Orthotopic liver transplantation for biliary atresia. Evolution of management

Forty-five patients with biliary atresia were accepted for orthotopic liver transplantation. Nine patients died awaiting transplantation, and 36 underwent transplantation. A portoenterostomy had been performed in 28 of these 36 patients, and its presence did not significantly affect the intraoperative blood loss (5.6 vs 4.1 blood volumes), the need for retransplantation (21% vs 12%), biliary complications (21% vs 12%), postoperative infections (36% vs 25%), or survival (82% vs 63%). These results indicate that early portoenterostomy is appropriate early therapy for biliary atresia; however, prompt referral to a liver transplant center for evaluation at the first sign of cholestasis is needed to attain optimal results for transplantation. Revisions of the portoenterostomy prior to transplantation did not improve the longevity of the procedure but did substantially increase complications and death after orthotopic liver transplantation.     

Early postoperative hemorrhage requiring urgent surgical reintervention after orthotopic liver transplantation

Hemorrhage is a common complication in the early postoperative period after orthotopic liver transplantation (OLT) and surgical reintervention may be necessary. We sought to assess the incidence as well as to identify potential risk factors for bleeding requiring surgical reintervention in the early postoperative period. From January 2003 to December 2005, we retrospectively reviewed the courses of 261 patients who underwent OLT. We analyzed the pretransplantation parameters, transplantation features, and clinical data for surgical reintervention due to early postoperative hemorrhage. Twenty-two of 261 patients (8.4%) had early postoperative hemorrhage requiring urgent surgical reintervention during the initial hospital stay. In-hospital mortality of the patients with hemorrhage (9/22; 41%) was significantly higher than that of other patients (29/239; 12.1%; P < .001). The surgical problem was the main cause of hemorrhage (18/22; 81.8%). More intraoperative blood transfusions were necessary for patients with hemorrhage than for other patients. Furthermore, a greater number of blood transfusions, including red blood cells, plasma, and platelet concentrates, during the transplantation procedure correlated with a greater mortality. In conclusion, early postoperative hemorrhage requiring urgent surgical reintervention is a severe complication with a high mortality. It is mainly caused by errors in surgical technique. Blood transfusion during transplantation was correlated with a higher mortality.     

肝移植术后早期急性肾功能衰竭的影响因素及其临床意义

目的 探讨肝移植术后早期急性肾功能衰竭(ARF)的相关危险因素.方法 对2000年8月至2010年12月收治的362例连续肝移植患者的临床资料进行回顾性分析,根据术后是否发生ARF,分为肾功能衰竭组(n=71)和无肾功能衰竭组(n =291).以围术期常用的临床及实验室指标共计36项作为危险因素的分析对象,先对这些指标进行单因素分析,再以单因素分析中P＜0.05的术后ARF影响因素为自变量进行Stepwise logistic回归分析.结果 在单因素分析中两组间差异有统计学意义的指标有术前血清肌酐、血红蛋白、凝血酶原活动度、总胆红素、MELD评分、总手术时间、术中出血量、输血量、术中尿量、术前有无肝性脑病、术中有无低血压及术后有无感染等指标,两组间的差异有统计学意义(F=10.30～182.70,P=0.000～0.041).对上述12项指标进行回归分析,发现术前高血清肌酐水平、低凝血酶原活动度水平、MELD评分、术中失血量多、术后合并感染与肝移植术后发生ARF密切相关(P＜0.05).结论 肝移植术后并发ARF的原因可能是多方面的,改善肝移植患者的术前状况是预防术后早期ARF的关键.血清肌酐水平高、凝血酶原活动度低、MELD评分、术中失血量多和术后合并感染是肝移植术后发生早期ARF的独立危险因素.     

