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Gaspari R, Aceto P, Carelli S, Avolio AW, Bocci MG, Postorino S, Spinazzola G, Caporale M, Giuliante F, Antonelli M. Discrepancy Between Conventional Coagulation Tests and Thromboelastography During the Early Postoperative Phase of Liver Resection in Neoplastic Patients: A Prospective Study Using the New-Generation TEG ®6s. J Clin Med 2025; 14:2866. [PMID: 40363898 PMCID: PMC12072496 DOI: 10.3390/jcm14092866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2025] [Revised: 04/14/2025] [Accepted: 04/16/2025] [Indexed: 05/15/2025] Open
Abstract
Background: Thromboelastography-6s (TEG®6s), a novel device developed to assess coagulation status, presents advantages such as less frequent calibration, ease of use, and greater stability against movements compared to the previous system (TEG5000). This is the first study in the literature to compare coagulation profiles in the early postoperative period of liver resection (LR) using conventional coagulation tests (CCTs) and TEG®6s. Methods: Forty-six adult patients admitted to the ICU post-surgery after elective LR for malignancy were included. CCTs were used to classify patients into hypocoagulable (HCG) (platelet count < 80 × 109/L, international normalized ratio ≥ 1.4, or activated partial thromboplastin time > 38 s) and normocoagulable (all other cases) groups. Mann-Whitney tests, Spearman's correlation, and linear regression were used. Results: On ICU admission, nineteen (41.3%) patients had a hypocoagulable profile based on CCTs, but only two (10.5%) of them were rated as hypocoagulable by TEG (p = 0.165). Intraoperatively, HCG patients experienced higher estimated blood loss (EBL) (p = 0.002); they required more fluids (p = 0.019), and more of them received red blood cell transfusions (p = 0.025). They also had higher postoperative arterial lactate levels (p = 0.036). Postoperative 12 h EBL was similar in the two groups (around 150 mL). The ICU stay was longer for HCG group (p = 0.010). Weak associations were observed between TEG/CCTs measures of coagulation initiation [e.g., between R time citrated rapid TEG, and international normalized ratio (r2 = 0.448; p < 0.001)], clot formation [i.e., between conventional fibrinogen value using Clauss method and α-angle citrated rapid TEG (r2 = 0.542; p < 0.001)], and clot strength [e.g., between conventional fibrinogen and citrated kaolin maximum amplitude (r2 = 0.484; p < 0.001)]. Conclusions: CCTs revealed hypocoagulability that was not confirmed by TEG®6s. However, the thromboelastography coagulation profile was more consistent with the detected non-relevant postoperative bleeding.
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Affiliation(s)
- Rita Gaspari
- Department of Basic Biotechnological Sciences, Intensive Care Peri-Operative Clinics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (R.G.); (M.A.)
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (S.C.); (S.P.); (G.S.)
| | - Paola Aceto
- Department of Basic Biotechnological Sciences, Intensive Care Peri-Operative Clinics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (R.G.); (M.A.)
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (S.C.); (S.P.); (G.S.)
| | - Simone Carelli
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (S.C.); (S.P.); (G.S.)
| | - Alfonso Wolfango Avolio
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy (F.G.)
- General Surgery and Transplantation Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Maria Grazia Bocci
- UOC Resuscitation, Istituto Nazionale per le Malattie Infettive L. Spallanzani IRCCS, 00149 Rome, Italy;
| | - Stefania Postorino
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (S.C.); (S.P.); (G.S.)
| | - Giorgia Spinazzola
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (S.C.); (S.P.); (G.S.)
| | - Mariagiovanna Caporale
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (S.C.); (S.P.); (G.S.)
| | - Felice Giuliante
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, 00168 Rome, Italy (F.G.)
- Hepatobiliary Surgery Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Massimo Antonelli
- Department of Basic Biotechnological Sciences, Intensive Care Peri-Operative Clinics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (R.G.); (M.A.)
- Department of Emergency, Anesthesiological and Reanimation Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (S.C.); (S.P.); (G.S.)
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Solid Organ Transplantation During COVID-19 Pandemic: An International Web-based Survey on Resources' Allocation. Transplant Direct 2021; 7:e669. [PMID: 34113712 PMCID: PMC8184017 DOI: 10.1097/txd.0000000000001115] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/31/2020] [Accepted: 11/07/2020] [Indexed: 02/06/2023] Open
Abstract
Supplemental Digital Content is available in the text. Solid organ transplants (SOTs) are life-saving interventions, recently challenged by coronavirus disease 2019 (COVID-19). SOTs require a multistep process, which can be affected by COVID-19 at several phases.
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Gaspari R, Teofili L, Aceto P, Valentini CG, Punzo G, Sollazzi L, Agnes S, Avolio AW. Thromboelastography does not reduce transfusion requirements in liver transplantation: A propensity score-matched study. J Clin Anesth 2020; 69:110154. [PMID: 33333373 DOI: 10.1016/j.jclinane.2020.110154] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 11/05/2020] [Accepted: 11/21/2020] [Indexed: 01/02/2023]
Abstract
STUDY OBJECTIVE To compare total blood product requirements in liver transplantation (LT) assisted by thromboelastography (TEG) or conventional coagulation tests (CCTs). DESIGN Retrospective observational study. SETTING A tertiary care referral center for LT. PATIENTS Adult patients undergoing LT from deceased donor. INTERVENTION Hemostasis was monitored by TEG or CCTs and corresponding transfusion algorithms were adopted. MEASUREMENTS Number and types of blood products (red blood cells, RBC; fresh-frozen plasma, FFP; platelets, PLT) transfused from the beginning of surgery until the admission to the intensive care unit. METHODS We compared data retrospectively collected in 226 LTs, grouped according to the type of hemostasis monitoring (90 with TEG and 136 with CCTs, respectively). Confounding variables affecting transfusion needs (recipient age, sex, previous hepatocellular carcinoma surgery, Model for End Stage Liver Disease - MELD, baseline hemoglobin, fibrinogen, creatinine, veno-venous by pass, and trans-jugular intrahepatic portosystemic shunt) were managed by propensity score match (PSM). MAIN RESULTS The preliminary analysis showed that patients in the TEG group received fewer total blood products (RBC + FFP + PLT; p = 0.001, FFP (p = 0.001), and RBC (p = 0.001). After PSM, 89 CCT patients were selected and matched to the 90 TEG patients. CCT and TEG matched patients received similar amount of total blood products. In a subgroup of 39 patients in the top MELD quartile (MELD ≥25), the TEG use resulted in lower consumption of FFP units and total blood products. Nevertheless, due to the low number of patients, any meaningful conclusion could be achieved in this subgroup. CONCLUSIONS In our experience, TEG-guided transfusion in LT does not reduce the intraoperative blood product consumption. Further studies are warranted to assess an advantage for TEG in either the entire LT population or the high-MELD subgroup of patients.
