A single-center experience with retrograde reperfusion in liver transplantation

Poor graft function secondary to injury by ischemia and reperfusion remains a major problem with regard to morbidity and mortality in clinical liver transplantation (LTX). Up to one fifth of patients suffer from poor initial liver function due to severe damage to hepatocytes. This situation leads either to primary nonfunction described in approximately 6% of LTX or to slow recovery. We present a new method of reperfusion during LTX. From July 1998 to July 2002, 42 LTX in 39 recipients, (10 female, 52 years old (26–70) were performed. LTX was carried out in piggy-back technique. After completing the piggy-back anastomosis, the caval vein was declamped immediately, and retrograde low pressure reperfusion of the graft with low oxygenated venous blood was established. Portal anastomosis was performed using a running suture. In order to provide optimal retrograde liver perfusion, no clamping of the donor portal vein was done. After completing portal anastomosis, the recipient portal vein was declamped immediately. During arterial anastomosis, the transplanted liver was antegradely perfused via the portal vein. After completing hepatic artery anastomosis, declamping of the hepatic artery was done and arterial perfusion started. No backtable or in-situ-flushing except the described reperfusion technique was performed. Forty-two LTX in 39 recipients using piggy-back technique and retrograde reperfusion via the caval vein followed by antegrade reperfusion via the portal vein were performed; 38 out of 39 patients (97.44%) were alive and well at day 8 after LTX. One patient (2.56%) died of a pre-existing portal vein thrombosis on day 2 after LTX. Three patients had to undergo retransplantation for hepatic artery thrombosis (7.14%). Liver enzymes, bilirubine, prothrombine time and AT III on day 1, 3, 5 and 8 after LTX showed favourable values. Median aspartate aminotransferase (ASAT) was 219 U/l on day 1 after LTX. One-month survival rate was 95.23%, and 1-year survival rate 87.88%. Two patients died of liver-associated causes (5.12%). One patient died of a late hepatic artery thrombosis, and one more of rejection. No other severe case of rejection appeared. We can conclude that retrograde reperfusion might be highly sufficient method of removing perfusion fluid from the transplanted liver. Low pressure perfusion with low oxygenated blood might reduce the production of free oxygen radicals. Retrograde reperfusion via the caval vein and antegrade reperfusion via the portal vein seemed to lower postoperative liver enzyme values and to improve initial liver function after LTX.     

Simultaneous antegrade and retrograde reperfusion after cardioplegic arrest for coronary artery bypass

Retrograde coronary sinus reperfusion with warm blood during proximal anastomoses permits completion of myocardial revascularization under a single cross-clamp application. Reperfusion with both antegrade (via arterial and vein grafts) and retrograde (via coronary sinus catheter) warm blood has raised concerns about maldistribution of perfusate or overpressurization of capillary beds. This prospective, randomized design compares postcardioplegic myocardial recovery among patients receiving retrograde reperfusion only and patients receiving simultaneous antegrade/retrograde reperfusion. Twenty-four patients were selected among all presenting as outpatients for elective coronary artery bypass (CAB). Each patient underwent CAB with cardioplegic arrest and single cross-clamp technique. During proximal anastomoses the heart was reperfused with warm blood from the cardiopulmonary bypass (CPB) circuit. Twelve received retrograde reperfusion only, and 12 received simultaneous antegrade/retrograde reperfusion via an internal mammary artery (IMA) graft, all vein grafts, and the coronary sinus catheter. Vein graft perfusion was interrupted in each vein as the proximal anastomosis was performed. Myocardial recovery time (interval from initiating reperfusion until electrical and mechanical activity), cardioversion incidence, requirement for inotropic support, and Swan-Ganz hemodynamic parameters measured immediately 6 and 24 hours postoperatively were compared between groups. There were no differences between groups in age, ventricular function, number of grafts, or CPB time. Also, there were no differences in cardioversion, inotropic need, or postoperative hemodynamic performance. Myocardial recovery time was reduced in patients receiving simultaneous antegrade/retrograde reperfusion (13.9+/-7.0 vs 2.6+/-2.1 minutes). Simultaneous reperfusion of warm blood antegrade and retrograde is not deleterious to the myocardium. More rapid recovery of myocardial function may represent a shorter period of warm ischemia but does not appear to translate to improved postoperative myocardial performance.     

