor Manuel Paez-Zayas
- Gastroenterology Department Hospital General de México Dr. Eduardo Liceaga, Mexico City 06720, Mexico
| | | | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, 45131 Essen, Germany
- TEM Innovations GmbH, 81829 Munich, Germany
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4
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Fernández-Castellano G, Pueyo-Périz EM, Triano MB, Romero JLL, Bravo MÁG, Linero IB. Importance of Preventing Inadvertent Perioperative Hypothermia During Liver Transplant. Transplant Proc 2022; 54:2549-2551. [DOI: 10.1016/j.transproceed.2022.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/27/2022] [Accepted: 10/01/2022] [Indexed: 11/07/2022]
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5
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Sim J, Kwon H, Jun I, Kim S, Kim B, Kim S, Song J, Hwang G. Association between red blood cell distribution width and blood transfusion in patients undergoing living donor liver transplantation: propensity score analysis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:983-993. [DOI: 10.1002/jhbp.1163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/26/2022] [Accepted: 03/27/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Ji‐Hoon Sim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Hye‐Mee Kwon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - In‐Gu Jun
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Sung‐Hoon Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Bomi Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Sehee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Jun‐Gol Song
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
| | - Gyu‐Sam Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center University of Ulsan College of Medicine Seoul Republic of Korea
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Milan Z, Cirkovic A, Macmillan J, Zaky M, Pereira JFB. Hemostatic Markers as Predictors of Massive Blood Transfusion in Orthotopic Liver Transplantation. Transplant Proc 2022; 54:734-737. [DOI: 10.1016/j.transproceed.2022.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/12/2022] [Indexed: 11/24/2022]
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Sim JH, Kim SH, Jun IG, Kang SJ, Kim B, Kim S, Song JG. The Association between Prognostic Nutritional Index (PNI) and Intraoperative Transfusion in Patients Undergoing Hepatectomy for Hepatocellular Carcinoma: A Retrospective Cohort Study. Cancers (Basel) 2021; 13:cancers13112508. [PMID: 34063772 PMCID: PMC8196581 DOI: 10.3390/cancers13112508] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/05/2021] [Accepted: 05/17/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND PNI is significantly associated with surgical outcomes; however, the association between PNI and intraoperative transfusions is unknown. METHODS This study retrospectively analyzed 1065 patients who underwent hepatectomy. We divided patients into two groups according to the PNI (<44 and >44) and compared their transfusion rates and surgical outcomes. We performed multivariate logistic and Cox regression analysis to determine risk factors for transfusion and the 5-year survival. Additionally, we found the net reclassification index (NRI) to validate the discriminatory power of PNI. RESULTS The PNI <44 group had higher transfusion rates (adjusted odds ratio [OR]: 2.20, 95%CI: 1.06-4.60, p = 0.035) and poor surgical outcomes, such as post hepatectomy liver failure (adjusted [OR]: 3.02, 95%CI: 1.87-4.87, p < 0.001), and low 5-year survival (adjusted OR: 1.68, 95%CI: 1.17-2.24, p < 0.001). On multivariate analysis, PNI <44, age, hemoglobin, operation time, synthetic colloid use, and laparoscopic surgery were risk factors for intraoperative transfusion. On Cox regression analysis, PNI <44, MELD score, TNM staging, synthetic colloid use, and transfusion were associated with poorer 5-year survival. NRI analysis showed significant improvement in the predictive power of PNI for transfusion (p = 0.002) and 5-year survival (p = 0.004). CONCLUSIONS Preoperative PNI <44 was significantly associated with higher transfusion rates and surgical outcomes.
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Affiliation(s)
- Ji Hoon Sim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.H.S.); (S.-H.K.); (I.-G.J.); (S.-J.K.); (B.K.)
| | - Sung-Hoon Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.H.S.); (S.-H.K.); (I.-G.J.); (S.-J.K.); (B.K.)
| | - In-Gu Jun
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.H.S.); (S.-H.K.); (I.-G.J.); (S.-J.K.); (B.K.)
| | - Sa-Jin Kang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.H.S.); (S.-H.K.); (I.-G.J.); (S.-J.K.); (B.K.)
| | - Bomi Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.H.S.); (S.-H.K.); (I.-G.J.); (S.-J.K.); (B.K.)
| | - Seonok Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea;
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (J.H.S.); (S.-H.K.); (I.-G.J.); (S.-J.K.); (B.K.)
