How Much Is the Inevitable Loss of Different Coagulation Factors During Blood Product-Free Liver Transplantations?

BACKGROUND

Bloodless liver transplantations (LT) have already been reported, but special characteristics of hemostatic changes remain less defined. The aim of this study was to evaluate the "inevitable" loss of coagulation factors (CF) in blood product-free LT.

METHODS

Blood product and CF concentrate-free LT patient data were analyzed in terms of the first 2 days of perioperative hemostasis kinetics (N = 59). CF levels (FI, II, V, VII, X, and XIII), platelet (PLT) levels, and hemoglobin levels were measured before LT (T1), on arrival at the intensive care unit (T2), and 12, 24, and 48 hours after LT (T3, T4, and T5, respectively). Thromboelastographic (TEG) parameters were determined before and at the end of LT (T1-T2).

RESULTS

Fibrinogen levels decreased by 1.2 ± 0.6 g/L, prothrombin levels by 26% ± 14%, factor V levels by 40% ± 23%, VII levels by 29% ± 19%, and X levels by 39% ± 22% (P < .001). From T2 to T4 fibrinogen increased by 0.9 ± 0.6g/L for 24 hours (P < .001). Factor II, V, and VII levels increased by 20% ± 16%, 31% ± 32%, and 12% ± 27%, respectively, between T3 and T5 (P < .001). However, factor X reached only half of the T1 level (T3-T5, P < .001). Platelet count increased in 34 (58%) patients at T2 (P < .001). The TEG parameters remained in the normal range during LT (T1-T2).

CONCLUSION

The major findings of this study advocate that "inevitable" levels of CF decrease during LT by an average of 1.2 g/L in terms of fibrinogen and 23% to 40% regarding factors II, V, VII, and X. The authors suggest that knowing the "magic numbers" and comparing them against baseline laboratory results might predict the possibility of blood product-free transplant, providing confidence and safety to the surgeon and the anesthetist.

Successful Treatment of the Gastrointestinal Manifestation of Prototheca in a Kidney Transplant Recipient: A Case Report

INTRODUCTION

The Prototheca species are achlorophyllic algae and they are recognized pathogens in animals. They have been reported to cause infections in humans; the majority of the infected patients are immunocompromised. Organ transplant recipients are at risk of infection caused by such unusual organisms.

THE CASE

Here we present a highly atypical case report of Prototheca mimicking a cecum tumor in a kidney recipient 7 years after the transplantation. Three years before this Prototheca infection, after a native nephrectomy, the patient underwent a complicated duodeno-jejunal reconstruction with feeding catheter jejunostomy. Imaging studies indicated a tumor-like space occupying lesion in the cecum. The patient was treated successfully with colon resection. Detailed histology excluded malignancy and proved Prototheca wickerhamii.

DISCUSSION

The pathogenesis and many biological aspects of human protothecosis are unclear. Usually, treatment involves both medical and surgical approaches. The surgical treatment should be complete excision. The literature suggests an extremely high mortality rate, and therefore we advocate aggressive surgery in organ transplant recipients. This case is the first report of a successfully treated gastrointestinal manifestation of protothecosis in an organ transplant recipient.

Management of Portal Hypertension After Liver Transplantation

INTRODUCTION

Post-transplantation portal hypertension has severe complications, such as esophageal varix bleeding, therapy refractory ascites, extreme splenomegaly, and graft dysfunction. The aim of our study was to analyze the effectiveness of the therapeutic strategies and how to visualize the procedure.

METHODS

A retrospective study involving liver transplantation patients from the Semmelweis University Department of Transplantation and Surgery was performed between 2005 and 2015. The prevalence, etiology, and leading complications of the condition were determined. The applied interventions' effects on the patients' ascites volume, splenic volume, and the occurrence of variceal bleeding were determined. Mean portal blood flow velocity and congestion index values were calculated using Doppler ultrasonography.

