Thrombocytopenia after liver transplantation

BACKGROUND: Thrombocytopenia after orthotopic liver transplantation (OLT) is a well recognized and prevalent early postoperative complication. The etiology, as well as the effect of this phenomenon on transplant outcome, however, are vague. The aims of this study are to identify factors contributing to thrombocytopenia and to ascertain whether there is any correlation with early rejection and ultimate survival. METHODS: This study examines 541 OLTs (541 grafts in 494 patients) that were transplanted at the University of Miami during the 3-year period from June 1994 to September 1997. The patients with severe postoperative thrombocytopenia (nadir platelet count [PLT] < 20,000/mm3), as well as the whole group of patients, were analyzed. The preoperative PLT, intra-operative platelet transfusion requirements, cross-match, recipient and donor cytomegalovirus (CMV) status, infusion of donor bone marrow cells (DBMC), occurrence of early rejection episodes (in the first posttransplant month), and re-transplantation were factors examined for any association with thrombocytopenia. Total bilirubin (TB) and direct bilirubin (dB), hematocrit, white blood cell count (WBC), aspartate aminotransferase and alanine aminotransferase, determined on the day that platelets reached a nadir (nadir day), were also analyzed. RESULTS: In 90.9% of the cases, there was a 56.5%+/-23.5% fall in platelets in the immediate posttransplant period (first 2 weeks), but the mean PLT exceeded preoperative levels during the 3rd and 4th postoperative weeks. The nadir of the drop in the PLT most commonly occurred on posttransplant day 4. For preoperative PLT, platelet transfusions during the operation, re-transplantation, early rejection, cross-match, and recipient CMV status, there was significant statistical correlation with any degree of postoperative thrombocytopenia. Four of these factors, preoperative PLT, intra-operative platelet transfusions, re-transplantation, and early rejection, were found to be independently associated with thrombocytopenia in general. None of them was found to be independently correlated with severe thrombocytopenia. A statistically significant correlation between bilirubin and WBC on the nadir day and the degree of thrombocytopenia was observed. No correlation was found between infusion of DBMC or donor CMV serology and thrombocytopenia. Both the nadir PLT and the percentage of the platelet fall were independent predictive factors (p<0.01 and 0.005, respectively) of patient and graft survival. CONCLUSIONS: Thrombocytopenia in the immediate posttransplant period is correlated with low preoperative PLT, massive platelet transfusions, and re-transplantation. These factors reflect a poor preoperative condition. There is also a correlation with allograft dysfunction, rejection, and poorer patient and graft survival. A rise in the mean PLT after the 2nd postoperative week reflects proper graft function.     

肝移植术后的低钠血症

目的探讨肝移植术后低钠血症的原因及治疗。方法对肝移植术后发生低钠血症的27例患者的临床资料进行回顾性分析。结果25例在术后1周左右发生低钠血症,2例术前已有低钠血症,术后即发生严重低钠血症,一例患者发生急性低钠综合征;血钠为130～135mmol/L者10例,120～130mmol/L者12例,低于120mmol/L者5例;血钾、血磷及血钙均在正常范围;尿钠、钾、氯均在正常范围;5例患者测定腹水钠含量,均高于同时段血钠含量。治疗主要是通过胃肠和/或静脉补给高渗盐水。结论肝移植术后发生低钠血症的原因是多方面的,治疗上应去除导致低钠血症的原因,并持续、缓慢地补充高渗盐水。     

Ascites after liver transplantation

Massive ascites after liver transplantation, although uncommon, usually represents a serious adverse event. The pathogenesis of this complication has not been adequately investigated. To determine the incidence, characteristics, and pathogenic factors of massive ascites after liver transplantation (ascitic fluid > 500 mL/d for > 10 days), the charts of 378 liver transplant recipients were reviewed. Massive ascites occurred in 25 patients (7%). Mean ascitic fluid production was 960 mL/d (range, 625 to 2,350 mL/d), and the duration of ascites was 77 days (range, 15 to 223 days). The ascitic fluid had a high protein content (36 ± 7 g/L; range, 25 to 50 g/L). When patients who did and did not develop massive ascites were compared, significant differences were found in receptor sex (men, 88% v 60%, respectively; P < .01) and surgical technique (inferior vena cava preservation with piggyback technique, 72% v 41%; P < .01). Significantly increased wedged and free hepatic venous pressures and gradients between hepatic vein and right atrial pressures were found in patients who developed ascites, suggesting a difficulty in graft blood outflow. Massive ascites was associated with renal impairment, increased incidence of abdominal infection, prolonged hospitalization, and a tendency toward reduced survival. In conclusion, massive ascites after liver transplantation is relatively uncommon but associated with increased morbidity and mortality and is predominantly related to difficulties of hepatic venous drainage. Measurement of hepatic vein and atrial pressures to detect a significant gradient and correct possible alterations in hepatic vein outflow should be the first approach in the management of these patients.     

