Factors to consider during anesthesia in patients undergoing preemptive kidney transplantation: a propensity-score matched analysis.

BACKGROUND: International guidelines have recommended preemptive kidney transplantation (KT) as the preferred approach, advocating for transplantation before the initiation of dialysis. This approach is advantageous for graft and patient survival by avoiding dialysis-related complications. However, recipients of preemptive KT may undergo anesthesia without the opportunity to optimize volume status or correct metabolic disturbances associated with end-stage renal disease. In these regard, we aimed to investigate the anesthetic events that occur more frequently during preemptive KT compared to nonpreemptive KT. METHODS: This is a single-center retrospective study. Of the 672 patients who underwent Living donor KT (LDKT), 388 of 519 who underwent nonpreemptive KT were matched with 153 of 153 who underwent preemptive KT using propensity score based on preoperative covariates. The primary outcome was intraoperative hypotension defined as area under the threshold (AUT), with a threshold set at a mean arterial blood pressure below 70 mmHg. The secondary outcomes were intraoperative metabolic acidosis estimated by base excess and serum bicarbonate, electrolyte imbalance, the use of inotropes or vasopressors, intraoperative transfusion, immediate graft function evaluated by the nadir creatinine, and re-operation due to bleeding. RESULTS: After propensity score matching, we analyzed 388 and 153 patients in non-preemptive and preemptive groups. The multivariable analysis revealed the AUT of the preemptive group to be significantly greater than that of the nonpreemptive group (mean ± standard deviation, 29.7 ± 61.5 and 14.5 ± 37.7, respectively, P = 0.007). Metabolic acidosis was more severe in the preemptive group compared to the nonpreemptive group. The differences in the nadir creatinine value and times to nadir creatinine were statistically significant, but clinically insignificant. CONCLUSION: Intraoperative hypotension and metabolic acidosis occurred more frequently in the preemptive group during LDKT. These findings highlight the need for anesthesiologists to be prepared and vigilant in managing these events during surgery.

Blood Salvage and Autotransfusion With Single Leukoreduction Does Not Increase the Risk of Tumor Recurrence After Liver Transplantation for Advanced Hepatocellular Carcinoma.

OBJECTIVE: The aim of this study was to determine whether autotransfusion of salvaged blood with single leukoreduction is associated with post-transplant tumor recurrence in patients with advanced hepatocellular carcinoma (HCC). BACKGROUND: Previous studies have consistently demonstrated the safety of autotransfusion of salvaged and leukoreduced blood during liver transplantation for HCC. However, the effects of this technique remained unknown for advanced HCC. METHODS: Of 349 patients who underwent living donor liver transplantation for advanced HCC: 74 of 129 without autotransfusion were matched with 74 of 220 with autotransfusion using propensity score based on tumor biology, allogeneic transfusion, and others. Survival analysis was performed with death as a competing risk event. The primary outcome was HCC recurrence. RESULTS: Recipients in autotransfusion group received 811 (497-1247) mL of salvaged blood with single leukoreduction. In the matched cohort, cumulative overall recurrence probability at 1/2/5 years after transplantation was 24.6%/ 38.3%/39.7% for nonautotransfusion group and 16.2%/23.1%/32.5% for autotransfusion group. There were no significant differences between the 2 groups in overall recurrence [hazard ratio (HR) = 0.72 (0.43-1.21)], intrahepatic recurrence [HR = 0.70 (0.35-1.40)], and extrahepatic recurrence [HR = 0.82 (0.46-1.47)]. Also, there were no significant differences in overall death [HR = 0.57 (0.29-1.12)], HCC-related death [HR = 0.59 (0.29-1.20)], and HCC-unrelated death [HR = 0.48 (0.09-2.65)]. CONCLUSIONS: When allogeneic transfusion was matched, autotransfusion was not significantly related to HCC recurrence, with more favorable probabilities for autotransfusion, in patients with advanced HCC. Thus, blood salvage and autotransfusion could be safely used with single leukoreduction, without double-filtered leukoreduction, during liver transplantation for HCC with potential benefits from avoiding allogeneic red blood cell transfusion.