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Affiliation(s)
- Rita Gaspari
- Dipartimento di Scienze dell'emergenza, Anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Luciana Teofili
- Dipartimento di Diagnostica per immagini, Radioterapia oncologia ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Paola Aceto
- Dipartimento di Scienze dell'emergenza, Anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
| | - Caterina G Valentini
- Dipartimento di Diagnostica per immagini, Radioterapia oncologia ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Giovanni Punzo
- Dipartimento di Scienze dell'emergenza, Anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Liliana Sollazzi
- Dipartimento di Scienze dell'emergenza, Anestesiologiche e della rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy
| | - Salvatore Agnes
- Università Cattolica del Sacro Cuore, Roma, Italy; Dipartimento di scienze mediche e chirurgiche, Chirurgia Generale e del Trapianto di Fegato, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Alfonso W Avolio
- Università Cattolica del Sacro Cuore, Roma, Italy; Dipartimento di scienze mediche e chirurgiche, Chirurgia Generale e del Trapianto di Fegato, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
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Avolio AW, Franco A, Schlegel A, Lai Q, Meli S, Burra P, Patrono D, Ravaioli M, Bassi D, Ferla F, Pagano D, Violi P, Camagni S, Dondossola D, Montalti R, Alrawashdeh W, Vitale A, Teofili L, Spoletini G, Magistri P, Bongini M, Rossi M, Mazzaferro V, Di Benedetto F, Hammond J, Vivarelli M, Agnes S, Colledan M, Carraro A, Cescon M, De Carlis L, Caccamo L, Gruttadauria S, Muiesan P, Cillo U, Romagnoli R, De Simone P. Development and Validation of a Comprehensive Model to Estimate Early Allograft Failure Among Patients Requiring Early Liver Retransplant. JAMA Surg 2020; 155:e204095. [PMID: 33112390 PMCID: PMC7593884 DOI: 10.1001/jamasurg.2020.4095] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 06/21/2020] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Expansion of donor acceptance criteria for liver transplant increased the risk for early allograft failure (EAF), and although EAF prediction is pivotal to optimize transplant outcomes, there is no consensus on specific EAF indicators or timing to evaluate EAF. Recently, the Liver Graft Assessment Following Transplantation (L-GrAFT) algorithm, based on aspartate transaminase, bilirubin, platelet, and international normalized ratio kinetics, was developed from a single-center database gathered from 2002 to 2015. OBJECTIVE To develop and validate a simplified comprehensive model estimating at day 10 after liver transplant the EAF risk at day 90 (the Early Allograft Failure Simplified Estimation [EASE] score) and, secondarily, to identify early those patients with unsustainable EAF risk who are suitable for retransplant. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study was designed to develop a score capturing a continuum from normal graft function to nonfunction after transplant. Both parenchymal and vascular factors, which provide an indication to list for retransplant, were included among the EAF determinants. The L-GrAFT kinetic approach was adopted and modified with fewer data entries and novel variables. The population included 1609 patients in Italy for the derivation set and 538 patients in the UK for the validation set; all were patients who underwent transplant in 2016 and 2017. MAIN OUTCOMES AND MEASURES Early allograft failure was defined as graft failure (codified by retransplant or death) for any reason within 90 days after transplant. RESULTS At day 90 after transplant, the incidence of EAF was 110 of 1609 patients (6.8%) in the derivation set and 41 of 538 patients (7.6%) in the external validation set. Median (interquartile range) ages were 57 (51-62) years in the derivation data set and 56 (49-62) years in the validation data set. The EASE score was developed through 17 entries derived from 8 variables, including the Model for End-stage Liver Disease score, blood transfusion, early thrombosis of hepatic vessels, and kinetic parameters of transaminases, platelet count, and bilirubin. Donor parameters (age, donation after cardiac death, and machine perfusion) were not associated with EAF risk. Results were adjusted for transplant center volume. In receiver operating characteristic curve analyses, the EASE score outperformed L-GrAFT, Model for Early Allograft Function, Early Allograft Dysfunction, Eurotransplant Donor Risk Index, donor age × Model for End-stage Liver Disease, and Donor Risk Index scores, estimating day 90 EAF in 87% (95% CI, 83%-91%) of cases in both the derivation data set and the internal validation data set. Patients could be stratified in 5 classes, with those in the highest class exhibiting unsustainable EAF risk. CONCLUSIONS AND RELEVANCE This study found that the developed EASE score reliably estimated EAF risk. Knowledge of contributing factors may help clinicians to mitigate risk factors and guide them through the challenging clinical decision to allocate patients to early liver retransplant. The EASE score may be used in translational research across transplant centers.
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Affiliation(s)
- Alfonso W. Avolio
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Franco
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | | | | | | | | | | | | | | | | | - Duilio Pagano
- ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | | | | | - Daniele Dondossola
- Fondazione IRCCS Ospedale Maggiore Policlinico, Università degli Studi, Milan, Italy
| | | | | | | | - Luciana Teofili
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gabriele Spoletini
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
- Newcastle Upon Tyne Hospital, Newcastle Upon Tyne, United Kingdom
| | | | - Marco Bongini
- Istituto Nazionale Tumori, IRCCS, and Università degli Studi, Milan, Italy
| | | | | | | | - John Hammond
- Newcastle Upon Tyne Hospital, Newcastle Upon Tyne, United Kingdom
| | | | - Salvatore Agnes
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | | | | | - Matteo Cescon
- S. Orsola-Malpighi University Hospital, Bologna, Italy
| | | | - Lucio Caccamo
- Fondazione IRCCS Ospedale Maggiore Policlinico, Università degli Studi, Milan, Italy
| | - Salvatore Gruttadauria
- ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | - Paolo Muiesan
- Queen Elizabeth Hospital, Birmingham, United Kingdom
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Diagnosis of Acute Rejection of Liver Grafts in Young Children Using Acoustic Radiation Force Impulse Imaging. AJR Am J Roentgenol 2020; 215:1229-1237. [PMID: 32877250 DOI: 10.2214/ajr.19.22057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE. Frequency of acute rejection (AR) after pediatric liver transplant remains high despite progress in immunosuppression. Liver biopsy (LB) is the reference standard for the diagnosis of AR despite its potential for morbidity. The purpose of our study was to evaluate the ability of acoustic radiation force impulse (ARFI) imaging to distinguish AR from other causes of short- and medium-term liver dysfunction and to identify liver transplant cases with normal liver function. MATERIALS AND METHODS. ARFI imaging was used to evaluate shear wave velocity (SWV) after liver transplant in young children. All pediatric liver grafts that had LB and ARFI examination between January 2014 and December 2017 were included in this retrospective study. Results of LB were compared with those of SWV. Collected data included age at biopsy and transplant, sex, weight, height, body mass index, interval between liver transplant and shear wave elastography and LB, kind of graft, type of donor, and diagnosis at transplant. ROC curve analysis was performed to assess the diagnostic performance of SWV. Optimal cutoff of SWV using ARFI imaging in predicting AR was identified using the Youden index. RESULTS. Statistical analysis was performed on 54 children; six of the original 60 were excluded because of confounding alterations or changes in outcome. Median SWV was higher in patients with AR (2.03 m/s; interquartile range [IQR], 1.80-2.45 m/s) compared with those with idiopathic hepatitis (1.33 m/s; IQR, 1.12-1.53 m/s), portal hypertension (1.42 m/s; IQR, 1.32-1.72 m/s), cholangitis (1.56 m/s; IQR, 1.07-1.62 m/s) or normal liver function (1.23 m/s; IQR 1.12-1.29 m/s) at protocol biopsies (all comparisons, p < 0.01). SWV higher than 1.73 m/s was predictive for AR (AUC, 0.966). SWV also showed good diagnostic accuracy in normal liver function (AUC, 0.791). ARFI imaging was not predictive for hepatitis (AUC, 0.402), portal hypertension (AUC, 0.556), or cholangitis (AUC, 0.420). CONCLUSION. ARFI imaging could be routinely used in place of LB in pediatric patients with liver dysfunction after liver transplant, restricting indication and risks of biopsy to selected cases.
