Liver transplantation and surgery : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society最新文献

Jejunoileal bypass (JIB) is a well known cause of steatohepatitis, which may, on occasion, progress to cirrhosis and require liver transplantation. We report 3 patients who underwent orthotopic liver transplantation (OLT) for steatohepatitic cirrhosis secondary to JIB in which the JIB was left intact. All 3 patients have demonstrated recurrent steatosis in the graft after liver transplantation. In two of the cases, the changes are moderately severe, whereas in one case the changes are mild. All 3 patients have essentially normal liver function tests and are clinically asymptomatic; 1 of the patients has undergone removal of the JIB 2.5 years after transplantation. Control hepatic allografts in patients with primary biliary cirrhosis and primary sclerosing cholangitis show negligible fatty change, and in patients who receive transplants for alcoholic steatohepatitis, they rarely (2 of 20 patients) contain greater than 10% fat. We conclude that transplantation alone is not associated with subsequent steatosis. Presence of JIB is, therefore, a continuing risk factor for steatosis in patients who have undergone OLT. Reversal of JIB after OLT may be considered if fatty changes are severe or associated with significant fibrosis.

Background: We evaluated the effect of warm (37 degrees C) versus cold (4 degrees C) solutions as the initial flush for liver preservation from non-heart beating donors in rats.

Methods: An initial flush was performed just before donor hepatectomy with cold or warm University of Wisconsin solution (UW), UW without hydroxyethyl starch, sodium lactobionate sucrose solution, or lactated Ringer's solution as the control group. A separate group also used as control received no initial flushing. Liver transplantation was performed, and the graft function was determined by survival and assessment of enzyme release. The viscosity of each solution and the vascular resistance of the graft were measured.

Results: The 7-day survival rate was 83% and 100% in the warm and cold sodium lactobionate sucrose solution groups and 60% and 50% in the warm and cold lactated Ringer's solution groups, respectively. In the no-initial-flush group, rats did not survive. The 7-day survival rate was 67% and 0% in the warm and cold UW groups, respectively. Eliminating the hydroxyethyl starch from the cold UW improved the survival to 67%. Serum alanine aminotransferase levels 1 day after transplantation in the no-initial-flush and the cold UW groups were significantly higher than those of the remaining groups. At 4 degrees C the viscosity was higher in the UW (86.2 cp) compared to hydroxyethyl starch-free UW solution (30.9 cp), lactated Ringer's solution (24.5 cp), and sodium lactobionate sucrose solution (32.7 cp). The viscosity of UW at 37 degrees C was 34.7 cp. Vascular resistance correlated well with the viscosity. Livers flushed with solutions with a low viscosity showed lower vascular resistance than those flushed with cold UW and led to better survival.

Conclusions: These data suggest that the viscosity of the initial flushing solution may play an important role in determining the outcome of organ procurement from non-heart beating donors.

Pretransplant nutritional assessment in the patient with ESLD is problematic. The best system for nutritional assessment uses a "global" evaluation of the patient's nutritional reserves. With such a technique, the vast majority of transplant candidates have been shown to have evidence of malnutrition. Several investigators have demonstrated the risk of significant malnutrition on posttransplant outcome. An aggressive approach to nutritional repletion is necessary to improve the ESLD patient's metabolic reserves, maintain remaining hepatic function, and better the outcome after liver transplantation.