- Correspondence: ; Tel.: +82-2-3010-3869; Fax: +82-2-3010-6790
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Analysis of the hemostatic therapy in liver transplantation guided by rotational thromboelastometry or conventional laboratory tests. Eur J Gastroenterol Hepatol 2020; 32:1452-1457. [PMID: 32118854 DOI: 10.1097/meg.0000000000001660] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Coagulopathy is quite common in chronic liver disease patients undergoing orthotopic liver transplantation (OLT). Diagnosis of intraoperative bleeding disorders is based on conventional laboratory tests (CLTs), and thus, the patients are frequently exposed to unnecessary transfusions of blood products. The present study aimed to analyze the intraoperative administration of blood products in patients undergoing OLT, using rotational thromboelastometry (ROTEM) or CLTs. PATIENTS AND METHODS A cohort comprising 153 patients undergoing OLT, of whom 82 were evaluated with ROTEM and 71 by CLTs. Both groups were analyzed intraoperatively: the transfusion of blood products. RESULTS The incidence of patients transfused with cryoprecipitate (CRYO) and/or fibrinogen concentrate (54.9 vs. 19.7%; P < 0.001) and prothrombin complex concentrate (PCC) (32.9 vs. 9.9%; P = 0.008) increased significantly in the ROTEM group than in CLT group, respectively. The amount of transfused patient with CRYO (7.6 vs. 1.2; P < 0.001), fibrinogen concentrate (0.8 vs. 0.2; P = 0.004) and PCC (1.4 vs. 0.2; P = 0.002) increased significantly in the ROTEM group than in the CLT group, respectively. In the analysis of fresh-frozen plasma (FFP), the incidence of transfused patients was significantly higher in the CLT group than in the ROTEM group (46.5 vs. 30.5%; P = 0.047, respectively), with a moderate correlation with red blood cells transfusion (r = 0.67, P < 0.001). The incidence of patients receiving antifibrinolytics was significantly higher in the CLT group than in the ROTEM group (85.9 vs. 47.6%; P < 0.001, respectively). CONCLUSION Transfusion protocol-based thromboelastometry was able to guide administration of hemostatic factors and reduced administration of FFP and antifibrinolytics.
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9
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Massive Pulmonary Artery Thromboembolism in a Liver Transplant Recipient: Case Study and Literature Review. Transplant Proc 2020; 52:2795-2801. [PMID: 32713815 DOI: 10.1016/j.transproceed.2020.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 06/04/2020] [Indexed: 11/20/2022]
Abstract
The hypercoagulable state in liver transplant recipients that may manifest as abnormal thrombus formation in large vessel structures, such as cardiac chambers and the pulmonary arteries, poses a substantial threat for the patient and graft survival. Massive pulmonary embolism is a rare, albeit potentially lethal, complication that may occur at any stage of liver transplant surgery. In this study, we present the case of a major perioperative thromboembolic event in a liver transplant recipient that had taken place in the early post-transplant period during the second-look surgery that was then successfully treated by catheter-directed clot removal. We will attempt to identify potential factors that may have been associated with abnormal thrombus formation.
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10
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Pravisani R, Baccarani U, Montaldo L, Clocchiatti L, Faion M, Cherchi V, Terrosu G, Risaliti A, Girometti R, Lorenzin D. Can Preoperative Multidetector Computed Tomography Identify Predictive Features of Difficult Native Hepatectomy at Liver Transplantation? Transplant Proc 2020; 52:1581-1584. [PMID: 32402453 DOI: 10.1016/j.transproceed.2020.02.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/05/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Native hepatectomy represents the most demanding surgical step during orthotopic whole liver transplantation (LT). The surgical risk assessment of LT candidates is currently mainly based on clinical and laboratory data, but even preoperative imaging data may be predictive of a complex native hepatectomy. METHODS A retrospective study on a cohort of 110 LT recipients was conducted. The radiologic variables investigated on pre-LT multidetector computed tomography scan were the length of the retrohepatic inferior vena cava (IVC-L), volume of the dorsal liver sector (DLS-V), complete encirclement of the IVC by the DLS (IVC-CE), max diameter of the native liver (L-D), max diameter of the spleen (S-D), and presence of large spontaneous portosystemic shunts (SPSS). The parameters defining complex native hepatectomy were the operative time, number of red blood cell (RBC) units transfused, IVC replacement technique switch, and post-LT relaparotomy for major bleeding. RESULTS In a multivariate analysis, the operative time was predicted by hepatocellular carcinoma (HCC) diagnosis (regression coefficient [RC]: 18.237, P = .009), S-D (RC: 3.733, P = .007), and IVC-CE (RC: 20.174, P = .01); the RBC units transfused by an history of gastroesophageal variceal bleeding (RC: 2.503, P = .039), Model for End-Stage Liver Disease (MELD) score (RC: .259, P = .039), and L-D (RC: -0.519, P = .027); the switch to a IVC replacement technique by L-D (odds ratio [OR]: 0.641, P = .028) and IVC-L (OR: 1.065, P = .023); and the relaparotomy for bleeding by L-D (OR: 0.632, confidence interval [CI]: 0.437 to 0.916, P = .015). CONCLUSIONS Pre-LT multidetector computed tomography (MDCT) seems to be a very useful tool in the surgical risk assessment of LT candidates.
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Affiliation(s)
- Riccardo Pravisani
- Liver-Kidney Transplant Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Umberto Baccarani
- Liver-Kidney Transplant Unit, Department of Medicine, University of Udine, Udine, Italy.
| | - Luca Montaldo
- Institute of Radiology, Department of Medicine, University of Udine, Udine, Italy
| | - Lucrezia Clocchiatti
- Liver-Kidney Transplant Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Matteo Faion
- Liver-Kidney Transplant Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Vittorio Cherchi
- Liver-Kidney Transplant Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Giovanni Terrosu
- Liver-Kidney Transplant Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Andrea Risaliti
- Liver-Kidney Transplant Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Rossano Girometti
- Institute of Radiology, Department of Medicine, University of Udine, Udine, Italy
| | - Dario Lorenzin
- Liver-Kidney Transplant Unit, Department of Medicine, University of Udine, Udine, Italy
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Görlinger K, Pérez-Ferrer A, Dirkmann D, Saner F, Maegele M, Calatayud ÁAP, Kim TY. The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management. Korean J Anesthesiol 2019; 72:297-322. [PMID: 31096732 PMCID: PMC6676023 DOI: 10.4097/kja.19169] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/08/2019] [Indexed: 02/07/2023] Open
Abstract
Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management (‘theranostic’ approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient’s safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration.