Mycotic pseudoaneurysms after liver transplantation

The most frequent etiology of visceral artery aneurysms is arteriosclerosis, but vascular manipulation during hepatic transplantation may also cause a mycotic pseudoaneurysm. Treatment with embolization, stents or percutaneous thrombin injection have been recommended but surgical revascularization is indicated when interventional techniques fail. A 43-year-old man with hepatitis C virus cirrhosis who underwent orthotopic liver transplantation from a cadaveric donor was treated with cyclosporine, mycophenolate, and steroids and was discharged from hospital at 35 days. Two months later he was readmitted with a febrile syndrome. Abdominal computed tomography showed necrosis of hepatic segments IV, V, and VI. Magnetic resonance imaging and angiography revealed partial thrombosis of the hepatic artery and stenosis of the portal anastomosis secondary to an aneurysm of the hepatic artery. A few hours after the radiological diagnosis, the patient suffered a bout of upper gastrointestinal bleeding and shock. Emergency surgery revealed a mycotic pseudoaneurysm of the common hepatic artery, which had ruptured into the bile tract with hemobilia. The liver graft was removed because of severe necrosis of the right liver. The patient died awaiting a new liver transplantation.     

肝移植术后营养支持的应用

目的:探讨营养支持在肝移植术后治疗中的作用。方法:将2003年7月～2004年6月在我院行肝移植术后的病人随机分为肠内(EN)组和肠外(PN)组。与PN比较,分析早期EN对肝移植术后病人肝功能恢复和预防继发感染方面的作用。结果:顺利进行营养支持共59例,其中EN组和PN组分别为38例和21例;两组在一般资料上具有可比性。与PN组比较,EN组病人术后一周的白蛋白和前白蛋白恢复较好,胆汁量较多,肺炎等感染的发生率下降,发生腹泻的机会也下降。结论:①与PN比较,EN能促进肝移植术后肝功能,特别是蛋白合成功能的恢复。②与PN比较,EN能减少肝移植术后感染的发生率。③早期EN、肝移植术后是安全、有效的。     

Biliary complications after liver transplantation

Abstract:  Biliary complications remain a substantial cause of morbidity following liver transplantation. They have been reported to occur in a rate of 10–15% of full-size transplantations and may be higher in living donor, split or reduced size liver transplantations. The most common biliary complications following liver transplantations are leaks and strictures. In both, the incidence varies with respect to type of graft and donor as well as the type of biliary anastomosis. The management of the biliary complications requires a multidisciplinary approach and has changed over the past decade, favoring endoscopic and radiological techniques. Surgical revision including retransplantation is reserved for patients in whom endoscopic and interventional modalities are unsuccessful.     

Surgical complications after liver transplantation

AIM: The number of liver transplantations in Italy has steadily increased over the last 10 years as a result of the use of donors aged more than 60 years. The use of organs with a reduced functional reserve has been compensated for by improvements in immunosuppressive therapy, surgical techniques and the management of postoperative complications. This article describes the incidence and treatment of the main surgical complications after liver transplantation. METHODS: Between January 1996 and June 2003, 398 patients received 430 transplants at our Centre. Thirty-seven early relaparotomies were performed (8.6%), including 12 retransplantation (2.8%). The 1-, 3- and 5-year actuarial survival of the patients was 79.8%, 72.2% and 67.5%, and that of the grafts was 75.9%, 68% and 63.4%. Perioperative mortality was 10.5% (with no intraoperative deaths). RESULTS: The overall incidence of biliary complications was 31.6%, 9.1% of which were due to the removal of the Kehr tube. There were 42 (9.8%) anastomotic stenoses, 5 (1.2%) extra-anastomotic stenoses, 1 (0.2%) anastomotic leak, 5 (1.2%) extra-anastomotic leaks, and 19 (4.4%) ischemic-type biliary lesions. The overall incidence of vascular complications was 6.9%: 7 (1.6%) cases of hepatic artery thrombosis, 17 (4.0%) arterial stenoses, 1 (0.2%) arterial pseudoaneurysm, 4 (0.9%) cases of portal thromboses and 1 (0.2%) case of caval laminar thrombosis. Eight patients (1.9%) developed massive and persistent post-transplant ascites and/or hydrothorax. CONCLUSION: The use of donors aged more than 60 years makes it possible to maintain high standards of patient and graft survival that is not only due to the optimisation of immunosuppressive protocols, but also to improvements in surgical techniques, intensive care and the management of surgical complications.     