Hemodynamic Implications of Carbon Monoxide (CO) and Nitrogen Oxide (NO) during Living Donor Liver Transplantation.

Carbon monoxide (CO) and nitrogen oxide (NO) affect vasodilation and cause hemodynamic change. Hemodynamic instability due to liver transplantation may result in poor prognosis of graft. This study investigated the hemodynamic implications of CO and NO levels measured using carboxyhemoglobin (COHb) and methemoglobin (MetHb) during living donor liver transplantation (LDLT). The hemodynamic instability with a pressor dose (norepinephrine equivalent) was estimated 1 hour after graft reperfusion. COHb and MetHb were used as indexes of CO and NO, and were measured using an arterial blood gas analyzer. One hundred and ten recipients who underwent LDLT from May 2011 to July 2013 were selected. Recipients were divided into high (≥ 1.9%) and low (< 1.9%) COHb groups with COHb concentrations at 5 minutes after reperfusion. Recipients were also divided into high (≥ 0.4%) and low (< 0.4%) MetHb groups with MetHb concentrations at 30 minutes after reperfusion. Data are presented as mean ± standard deviation or number (percentage). Model for End-stage Liver Disease (MELD) scores were different for the two COHb groups (low: 13.4 ± 9.0 vs. high: 19.7 ± 10.6, p < 0.001), and pressor doses adjusted by MELD scores were also different between the two COHb groups (low: 0.09 ± 0.01 µg/kg/min vs. high: 0.14 ± 0.01 µg/kg/min, p = 0.029). By contrast, pressor doses and MELD scores were not different between the two MetHb groups. In conclusion, CO rather than NO has hemodynamic implications during LDLT. Therefore, the increase in COHb during LDLT is predictive of hemodynamic instability.

Safety of the Use of Blood Salvage and Autotransfusion During Liver Transplantation for Hepatocellular Carcinoma.

OBJECTIVE: To determine whether autotransfusion of red blood cells (RBCs) salvaged during liver transplantation is associated with the recurrence of hepatocellular carcinoma (HCC). BACKGROUND: Blood salvage is widely used during liver transplantation to reinfuse salvaged autologous RBCs and reduce allogeneic transfusion. However, the reintroduction of cancer cells via autotransfusion is a major concern in HCC patients. METHODS: Among 397 patients who underwent living-donor liver transplantation for HCC, 97 of 114 recipients without intraoperative autotransfusion were matched with 222 of 283 recipients with intraoperative autotransfusion with unfixed matching ratio using the propensity score based on age, sex, allogeneic transfusion, immunosuppression, tumor biology, and others. Competing risks Cox regression was used to compare HCC recurrence risk of the 2 paired groups. RESULTS: Recipients in autotransfusion group received 1177 ±â€Š1318 mL of salvaged RBCs during surgery. A leukocyte depletion filter was used for all autotransfused RBCs. Cumulative HCC recurrence rate at 1, 2, and 5 years after transplantation were 10.4% (5.3%-17.6%), 19.1% (11.6%-28.0%), and 24.1% (15.2%-34.0%) for nonautotransfusion group and 10.8% (7.2%-15.4%), 14.9% (10.5%-20.0%), and 20.3% (14.9%-26.4%) for autotransfusion group, respectively. Autotransfusion versus nonautotransfusion group was not significantly different in overall recurrence [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.47-1.53, P = 0.579] and intrahepatic recurrence (HR 0.75, 95% CI 0.36-1.56) or extrahepatic recurrence (HR 1.00, 95% CI 0.49-2.04). CONCLUSIONS: We found no evidence of a significant impact of autotransfusion on posttransplant HCC recurrence. Thus, salvaged and filtered RBCs could be used in HCC patients undergoing liver transplantation with potential benefits from avoiding allogeneic RBCs transfusion and its complications.

