Combined heart–liver transplantation: a single‐center experience

Combined orthotopic heart and liver transplantation (CHLT) is a lifesaving procedure for patients with end‐stage heart–liver disease. We reviewed the long‐term outcome of patients who have undergone CHLT at the University of Bologna, Italy. Fifteen patients with heart and liver failure were placed on the transplant list between November 1999 and March 2012. The pretransplant cardiac diagnoses were familial amyloidosis in 14 patients and chronic heart failure due to chemotherapy with liver failure due to chronic hepatitis in one patient. CHLT was performed as a single combined procedure in 14 hemodynamically stable patients; there was no peri‐operative mortality. The survival rates for the CHLT recipients were 93%, 93%, and 82% at 1 month and 1 and 5 years, respectively. Freedom from graft rejection was 100%, 90%, and 36% at 1, 5, and 10 years, respectively, for the heart graft and 100%, 91%, and 86% for the liver graft. The livers of eight recipients were transplanted as a “domino” with mean overall 1‐year survival of 93%. Simultaneous heart and liver transplantation is feasible and was achieved in this extremely sick cohort of patients. By adopting the domino technique, we were able to enlarge the donor cohort and include high‐risk patients.     

Combined liver–kidney transplantation versus liver transplant alone based on KDIGO stratification of estimated glomerular filtration rate: data from the United Kingdom Transplant registry – a retrospective cohort study

Patient selection for combined liver–kidney transplantation (CLKT) is a current issue on the background of organ shortage. This study aimed to compare outcomes and post‐transplant renal function for patients receiving CLKT and liver transplantation alone (LTA) based on native renal function using estimated glomerular filtration rate (eGFR) stratification. Using the UK National transplant database (NHSBT) 6035 patients receiving a LTA (N = 5912; 98%) or CLKT (N = 123; 2%) [2001–2013] were analysed, and stratified by KDIGO stages of eGFR at transplant (eGFR group‐strata). There was no difference in patient/graft survival between LTA and CLKT in eGFR group‐strata (P > 0.05). Of 377 patients undergoing renal replacement therapy (RRT) at time of transplantation, 305 (81%) and 72 (19%) patients received LTA and CLKT respectively. A significantly greater proportion of CLKT patients had severe end‐stage renal disease (eGFR < 30 ml/min/1.73 m²) at 1 year post‐transplant compared to LTA (9.5% vs. 5.7%, P = 0.001). Patient and graft survival benefit for patients on RRT at transplantation was favouring CLKT versus LTA (P = 0.038 and P = 0.018, respectively) but the renal function of the long‐term survivors was not superior following CLKT. The data does not support CLKT approach based on eGFR alone, and the advantage of CLKT appear to benefit only those who are on established RRT at the time of transplant.     

Incidence of nosocomial pneumonia and risk of recurrence after antimicrobial therapy in critically ill lung and heart–lung transplant patients

Little is known about the resolution of symptoms of nosocomial pneumonia (NosoP) after lung and heart–lung transplantation. The aim of this study was to describe the clinical response to antimicrobial therapy in (ICU) patients with NosoP after lung or heart–lung transplantation. Between January 2008 and August 2010, 79 lung or heart–lung transplantations patients were prospectively studied. NosoPwas confirmed by quantitative cultures of bronchoalveolar lavage or endotracheal aspirates. Clinical variables, sequential organ failure assessment (SOFA) score, and radiologic score were recorded from start of therapy until day 9. Thirty‐five patients (44%) experienced 64 episodes of NosoP in ICU. Fourteen patients (40%) had NosoP recurrence. Most frequently isolated organisms were Enterobacteriaceae (30%), Pseudomonas aeruginosa (25%), and Staphylococcus aureus (20%). Sequential organ failure assessment (SOFA) score improved significantly at day 6 and C‐reactive protein level at day 9. SOFA and radiologic scores differed significantly between patients with and without NosoP recurrence at day 3 and 9. The ICU mortality rate did not differ between patients with and without NosoP recurrence, and free of NosoP (14.3%, 9.5%, 11.4%, respectively) (p = 0.91). Severities of illness and lung injury were the two major risk factors for NosoP recurrence. Occurrence of NosoP has no impact on ICU mortality.     

Corticosteroid elimination in simultaneous liver–kidney transplantation recipients

Abstract: Background: Simultaneous liver–kidney transplantation (SLK) has more than doubled since 2002. While less common in kidney transplant alone recipients (KTA), corticosteroid discontinuation is performed routinely in liver transplantation, raising the question of optimal immunosuppression for SLK recipients. Methods: A retrospective case series of 16 SLK recipients under a steroid withdrawal protocol was performed to compare short‐term outcomes to a contemporaneous cohort of 32 KTA recipients. Results: In 69% of SLK recipients, corticosteroids were eliminated compared to 3% of KTA recipients, p < 0.0001. When comparing SLK and KTA recipients one yr post‐transplant, there were no significant differences in renal graft rejection (23.1% vs. 6.3%), death‐censored renal graft survival (100% vs. 97%), estimated glomerular filtration rate (74.4 vs. 62.6 mL/min), serum creatinine (1.10 vs. 1.39 mg/dL), or maintenance immunosuppression, respectively. Conclusions: Corticosteroids may be withdrawn safely in SLK recipients with one‐yr renal outcomes comparable to a KTA cohort.     

