Long-term Outcome of a Modified Piggyback Liver Transplantation Technique Using the Recipient's Right and Middle Hepatic Veins.

In early piggyback liver transplantation (LT) descriptions, the common stump of the middle and left hepatic veins (ML) was used for upper caval anastomosis. In this variant, stenosis or kinking of graft venous outflow path was frequent. Over time, most authors adopted the use of the recipient's right, middle, and left hepatic veins (RML) or a side-to-side anastomosis (SS) between the graft's and recipient's inferior vena cava (IVC). Nonetheless, partial IVC clamping required in RML and SS can reduce IVC flow. Since 1998, we incorporated a modified piggyback procedure using the recipient's right and middle hepatic veins (RM) to simultaneously achieve better preservation of IVC flow and a wide and well-positioned anastomosis. OBJECTIVE: The aim of this study is to describe the RM method and to compare this technique with other standard variants of piggyback LT. METHOD: We conducted a retrospective analysis of 477 piggyback LTs classified in 4 groups: ML (n = 102); RM (n = 171); RML (n = 150); and SS (n = 54). RESULTS: The incidence of venous outflow block was 3.9% (4/102) in ML, 2.3% (4/171) in RM, 0% (0/150) in RML, and 3.7% (2/54) in SS (P = .049). On Bonferroni multiple comparison analysis, no statistically significant paired difference was identified. Results showed that 1-, 3-, 5-, and 10-year patient survival was 76%, 67%, 63%, and 51% in the ML group; 80%, 71%, 68%, and 62% in the RM group; 77%, 75%, 70%, and 64% in the RML group; and 76%, 76%, 76%, and 70% in the SS group, respectively (P = .193). CONCLUSION: The RM modified piggyback LT technique is feasible and safe.

Prospective Randomized Trial Comparing Hepatic Venous Outflow and Renal Function after Conventional versus Piggyback Liver Transplantation.

BACKGROUND: This randomized prospective clinical trial compared the hepatic venous outflow drainage and renal function after conventional with venovenous bypass (n = 15) or piggyback (n = 17) liver transplantation. METHODS: Free hepatic vein pressure (FHVP) and central venous pressure (CVP) measurements were performed after graft reperfusion. Postoperative serum creatinine (Cr) was measured daily on the first week and on the 14th, 21st and 28th postoperative days (PO). The prevalence of acute renal failure (ARF) up to the 28th PO was analyzed by RIFLE-AKIN criteria. A Generalized Estimating Equation (GEE) approach was used for comparison of longitudinal measurements of renal function. RESULTS: FHVP-CVP gradient > 3 mm Hg was observed in 26.7% (4/15) of the patients in the conventional group and in 17.6% (3/17) in the piggyback group (p = 0.68). Median FHVP-CVP gradient was 2 mm Hg (0-8 mmHg) vs. 3 mm Hg (0-7 mm Hg) in conventional and piggyback groups, respectively (p = 0.73). There is no statistically significant difference between the conventional (1/15) and the piggyback (2/17) groups regarding massive ascites development (p = 1.00). GEE estimated marginal mean for Cr was significantly higher in conventional than in piggyback group (2.14 ± 0.26 vs. 1.47 ± 0.15 mg/dL; p = 0.02). The conventional method presented a higher prevalence of severe ARF during the first 28 PO days (OR = 3.207; 95% CI, 1.010 to 10.179; p = 0.048). CONCLUSION: Patients submitted to liver transplantation using conventional or piggyback methods present similar results regarding venous outflow drainage of the graft. Conventional with venovenous bypass technique significantly increases the harm of postoperative renal dysfunction. TRIAL REGISTRATION: ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT01707810.

Impact of acute kidney injury exposure period among liver transplantation patients.