Goal directed preemptive ephedrine attenuates the reperfusion syndrome during adult living donor liver transplantation

BackgroundEnd-stage liver disease is associated with marked hemodynamic disturbances that are further deteriorated during liver transplantation and is aggressively represented in the form of postreperfusion syndrome (PRS).AimThe aim was to test the hypothesis that preemptive ephedrine administration pre-reperfusion targeting a rational level of mean arterial blood pressure (MAP) of 85–100 mmHg, may reduce the incidence of PRS.Patient and methodsOne hundred recipients for adult living donor liver transplantation (ALDLT) were prospectively randomized into 2 groups; group C, control group and group E, who received ephedrine 2.5–5 mg/min starting 5 min before reperfusion till mean arterial blood pressure (MAP) reached 85–100 mmHg. Hemodynamic parameters including MAP, heart rate (HR), Transesophageal Doppler (TED) parameters including corrected flow time (FTc), systemic vascular resistance (SVR), and cardiac output (COP) were measured; just predrug administration, just before reperfusion, just after reperfusion, 5 min after reperfusion and at the end of surgery. Cold and warm ischemia times (C/WIT), duration of anhepatic phase and total duration of surgery were recorded. The incidence of PRS, the need of rescue vasoconstrictor for hemodynamic instability at time of reperfusion, need for postreperfusion vasoconstrictor infusions, over shooting of hemodynamics, postreperfusion fibrinolysis indicated by fibrinogen level and maximum lysis parameter of rotational thromboelastometry (ROTEM) were compared between both groups.ResultsThe mean dose of ephedrine required was (12.5 ± 7.5 mg). Group E had statistically significant increase in MAP, SVR, and COP; just before reperfusion, just after reperfusion and 5 min after reperfusion readings. There were no statistical significant differences between the 2 groups at the end of surgery. The incidence of PRS and the need of rescue adrenaline at the time of reperfusion, and the postreperfusion need for vasoconstrictor infusion decreased significantly in group E when compared to group C. Also postoperative mechanical ventilation decreased significantly in group E.ConclusionThe preemptive goal directed titration of ephedrine against a target MAP pre-reperfusion could decrease the incidence of PRS by 40%, attenuated the hypotensive response to reperfusion and decreased the need for postreperfusion vasoconstrictor support without over shooting of any of the monitored hemodynamic indices.     

Greater Hemodynamic Instability With Histidine-Tryptophan-Ketoglutarate Solution Than University of Wisconsin Solution During the Reperfusion Period in Living Donor Liver Transplantation

Objective

University of Wisconsin (UW) and histidine-tryptophan-ketoglutarate (HTK) solutions are the 2 most commonly used liver preservation solutions. The aim of this study was to compare cardiovascular stability, acid-base status, and potassium concentrations between patients who received grafts preserved in either UW or HTK solution in orthotopic liver transplantation (OLT).

Patients and Methods

In this retrospective study, 87 patients who underwent living donor OLT were divided into 2 groups: UW (n = 28) and HTK (n = 59). Group HTK was subdivided into group NF-HTK (n = 31; nonflushed before reperfusion) and group F-HTK (n = 28; flushed before reperfusion). We determined mean arterial pressure (MAP) and heart rate every minute for 5 minutes after reperfusion and the maximum change in these values and incidence of postreperfusion syndrome (PRS). Body temperature, cardiovascular and acid-base parameters, as well as potassium concentrations were compared at 5 minutes before and 5 and 30 minutes after reperfusion.

Results

The maximum decreases in MAP within 5 minutes after reperfusion were significantly greater in both the NF-HTK and the F-HTK groups. The rate of PRS was significantly greater in the NF-HTK compared with the UW group. Flushing with HTK solution decreased the rate of PRS; there was no significant difference between the F-HTK and UW groups. All serial changes in body temperature, cardiovascular and acid-base parameters, as well as potassium concentrations were similar among the 3 groups.

Conclusions

The incidence of PRS was greater using HTK compared with UW solution during the reperfusion period. Therefore, careful hemodynamic management is advised when using HTK solution.     