RESULTS

The prevalence of post-transplantation portal hypertension requiring intervention was 2.8%. The most common etiology of the disease was portal anastomotic stenosis. The most common complications were esophageal varix bleeding and therapy refractory ascites. The patients' ascites volume decreased significantly (2923.3 ± 1893.2 mL vs. 423.3 ± 634.3 mL; P < .05), their splenic volume decreased markedly. After the interventions, only one case of recurrent variceal bleeding was reported. The calculated Doppler parameters were altered in the opposite direction in cases of pre-hepatic versus intra- or post-hepatic portal hypertension. After the interventions, these parameters shifted towards the physiologic ranges.

CONCLUSION

The interventions performed in our clinic were effective in most cases. The patients' ascites volume, splenic volume, and the prevalence of variceal bleeding decreased after the treatment. Doppler ultrasonography has proved to be a valuable imaging modality in the diagnosis and the follow-up of post-transplantation portal hypertension.

The impact of Milan criteria on liver transplantation for hepatocellular carcinoma: first 15 years' experience of the Hungarian Liver Transplant Program

In addition to hepatitis C, hepatocellular carcinoma. is a leading indication for orthotopic liver transplantation (OLT). The indications for OLT in HCC remains a topic of debate. The successful Milan criteria are still accepted as the gold standard to select candidates with a good chance for long-term survival. The Hungarian Liver Transplant Program launched in 1995 reached 45 OLT/year in 2010. Among 412 first OLTs, there were 49 cases of a malignant tumor, including 41 among which the indication was the tumor. Of the 412 patients, 154 (37.4%) were hepatitic C virus (HCV) positive, including 29 with HCC and 23 cases in which HCC was the indication itself. Half of the HCC patients were within the Milan criteria; 50% exceeded the criteria. We observed a solitary HCC in 36% of cases: 2 foci in 18%; 3 in 7%, 4 in 14%, and ≥5 in 25%. Only 12 patients underwent a "down-staging" treatment before OLT: 8 radiofrequency ablation (RFA) and 4 transarterial chemoembolization (TACE). Cumulative 1-, 3-, and 5-year patient survivals were 62%, 54%, and 43%, respectively in HCC/HCV-positive patients and they were 74%, 67%, and 61% among non-HCC HCV-positive subjects. The cumulative HCC patient survival rates of 64%, 64%, and 53% among Milan criteria were superior to those of 57%, 40%, and 27% among subjects exceeding the Milan criteria (P=.01). Pre-OLT "down-staging" treatment increased the 1-year patient survival from 64% to 70%; however, it did not affect the long-term results. Among items of the Milan criteria tumor size had less impact on outcomes then number of foci. The majority of cases who exceeded the Milan criteria had been transplanted before 2003. Our results suggested that the Milan criteria should be applied for the selection of candidates in order to promise good survival after OLT for HCC.

Examination of claudin-1 expression in patients undergoing liver transplantation owing to hepatitis C virus cirrhosis

The cell adhesion molecule claudin-1 (CLDN-1) is a well known co-factor for the cell entry of hepatitis C virus (HCV). We examined 24 hepatic biopsies from liver transplant patients. Reverse transcriptase polymerase chain reaction (RT-PCR) and immunohistochemistry were performed according to standard procedures. RT-PCR results were shown as relative expression (ΔCT) with beta-actin as the reference gene. Immunohistochemistry results are shown by morphometry. The CLDN-1 mRNS expression rate was significantly lower when the patient displayed favorably with an unsatisfactory to antiviral therapy 0.756 ± 0.249 versus 1.304 ± 0.28 (P=.012). There was also a strong positive correlation between CLDN-1 protein expression and liver fibrosis (Pearson correlation coefficients: r=0.476; P=.034).

Treatment of early hepatic artery complications after adult liver transplantation: A single center experience

Introduction

Hepatic artery complication represents recognized sequel of liver transplantation that carries significant morbidity and mortality. Besides retransplantation, hepatic artery recanalization is provided surgically, or by percutaneous angioplasty and stent placement. This study provides an analysis of a single center experience comparing surgical and interventional treatments in cases of early hepatic artery complications.

Methods

In this retrospective single center study, 25 of 365 liver transplant recipients were enrolled who developed early hepatic artery complication after transplantation. Percutaneous intervention was performed in 10 cases, while surgical therapy in 15 cases. Mean follow-up time was not different between the groups (505±377 vs. 706±940 days, respectively).

