Cardiovascular morbidity and mortality after orthotopic liver transplantation

BACKGROUND: Hyperlipidemia and hypertension have been reported in liver allograft recipients and contribute to an increased risk of ischemic heart disease (IHD) after orthotopic liver transplantation (OLT). The aims of the study were (1) to determine the prevalence of risk factors for IHD in these patients and (2) to compare the observed incidence of cardiovascular events and related mortality in allograft recipients with a matched population. METHODS: One hundred ten consecutive adults (50 male) who attended for review after OLT (median follow-up 3.9 years; range 0.1-17.9) were assessed for cardiovascular risk factors using current blood pressure, diabetic status, and smoking history and measurements of total cholesterol, high-density lipoprotein cholesterol, and triglyceride concentrations. Cardiovascular events and cardiovascular mortality data were collected from the prospective database of all adult liver allograft recipients and compared to matched data from myocardial infarction registries and Office for National Statistics data, respectively. RESULTS: Raised serum cholesterol (>5.0 mmol/L) was found in 48 (44%) patients (18 male), and systolic hypertension (>140 mmHg) was found in 69 (63%) patients (27 male). The relative risk of ischemic cardiac events was 3.07 (95% [confidence interval] CI, 1.98-4.53) and the relative risk for cardiovascular deaths was 2.56 (95% CI, 1.52-4.05) in allograft recipients compared to an age-matched population without transplants. CONCLUSIONS: Liver allograft recipients have a greater risk of cardiovascular deaths and ischemic events than an age- and sex-matched population. The prevalence of raised cholesterol concentrations in patients after OLT is similar to those in previous reports. Moderate hypertension and hyperlipidemia may be more detrimental in patients after OLT compared to non-transplant patients without these risk factors.     

Sexual health after orthotopic liver transplantation.

Many studies have reported improved health-related quality of life outcomes after orthotopic liver transplantation; however, specific research regarding sexual health in liver transplant recipients is limited. We surveyed liver transplant recipients to determine the prevalence of sexual dysfunction. Of the 320 adult liver transplant recipients surveyed by mailed questionnaire, 150 responded (42%). The median age was 54 years. A total of 62% of respondents were male, and 93% were at least 1 year after transplantation. Thirty-six respondents (24%) reported sexual dysfunction before transplantation; this persisted in 22 patients (15%) after transplantation. A total of 48 respondents (32%) reported de novo sexual dysfunction after transplantation. After transplantation, 23% of male and 26% of female respondents reported decreased libido, and 33% of men and 26% of women reported having difficulty reaching orgasm with intercourse. A total of 42% of respondents felt that immunosuppressive medication was the main contributing factor to their sexual problems: 33% and 35% of respondents receiving tacrolimus or cyclosporine monotherapy, respectively, experienced some degree of sexual problems after transplantation. Despite the reported sexual problems, 59% of respondents were "moderately" to "very satisfied" with their sexual relationships after transplantation. Nineteen percent of the respondents used sildenafil to improve their sexual function, and 65% of these reported benefit. In conclusion, sexual problem after orthotopic liver transplantation is a common but poorly studied problem. Although this single-center study has shed some light on the relationship between liver transplantation and sexual health, further prospective studies, involving larger study population and validated instruments, will be needed to better evaluate the influence of liver transplantation on recipients' sexual health.     

Mortality after orthotopic liver transplantation

An analysis was made of the causes of death in 22 of 50 patients receiving consecutive orthotopic liver transplants. A close look at the fatal course of these patients revealed three major patterns: surgical complications (27%), pathology of the hepatic artery anastomosis (23%), and cholestasis (32%). Technical factors were the major reasons for excessive peroperative blood loss, and not the coagulopathy accompanying the liver disease. The etiology of hepatic artery thrombosis is not known. It leads to irreversible damage of the graft, causing death due to acute hepatic failure or to cholangitis and sepsis. The only way to treat patients with this complication is retransplantation. Several factors can induce cholestasis. Retrospectively, it appears that this was mostly due to inappropriate immunosuppression, often a result of the difficult differential diagnosis between rejection and viral infection. Recognition of these three basic patterns should enable us to anticipate their subsequent complications. This may lead to a reduction in morbidity and mortality after liver transplantation.     