Retrograde reperfusion via vena cava lowers the risk of initial nonfunction but increases the risk of ischemic-type biliary lesions in liver transplantation – a randomized clinical trial

Initial nonfunction (INF) and biliary complications such as ischemic-type biliary lesion (ITBL) remain two major complications in clinical orthotopic liver transplantation (OLT). The influence of ischemia and reperfusion injury (I/R) as a significant risk factor for both complications is widely unquestioned. A new reperfusion technique that reduces I/R injury should lead to a reduction in both INF and ITBL. One hundred and thirty two OLT patients were included in this study and randomized into two groups. Group A underwent standard reperfusion with anterograde simultaneous arterial and portal reperfusion and group B received retrograde reperfusion via the vena cava before sequential anterograde reperfusion of portal vein and hepatic artery. Serum transaminase level as a surrogate parameter for I/R injury and serum bilirubin level as a parameter for graft function were significantly reduced during the first week after OLT in group B. INF rate was 7.7% in group A and 0% in group B (P = 0.058). ITBL incidence was 4.55% in group A versus 12.3% in group B (P = 0.053). Retrograde reperfusion seemed to be beneficial for hepatocytes, but was detrimental for the biliary epithelium. The unexplained increased incidence of ITBL after retrograde reperfusion will be focus of further investigation.     

The postreperfusion syndrome is associated with acute kidney injury following donation after brain death liver transplantation

Acute kidney injury (AKI) is frequently observed after donation after brain death (DBD) liver transplantation (LT) and associated with impaired recipient survival and chronic kidney disease. Hepatic ischemia/reperfusion injury (IRI) is suggested to be an important factor in this process. The postreperfusion syndrome (PRS) is the first manifestation of severe hepatic IRI directly after reperfusion. We performed a retrospective study on the relation between hepatic IRI and PRS and their impact on AKI in 155 DBD LT recipients. Severity of hepatic IRI was measured by peak postoperative AST levels and PRS was defined as >30% decrease in MAP ≥1 min within 5 min after reperfusion. AKI was observed in 39% of the recipients. AKI was significantly more observed in recipients with PRS (53% vs. 32%; P = 0.013). Median peak AST level was higher in recipients with PRS (1388 vs. 771 U/l; P < 0.001). Decrease in MAP after reperfusion correlated well with both severity of AKI (P = 0.012) and hepatic IRI (P < 0.001). Multiple logistic regression identified PRS as an independent factor for postoperative AKI (OR 2.28; 95% CI 1.06–4.99; P = 0.035). In conclusion, PRS reflects severe hepatic IRI and predicts AKI after DBD LT. PRS immediately after reperfusion is an early warning sign and creates opportunities to preserve postoperative renal function.     

Replacing cardiopulmonary bypass with extracorporeal membrane oxygenation in lung transplantation operations.

OBJECTIVE: Cardiopulmonary bypass (CPB) support is required in some lung transplantation (LTX) operations. CPB support and full-dose heparin increases the risks of bleeding and early graft dysfunction. We report our experiences of replacing CPB with heparin-bonded low-dose heparin extracorporeal membrane oxygenation (ECMO) support in LTX surgery. METHODS: From 2003 to 2005 forty-seven patients were transplanted. Thirty-seven LTX patients were retrospectively evaluated for this study (10 patients were excluded due to heart-lung-, lung-kidney transplantation, LTX with bypass grafting, and ASD closure or emergency CPB support). Extracorporeal circulation support was necessary in 40% of the 37 LTX patients due to severe primary or secondary pulmonary hypertension (P or SPHTN), right heart dysfunction, or hemodynamic instability. There were seven LTX procedures with CPB and eight implantations with ECMO support. CPB (high-dose heparin) and ECMO support (ACT 160-220 s) was always set up through femoral veno-arterial canulation. All patients had limited access thoracotomies without transsection of the sternum. Normothermia was maintained in all patients. CPB patients: PPH 15%, COPD 15%, IPF with mean PAP>40 mmHg 70%. ECMO patients: PPH 13%, COPD 13%, IPF with severe PAP pressure elevation 74%. RESULTS: In patients undergoing LTX for PPH, the ECMO support was directly extended into the post-operative period. Packed red blood cell (PRBC) transfusion requirements during the operation and the first 24h were 13.25+/-1.6 PRBC units versus 5.1+/-2.8 PRBC units on CBP (p=0.02). Operative time was longer (p=0.11) in the ECMO LTX (451 min+/-76 vs 346+/-140). The increased 90-day mortality rate of the ECMO patients showed a trend toward significance (p=0.056), which was related to infectious complications (3 vs 1 patient). Severe graft ischemia/reperfusion injury occurred in 9% in the CPB versus 13% in the ECMO group. The 1-year survival was significantly reduced in ECMO patients (p=0.004, log-rank test). CONCLUSIONS: The advantages of femoral canulation rather than conventional central connections in lung transplantation procedures led to an undisturbed operative field. A significantly higher blood product amount was required in ECMO patients, which might lead to increased infection and mortality rates. CPB, obviously, should remain the standard support technique if extracorporeal circulation is required in lung transplantation surgery.     