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Martínez JA, Pacheco S, Bachler JP, Jarufe N, Briceño E, Guerra JF, Benítez C, Wolff R, Barrera F, Arrese M. Accuracy of the BAR score in the prediction of survival after liver transplantation. Ann Hepatol 2020; 18:386-392. [PMID: 31036493 DOI: 10.1016/j.aohep.2019.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/21/2018] [Accepted: 01/23/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM The Balance of Risk (BAR) Score, a simple scoring system that combines six independent donor and recipient variables to predict outcome after liver transplantation (LT), was validated in a large U.S./European cohort of patients. This study aims to assess the performance of the BAR score to predict survival after liver transplantation and determine the factors associated with short and long-term survival in Latin-American patients. MATERIAL AND METHODS A retrospective cohort study was performed in 194 patients [112 (55.4%) males; mean age 52±14 years] who underwent 202 LT during the period 2003-2015. Demographic, clinical, pathological and surgical variables, as well as mortality and survival rates, were analyzed. The BAR score was investigated through a receiver operating characteristics (ROC) curve with the calculation of the area under the curve (AUC) to evaluate the predictive score power for 3-month, 1 and 5-year mortality in a matched donor-recipient cohort. Youden index was calculated to identify optimal cutoff points. RESULTS The AUC of BAR score in predicting 3-month, 1-year and 5-year mortality were 0.755 (CI95% 0.689-0.812), 0.702 (CI95% 0.634-0.764) and 0.610 (CI95% 0.539-0.678) respectively. The best cut-off point was a BAR score ≥15 points. In the multivariate analysis BAR score <15 was associated with higher survival rates at 3 months and 1 and 5-years. CONCLUSIONS BAR score <15 points is an independent predictor of better short and long-term survival in Latin-American patients undergoing LT. The BAR scoring system has an adequate diagnostic capacity allowing to predict 3 and 12-month mortality.
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Affiliation(s)
- Jorge A Martínez
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile.
| | - Sergio Pacheco
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Jean P Bachler
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Nicolás Jarufe
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Eduardo Briceño
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Juan F Guerra
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Carlos Benítez
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Rodrigo Wolff
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Francisco Barrera
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
| | - Marco Arrese
- Department of Digestive Surgery & Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Región Metropolitana, Chile
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Gaspari R, Teofili L, Mignani V, Franco A, Valentini CG, Cutuli SL, Cina A, Agnes S, Avolio AW, Antonelli M. Duplex Doppler evidence of high hepatic artery resistive index after liver transplantation: Role of portal hypertension and clinical impact. Dig Liver Dis 2020; 52:301-307. [PMID: 31806469 DOI: 10.1016/j.dld.2019.10.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 10/01/2019] [Accepted: 10/24/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Early increase of hepatic artery resistive index (HARI) is frequently observed after liver transplant (LTx). AIM We aimed to investigate contributing factors and prognostic relevance of high HARI after LTx from deceased donor. METHODS We conducted a retrospective analysis of prospectively collected data from January 2017 and February 2019. According to the Duplex Doppler HARI values (3d post-operative day), patients were grouped in normal (0.55-0.80) and high (>0.80-1) HARI groups. RESULTS Among 81 LTx, 36 had a high HARI and 45 a normal HARI. Patients developing high HARI were older, exhibited lower platelet, hemoglobin, platelet count/spleen diameter ratio, higher serum creatinine, and a more pronounced spleen enlargement (median values 170 versus 120 mm). At multivariate analysis, PLT/spleen diameter ratio (OR 0.994, p < 0.001) creatinine levels (OR 2.418, p = 0.029), and recipient age (OR 1.157, p = 0.004) significantly predicted the occurrence of high HARI. Patients with high or normal HARI had similar vascular complications, rejection rate and 90-day mortality. In most cases, HARI recovered to normal without any clinical effect. CONCLUSIONS HARI rises in presence of several surrogate markers of portal hypertension. The increase is mostly transitory, and it may result from the hepatic artery spasm due to the high portal blood flow.
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Affiliation(s)
- Rita Gaspari
- Dipartimento di Scienze dell'emergenza, anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luciana Teofili
- Dipartimento di Diagnostica per immagini, radioterapia, oncologia ed ematologia, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vittorio Mignani
- Dipartimento di Scienze dell'emergenza, anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Franco
- Dipartimento di Scienze gastroenterologiche, endocrino-metaboliche e nefro-urologiche, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy
| | - Caterina G Valentini
- Dipartimento di Diagnostica per immagini, radioterapia, oncologia ed ematologia, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy
| | - Salvatore L Cutuli
- Dipartimento di Scienze dell'emergenza, anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy
| | - Alessandro Cina
- Dipartimento di Diagnostica per immagini, radioterapia, oncologia ed ematologia, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy
| | - Salvatore Agnes
- Dipartimento di Scienze gastroenterologiche, endocrino-metaboliche e nefro-urologiche, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alfonso W Avolio
- Dipartimento di Scienze gastroenterologiche, endocrino-metaboliche e nefro-urologiche, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Massimo Antonelli
- Dipartimento di Scienze dell'emergenza, anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A, Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
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Predictive Capacity of Risk Models in Liver Transplantation. Transplant Direct 2019; 5:e457. [PMID: 31321293 PMCID: PMC6553625 DOI: 10.1097/txd.0000000000000896] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 03/16/2019] [Accepted: 03/19/2019] [Indexed: 02/07/2023] Open
Abstract
Supplemental Digital Content is available in the text. Several risk models to predict outcome after liver transplantation (LT) have been developed in the last decade. This study compares the predictive performance of 7 risk models.