Cardiac morbidity and mortality related to orthotopic liver transplantation.

This article briefly discusses the cardiac status of liver transplant recipients and their preoperative cardiac evaluation. It describes in detail perioperative and early and late postoperative complications as well as the cardiac problems associated with immunosuppression. The preoperative cardiovascular status of patients is important in determining how they cope with the stresses imposed by liver transplantation. Minor early cardiac events are common and may influence longer term cardiac morbidity. Immunosuppressive therapy may have short term effects but is likely to adversely affect long term cardiac risk.     

Improved physical performance after orthotopic liver transplantation.

Orthotopic liver transplantation (OLT) has become a frequently used treatment for end-stage liver disease and acute liver failure, and liver function is markedly improved after transplantation. However, no studies have investigated the development in physical capacity after OLT. On this basis, the aim of the present study is to study the influence of OLT on physical fitness during the first postoperative year. Twenty-three men with a mean age of 45.1 years (range, 24 to 62 years) and 15 women with a mean age of 44.6 years (range, 21 to 62 years) were included in the study. Preoperative maximal oxygen uptake (VO2max) during graded ergometer bicycling, isokinetic knee extension/flexion moments, and functional performance (i.e., 6-minute walking distance and standardized transfers and squats) was measured. Preoperative fitness and strength was 40% to 50% less than expected in the age-matched general population. Post-OLT, all patients underwent a supervised exercise program for 8 to 24 weeks. Follow-up data showed a significant increase in all tested physical performance parameters after OLT. Six months post-OLT, VO2max had increased 43%; knee strength, 60% to 100%; and functional performance, 22% to 27%. One year postsurgery, general health was improved and perceived as excellent or good in all patients. All patients were independent in activities of daily living, and the level of physical activity increased after OLT. No further improvement in either physical performance parameters or self-assessed parameters was seen beyond 6 months after OLT. In conclusion, these findings indicate that OLT combined with a supervised post-OLT exercise program improves physical fitness, muscle strength, and functional performance in individuals with chronic liver disease.     

Pulmonic valve endocarditis after orthotopic liver transplantation.

Infective endocarditis is a rare complication affecting solid-organ transplant recipients. Isolated pulmonic valve endocarditis is also rare. A case of persistent bacteremia secondary to an isolated pulmonic valve vegetation occurred in a woman 10 days after liver transplantation. A pulmonary vegetectomy was performed as an alternative to valve replacement in addition to long-term antibiotic therapy.     

Recurrent hepatic lymphangiomatosis after orthotopic liver transplantation.

Hepatic lymphangiomatosis is a rare disease characterized by an abnormal lymphatic proliferation involving the liver alone, liver and spleen, or multiple organs. Hepatic lymphangiomatosis becomes symptomatic secondary to compression or replacement of the normal parenchyma, which can lead to liver failure. Resection and orthotopic liver transplantation (OLT) can be used as treatment for this disease. We herein describe a 42-year-old female who had undergone successful OLT for hepatic lymphangiomatosis with recurrent disease detected 19 yr later in the transplanted liver. This is, to our knowledge, the first described case of recurrent hepatic lymphangiomatosis after OLT. In conclusion, we discuss the clinical, radiologic, pathologic, and immunohistochemical findings and review other reported cases of hepatic lymphangiomatosis that have undergone OLT.     

Early complications after orthotopic liver transplantation

The cost and impact of early post-transplant complications continue to be high. Diagnosis and management involves a high index of suspicion, rapid diagnostic and therapeutic interventions, and elimination of technical problems. Preoperative assessment of the donor and recipient medical condition and meticulous attention to detail during the technical performance of OLTx are the mainstays in achieving a good outcome.     