Association Between Intraoperative Platelet Transfusion and Early Graft Regeneration in Living Donor Liver Transplantation.

OBJECTIVE: To evaluate the association between anesthetic management before and after graft reperfusion and early graft regeneration in living donor liver transplantation (LDLT). BACKGROUND: Sufficient graft regeneration is essential for the success of LDLT. Diverse signals start to trigger liver regeneration immediately after graft reperfusion. METHODS: Graft volume at 14 ±â€Š2 days after LDLT was measured in 379 consecutive recipients using computed tomography images with 3-dimensional reconstruction. The association between anesthetic variables and the degree of graft regeneration for 2 weeks was analyzed using simple and multiple linear regressions. The anesthetic variables included hemodynamics, laboratory measurements, vasoactive drugs, and blood products transfusion. RESULTS: The degree of graft regeneration for 2 weeks was 52% in median and ranged from 5% to 123%. Platelet transfusion was identified as the sole independent anesthetic factor contributing to graft regeneration. Platelet concentrate transfusion of 1 to 6 units vs none was correlated with a 6.5% increase in graft regeneration (P = 0.012). Platelet concentrate transfusion of more than 6 units vs none was further correlated with an 18.4% increase in regeneration (P < 0.001). In the subgroup of recipients without intraoperative platelet transfusion, mean platelet count measured during the intraoperative reperfusion phase was positively associated with graft regeneration (P = 0.033). CONCLUSIONS: Graft regeneration after LDLT increased in relation to a graded increase in the amount of transfused platelets and higher postreperfusion platelet counts during surgery. These results offer additional evidence regarding the important role of platelets in initiating liver regeneration and, furthermore, the indications for and the benefits vs risks of platelet transfusion during LDLT.

Microsteatosis may not interact with macrosteatosis in living donor liver transplantation.

BACKGROUND & AIMS: The insignificance of pure microsteatosis (MiS) was reported in living donor liver transplantation (LDLT). However, since steatosis is mostly found in a mixed form of microsteatosis (MiS) and macrosteatosis (MaS), we aimed to determine the importance of MiS mixed with MaS in LDLT. METHODS: Donor matching and recipient matching were independently performed with unfixed matching ratios. In donor matching, 51 donors with high (⩾30%) MiS mixed with MaS (H-MiS) were matched with 160 donors with low (⩽10%) MiS mixed with MaS (L-MiS), based on MaS degree, remnant liver volume, and others. In recipient matching, 50 recipients who received H-MiS grafts were matched with 176 recipients who received L-MiS grafts, based on MaS degree, graft volume, MELD score, and others. RESULTS: The median MiS degree was 10% (range 0%-10%) vs. 35% (range 30%-80%) in L-MiS livers vs. H-MiS livers after both matching. L-MiS and H-MiS donors were not significantly different regarding postoperative biochemical liver function (e.g. peak AST 232 vs. 246 IU/L, p=0.931). L-MiS and H-MiS recipients were not significantly different regarding 2-week graft regeneration (51% for both) and 5-year survival (HR 0.87, 95% CI 0.43-1.76, p=0.699). Post-transplant donor/recipient complication rates were not significantly different, either. CONCLUSIONS: There were no evidences of a significant impact of MiS mixed with MaS on post-LDLT outcomes. The results suggest less importance of MiS, and further indicate that there is no interaction between MiS and MaS. Thus, the risk of steatosis may be determined by the relative composition of MiS and MaS, rather than the total quantitative degree.

Glycemic responses to intermittent hepatic inflow occlusion in living liver donors.