Incidence and predictors of post-reperfusion syndrome in living donor liver transplantation

A characteristic pattern of hemodynamic changes that may occur in reperfusion phase of liver transplantation (LT) is known as post-reperfusion syndrome (PRS). In this study, we determined the frequency of PRS and evaluated possible predictors of PRS. The medical records of 152 patients who underwent living donor LT were reviewed. PRS was defined as a decrease in mean arterial pressure of more than 30% from the baseline value for more than one min during the first five min after reperfusion. The frequency of PRS was determined, and patients were divided into two groups: PRS group and non-PRS group. Donor factors, preoperative and intraoperative recipient factors, and postoperative outcomes were compared between the two groups. PRS occurred in 58 recipients (34.2%). Preoperative model for end-stage liver disease scores of recipients and percentage of graft steatotic changes were higher in PRS group. PRS group showed higher heart rates and lower hemoglobin values preoperatively. Before reperfusion, PRS group received more transfusion and their urine output was less than that of non-PRS group. Postoperatively, peak bilirubin during the first five d after LT was higher in PRS group. In conclusion, both severity of liver disease and graft steatosis may increase risk for PRS in LT. Further prospective studies of PRS in its relationship to outcome are indicated.     

Comparison of the Incidence of Postreperfusion Syndrome During Liver Transplantation Between Radial and Femoral Artery

BackgroundPostreperfusion syndrome (PRS) is a serious complication that can occur during liver transplantation (LT) and is known to affect morbidity and mortality after surgery. However, PRS definition does not include which artery is used to measure blood pressure. Until now, various studies have reported on the incidence, prognosis, and prevention strategies of PRS, but the arterial pressure used in these studies shows heterogeneity. Moreover, femoral arterial pressure and radial arterial pressure show a significant difference especially immediately after reperfusion. To the best of our knowledge there was no study about the comparison of the incidence of PRS according to artery. Therefore, in this study, we would like to investigate if there is a difference in the incidence of PRS between the radial and femoral artery.MethodsWith approval of IRB, we retrospectively reviewed medical records of adult LT patients from April 2017 to April 2019. We reviewed each patient's anesthesia record and confirmed if PRS has occurred.ResultsA total of 251 patients were enrolled. The PRS was measured in radial artery from 84 patients (33.5%) and femoral artery from 71 patients (28.3%). McNemar's test was performed and there was a significant difference (P value .007).ConclusionsThis study confirmed that radial artery had higher incidence of PRS than femoral artery. However, it was not confirmed if PRS measurement at any artery is appropriate for predicting morbidity and mortality after surgery. Therefore, in the future, it is better to conduct research based on arteries that predict the prognosis better.     

Warm retrograde blood cardioplegia saves more ischemic myocardium but may cause a functional impairment compared to cold crystalloid.