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Affiliation(s)
- Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Tem Innovations, Munich, Germany
| | - Antonio Pérez-Ferrer
- Department of Anesthesiology, Infanta Sofia University Hospital, San Sebastián de los Reyes, Madrid, Spain
| | - Daniel Dirkmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Fuat Saner
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Marc Maegele
- Department for Trauma and Orthopedic Surgery, CologneMerheim Medical Center (CMMC), Cologne, Germany.,Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke (UW/H), Campus Cologne-Merheim, Cologne, Germany
| | - Ángel Augusto Pérez Calatayud
- Terapia Intensiva Adultos, Hospital de Especialidades del Niño y la Mujer, Coordinador Grupo Mexicano para el Estudio de la Medicina Intensiva, Colegio Mexicano de Especialistas en Obstetrica Critica (COMEOC), Queretarco, Mexico
| | - Tae-Yop Kim
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
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12
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Milan Z, Katyayani K, Cubas G, Unic‐Stojanovic D, Cooper M, Bras P, Macmillan J. Trends in transfusion practice over 20 years in paediatric liver transplant programme. Vox Sang 2019; 114:355-362. [DOI: 10.1111/vox.12771] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 02/13/2019] [Accepted: 02/18/2019] [Indexed: 12/14/2022]
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13
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Incidence, Predictors, and Outcomes of New-Onset Left Ventricular Systolic Dysfunction After Orthotopic Liver Transplantation. J Card Fail 2018; 25:166-172. [PMID: 30412734 DOI: 10.1016/j.cardfail.2018.10.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 10/27/2018] [Accepted: 10/31/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Adverse cardiovascular events after liver transplantation (LT) are relatively common and are a significant source of early mortality. Although new-onset systolic dysfunction after LT is a reported phenomenon, there is little data regarding its incidence, risk factors, and outcomes. METHODS AND RESULTS This single-center retrospective study included all adult patients from January 2002 to March 2015 with deceased-donor LT and available preoperative transthoracic echocardiograms (TTEs). In total, 1,760 patients were included in the study, 602 (34.2%) of whom had a postoperative TTE. The primary end point was development of new-onset cardiomyopathy, defined as a new left ventricular ejection fraction (LVEF) of <40% within 180days of transplant. Sixty-nine (11.4%) of the patients who received post-LT TTE had a reduction in LVEF to <40% within 6 months. Clinical parameters of donor and recipient did not show significant impact on development of post-LT LV systolic dysfunction (LVSD). Presence of wall motion abnormalities (P = .004) on preoperative TTE was predictive of development of post-LT LVSD. These patients did not have longer hospitalizations, but they had worse survival. CONCLUSIONS Post-LT LV systolic dysfunction occurs at higher rates than previously suspected and may develop more frequently in patients with underlying cardiac structural abnormalities, which appear to adversely affect post-LT survival.
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14
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Reshetnyak VI, Zhuravel SV, Kuznetsova NK, Pisarev VМ, Klychnikova EV, Syutkin VЕ, Reshetnyak ТM. The System of Blood Coagulation in Normal and in Liver Transplantation (Review). GENERAL REANIMATOLOGY 2018. [DOI: 10.15360/1813-9779-2018-5-58-84] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The review dwells on the problem of hemostatic disorders in patients undergoing liver transplantation and their correction in the perioperative period. The physiology of the hemostatic system, disorders of the blood coagulation system in patients at various stages of liver transplantation, correction of hemostatic disorders during and after orthotopic liver transplantation are discussed. Liver transplantation is performed in patients with liver diseases in the terminal stage of liver failure. At the same time, changes in the hemostatic system of these patients pose a significant risk of developing bleeding and/or thrombosis during and after liver transplantation. The hypothesis is suggested that the personalized correction of hemostasis disorder in liver transplantation should be based on considerating the nosological forms of the liver damage, mechanisms of development of recipient’s hemostatic disorders, and the stage of the surgery.