The management of perioperative nutrition in patients with end stage liver disease undergoing liver transplantation

Malnutrition is found in almost 100% of patients with end stage liver disease (ESLD) awaiting transplantation and malnutrition before transplantation leads to higher rates of post-transplant complications and worse graft survival outcomes. Reasons for protein energy malnutrition include several metabolic alterations such as inadequate intake, malabsorption, and overloaded expenditure. And also, stress from surgery, gastrointestinal reperfusion injury, immunosuppressive therapy and corticosteriods use lead to delayed bowl function recovery and disorder of nutrients absorption. In the pretransplant phase, nutritional goals include optimization of nutritional status and treatment of nutrition-related symptoms induced by hepatic decompensation. During the acute post-transplant phase, adequate nutrition is required to help support metabolic demands, replenish lost stores, prevent infection, arrive at a new immunologic balance, and promote overall recovery. In a word, it is extremely important to identify and correct nutritional deficiencies in this population and provide an adequate nutritional support during all phases of liver transplantation (LT). This study review focuses on prevalence, nutrition support, evaluation, and management of perioperative nutrition disorder in patients with ESLD undergoing LT.     

Pulmonary vascular resistance determines mortality in end‐stage renal disease patients with pulmonary hypertension

The multifactorial etiology of pulmonary hypertension (PH) in end‐stage renal disease (ESRD) includes patients with and without elevated pulmonary vascular resistance (PVR). We explored the prognostic implication of this distinction by evaluating pretransplant ESRD patients who underwent right heart catheterization and echocardiography. Demographics, clinical data, and test results were analyzed. All‐cause mortality data were obtained. Median follow‐up was 4 years. Of the 150 patients evaluated, echocardiography identified 99 patients (66%) with estimated pulmonary artery (PA) systolic pressure > 36 mm Hg, which correlated poorly with mortality (HR = 1.28, 95% CI 0.72‐2.27, P = .387). Right heart catheterization identified 88 (59%) patients with mean PA pressure ≥ 25 mm Hg. Of these, 70 had PVR ≤ 3 Wood units and 18 had PVR > 3 Wood units. Survival analysis demonstrated a significant prognostic effect of an elevated PVR in patients with high mean PA pressures (HR = 2.26, 95% CI 1.07‐4.77, P = .03), while patients with high mean PA pressure and normal PVR had equivalent survival to those with normal PA pressure. Despite the high prevalence of PH in ESRD patients, elevated PVR is uncommon and is a determinant of prognosis in patients with PH. Patients with normal PVR had survival equivalent to those with normal PA pressures.     

A pocket guide to identify patients at risk for chronic kidney disease after liver transplantation

Chronic kidney disease (CKD) after liver transplantation (LT) has a strong impact on transplant and patient survival. After LT, a significant proportion of patients develop renal dysfunction with a high risk to progress to end‐stage renal disease (ESRD). Because of the multifactorial nature of CKD in the post‐transplant period, the ability to accurately identify patients at risk and the development of preventative strategies remain unsolved issues. In some patients, the pretransplant kidney function significantly declines within the first year post‐LT. Until now, no user‐friendly and reliable prediction scores exist to identify these patients early on. Data from 328 consecutive adult patients receiving their first LT between 2004 and 2008 at Hannover Medical School were analyzed to develop a prediction model using ordinal logistic regression. We developed a concise risk score identifying the five most important predictors and performed a temporal validation using a prospectively monitored patient cohort of 120 patients from our transplant center. Based on those five parameters, we developed a pocket guide card for clinical use that could be a useful tool for instant identification of patients at high risk as well as patients more suitable for combined liver and kidney transplantation (CLKT).     