OBJECTIVES: Ongoing ischemia, or even ischemia in progress, is regularly encountered in today's patients amenable to cardiac surgery. We set out to assess the effect of 'active resuscitation' during cardioplegia with warm continuous retrograde blood cardioplegia (WB) in a protocol simulating a clinical situation. METHODS: After 60 min with a regional ischemic injury to the left ventricle, 21 pigs were randomized to receive no treatment (control), cold retrograde intermittent crystalloid cardioplegia (CC) or WB. All animals were put on cardiopulmonary bypass. After 1h of cardioplegia and 1 h of reperfusion the perfused left ventricle was colored with methylene blue. After excision of the hearts a standard planimetri technique was used to determine the area at risk and amount of necrosis (triphenyltetrazolium). Heart rate, mean arterial pressure (MAP), cardiac output and myocardial blood flow were recorded as well as myocardial oxygen consumption, plasma levels of free fatty acids, glucose, lactate and Troponin T from the coronary sinus. RESULTS: The area at risk of the left ventricle was 13.6+/-1.2%. We found 71+/-2, 61+/-3 and 30+/-2% necrosis of the area at risk in the controls, CC and WB, respectively (P<0.001, CC versus control and P<0.0001, WB against CC and control). Troponin T release was highest in the CC group in the reperfusion period. Glucose levels increased significantly after ischemia in the controls and WB. In accordance with the amount of saved myocardium in the WB group which also had a normal coronary sinus lactate level as opposed to the fourfold increase in the CC group after ischemia. After standstill cardiac output and MAP were significantly lower than baseline values in the WB group only (P<0.05). CONCLUSIONS: CC did reduce the size of the infarction by about 10% compared to control animals, whereas WB reduced the infarction by more than 50% of that seen after CC. Both modalities are, however, associated with a functional reduction during the first 60 min of reperfusion, WB being the worst.     

Isolated Hypoxic Hepatic Perfusion With Orthograde or Retrograde Flow in Patients With Irresectable Liver Metastases Using Percutaneous Balloon Catheter Techniques: A Phase I and II Study

Background Isolated hepatic perfusion for irresectable metastases confined to the liver has reported response rates of 50% to 75%. Magnitude, costs, and nonrepeatability of the procedure are its major drawbacks. We developed a less invasive, less costly, and potentially repeatable balloon catheter–mediated isolated hypoxic hepatic perfusion (IHHP) technique.Methods In this phase I and II study, 18 consecutive patients with irresectable colorectal or ocular melanoma hepatic metastases were included. Two different perfusion methods were used, both with inflow via the hepatic artery, using melphalan 1 mg/kg. In the first eight patients, the portal vein was occluded, and outflow was via the hepatic veins into an intracaval double-balloon catheter. This orthograde IHHP had on average 56% leakage. In next 10 patients, we performed a retrograde outflow IHHP with a triple balloon blocking outflow into the caval vein and allowing outflow via the portal vein. The retrograde IHHP still had 35% leakage on average.Results Although local drug concentrations were high with retrograde IHHP, systemic toxicity was still moderate to severe. Partial responses were seen in 12% and stable disease in 81% of patients. The median time to local progression was 4.8 months.Conclusions We have abandoned occlusion balloon methodology for IHHP because it failed to obtain leakage control. We are presently conducting a study using a simplified surgical retrograde IHHP method, in which leakage is fully controlled, which translates into high response rates.     

Changes in intraoperative total oxygen consumption in patients during liver transplantation

The changes in O2-uptake (VO2) during 110 liver transplantations (LTX) were studied using Fick's principle (O2-uptake = cardiac index x arteriovenous O2-content difference). During each of the three operative periods [a dissecting period before clamping of the hepatic vessels (1), the anhepatic phase (2), and after reperfusion of the new liver (3)], two measurements (A and B) were taken. After removal of the liver (2A) the VO2 decreased about 11.4%, and increased after reperfusion (3A) about 44.0%; these changes were significant (P less than 0.001). To evaluate the influence of the various indications for LTX on the course of intraoperative VO2, the following patient groups were compared: patients with hepatic tumors (n = 17), patients with cirrhosis following hepatitis (n = 14), patients with primary biliary cirrhosis (n = 17), patients with cirrhosis plus tumor (n = 11), and patients in a hepatic coma (n = 20), regardless of the underlying liver disease. Groups with less than ten subjects were not considered. The drop of VO2 in the anhepatic period (1B----2A) was between -26.7% (patients with tumors) and -7.3% (patients with cirrhosis plus tumor). The patients with cirrhosis following hepatitis showed a special feature: their VO2 increased about 13.4% after cross-clamping the hepatic vessels. After revascularization, the VO2 increased in all groups between +37.2% and +69.8%. In all groups the level of VO2 was higher after reperfusion (3A) than in the dissecting period (1B), ranging from +5.3% in patients with tumors to +61.6% in patients with cirrhosis following hepatitis.(ABSTRACT TRUNCATED AT 250 WORDS)     

The failure of venovenous bypass to prevent graft liver postreperfusion syndrome.