肝移植患者术前的凝血治疗

目的探讨肝移植患者术前凝血治疗的时机、目标和方法选择.方法回顾性分析我院2002-2004年实施肝移植手术的168例病例资料.统计患者术前凝血酶原时间（PT）、凝血酶原活动度（PTA）、国际标准化比率（INR）、纤维蛋白原（FIB）、活化的部分凝血酶原时间（APTT）、血小板计数（PLT）和相应的凝血治疗措施,术中出血量、各种血制品的用量.分析术前因素与术中出血的关系,PTA分级与术中出血量、术中各种血制品用量的关系,术前血浆置换对术中出血量和术中输血制品量的影响.结果术前PTA趋于正常,术中出血量则少,对于严重凝血障碍的患者,术前应调整PTA至30%以上;术前实施血浆置换可以显著减少重症肝炎患者的术中出血量和血制品用量.结论肝移植患者术前应根据具体情况选择合适的治疗方法,尽量改善患者的凝血状态,以减少术中出血和血制品用量.     

Factors influencing early survival after liver transplantation

The purpose of this study was to analyze data from all adult and pediatric liver transplants performed between January 1, 1983 and January 15, 1986 at the University of Minnesota Hospital and identify perioperative variables that predict patient survival and could aid in patient selection. Charts, intraoperative anesthesia records, blood bank records, flow sheets, outpatient records, and autopsy reports were examined in 45 pediatric and 15 adult patients who underwent primary orthotopic liver transplantation. Analysis of the data can be summarized as follows: (1) Pediatric patients whose coagulation parameters could not be corrected prior to operation and who consequently required preoperative exchange transfusion had poorer outcomes than those not requiring an exchange to correct coagulation parameters. (2) The rapid infusion technique for massive blood transfusion resulted in significantly decreased blood loss and intraoperative blood product replacement. (3) Twenty-four hour postoperative factor V levels were good predictors of survival. Patients with poor factor V levels required rigorous replacement of coagulation factors. (4) Pediatric patients with uncorrectable coagulopathies requiring immediate postoperative exchange transfusion had extremely high mortality.     

肝移植手术后肺部感染的危险因素分析

目的 探讨肝移植手术患者术后肺部感染的危险因素。
方法 回顾性分析2005年6月至2013年6月于三家临床医疗中心首次行原位肝移植手术的1 358例患者的临床资料。根据患者术后30 d内是否发生肺部感染将患者分成两组：感染组和非感染组。收集术前资料、术中资料及术后资料，采用单因素分析及二元Logistic回归分析肝移植术后肺部感染的危险因素。
结果 肝移植手术后有316例（23.3%）发生肺部感染，其中有21例（6.7%）死亡。与非感染组比较，感染组术前诊断为慢性重型肝炎、肝癌、丙型肝炎肝硬化、先天性肝脏疾病及肝衰竭、术前合并肝肾综合征、肝昏迷、糖尿病的比例、术前肌酐浓度明显升高（P<0.05），术前总蛋白、白蛋白浓度明显降低（P<0.05），无肝期时间、术后苏醒时间及术后拔管时间明显延长（P<0.05），术中失血量明显增加（P<0.05），术中尿量明显减少（P<0.05），术中使用去氧肾上腺素、阿托品、利多卡因及呋塞米的比例明显降低（P<0.05），术后死亡率明显升高（P<0.05）。二元Logistic回归分析显示：慢性重型肝炎、丙型肝炎肝硬化、肝衰竭、术前合并糖尿病、术中失血量>1 900 ml、术后苏醒时间>7.3 h是肝移植患者术后肺部感染的危险因素；手术方式（经典非转流原位肝移植）、术中使用利多卡因、术前总蛋白>64.6 g/L、术中尿量>1 800 ml是肝移植手术患者术后肺部感染的保护因素。
结论 术前诊断慢性重型肝炎、丙型肝炎肝硬化、肝衰竭、术前合并糖尿病、术中失血量>1 900 ml、术后苏醒时间>7.3 h是肝移植手术后肺部感染的危险因素。     

Tranexamic Acid Reduces Blood Loss, Transfusion Requirements, and Coagulation Factor Use in Primary Orthotopic Liver Transplantation

Background: Patients with end-stage liver disease frequently incur large-volume blood loss during liver transplantation associated with mechanical factors, preexisting coagulopathy, and intraoperative fibrinolysis.