肝移植术后的肺部并发症

肝移植术后肺部并发症的发生率非常高,包括肺不张、胸腔积液、肺水肿、肺部感染和急性呼吸衰竭等,严重影响病人的预后.引起肝移植术后肺部并发症的因素很多,主要包括手术操作、感染、循环容量超负荷、输血相关的急性肺损伤、缺血/再灌注、呼吸机相关性肺损伤、肝肺综合征和门肺高压症等因素,以此为依据,现提出了具体的防治措施,包括完善的术前准备、防止容量超负荷、合理输血和血制品,调节凝血功能,注意预防输血相关的急性肺损伤(transtnsion related acutte lung injury,TRALL)、合理应用抑肽酶、减轻缺血/再灌注损伤(ischemia-reperfusion injury,L/R)和全身炎症反应、防治肺动脉高压、合理的呼吸机通气管理等,希望有助于肝移植术后肺部并发症的防治,促进肝移植病人预后.     

Venous complications after orthotopic liver transplantation

We report venous complications, including portal vein and hepatic vein stenoses, that required interventional radiological treatment in three pediatric and two adult living related liver transplant recipients. Between April 2001 and April 2005, 81 liver transplantations were performed at our hospital. Sixty-two grafts were from living donors. During follow-up, three portal vein stenoses were identified in three pediatric recipients, and two hepatic vein stenoses in two adult patients. In the children, two had received left lateral segment grafts, and one had received a right lobe graft from two mothers and one father, respectively. The etiologies of liver failure were Alagille syndrome, biliary atresia, and fulminant Wilson's disease. Portal vein stenoses were identified at 8, 11, and 12 months after transplantation; all three patients underwent percutaneous transhepatic portal venous angioplasty with a success rate of 100%. The mean follow-up was 102 days; no recurrence has occurred. In contrast, hepatic venous stenoses were diagnosed in two adult recipients. One of them was a 24-year-old woman with autoimmune hepatitis and the other a 43-year-old man with cryptogenic cirrhosis. Hepatic vein stenoses were diagnosed at 3 and 4 months after transplantation. Both hepatic vein stenoses were dilated with balloon angioplasties via the transjugular route. Venous complications identified by Doppler ultrasonography were confirmed by computerized tomographic angiography. Angioplasty represents an effective and safe alternative to reconstructive surgery in the treatment of venous complications after liver transplantation.     

Venous complications after orthotopic liver transplantation

Complications involving the portal vein or the vena cava, are rare after orthotopic liver transplantation. We report on the incidence and treatment of venous complications following 1000 orthotopic liver transplantations in 911 patients. Twenty-six of the adult patients (2.7%) suffered from portal complications after transplantation, whereas complications of the vena cava were observed in only 17 patients (1.8%). Technical problems or recurrence of the underlying disease (e.g. Budd-Chiari syndrome) accounted for the majority of complications of the vena cava, whereas alteration of the vessel wall or splenectomy during transplantation could be identified as important risk factors for portal vein complications. In patients undergoing modification of the standard end-to-end veno-venous anastomosis of the portal vein due to pathological changes of the vessel wall, complications occurred in 8.3%, whereas only 2.4% of patients who received a standard anastomosis of the portal vein experienced complications of the portal vein. Furthermore, splenectomy during transplantation was also associated with an increased incidence of portal vein complications (10.5 vs. 2.2% in patients without splenectomy). Treatment was dependent on the signs and symptoms of the patients, and varied considerably between patients with portal vein complications and patients suffering from complications of the vena cava. Complications of the vena cava led to retransplantation in about one-third of the patients, whereas in patients with occlusion of the portal vein, retransplantation was necessary in only 15%, and more than half of the patients suffering from portal vein complications did not require any treatment at all. Usually, treatment of patients with portal vein complications only became necessary when additional complications such as arterial occlusion or bile duct injuries occurred.     