We studied 58 patients undergoing orthotopic liver transplantation, aged 42 +/- 10 years (mean +/- SD), and weighing 65 +/- 14 kg. Anesthesia was maintained with fentanyl, midazolam, and vecuronium. Serum bicarbonate, serum potassium, serum ionized calcium and pH did not change significantly throughout the study. Usual hemodynamic parameters were recorded. Hemodynamic tolerance was assessed by a trial of clamping of the inferior vena cava, above and below the liver and the portal vein; patients were allocated to two groups: the group without venovenous bypass (NBP, n = 29) consisted of patients whose MAP did not decrease by more than 30% and/or cardiac output did not decrease by more than 50%; the group with venovenous bypass (BP, n = 29) consisted of patients whose MAP decreased by more than 30% and/or cardiac output decreased by more than 50% or required venovenous bypass for easier surgical dissection. After clamping of the vena cava and the portal vein, the cardiac index (CI) and mean pulmonary arterial pressure (MPAP) decreased significantly, whereas systemic vascular resistances (SVR) increased. After unclamping the inferior vena cava suprahepatically and infrahepatically, no hemodynamic change was observed. After unclamping the portal vein, MAP decreased, despite the increase in the CI, because of an significant decrease in SVR; in addition MPAP increased despite the decrease in pulmonary vascular resistances. The decrease in MAP of more than 30% during at least 1 min occurred in 6 patients (20%) in the NBP group and in 6 patients (20%) in the BP group. We concluded that the occurrence of the syndrome of cardiovascular collapse following liver reperfusion was similar whether venovenous bypass was used or not.     

Postreperfusion Syndrome in Liver Transplant: A Risk Factor for Acute Kidney Failure: A Retrospective Analysis

The maximum expression of hemodynamic instability during liver transplant is the so-called postreperfusion syndrome (PRS) that increases both overall mortality and postoperative complications. It was first defined by Aggarwal et al in 1987, but the results are still conflicting when establishing the relationship between PRS and acute kidney failure (AKF). We conducted a retrospective observational study of transplant recipients with deceased-donor liver grafts between January 2002 and December 2018. We analyzed the incidence of PRS and its potential negative impact over kidney function. A total of 551 transplants were analyzed. PRS was recorded in 130 patients (23.6%). The incidence of AKF was 61.5%. A total of 111 patients required kidney replacement therapy (32.7%). Regarding the severity of AKF, 128 patients were classified as acute kidney injury (AKI) 1 (23.2%), 76 as AKI 2 (13.8%), and 135 as AKI 3 (24.5%). In the group with PRS, 75.4% (n = 98) developed AKF vs 57.2% (n = 241) in the group without PRS. In the multivariate analysis we found a relationship between PRS and AKF with an odds ratio of 2.18 (95% CI, 1.30-3.64; P = .003), once adjusted by the length of the anhepatic phase, donor age, Model for End-Stage Liver Disease score, history of ascites, and need for early surgical reintervention. The incidence of AKF decreased (44.5%) ever since the implementation of delayed calcineurin inhibitors therapy and piggyback surgical technique, but a clear influence of the occurrence of PRS on the development of AKF is still observed, with an OR of 3.78 (95% CI, 1.92-7.43; P < .001), once adjusted by albumin and hemoglobin levels, Model for End-Stage Liver Disease score, and Child classification.     

Comparison of two different techniques of reperfusion in adult orthotopic liver transplantation

The aim of this study was to determine the impact of two reperfusion techniques on the peri-operative hemodynamic changes and early post-operative graft function of adult patients undergoing orthotopic liver transplantation. MATERIAL AND METHODS: From June 2003 to May 2004, 50 consecutive liver transplants were performed and divided into two groups: group A, 25 patients, portal vein flush with 500 cm(3) of Ringer's lactate without vena caval venting. Group B, 25 patients, vena caval venting with no portal vein flush. Donor and recipient characteristics were similar in both groups. Sixty-four different parameters were analyzed, and Pearson's chi(2) test and t-test were used for statistical analysis, p相似文献   

Successful lung volume reduction surgery brings patients into better condition for later lung transplantation.