The occurrence of glycemic disturbances has been described for patients undergoing intermittent hepatic inflow occlusion (IHIO) for tumor removal. However, the glycemic responses to IHIO in living liver donors are unknown. This study investigated the glycemic response to IHIO in these patients and examined the association between this procedure and the occurrence of hyperglycemia (blood glucose > 180 mg/dL). The data from 154 living donors were retrospectively reviewed. The decision to perform IHIO was made on the basis of the extent of bleeding that occurred during parenchymal dissection. One round of IHIO consisted of 15 minutes of clamping and 5 minutes of unclamping the hepatic artery and portal vein. Blood glucose concentrations were measured at predetermined time points, including the start and end of IHIO. Repeated hyperglycemic episodes occurred after unclamping. The mean maximum intraoperative blood glucose concentration was greater in donors who underwent ≥3 rounds of IHIO versus those who underwent 1 or 2 rounds (169 ± 30 versus 149 ± 31 mg/dL, P = 0.005). The incidence of intraoperative hyperglycemia was also greater in donors who underwent ≥3 rounds of IHIO versus those who underwent 1 or 2 rounds (38.7% versus 7.7%, odds ratio = 7.1, 95% confidence interval = 2.5-20.4, P < 0.001). Donors who did not undergo IHIO and those who underwent 1 or 2 rounds of IHIO exhibited similar maximum glucose concentrations and similar incidence rates of hyperglycemia. In conclusion, IHIO induced repeated hyperglycemic responses in living donors, and donors who underwent ≥3 rounds of IHIO were more likely to experience intraoperative hyperglycemia. These results provide additional information on the risks and benefits of IHIO in living donors.

Macrosteatotic and nonmacrosteatotic grafts respond differently to intermittent hepatic inflow occlusion: Comparison of recipient survival.

Intermittent hepatic inflow occlusion (IHIO) during liver graft procurement is known to confer protection against graft ischemia/reperfusion injury and thus may benefit the recipient's outcome. We evaluated whether the protective effect of IHIO differs with the presence of macrosteatosis (MaS) and with an increase or decrease in the cumulative occlusion time. The subgroup of 188 recipients who received grafts with MaS was divided into 3 groups according to the number of total IHIO rounds during graft procurement: no IHIO, n = 70; 1 to 2 rounds of IHIO, n = 50; and ≥3 rounds of IHIO, n = 68. Likewise, the subgroup of 200 recipients who received grafts without MaS was divided into 3 groups: no IHIO, n = 108; 1 to 2 rounds of IHIO, n = 40; and ≥3 rounds of IHIO, n = 52. The Cox model was applied to evaluate the association between the number of total IHIO rounds and recipient survival separately in the subgroup of MaS recipients and the subgroup of non-MaS recipients. Analyzed covariables included the etiology, Milan criteria, transfusion, immunosuppression, and others. In the subgroup of MaS recipients, 1 to 2 rounds of IHIO were favorably associated with recipient survival [hazard ratio (HR), 0.29; 95% confidence interval (CI), 0.10-0.80; P = 0.03 after Bonferroni correction], whereas ≥3 rounds of IHIO were not associated with recipient survival (HR, 0.56; 95% CI, 0.25-1.23). In the subgroup of non-MaS recipients, neither 1 to 2 rounds of IHIO (HR, 0.69; 95% CI, 0.30-1.61) nor ≥3 rounds of IHIO (HR, 0.91; 95% CI, 0.42-1.96) were associated with recipient survival. In conclusion, 1 to 2 rounds of IHIO may be used for the procurement of MaS grafts with potential benefit for recipient survival, whereas IHIO has a limited impact on recipient survival regardless of the cumulative occlusion time when it is used for non-MaS grafts.

Comparison of the tolerance of hepatic ischemia/reperfusion injury in living donors: macrosteatosis versus microsteatosis.