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Affiliation(s)
- V. I. Reshetnyak
- V. A. Negovsky Research Institute of General Reanimatology, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology
| | - S. V. Zhuravel
- N.V. Sklifosovsky Research Institute of Emergency Care, Moscow Healthcare Department
| | - N. K. Kuznetsova
- N.V. Sklifosovsky Research Institute of Emergency Care, Moscow Healthcare Department
| | - V. М. Pisarev
- V. A. Negovsky Research Institute of General Reanimatology, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology
| | - E. V. Klychnikova
- N.V. Sklifosovsky Research Institute of Emergency Care, Moscow Healthcare Department
| | - V. Е. Syutkin
- N.V. Sklifosovsky Research Institute of Emergency Care, Moscow Healthcare Department
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15
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Restoux A, Grassin-Delyle S, Liu N, Paugam-Burtz C, Mantz J, Le Guen M. Pilot study of closed-loop anaesthesia for liver transplantation. Br J Anaesth 2018; 117:332-40. [PMID: 27543528 DOI: 10.1093/bja/aew262] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2016] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Automated titration of propofol and remifentanil guided by the bispectral index (BIS) has been used for numerous surgical procedures. Orthotopic liver transplantation (OLT) uniquely combines major changes in circulating volume, an anhepatic phase, and ischaemia-reperfusion syndrome. We assessed the behaviour of this automated controller during OLT. METHODS Adult patients undergoing OLT were included in this pilot study. Consumption of propofol and remifentanil was calculated for each surgery period (dissection, anhepatic, and liver reperfusion phases). Arterial blood samples were collected at several time points to allow comparison of actual with calculated propofol and remifentanil concentrations. Data are presented as median [25th and 75th percentiles] or percentage (95% confidence interval). RESULTS Thirteen patients were studied. System performance, defined as the percentage of time with BIS in the range 40-60, was 88% (86-94) of the total duration of anaesthesia. Propofol requirement was decreased during the anhepatic phase compared with the dissection phase (2.9 [1.9-5.0] mg kg(-1) h(-1) and 4.6 [3.5-8.1] mg kg(-1) h(-1); P<0.03) while remifentanil consumption was unchanged (0.11 [0.09-0.19] µg kg- (1) min(-1)). Bland-Altman analysis showed a weak concordance for propofol (bias of 0.7 µg ml(-1) and limits of agreement of -2.2 to +3.7 µg ml(-1)) and remifentanil (bias of 1.3 ng ml(-1) and limits of agreement -4.3 to +6.8 ng ml(-1)). No adverse events were reported during anaesthesia. CONCLUSIONS This pilot study indicates that automated titration of propofol and remifentanil guided by the BIS is feasible during OLT.
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Affiliation(s)
- A Restoux
- Department of Anaesthesia and Critical Care, Hôpital Beaujon, Clichy, France Université Paris VII Denis Diderot, France
| | - S Grassin-Delyle
- Department of Pharmacology Mass Spectrometry Facility, UFR Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin en Yvelines, France
| | - N Liu
- Department of Anaesthesia, Hôpital Foch, Suresnes, France Université Versailles Saint-Quentin en Yvelines, France
| | - C Paugam-Burtz
- Department of Anaesthesia and Critical Care, Hôpital Beaujon, Clichy, France Université Paris VII Denis Diderot, France
| | - J Mantz
- Department of Anaesthesia and Critical Care, Hôpital Européen Georges Pompidou, Paris, France Université Paris Descartes, France
| | - M Le Guen
- Department of Anaesthesia, Hôpital Foch, Suresnes, France Université Versailles Saint-Quentin en Yvelines, France
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16
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Froghi F, Koti R, Gurusamy K, Mallett S, Thorburn D, Selves L, James S, Singh J, Pinto M, Eastgate C, McNeil M, Filipe H, Jichi F, Schofield N, Martin D, Davidson B. Cardiac output Optimisation following Liver Transplant (COLT) trial: study protocol for a feasibility randomised controlled trial. Trials 2018. [PMID: 29514697 PMCID: PMC5842525 DOI: 10.1186/s13063-018-2488-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background Patients with liver cirrhosis undergoing liver transplantation have a hyperdynamic circulation which persists into the early postoperative period making accurate assessment of fluid requirements challenging. Goal-directed fluid therapy (GDFT) has been shown to reduce morbidity and mortality in a number of surgery settings. The impact of GDFT in patients undergoing liver transplantation is unknown. A feasibility trial was designed to determine patient and clinician support for recruitment into a randomised controlled trial of GDFT following liver transplantation, adherence to a GDFT protocol, participant withdrawal, and to determine appropriate endpoints for a subsequent larger trial to evaluate the efficacy of GDFT in patients undergoing liver transplantation. Methods The Cardiac output Optimisation following Liver Transplant (COLT) trial is designed as a prospective, single-centre, randomised controlled study to assess the feasibility and safety of GDFT in liver transplantation for patients with cirrhosis. Consenting adults (aged between 18 and 80 years) with biopsy-proven liver cirrhosis who have been selected to undergo a first liver transplantation will be included in the trial and randomised into GDFT or standard care starting immediately after surgery and continuing for the first 12 h thereafter. Both groups will have cardiac output and stroke volume monitored using the FloTrac (EV1000) device. The intervention will consist of a protocolised GDFT approach to patient management, using stroke volume optimisation. The control group will receive standard care, without stroke volume and cardiac output measurement. After 12 h the patient’s fluid management will revert to standard of care. The primary endpoint of this study is feasibility. Secondary endpoints will include a safety assessment of the intervention, graft and patient survival, liver function, postoperative complications graded by Clavien-Dindo criteria, length of intensive care and hospital stay and quality of life across the intervention and control groups. Discussion There is a growing body of evidence that the use of perioperative GDFT in surgical patients can improve outcomes; however, signals of harm have also been detected. Patients with liver cirrhosis undergoing liver transplantation have markedly different cardiovascular physiology than general surgical patients. If GDFT is proven to be feasible and safe in this patient group, then a multicentre trial to demonstrate efficacy and cost-effectiveness will be required. Trial registration International Standard Randomised Controlled Trial Registry, ID: ISRCTN10329248. Registered on 4 April 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2488-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Farid Froghi