Results

6 patients in the Intervention Group and 10 patients in the Surgery Group are alive. The retransplantation rate (1 and 3) was lower after interventional procedures, while the development of biliary complications was higher. The mortality rate was higher after operative treatment (2 and 5).

Conclusion

Interventional therapy is a feasible and safe technique for treatment of early hepatic artery complication after transplantation. Being less invasive it is an invaluable alternative treatment having results comparable to surgical methods.

Unusual portal reconstructions after liver transplantation — Case report and review of literature

Portal vein reconstruction might be a challenge in certain cases of liver transplantation. The problem usually arises due to small vessels in pediatric transplantation and/or living related donor and split liver transplantation, or as a result of extensive PVT in adult recipients. Authors report a case of a 60-year-old alcoholic cirrhotic patient with reverse portal flow. The standard end to end portal anastomosis did not work well, so a mesoportal shunt with a donor iliac vein conduit was performed first, followed by a cavoportal hemitransposition. After unsuccessful attempts of providing good portal flow, the donor umbilical vein and the iliac conduit was used for portal flow reconstruction as meso-Rex graft. The patient has been doing fine for eight months after her liver transplantation. Unusual types of portal reconstructions consist of meso-portal, umbilico-portal, renoportal anastomoses that are primarily used as rescue techniques. However, it is rare that one has to use them sequentially in the same patient.

Successful urinary tract reconstruction following ureteral necrosis in kidney transplant patient

Ureteric complications following renal transplantation are well known to cause significant morbidity and compromised graft survival. The necrosis of a major part of the ureter could be a highly detrimental situation, and hardly solvable complication, that poses great challenges. Herein we are presenting a case report to introduce a possible surgical solution following repeated ineffective radiological interventions, in a patient with ureteric necrosis that appeared 3 months after cadaveric kidney transplantation. We transplanted the right kidney to the right iliac fossa performing end-to-side vascular anastomoses and end-to-side uretero-ureterostomy. His clinical course was uneventful during 3 months, when he presented a mild borderline acute cellular rejection together with dilatation of the pyelon. Percutaneous nephrostomy was performed by interventional radiologist. During further radiologic interventions the stenosis was not permeable. We finally made up our minds for surgical solution. We found a totally necrotized graftureter. During a second operation we performed a right nephrectomy, transsecting the pyelon. After mobilization of the transplanted kidney approaching and identifying the pyelon, a large pyelopyelar anastomosis was performed with stenting. The postoperative follow-up showed excellent urine flow from the kidney to the bladder, then the TRD was removed. Surgery had to be considered only if minimally invasive procedures are infeasible or ineffective. A regimen of reconstructive methods are well-known, but all cases have to be evaluated individually. If the native kidneys can be removed, their pyelons and entire ureters should be used for reconstruction.

De novo malignant melanoma occurred in renal allograft: DNA typing to determine the origin of the tumour

Malignant diseases are considered as great challenges in clinical transplantation. It is well known that the incidence of malignancy is higher in the transplanted population if compared with the normal population. It is important to distinguish between neoplastic diseases originating from pre-existing lesions in the transplanted organs and de novo graft tumours. Post-transplant malignancy of donor origin is a rare complication of organ transplantation, most likely transmitted as micrometastases within the parenchyma of the donor organ or from circulating tumour cells contained within the organ. Malignant melanoma, although its incidence is rather low, is one of the most common donor-derived tumour inadvertently transplanted, comprising 28% of donor transmitted tumours. Malignant melanoma in the graft without dermatological localisation is extremely rare. We report a case of de novo melanoma occurring in the allograft, where transmission from the donor was excluded by DNA (desoxyribonucleic acid) investigation. We did not find any data in the literature where a malignant melanoma occurred after transplantation in the transplanted kidney without any skin lesions and the donor origin was excluded. We draw attention to the importance of the DNA typing in case of tumours occurring in immunosuppressed patients.

