Prediction of outcomes for rescue cerclage in cervical insufficiency: A multicenter retrospective study.

Purpose: Cervical insufficiency is a significant risk factor for preterm birth and miscarriage during the second trimester; cervical cerclage is a treatment option. This study seeks to evaluate the predictive roles of various clinical factors and to develop predictive models for immediate and long-term outcomes after rescue cerclage. Methods: We conducted a multicenter retrospective study on patients who underwent rescue cerclage at 14 to 26 weeks of gestation. Data were collected from the Electronic Medical Record systems of participating hospitals. Outcomes were dichotomized into immediate failure (inability to maintain pregnancy for at least 48 hours post-cerclage, gestational latency < 2 days) and long-term success (maintenance of pregnancy until at least 28 weeks of gestation). Clinical factors influencing these outcomes were analyzed. Results: The study included 98 patients. Immediate failure correlated with longer prolapsed membrane lengths, elevated C-reactive protein levels at admission, and extended operation time. The successful maintenance of pregnancy until at least 28 weeks was associated with earlier gestational age at diagnosis, negative AmniSure test results, longer lengths of the functional cervix, and smaller cervical dilatation at the time of cerclage. Binary logistic regression models for immediate failure and long-term success exhibited excellent and good predictive abilities, respectively (AUROC = 0.912, 95% CI: 0.834-0.989; and AUROC = 0.872, 95% CI: 0.788-0.956). Conclusion: The developed logistic regression models offer a valuable tool for the prognostic assessment of patients undergoing rescue cerclage, enabling informed clinical decision-making.

Effects of Dexmedetomidine on Diaphragm Activity Measured by Ultrasonography in Spontaneously Breathing Patients.

Background: Diaphragm movement is well correlated with inspired volume of the lung. Dexmedetomidine (DEX) has less effect on respiratory functions than other sedatives. The objective of this study was to investigate diaphragmatic movement using ultrasound (US) during DEX infusion for sedation in spontaneously breathing patients undergoing unilateral upper limb surgery. Methods: A total of 33 consecutive patients were enrolled in this study. Patients were sedated using DEX with ipsilateral axillary brachial nerve plexus block. Diaphragmatic activity was evaluated using diaphragmatic thickening at end-inspiration (TEI), diaphragmatic thickening at end-expiration (TEE), and diaphragmatic thickening fraction (DTF) measured by diaphragmatic US at three time-points; T0, baseline; T1, after DEX sedation; and T2, after DEX recovery. Supplementary oxygen was applied with a simple mask at 5 L/min. Peripheral oxygen saturation (SpO2), end tidal CO2 (EtCO2), and respiratory rate (RR) were recorded. Results: TEI and TEE showed no significant changes during the study period (P = 0.394 and P = 0.205, respectively). DTF was maintained at both T0 and T1 (P = 1.000). At recovery after DEX infusion discontinued, DTF was increased by 3.85%, although such increase was not statistically significant (T0 vs. T2, P = 0.525). SpO2 remained above 99% and EtCO2 remained below 36 mmHg. Desaturation episodes were not observed during the study period. Conclusions: Results of this study showed that DEX sedation did not affect the diaphragmatic movement in situation of decreased RR induced by DEX. This finding implies that DEX-induced sedation does not result in clinically significant respiratory depression.

Combined B-type Natriuretic Peptide as strong predictor of short-term mortality in patients after Liver Transplantation.

Background: B-type natriuretic peptide (BNP) is a well-known predictor for prognosis in patients with cardiac and renal diseases. However, there is a lack of studies in patients with advanced hepatic disease, especially patients who underwent liver transplantation (LT). We evaluated whether BNP could predict the prognosis of patients who underwent LT. Material and Methods: The data from a total of 187 patients who underwent LT were collected retrospectively. The serum levels of BNP were acquired at four time points, the pre-anhepatic (T1), anhepatic (T2), and neohepatic phases (T3), and on postoperative day 1 (T4). The patients were dichotomized into survival and non-survival groups for 1-month mortality after LT. Combined BNP (cBNP) was calculated based on conditional logistic regression analysis of pairwise serum BNP measurements at two time points, T2 and T4. The area under the receiver operating characteristic curve (AUROC) was analyzed to determine the diagnostic accuracy and cut-off value of the predictive models, including cBNP. Results: Fourteen patients (7.5 %) expired within one month after LT. The leading cause of death was sepsis (N = 9, 64.3 %). The MELD and MELD-Na scores had an acceptable predictive ability for 1-month mortality (AUROC = 0.714, and 0.690, respectively). The BNPs at each time point (T1 - T4) showed excellent predictive ability (AUROC = 0.864, 0.962, 0.913, and 0.963, respectively). The cBNP value had an outstanding predictive ability for 1-month mortality after LT (AUROC = 0.976). The optimal cutoff values for cBNP at T2 and T4 were 137 and 187, respectively. Conclusions: The cBNP model showed the improved predictive ability for mortality within 1-month of LT. It could help clinicians stratify mortality risk and be a useful biomarker in patients undergoing LT.