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Rahul Koti
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Susan Mallett
- Critical Care Unit, Royal Free Hospital, London, NW3 2QG, UK
| | - Douglas Thorburn
- Institute for Liver and Digestive Health, University College London, London, UK
| | - Linda Selves
- Institute for Liver and Digestive Health, University College London, London, UK
| | - Sarah James
- Critical Care Unit, Royal Free Hospital, London, NW3 2QG, UK
| | - Jeshika Singh
- Health Economic Research Group, Brunel University, London, UK
| | - Manuel Pinto
- Critical Care Unit, Royal Free Hospital, London, NW3 2QG, UK
| | | | - Margaret McNeil
- Critical Care Unit, Royal Free Hospital, London, NW3 2QG, UK
| | - Helder Filipe
- Critical Care Unit, Royal Free Hospital, London, NW3 2QG, UK
| | - Fatima Jichi
- Biostatistics Group, Joint Research Office, University College London, London, UK
| | - Nick Schofield
- Royal Free Perioperative Research Group (RoFPoR), Royal Free Hospital, London, UK
| | - Daniel Martin
- Division of Surgery and Interventional Science, University College London, London, UK. .,Critical Care Unit, Royal Free Hospital, London, NW3 2QG, UK. .,Royal Free Perioperative Research Group (RoFPoR), Royal Free Hospital, London, UK.
| | - Brian Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
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17
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Prasad V, Guerrisi M, Dauri M, Coniglione F, Tisone G, De Carolis E, Cillis A, Canichella A, Toschi N, Heldt T. Prediction of postoperative outcomes using intraoperative hemodynamic monitoring data. Sci Rep 2017; 7:16376. [PMID: 29180647 PMCID: PMC5703992 DOI: 10.1038/s41598-017-16233-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 11/08/2017] [Indexed: 12/13/2022] Open
Abstract
Major surgeries can result in high rates of adverse postoperative events. Reliable prediction of which patient might be at risk for such events may help guide peri- and postoperative care. We show how archiving and mining of intraoperative hemodynamic data in orthotopic liver transplantation (OLT) can aid in the prediction of postoperative 180-day mortality and acute renal failure (ARF), improving upon predictions that rely on preoperative information only. From 101 patient records, we extracted 15 preoperative features from clinical records and 41 features from intraoperative hemodynamic signals. We used logistic regression with leave-one-out cross-validation to predict outcomes, and incorporated methods to limit potential model instabilities from feature multicollinearity. Using only preoperative features, mortality prediction achieved an area under the receiver operating characteristic curve (AUC) of 0.53 (95% CI: 0.44–0.78). By using intraoperative features, performance improved significantly to 0.82 (95% CI: 0.56–0.91, P = 0.001). Similarly, including intraoperative features (AUC = 0.82; 95% CI: 0.66–0.94) in ARF prediction improved performance over preoperative features (AUC = 0.72; 95% CI: 0.50–0.85), though not significantly (P = 0.32). We conclude that inclusion of intraoperative hemodynamic features significantly improves prediction of postoperative events in OLT. Features strongly associated with occurrence of both outcomes included greater intraoperative central venous pressure and greater transfusion volumes.
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Affiliation(s)
- Varesh Prasad
- Harvard-MIT Health Sciences and Technology Program, Massachusetts Institute of Technology, Cambridge, MA, USA. .,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.
| | - Maria Guerrisi
- Medical Physics Section, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Mario Dauri
- Department of Clinical Science and Translational Medicine, University of Rome "Tor Vergata", Rome, Italy.,Department of Emergency and Critical Care Medicine, Pain Medicine and Anaesthesiology, University Hospital "Tor Vergata", Rome, Italy
| | - Filadelfo Coniglione
- Department of Clinical Science and Translational Medicine, University of Rome "Tor Vergata", Rome, Italy.,Department of Emergency and Critical Care Medicine, Pain Medicine and Anaesthesiology, University Hospital "Tor Vergata", Rome, Italy.,University "Our Lady of Good Counsel", Tirana, Albania
| | - Giuseppe Tisone
- Department of Experimental Medicine and Surgery, University of Rome "Tor Vergata", Rome, Italy
| | - Elisa De Carolis
- Department of Emergency and Critical Care Medicine, Pain Medicine and Anaesthesiology, University Hospital "Tor Vergata", Rome, Italy
| | - Annagrazia Cillis
- Department of Emergency and Critical Care Medicine, Pain Medicine and Anaesthesiology, University Hospital "Tor Vergata", Rome, Italy
| | - Antonio Canichella
- Medical Physics Section, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Nicola Toschi
- Medical Physics Section, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy.,Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Thomas Heldt
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.,Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
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18
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Blaine KP, Sakai T. Viscoelastic Monitoring to Guide Hemostatic Resuscitation in Liver Transplantation Surgery. Semin Cardiothorac Vasc Anesth 2017; 22:150-163. [PMID: 29099334 DOI: 10.1177/1089253217739121] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Coagulopathic bleeding must be anticipated during liver transplantation (LT) surgery. Patients with end-stage liver disease (ESLD) often present with disease-related hematologic disturbances, including the loss of hepatic procoagulant and anticoagulant clotting factors and thrombocytopenia. Transplantation surgery itself presents additional hemostatic changes, including hyperfibrinolysis. Viscoelastic monitoring (VEM) is often used to provide targeted, personalized hemostatic therapies for complex bleeding states including cardiac surgery and major trauma. The use in these coagulopathic conditions led to its application to LT, although the mechanisms of coagulopathy in these patients are quite different. While VEM is often used during transplant surgeries in Europe and North America, evidence supporting its use is limited to a few small clinical studies. The theoretical and clinical applications of the standard and specialized VEM assays are discussed in the setting of LT and ESLD.