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Avolio AW, Gaspari R, Teofili L, Bianco G, Spinazzola G, Soave PM, Paiano G, Francesconi AG, Arcangeli A, Nicolotti N, Antonelli M. Postoperative respiratory failure in liver transplantation: Risk factors and effect on prognosis. PLoS One 2019; 14:e0211678. [PMID: 30742650 PMCID: PMC6370207 DOI: 10.1371/journal.pone.0211678] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 01/20/2019] [Indexed: 01/01/2023] Open
Abstract
Background Postoperative respiratory failure (PRF, namely mechanical ventilation >48 hours) significantly affects morbidity and mortality in liver transplantation (LTx). Previous studies analyzed only one or two categories of PRF risk factors (preoperative, intraoperative or postoperative ones). The aims of this study were to identify PRF predictors, to assess the length of stay (LoS) in ICU and the 90-day survival according to the PRF in LTx patients. Methods Two classification approaches were used: systematic classification (recipient-related preoperative factors; intraoperative factors; logistic factors; donor factors; postoperative ICU factors; postoperative surgical factors) and patient/organ classification (patient-related general factors; native-liver factors; new-liver factors; kidney factors; heart factors; brain factors; lung factors). Two hundred adult non-acute patients were included. Missing analysis was performed. The competitive role of each factor was assessed. Results PRF occurred in 36.0% of cases. Among 28 significant PRF predictors at univariate analysis, 6 were excluded because of collinearity, 22 were investigated by ROC curves and by logistic regression analysis. Recipient age (OR = 1.05; p = 0.010), female sex (OR = 2.75; p = 0.018), Model for End-Stage Liver Disease (MELD, OR = 1.09; p<0.001), restrictive lung pattern (OR = 2.49; p = 0.027), intraoperative veno-venous bypass (VVBP, OR = 3.03; p = 0.008), pre-extubation PaCO2 (OR = 1.11; p = 0.003) and Model for Early Allograft Function (MEAF, OR = 1.37; p<0.001) resulted independent PRF risk factors. As compared to patients without PRF, the PRF-group had longer LoS (10 days IQR 7–18 versus 5 days IQR 4–7, respectively; p<0.001) and lower day-90 survival (86.0% versus 97.6% respectively, p<0.001). Conclusion In conclusion, MELD, restrictive lung pattern, surgical complexity as captured by VVBP, pre-extubation PaCO2 and MEAF are the main predictors of PRF in non-acute LTx patients.
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Affiliation(s)
- Alfonso Wolfango Avolio
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Department of Surgery -Transplantation Service, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
- * E-mail:
| | - Rita Gaspari
- Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Department of Anaesthesiology and Intensive Care Medicine, Rome, Italy
| | - Luciana Teofili
- Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Institute of Hematology, Rome, Italy
| | - Giuseppe Bianco
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Department of Surgery -Transplantation Service, Rome, Italy
| | - Giorgia Spinazzola
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Department of Anaesthesiology and Intensive Care Medicine, Rome, Italy
| | - Paolo Maurizio Soave
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Department of Anaesthesiology and Intensive Care Medicine, Rome, Italy
| | - Gianfranco Paiano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Department of Anaesthesiology and Intensive Care Medicine, Rome, Italy
| | - Alessandra Gioia Francesconi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Department of Anaesthesiology and Intensive Care Medicine, Rome, Italy
| | - Andrea Arcangeli
- Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Department of Anaesthesiology and Intensive Care Medicine, Rome, Italy
| | - Nicola Nicolotti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Institute of Hygiene and Epidemiology, Rome, Italy
| | - Massimo Antonelli
- Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Department of Anaesthesiology and Intensive Care Medicine, Rome, Italy
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Laing RW, Mergental H, Yap C, Kirkham A, Whilku M, Barton D, Curbishley S, Boteon YL, Neil DA, Hübscher SG, Perera MTPR, Muiesan P, Isaac J, Roberts KJ, Cilliers H, Afford SC, Mirza DF. Viability testing and transplantation of marginal livers (VITTAL) using normothermic machine perfusion: study protocol for an open-label, non-randomised, prospective, single-arm trial. BMJ Open 2017; 7:e017733. [PMID: 29183928 PMCID: PMC5719273 DOI: 10.1136/bmjopen-2017-017733] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 06/26/2017] [Accepted: 07/27/2017] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION The use of marginal or extended criteria donor livers is increasing. These organs carry a greater risk of initial dysfunction and early failure, as well as inferior long-term outcomes. As such, many are rejected due to a perceived risk of use and use varies widely between centres. Ex situ normothermic machine perfusion of the liver (NMP-L) may enable the safe transplantation of organs that meet defined objective criteria denoting their high-risk status and are currently being declined for use by all the UK transplant centres. METHODS AND ANALYSIS Viability testing and transplantation of marginal livers is an open-label, non-randomised, prospective, single-arm trial designed to determine whether currently unused donor livers can be salvaged and safely transplanted with equivalent outcomes in terms of patient survival. The procured rejected livers must meet predefined criteria that objectively denote their marginal condition. The liver is subjected to NMP-L following a period of static cold storage. Organs metabolising lactate to ≤2.5 mmol/L within 4 hours of the perfusion commencing in combination with two or more of the following parameters-bile production, metabolism of glucose, a hepatic arterial flow rate ≥150 mL/min and a portal venous flow rate ≥500 mL/min, a pH ≥7.30 and/or maintain a homogeneous perfusion-will be considered viable and transplanted into a suitable consented recipient. The coprimary outcome measures are the success rate of NMP-L to produce a transplantable organ and 90-day patient post-transplant survival. ETHICS AND DISSEMINATION The protocol was approved by the National Research Ethics Service (London-Dulwich Research Ethics Committee, 16/LO/1056), the Medicines and Healthcare Products Regulatory Agency and is endorsed by the National Health Service Blood and Transplant Research, Innovation and Novel Technologies Advisory Group. The findings of this trial will be disseminated through national and international presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT02740608; Pre-results.