Methods: Between April 1992 and May 1994, the authors of this double-blind, randomized, placebo-controlled study examined the effect of high-dose tranexamic acid (maximum of 20 g) on blood loss and blood product requirements in patients undergoing primary isolated orthotopic liver transplantation. Primary outcome measures were volume of blood loss (intraoperative blood loss and postoperative drainage) and erythrocyte, plasma, platelet, and cryoprecipitate use during surgery and the first 24 h of intensive care unit stay.

Results: Patients receiving transexamic acid (n = 25) had less intraoperative blood loss (median, 4.3 l; interquartile range, 2.5 to 7.9; P = 0.006) compared with the placebo group (n = 20; median, 8 l; interquartile range, 5 to 15.8), and reduced intraoperative plasma, platelet, and cryoprecipitate requirements. Median perioperative erythrocyte use was 9 units (interquantile range, 4 to 14 units) in patients receiving transexamic acid and 13 units (interquantile range, 7.5 to 31 units) in controls (P = 0.03). Total perioperative donor exposure was 20.5 units (interquantile range, 16 to 41 units) in patients receiving transexamic acid and 43.5 units (interquantile range, 29.5 to 79 units) in controls (P = 0.003). Results for postoperative wound drainage were similar. Hospital stay and need for retransplantation were comparable in both groups. No patient in either group showed clinical evidence of hepatic artery or portal venous thrombosis within 1 month of transplantation.     

Liver transplantation in patients with portal vein thrombosis and central portacaval shunts.

The authors have analyzed the impact of pre-existing portal vein pathology on the outcome of orthotopic liver transplantation. The incidence was high in patients suffering from chronic active hepatitis, hypercoagulable states, trauma or previous dissection of the porta hepatis, and splenectomy. The existence of portal vein thrombosis (23 patients) or surgical central portosystemic shunt (10 patients) was documented by preoperative Doppler sonogram or angiography (26/33), or operative findings of occluded vein (7/33). Successful thrombectomy and dismantling of portacaval shunts were achieved in most cases (24/33). Only nine patients required the placement of an interposition vein graft to the superior mesenteric vein. The intraoperative course was characterized by increased blood loss and coagulopathy, significantly higher than in patients with a patent portal vein. When compared with all liver transplants, the immediate postoperative complication rate was higher for primary nonfunction (33% versus 8%), re-exploration for intraperitoneal bleeding and hematomas, and morbid infections. Rethrombosis rate of thrombectomized veins or vein graft was low (2/33). The mortality rate was 35% in the presence of portal vein thrombosis (PVT) and 30% for portacaval shuct (PCS), both significantly higher than the 12% for other orthotopic liver transplant (OLT) patients. These results are expected to improve with better patient selection, surgical experience, and anticipation of the complex postoperative course. The authors conclude that PVT or the presence of PCS are not contraindications to orthotopic liver transplantation.     

肝移植术后早期肺部细菌感染的危险因素分析

目的 分析原位肝移植术后早期肺部细菌感染的发生情况及其危险因素。方法 回顾性分析笔者所在医院2010年1月至2012年6月期间行下腔静脉逆灌注法原位肝移植术的96例终末期肝病患者的临床资料。采用多因素非条件logistic回归分析探索肝移植术后早期肺部细菌感染的危险因素。结果 96例患者中有29例于肝移植术后早期发生肺部细菌感染,感染率为30.21%,其中感染G-需氧菌19例（65.52%）,感染G＋需氧菌10例（34.48%）。患者的术前终末期肝病模型评分（OR=2.165,P=0.001）、术中输血量（OR=1.952,P=0.003）、术后3 d血肌酐平均值（OR=1.913,P=0.001）、术后3 d液体负平衡时间（OR=0.196,P=0.023）及术后住院时间（OR=1.923,P=0.003）均与术后早期肺部细菌感染有关。结论 原位肝移植术后早期易发生肺部细菌感染。术前改善患者基础状况、术中控制输血量、术后控制输液量和住院时间及术后改善肾功能均可减少术后早期肺部细菌感染的发生。     

