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Mitigation of cardiac disease during liver transplantation through concomitant cardiac surgery and liver transplant: Pushing the boundaries of acceptable surgical candidacy 通过同时进行心脏手术和肝移植减轻肝移植期间的心脏病:突破可接受手术候选者的界限
Pub Date : 2024-05-18 DOI: 10.1016/j.liver.2024.100229
George Furey, David Moros, Michael Zhen-Yu Tong

Introduction

The prevalence of cardiac disease is high in patients with liver cirrhosis, making it one of the leading causes of death in this population. However, the presence of cardiac diseases (coronary artery disease and valvular heart disease) often leads to disqualification of potential liver transplantation (LT) candidates, resulting in limited treatment options available for these complex patients. In recent years, some medical centers, including Cleveland Clinic, have provided concomitant cardiac surgery (CS) and LT to carefully selected patients.

Methods

A comprehensive literature review was conducted, compiling our experience and that of other medical centers performing concomitant CS and LT. We highlight Cleveland Clinic's approach for LT candidates with cardiac diseases. This includes a description of our initial evaluation, designed to detect cardiac diseases, followed by an explanation of our patient selection criteria and intraoperative strategies for concomitant CS and LT.

Conclusion

In patients with liver cirrhosis who are candidates for LT but also present cardiac diseases, a cautious evaluation by a multidisciplinary team is required to determine the feasibility of performing concomitant CS and LT. Available evidence suggests that this combined approach is a potential treatment option, offering acceptable postoperative outcomes and overall survival, despite the often perceived high-risk nature of this complex patient population.

导言肝硬化患者中心脏病的发病率很高,是导致肝硬化患者死亡的主要原因之一。然而,心脏疾病(冠状动脉疾病和瓣膜性心脏病)的存在往往导致潜在的肝移植(LT)候选者被取消资格,从而导致这些复杂患者可选择的治疗方案有限。近年来,包括克利夫兰诊所在内的一些医疗中心为精心挑选的患者同时进行心脏手术(CS)和肝移植。我们重点介绍了克利夫兰诊所针对患有心脏疾病的 LT 候选者的方法。结论对于肝硬化患者,如果他们既是LT的候选者,又患有心脏疾病,则需要由一个多学科团队进行谨慎评估,以确定同时进行CS和LT的可行性。现有证据表明,这种联合治疗方法是一种潜在的治疗选择,可提供可接受的术后效果和总生存率,尽管这种复杂的患者群体通常被认为具有高风险。
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引用次数: 0
Outcomes of hypothermic hyperoxygenated perfusion compared to static cold storage for liver transplant. A systematic review and meta-analysis of randomized clinical trials 肝移植低温高氧灌注与静态冷藏相比的结果。随机临床试验的系统回顾和元分析》。
Pub Date : 2024-05-17 DOI: 10.1016/j.liver.2024.100226
Mario A. O'Connor Cordova , Alan G. Ortega-Macias , Francisco Altamirano , Maria E. Hoyos , Fernando Gonzalez-Zorrilla

Background

While liver transplant effectiveness in treating life-limiting liver disease is uncontested, challenges remain in organ preservation.

Methods

Following PRISMA guidelines, a systematic review was performed to determine the impact of Hypothermic Oxygenated Perfusion (HOPE) on liver transplant outcomes compared to static cold storage (SCS).

Results

A total of five studies were included, totaling 586 patients, out of which 267 patients had HOPE-preserved grafts and 319 SCS-preserved grafts. Analysis showed a significant decrease in early graft dysfunction and biliary complications in the HOPE group when compared to SCS (RR = 0.52; 95 % CI = 0.33–0.81]; p = 0.01) (RR = 0.75; 95 % CI = [0.60–0.94]; p = 0.02), respectively. Similarly, non-anastomotic biliary strictures were significantly reduced in the HOPE group (RR = 0.41; 95 % CI = [0.20–0.86]; p = 0.03). Of note, no statistical significance was found on the one-year graft loss and recipient death (RR = 0.40; 95 % CI = [0.09–1.83]; p = 0.12 and RR = 0.62; 95 % CI = [0.29–1.32]; p = 0.14, respectively). Likewise, no statistical difference was evident in acute rejection (RR = 0.54; 95 % CI = [0.04–7.14]; p = 0.20) and postreperfusion syndrome rate (RR = 0.92; 95 % CI = [0.35–2.41]; p = 0.73). After statistical analysis, no significant differences in major complications, primary nonfunction, re-transplantation, hepatic artery thrombosis, need for renal replacement therapy, intensive care unit, and hospital length of stay were evident.