肝胰十二指肠器官簇移植五例治疗分析

目的总结肝胰十二指肠器官簇移植术后并发症发生和器官功能恢复情况。方法对5例终末期肝病合并2型糖尿病患者进行肝胰十二指肠器官簇移植．术中保留受体胰和全消化道．行单纯肝切除术后,予以肝胰十二指肠器官簇移植。结果5例患者术程均顺利,手术时间9。16h,术中出血1600～3000ml。术后1例出现肺部感染;1例出现移植物抗宿主病（GVHD）并肺部感染;1例出现急性肾功能衰竭。5例患者均未出现肠瘘、吻合口瘘、胆道并发症、急慢性排斥反应及胰腺炎。5例患者丙氨酸转氨酶、天冬氨酸转氨酶及总胆红素等肝功能指标在术后1周趋于正常水平：C肽、血糖水平在1。2周达到正常范围。术后经2～23个月的随访,除1例因GVHD死亡外,其余4例患者肝功能均维持正常．无需外援性胰岛素即可维持血糖稳定。结论肝胰十二指肠器官簇移植在技术上具有可行性,是一种治疗多器官病变的有效方法。     

Perioperative management of living‐donor liver transplantation for methylmalonic acidemia

Methymalonic acidemia (MMA) is a hereditary metabolic disorder characterized by a defect of the methylmalonyl‐CoA mutase that breaks down propionate. The efficacy of liver transplantation for MMA was recently reported. However, the anesthetic management of liver transplant for MMA is not clear. The aim of this article is to describe an anesthetic management algorithm of liver transplant for MMA by reviewing our cases of liver transplant for MMA. Fourteen patients received a liver transplant; three cases showed metabolic decompensation during the transplant and two of the patients died. In the two patients who expired, propofol was used for maintenance anesthesia and preoperative continuous hemodiafiltration was used to reduce plasma methylmalonic acid level in one case, and to control severe metabolic decompensation before transplant for the other case. Their renal function was also worse than others and they were already experiencing metabolic decompensation before induction of anesthesia. Based on our experience of these 14 cases, we have established an anesthetic algorithm for patients with MMA undergoing liver transplant or other procedures. There are three important points in our experience: propofol should be avoided, dextrose infusion therapy should be continued to prevent metabolic decompensation, and liver transplant or other procedures should be avoided during metabolic decompensation.     

劈离式肝移植围手术期管理

在肝源短缺的背景下,劈离式肝移植实现了“一肝两用”的目的,有效缓解了供肝短缺的现状,具有较大的发展前景。且随着肝移植手术技术的进步,劈离式肝移植可获得接近全肝移植的预后。但劈离式肝移植围手术期管理仍面临着诸多挑战,其技术要求更高,发生并发症的风险较大,并有可能将1个高质量的供肝转化为2个边缘供肝,影响肝移植手术的开展。本文就术前评估、受者管理及术后并发症管理等方面探讨劈离式肝移植的围手术期管理,为促进临床劈离式肝移植的发展,改善劈离式肝移植受者预后提供参考。     

终末期肝病合并肺动脉高压患者行肝移植术的麻醉处理

目的　观察终末期肝病合并肺动脉高压 (pulmonaryhypertension ,PHP)患者行肝脏移植术时 ,合用前列腺素E1(PGE1)与小剂量硝酸甘油 (NG)对体、肺循环功能的影响。方法　 7例终末期肝病合并PHP行肝脏移植术的患者 ,术中持续给予PGE10 0 2～ 0 0 5 μg·kg 1·min 1与NG 1～ 2 μg·kg 1·min 1,观察记录手术开始前 (术前 ,即用药前 ) ,无肝前期 (给予PGE1后 30min)、无肝期 (阻断肝血流后30min)、新肝期 (开放肝血流后 30min)及术毕患者的平均动脉压 (MAP)、心率 (HR)、中心静脉压(CVP)、平均肺动脉压 (MPAP)、肺动脉楔压 (PCWP)、肺血管阻力指数 (PVRI)、外周血管阻力指数(SVRI)的变化情况。结果　PGE1与小剂量NG合用可明显降低MPAP、PCWP、PVRI、SVRI,而MAP、HR、CVP无显著改变。结论　PGE1与小剂量NG合用可明显降低PHP患者的PAP、PVRI及SVRI,可安全用于合并PHP患者行肝脏移植术时肺动脉压的控制。     

肝移植术后肺部并发症分析

目的 评估原位肝移植患者术前肺功能情况及其在预测肝移植术后肺部并发症(postoperative pulmonary complications,PPC)中的作用.方法 2008年8月至2009年6月天津市第一中心医院完成71例原位肝移植手术,分析患者术前肺功能状况及其与术后肺部并发症的关系.结果 71例患者中肝移植术前肺功能异常者65例,肺弥散功能减低65例(91.5%),限制性通气功能减低30例(42.2%),小气道功能减低28例(39.4%),阻塞性通气功能减低21例(29.6%).移植术后肺部并发症的发生率为56.3%,肺部并发症包括:肺不张,肺炎,急性呼吸衰竭.限制性和阻塞性通气功能减低组肺部并发症的发生率与正常组相比差异有统计学意义(x2=6.703,P=0.010;x2=4.768,P=0.029),中、重度的弥散功能减低组肺部并发症的发生率与轻度和正常组相比差异有统计学意义(x2=8.478,P=0.004).结论 肝移植患者术前肺功能异常是常见的,通气功能减低(VCmax＜80%或FEV1.0＜80%)及中、重度肺弥散功能减低(TLCOSB＜60%)可作为预测术后肺部发生并发症的一个指标.