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Affiliation(s)
- Kevin P Blaine
- 1 Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Tetsuro Sakai
- 2 University of Pittsburgh Medical Center Health System, Pittsburgh, PA, USA
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19
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Eghbal MH, Samadi K, Khosravi MB, Sahmeddini MA, Ghaffaripoor S, Ghorbani M, Shokrizadeh S. The Impact of Preoperative Variables on Intraoperative Blood Loss and Transfusion Requirements During Orthotopic Liver Transplant. EXP CLIN TRANSPLANT 2017; 17:507-512. [PMID: 29025385 DOI: 10.6002/ect.2016.0325] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Liver transplant traditionally and potentially is associated with the risk of massive blood loss and transfusion, which can adversely affect transplant outcomes. Many variables influence the amount of bleeding, and these can be categorized as patient related, surgery related, and graft related. We aimed to assess the effects of these variables on the amount of bleeding and transfusion during liver transplant; predicting the risk of massive blood loss can help transplant teams to select and manage patients more effectively. MATERIALS AND METHODS We retrospectively studied 754 patients who underwent liver transplant from 2013 to 2016 and analyzed more than 20 variables that could influence the volume of blood loss and packed cell transfusion. RESULTS We found that at least 4 variables are strongly and independently correlated with blood loss volume: age, Model for End-Stage Liver Disease score, warm ischemia time, and total bilirubin. Furthermore, intraoperative blood loss had a weak but clinically important correlation with the underlying disease (ie, the cause of liver cirrhosis). Some variables, including international normalized ratio, platelet count, albumin, serum urea nitrogen, creatinine level, sodium level, and the amount of ascites, could be considered as 'dependent' and weak predictors of massive blood loss. Sex of patient, cold ischemia time, surgery technique, and history of previous abdominal surgery were not correlated with the amount of bleeding. CONCLUSIONS With the use of the variables identified, we can properly select patients and surgical teams and promptly use modalities for decreasing and managing blood loss.
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Affiliation(s)
- Mohammad Hossein Eghbal
- From the Department of Anesthesiology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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20
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Post-reperfusion syndrome during orthotopic liver transplantation, which definition best predicts postoperative graft failure and recipient mortality? J Crit Care 2017; 41:156-160. [DOI: 10.1016/j.jcrc.2017.05.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 05/09/2017] [Accepted: 05/20/2017] [Indexed: 01/15/2023]
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21
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Kloesel B, Kovatsis PG, Faraoni D, Young V, Kim HB, Vakili K, Goobie SM. Incidence and predictors of massive bleeding in children undergoing liver transplantation: A single-center retrospective analysis. Paediatr Anaesth 2017; 27:718-725. [PMID: 28557286 DOI: 10.1111/pan.13162] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Liver transplantation represents a major surgery involving a highly vascular organ. Reports defining the scope of bleeding in pediatric liver transplants are few. AIMS We conducted a retrospective analysis of liver transplants performed at our pediatric tertiary care center to quantify blood loss, blood product utilization, and to determine predictors for massive intraoperative bleeding. METHODS Pediatric patients who underwent isolated liver transplantation at Boston Children's Hospital between 2011 and 2016 were included. The amount of blood product transfused in the perioperative period and the incidence of postoperative complications were reported. Univariable and multivariable logistic regressions were used to determine predictors for massive bleeding, defined as estimated blood loss exceeding one circulating blood volume within 24 hours. RESULTS Sixty-eight children underwent liver transplantation during the study period and were included in the analysis. Multivariable logistic regression analysis identified the following independent predictors of massive bleeding: preoperative hemoglobin level <8.5 g/dL (OR 11.09, 95% CI 1.87-65.76), INR >1.5 (OR 11.62, 95% CI 2.36-57.26), platelet count <100 109 /L (OR 7.92, 95% CI 1.46-43.05), and surgery duration >600 minutes (OR 6.97, 95% CI 0.99-48.92). CONCLUSIONS Pediatric liver transplantation is associated with substantial blood loss and a significant blood product transfusion burden. A 43% incidence of massive bleeding is reported. Further efforts are needed to improve bleeding management in this high-risk population.