A safe use of intermittent hepatic inflow occlusion (IHIO) has been reported for living donor hepatectomy. However, it remains unclear whether the maneuver is safe in steatotic donors. In addition, the respective importance of macrosteatosis (MaS) and microsteatosis (MiS) is an important issue. Thus, we compared MiS and MaS with respect to the tolerance of hepatic ischemia/reperfusion (IR) injury induced by IHIO. One hundred forty-four donors who underwent a right hepatectomy were grouped according to the presence of MaS and MiS: a non-MaS group (n = 68) versus an MaS group (n = 76) and a non-MiS group (n = 51) versus an MiS group (n = 93). The coefficients of the regression lines between the cumulative IHIO time and the peak postoperative transaminase concentrations were used as surrogate parameters indicating the tolerance of hepatic IR injury. The coefficients were significantly greater for the MaS group versus the non-MaS group (4.12 ± 0.59 versus 2.22 ± 0.46 for alanine aminotransferase, P = 0.01). Conversely, the MiS and non-MiS groups were comparable. A subgroup analysis of donors who underwent IHIO for >30 minutes showed that MaS significantly increased the transaminase concentrations, whereas MiS had no impact. Also, IHIO for >30 minutes significantly increased the biliary complication rate for MaS donors (12.1% for ≤ 30 minutes versus 32.6% for >30 minutes, P = 0.04), whereas MiS donors were not affected. In conclusion, the tolerance of hepatic IR injury might differ between MaS livers and MiS livers. It would be rational to assign more clinical importance to MaS versus MiS. We further recommend limiting the cumulative IHIO time to 30 minutes or less for MaS donors undergoing right hepatectomy.

Effect of pure microsteatosis on transplant outcomes after living donor liver transplantation: a matched case-control study.

Liver steatosis mostly exists in a mixed form of macrosteatosis (MaS) and microsteatosis (MiS). This coexistence is responsible for previous conflicting results regarding the importance of MiS in liver transplantation. We aimed to evaluate the independent effect of MiS on posttransplant outcomes with the exclusion of the confounding effect of MaS. Seventy-one living donors who had pure MiS (defined as an MiS degree > 5% without MaS) were matched 1:1 with control donors, and 66 recipients who received pure MiS grafts were matched 1:1 with control recipients on the basis of propensity scores. Matched variables included the donor age, remnant liver volume, cold ischemia time, graft-to-recipient weight ratio and Model for End-Stage Liver Disease score. The degree of pure MiS ranged from 5% to 50%. Donors in the control and pure MiS groups were comparable with respect to peak postoperative transaminase concentrations [alanine aminotransferase (ALT): 194 versus 176 IU/L, P = 0.61] and postoperative complications. Recipients in the control and pure MiS groups were comparable with respect to recipient (P = 0.15) and graft survival rates (P = 0.56) as well as peak postoperative transaminase concentrations (ALT: 266 versus 281 IU/L, P = 0.88), and graft regeneration rates at 2 weeks (61% versus 59%, P = 0.73). The 2 groups were also comparable with respect to major complications, primary graft dysfunction/nonfunction, intensive care unit/hospital stays, and metabolic diseases. In conclusion, MiS alone does not seem to impair the posttransplant outcomes of living donors and their recipients. The interaction between MiS and MaS, and the effect of a greater degree of MiS are the next important topics to be further evaluated in the mixed steatosis population.

Successful ABO-Incompatible Living Donor Liver Transplantation in a Patient with an Anaphylactic Reaction to Fresh Frozen Plasma During Therapeutic Plasma Exchange: A Case Report.

BACKGROUND: ABO-incompatible living donor liver transplantation (ABOi LDLT) is a complex procedure involving the reduction of anti-A and anti-B antibodies by therapeutic plasma exchange (TPE) to prevent acute antibody-mediated rejection. Fresh frozen plasma (FFP) is often used as replacement fluid during TPE. CASE DESCRIPTION: We report an ABOi LDLT case in which the patient experienced an anaphylactic reaction to FFP during TPE. Additional TPE was performed using 5% albumin as replacement fluid. ABOi LDLT was successfully performed by adapting the transfusion strategy to avoid FFP and cryoprecipitate and to administer washed platelets. CONCLUSION: This case highlights the importance of careful preoperative assessment, multidisciplinary coordination, and individualized approaches in ABOi LDLT, especially when the patient has an anaphylactic reaction to FFP.

Living Donor Liver Transplantation for an Infant Having Tracheostomy and Subglottic Stenosis: A Case Report.