Predictive Impact of Modified-Prognostic Nutritional Index for Acute Kidney Injury within 1-week after Living Donor Liver Transplantation.

Background. Acute kidney injury (AKI) is one of the common complications after living donor liver transplantation (LDLT) and is associated with increased mortality and morbidity. The prognostic nutritional index (PNI) has been used as a predictive model for postoperative complications. Here, we create a new predictive model based on the PNI and compared its predictive accuracy to other models in patients who underwent LDLT. Material and Methods: The data from 423 patients were collected retrospectively. The patients were dichotomized into the non-AKI and the AKI groups. Multivariate adjustment for significant postoperative variables based on univariate analysis was performed. A new predictive model was created using the results from logistic regression analysis, dubbed the modified-PNI model (mPNI). The area under the receiver operating characteristic curve (AUC) was generated to determine the diagnostic accuracy and cutoff value of individual models. The net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were calculated to investigate diagnostic improvement by the mPNI. Results: Fifty-four patients (12.7 %) were diagnosed with AKI within 1-week after LDLT. The mPNI had the highest predictive accuracy (AUC = 0.823). The model of end-stage liver disease (MELD) scores and PNI were 0.793 and 0.749, respectively, and the INR and serum bilirubin were 0.705 and 0.637, respectively. The differences in the AUCs were statistically significant among the mPNI, PNI, INR, and serum bilirubin. The cutoff value for mPNI was 8.7. The NRI was 10.4% and the IDI was 3.3%. Conclusions: The mPNI predicted AKI within 1-week better than other scoring systems in patients who underwent LDLT. The recommended cutoff value of mPNI is 8.7.

Analysis of pre- and intraoperative clinical for successful operating room extubation after living donor liver transplantation: a retrospective observational cohort study.

BACKGROUND: Early extubation after liver transplantation is safe and accelerates patient recovery. Patients with end-stage liver disease undergo sarcopenic changes, and sarcopenia is associated with postoperative morbidity and mortality. We investigated the impact of core muscle mass on the feasibility of immediate extubation in the operating room (OR) after living donor liver transplantation (LDLT). METHODS: A total of 295 male adult LDLT patients were retrospectively reviewed between January 2011 and December 2017. In total, 40 patients were excluded due to emergency surgery or severe encephalopathy. A total of 255 male LDLT patients were analyzed in this study. According to the OR extubation criteria, the study population was classified into immediate and conventional extubation groups (39.6 vs. 60.4%). Psoas muscle area was estimated using abdominal computed tomography and normalized by height squared (psoas muscle index [PMI]). RESULTS: There were no significant differences in OR extubation rates among the five attending transplant anesthesiologists. The preoperative PMI correlated with respiratory performance. The preoperative PMI was higher in the immediate extubation group than in the conventional extubation group. Potentially significant perioperative factors in the univariate analysis were entered into a multivariate analysis, in which preoperative PMI and intraoperative factors (i.e., continuous renal replacement therapy, significant post-reperfusion syndrome, and fresh frozen plasma transfusion) were associated with OR extubation. The duration of ventilator support and length of intensive care unit stay were shorter in the immediate extubation group than in the conventional extubation group, and the incidence of pneumonia and early allograft dysfunction were also lower in the immediate extubation group. CONCLUSIONS: Our study could improve the accuracy of predictions concerning immediate post-transplant extubation in the OR by introducing preoperative PMI into predictive models for patients who underwent elective LDLT.