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Affiliation(s)
- Benjamin Kloesel
- Department of Anesthesiology, Critical Care, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pete G Kovatsis
- Department of Anesthesiology, Critical Care, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Pediatric Transplant Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Vanessa Young
- Department of Anesthesiology, Critical Care, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Heung Bae Kim
- Pediatric Transplant Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Khashayar Vakili
- Pediatric Transplant Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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22
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Liu H, Jayakumar S, Traboulsi M, Lee SS. Cirrhotic cardiomyopathy: Implications for liver transplantation. Liver Transpl 2017; 23:826-835. [PMID: 28407402 DOI: 10.1002/lt.24768] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 03/23/2017] [Indexed: 12/12/2022]
Abstract
The majority of patients on a waiting list for liver transplantation have end-stage liver disease. Because of the marked peripheral vasodilatation of end-stage cirrhosis that masks a latent myocardial dysfunction, cardiac abnormalities in the resting state are usually subclinical and escape the attention of physicians. However, when challenged, the systolic and diastolic contractile responses are attenuated. In addition to these contractile abnormalities, morphological changes, such as enlargement or hypertrophy of cardiac chambers, and electrophysiological repolarization changes, including a prolonged QT interval, can be observed. The constellation of these cardiac abnormalities is termed cirrhotic cardiomyopathy. Liver transplantation induces significant cardiovascular stress. Clamping of the inferior vena cava and portal vein, hemorrhage and blood/volume infusion, and ischemia/reperfusion all cause hemodynamic fluctuation. The changing cardiac preload and afterload status increases the cardiac workload, and thus, the previously subclinical ventricular dysfunction may manifest as overt heart failure during the operative and perioperative periods. Cardiac dysfunction contributes to morbidity and mortality associated with liver transplantation. Cardiovascular events are the third leading cause of death in liver recipients. However, because liver transplantation is the only definitive treatment for end-stage liver failure and also appears to reverse cardiac abnormalities, it is important to understand the challenges of the heart in liver transplantation. This review focuses on cardiac status before, during, and after liver transplantation. Liver Transplantation 23 826-835 2017 AASLD.
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Affiliation(s)
- Hongqun Liu
- Liver Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Saumya Jayakumar
- Liver Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Mouhieddin Traboulsi
- Division of Cardiology and Libin Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Samuel S Lee
- Liver Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
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23
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Risk factors of acute kidney injury after orthotopic liver transplantation in China. Sci Rep 2017; 7:41555. [PMID: 28134286 PMCID: PMC5278509 DOI: 10.1038/srep41555] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 12/21/2016] [Indexed: 12/17/2022] Open
Abstract
In this study, we determined the risk factors for acute kidney injury (AKI) following orthotopic liver transplantation (OLT) in China. We collected 5074 donation after cardiac death (DCD) OLT recipients who underwent surgery between January 1, 2010, and December 31, 2015, in 86 academic hospitals or transplant centers in China. Univariate and multivariate analyses were used to investigate the criticality of donor, graft, or recipient variables in the development of post-OLT AKI. In all, 4482 patients were included (median age, 49.31 years). Post-OLT AKI occurred in 3.97% patients, and 73.6% of all OLT patients were male. The 1- and 5-year cumulative survival rates (CSRs) of the AKI group were 33.95% and 25.24%, respectively, compared with 86.34% and 70.05%, respectively, of the non-AKI group (P < 0.001). The independent risk factors for post-OLT AKI were blood loss, cold ischemia time, warm ischemia time, preoperative serum creatinine, the treatment period with dopamine, overexposure to calcineurin inhibitor, and combined mycophenolate mofetil use (P < 0.05). These had a high prediction accuracy for post-OLT AKI (area under the curve [AUC] = 0.740).
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24
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Jin SJ, Kim SK, Choi SS, Kang KN, Rhyu CJ, Hwang S, Lee SG, Namgoong JM, Kim YK. Risk factors for intraoperative massive transfusion in pediatric liver transplantation: a multivariate analysis. Int J Med Sci 2017; 14:173-180. [PMID: 28260994 PMCID: PMC5332847 DOI: 10.7150/ijms.17502] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/21/2016] [Indexed: 01/10/2023] Open
Abstract
Background: Pediatric liver transplantation (LT) is strongly associated with increased intraoperative blood transfusion requirement and postoperative morbidity and mortality. In the present study, we aimed to assess the risk factors associated with massive transfusion in pediatric LT, and examined the effect of massive transfusion on the postoperative outcomes. Methods: We enrolled pediatric patients who underwent LT between December 1994 and June 2015. Massive transfusion was defined as the administration of red blood cells ≥100% of the total blood volume during LT. The cases of pediatric LT were assigned to the massive transfusion or no-massive transfusion (administration of red blood cells <100% of the total blood volume during LT) group. Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors associated with massive transfusion in pediatric LT. Kaplan-Meier survival analysis, with the log rank test, was used to compare graft and patient survival within 6 months after pediatric LT between the 2 groups. Results: The total number of LT was 112 (45.0%) and 137 (55.0%) in the no-massive transfusion and massive transfusion groups, respectively. Multivariate logistic regression analysis indicated that high white blood cell (WBC) count, low platelet count, and cadaveric donors were significant predictive factors of massive transfusion during pediatric LT. The graft failure rate within 6 months in the massive transfusion group tended to be higher than that in the no-massive transfusion group (6.6% vs. 1.8%, P = 0.068). However, the patient mortality rate within 6 months did not differ significantly between the massive transfusion and no-massive transfusion groups (7.3% vs. 7.1%, P = 0.964). Conclusion: Massive transfusion during pediatric LT is significantly associated with a high WBC count, low platelet count, and cadaveric donor. This finding can provide a better understanding of perioperative blood transfusion management in pediatric LT recipients.