BACKGROUND: It is uncommon to perform liver transplantation for patients with end-stage liver disease having tracheostomy. Usually, the tracheostomy cannula is changed to an oral endotracheal tube (ETT) before operation because ETT is easy to handle during operation. If routine oral ETT insertion is difficult, we should seek other solutions. CASE DESCRIPTION: We report a successful conversion from tracheostomy tube to ETT in a patient with subglottic stenosis. The patient was an 8-month-old infant who was scheduled for living donor liver transplantation due to acute hepatic failure. The original plan was to convert the tracheostomy tube to oral ETT, which failed due to aggravation of subglottic stenosis. An otolaryngologist performed balloon dilatation surgery, and ETT was successfully intubated. Owing to a multidisciplinary approach, the surgery was successfully performed without fatal adverse events, and the patient was later discharged with a tracheostomy. CONCLUSIONS: It is unusual for pediatric patients with tracheostomy tubes to undergo major surgeries like liver transplantation. We hope that this case of successful anesthetic management based on a multidisciplinary approach suggests new ideas to anesthesiologists seeking safe anesthesia.

Preoperative Intrathecal Morphine is Associated With Reduced Postoperative Pain, Agitation, and Delirium In Living Donor Kidney Transplantation Recipients.

BACKGROUND: Postoperative delirium after organ transplantation can lead to increased length of hospital stay and mortality. Because pain is an important risk factor for delirium, perioperative analgesia with intrathecal morphine (ITM) may mitigate postoperative delirium development. We evaluated if ITM reduces postoperative delirium incidence in living donor kidney transplant (LDKT) recipients. METHODS: Two hundred ninety-six patients who received LDKT between 2014 and 2018 at our hospital were retrospectively analyzed. Recipients who received preoperative ITM (ITM group) were compared with those who did not (control group). The primary outcome was postoperative delirium based on the Confusion Assessment Method for Intensive Care Unit results during the first 4 postoperative days. RESULTS: Delirium occurred in 2.6% (4/154) and 7.0% (10/142) of the ITM and control groups, respectively. Multivariable analysis showed age (odds ratio [OR]: 1.07, 95% CI: 1.01-1.14; P = .031), recent smoking (OR: 7.87, 95% CI: 1.43-43.31; P = .018), preoperative psychotropics (OR: 23.01, 95% CI: 3.22-164.66; P = .002) were risk factors, whereas ITM was a protective factor (OR: 0.23, 95% CI: 0.06-0.89; P = .033). CONCLUSIONS: Preoperative ITM showed an independent association with reduced post-LDKT delirium. Further studies and the development of regional analgesia for delirium prevention may enhance the postoperative recovery of transplant recipients.

Sudden mode change of permanent pacemaker during living donor liver transplantation - A case report.

BACKGROUND: Pacemakers assist circulation by generating electrical impulses. Patients with pacemakers scheduled to undergo surgery are vulnerable to device-related complications. Therefore, careful perioperative management is required to prevent undesirable events. CASE: A 66-year-old man with alcohol-related hepatocellular carcinoma was referred for liver transplantation. The pacemaker was inserted preoperatively to manage sick sinus syndrome and paroxysmal atrial fibrillation. Overall liver transplantation was performed without any adverse events. However, the pacemaker suddenly failed to provide regular pacing rhythm during abdominal closure. Fortunately, the native heart rate was maintained above 70 beats per minute and blood pressure did not fluctuate after pacing failure. After retrospective analysis, the duration setting of preoperative pacemaker reprogramming (24 h) was revealed as the cause of unexpected pacing failure. CONCLUSIONS: Anesthesiologists should be alert in patients with pacemakers because minor errors may lead to inadvertent failure of pacing or severe hemodynamic instability.

Cumulative postoperative change in serum albumin levels and organ failure after living-donor liver transplantation: A retrospective cohort analysis.