Perioperative loss of psoas muscle is associated with patient survival in living donor liver transplantation.

Patients with end-stage liver disease show sarcopenia, and preoperative sarcopenia is independently associated with patient mortality after liver transplantation. However, few studies have examined the relationship between perioperative loss of core muscle and patient mortality in living donor liver transplantation (LDLT). This study was performed to investigate the association between a perioperative decrease in the psoas muscle index (PMI) and patient mortality after LDLT. Adult patients (age ≥ 18 years) undergoing LDLT between January 2009 and December 2016 were classified into low-loss (>25th quartile) versus high-loss (≤25th quartile) groups according to PMI change between the day before surgery and postoperative day (POD) 7. Patient survival was compared between the 2 groups, and factors affecting survival were analyzed. The median (interquartile range) level of PMI change from the day before surgery to POD 7 was -4.8% (-11.7%-1.2%). Although there was no preoperative difference in PMI between the low-loss and high-loss groups, patients with PMI change ≤-11.7% showed poorer survival than those with PMI change >-11.7% during the follow-up period. A PMI decrease ≤-11.7% between the day before surgery and POD 7 is an independent predictor of patient mortality after LDLT. In addition, intraoperative packed red blood cell transfusion, graft fat percentage, and reoperation and infection after surgery were significantly associated with patient mortality. In conclusion, a PMI decrease ≤-11.7% between the day before surgery and POD 7 is an independent predictor of patient mortality after LDLT. It is necessary to identify the factors responsible for the perioperative decrease in skeletal muscle mass and to ascertain if they are modifiable to improve patient survival after LDLT. Liver Transplantation 24 623-633 2018 AASLD.

Predictive Role of Serum Cytokine Profiles in Acute Kidney Injury after Living Donor Liver Transplantation.

INTRODUCTION: Previous studies have shown that a higher serum interleukin- (IL-) 6 level is associated with a higher risk of acute kidney injury (AKI) development after major nontransplant surgery. Our study investigated the potential association of preoperative serum cytokine profiles with new AKI development in patients who underwent living donor liver transplantation (LDLT). METHODS: Serum levels of cytokines IL-2, IL-6, IL-10, IL-12, and IL-17, interferon-γ, and tumor necrosis factor- (TNF-) α were measured in 226 LDLT recipients preoperatively and analyzed retrospectively. Recipients with a preoperative functional impairment of the kidney were excluded. AKI was defined according to Kidney Disease: Improving Global Outcomes (KDIGO) criteria. RESULTS: In a univariate regression model, IL-6, IL-17, and TNF-α levels showed an association with AKI development after LDLT. Multivariate analysis showed an independent association of the preoperative serum IL-6 level with AKI development after LDLT and a significant relationship between higher serum IL-6 levels and a greater likelihood of developing AKI. Serum IL-6 levels were higher in patients with stage 3 AKI than in patients who did not develop AKI. CONCLUSIONS: Our results support the need for further investigations of IL-6 as a predictor of AKI development in patients undergoing LDLT.

Predictive Ability of Perfusion Index for Determining the Success of Adductor Canal Nerve Block for Postoperative Analgesia in Patients Undergoing Unilateral Total Knee Arthroplasty.

BACKGROUND: The perfusion index (PI) is an objective method used to determine a successful nerve block. This study aimed to investigate the prognostic ability of the PI for a successful adductor canal nerve block (ACB) and suggest the optimal PI cut-off value for predicting a block. METHODS: This study was a prospective observational study and enrolled a total of 39 patients. The patients were dichotomized into successful and inappropriate ACB groups according to the results of the sensation tests. The PI value, Pleth variability index (PVi) value, and heart rate were recorded one minute before the block, at the time of the block, and one to 30 min after the block at one-minute intervals. Delta (dPI), which was defined as the difference in PI value from the baseline (the value one minute before the block), was the primary outcome. The area under the receiver operating characteristic curve (AUROC) was calculated to determine the dPI prognostic accuracy and optimal cut-off value. RESULTS: Successful ACB was achieved in 33 patients, while ACB was inappropriate in six patients. The dPI showed significant differences between the two groups under the time interval measured (p = 0.001). The dPI at 5 and 20 min showed good prognostic ability for a successful block, with optimal cut-off values of 0.33 (AUROC: 0.725, 95% CI 0.499-0.951) and 0.64 (AUROC: 0.813, 95% CI 0.599-1.000), respectively. CONCLUSIONS: The dPI is an effective predictor of successful ACB. The suggested dPI cut-off values at 5 and 20 min were below 0.33 and 0.64, respectively.