Conclusions

Liver preservation techniques are gaining popularity by enabling rescue and transplantation of marginal livers. In this study, HOPE showed statistically significant differences in reducing rates of biliary complications, biliary stricture, and early graft dysfunction. Further studies are needed to evaluate financial burden and long-term outcomes to completely elucidate the impact of this organ preservation technique.

背景虽然肝移植在治疗局限性肝病方面的有效性毋庸置疑,但在器官保存方面仍存在挑战。方法根据PRISMA指南,进行了一项系统性回顾,以确定低温氧合灌注(HOPE)与静态冷藏(SCS)相比对肝移植结果的影响。结果共纳入了5项研究,共有586名患者,其中267名患者的移植物由HOPE保存,319名患者的移植物由SCS保存。分析显示,与 SCS 相比,HOPE 组早期移植物功能障碍和胆道并发症明显减少(RR = 0.52; 95 % CI = 0.33-0.81]; p = 0.01)(RR = 0.75; 95 % CI = [0.60-0.94]; p = 0.02)。同样,HOPE 组非吻合口胆道狭窄也显著减少(RR = 0.41;95 % CI = [0.20-0.86];P = 0.03)。值得注意的是,一年期移植物损失和受体死亡没有统计学意义(RR = 0.40; 95 % CI = [0.09-1.83]; p = 0.12 和 RR = 0.62; 95 % CI = [0.29-1.32]; p = 0.14)。同样,急性排斥反应(RR = 0.54; 95 % CI = [0.04-7.14]; p = 0.20)和再灌注后综合征率(RR = 0.92; 95 % CI = [0.35-2.41]; p = 0.73)也没有明显的统计学差异。经过统计分析,在主要并发症、原发性无功能、再移植、肝动脉血栓、肾替代治疗需求、重症监护室和住院时间等方面没有明显差异。在这项研究中,HOPE 在降低胆道并发症、胆道狭窄和早期移植物功能障碍的发生率方面具有显著的统计学差异。要彻底阐明这种器官保存技术的影响,还需要进一步的研究来评估经济负担和长期结果。
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引用次数: 0
Experience with Epstein barr virus and Cytomegalovirus infection in pediatric liver transplant recipients: A 2014–2017 study 小儿肝移植受者感染爱泼斯坦巴氏病毒和巨细胞病毒的经验:2014-2017 年研究
Pub Date : 2024-05-02 DOI: 10.1016/j.liver.2024.100222
Paola Marsela Pérez Camacho , Jaime Alberto Patiño-Niño , Lina María Jaimes , María Camila López-Girón , Laura Torres-Canchala , Víctor García-Montoya , Camila Ariza-Insignares , Lina M. Sandoval-Calle , Inés E. Gómez , Mario Bustos-Paz , Luis Armando Caicedo , Verónica Botero-Osorio

Introduction

This study presents our experience with Epstein Barr virus (EBV) and Cytomegalovirus (CMV) infections in the pediatric liver transplant population and their potential association with the development of the post-transplant lymphoproliferative syndrome (PTLD).

Patients and methods

This retrospective descriptive study covers the period from 2014 to 2017 and includes pediatric liver transplanted recipients who underwent viral load monitoring for EVB and CMV during the first-year post-transplant.

Results

A total of 89 patients were included in the study, with a median age of 0.68 years (RIQ 0.31–0.96) (10.8 months RIQ 8.4–25.2). The most common underlying pathology leading to transplantation was biliary atresia, observed in 55 (61.6 %) cases. Regarding EBV viral loads, values exceeding 10,000 copies/ml were observed in 9 (8 %) patients at 3 months, 33 (29.3 %) at 6 months, 31 (27.6 %) at 9 months and 25 (22.3 %) at 12 months post-transplantation. The probability of developing EBV infection within one-year post-transplantation was 81.3 %, while the probability of CMV infection was 29 %. A total of 8 (8.9 %) biopsy-confirmed graft rejections occurred, only 1 was EBV and CMV-negative. The likelihood of graft rejection in patients with EBV infection was 21.5 %, and for CMV it was 20.8 %. Importantly, only one case of PTLD was documented during 12 months follow-up.

Conclusion

Characterizing this pediatric liver transplant population and monitoring EBV and CMV viral loads enables timely interventions, potentially reducing the risk of PTLD and graft rejection.

