Expected Life Expectancy on Liver Transplantation and Aging Donor.

In this study, our aim was to show the life expectancy according to donor age groups at 1, 3, 5, 10, 15, and 20 years after liver transplant in liver transplant recipients. In this retrospective study, we analyzed the survival rate of 236 patients who had liver transplant procedures between 1988 and 2021. The 5-year life expectancy of recipients with donors over age 50 years in the literature has been shown to vary between 50% and 80%. Little information could be found on life expectancy after 10, 15, and 20 years in other studies. In the studies from Haberal and colleagues, life expectancy at 10, 15, and 20 years was 49%, 42%, and 42%, respectively. This study presents an evidence-based example of the use of elderly donors to enlarge the donor pool.

Predictors of Immediate Tracheal Extubation in the Operating Room After Pediatric Liver Transplantation.

OBJECTIVES: Pediatric orthotopic liver transplant recipients frequently need mechanical ventilation during the immediate posttransplant period. However, intensive care unit beds are costly and scarce; therefore, anticipating which patients will require postoperative mechanical ventilation support is important. In addition, immediate postoperative extubation may reduce the incidence of postoperative respiratory complications and improve patient outcomes after orthotopic liver transplant. Here, we aimed to determine the predictors of need for mechanical ventilation after orthotopic liver transplant in pediatric patients. MATERIALS AND METHODS: We retrospectively analyzed the records of 57 pediatric patients who underwent orthotopic liver transplant (performed by the same team at Baskent University Hospital from April 1996 to August 2009). Patients were divided into 2 groups according to whether they required postoperative mechanical ventilation or not. Collected data included demographic features; comorbidities; cause of liver failure; perioperative laboratory values; intraoperative hemodynamic parameters; use and volume of crystalloids, colloids, and blood products; albumin levels; portal vein clamping time, requirement of inotropes/vasopressors; and anesthesia duration. RESULTS: Mean age and body weight of patients were 25.0 ± 23.1 months and 10.8 ± 5.3 kg, respectively. Of 57 patients, 26 (46%) needed postoperative mechanical ventilation. Compared with those who did not require postoperative mechanical ventilation, patients who required mechanical ventilation had growth failure (P = .03), higher mean intraoperative lactate level (P = .03), and higher mean intraoperative fresh frozen plasma/erythrocyte suspension (P = .049) and intraoperative vasopressor (P = .022) requirements. Multivariate logistic regression analysis revealed that growth failure (odds ratio = 37; P = .03) and higher intraoperative lactate level (odds ratio = 1.5; P = .03) were predictors of the need for mechanical ventilation. CONCLUSIONS: About 46% of our pediatric orthotopic liver transplant recipients required mechanical ventilation postoperatively. Growth failure and higher intraoperative lactate levels were associated with need for postoperative mechanical ventilation.

Expanded Criteria for Hepatocellular Carcinoma in Liver Transplant.

OBJECTIVES: Hepatocellular carcinoma is the sixth most common cancer worldwide and is the third highest cause of malignancy-related death. Because of its typically late diagnosis, median survival is approximately 6 to 20 months, with 5-year survival of < 12%. Hepatocellular carcinoma typically arises in the background of cirrhosis, with liver transplant regarded as the optimal therapy for selected patients. Initially, orthotopic liver transplant was limited to patients with extensive unresectable tumors, resulting in uniformly dismal outcomes due to high tumor recurrence rates. Here, we evaluated our long-term results with expanded-criteria liver transplant. MATERIALS AND METHODS: From December 1988 to January 2017, we performed 552 liver transplants at Baskent University. In candidates with hepatocellular carcinoma, our expanded criteria for liver transplant is applied regardless of tumor size and number, includes those without major vascular invasion and without distant metastasis, and those with negative cytology (if the patient has ascites). Since 1994, of 61 liver transplants for hepatocellular carcinoma, 36 patients received transplants according to our expanded criteria. RESULTS: Of 36 expanded-criteria patients, 11 were children and 25 were adults. Sixteen patients (4 pediatric, 12 adult) were within our expanded criteria both radiologically and pathologically before transplant. The other 20 patients (7 pediatric, 13 adult) were within Milan criteria radiologically before transplant; however, after liver transplant, when pathologic specimens were evaluated, patients were found to be within our center's expanded criteria. During follow-up, 9/36 patients (25%) had hepatocellular carcinoma recurrence. In pediatric patients, 5-year and 10-year survival rates were 90%; in adults, 5-year survival was 58.7% and 10-year survival was 49.7%. Overall 5-year and 10-year survival rates were 71.7% and 62.7%. CONCLUSIONS: Liver transplant is safe and effective in patients with hepatocellular carcinoma in combination with interventional radiology procedures, regardless of tumor size and number, without major vascular invasion and distant metastasis.