BACKGROUND: Acute kidney injury is a common complication of liver transplantation. In this single-centre retrospective observational study, we investigated the impact of acute kidney disease on liver recipient survival. METHODS: The study population consisted of patients who underwent a liver engraftment between January 2002 and November 2006, at a single transplantation centre in São Paulo, Brazil. Acute kidney injury diagnosis and staging were according to the recommendations of the Acute Kidney Injury Network and consisted of scanning the daily serum creatinine levels throughout the hospital stay. Patients requiring renal replacement therapy prior to transplantation, those who developed acute kidney injury before the procedure or those receiving their second liver graft were excluded from the study. RESULTS: A total of 444 liver transplantations were performed during the study period, and 129 procedures (29%) were excluded. The remaining 315 patients constituted the study population. In 207 procedures, the recipient was male (65%). The mean age of the population was 51 years. Cumulative incidence of acute kidney injury within 48 h, during the first week after transplantation, and throughout the hospital stay was 32, 81 and 93%, respectively. Renal replacement therapy was required within a week after the transplantation in 31 procedures (10%), and another 17 (5%) required replacement therapy after that period. Mean follow-up period was 2.3 years. Time in days from acute kidney injury diagnosis to initiation of replacement therapy or reaching serum creatinine peak was associated with lower overall survival even when adjusted for significant potential confounders (HR 1.03; 95% CI 1.01, 1.05; p=0.002). Overall, patients experiencing acute kidney injury lasting for a week or more before initiation of replacement therapy experienced a threefold increase in risk of death (HR 3.02; 95% CI 2.04, 4.46; p<0.001). CONCLUSIONS: Acute kidney injury after liver transplantation is remarkably frequent and has a substantial impact on patient survival. Delaying the initiation of renal replacement therapy in such population may increase mortality by more than 20% per day.

Inflammatory cytokines during liver transplantation: prospective randomized trial comparing conventional and piggyback techniques.

BACKGROUND/AIMS: Cytokines have a significant role in the response to injury following liver transplantation, but the origin and course of such molecules are not completely known. The aim of this study was to evaluate the production and liver metabolism of the inflammatory cytokines interleukin (IL)-1beta, IL-6, IL-8, interferon (IFN)-gamma and tumor necrosis factor (TNF)-alpha in orthotopic liver transplantation (OLT), comparing the conventional and the piggyback methods. METHODOLOGY: We performed a study of 30 patients who underwent elective OLT and were randomized for the conventional or piggyback techniques at the beginning of the operation. The amount of cytokines and their hepatic metabolism were calculated based on plasma concentrations and vascular blood flow at 2, 5, 10, 15, 30, 60, 90, and 120 minutes after revascularization. RESULTS: The amount of IL-11 in portal blood was higher in patients who underwent surgery using the conventional technique (estimate interest = 63,783.9 +/-16,586.1 pg/min, versus 11,979.6 +/-16,585.7 pg/min in the piggyback group, p = 0.035). There were no significant differences between the two operative's methods for IL-6, IL-8, IFN-gamma and TNF-alpha production. The hepatic metabolism of cytokines was not different between groups. Although all the curves showed higher amounts of cytokines with the conventional technique, these were not statistically significant. CONCLUSION: The study shows the similarity between the two techniques concerning the stimuli for the production of inflammatory molecules.

Comparative study of etiological diagnosis of nosocomial pneumonia.

Nosocomial pneumonia is a common complication in patients on mechanical ventilation and results in significant mortality. Diagnosis of pneumonia in patients who are intubated and under mechanical ventilation is difficult, even with the aid of clinical, laboratory, and endoscopic tests. The objective of this study was to compare three methods of tracheal sputum collection in patients with a clinical and radiological diagnosis of pneumonia. Twenty-two patients with a clinical diagnosis of liver disease were enrolled, 18 years of age or older, 13 males and nine females, who had been mechanically ventilated over an intubation period of 5.86 +/- 4.62 days. These patients were being treated in intensive care unit (ICU) of the Liver Transplant department. Secretion collection was carried out according to a protocol with three distinct methods: endotracheal aspiration with a closed aspiration system, Bal cath and bronchoalveolar lavage. Of the 22 patients analyzed, 21 (95.4%) showed one or more infectious agent when the closed aspiration system was used. With the Bal cathâ collection, 19 patients (86.3%) had one or more infectious agents; in the collection by bronchoalveolar lavage, 10 patients (45.4%) presented one or more infectious agent. According to the laboratory analysis, 14 different microorganisms were isolated, the most frequent of which were Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pneumoniae. We concluded that aspiration with the closed system produced the most effective results in comparison with those of bronchoalveolar lavage and the Bal cathâ, and may be an acceptable method for diagnosing hospital-acquired pneumonia when no fiberoptic technique is available.