Acute mental change as the presenting sign of posthepatectomy hepatic failure: A case report.

RATIONALE: Hepatectomy is a treatment to increase survival and curability of patients with intrahepatic lesions or malignant tumors. However, posthepatectomy liver failure (PHLF) can occur. This case is a patient showing acute mental change in postanesthetic care unit (PACU) as an uncommon symptom of PHLF after extended right hepatectomy. PATIENT CONCERNS: A 68-year-old male patient was admitted for surgery of Klatskin tumor. He had hypertension and atrial fibrillation. His model for end-stage liver disease score was 16 pts. His serum bilirubin and ammonia levels were 4.75 mg/dL and 132.8 mcg/dL, respectively. Other laboratory data were nonspecific. He underwent extended right hepatic lobectomy including segments IV-VIII for 9 hours. Weight of liver specimen was 1028 g which was about 58% of total liver volume based on computed tomographic volumetry. The patient was extubated and moved to the PACU with stable vital sign and regular self-breathing. He could obey verbal commands. Fifteen minutes after admission to the PACU, the patient showed abruptly decreasing mental status and self-breathing. DIAGNOSES: Brain computed tomography, blood culture, and sputum culture were performed to diagnose brain lesions and sepsis for evaluating the sudden onset comatous mental status. Results showed nonspecific finding. INTERVENTIONS: He was intubated for securing airway and applying ventilatory care. The patient was moved to the intensive care unit. He received intensive conservative therapy including continuous renal replacement therapy and broad-spectrum antibiotics. OUTCOMES: The patient's condition was worsened. He expired on postoperative day 3. LESSONS: Acute mental change is uncommon and rare as initial symptoms of PHLF. Therefore, clinician may overlook the diagnosis of PHLF in patients with acute mental change after hepatectomy. Thus, clinician should plan an aggressive treatment for PHLF including liver transplantation by recognizing any suspicious symptom, although such symptom is rare.

Ischemic time of graft liver forces Th1-to-Th2 activity toward Th1 activity in patients who underwent living donor liver transplantation.

Recipient's immune responses are an important factor in allograft survival in transplantation. Cytokines are reflected with immune responses. In the present study, we aimed to evaluate potential affecting factors of liver allograft survival and their possible correlation with seroum cytokine levels in living donor liver transplantation (LDLT). One hundred and seventy-one adult patients' data were collected retrospectively. Five cytokines were collected: interferon (IFN)-γ, interleukin (IL)-2, IL-10, IL-6, and IL-17. Ischemic time of liver grafts was divided into two periods: cold and warm ischemic times (CIT and WIT, respectively). CIT had no statically significant correlation, but WIT showed a significant correlation with IFN-γ, IL-2, and IL-17 serum levels (r = 0.0252, 0.282, 0.178, respectively; P < 0.05). WIT was dichotomized as T1 (<22 min), T2 (22-70 min), and T3 (>70 min). IFN-γ was significantly increased in T2 and T3 as compared to T1. IL-6 was in T3 compared to T1 and T2. IL-17 was in T3 compared to T1. For the Th1-to-Th2 ratio, IFN-γ/IL-10, IFN-γ/IL-6, and IL-2/IL-10 were significantly different in T2 and T3 as compared to T1, and also in T3 as compared to T2. Th1 cell activities were enhanced with increased WIT. In conclusion, the longer WIT (>70 min) in LDLT is more likely to induce immunological reactions of recipients by leading to a deleterious cytokine balances in favor of an reinforced production of Th1 cytokines.

Serum Tumor Necrosis Factor-α Is Inversely Associated With the Psoas Muscle Index in Both Male and Female Patients Scheduled for Living Donor Liver Transplantation.