New-onset diabetes after liver transplantation

AIM: The impact of new-onset diabetes (NOD) posttransplantation has been underestimated in the past. The aim of this study was to evaluate the incidence of diabetes after liver transplantation. METHODS: We retrospectively analyzed the incidence of NOD in 899 patients transplanted in our center. According to International Consensus 2003 Guidelines, criteria for diagnosis of diabetes were: fasting plasma glucose > or =126 mg/dL, symptoms of diabetes plus casual plasma glucose concentrations > or =200 mg/dL, and 2-hour plasma glucose levels > or =200 mg/dL during an oral glucose tolerance test. We considered only patients with follow-up over 10 months. We evaluated the risk factors correlated with NOD (age, hepatitis C virus [HCV] positivity, tacrolimus vs cyclosporine, steatosic graft), and the outcomes of diabetic patient and their grafts. RESULTS: The incidence of NOD was 10.8% (90/830 patients). Sixty nine patients were diabetic before transplantation. Recipient age >45 years (14.7% vs 6.8%, P = .002, OR = 2.4) and HCV positivity (15.5% vs 7.8%, P = .001, OR = 2.2) significantly correlated with NOD. Multivariate analysis confirmed these variables to be independently associated with diabetic risk. Tacrolimus was associated with an increased risk of NOD (16.2% in HCV-negative patients, 25% in HCV-positive patients), but this difference was not statistically significant. Steatotic grafts (>10%) were associated with an increased risk of NOD (28.6% vs 10%, P = .001, OR = 3.6). The outcome of patients and grafts in the group of diabetic patients was not significantly different from all other patients. CONCLUSIONS: The incidence of NOD was more relevant in patients older than 45 years and/or HCV-positive. A steatotic graft was an important risk factor, and the match with high-risk patients should be avoided.     

Peroneal neuropathy after liver transplantation

Introduction

The incidence of peroneal neuropathy (PN), occurring predominantly in the left leg, increases after the incorporation of intermittent pneumatic compression (IPC) devices among adult liver transplantation (OLT) recipients in our hospital. The aim of this study was to investigate the possible risk factors for PN and the reason for the left-leg predominance.

Methods

We retrospectively reviewed the medical records of 501 OLT recipients. The patients were first divided into 2 groups, PN (n = 33) and non-PN (n = 468), to assess possible risk factors. The patients were then categorized into IPC (n = 262) and non-IPC (n = 239) groups according to the use of IPC devices. In a subsequent prospective study, we measured the degree and duration of the tilt of the operating table during OLT to investigate their relationship to the predominant left-leg PN.

Results

The rate of IPC device use was significantly greater among the PN than non-PN group (78.8% vs 50.4%, P < .01). The incidence of PN was significantly higher among the IPC than non-IPC group (9.9% vs 2.9%, P < .01). The degree and duration of left tilt of the operating table were greater and longer than the right tilt.

Conclusions

The use of IPC devices during OLT increased the occurrence of PN and the left tilt of the operating table was strongly related to the predominant left-leg PN. Careful protection of the vulnerable point and minimization of the tilting of the operating table is advised during OLT, especially when IPC devices are used.     

肝移植术后巨细胞病毒感染的防治研究

目的探讨肝移植患者术后巨细胞病毒 (CMV)感染情况及其与急性排斥反应的关系。方法应用PCR和ELISA方法检测 78例肝移植受体手术前后、78例供体及 70例接受上腹部手术的非肿瘤患者血清中的CMV DNA和CMV抗体 ,用免疫组织化学方法检测肝组织中CMV抗原。结果供、受体术中肝脏活体组织学检查的CMV早期抗原 (EA)和晚期抗原 (LA)全部为阴性。术前CMV DNA或CMV IgM阳性的受体术后均为阳性 ;术前CMV DNA或CMV IgM阴性的受体术后CMV DNA或CMV IgM转为阳性的分别有 2 6 %和 10 %。 78例受体CMV DNA阳性率由术前的 5 %增加到术后的 31% ,两者比较差异有显著意义 (P <0 0 5 )。 2 6例患者发生了 33次急性排斥反应 ,16次 (49% )CMV DNA检测阳性、11次 (33% )CMV IgM检测阳性 ,而在术后常规检测血CMV DNA和CMV IgM的阳性率分别不超过 13%和 9% ,两者比较差异有显著意义 (P <0 0 5 )。 2 6例发生急性排斥患者肝脏活体组织学检查CMV EA和CMV LA阳性者均为 9例 (2 7% ) ,与术后的常规肝脏穿刺结果比较差异有显著意义 (P <0 0 5 )。结论 1.肝移植术后CMV感染率明显升高。 2 .CMV感染可能是发生急性排斥反应的危险因素。 3.发生急性排斥反应时 ,应使用抗CMV药物 ;未感染CMV的受体接受感染供体的肝脏时应预防用药。     