Splanchnic non-hepatic hemodynamics and metabolism during liver transplantation.

BACKGROUND/AIMS: The aim of this study is to compare the splanchnic non-hepatic hemodynamics and the metabolic changes during orthotopic liver transplantation between the conventional with bypass and the piggyback methods. METHODOLOGY: A prospective, consecutive series of 59 primary transplants were analyzed. Oxygen consumption, glucose, potassium, and lactate metabolism were quantitatively estimated from blood samples from the radial artery and portal vein, collected up to 120 minutes after graft reperfusion. Mean arterial pressure, portal venous pressure, portal venous blood flow, and splanchnic vascular resistance were also measured or calculated at postreperfusion collection times. RESULTS: There was a greater increase in portal venous blood flow (p=0.05) and lower splanchnic vascular resistance (p=0.04) in the piggyback group. Mean arterial pressure and portal venous pressure were similar for both groups. Oxygen, glucose and potassium consumption were higher in the piggyback group, but none of the metabolic parameters differed significantly between groups. CONCLUSIONS: In conclusion, the study detected a higher portal venous blood flow and a lower and splanchnic vascular resistance associated with the piggyback technique. After graft reperfusion, no difference in the splanchnic non-hepatic metabolic parameters was observed between the conventional with bypass and the piggyback methods of orthotopic liver transplantation.

Comparative study of etiological diagnosis of nosocomial pneumonia

Nosocomial pneumonia is a common complication in patients on mechanical ventilation and results in significant mortality. Diagnosis of pneumonia in patients who are intubated and under mechanical ventilation is difficult, even with the aid of clinical, laboratorial, and endoscopic tests. The objective of this study was to compare three methods of tracheal sputum collection in patients with a clinical and radiological diagnosis of pneumonia. Twenty-two patients with a clinical diagnosis of liver disease were enrolled, 18 years of age or older, 13 males and nine females, who had been mechanically ventilated over an intubation period of 5.86 ± 4.62 days. These patients were being treated in intensive care unit (ICU) of the Liver Transplantdepartment. Secretion collection was carried out according to a protocol with three distinct methods: endotracheal aspiration with a closed aspiration system, Bal cath and bronchoalveolar lavage. Of the 22 patients analyzed, 21 (95.4 percent) showed one or more infectious agent when the closed aspiration system was used. With the Bal cathâ collection, 19 patients (86.3 percent) had one or more infectious agents; in the collection by bronchoalveolar lavage, 10 patients (45.4 percent) presented one or more infectious agent. According to the laboratorial analysis, 14 different microorganisms were isolated, the most frequent of which were Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pneumoniae. We concluded that aspiration with the closed system produced the most effective results in comparison with those of bronchoalveolar lavage and the Bal cathâ, and may be an acceptable method for diagnosing hospital-acquired pneumonia when no fiberoptic technique is available.

Splanchnic non-hepatic hemodynamics and metabolism during liver transplantation

Background/Aims:The aim of the study is to compare the splnchnic non-hepatic hemodynamics and the metabolic changes during orthopic liver transplantation between the conventional with bypass and the piggyback methods. Methodology: A prospective, consecutive series of 59 primary transplants were analyzed. Oxygen consumption, glucose, potassium, and lactate metabolism were quantitatively estimated from blood samples from the radial artery portal vein, collected up to 20 minutes after graft reperfusion. Mean arterial pressure, portal venous pressure, portal venous blood flow, and splanchnic vascular resistance were also measured or calculated at postreperfusion collection times...

Bacterial translocation during liver transplantation: a randomized trial comparing conventional with venovenous bypass vs. piggyback methods.