Radiofrequency ablation of an intercalyceal neoplasm in a transplanted kidney using percutaneous nephrostomy for cooling — Safety and early result

Kidney neoplasms can occur after kidney transplantation in low percentage. In this report we delineate a rare case of neoplasm in the transplanted kidney detected on screening ultrasonographic examination. Due to the intercalyceal location of the tumor percutaneous radiofrequency ablation was planned with continuous cooling the collecting system avoiding the thermal damage. To the best of our knowledge this method has never been reported applying in transplanted kidney. The two-month CT follow-up verified no residual tumor and the kidney function remained in normal range during this period. These facts imply that the method can be safely applied.

Expression pattern of molecular chaperones after liver transplantation in hepatitis C positive recipients. Relation to serum HCV-RNA titers

Hepatitis C (HCV) is one of the main causes of liver transplantation (OLT). Previously we have reported that high serum C RNA level correlates with the severity of histopathological signs and poor clinical outcome. The core antigen of virus C is known to interfere with chaperones in the hepatocytes, results in an endoplasmic reticulum (ER) stress. In this study HCV positive liver transplanted patients were evaluated, whether there are correlations among chaperone expression, recurrence and viral titer. Patients were enrolled after surviving the first month following OLT. Sera were collected regularly, and biopsies were taken on demand following OLT. The diagnosis of recurrent HCV was proven by Knodell-Ishak scoring. In this case ribavirin+interferon were initiated, and maintained for one year. All chaperones were upregulated in the transplanted liver graft showing recurrent hepatitis C disease. ATF6, GP96, GRP78, CNX and CLR chaperones were upregulated significantly compared to their levels in normal livers. Except for one chaperone, the level of upregulation did not correlate with the serum's HCV-RNA titre: the only difference between Group1 and 2 (RNA titre above and below 8.78 106 respectively) was that the level of ATF6 was 1.6 times higher in Group1 compared to Group2. The expression of all chaperones was reduced, and some even became downregulated after the interferon treatment. In accordance with the literature our results suggest that hepatitis C might induce apoptosis through ER-stress. Those cells exposed to a high C viral load, had a lower chance to be eliminated.

Downstaging of hepatocellular carcinoma with radiofrequency ablation on the Hungarian liver transplantation waiting list — Early results and learned lessons

Hepatocellular carcinoma, which has developed in liver cirrhosis is a disease where liver transplantation can provide a cure both for the tumour and the underlying liver damage. However, patients can only be transplanted when the tumour number and size do not exceed the Milan criteria. Tumour ablation methods — such as radiofrequency ablation — can provide a chance to make the patient eligible for transplantation. Among the 416 Hungarian liver transplanted patients there are 6 who had received different types of ablative therapy as bridging therapy in different institutions. On the basis of analysis of the patients' data we created a guideline for the treatment of cirrhotic patients with hepatocellular carcinoma with the aim of developing a uniform Hungarian approach.

Epidural anesthesia? No of course

Although the contraindications for thoracic epidural anesthesia (TEA) are well defined, the debate continues about whether TEA improves outcomes. Pro and con trials and a metaanalysis in the past have yielded equivocal results; they did not deal with new vascular intervention or drugs. The benefit of TEA in surgery is to provide analgesia. In subgroups, TEA can decrease the mortality and morbidity. In contrast, the cost can increase in the situation of a complication that is opposite to the side effects is rare, but the impairment caused by them is out of proportion to the benefits. Primary or secondary prophylaxis with antithrombotic drugs is increasing in developed countries because of the increasing cardiovascular interventions and aging of the population. The neuroaxial guidelines are useful, but the changing of the coagulation profile after hepatectomy is not included in them. The decision to use TEA in liver surgery must be individualized with steps planned from the beginning. TEA suitability is based on an evaluation of the contraindications, comorbidities, coagulation profiles, hepatic reserve, and balance of benefits and risks. The insertion or withdrawal of the epidural catheter should be made with care according to the neuroaxial guidelines and in the presence of a normal TEG. The decreasing level of prothrombin content and platelet counts after hepatectomy should be closely monitored every 2 to 5 days.