BACKGROUND: Patients on a waiting list for liver transplantation frequently show core muscle wasting, referred to as sarcopenia, which results in poor prognosis. To date, there has been a lack of research on the association between inflammation mediators, including cytokines, and loss of core muscle mass in cirrhotic patients scheduled for living donor liver transplantation (LDLT). METHODS: Cytokines in serum, such as interleukin (IL)-2, IL-6, IL-10, IL-12, IL-17, interferon-γ, and tumor necrosis factor (TNF)-α, were retrospectively investigated in 234 LDLT patients 1 day before surgery. The psoas muscle area was measured using abdominal computed tomography within 1 month before surgery and used to calculate the psoas muscle index (PMI = psoas muscle area/height2). The study population was classified into 2 groups according to the interquartile range of PMI: a non-sarcopenia group (> 25th quartile) and a sarcopenia group (≤ 25th quartile) in each sex. RESULTS: In both sexes, IL-10 and TNF-α levels were significantly higher in the sarcopenia group than the non-sarcopenia group. In a univariate analysis, male patients showed that serum IL-10 and TNF-α levels were potentially associated with sarcopenia. Serum TNF-α was independently associated with sarcopenia in a multivariate analysis. In female patients, TNF-α was significantly associated with sarcopenia in both univariate and multivariate analyses. Male patients with a PMI ≤ 25th quartile had significantly higher TNF-α levels than those in other quartile ranges, and female patients with a PMI ≤ 25th quartile had a significantly higher TNF-α level than those with a PMI > 75th quartile. CONCLUSIONS: Serum levels of TNF-α are inversely associated with skeletal muscle wasting in both male and female patients scheduled for LDLT.

The 2016 ASE/EACVI recommendations may be able to more accurately identify patients at risk for diastolic dysfunction in living donor liver transplantation.

BACKGROUND: The aim of this study was to compare the prevalence of diastolic dysfunction between the 2016 American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging and 2009 ASE/European Association of Echocardiography recommendations in patients undergoing living-donor liver transplantation (LDLT). PATIENTS AND METHODS: A total of 312 adult patients who underwent LDLT at our hospital from January 2010 to December 2017 were retrospectively analyzed. Exclusion criteria were systolic dysfunction, arrhythmia, myocardial ischemia, and mitral or aortic valvular insufficiency. RESULTS: The study population was largely male (68.3%), and the median age was 54 (49-59) years. The median model for end-stage liver disease score was 12 (6-22) points. A predominant difference in the prevalence rates of diastolic dysfunction was observed between the two recommendations. The prevalence rates of diastolic dysfunction and indeterminate diastolic function were lower according to the 2016 recommendations than the 2009 recommendations. The level of concordance between the two recommendations was poor. The proportion of patients with a high brain natriuretic peptide level (> 100 pg/mL) decreased significantly during surgery in the normal and indeterminate groups according to the 2009 recommendations; however, only the normal group showed an intraoperative decrease in the proportion according to the 2016 recommendations. Patients with diastolic dysfunction showed a poorer overall-survival rate than those with normal function according to both recommendations. However, there was a difference in the survival rate in the indeterminate group between the two recommendations. A significant difference in patient survival rate was observed between the dysfunction and indeterminate groups according to the 2009 recommendations; however, the difference was not significant in the 2016 recommendations. CONCLUSIONS: The 2016 classification may be better able to identify patients with a risk for diastolic dysfunction. Particularly, patients in the 2016 indeterminate group seemed to require a cardiac diastolic functional evaluation more frequently during and after surgery than those in the 2009 indeterminate group.

Recovery of the Psoas Muscle Index in Living Donors after a Right Lobe Hepatectomy for Liver Transplantation: A Single-Center Experience.

