Journal of Liver Transplantation最新文献

Background

Patients with advanced liver disease (ALD) have unique hemodynamics including high resting cardiac output and low systemic vascular resistance which may reduce the sensitivity of pharmacological myocardial perfusion imaging (MPI). MPI is frequently ordered for patients with ALD if liver transplantation is being considered. Because of the limited data on effectiveness of MPI in the ALD population, we conducted this cohort study focused on cardiac outcomes after pharmacological MPI.

Methods

We conducted a cohort study comparing normal versus abnormal MPI among 454 patients with ALD between 1/1/2011 and 06/01/2021 at a single tertiarycare academic medical center. Abnormal MPI was defined as summed stress score > 2 on LVEF < 40 %. The primary outcome was to compare the frequency of major adverse cardiovascular events (MACEs) among ALD patients with and without abnormal MPI. Secondary outcome included individual components of MACE analyzed by chi square. Kaplan-Meier survival curves and a logistic-regression model of associations with MACE were also performed.

Results

In this cohort, 58 patients were observed to have an abnormal MPI. Baseline characteristics between the groups were similar, except prior coronary disease, which was more common among the abnormal MPI group (risk ratio 2.07, 95 % confidence interval 1.30–3.30, P = 0.003). MACE was more common in the group with abnormal MPI (n = 24, 41.4 % versus normal MPI n = 104, 26.3 %, P < .001). No difference in MACE was observed when stratified by liver disease type. In the logistic regression model, diabetes mellitus, stage 3 chronic kidney disease, and summed stress score >2 were retained as being associated with MACE.

Conclusions

Our data suggest that MPI remains an effective test for identifying ALD patients at higher risk of mortality and cardiac events. Further study is needed to understand whether a strategy of routine MPI for liver transplant candidates effectively improves long term survival.

Enhanced recovery after surgery (ERAS) is a fascinating new approach to the perioperative care of liver transplantation (LT). Being an already established pathway in other surgical fields, ERAS in LT (ERALT) is moving its first steps into a complex scenario.

Material and Methods

In this study, using an Italian multicentre database dedicated to LT (Petalo Trapianto Fegato), we compared a group of patients who had a relatively short length of hospital stay (LHoS) after LT (12 days, 569 patients) vs a group that exceeded this LHoS (1017 patients). The main aim was to find a clinical rule to select patients who could afford safely and successfully an ERAS pathway. We used several machine learning techniques to find the best model to predict a short LHoS. We used logistic regression and Boruta random forest to select the most important features to be included in a prognostic score.

Results

According to our results, early after LT, an ERAS pathway might be confidently considered early after LT when the MELDNa is less than 10 or when the MELDNa is between 10 and 17 and the patient received ≤ 5 units of Packed Red Blood Cells intraoperatively (accuracy 72%, sensitivity 78%, specificity 66%, positive predictive value 78%).

Conclusion

This simple clinical rule is intended to be used as a screening tool in patient selection for centres approaching ERAS in LT focusing clinical safety and efficacy, physician confidence and patients’ satisfaction.

Background

Crigler-Najjar syndrome is an ultra-rare hereditary disorder characterized by severe jaundice and risk of neurological complications. Current treatments, such as phototherapy, have limitations, and liver transplantation is often necessary. Auxiliary partial orthotopic liver transplantation (APOLT) is a potential treatment option. Still, its safety and efficacy in Pakistani patients with Crigler-Najjar syndrome Type I (CNS-I) have not been well established.

Methods

This retrospective study reviewed the outcomes of five pediatric patients with CNS-I who underwent APOLT at a tertiary care center in Pakistan. Patient demographics, surgical details, postoperative course, complications, and follow-up data were analyzed. The primary endpoint was the feasibility and safety of APOLT, while secondary endpoints included improvement in serum bilirubin levels, neurological symptoms, and survival rates.

Results

Among five patients diagnosed with CNS-I, APOLT was performed without intraoperative complications. During the median follow-up period of 6 months, there were no cases of relaparotomy, graft rejection, biliary complications, or portal venous thrombosis. One patient developed a portal venous stricture, but his symptoms were controlled with conservative measures. Postoperative liver function tests showed a significant improvement, with an average reduction of 90% in serum bilirubin levels. There was some improvement in neurological symptoms, and the overall patient and graft survival rate was 100%.

Conclusion

This study suggests that APOLT is a feasible and safe treatment option in patients with CNS-I. It improves liver function, bilirubin levels, and neurological symptoms. Further research with larger sample sizes is warranted to confirm these findings and evaluate the long-term outcomes of APOLT in this patient population.

Background

In contemporary transplantation research, the utilization of machine perfusion to facilitate the perfusion, preservation, evaluation, and repair of donor livers has garnered considerable attention.In an effort to comprehensively assess the clinical outcomes of liver transplantation procedures incorporating machine perfusion, a meta-analysis of published randomized controlled trials (RCTs) was undertaken.

Methods

The relevant literature was obtained from PubMed, EMBASE, Web of Science, and other databases up until December 2022. Subsequently, the authors extracted the requisite data, conducted a meta-analysis, and arrived at a conclusion based on the findings derived from the analysis.