OBJECTIVES: Lung volume reduction surgery (LVRS) is accepted as a potential alternative therapy to lung transplantation (LTX) for selected patients. However, the possible impact of LVRS on a subsequent LTX has not been clearly elucidated so far. We therefore analyzed the course of 27 patients who underwent LVRS followed by LTX in our institution. METHODS: Twenty-seven patients (11 male, 16 female, mean age 51.9+/-2.2 years) out of 119 patients who underwent LVRS between 1994 and 1999 underwent LTX 29.7+/-3.2 months (range 2-57 months) after LVRS. Based on the postoperative course of FeV1 after LVRS (best value within the first 6 months postoperatively compared with the preoperative value) patients were divided into two groups: Group A (n=11) without any improvement (FeV1 <20% increase), and Group B (n=16) with FeV1 increase > or = 20% after successful LVRS which declined to preoperative values after 8-42 months. Subsequent LTX was performed 22.9+/-5.6 months after LVRS in Group A and 34.3+/-4.9 months after LVRS in Group B (P<0.05). Patients were analyzed according to the course of their functional improvement and of their body mass index (BMI) after LVRS and to survival after LTX, respectively. Values are given as the mean+/-SEM and significance was calculated by the chi(2)-test whereas continuous values were estimated by Student's t-test. RESULTS: Patients in Group A without improvement in FeV1 after LVRS had no increase in BMI as well and this resulted in a high perioperative mortality of 27.3% after LTX. On the contrary, patients in Group B, who had a clear increase of FeV1 after LVRS, experienced a significant increase of BMI of 23.2+/-4.5% as well (P<0.05). This improvement in BMI remained stable despite a later deterioration of FeV1 prior to LTX. After LTX, these patients had a significantly lower perioperative mortality of 6.3% as compared to Group A (P=0.03). CONCLUSIONS: Successful LVRS delays the need for transplantation, improves nutritional status and brings patients into a better pretransplant condition, which results in decreased perioperative mortality at LTX. Patients after failed LVRS, however, should be considered as poor candidates for later transplantation.     

Lung transplantation in patients with scleroderma: case series, review of the literature, and criteria for transplantation

Abstract: Backgrounds: The use of lung transplantation (LTX) to treat respiratory failure because of scleroderma is controversial. We present our experience, review the current literature, and suggest specific criteria for LTX in scleroderma. Of the 174 patients who underwent LTX at our center, seven (4%) had scleroderma‐associated respiratory failure. Patients and methods: A MEDLINE search of the English literature was performed for studies of LTX in patients with scleroderma between 1986 and 2006. A Kaplan–Meier survival curve was calculated over the time of the studies. Results: The MEDLINE search yielded one large review and four small case series. The small case series were included in the review. The review and our series yield a total of 54 patients. Mean patient age was 47.1 yr; 59.3% were female. Pre‐operative lung data were available for 24 patients: 22 (92%) had pulmonary fibrosis and 17 (71%) had pulmonary hypertension. Most patients (69%) underwent single‐lung transplantation. Mean forced expiratory volume at one s after LTX was 67% (range 56–87%). There was no difference in infection and rejection rates between the patients with scleroderma and other LTX recipients. The two‐ and five‐yr survival rates were 72% and 55%, respectively. Conclusions: LTX is a valid option in well‐selected patients with scleroderma and pulmonary fibrosis, yielding good pulmonary function and acceptable morbidity and mortality.     