The aim of this study was to evaluate the bacterial translocation in liver transplantation (LT), comparing the conventional and the piggyback methods. A total of 32 patients were randomized into the 2 groups. Samples of blood were collected from the radial artery, portal vein (PV) and hepatic vein (HV), in up to 120 minutes postreperfusion. The samples were sent for endotoxin level, as well as samples up to 2 minutes post-perfusion were sent to culture. Hepatic artery and PV blood flows were measured at postreperfusion collection times. The results analyzed were: endotoxin concentration, its quantity, and hepatic clearance. The statistical treatment consisted of analyzing each group's mean profile. The analysis for endotoxin concentration in the radial artery was the deviation related to presurgery measure, and in the PV the deviation related to preclamping (PC) measure. The overall mean level of endotoxin concentration was 0.99 EU/mL in the artery, 1.30 EU/mL in the PV, and 1.22 EU/mL in the HV. The deviation was significant in the portal (P = 0.0031), but not in the artery samples (P = 0.2092). We detected a significant quantity of endotoxin in the artery and in the portal and the HVs (P < 0.001). There was no difference between the 2 groups and no hepatic clearance of endotoxin was detected either (P = 0.1515). All the cultures were negative. In conclusion, the study detected a significant translocation of endotoxin, but not of bacteria. The study also detected the absence of endotoxin hepatic clearance in both the piggyback and the conventional methods without any difference between them.

Comparison of cyclosporine microemulsion and tacrolimus in 39 recipients of living donor liver transplantation.

New immunosuppressive agents and regimens should be evaluated specifically in living donor liver transplant patients due to potential clinical and pharmacokinetic differences between deceased donor and living donor transplant recipients. The analysis presented here is the first direct comparison of clinical outcomes using cyclosporine microemulsion (CsA-ME) with monitoring of blood concentration at 2 hours postdose (C2) and tacrolimus-based immunosuppression in living donor liver transplantation. The analysis was conducted on the data provided by the 39 recipients of a living donor transplant out of the 495 patients enrolled in a 6-month, randomized, prospective, multicenter, open-label study (LIS2T). Patients were randomized to CsA-ME (C2 monitoring) or tacrolimus (monitoring of predose trough drug blood level [C0)]) and were administered corticosteroids with or without azathioprine. Twenty-three living-donor patients received CsA-ME and 16 received tacrolimus. By month 6, 9% of patients receiving CsA-ME and 19% of those receiving tacrolimus had lost their graft or died (not significant [NS]). Nine episodes of biopsy-proven acute rejection were reported: 4 in the CsA-ME group (17%) and 5 in the tacrolimus cohort (31%, NS). There were no significant differences in any safety parameter between groups. The most frequently reported serious adverse events were infections, which occurred in 14 patients in the CsA-ME group (61%) and 13 patients in the tacrolimus arm (81%, NS). Twelve patients in the CsA-ME arm (52%) and 5 in the tacrolimus arm (31%, NS) discontinued the study prematurely. In conclusion, CsA-ME C2 monitoring or tacrolimus both offer effective protection against rejection in living donor liver transplants while maintaining a good safety profile.

Cyclosporine A-induced ocular opsoclonus and reversible leukoencephalopathy after orthotopic liver transplantation: brief report.

Ocular opsoclonus is a rare neurologic condition that occurs in patients with brain stem encephalitis, neoplasm of the mesencephalon, paraneoplastic syndrome or intoxication. Neurotoxicity is a well-known complication of cyclosporine-A (CSA) therapy. We report a case of a 17-year-old patient, a Caucasian female, who underwent an orthotopic liver transplantation (OLT) for immunologic cirrhosis and chronic cellular rejection respectively. The ocular symptoms occurred 8 days after the OLT. She also developed reversible posterior leukoencephalopathy. The serum level of CSA was 412 ng/mL. The ocular symptoms improved 21 days after the reduction of the CSA level.

Randomized trial comparing pulmonary alterations after conventional with venovenous bypass versus piggyback liver transplantation.