原位肝移植术后早期肝功能不全的相关危险因素分析

目的分析原位肝移植术后早期肝功能不全(early allograft dysfunction,EAD)的发生情况,并探讨EAD发生的相关危险因素。方法回顾性分析武汉大学人民医院2016年1月至2020年12月实施的74例原位肝移植病人的临床资料,对可能导致术后EAD的围手术期相关因素进行单因素分析,然后将有显著性差异的因素纳入Logistic回归多因素分析。结果74例肝移植病人术后EAD的发生率为36.5%(27/74)。单因素分析结果显示,受者术前中性粒细胞与淋巴细胞比值(NLR)、术前血清总胆红素、术中失血量、术前肝功能Child-Pugh分级C级、术前终末期肝病模型(MELD)评分≥18分及术后出现胆道及血管并发症是EAD发生的潜在危险因素(均P<0.05);多因素Logistic回归分析结果显示,肝移植术后EAD的独立危险因素为:术前MELD评分≥18分[OR=0.045,95%CI(0.003,0.605),P=0.045];移植术后出现胆道及血管并发症[OR=0.061,95%CI(0.009.0.419),P=0.004]。结论术前MELD评分≥18分及术后出现胆道及血管并发症是影响肝移植术后EAD的独立危险因素。临床上应该通过改善受者术前较差的肝功能和提高临床医师手术技巧来降低EAD的发生率。     

Reversal of hypersplenism following orthotopic liver transplantation.

The purpose of this study was to clarify the effect of orthotopic liver transplantation on hypersplenism. In a 1-year period from July 1, 1986 to June 30, 1987, 196 adult patients underwent 233 orthotopic liver transplantations. Of the 58 patients with hypersplenism who were analyzed in this study, hypersplenism was more commonly associated with postnecrotic cirrhosis than other kinds of liver disease (55.3% (47/85) vs. 14.5% (11/76); p less than 0.001). Postoperative platelet counts were statistically higher than preoperative values (p less than 0.05). The latest platelet counts were more than 100,000/mm3 in 53 patients (91.4%). Of the eight patients whose preoperative and postoperative spleen volumes could be compared, all showed the reduction in the spleen size (p less than 0.02). We conclude that orthotopic liver transplantation, which is a radical surgical procedure for portal hypertension, reverses hypersplenism.     

Efficacy and safety of repeated perioperative doses of recombinant factor VIIa in liver transplantation.

Patients undergoing orthotopic liver transplantation (OLT) have excessive blood loss during surgery that requires blood transfusions, leading to increased postoperative morbidity and mortality. We studied the efficacy and safety of activated recombinant factor VII (rFVIIa) in reducing transfusion requirements in OLT. This multicenter, randomized, double-blind, placebo-controlled trial enrolled patients undergoing OLT because of cirrhosis (Child-Turcotte-Pugh class B or C). Patients received a repeated intravenous bolus regimen of rFVIIa 60 or 120 microg/kg or placebo. The primary efficacy endpoint was the total number of red blood cell (RBC) units transfused during the perioperative period. A total of 182 patients were analyzed for efficacy and 183 for safety. No significant effect of rFVIIa was observed on the number of RBC units transfused or intraoperative blood loss compared with the placebo group. A significantly higher number of patients in the rFVIIa study groups avoided RBC transfusion. Administration of rFVIIa but not placebo restored the preoperative prolonged prothrombin time to normal value during surgery. Patients receiving rFVIIa and placebo did not experience a significant difference in rate of thromboembolic events. Additionally, there was no statistically significant effect of rFVIIa treatment on hospitalization rate, total surgery time, and the proportion of patients undergoing retransplantation. In conclusion, use of rFVIIa during OLT significantly reduced the number of patients requiring RBC transfusion. There was no increase in thromboembolic events with rFVIIa administration compared with placebo.     

Orthotopic liver transplantation with a reduced-size graft: an ideal compromise in pediatrics?