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Affiliation(s)
- Richard W Laing
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Hynek Mergental
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Christina Yap
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Amanda Kirkham
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Manpreet Whilku
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Darren Barton
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Stuart Curbishley
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Yuri L Boteon
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Desley A Neil
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stefan G Hübscher
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - M Thamara P R Perera
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Paolo Muiesan
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - John Isaac
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Keith J Roberts
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Hentie Cilliers
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon C Afford
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Darius F Mirza
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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11
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Schrem H, Focken M, Gunson B, Reichert B, Mirza D, Kreipe HH, Neil D, Kaltenborn A, Goldis A, Krauth C, Roberts K, Becker T, Klempnauer J, Neuberger J. The new liver allocation score for transplantation is validated and improved transplant survival benefit in Germany but not in the United Kingdom. Liver Transpl 2016; 22:743-756. [PMID: 26947766 DOI: 10.1002/lt.24421] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Revised: 12/27/2015] [Accepted: 01/11/2016] [Indexed: 12/13/2022]
Abstract
Prognostic models for the prediction of 90-day mortality after transplantation with pretransplant donor and recipient variables are needed to calculate transplant benefit. Transplants in adult recipients in Germany (Hannover, n = 770; Kiel, n = 234) and the United Kingdom (Birmingham, n = 829) were used for prognostic model design and validation in separate training and validation cohorts. The survival benefit of transplantation was estimated by subtracting the observed posttransplant 90-day mortality from the expected 90-day mortality without transplantation determined by the Model for End-Stage Liver Disease (MELD) score. A prognostic model called the liver allocation score (LivAS) was derived using a randomized sample from Hannover using pretransplant donor and recipient variables. This model could be validated in the German training and validation cohorts (area under the receiver operating characteristic curve [AUROC] > 0.70) but not in the English cohort (AUROC, 0.58). Although 90-day mortality rates after transplantation were 13.7% in Hannover, 12.1% in Kiel, and 8.3% in Birmingham, the calculated 90-day survival benefits of transplantation were 6.8% in Hannover, 7.8% in Kiel, and 2.8% in Birmingham. Deployment of the LivAS for limiting allocation to donor and recipient combinations with likely 90-day survival as indicated by pretransplant LivAS values below the cutoff value would have increased the survival benefit to 12.9% in the German cohorts, whereas this would have decreased the benefit in England to 1.3%. The English and German cohorts revealed significant differences in 21 of 28 pretransplant variables. In conclusion, the LivAS could be validated in Germany and may improve German allocation policies leading to greater survival benefits, whereas validation failed in England due to profound differences in the selection criteria for liver transplantation. This study suggests the need for national prognostic models. Even though the German centers had higher rates of 90-day mortality, estimated survival benefits were greater. Liver Transplantation 22 743-756 2016 AASLD.
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Affiliation(s)
- Harald Schrem
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation
- General, Visceral, and Transplant Surgery
| | - Moritz Focken
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation
| | - Bridget Gunson
- The Liver Unit and, Birmingham, United Kingdom
- Liver Biomedical Research Unit, National Institute for Health Research, University of Birmingham, United Kingdom
| | - Benedikt Reichert
- General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital Schleswig Holstein, Kiel, Germany
| | | | | | - Desley Neil
- Pathology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Alexander Kaltenborn
- Core Facility Quality Management and Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation
- Trauma and Orthopedic Surgery, Federal Armed Forces Hospital, Westerstede, Germany
| | - Alon Goldis
- Lean Six Sigma Black Belt, Amstelveen, Netherlands
| | - Christian Krauth
- Health Economics and Health Systems Research, Institute of Epidemiology, Social Medicine and Health Systems Research, Institute of Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Germany
| | | | - Thomas Becker
- General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital Schleswig Holstein, Kiel, Germany
| | | | - James Neuberger
- The Liver Unit and, Birmingham, United Kingdom
- Blood and Transplant, Organ Donation and Transplant, National Health Service, Bristol, United Kingdom
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12
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Lan T, Chang L, Mn R, Wu L, Yuan YF. Comparative Efficacy of Interventional Therapies for Early-stage Hepatocellular Carcinoma: A PRISMA-compliant Systematic Review and Network Meta-analysis. Medicine (Baltimore) 2016; 95:e3185. [PMID: 27082558 PMCID: PMC4839802 DOI: 10.1097/md.0000000000003185] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
There are several interventional therapies that improve the prognosis and increase the survival rate of early-stage hepatocellular carcinoma (early-stage HCC), but it is uncertain about whether one is superior to others, and available researches investigating the comparative effects of different treatments are limited. The main objective of this Bayesian network meta-analysis was to compare the efficacy of these different treatment strategies for early-stage HCC and rank these interventions for practical consideration. We performed an electronic search of PubMed, Embase, and Cochrane Library, and extracted data from randomized controlled trials that compared different interventional therapies for early-stage HCC. Direct comparison and network meta-analyses were conducted with Aggregate Data Drug Information System software. Consistency models were created to determine whether there was a significant difference between any 2 therapies, and cumulative probability was used to rank different treatments. Twenty-one randomized controlled trials involving 2691 patients were included. In our network meta-analysis, the combination therapy of transcatheter arterial chemoembolization (TACE) and radiofrequency ablation (RFA) was associated with better 1-year survival rate, as compared with hepatic resection alone (P < 0.05, odds ratio [OR] 0.25, 95% confidence interval [CI] 0.06-0.83), percutaneous ethanol injection (PEI) alone (P < 0.05, OR 0.13, 95% CI 0.03-0.45), and RFA alone (P < 0.05, OR 0.23, 95% CI 0.07-0.70). TACE + RFA had a higher 3-year survival rate than PEI alone (P < 0.05, OR 0.32, 95% CI 0.15-0.72) and RFA alone (P < 0.05, OR 0.45, 95% CI 0.24-0.87). And there was a statistical difference between RFA + PEI and PEI alone (P < 0.05, OR 0.33, 95% CI 0.12-0.93) for 3-year survival rate. The results of rank test and cumulative probability showed that TACE + RFA ranked highest on the evaluation of 1-year, 3-year, and 5-year survival rate. Based on Bayesian network meta-analysis combining direct and indirect comparisons, the combination therapy of TACE and RFA seemed to be the most effective strategy for early-stage HCC.
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Affiliation(s)
- Tian Lan
- From the Department of Hepatobiliary Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
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13
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Brandl A, Stolzlechner P, Eschertzhuber S, Aigner F, Weiss S, Vogel W, Krannich A, Neururer S, Pratschke J, Graziadei I, Öllinger R. Inferior graft survival of hepatitis B core positive grafts is not influenced by post-transplant hepatitis B infection in liver recipients--5-year single-center experience. Transpl Int 2016; 29:471-82. [PMID: 26716608 DOI: 10.1111/tri.12741] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 02/11/2015] [Accepted: 12/23/2015] [Indexed: 12/21/2022]
Abstract
Nonoptimal liver grafts, and among them organs from anti-HBc+ donors, are increasingly used for liver transplantation. In this retrospective study including 1065 adult liver transplantations performed between 1977 and 2012, we analyzed long-term patient and graft survival and occurrence of HBV infection. A total of 52 (5.1%) patients received an anti-HBc+ graft. The 10-year graft and patient survival of these recipients were 50.9% and 59.0% compared to 72.0% and 76.5% (P = 0.001; P = 0.004) of patients receiving anti-HBc- grafts, respectively. Cox regression model showed that high urgency allocation (P = 0.003), recipient age (P = 0.027), anti-HCV+ recipients (P = 0.005), and anti-HBc+ organs (P = 0.048) are associated with decreased graft survival. Thirteen of 52 (25.0%) patients receiving anti-HBc+ grafts developed post-transplant HBV infection within a mean of 2.8 years. In this study, antiviral prophylaxis did not have significant impact on HBV infection, but long-term survival (P = 0.008). Development of post-transplant HBV infection did not affect adjusted 10-year graft survival (100% vs. 100%; P = 1). Anti-HBc+ liver grafts can be transplanted with reasonable but inferior long-term patient and graft survival. The inferior graft survival is not, however, related with post-transplant HBV infection as long as early diagnosis and treatment take place.