导言本研究介绍了我们在小儿肝移植人群中发现的爱泼斯坦巴氏病毒(EBV)和巨细胞病毒(CMV)感染及其与移植后淋巴细胞增生综合征(PTLD)发生的潜在关联。患者和方法这项回顾性描述性研究的时间跨度为2014年至2017年,研究对象包括在移植后第一年接受EVB和CMV病毒载量监测的小儿肝移植受者。结果研究共纳入89名患者,中位年龄为0.68岁(RIQ 0.31-0.96)(10.8个月RIQ 8.4-25.2)。导致移植的最常见的基础病变是胆道闭锁,有 55 例(61.6%)。在 EBV 病毒载量方面,移植后 3 个月时超过 10,000 拷贝/毫升的患者有 9 人(8%),6 个月时有 33 人(29.3%),9 个月时有 31 人(27.6%),12 个月时有 25 人(22.3%)。移植后一年内感染 EBV 的概率为 81.3%,感染 CMV 的概率为 29%。共有 8 例(8.9%)活检证实发生移植物排斥,其中只有 1 例为 EBV 和 CMV 阴性。EB病毒感染者发生移植物排斥反应的可能性为21.5%,CMV感染者为20.8%。重要的是,在12个月的随访期间,仅记录到一例PTLD病例。结论对这一小儿肝移植人群进行特征描述并监测EBV和CMV病毒载量,可以及时采取干预措施,从而降低PTLD和移植物排斥反应的风险。
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引用次数: 0
Infectious complications in pediatric patients after liver transplantation in the first 3 months at the Fundación Valle del Lili, a Latin American transplant center 拉丁美洲移植中心 Valle del Lili 基金会肝移植术后头 3 个月小儿患者的感染并发症
Pub Date : 2024-04-26 DOI: 10.1016/j.liver.2024.100221
Paola Marsela Pérez Camacho , Verónica Botero Osorio , Daniel Fernando Carvajal Cárdenas , María Alejandra Acevedo García , Eliana Manzi Tarapués , Laura Torres-Cánchala , Inés Elvira Gómez Hernández , Lina M. Sandoval-Calle , Luis Armando Caicedo Rusca , Jaime A. Patiño Niño

Introduction

In pediatric patients undergoing liver transplantation, infections are one of the primary complications. The etiology varies depending on the time elapsed post-transplant, with early presentations of bacterial and fungal infections, followed by viral and parasitic infections. There is limited literature describing the prevalence of infectious complications in this group of patients in Colombia.

Objective

To describe infectious complications in patients undergoing liver transplantation within the first 3 months post-procedure at the Fundación Valle del Lili, Cali, Colombia.

Methods

A case series of 165 pediatric liver transplant patients during the period 2011–2017. A descriptive analysis of all entered data was conducted. Survival analysis using the Kaplan-Meier method was performed, with an exploratory analysis comparing patient survival based on the presence of infection, censored for death related to postoperative complications.

Results

The primary diagnosis at the time of transplantation was biliary atresia in 65% of cases. A total of 215 infectious episodes were recorded in 92 pediatric liver transplants. The most frequent microorganisms were Klebsiella pneumoniae (21%), Cytomegalovirus (CMV) (7%), Pseudomonas aeruginosa (7%), Escherichia coli (6%), and Epstein Barr Virus (EBV) (6%). Three-month patient survival was 92% for infection-related mortality.

Discussion

Infectious complications within the first three months post-pediatric liver transplantation were predominantly bacterial in origin. Bacterial and fungal infections manifested earlier, while viral infections appeared later. Infectious complications did not impact the three-month patient survival in this group.