Many studies have reported that hypoalbuminemia could be associated with organ failure after liver transplantation. However, most of them focused on serum albumin levels measured at specific time points and not on the trend of serum albumin change. We investigated whether a cumulative postoperative change in serum albumin level up to postoperative day (POD) 5 is related to organ failure in patients who underwent living-donor liver transplantation (LDLT). Data of adult recipients who underwent LDLT between January 2016 and December 2020 at a single tertiary hospital were reviewed (n = 399). After screening, three patients were excluded because of insufficient data. A cumulative change in serum albumin level was demonstrated using the area under the threshold (AUT, threshold = 3.0 g/dL) of the serum albumin curve up to POD 5. Based on the AUT, the patients were divided into a high-decrease group (n = 156) and a low-decrease group (n = 240). All analyses were conducted using 1:1 propensity score matching. The primary endpoint was the Sequential Organ Failure Assessment (SOFA) score on POD 5. The secondary endpoints were postoperative hospital stay and postoperative 90-day mortality. A total of 162 patients were included. The SOFA score on POD 5 was significantly higher in the High-decrease group compared with the Low-decrease group (5.2 ± 2.6 vs. 4.1 ± 2.3; mean difference: 1.1, 95% CI: 0.3 to 1.8; P = 0.005). However, the length of postoperative hospital stay (P = 0.661) and 90-day mortality (P = 0.497) did not differ between the groups. In conclusion, a cumulative postoperative change in serum albumin level up to POD 5 could help predict postoperative organ failure on POD 5 in patients who underwent LDLT.

Liver transplantation of a patient with extreme thrombocytopenia - A case report.

BACKGROUND: Patients with chronic liver disease (CLD) planned for liver transplantation (LT) often show severe thrombocytopenia, but there is a lack of evidence in deciding the threshold for prophylactic platelet transfusion. CASE: A 47-year-old female with acute liver failure was referred for LT. Despite daily transfusion of platelets, platelet counts remained under 10,000/µl. During LT, 2 units of single donor platelets (SDP) were transfused. Although platelet counts remained extremely low (3,000-4,000/µl) no diffuse oozing was observed and the blood loss was 860 ml. Postoperatively, there was no sign of active bleeding or oozing, and the patient received only 1 unit SDP transfusion. CONCLUSIONS: CLD patients may have severe thrombocytopenia. However, primary hemostasis may not be significantly hindered due to the existence of rebalanced hemostasis. Prophylactic platelet transfusion in these patients should not be decided based on platelet counts only, but also take other coagulation tests and clinical signs into consideration.

Realization of improved outcomes following liver resection in hepatocellular carcinoma patients aged 75 years and older.

PURPOSE: Little is known about liver resection (LR) in hepatocellular carcinoma (HCC) patients older than 75 years of age. This study aimed to compare the postoperative and long-term outcomes of hepatectomy in this patient population according to operation period. METHODS: This study included 130 elderly patients who underwent LR for solitary treatment-naïve HCC between November 1998 and March 2020. Group 1 included patients who underwent LR before 2016 (n = 68) and group 2 included those who underwent LR during or after 2016 (n = 62). RESULTS: The proportion of major LR, anatomical LR, and laparoscopic LR (LLR) in group 1 was significantly lower than those in group 2. Also, the median operation time, amount of blood loss, hospitalization length, rates of intraoperative blood transfusion, and complications in group 2 were less than those in group 1. In the subgroup analysis of group 1, high proteins induced by vitamin K absence or antagonist-II, long hospitalization, and LLR were closely associated with mortality. In the subgroup analysis of group 2, however, none of the factors increased mortality. Nevertheless, the presence of tumor grade 3 or 4 and the incidence of microvascular invasion were higher in group 1 than in group 2, and the disease-free survival and overall survival were better in group 2 than in group 1 because of minimized blood loss and quicker recovery period by increased surgical techniques and anatomical approach, and LLR. CONCLUSION: LR in elderly HCC patients has been frequently performed recently, and the outcomes have improved significantly compared to the past.

Decreased analgesic requirement in recipient of liver transplantation from monozygotic twin - A case report.