OBJECTIVE: The development of sarcopenia leads to adverse postoperative outcomes. However, no study has investigated perioperative loss in core muscle and the correlation between core muscle and residual liver volume in living donors for liver transplant. PATIENTS AND METHODS: A total of 457 adult healthy donors who underwent a right lobe hepatectomy without the middle hepatic vein for elective liver transplant were retrospectively analyzed. Abdominal computed tomography was performed within 1 month before surgery and the first week and 3 months after the surgery. The average psoas muscle area between lumbar vertebrae 3 and 4 was measured and normalized by height squared (psoas muscle index [PMI] = psoas muscle area/height2). The initial whole liver volume and remnant left lobe volume were measured on computed tomography images. RESULTS: The study cohort included 279 men (61.1%) and 178 women (38.9%). The median preoperative PMIs were 420.9 mm2/m2 (interquartile range, 360.6-487.0 mm2/m2) in men and 280.9 mm2/m2 (interquartile range, 243.5-318.7 mm2/m2) in women. The PMIs in men and women significantly decreased during the first week after surgery, and gradually recovered to preoperative levels during the first 3 months after surgery. Based on the ratio between the remnant left lobe and initial whole liver volume (≥30%), the increase in remnant left lobe volume was not correlated with the decrease in PMI on postoperative day 7. A postoperative U-shaped recovery in the core muscles was present in both male and female donors, independent of the remnant liver ratio. CONCLUSIONS: Despite the requirements of partial liver regeneration and surgical wound repair, healthy donors did not suffer from sustained core muscle loss after surgery.

Role of serum levels of intraoperative brain natriuretic peptide for predicting acute kidney injury in living donor liver transplantation.

BACKGROUND: Patients with end-stage liver disease frequently experience acute kidney injury (AKI) after living donor liver transplantation (LDLT). Serum levels of brain natriuretic peptide (BNP) have increasingly been accepted as a predictor of AKI in clinical settings. This study investigated the predictive role of intraoperative BNP levels in the early development of AKI after LDLT. PATIENTS AND METHODS: Adult patients (≥19 years old) who had undergone elective LDLT from January 2011 to December 2017 were classified into the non-AKI and AKI groups according to the Kidney Disease: Improving Global Outcomes criteria. Serum levels of BNP were measured three times in the preanhepatic, anhepatic, and neohepatic phases. Perioperative data in recipients and donors were analyzed retrospectively. RESULTS: Sixty-one patients (22.4%) suffered from AKI immediately after LDLT. Severity according to AKI stage was as follows: 28 patients in stage 1 (10.3%), 18 patients in stage 2 (6.6%), and 15 patients in stage 3 (5.5%). In the neohepatic phase, both BNP levels and proportions of patients with high BNP levels (≥100 pg/mL) were higher in the AKI group than in the non-AKI group. Only BNP levels in the non-AKI and AKI stage 1 groups significantly decreased from the preanhepatic phase to the neohepatic phase; those in AKI stages 2 and 3 groups did not. In particular, BNP levels of all AKI stage 3 patients increased to more than 100 pg/mL, and the proportion of patients with high levels also increased significantly through the surgical phases in the AKI stage 3 group. In multivariate analyses, BNP levels in the neohepatic phase were significantly associated with early development of AKI after LDLT, as well as the total amount of packed red blood cells in transfusions and total duration of graft ischemia. CONCLUSIONS: Monitoring serum levels of BNP is useful for predicting the early development of AKI after LDLT.

Comparison of Liver Graft Regeneration Between ABO-Compatible and ABO-Incompatible Living Donor Liver Transplantation: A Propensity Score Matching Analysis.

BACKGROUND ABO-incompatible (ABOi) living donor liver transplantation (LDLT) was accepted as a feasible therapy for end-stage liver disease after the introduction of rituximab. The present study investigated the association between ABO incompatibility and graft regeneration in patients who underwent LDLT. MATERIAL AND METHODS A total of 335 adult patients who underwent elective LDLT were divided into ABO-compatible (ABOc) and ABOi LDLT groups using propensity score (PS) matching of graft regeneration-related factors. Postoperative serial changes in graft volumes were compared between the groups. The factors associated with graft volume on postoperative day (POD) 21 were investigated in patients who underwent ABOi LDLT. RESULTS In total, 300 (89.6%) patients underwent ABOc LDLT and 35 (10.4%) patients underwent ABOi LDLT. After PS matching, the ABOc and ABOi groups each included 32 paired patients. The absolute liver graft volumes on POD 21 were significantly lower in the ABOi group than those in the ABOc group in the PS-matched patients (1098.4 [964.0-1,162.0] vs. 1202.0 [1107.8-1455.2] mL; p=0.007). Major complications, including overall patient mortality during the follow-up period, did not differ between the groups. In patients who underwent ABOi LDLT, the preoperative graft volume/standard liver volume ratio and CD4+ cell level on POD 14 were independent factors related to liver graft volume on POD 21. CONCLUSIONS These results suggest that ABO incompatibility could affect postoperative liver graft regeneration. Therefore, graft regeneration must be investigated using a volumetric assessment in patients who have undergone ABOi LDLT.