导言在接受肝移植的儿科患者中,感染是主要并发症之一。病因因移植后的时间而异,早期表现为细菌和真菌感染,随后是病毒和寄生虫感染。描述哥伦比亚这组患者感染性并发症发生率的文献有限。目的 描述哥伦比亚卡利 Valle del Lili 基金会肝移植患者术后头 3 个月内的感染性并发症。对所有输入数据进行描述性分析。采用 Kaplan-Meier 法进行生存率分析,并根据感染情况对患者生存率进行了探索性分析,同时对术后并发症导致的死亡进行了筛查。结果65%的病例在移植时的主要诊断为胆道闭锁。在92例小儿肝移植中,共记录了215次感染。最常见的微生物是肺炎克雷伯菌(21%)、巨细胞病毒(CMV)(7%)、铜绿假单胞菌(7%)、大肠埃希菌(6%)和爱泼斯坦巴氏病毒(EBV)(6%)。讨论小儿肝移植术后头三个月内的感染并发症主要由细菌引起。细菌和真菌感染出现较早,而病毒感染出现较晚。感染并发症并不影响本组患者三个月的存活率。
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引用次数: 0
Challenges in deceased organ transplantation in Pakistan: The final heroic act of a modern-day hero 巴基斯坦已故器官移植面临的挑战:现代英雄的最后壮举
Pub Date : 2024-04-01 DOI: 10.1016/j.liver.2024.100220
Zubia Afzal , Abdul Rehman Gull
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引用次数: 0
Peak systolic velocity at arterial Doppler ultrasound in pediatric liver transplantation: A predictor of acute severe complications 小儿肝移植手术中动脉多普勒超声的峰值收缩速度:预测急性严重并发症
Pub Date : 2024-03-29 DOI: 10.1016/j.liver.2024.100218
Ana Coma , Maria Victoria Fasano , Alba Anton-Jimenez , Jose Andres Molino , Jesus Quintero , Maria Margaret Mercadal-Hally , Mercedes Perez , Juan Ortega , Jose Miguel Escudero-Fernandez , Ernest Hidalgo , Ramon Charco

The diagnosis of arterial complications in children after Liver Transplantation (LT) urges prompt diagnosis and treatment. This study aims to determine whether hepatic artery Doppler Ultrasound (DUS) parameters can predict arterial complications in the immediate period after LT in children.

A retrospective review of the pediatric liver database at our tertiary-care pediatric hospital was performed. The study included 70 pediatric patients who underwent a liver transplantation from 2016 to 2021. Clinical, laboratory and Doppler findings were recorded daily the first 5 days after transplantation, with special attention given to post-anastomotic Peak Systolic Velocity (PSV) and Resistive Index (RI).

Patients with hepatic artery complications, including acute thrombosis and stenosis, had lower PSV values after surgery compared to the group with non-complications, with a statistical significance (< 0.001). Receiver operating characteristic (ROC) curve analysis determined an optimal cut-off value of PSV less than 29 cm/s the 2nd day after LT, 25.2 cm/s the 3rd day, 28.5 cm/s the 4th day and 29.4 cm/s the 5th day, to discriminate children with and without hepatic arterial complications. Notably, these cut-off values are lower than those proposed in adults.

Optimal PSV cutt-off values in children in the immediate period after LT are presented. Knowledge of these cutt-off values improves the interpretation of DUS measurements and thereby, may help to accurately guide the clinical management.

肝移植(LT)术后儿童动脉并发症的诊断要求及时诊断和治疗。本研究旨在确定肝动脉多普勒超声(DUS)参数能否预测儿童肝移植术后初期的动脉并发症。该研究纳入了2016年至2021年期间接受肝移植手术的70名儿科患者。与无并发症组相比,有肝动脉并发症(包括急性血栓形成和狭窄)的患者术后PSV值较低,且有统计学意义(< 0.001)。接收操作特征(ROC)曲线分析确定了最佳临界值:LT术后第2天PSV小于29 cm/s,第3天小于25.2 cm/s,第4天小于28.5 cm/s,第5天小于29.4 cm/s,以此来区分有肝动脉并发症和无肝动脉并发症的患儿。值得注意的是,这些临界值低于成人的临界值。了解这些临界值可改善对 DUS 测量的解释,从而有助于准确指导临床治疗。
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引用次数: 0
Sequential bone marrow and combined liver-kidney transplantations for a non-amyloid light chain deposition disease: A unique case report with a complete remission at 6 years 非淀粉样轻链沉积症的骨髓和肝肾联合移植手术:6年后病情完全缓解的独特病例报告
Pub Date : 2024-03-29 DOI: 10.1016/j.liver.2024.100219
Carolina R D Carmo , Madalina Uzunov , Nadia Arzouk , Frederic Charlotte , Magali Colombat , Pascal Lebray

Light Chain Deposition Disease (LCDD) is a rare monoclonal gammopathy characterized by deposition of light chains along the basement membranes of various organs, leading to progressive dysfunction (1,2). It has histological features that differ from amyloidosis and is most often characterized by the overproduction of kappa light chains (2). The kidney is usually the most affected organ and is responsible for the initial clinical manifestations, whereas liver dysfunction is less common and generally less severe than kidney involvement (1,3). We present a case of LCDD in a patient with renal dysfunction associated with secondary sclerosing cholangitis (SSC) and severe liver and kidney involvement, efficiently treated with autologous stem cell transplantation followed by double liver-kidney transplantation.