Anesthetic and Perioperative Management of Nontransplant Surgery in Patients After Liver Transplant.

OBJECTIVES: We aimed to document the anesthetic management and metabolic, hemodynamic, and clinical outcomes of liver-graft recipients who subsequently undergo nontransplant surgical procedures. MATERIALS AND METHODS: We retrospectively analyzed the data of 96 liver-graft recipients who underwent 144 nontransplant surgeries between October 1998 and April 2016 at Baskent University Hospital. RESULTS: The median patient age at the time of nontransplant surgery was 32 years, and 35% were female (n = 33). The median time between transplant and nontransplant surgery was 1231 days. The most frequent types of nontransplant surgery were abdominal (22%), orthopedic (16%), and urologic (13%). Seventy patients had an American Society of Anesthesiologists status of 2 (49%); the status was 3 in 71 patients (49%) and 4 in 3 patients (2%). Of the 144 procedures, 23 were emergent (16%) and 48% were abdominal. General anesthesia was used in 69%, regional anesthesia in 19%, and sedoanalgesia in 11%. Twenty-five patients required intraoperative blood-product transfusion (17%). Intraoperative hemodynamic instability developed in 17% of patients, and hypoxemia developed in 2%. Eleven patients remained intubated at the end of surgery (8%). Of the 144 procedures, 19 (13%) required transfer to the intensive care unit, 108 (75%) transferred to the ward, and the remaining 17 (12%) were discharged on the same day. Eight patients developed respiratory failure (6%), 7 had renal dysfunction (5%), 4 had coagulation abnormalities (3%), and 10 had infectious complications (7%) in the early postoperative period. The median hospital stay was 4 days, and 5 patients (4%) developed rejection during hospitalization. Five patients died of respiratory or infectious complications (4%). CONCLUSIONS: Most liver-graft recipients who undergo nontransplant surgery are given general anesthesia, transferred to the ward after the procedure, and discharged without major complications. We suggest that orthotopic liver transplant recipients may undergo nontransplant surgery without any postoperative graft dysfunction.

Effect of Graft Weight to Recipient Body Weight Ratio on Hemodynamic and Metabolic Parameters in Pediatric Liver Transplant: A Retrospective Analysis.

OBJECTIVES: To analyze how graft-weight-to-bodyweight ratio in pediatric liver transplant affects intraoperative and early postoperative hemodynamic and metabolic parameters. MATERIALS AND METHODS: We reviewed data from 130 children who underwent liver transplant between 2005 and 2015. Recipients were divided into 2 groups: those with a graft weight to body weight ratio > 4% (large for size) and those with a ratio ≤ 4% (normal for size). Data included demographics, preoperative laboratory findings, intraoperative metabolic and hemodynamic parameters, and intensive care follow-up parameters. RESULTS: Patients in the large-graft-for-size group (>4%) received more colloid solution (57.7 ± 20.1 mL/kg vs 45.1 ± 21.9 mL/kg; P = .08) and higher doses of furosemide (0.7 ± 0.6 mg/kg vs 0.4 ± 0.7 mg/kg; P = .018). They had lower mean pH (7.1 ± 0.1 vs 7.2 ± 0.1; P = .004) and PO2 (115.4 ± 44.6 mm Hg vs 147.6 ± 49.3 mm Hg; P = .004) values, higher blood glucose values (352.8 ± 96.9 mg/dL vs 262.8 ± 88.2 mg/dL; P < .001), and lower mean body temperature (34.8 ± 0.7°C vs 35.2 ± 0.6°C; P = .016) during the neohepatic phase. They received more blood transfusions during both the anhepatic (30.3 ± 24.3 mL/kg vs 18.8 ± 21.8 mL/kg; P = .013) and neohepatic (17.7 ± 20.4 mL/kg vs 10.3 ± 15.5 mL/kg; P = .031) phases and more fresh frozen plasma (13.6 ± 17.6 mL/kg vs 6.2 ± 10.2 mL/kg; P = .012) during the neohepatic phase. They also were more likely to be hypotensive (P < .05) and to receive norepinephrine infusion more often (44% vs 22%; P < .05) intraoperatively. More patients in this group were mechanically ventilated in the intensive care unit (56% vs 31%; P = .035). There were no significant differences between the groups in postoperative acute renal dysfunction, graft rejection or loss, infections, length of intensive care stay, and mortality (P > .05). CONCLUSIONS: High graft weight-to-body-weight ratio is associated with adverse metabolic and hemodynamic changes during the intraoperative and early postoperative periods. These results emphasize the importance of using an appropriately sized graft in liver transplant.