This study retrospectively reviewed the results of 81 orthotopic liver transplantations in 72 pediatric patients with either a full-size graft (n = 41) or a reduced-size graft (n = 40) during a 4-year period. Two types of liver reduction were used to obtain a left lobe graft (n = 30) or a left lateral segment graft (n = 10). The choice of the reduction technique was based on two criteria: the donor/recipient body weight ratio and the transverse size of the recipient's abdomen. The patients who underwent transplantation with a reduced-size graft were younger and smaller than those who received a full-size graft. The mortality rate of the candidates on the pediatric transplantation waiting list was 2.7% during the same period. The 3-year survival rate after elective transplantation was 85% and 75% in the full-size graft group and the reduced-size graft group, respectively (difference not significant). The use of reduced-size grafts was associated with higher amounts of red cell and fresh-frozen plasma transfusions after graft revascularization. The incidence of postoperative bleeding and bile leakage from the transected surface was low, whereas hepatic artery and biliary complications were less frequent in the reduced-size graft group than in the full-size graft group. At the time of follow-up, liver biochemical test results and quality of life were not different between the two groups. Despite the constraining technique and the increase in intraoperative blood loss, orthotopic liver transplantation with a reduced-size graft allows us to overcome the shortage of pediatric donors and improve the overall survival rate of children with end-stage liver disease.     

Leukocyte reduction during orthotopic liver transplantation and postoperative outcome: a pilot study

STUDY OBJECTIVE: To investigate the effect of intraoperative leukocyte reduction of administered blood products on the incidence of acute cellular rejection and postoperative patient outcome. DESIGN: Prospective, nonrandomized, historical control study. SETTING: Academic tertiary medical center. PATIENTS: The study group (Group 1) consisted of 30 consecutive adult patients with end-stage liver disease scheduled to undergo orthotopic liver transplantation (OLT) between 1998 and 2000. The historical control group (Group 2) consisted of 30 adult patients with end-stage liver disease matched to study group patients as closely as possible for age, gender, and etiology of liver disease who underwent OLT between 1995 and 1999. INTERVENTIONS: Group 1 patients had all intraoperative allogeneic and cell salvaged blood products leukocyte reduced before administration. Group 2 patients underwent OLT without leukocyte filtration of any administered blood products. MEASUREMENTS: Demographic data were collected for both patient groups and included age, gender, etiology of liver disease, and both intraoperative and postoperative immunosuppression. Demographic allograft donor data for both patient groups were collected and included age, gender, use of vasopressors during procurement, and cold and warm donor organ ischemic times. Outcome variables measured included incidence of acute cellular rejection, length of intensive care unit (ICU) and length of hospital stay, incidence of both graft loss and retransplantation, and mortality. MAIN RESULTS: The incidence of acute cellular rejection was 40% in Group 1 and 66.7% in Group 2 (p = 0.037). Length of ICU stay was 3.0 (2.0, 5.0) days in Group 1 and 4.0 (3.0, 6.0) days in Group 2 (p = 0.16). Length of hospital stay was 14.0 (11.0, 18.0) days in Group 1 and 18.0 (14.0, 27.0) days in Group 2 (p = 0.035). One allograft was lost in Group 2 because of primary nonfunction requiring retransplantation (p = 0.31), and three postoperative deaths occurred in Group 1 as a result of multisystem organ failure (p = 0.08). CONCLUSIONS: Coincident with leukocyte reduction of all administered blood products during OLT, an improved outcome was observed in Group 1 patients as demonstrated by both a decreased incidence of acute cellular rejection and length of hospital stay.     

Correlation between intraoperative blood flows and hepatic artery strictures in liver transplantation

Hepatic artery strictures (HASs) may be a source of morbidity and mortality in liver transplant recipients. This study evaluated the potential correlation between intraoperative arterial and venous blood flows measured after implantation of the liver allograft and the occurrence of postoperative HASs requiring repair. Prospectively collected data from 1,038 patients with complete data sets who underwent initial orthotopic liver transplantations between December 1984 and December 1999 were used. Electromagnetic flow measurements were routinely obtained in these cases. Hepatic artery and portal vein patency were reassessed routinely according to our protocol in the first postoperative day by Doppler ultrasound. When considered hemodynamically significant, strictures were corrected. There was a 6.2% incidence (n = 64) of hepatic artery stenosis in our transplant population. When considered as a whole, the hepatic artery stenosis group had lower intraoperative flow volumes than transplant recipients who did not develop strictures (mean flows, 452 v 518 mL/min, respectively; P = .025). The hepatic artery stenosis group also had lower intraoperative portal vein flows compared with the group without hepatic artery stenosis (1.80 v 2.11 L/min, respectively; P = .0043). Strictures were less frequent among transplant recipients with cryptogenic cirrhosis. We did not observe differences among the groups for retransplantation or patient and graft survival. In our series, there was a 6.2% incidence of postoperative HASs. We observed a significant association between intraoperative hepatic artery and portal vein flows and postoperative HASs. (Liver Transpl 2002;8:160-163.)     