Graft Regeneration and Functional Recovery in Patients with Early Allograft Dysfunction After Living-Donor Liver Transplantation.

BACKGROUND Successful graft regeneration is important in living-donor liver transplantation (LDLT) because partial liver grafts are used. Early allograft dysfunction (EAD) is an intermediate outcome that affects the long-term postoperative course in liver transplantation. The aim of the present study was to investigate liver graft regeneration under EAD development in LDLT. MATERIAL AND METHODS The data of 226 patients who underwent LDLT from September 2010 to July 2014 were retrospectively analyzed. The patients were classified into 2 groups: one with and one without EAD. Graft regeneration, functional recovery, and long-term patient survival were compared between the 2 groups. RESULTS The grafts grew more vigorously in the EAD group than in the non-EAD group, as evidenced by the larger absolute (ALV) and relative liver volumes (RLV) of the former on postoperative days (POD) 7 and 21. The median (interquartile range) RLVs of the non-EAD group versus the EAD group were as follows: 55.2 (47.9-65.8) vs. 53.7 (46.6-64.5)% preoperatively, p>0.05; 76.1 (66.9-85.7) vs. 86.7 (73.9-96.8)% on POD 7, p<0.01; 79.6 (69.3-91.2) vs. 93.7 (79.6-101.6)%, p<0.01 on POD 21. In the early postoperative period, hepatic function, measured as total bilirubin and international normalized ratio, was higher in the EAD group; however, after EAD development, graft function recovered in these patients. In the follow-up period, overall patient survival was comparable between the 2 groups. CONCLUSIONS The liver grafts of EAD patients steadily regenerated, such that the development of EAD did not affect long-term patient survival after LDLT.

The impact of serum cytokines in the development of early allograft dysfunction in living donor liver transplantation.

Early allograft dysfunction (EAD) is considered a precursor to graft loss in liver transplantation. To date, the use of preoperative serum cytokine profiles to predict EAD development has not been systematically investigated in living donor liver transplantation (LDLT). Here, we investigated the association between preoperative serum cytokine profiles and EAD development in LDLT patients.Serum cytokine profiles collected preoperatively and on postoperative day 7 were retrospectively reviewed. The specific serum cytokines analyzed included interleukin (IL)-2, IL-6, IL-10, IL-12, IL-17, interferon (IFN)-γ, and tumor necrosis factor (TNF)-α. The cytokine levels of patients with EAD were compared with those of patients without EAD and the impact of cytokine levels on the occurrence of EAD was evaluated.Preoperatively, the serum levels of IL-6, 10, 17, and TNF-α were significantly higher in the EAD group than in the non-EAD group. In univariate logistic analysis, the preoperative levels of IL-6, IL-10, IL-17, IFN-γ, and TNF-α were potentially associated with EAD development. After multivariate logistic analysis, higher preoperative serum levels of IL-6 and 17 were significantly associated with EAD development. In addition, the incidence of EAD increased as the preoperative serum levels of IL-6 and IL-17 increased.Preoperative serum levels of IL-6 and IL-17 were significantly associated with EAD development in LDLT.

Serum interleukin-6 and tumor necrosis factor-α are associated with early graft regeneration after living donor liver transplantation.