BACKGROUND: There have been many reports about decreased analgesic requirements in liver transplant recipients compared with patients undergoing other abdominal surgery. CASE: Herein we describe a case in which a 42-year-old man underwent living donor liver transplantation from his monozygotic twin. Because innate pain thresholds may be similar in monozygotic twins, we could effectively investigate postoperative pain in the donor and the recipient. Concordant with previous reports, the recipient used less analgesic than the donor in the present study. CONCLUSIONS: Physicians caring for patients who have received liver transplantation should consider their comparatively low requirement for analgesic, to prevent delayed recovery due to excessive use of analgesic.

Symptomatic (Hypotensive) Bradycardia During Laparoscopic Living Donor Hepatectomy: Incidence and Risk Factors.

BACKGROUND: The use of a minimally invasive laparoscopic approach in living donor hepatectomy is increasing with the need for enhanced management of living donors. Hypotensive bradycardia often occurs during abdominal surgery and can be fatal without proper management. We conducted a retrospective study to investigate the incidence and risk factors of symptomatic (hypotensive) bradycardia in laparoscopic living donor hepatectomy. METHODS: Hypotensive bradycardia is defined as the heart rate below 60 beats per minute with simultaneous mean arterial blood pressure (MAP) below 65 mm Hg. Clinical characteristics of liver donors were collected and analyzed from May 2018 to July 2019. RESULTS: This study included 129 cases of living donor hepatectomy; 11 donors of open hepatectomy were excluded, and 118 donors undergoing laparoscopic hepatectomy were analyzed. Hypotensive bradycardia was shown in 27 donors. Hypertension or angiotensin receptor blocker medication were significantly related to hypotensive bradycardia. Hypotensive bradycardia occurred after incision in 22 donors, and the onset time from the incision was 7.5 minutes [first quartile (Q1) 5.75, third quartile (Q3) 11.5, range 0-25], the minimum heart rate was 48.5 beats per minute (Q1 41.5, Q3 53.25, range 25-57), and the minimum MAP was 55 mm Hg (Q1 45, Q3 57.5, range 35-63). It took 132 seconds (Q1 42, Q3 189, range 12-408) to recover MAP over 65 mm Hg. CONCLUSIONS: Hypotensive bradycardia occurred in 22.9% of the laparoscopic living donor hepatectomy cases, and 80.6% of cases occurred after incision. Thorough preoperative evaluation and close monitoring is important even in a healthy donor.

Perioperative risk factors of progressive chronic kidney disease following liver transplantation: analyses of a 10-year follow-up single-center cohort.

PURPOSE: The incidence of chronic kidney disease (CKD) has been increasing due to improved survival after liver transplantation (LT). Risk factors of kidney injury after LT, especially perioperative management factors, are potentially modifiable. We investigated the risk factors associated with progressive CKD for 10 years after LT. METHODS: This retrospective cohort study included 292 adult patients who underwent LT at a tertiary referral hospital between 2000 and 2008. Renal function was assessed by the e stimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease formula. The area under the curve of serial eGFR (AUCeGFR) was calculated for each patient to assess the trajectory of eGFR over the 10 years. Low AUCeGFR was considered progressive CKD. Linear regression analyses were performed to examine the associations between the variables and AUCeGFR. RESULTS: Multivariable analysis showed that older age (regression coefficient = -0.53, P < 0.001), diabetes mellitus (DM) (regression coefficient = -6.93, P = 0.007), preoperative proteinuria (regression coefficient = -16.11, P < 0.001), preoperative acute kidney injury (AKI) (regression coefficient = -14.35, P < 0.001), postoperative AKI (regression coefficient = -3.86, P = 0.007), and postoperative mean vasopressor score (regression coefficient = -0.45, P = 0.034) were independently associated with progressive CKD. CONCLUSION: More careful renoprotective management is required in elderly LT patients with DM or preexisting proteinuria. Postoperative AKI and vasopressor dose may be potentially modifiable risk factors for progressive CKD.