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Affiliation(s)
- Andreas Brandl
- Department of Visceral-, Transplant-, and Thoracic Surgery, Medical University, Innsbruck, Austria.,Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany
| | - Philipp Stolzlechner
- Department of Visceral-, Transplant-, and Thoracic Surgery, Medical University, Innsbruck, Austria
| | - Stephan Eschertzhuber
- Department of Anaesthesia and Intensive Care Medicine, Medical University, Innsbruck, Austria
| | - Felix Aigner
- Department of Visceral-, Transplant-, and Thoracic Surgery, Medical University, Innsbruck, Austria.,Department of Anaesthesia and Intensive Care Medicine, Medical University, Innsbruck, Austria
| | - Sascha Weiss
- Department of Visceral-, Transplant-, and Thoracic Surgery, Medical University, Innsbruck, Austria.,Department of General, Visceral, Vascular and Thoracic Surgery, Charité Campus Mitte, Berlin, Germany
| | - Wolfgang Vogel
- Department of Internal Medicine II, Gastroenterology & Hepatology, Medical University, Innsbruck, Austria
| | - Alexander Krannich
- Department of Biostatistics, Coordination Center for Clinical Trials, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Sabrina Neururer
- Department of Medical Statistics, Medical University, Innsbruck, Austria
| | - Johann Pratschke
- Department of Visceral-, Transplant-, and Thoracic Surgery, Medical University, Innsbruck, Austria.,Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany
| | - Ivo Graziadei
- Department of Internal Medicine II, Gastroenterology & Hepatology, Medical University, Innsbruck, Austria.,Department of Internal Medicine, District Hospital Hall, Innsbruck, Austria
| | - Robert Öllinger
- Department of Visceral-, Transplant-, and Thoracic Surgery, Medical University, Innsbruck, Austria.,Department of General, Visceral and Transplant Surgery, Charité Campus Virchow-Klinikum, Berlin, Germany
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14
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Lai Q, Lerut J. Proposal for an algorithm for liver transplantation in Caroli's disease and syndrome: putting an uncommon effort into a common task. Clin Transplant 2016; 30:3-9. [PMID: 26385435 DOI: 10.1111/ctr.12640] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2015] [Indexed: 12/12/2022]
Abstract
Liver transplantation (LT) represents an uncommon indication for Caroli's disease (CD) or syndrome (CS). Excellent results of LT have been reported as shown by recent multicentric European and American registry reports. Clear therapeutic flowcharts to adopt in these diseases are still lacking. This review aims at analyzing highlighting recent transplant experiences in this field and also at focusing on the role of LT in case-specific comorbidities such as development of cholangiocellular cancer or renal failure are present.
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Affiliation(s)
- Quirino Lai
- Starzl Unit Abdominal Transplantation, University Hospitals Saint Luc, Université catholique Louvain, UCL, Brussels, Belgium
- Transplant Unit, Department of Surgery, University of L'Aquila, San Salvatore Hospital, L'Aquila, Italy
| | - Jan Lerut
- Starzl Unit Abdominal Transplantation, University Hospitals Saint Luc, Université catholique Louvain, UCL, Brussels, Belgium
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15
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16
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Dutkowski P, Linecker M, DeOliveira ML, Müllhaupt B, Clavien PA. Challenges to liver transplantation and strategies to improve outcomes. Gastroenterology 2015; 148:307-23. [PMID: 25224524 DOI: 10.1053/j.gastro.2014.08.045] [Citation(s) in RCA: 191] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 08/29/2014] [Accepted: 08/29/2014] [Indexed: 02/07/2023]
Abstract
Liver transplantation (LT) is a highly successful treatment for many patients with nonmalignant and malignant liver diseases. However, there is a worldwide shortage of available organs; many patients deteriorate or die while on waiting lists. We review the important clinical challenges to LT and the best use of the scarce organs. We focus on changes in indications for LT and discuss scoring systems to best match donors with recipients and optimize outcomes, particularly for the sickest patients. We also cover controversial guidelines for the use of LT in patients with hepatocellular carcinoma and cholangiocarcinoma. Strategies to increase the number of functional donor organs involve techniques to perfuse the organs before implantation. Partial LT (living donor and split liver transplantation) techniques might help to overcome organ shortages, and we discuss small-for-size syndrome. Many new developments could increase the success of this procedure, which is already one of the major achievements in medicine during the second part of the 20th century.
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Affiliation(s)
- Philipp Dutkowski
- Swiss HPB and Transplantation Center, Departments of Surgery and Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Michael Linecker
- Swiss HPB and Transplantation Center, Departments of Surgery and Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Michelle L DeOliveira
- Swiss HPB and Transplantation Center, Departments of Surgery and Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Beat Müllhaupt
- Swiss HPB and Transplantation Center, Departments of Surgery and Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Swiss HPB and Transplantation Center, Departments of Surgery and Medicine, University Hospital Zurich, Zurich, Switzerland.
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18
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Halldorson JB, Jr RLC, Bhattacharya R, Bakthavatsalam R, Liou IW, Dick AA, Reyes JD, Perkins JD. D-MELD risk capping improves post-transplant and overall mortality under markov microsimulation. World J Transplant 2014; 4:206-215. [PMID: 25346894 PMCID: PMC4208084 DOI: 10.5500/wjt.v4.i3.206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 07/08/2014] [Accepted: 07/18/2014] [Indexed: 02/05/2023] Open
Abstract
AIM: To hypothesize that the product of calculated Model for End-Stage Liver Disease score excluding exception points and donor age (D-MELD) risk capping ± Rule 14 could improve post liver transplant and overall survival after listing.
METHODS: Probabilities derived from the United Network for Organ Sharing database between 2002 and 2004 were used to simulate potential outcomes for all patients listed for transplantation. The Markov simulation was then modified by screening matches using a 1200 or 1600 D-MELD risk cap ± allowing transplants for Model for End-Stage Liver Disease (MELD) ≤ 14 (Rule 14). The differential impact of the rule changes was assessed.