During the anhepatic phase of conventional liver transplantation (LT), the inferior vena cava (IVC) is cross-clamped and venovenous bypass (VVB) is usually indicated for diversion of IVC and portal blood flow. VVB can theoretically lead to pulmonary complications due to the contact of the blood with the surfaces of the circuit. In the piggyback method, preservation of the IVC avoids VVB. The aim of this study is to compare pulmonary alterations after conventional with VVB versus piggyback LT. Sixty-seven patients were randomized for conventional VVB (n = 34) or piggyback (n = 33) LT. Pulmonary static compliance (C(st)) and Pa(O2)/F(IO2) ratio were measured pre- and post-LT. Chest X-rays were obtained daily from the 1st to the 5th postoperative day. Pre- and post-LT C(st) were 73.4 +/- 36.0 mL/cm H(2)O and 59.7 +/- 22.0 mL/cm H(2)O in the conventional group and 69.1 +/- 20.0 mL/cm H(2)O and 58.7 +/- 27.1 mL/cmH(2)O in the piggyback group. The difference between the two groups was not significant (P =.702). C(st) significantly decreased after LT (P =.008). The pre- and post-LT Pa(O2)/F(IO2) were 455.6 +/- 126.6 mm Hg and 463.1 +/- 105.9 mm Hg in the conventional group and 468.9 +/- 114.1 mm Hg and 483.3 +/- 119.8 mm Hg in the piggyback group. The difference among the two groups was not significant (P = 0.331). There was no significant difference after LT (P =.382). Upon the radiological evaluation, piggyback group presented a higher frequency of pulmonary infiltrates (80.6% vs. 50.0%; P =.025). In conclusion, piggyback LT recipients have a higher rate of pulmonary infiltrates when compared to those operated upon using the conventional VVB method.

Risk factors for development of acute renal failure after liver transplantation.

BACKGROUND: Acute renal failure (ARF) is a common complication after liver transplantation (LTx). Identification of risk factors may prevent the development and attenuate the impact of ARF on patients outcome after LTX. METHODS: Retrospective analysis of variables in the pre, intra, and postoperative periods of 92 patients submitted to LTx was performed in order to identify risk factors for development of ARF after LTx. ARF was defined as serum creatinine > or = 2.0 mg/dL in the first 30 days after LTx. Univariate and multivariate analysis by logistic regression were performed. RESULTS: ARF group comprised 56 patients (61%). Preoperative serum creatinine was higher in ARF group. During the intraoperative period, ARF group required more blood transfusions, developed more episodes of hypotension and presented longer anesthesia time. In the postoperative period, ARF group presented higher serum bilirubin and more episodes of hypotension. Dialysis was required in 10 patients (11%). The identifled risk factors for development of ARF were: preoperative serum creatinine > 1.0 mg/dL. more than five blood transfusions in the intraoperative period, hypotension during intra and postoperative periods. The identified mortality risk factors were hypotension in the postoperative period and no recovery of renal function after 30 days. CONCLUSIONS: Several factors are involved in the pathogenesis of ARF after LTx and may influence patients outcome and mortality. Pretransplant renal function and hemodynamic conditions in the operative and postoperative periods were identified as risk factors for development of ARF after LTx. Nonrenal function recovery and postoperative hypotension were identified as mortality risk factors after LTx.

Use of tacrolimus in rescue therapy of acute and chronic rejection in liver transplantation.

PURPOSE: To study the indications and results of tacrolimus as rescue therapy for acute cellular or chronic rejection in liver transplantation. PATIENTS AND METHODS: Eighteen liver transplant recipients who underwent rescue therapy with tacrolimus between March 1995 and August 1999 were retrospectively studied. The treatment indication, patients, and graft situation were recorded as of October 31st, 1999. The response to tacrolimus was defined as patient survival with a functional graft and histological reversal of acute cellular, or for chronic rejection, bilirubin serum levels decreasing to up to twice the upper normal limit. RESULTS: Fourteen cases (77.8%) presented a good response. The response rate for the different indications was: (1) acute cellular + sepsis - 0/1 case; (2) recurrent acute cellular - 1/1 case; (3) OKT3-resistant acute cellular - 2/2 cases; (4) steroid-resistant acute cellular + active viral infection - 3/3 cases; (5) chronic rejection - 8/11 cases (72.7% response rate). The 4 patients who did not respond died. CONCLUSION: Tacrolimus rescue therapy was successful in most cases of acute cellular and chronic rejection in liver transplantation.