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Affiliation(s)
- Seok-Joon Jin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sun-Key Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Keum Nae Kang
- Department of Anesthesiology and Pain Medicine, National Police Hospital, Seoul, Republic of Korea
| | - Chang Joon Rhyu
- Department of Anesthesiology and Pain Medicine, National Police Hospital, Seoul, Republic of Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Gyu Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung-Man Namgoong
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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25
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Zongyi Y, Baifeng L, Funian Z, Hao L, Xin W. WITHDRAWN: Risk factors of acute kidney injury after orthotopic liver transplantation in China. EBioMedicine 2016:S2352-3964(16)30357-7. [PMID: 27543153 DOI: 10.1016/j.ebiom.2016.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 07/28/2016] [Accepted: 08/04/2016] [Indexed: 12/07/2022] Open
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
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Affiliation(s)
- Yin Zongyi
- Department of hepatobiliary surgery and organ transplantation, the First Hospital of China Medical University, Shenyang 110001, China
| | - Li Baifeng
- Department of hepatobiliary surgery and organ transplantation, the First Hospital of China Medical University, Shenyang 110001, China.
| | - Zou Funian
- Department of hepatobiliary surgery and organ transplantation, the First Hospital of China Medical University, Shenyang 110001, China
| | - Li Hao
- Department of hepatobiliary surgery and organ transplantation, the First Hospital of China Medical University, Shenyang 110001, China
| | - Wang Xin
- Department of hepatobiliary surgery and organ transplantation, the First Hospital of China Medical University, Shenyang 110001, China
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26
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Cleland S, Corredor C, Ye JJ, Srinivas C, McCluskey SA. Massive haemorrhage in liver transplantation: Consequences, prediction and management. World J Transplant 2016; 6:291-305. [PMID: 27358774 PMCID: PMC4919733 DOI: 10.5500/wjt.v6.i2.291] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 03/16/2016] [Accepted: 04/11/2016] [Indexed: 02/05/2023] Open
Abstract
From its inception the success of liver transplantation has been associated with massive blood loss. Massive transfusion is classically defined as > 10 units of red blood cells within 24 h, but describing transfusion rates over a shorter period of time may reduce the potential for survival bias. Both massive haemorrhage and transfusion are associated with increased risk of mortality and morbidity (need for dialysis/surgical site infection) following liver transplantation although causality is difficult to prove due to the observational design of most trials. The blood loss associated with liver transplantation is multifactorial. Portal hypertension secondary to cirrhosis results in extensive collateral circulation, which can bleed during hepatectomy particular if portal pressures are increased. Avoiding volume loading and maintenance of a low central venous pressure together with the use of vasopressors have been shown to reduce blood loss and transfusion during liver transplantation, but may increase the risk of renal impairment post-operatively. Coagulation defects may be present pre-transplant, but haemostasis is often re-balanced due to a deficit in both pro- and anti-coagulation factors. Further derangement of haemostasis may develop in the anhepatic and neohepatic phases due to absent hepatic metabolic function, hyperfibrinolysis and platelet sequestration in the donor liver. Point-of-care tests of coagulation such as the viscoelastic tests rotation thromboelastometry/thromboelastometry allow and more accurate and rapid assessment of these derangements in coagulation and guide the use of factor replacement and antifibrinolytics. Transfusion protocols guided by these tests have been shown to reduce transfusion rates compared with conventional coagulation tests, but have not shown improvements in mortality or morbidity. Pre-operative factors associated with massive transfusion include previous surgery, re-do transplantation, the aetiology and severity of liver disease. Intra-operatively the use of piggy-back technique and avoiding veno-veno bypass has been shown to reduced blood loss.
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Postoperative Care of a Liver Transplant Recipient Using a Classification System: Type A (Stable) Versus Type B (Unstable). Crit Care Nurs Q 2016; 39:252-66. [PMID: 27254641 DOI: 10.1097/cnq.0000000000000119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Liver transplantation has become an effective and valuable option for patients with end-stage liver disease and hepatocellular carcinoma. Liver failure, an acute or chronic condition, results in impaired bile production and excretion, clotting factor production, protein synthesis, and regulation of metabolism and glucose. Some acute conditions of liver disease have the potential to recover if the liver heals on its own. However, chronic conditions, such as cirrhosis, often lead to irreversible disease and require liver transplantation. In this publication, we review the pathophysiology of liver failure, examine common conditions that ultimately lead to liver transplantation, and discuss the postoperative management of patients who are either hemodynamically stable (type A) or unstable (type B).
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Tsai HW, Hsieh FC, Chang CC, Su MJ, Chu FY, Chen KH, Jeng KS, Chen Y. Clinical Practice of Blood Transfusion in Orthotopic Organ Transplantation: A Single Institution Experience. Asian Pac J Cancer Prev 2015; 16:8009-13. [DOI: 10.7314/apjcp.2015.16.17.8009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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