RESULTS: The Markov simulation accurately reproduced overall and post transplant survival. A 1200 D-MELD risk cap improved post-transplant survival. Both the 1200 and 1600 risk caps improved overall survival for waitlisted patients. The addition of Rule 14 further improved post transplant and overall survival by redistribution of donor livers to recipients in higher MELD subgroups. The mechanism for improved overall and post-transplant survival after listing was due to shifting a larger percentage of transplants to the moderate MELD score subgroup (MELD 15-29) while also ensuring that high MELD recipients have livers of high quality to achieve excellent post transplant survival.
CONCLUSION: A 1200 D-MELD risk cap + Rule 14 provided the greatest overall benefit primarily by focusing liver transplantation towards the moderate MELD recipient.
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Schrem H, Platsakis AL, Kaltenborn A, Koch A, Metz C, Barthold M, Krauth C, Amelung V, Braun F, Becker T, Klempnauer J, Reichert B. Value and limitations of the BAR-score for donor allocation in liver transplantation. Langenbecks Arch Surg 2014; 399:1011-9. [PMID: 25218679 DOI: 10.1007/s00423-014-1247-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 09/08/2014] [Indexed: 12/16/2022]
Abstract
PURPOSE The MELD-score was shown to be able to predict 90-day mortality in most patients with end-stage liver disease prior to liver transplantation and is used as a widely accepted measure for transplantation urgency. Prognostic ability of the BAR-score to predict 90-day post-transplant mortality by detection of unfavourable pretransplant combinations of donor and recipient factors may help to better balance urgency versus utility. METHODS Two German cohorts (Hannover, n=453; Kiel, n=234) were retrospectively analyzed using ROC-curve analysis, goodness-of-model-fit tests, summary measures and risk-adjusted multivariate binary regression. Included were all consecutive liver transplants performed in adult recipients (minimum age 18 years). Excluded were all combined transplants and living-related organ donor transplants. RESULTS Risk-adjusted multivariate regression revealed that the BAR-score is an independent risk factor for 90-day mortality after transplantation in both cohorts from Hannover and Kiel combined (p<0.001, OR=1.017, 95% CI:1.031-1.113). The area under the ROC-curve (AUROC) for the prediction of 90-day mortality using the BAR-score was 0.662 (95% CI 0.624-0.699, power>95%). Measures for association between observed 90-day mortality and the predicted probabilities in the combined cohort were concordant in 63.5% with low summary measures (Somers' D test 0.32, Goodman-Kruskal Gamma test 0.34 and Kendall's Tau a test 0.07). CONCLUSIONS The BAR-score performed below accepted thresholds for potentially useful clinical prognostic models. Prognostic models with better predictive ability with AUROCs>0.700, concordance>70% and larger summary measures are required for the prediction of 90-day post-transplant mortality to enable donor organ allocation with reliable weighing of urgency versus utility.
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Affiliation(s)
- Harald Schrem
- General, Visceral and Transplantation Surgery, Hanover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany,
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Wu FL, Shi KQ, Chen YP, Braddock M, Zou H, Zheng MH. Scoring systems predict the prognosis of acute-on-chronic hepatitis B liver failure: an evidence-based review. Expert Rev Gastroenterol Hepatol 2014; 8:623-632. [PMID: 24762209 DOI: 10.1586/17474124.2014.906899] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute-on-chronic hepatitis B liver failure is a devastating condition that is associated with mortality rates of over 50% and is consequent to acute exacerbation of chronic hepatitis B in patients with previously diagnosed or undiagnosed chronic liver disease. Liver transplantation is the definitive treatment to lower mortality rate, but there is a great imbalance between donation and potential recipients. An early and accurate prognostic system based on the integration of laboratory indicators, clinical events and some mathematic logistic equations is needed to optimize treatment for patients. As parts of the scoring systems, the MELD was the most common and the donor-MELD was the most innovative for patients on the waiting list for liver transplantation. This review aims to highlight the various features and prognostic capabilities of these scoring systems.
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Affiliation(s)
- Fa-Ling Wu
- Department of Infection and Liver Diseases, Liver Research Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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21
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Ponziani FR, Zocco MA, Senzolo M, Pompili M, Gasbarrini A, Avolio AW. Portal vein thrombosis and liver transplantation: implications for waiting list period, surgical approach, early and late follow-up. Transplant Rev (Orlando) 2014; 28:92-101. [PMID: 24582320 DOI: 10.1016/j.trre.2014.01.003] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 09/19/2013] [Accepted: 01/19/2014] [Indexed: 02/07/2023]
Abstract
Portal vein thrombosis (PVT) is a well-known and relatively common complication of liver cirrhosis. In the past, PVT was considered as a contraindication for liver transplantation (LT). To characterize prevalence, risk factors, perioperative management and outcome of PVT in the setting of LT, the English literature published between 1991 and 2011 was reviewed. Of 6807 articles, 280 were selected, and 39 experiences were analyzed in detail (methodology, type and duration of treatments, peri-operative management, strategy to avoid recurrence, strengths and weaknesses, Oxford evidence level, citations). 3/39 studies were prospective; 9/39 were based on prospectively recorded databases; no studies of 1, 2a, 3a level of evidence were present; 5/39 were recognized as level 2b, 23/39 as level 3b, and 8/39 as level 4. High complication rate has been reported with consequent effect on graft and patient survival. Overall, PVT presents today good results similar to those obtained in patients without PVT undergoing LT even if they require a higher transfusion number and a longer ICU/hospital stay. Reported cases were retrospectively stratified according to Yerdel classification. Grade 1-2 patients (76%) do well with eversion thromboendovenectomy, resection of damaged vein and porto-portal anastomosis. Results of patients with grade 3-4 (24%) are inferior, however data on outcome in this subsets are fragmented and do not allow a reliable analysis. Moreover, results obtained in grade 3-4 cases are better in transplant centers with large specific experience. The small number of reports suggests caution. The role of anticoagulant treatment is still debated. Although in cirrhotics with PVT LT remains a demanding procedure, PVT should not be considered a contraindication anymore.