Increased prothrombin time and platelet counts in living donor right hepatectomy: implications for epidural anesthesia.

The risks and benefits of adult-to-adult living donor liver transplantation need to be carefully evaluated. Anesthetic management includes postoperative epidural pain relief; however, even patients with a normal preoperative coagulation profile may suffer transient postoperative coagulation derangement. This study explores the possible causes of postoperative coagulation derangement after donor hepatectomy and the possible implications on epidural analgesia. Thirty donors, American Society of Anesthesiology I, with no history of liver disease were considered suitable for the study. A thoracic epidural catheter was inserted before induction and removed when laboratory values were as follows: prothrombin time (PT) > 60%, activated partial thromboplastin time < 1.24 (sec), and platelet count > 100,000 mmf pound sterling (mm3). Standard blood tests were evaluated before surgery, on admission to the recovery room, and daily until postoperative day (POD) 5. The volumes of blood loss and of intraoperative fluids administered were recorded. Coagulation abnormalities observed immediately after surgery may be related mostly to blood loss and to the diluting effect of the intraoperative infused fluids, although the extent of the resection appears to be the most important factor in the extension of the PT observed from POD 1. In conclusion, significant alterations in PT and platelet values were observed in our patients who underwent uncomplicated major liver resection for living donor liver transplantation. Because the potential benefits of epidural analgesia for liver resection are undefined according to available data, additional prospective randomized studies comparing the effectiveness and safety of intravenous versus epidural analgesia in this patient population should be performed.     

Fast tracking in liver transplantation: which patient benefits from this approach?

In liver transplantation, "fast tracking" means postoperative extubation in the operating theater immediately after surgery. This procedure was performed in a series of 837 adult liver transplant recipients between January 1997 and April 2005, proving to be safe and feasible in almost 80% of patients without increasing the incidence of reintubation. This patient population experienced a significantly higher survival compared to patients who were extubated in the intensive care unit. Consequently, fast tracking should become the standard procedure after orthotopic liver transplantation. However, special attention is required for recipients with acute liver failure, retransplantation, Child C status, or complicated surgery in terms of increased transfusion of red blood cells. These patients do not participate in fast-tracking protocols, as demonstrated by a uni- and multivariate logistic regression analysis. Moreover, ROC analysis revealed that only intraoperative transfusion of 相似文献   

Evolving experience with prevention and treatment of splenic artery syndrome after orthotopic liver transplantation

Impaired hepatic arterial perfusion after orthotopic liver transplantation (OLT) may lead to ischemic biliary tract lesions and graft‐loss. Hampered hepatic arterial blood flow is observed in patients with hypersplenism, often described as arterial steal syndrome (ASS). However, arterial and portal perfusions are directly linked via the hepatic arterial buffer response (HABR). Recently, the term ‘splenic artery syndrome’ (SAS) was coined to describe the effect of portal hyperperfusion leading to diminished hepatic arterial blood flow. We retrospectively analyzed 650 transplantations in 585 patients. According to preoperative imaging, 78 patients underwent prophylactic intraoperative ligation of the splenic artery. In case of postoperative SAS, coil‐embolization of the splenic artery was performed. After exclusion of 14 2nd and 3rd retransplantations and 83 procedures with arterial interposition grafts, SAS was diagnosed in 28 of 553 transplantations (5.1%). Twenty‐six patients were treated with coil‐embolization, leading to improved liver function, but requiring postinterventional splenectomy in two patients. Additionally, two patients with SAS underwent splenectomy or retransplantation without preceding embolization. Prophylactic ligation could not prevent SAS entirely (n = 2), but resulted in a significantly lower rate of complications than postoperative coil‐embolization. We recommend prophylactic ligation of the splenic artery for patients at risk of developing SAS. Post‐transplant coil‐embolization of the splenic artery corrected hemodynamic changes of SAS, but was associated with a significant morbidity.     