Physical frailty after liver transplantation

Frailty is prevalent in liver transplant candidates, but little is known of what happens to frailty after liver transplantation. We analyzed data for 214 adult liver transplant recipients who had ≥1 frailty assessment using the Liver Frailty Index (LFI) at 3‐ (n = 178), 6‐ (n = 139), or 12‐ (n = 107) months posttransplant (higher values=more frail). “Frail” and “robust” were defined as LFI ≥4.5 and <3.2. Median pre–liver transplant LFI was 3.7, and was worse at 3 months (3.9; P = .02), similar at 6 months (3.7; P = .07), and improved at 12 months (3.4; P < .001). The percentage who were robust pre‐ and 3‐, 6‐, and 12‐months posttransplant were 25%, 14%, 28%, and 37%; the percentage frail were 21%, 21%, 10%, and 7%. In univariable analysis, each 0.1 pretransplant LFI point more frail was associated with a decreased odds of being robust at 3‐ (odds ratio [OR] 0.75), 6‐ (OR 0.77), and 12‐months (OR 0.90) posttransplant (P ≤ .001), which did not change substantially with multivariable adjustment. In conclusion, frailty worsens 3 months posttransplant and improves modestly by 12 months, but fewer than 2 of 5 patients achieve robustness. Pretransplant LFI was a potent predictor of posttransplant robustness. Aggressive interventions aimed at preventing frailty pretransplant are urgently needed to maximize physical health after liver transplantation.     

肝移植术后巨细胞病毒感染

目的 探讨肝移植术后巨细胞病毒感染的诊断和防治方法。方法 回顾分析10例肝移植患者临床资料,并结合文献进行讨论。结果 共有6例患者发生巨细胞病毒感染,6例均为无临床症状的巨细胞病毒感染,其中5例治愈。结论 荧光探针定量基因检测技术是诊断巨细胞病毒感染的一种快速、敏感性和特异性很高的方法。重视术前、术后巨细胞病毒感染的监测、积极预防及早期治疗是关键。更昔洛韦能有效治疗巨细胞病毒感染。     

Heparin-induced thrombocytopenia after liver transplantation

BACKGROUND: Unfractionated heparin sodium (UFH) or low-molecular weight heparin (LMWH) is used in anticoagulant protocols at several institutions to prevent thrombosis after liver transplantation. Heparin-induced thrombocytopenia (HIT) is an adverse immune-mediated reaction to heparin, resulting in platelet count decreases of more than 50%. The frequencies of HIT after liver transplantation and platelet factor 4/heparin-reactive antibody (HIT antibody) positivity in liver transplantation patients, however, are unknown. PATIENTS AND METHODS: The 32 men and 20 women underwent living donor liver transplantation. We started LMWH (25 IU/kg/h) on postoperative day (POD) 1, switching to UFH (5000 U/d) on POD 2 or 3. The dose of UFH was changed according to the activated clotting time level. HIT antibody levels were measured the day before surgery and on POD 7 and 14. Platelet count was measured daily for 3 weeks. RESULTS: The average platelet counts preoperatively, and on POD 7, 14, and 21 were 65, 88, 149, and 169 x 10(9)/L, respectively. Two patients developed hepatic artery thrombosis on POD 11 and 19, respectively, although they were HIT antibody-negative and their platelet counts were stable. In 2 other patients, the platelet count decreased suddenly from 107 x 10(9)/L on POD 4 to 65 x 10(9)/L on POD 6 and from 76 x 10(9)/L on POD 7 to 33 x 10(9)/L on POD 9, respectively. The heparin-induced platelet aggregation test was negative in these patients. The percentage of HIT antibody-positive patients was 0.5% preoperatively, 5.6% on POD 7, and 5.6% on POD 14. None of the subjects/patients developed UFH-related HIT. CONCLUSIONS: In our series, the occurrence of HIT after liver transplantation was uncommon.     

肝移植术后的细菌感染

目的观察原位肝移植术后细菌感染的特点和相关因素，总结诊断和治疗经验。方法回顾分析我院2000年12月至2002年12月治疗的17例肝移植受体的细菌感染率、感染部位、常见致病菌和耐药情况。结果肝移植术后15例(88．2％)发生34次细菌感染，以肺部感染和腹腔感染多见。手术时间延长、伴随糖尿病及胆道狭窄的发生分别与腹腔、泌尿系和胆道细菌感染有关。多种细菌混合感染、院内感染、条件致病菌所致感染比例大，耐药菌株检出率高。结论细菌感染是肝移植术后的主要并发症之一，手术时间延长、伴随糖尿病及胆管狭窄的发生是细菌感染的相关因素。有效的预防、早期确诊和治疗是控制细菌感染的关键。