Results

A total of seven high-quality prospective RCTs, comprising 917 patients, were included in the analysis. Machine perfusion demonstrated significant superiority over cold storage in reducing the incidence of major postoperative complications (RR 0.55, 95% CI 0.42 to 0.73; p < 0.0001) and early allograft dysfunction (RR 0.52, 95% CI 0.41 to 0.67; p < 0.00001). Notably, postoperative aspartate aminotransferase peak, bilirubin levels, and post-reperfusion lactate were also found to decrease. However, no statistically significant differences were observed for other outcomes. Hypothermic oxygenation machine perfusion demonstrated a lower frequency of re-transplantation (RR 0.29, 95% CI 0.10 to 0.86; p = 0.03), rejection (RR 0.55, 95% CI 0.32 to 0.95; p = 0.03), and resulted in shorter hospital stays (Std, MD -0.30, 95% CI -0.52 to -0.07; p = 0.009).

Conclusions

The application of machine perfusion can yield significant improvements in the outcomes of liver transplantation.

Background

The persistent shortage of liver allografts contributes to significant waitlist mortality. Normothermic machine perfusion (NMP) has the potential to extend viability and allow liver function evaluation in discarded organs. The main aim of the study was to evaluate the possibility for extended preservation and the potential recovery of non-usable human livers utilizing NMP.

Methods

6 high-risk human liver grafts that were discarded after national allocation underwent normothermic liver preservation for an extended period of 24 h. Transmedics Organ Care System™ liver perfusion device was used to preserve a donor liver in a functioning, near physiologic state. Parameters of biochemical and synthetic liver function were collected periodically and subsequently analyzed. Liver parenchyma and bile duct biopsies were obtained pre- and 24 h post-NMP.

Results

4/6 (67%) grafts were DCDs with a median age of 54 (IQR: 42–61) years and median CIT of 262 (IQR: 209–1024) minutes. 5/6 (83%) livers produced a median of 75 ml of bile (Range 55–100) after 24 h of NMP. Lactate dropped to normal levels (<2 mmol/L) for all livers after around 4 h on NMP. The overall cellular architecture, lobular steatosis and necrosis grades were preserved after extended NMP. Biopsies showed improvement of liver parenchyma architecture with reduced inflammation for 2/6 (33%) at the end of the perfusion.

Conclusion

Prolonged NMP for discarded liver grafts can be safely maintained on NMP and may identify certain grafts that are suitable for transplantation. Further studies utilizing NMP with subsequent transplantation would validate this strategy, as well as existing viability markers.

portal hypertension and bacterial infections are frequent in cirrhosis and their coexistence may render this population susceptible to severe drug-induced thrombocytopenia. We describe frequency, clinical characteristics and prognosis of Piperacillin/Tazobactan associated thrombocytopenia. 84 patients [Child 10±1, MELD 18±8; SIRS and ACLF in 28% and 24%] were included. Thrombocytopenia developed in 12 patients and was associated with a higher frequency of bleeding from multiple sites and platelet transfusion. Severe/persistent thrombocytopenia correlated with in-hospital mortality. In conclusion, development of thrombocytopenia is frequent in cirrhotic patients treated with Piperacillin/Tazobactan and this complication, especially in most severe forms, is associated with high morbidity and mortality.

Background

Living Donor Liver Transplantation (LDLT) is common in Pakistan, where the deceased organ donation is lacking. However, not all potential living donors are suitable for the procedure due to various medical, technical, psychosocial, and ethical reasons. This study aims to investigate the reasons for the ineligibility of potential living liver donors in Pakistan.

Methods

Between June 2022 and March 2023, 530 potential living liver donors were assessed for liver transplant recipients at the Pakistan Kidney and Liver Institute & Research center (PKLI&RC). Potential donors were evaluated in three steps, including laboratory tests imaging, and consultations. Prospectively maintained data on all potential donors were examined and retrospectively assessed to identify the causes of donor rejection.

Results

Of the 530 potential living donors evaluated, 364 of the potential donors were considered ineligible (68.67% of donors were rejected). From these rejected donors, 193 (53%) were males, and 171 (47%) were females. The mean age of the rejected donors was 26 years old. The most common reason for disqualifying potential living liver donors was a withdrawal of consent (65 cases, 17.9%). Other factors contributing to ineligibility included fatty liver infiltration reflected by a liver attenuation index (LAI) < 0, future liver remnant (FLR) < 28%, and a graft-to-recipient weight ratio (GRWR) < 0.6. Medical issues, such as abnormal liver function tests and positive hepatitis serology, also resulted in disqualification.

Conclusion

This study highlights the importance of meticulous assessment of potential living liver donors to ensure their safety and the success of the transplant. The high rate of withdrawal of consent and the prevalence of medical issues indicates the need for addressing ethical concerns and improving public education on the donation process. This study also emphasizes the importance of a deceased organ donation in developing countries like Pakistan to ensure the availability of organs for transplantation.