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Affiliation(s)
- Francesca Romana Ponziani
- Department of Internal Medicine and Gastroenterology, Catholic University, Agostino Gemelli Hospital, Rome, Italy.
| | - Maria Assunta Zocco
- Department of Internal Medicine and Gastroenterology, Catholic University, Agostino Gemelli Hospital, Rome, Italy
| | - Marco Senzolo
- Department of surgical, Oncological, and Gastroenterological Sciences University hospital of Padua, Padua, Italy
| | - Maurizio Pompili
- Department of Internal Medicine, Catholic University, Agostino Gemelli Hospital, Rome, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine and Gastroenterology, Catholic University, Agostino Gemelli Hospital, Rome, Italy
| | - Alfonso Wolfango Avolio
- Department of Surgical Sciences, Division of General Surgery and Organs Transplantation, Catholic University, Agostino Gemelli Hospital, Rome, Italy
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Hibi T, Nishida S, Sageshima J, Levi DM, Ruiz P, Roth D, Martin P, Okabayashi K, Burke GW, Ciancio G, Tzakis AG. Excessive immunosuppression as a potential cause of poor survival in simultaneous liver/kidney transplantation for hepatitis C. Transpl Int 2014; 27:606-16. [PMID: 24606223 DOI: 10.1111/tri.12303] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 08/26/2013] [Accepted: 03/03/2014] [Indexed: 02/06/2023]
Abstract
Appropriate recipient selection of simultaneous liver/kidney transplantation (SLKT) remains controversial. In particular, data on liver graft survival in hepatitis C virus-infected (HCV+) SLKT recipients are lacking. We conducted a single-center, retrospective study of HCV+ SLKT recipients (N = 25) in comparison with HCV- SLKT (N = 26) and HCV+ liver transplantation alone (LTA, N = 296). Despite backgrounds of HCV+ and HCV- SLKT being similar, HCV+ SLKT demonstrated significantly impaired 5-year liver graft survival of 35% (HCV- SLKT, 79%, P = 0.004). Compared with HCV+ LTA, induction immunosuppression was more frequently used in HCV+ SLKT. Five-year liver graft survival rate for HCV+ SLKT was significantly lower than that for LTA (35% vs. 74%, respectively, P < 0.001). Adjusted hazard ratio of liver graft loss in HCV+ SLKT was 4.9 (95% confidence interval 2.0-12.1, P = 0.001). HCV+ SLKT recipients were more likely to succumb to recurrent HCV and sepsis compared with LTA (32% vs. 8.8%, P < 0.001 and 24% vs. 8.8%, P = 0.030, respectively). Ten HCV+ SLKT recipients underwent anti-HCV therapy for recurrent HCV; only 1 achieved sustained virological response. HCV+ SLKT is associated with significantly decreased long-term prognosis compared with HCV- SLKT and HCV+ LTA.
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Affiliation(s)
- Taizo Hibi
- Miami Transplant Institute, University of Miami Leonard M. Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA; DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA; Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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23
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Pompili M, Francica G, Ponziani FR, Iezzi R, Avolio AW. Bridging and downstaging treatments for hepatocellular carcinoma in patients on the waiting list for liver transplantation. World J Gastroenterol 2013; 19:7515-7530. [PMID: 24282343 PMCID: PMC3837250 DOI: 10.3748/wjg.v19.i43.7515] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 09/30/2013] [Accepted: 10/18/2013] [Indexed: 02/06/2023] Open
Abstract
Several therapeutic procedures have been proposed as bridging treatments for patients with hepatocellular carcinoma (HCC) awaiting liver transplantation (LT). The most used treatments include transarterial chemoembolization and radiofrequency ablation. Surgical resection has also been successfully used as a bridging procedure, and LT should be considered a rescue treatment in patients with previous HCC resection who experience tumor recurrence or post-treatment severe decompensation of liver function. The aims of bridging treatments include decreasing the waiting list dropout rate before transplantation, reducing HCC recurrence after transplantation, and improving post-transplant overall survival. To date, no data from prospective randomized studies are available; however, for HCC patients listed for LT within the Milan criteria, prolonging the waiting time over 6-12 mo is a risk factor for tumor spread. Bridging treatments are useful in containing tumor progression and decreasing dropout. Furthermore, the response to pre-LT treatments may represent a surrogate marker of tumor biological aggressiveness and could therefore be evaluated to prioritize HCC candidates for LT. Lastly, although a definitive conclusion can not be reached, the experiences reported to date suggest a positive impact of these treatments on both tumor recurrence and post-transplant patient survival. Advanced HCC may be downstaged to achieve and maintain the current conventional criteria for inclusion in the waiting list for LT. Recent studies have demonstrated that successfully downstaged patients can achieve a 5-year survival rate comparable to that of patients meeting the conventional criteria without requiring downstaging.
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24
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Avolio AW, Burra P. Can we match donors and recipients in a cost-effective way? Transpl Int 2013; 26:1061-2. [PMID: 24138200 DOI: 10.1111/tri.12189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 09/01/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Alfonso W. Avolio
- Division of Transplantation; Department of Surgery; Catholic University; Rome; Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit; Gastroenterology; Department of Surgery; Oncology and Gastroenterology; Padua University Hospital; Padua; Italy
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25
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Frongillo F, Grossi U, Lirosi MC, Nure E, Sganga G, Avolio AW, Inchingolo R, Di Stasi C, Rinaldi P, Agnes S. Incidence, management, and results of hepatic artery stenosis after liver transplantation in the era of donor to recipient match. Transplant Proc 2013; 45:2722-2725. [PMID: 24034032 DOI: 10.1016/j.transproceed.2013.08.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Hepatic artery stenosis (HAS) is an important complication after liver transplantation. However, studies are not conclusive in terms of definition, incidence, best treatment, and timing of intervention. The aim of this study was to evaluate the incidence of SSHA that occurred in a single center over the past 12 years, pointing out diagnostic and therapeutic strategies. METHODS The incidence of HAS was reviewed in 258 liver transplant recipients between January 1999 and December 2011. All patients underwent Doppler ultrasound (DUS) at fixed times. Multidetector computed tomographic angiography (MDCTA) was performed to confirm the DUS findings. RESULTS HAS occurred in 23 cases (9.3%). In all cases diagnosis was performed by DUS resulting in a sensitivity of 100% and a specificity of 99.6%. Based on DUS and MDCTA data integration, in 10 cases we adopted the "wait and see" strategy, whereas 13 patients underwent interventional radiology techniques. CONCLUSION DUS monitoring is efficacious in the diagnosis of HAS after liver transplantation. Interventional radiology procedures are safe and efficacious.
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Affiliation(s)
- F Frongillo
- Division of General Surgery and Organ's Transplantation Service, Department of Surgical Sciences, Catholic University, "A. Gemelli" University Hospital, Largo A. Gemelli, 8 - 00168 Rome, Italy; Department of Bioimaging and Radiological Sciences, Catholic University, "A. Gemelli" University Hospital, Largo A. Gemelli, 8 - 00168 Rome, Italy.
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Braat AE, Blok JJ, Rahmel AO, Adam R, Burroughs AK, Putter H, Porte RJ, Rogiers X, Ringers J. Incorporation of donor risk into liver allocation algorithms. Am J Transplant 2013; 13:524-5. [PMID: 23356899 DOI: 10.1111/ajt.12038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Revised: 10/25/2012] [Accepted: 10/25/2012] [Indexed: 01/25/2023]
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