Factors in association with sepsis after liver transplantation: the Hungarian experience

Sepsis is the major cause of patient death after orthotopic liver transplantation (OLT). To identify risk factors for sepsis, we analyzed all 199 primary OLTs performed between 1995 and 2004. Patients were divided into 2 groups according to whether they experienced sepsis after liver transplantation. Recipient, perioperative factors, and complications were subjected to univariate analyses. Statistically significant factors were exposed to multivariate analyses: Cox regression and Hosmer-Lemeshow test. Sepsis occurred in 45 (23%) patients. Recipient Child-Pugh score, preoperative broad spectrum antibiotic (meropenem) prophylaxis, intraoperative red blood cell transfusion, starch infusion, postoperative bleeding, hepatic artery thrombosis, and biliary leakage/necrosis were independent risk factors for sepsis. Our results agree with the international experience. A high amount of starch infusion and an extended use of broad spectrum antibiotics for prophylaxis adverse experiences in our center and have been removed from the protocol.

Successful islet after kidney transplantations in a distance over 1000 kilometres: Preliminary results of the Budapest-Geneva collaboration

To overcome critical islet processing and to ensure patient safety and quality care, we have established an international collaboration between two geographically distant transplant centers for islet transplantation. Four pancreata were harvested and immediately preserved by the two-layer method (oxygenated perfluorocarbon+University of Wisconsin) and subsequently transported for the automated method isolation to Geneva. After purification, the islets were cultured overnight and transported the next day back to Budapest. Three consecutive kidney transplant patients with type 1 diabetes mellitus underwent islet transplantation via percutaneous transhepatic portal embolization using the bag-method. The immunosuppression consisted of daclizumab, sirolimus, and low-dose tacrolimus. Mean donor age was 43.7 years, mean body mass index: 26.5. The islet isolation process began within 8 hours from the donor aorta cross-clamp in all cases. The isolation success rate was 80% (4 of 5). In Budapest, the islets were assessed for viability. No complications occurred during the transplantation, and the portal pressure remained within the normal range. The first patient received 12,000 IU/BW from two donors and the insulin requirement decreased from 40 U/d to 10 U/d. The second patient received 7200 IU/BW from a single donor and became immediately insulin free. The third patient was given 7100 IU/BW; the insulin requirement decreased from 39 U/d to 14 U/d. Posttransplant follow-up for the three patients are 7 months, 4 months, and 2 weeks, respectively. All patients achieved metabolic stability. These preliminary results demonstrate the feasibility of an international collaborative islet transplantation program at a distance over 1000 km.

[Papillary renal cell carcinoma]

The authors present a case of a papillary type renal cell carcinoma. The tumor is mostly discovered accidentally; a histopathological evaluation is indispensable for an exact diagnosis. Because of a better prognosis, differentiation of this tumor type from the classic variant of renal cell carcinoma is necessary, however, the contralateral appearance of a second tumor is not to be excluded, which necessitates a strict patient follow-up. Prevalence of this tumor is higher in patients with chronic dialysis.

[Pathologic evaluation of orthotopic liver transplantation in Hungary]

A total of 81 orthotopic liver transplantations were performed on 74 patients between January 1995 and December 1999 at the Department of Transplantation and Surgery of the Semmelweis University in Budapest. Indication for transplantation was liver cirrhosis in 57 cases, 10 patients were transplanted due to fulminant liver failure, while 7 patients underwent transplantation because of liver metastasis of different semimalignant tumours. During the above period, retrospective studies on 205 pre- and posttransplantation liver biopsies, 74 explanted livers, 7 explanted liver grafts and 22 autopsy cases were performed at the First Institute of Pathology and Experimental Cancer Research of the Semmelweis University in Budapest. A number of 116 protocol biopsies (dates as zero time, 7th day, 6th month and 12th month) and 73 non-protocol biopsies (taken due to liver allograft dysfunction) were analysed. Different gradings of acute rejection--characterised by trias of portal inflammation, venous endothelitis and bile duct damage--were detected in 62 cases. Chronic rejection occurred in 7 patients, with 4 cases of vanishing bile duct syndrome and one of the case of foam cell arteriopathy, add to 2 cases of chronic rejection characterized by undetermined bile duct damage. The present study includes the evaluation of 22 autopsy cases according to liver transplantation in Hungary, with the finding that liver allograft insufficiency was the main cause of mortality. Authors conclude that pathomorphological analysis has an important role in relation to liver transplantation.