Causes of postreperfusion syndrome in living or cadaveric donor liver transplantations

OBJECTIVE: The postreperfusion syndrome (PRS) occurrence was evaluated in patients undergoing liver transplantation in our institution to determine the relationship between PRS and associated variables. METHODS: Of the 185 consecutive liver transplants, pediatric patients, patients with uncompleted data or retransplantations were excluded. The remaining 145 adult patients having 77 cadaveric and 68 living donor right lobe liver transplantations were studied. PRS was defined as a decrease in mean arterial pressure >30% below the baseline value. Logistic regression was used for statistical analyses. A P value <.05 was considered as significant. RESULTS: Total rate of PRS occurrence was 48.9% (71 patients) for the 145 patients. Logistic regression analyses revealed a significant relationship between the PRS and four of the variables: shorter duration of the anhepatic period, higher mean calcium requirement, higher mean heart rate difference from anhepatic to reperfusion period and lower central venous pressure at the dissection period during operations (P <.05). We could not demonstrate any significant effect of the operation type-surgical technique and duration of operations, blood and fresh frozen plasma volume transfused, demographic variables of the recipients, donor liver factors, other haemodynamic and metabolic variables at specific time periods (P >.05). CONCLUSIONS: In conclusion, it is important that PRS does not seem to occur in a predictable manner in this study except for the increased calcium requirements during the operations in PRS experienced patients. The clinical parameters as graft ischemia time, the type of the operation, demographic variables of the recipient, hemodynamic or metabolic variables and transfusion needs during the operations seemed to have no contribution to PRS occurrence.     

Post-reperfusion syndrome during isolated intestinal transplantation: outcome and predictors

Siniscalchi A, Cucchetti A, Miklosova Z, Lauro A, Zanoni A, Spedicato S, Bernardi E, Aurini L, Pinna AD, Faenza S. Post‐reperfusion syndrome during isolated intestinal transplantation: outcome and predictors.
Clin Transplant 2011 DOI: 10.1111/j.1399‐0012.2011.01530.x
© 2011 John Wiley & Sons A/S. Abstract: Background: Post‐reperfusion syndrome (PRS) during isolated intestinal transplantation (ITx) is characterized by decreased systemic blood pressure, systemic vascular resistance, and cardiac output and by a moderate increased pulmonary arterial pressure. We hypothesize that the more severe PRS causes a poorer long‐term outcome. The primary aim of this study was to determine the independent clinical predictors of intra‐operative PRS, as well as to investigate the link between the severity of PRS and the intra‐operative profiles and to examine the post‐operative complications and their relationship with transplant outcome. Methods: This observational study was conducted on 27 patients undergoing isolated ITx in a single adult liver and multivisceral transplantation center. PRS was considered when the mean arterial blood pressure was 30% lower than the pre‐unclamping value and lasted for at least one min within 10 min after unclamping. Results and conclusions: The main results of this study can be summarized in two findings: in patients undergoing ITx, the duration of cold ischemia and the pre‐operative glomerular filtration rate were independent predictors of PRS and the occurrence of intra‐operative PRS was associated with significantly more frequent post‐operative renal failure and early post‐operative death.     

Analysis of postrevascularization syndrome after orthotopic liver transplantation: the experience of an Australian liver transplantation center

Abstract. Background/Purpose: We investigated the causes and examined patient outcomes following the postrevascularization syndrome (PRS) during orthotopic liver transplantation (OLTx). Methods: PRS was defined as a fall in the mean arterial pressure at 5 min after revascularization to less than 70% of the baseline and lasting for 5 min. Data from 100 adult patients who underwent OLTx between January 1998 and September 2000 were analyzed. Analyzed data included donor and recipient demographic data, recipient operative and postoperative courses, and recipient outcome. Results: Twenty-nine patients (29%) exhibited PRS during OLTx (PRS group). There was a higher incidence of older donors (>50 years) in the PRS group (48% vs 23%; P < 0.05). Postrevascularization hyperkalemia and metabolic acidosis were observed in both the PRS and non-PRS groups. Transaminase and lactate levels after revascularization were significantly higher in the PRS group (P < 0.05). Alkaline phosphatase and gamma-glutamyl transpeptidase levels on day 7 tended to be higher in the PRS group; although the difference was not significant (p ≧ 0.05). Serum creatinine was significantly elevated on day 7 in the PRS group (P < 0.01). Conclusions: Our results indicate that PRS following OLTx tended to be more common in liver allografts from older donors and was associated with posttransplantation liver and renal dysfunction. Received: May 11, 2001 / Accepted: September 26, 2001