Right hemidiaphragmatic mobility: assessment with US measurement of craniocaudal displacement of left branches of portal vein.

PURPOSE: To evaluate the correlation and agreement between ultrasonographic (US) measurement of craniocaudal displacement of the left intrahepatic branches of the portal vein and radiographic measurement of right hemidiaphragmatic mobility. MATERIALS AND METHODS: Fifty-one patients with indications for abdominal angiography or percutaneous cholangiography prospectively underwent radiographic evaluation of right hemidiaphragmatic mobility and B-mode US measurement of craniocaudal displacement of the left intrahepatic branches of the portal vein. US was performed by using a 3.5-MHz convex transducer in a right subcostal position with a longitudinal orientation. Statistical analyses were performed by using linear regression, paired Student t test, and Bland-Altman analyses. RESULTS: The correlation between the US and radiographic measurements was found to be linear: hemidiaphragmatic mobility = (-1.562 + 1.032) x portal vein branch displacement (r = 0.651, P <.001). The mean craniocaudal displacement of the intrahepatic branches of the portal vein measured at US was 35.2 mm +/- 10.7 (SD). The mean right hemidiaphragmatic mobility measured at radiography was 34.8 mm +/- 17.0. The mean difference between the two measurements was not statistically significant (0.4 mm +/- 12.9, P =.807). CONCLUSION: US measurement of craniocaudal displacement of the left intrahepatic branches of the portal vein can be used for indirect assessment of right hemidiaphragmatic mobility.

Use of tacrolimus in rescue therapy of acute and chronic rejection in liver transplantation

PURPOSE: To study the indications and results of tacrolimus as rescue therapy for acute cellular or chronic rejection in liver transplantation. PATIENTS AND METHODS: Eighteen liver transplant recipients who underwent rescue therapy with tacrolimus between March 1995 and August 1999 were retrospectively studied. The treatment indication, patients, and graft situation were recorded as of October 31st, 1999. The response to tacrolimus was defined as patient survival with a functional graft and histological reversal of acute cellular, or for chronic rejection, bilirubin serum levels decreasing to up to twice the upper normal limit. RESULTS: Fourteen cases (77.8 percent) presented a good response. The response rate for the different indications was: (1) acute cellular + sepsis - 0/1 case; (2) recurrent acute cellular - 1/1 case; (3) OKT3-resistant acute cellular - 2/2 cases; (4) steroid-resistant acute cellular + active viral infection - 3/3 cases; (5) chronic rejection - 8/11 cases (72.7 percent response rate). The 4 patients who did not respond died. CONCLUSION: Tacrolimus rescue therapy was successful in most cases of acute cellular and chronic rejection in liver transplantation

Efeito da escola MELD na mortalidade apos transplante de figado / The effect of MELD on the post liver transplantation mortality rate

A alta mortalidade na lista de espera por transplante de figado (Tx) tem estimulado a adocao de criterios de gravidade...

No evidence of de novo amyloidosis in recipients of domino liver transplantation: 12 to 40 (mean 24) month follow-up.

UNLABELLED: Domino liver transplantation (DLT) has been performed for selected recipients at several centers, but de novo amyloidosis in recipients of livers from patients with familial amyloid polyneuropathy (FAP) remains a serious concern. AIM: To evaluate the occurrence of de novo amyloidosis in recipients of DLT. PATIENTS AND METHODS: Seven recipients of FAP livers were followed for clinical and electroneuromyographic signs of FAP and also for de novo amyloid deposition in the gut. RESULTS: No signs and symptoms of de novo FAP nor any evidence of amyloid deposits in the gut were observed in recipients of DLT after a mean follow-up of 24 [12-40] months. CONCLUSIONS: Signs and symptoms of FAP do not occur early in recipients of DLT. These livers could therefore be offered to patients suitable for conventional LT, particularly older subjects in whom the event of de novo amyloidosis would seem improbable.