轻链沉积病(LCDD)是一种罕见的单克隆丙种球蛋白病,其特征是轻链沿各种器官的基底膜沉积,导致进行性功能障碍(1,2)。它的组织学特征不同于淀粉样变性,最常见的特征是卡帕轻链的过度产生(2)。肾脏通常是受影响最严重的器官,也是最初临床表现的罪魁祸首,而肝功能障碍则较少见,且通常不如肾脏受累严重(1,3)。我们介绍了一例LCDD患者,该患者肾功能不全,伴有继发性硬化性胆管炎(SSC)和严重的肝肾受累,通过自体干细胞移植和双肝肾移植得到了有效治疗。
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引用次数: 0
Erratum regarding previously published articles 关于以前发表的文章的勘误
Pub Date : 2024-03-28 DOI: 10.1016/j.liver.2024.100217
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引用次数: 0
Congenital diseases with multi-organ expression as an indication for liver transplantation in children during the first years of life: Integrative approach to improve the outcomes 多器官表现的先天性疾病是儿童生命最初几年进行肝脏移植的适应症:改善疗效的综合方法
Pub Date : 2024-03-20 DOI: 10.1016/j.liver.2024.100216
Marina Moguilevitch, Ingrid Fitz-james

Pediatric liver transplantation has evolved since the first transplant was performed by Dr. Starzl more than 50 years ago. Innovations in surgical techniques, immunosuppression, and infection control have significantly improved patient outcomes, graft survival, and quality of life. However, further progress depends not only on the discovery of new treatment option but should rely upon the identification of the factors in the perioperative care which contribute to successful outcomes and guide our decision-making process.

Indications for pediatric liver transplantation can be divided into three major groups: cholestatic liver conditions, liver based metabolic disorders, and others represented by acute liver failure of different etiologies, tumors, inherited autoimmune diseases, and multiple infectious causes.

Many of these conditions manifest themselves with multi organ pathologic expression, requiring earlier interventions to treat acute liver failure or chronic cholestasis leading to failure to thrive. Containment of patient pathology and maintenance of optimal neurologic and extra-hepatic visceral organ function is paramount during the pre - transplant period.

Multidisciplinary management of comorbid conditions in complex pediatric liver transplant candidates during the perioperative period with the emphases on optimization and patient selection has never been summarized in the literature. Thant is why this review focuses on a comprehensive, multidisciplinary preoperative evaluation of pediatric patients in whom progressive liver disfunction manifests early in life and eventually requires liver transplantation. We will address multi-organ system involvement, preoperative optimization in anticipation of the complexity of intraoperative care, as well as short- and long-term postoperative management.

自 50 多年前斯塔泽尔医生实施首例移植手术以来,小儿肝脏移植手术不断发展。手术技术、免疫抑制和感染控制方面的创新大大改善了患者的预后、移植物存活率和生活质量。然而,进一步的进步不仅取决于新治疗方案的发现,还应该依赖于围手术期护理中有助于取得成功结果的因素的识别,并指导我们的决策过程。小儿肝移植的适应症可分为三大类:胆汁淤积性肝病、以肝脏为基础的代谢性疾病,以及以不同病因引起的急性肝衰竭、肿瘤、遗传性自身免疫性疾病和多种感染性病因为代表的其他疾病。其中许多疾病表现为多器官病理表现,需要更早地干预治疗急性肝衰竭或导致发育不良的慢性胆汁淤积。在移植前期,控制患者的病理变化并维持神经系统和肝外内脏器官的最佳功能至关重要。文献中从未总结过在围手术期对复杂的小儿肝移植候选者的合并症进行多学科管理,重点是优化和选择患者。因此,本综述将重点放在对早期出现进行性肝功能障碍并最终需要进行肝移植的儿科患者进行全面、多学科的术前评估。我们将讨论多器官系统参与、术前优化以应对术中护理的复杂性,以及短期和长期的术后管理。
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引用次数: 0
Spontaneous Subdural hematomas must remain a can't-miss diagnosis in patients who have undergone orthotopic liver transplantation with no history of trauma 自发性硬膜下血肿仍是接受无外伤史的正位肝移植患者不可忽视的诊断依据
Pub Date : 2024-03-01 DOI: 10.1016/j.liver.2024.100215
Pranvera Sulejmani , Morgan Sturgis , Nathalie Sela
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引用次数: 0
期刊
Journal of Liver Transplantation
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