Tacrolimus-associated mutism after orthotopic liver transplantation

BACKGROUND: Mutism/speech apraxia has been well documented as a toxic effect of cyclosporine after liver transplantation but has been reported only rarely with tacrolimus. Brain imaging with magnetic resonance or computed tomography has failed to demonstrate abnormalities in affected patients. METHODS: We present the first example of an acute onset of loss of speech associated with a sudden elevation of serum tacrolimus level after successful orthotopic liver transplantation. We also describe the positron emission tomography (PET) scan of this patient's brain. RESULTS: PET scan imaging of the brain was abnormal, demonstrating decreased metabolism in the posterior temporo-parieto-occipital regions. Statistical probability mapping revealed additional areas of hypometabolism in the cingulate gyrus. CONCLUSIONS: PET scan revealed abnormalities of the brain in a patient with tacrolimus-induced mutism. The cingulate gyrus may play a role in the mutism/speech apraxia syndrome seen with cyclosporine/tacrolimus neurotoxicity.     

原位肝移植术后并发曲霉菌感染的诊断和治疗

目的 探讨原位肝移植术后并发曲霉菌感染的诊断和治疗措施. 方法对2000年1月至2006年12月中山大学附属第一医院施行的776例同种原位肝移植患者的临床资料进行回顾性分析,总结原位肝移植术后发生曲霉菌感染的诊治经过.结果 本组患者发生曲霉菌感染13例,感染发生率为1.68%(13/776);其中肺部感染7例,肝脏感染2例,颅内感染1例,多器官感染3例.两性霉素B脂质体是治疗肝移植术后曲霉菌感染的主要药物,对早期病例疗效满意.因曲霉菌感染死亡7例,病死率为53.8%(7/13).结论 防治肝移植术后曲霉菌感染的关键是做好早期诊断,及时治疗.抗真菌治疗应该清除病灶、调整免疫抑制剂及选用敏感抗真菌药物;抗真菌药物的使用应该早期、足量、全程用药.     

Vascular complications after orthotopic liver transplantation

Over a 57-month period, we performed 430 orthotopic liver transplants in 372 patients. A total of 38 vascular complications were identified including hepatic artery thrombosis (n = 24), portal vein thrombosis (n = 6), combined hepatic artery thrombosis/portal vein thrombosis (n = 3), and hepatic artery rupture (n = 5). A number of potential risk factors for the development of vascular thrombosis were evaluated with only children, weight less than 10 kg, and cold ischemia time found to be significant. The clinical presentation included fulminant hepatic failure, allograft dysfunction, biliary sepsis, and screening ultrasound. Duplex ultrasonography was diagnostic in nearly all cases. Therapeutic modalities included revascularization, revascularization followed by retransplantation, retransplantation alone, and observation. Five cases of hepatic artery rupture occurred in four patients. Infectious arteritis was present in four patients. The 6-month actuarial survival in patients with vascular complications was 70%. Early diagnosis is critical for graft salvage, with surgical intervention the mainstay of therapy.     

Laparoscopic surgery after orthotopic liver transplantation

Laparoscopic surgery is currently a widely accepted approach to several surgical fields because of its advantages in terms of postoperative pain reduction and easy patient recovery. This approach may be useful even in solid-organ transplantation surgery as a diagnostic or treatment procedure in some surgical complications. From July 1991 to December 1998, we performed 142 liver transplantations on 129 patients. During the postoperative period, many complications occurred. Here we report two cases of intestinal occlusion caused by adhesions and three cases of lymphocele, all approached with laparoscopic surgery. In all cases but one, we were able to complete the surgery by laparoscopic means; in one of the two occlusions, the procedure was switched to laparotomy because of a choledochojejunal anastomosis lesion. The three cases of lymphocele must be considered in a particular manner because such cases, to our knowledge, have never been described in the literature. They always presented with a late-onset right pleural effusion and were located in the retrohepatic, retrogastric, and left paracaval areas, close to the esophageal hiatus. In conclusion, we believe a laparoscopic approach is a useful strategy to solve some surgical complications in patients who underwent orthotopic liver transplantation; however, the use of laparoscopic surgery in this field is strictly connected to the surgeon's experience and versatility.