BACKGROUND: Liver graft regeneration is orchestrated by specific and sequential stimuli, including hepatocyte growth factors, cytokines, and catecholamines. We evaluated the association between preoperative serum cytokines and early liver graft regeneration in human living donor liver transplantation (LDLT). PATIENTS AND METHODS: We retrospectively reviewed the data of adult patients who underwent LDLT from January 2010 to December 2014. Serum cytokines, including interleukin (IL)-2, 6, 10, 12, 17, interferon (IFN)-γ and tumor necrosis factor (TNF)-α were measured in the recipients 1 day before surgery and on postoperative day (POD) 7. Liver graft volume was estimated using abdominal computed tomography images of the donors and recipients. RESULTS: In total, 226 patients were analyzed in this study. Median preoperative levels of serum cytokines were as follows: IL-2, 0.1 (0.1-1.6) pg/mL; IL-6, 7.3 (0.1-30.2) pg/mL; IL-10, 0.5 (0.1-11.0) pg/mL; IL-12, 0.1 (0.1-0.1) pg/mL; IL-17, 2.0 (0.1-16.4) pg/mL; IFN-γ, 3.2 (0.1-16.0) pg/mL; and TNF-α, 9.8 (5.4-17.9) pg/mL. Higher preoperative serum levels of IL-6, IL-10, and TNF-α, dichotomized at the median, were associated with increased relative liver volumes by POD 7. Multivariate analysis revealed that higher levels of serum IL-6 and TNF-α were independently associated with increased graft volume during the first 1 week after LDLT, based on the lower levels of those cytokines. CONCLUSIONS: IL-6 and TNF-α were important mediators of the success of early graft regeneration in patients who underwent LDLT.

Proposal for a New Predictive Model of Short-Term Mortality After Living Donor Liver Transplantation due to Acute Liver Failure.

BACKGROUND Acute liver failure (ALF) is known to be a rapidly progressive and fatal disease. Various models which could help to estimate the post-transplant outcome for ALF have been developed; however, none of them have been proved to be the definitive predictive model of accuracy. We suggest a new predictive model, and investigated which model has the highest predictive accuracy for the short-term outcome in patients who underwent living donor liver transplantation (LDLT) due to ALF. MATERIAL AND METHODS Data from a total 88 patients were collected retrospectively. King's College Hospital criteria (KCH), Child-Turcotte-Pugh (CTP) classification, and model for end-stage liver disease (MELD) score were calculated. Univariate analysis was performed, and then multivariate statistical adjustment for preoperative variables of ALF prognosis was performed. A new predictive model was developed, called the MELD conjugated serum phosphorus model (MELD-p). The individual diagnostic accuracy and cut-off value of models in predicting 3-month post-transplant mortality were evaluated using the area under the receiver operating characteristic curve (AUC). The difference in AUC between MELD-p and the other models was analyzed. The diagnostic improvement in MELD-p was assessed using the net reclassification improvement (NRI) and integrated discrimination improvement (IDI). RESULTS The MELD-p and MELD scores had high predictive accuracy (AUC >0.9). KCH and serum phosphorus had an acceptable predictive ability (AUC >0.7). The CTP classification failed to show discriminative accuracy in predicting 3-month post-transplant mortality. The difference in AUC between MELD-p and the other models had statistically significant associations with CTP and KCH. The cut-off value of MELD-p was 3.98 for predicting 3-month post-transplant mortality. The NRI was 9.9% and the IDI was 2.9%. CONCLUSIONS MELD-p score can predict 3-month post-transplant mortality better than other scoring systems after LDLT due to ALF. The recommended cut-off value of MELD-p is 3.98.

Practice guidelines for propofol sedation by non-anesthesiologists: the Korean Society of Anesthesiologists Task Force recommendations on propofol sedation.

In South Korea, as in many other countries, propofol sedation is performed by practitioners across a broad range of specialties in our country. However, this has led to significant variation in propofol sedation practices, as shown in a series of reports by the Korean Society of Anesthesiologists (KSA). This has led the KSA to develop a set of evidence-based practical guidelines for propofol sedation by non-anesthesiologists. Here, we provide a set of recommendations for propofol sedation, with the aim of ensuring patient safety in a variety of clinical settings. The subjects of the guidelines are patients aged ≥ 18 years who were receiving diagnostic or therapeutic procedures under propofol sedation in a variety of hospital classes. The committee developed the guidelines via a de novo method, using key questions created across 10 sub-themes for data collection as well as evidence from the literature. In addition, meta-analyses were performed for three key questions. Recommendations were made based on the available evidence, and graded according to the modified Grading of Recommendations Assessment, Development and Evaluation system. Draft guidelines were scrutinized and discussed by advisory panels, and agreement was achieved via the Delphi consensus process. The guidelines contain 33 recommendations that have been endorsed by the KSA Executive Committee. These guidelines are not a legal standard of care and are not absolute requirements; rather they are recommendations that may be adopted, modified, or rejected according to clinical considerations.