Abstract：

Objective To probe the correlation between preoperative pulmonary dysfunction and postoperative pulmonary complications in patients of orthotopic liver transplantation. Methods From August 2008 to June 2009, 71 orthotopic liver transplantation patients were studied. Preoperative pulmonary function and its relationship with postoperative pulmonary complications were analyzed.Results Preoperatively 65 out of 71 patients had abnormal lung functions, suffering from pulmonary diffusing capacity reduction (65 cases, 91.5% ), followed by reduction of restrictive ventilation function (30 cases, 42. 2% ), small airway function reduction ( 28 cases, 39.4% ), and obstructive ventilatory function reduction (21 cases, 29. 6% ). The incidence of postoperative pulmonary complications was 56. 3% including: pulmonary atelectasis, pneumonia, acute respiratory failure. The incidence of posttransplantation pulmonary complications in patients with pulmonary restrictive or obstructive ventilation function reduction was higher than in normal group (x2 = 6.703, P= 0.010; x2 = 4.768, P = 0.029), and there was significant difference in pulmonary complication rate between groups of moderate and severe diffusing capacity reduction and mild reduction and normal range (x2 = 8.478, P = 0.004 ).Conclusions Preoperative pulmonary function abnormality in patients before liver transplantation such as pulmonary ventilatory function reduction (VCmax ＜ 80% or FEV1.0 ＜ 80% ) and moderate to severe pulmonary diffusing capacity reduction (TLCOSB ＜ 60% ) predicts higher incidence of postoperative pulmonary complications.     

重型肝炎肝移植的围手术期处理

目的 总结重型肝炎病人肝移植围手术期若干问题的处理经验.方法 对中山大学附属第三医院肝移植中心2004年6月至2006年6月完成的218例重型肝炎肝移植病例资料进行回顾性分析.结果 218例重型肝炎肝移植围手术期成活率92.7%(202/218),其中急性重型肝炎肝移植为90.4%(57/63),慢性重型肝炎肝移植为93.5%(145/155).术后常见的并发症分别为感染(74.7%)、肝移植相关性脑病(65.6%)和.肾功能不全(14.7%).结论 重型肝炎肝移植的围手术期死亡率高.重视围手术期的处理足提高重型肝炎肝移植成功率的关键.     

活体亲属肾移植受体围手术期钾离子浓度及肾功能变化分析

目的：总结接受活体亲属肾移植术的患者围手术期。肾功能及钾离子浓度的变化,讨论其意义。方法：回顾性分析近期进行的活体亲属肾移植术患者围手术期肾功能及钾离子浓度的变化,记录术后尿量变化并进行分析。结果l共有60名活体亲属肾移植患者纳入研究。手术前患者血肌酐为（827．7±199．4）mmol／L,高于正常值,血清钾离子经术前透析为（5．228±0．847）mmol／L,接近正常范围;术后连续监测显示血肌酐和血清钾离子浓度逐渐下降,于术后4小时开始血肌酐和血清钾离子浓度的变化差异有统计学意义（P〈0．01）。结论：活体亲属肾移植术术后早期已经出现肾功能及血电解质明显变化,并逐渐趋于正常值,早期监测肾功能及血电解质浓度,及时处理,围手术期处理十分重要。     

Simultaneous heart and kidney transplantation in patients with end-stage heart and renal failure.

Combined simultaneous organ transplantation has become more common as selection criteria for transplantation have broadened. Broadening selection criteria is secondary to improved immunosuppression and surgical techniques. The kidney is the most common extrathoracic organ to be simultaneously transplanted with the heart. A series of 13 patients suffering from both end-stage heart and renal failure underwent 14 simultaneous heart and kidney transplantations at Temple University Hospital between 1990 and 1999. This is the largest series reported from a single center. Three patients died during the initial hospitalization for an in-hospital mortality of 21%. Of 10 patients who left the hospital, 1-year survival was 100% and 2-year survival 75%. One patient required retransplant for rejection within the first year. Overall mortality at 1 and 2 years was 25 and 41%, respectively. Four out of nine (44%) patients greater than 5 years post-transplant were alive. Of the 10 patients who left the hospital, 66% were alive at 5 years. One patient succumbed to primary nonfunction of the cardiac allograft, while the four other deaths were secondary to bacterial or fungal sepsis. The patient's racial backgrounds were equally divided between African-American and white. These results are similar to those reported in a United Network of Organ Sharing Database (UNOS) registry analysis of 84 simultaneous heart and kidney transplants that found 1- and 2-year survival to be 76 and 67%, respectively. Simultaneous heart and kidney transplantation continues to be a viable option for patients suffering from failure of these two organ systems, although the results do not match those of heart transplant alone.