Cavocaval liver transplantation without venovenous bypass and without temporary portocaval shunting: the ideal technique for adult liver grafting?

The influence of the implantation technique on the outcome was studied prospectively in a series of 116 consecutive adult patients undergoing primary liver transplantation during the period January 1991–June 1994. Thirty-eight patients (32.8 %; group 1) underwent classical orthotopic liver transplantation (OLT) with replacement of the recipient's inferior vena cava (R-IVC) and with veno-venous bypass (VVB). Thirty-nine patients (33.6 %) had a piggy-back OLT with preservation of the R-IVC (group 2); bypass was used in 17 of them (43.6 %) because of poor hemodynamic tolerance of R-IVC occlusion. Thirty-nine patients (33.6 %) had OLT without VVB and with side-to-side cavocaval anastomosis (group 3). The three techniques were performed irrespective of the anatomical situation and of the status of the recipient at the time of transplantation. The following parameters were assessed in all patients: implantation time, blood product use, morbidity (e. g., hemorrhagic, thoracic, gastrointestinal, neurological, and renal complications), and outcome. Thirty-one patients underwent detailed intraoperative hemodynamic assessment. The early ( < 3 months) post-transplant mortality of 10.3 % (12/116 patients) was unrelated to the implantation technique. Group 3 had a significantly shorter mean implantation time, a reduced need for intraoperative blood products, and a lower rate of reoperation due to intra-abdominal bleeding. After excluding two immediate perioperative deaths and eight patients requiring early retransplantation because of primary nonfunction, the frequency of immediate extubation was significantly higher in group 3. Detailed hemodynamic assessment did not show a difference between 6 group 1 patients and 17 group 3 patients, indicating that partial lateral clamping of the IVC fullfills the function of venous bypass. Similar results were obtained in 6 group 2 patients who did not have IVC occlusion. Cavocaval OLT has become our preferred method of liver implantation. It allows the transplantation to be performed without VVB, regardless of the anatomical situation and of the condition of the patient at the time of transplantation. Moreover, it avoids all of the potential complications and costs of VVB. Received: 25 November 1996 Received after revision: 28 January 1997 Accepted: 30 January 1997     

The effect of aprotinin on renal function in orthotopic liver transplantation

BACKGROUND: In the European Multicenter Study on the Use of Aprotinin in Liver Transplantation (EMSALT), a randomized, double-blind, placebo-controlled, prospective study, we demonstrated that aprotinin significantly reduces intraoperative blood loss during orthotopic liver transplantation (OLT). Aprotinin is metabolized in the kidney and potentially nephrotoxic at high concentrations. Renal insufficiency is a common and serious complication after OLT. It is unknown whether aprotinin increases the risk of renal failure after OLT. METHODS: We analyzed intraoperative urine output, need for postoperative dialysis, perioperative serum creatinine levels, and creatinine clearance in 93 patients enrolled in EMSALT, receiving a high dose of aprotinin, a regular dose, or placebo. RESULTS: Peak increase in serum creatinine exceeding 0.5 mg/dl during one of the postoperative days occurred in 11 (35%) patients in the placebo group, in 11 (34%) patients in the high-dose group, but only in 1 (3%) patient in the regular-dose group (P=0.007). Furthermore, a perioperative decrease in creatinine clearance was seen in the placebo group (-23.9+/-10.1 ml/min) but not in both high-dose (-1.6+/-13.3 ml/min) and regular-dose (9.7+/-10.3 ml/min) groups (P<0.02 comparing regular-dose and placebo group). CONCLUSIONS: Despite its potential nephrotoxicity, the use of aprotinin for reducing blood loss during OLT does not lead to a higher incidence of postoperative renal insufficiency. In combination with the observed reduction in blood loss, these findings support the prophylactic use of regular-dose aprotinin during OLT.