Unusual Indications for a Liver Transplant: A Single-Center Experience.

OBJECTIVES: This study sought to evaluate the efficacy of liver transplant for unusual liver diseases. MATERIALS AND METHODS: The results of 476 patients who underwent liver transplant from 1988 to January 2015 were retrospectively analyzed. Two hundred forty-five of them were adult patients and 231 of them were pediatric. Thirty-one patients had unusual liver disease. RESULTS: Of the 31 patients with unusual liver disease, 9 (29%) were adult and 22 (71%) were pediatric patients. In the pediatric group, indications for liver transplant were Alagille syndrome (n = 5), Crigler-Najjar syndrome type 1 (n = 5), glycogen storage disease (n = 3), oxalosis (n = 3), familial hypercholesterolemia (n = 2), alpha-1-antitrypsin deficiency (n = 2), Caroli disease (n = 1), and cystic neuroblastoma metastasis (n = 1). Six patients (27.2%) had acute rejection episodes and were successfully treated with pulse steroids. In 2 patients, retransplant was performed for chronic rejection. Three patients died during follow-up (13.6%): 2 because of sepsis and 1 because of cranial hemorrhage. In the adult group, indications for liver transplant were neuroendocrine tumor metastasis (n = 1), liver angiosarcoma (n = 1), familial hypercholesterolemia (n = 2), alveolar hydatid disease (n = 2), cystic fibrosis (n = 1), congenital hepatic fibrosis (n = 1), and oxalosis (n = 1). Four patients (44.4%) had acute rejection episodes and were successfully treated with pulse steroid therapy. One patient died due to the recurrence of primary disease (liver angiosarcoma) during follow-up (11.1%). CONCLUSIONS: Advances in liver transplant and our understanding about unusual liver disease have led to significant improvements in managing these diseases. Liver transplant effectively treats the underlying defect and the complications of portal hypertension, or risk of malignancy for those disorders, in which the liver is affected.

Auxiliary Partial Orthotopic Living Liver Transplant for Wilson Disease.

Wilson disease is a genetic disease involving copper metabolism disturbances that result in copper accumulations, especially in the liver and brain. Wilson disease can be treated with pharmacologic agents, such as chelators that induce urinary excretion of copper or zinc salts that inhibit copper absorption in the digestive tract. Liver transplant is the only treatment option for Wilson disease when liver failure has occurred. In some patients, that is, in those with Child-Pugh A score, neurologic disease can be seen without hepatic failure. Our recommendation is for these patients to have auxiliary partial orthotopic liver transplant. Here, we present a 36-year-old male patient with neurologic disease associated with Wilson disease who had successful related living-donor auxiliary partial orthotopic liver transplant using a left lobe. The patient, as a result of neurologic symptoms that included tremor walking and speaking problems and low serum ceruloplasmin level of 7 mg/dL, was diagnosed with Wilson disease, and a liver biopsy was performed. Chronic necroinflammatory disease activity was 4/18, and the patient received chelation treatment. His hepatic functions were normal. The donor was the patient's 57-year-old father whose liver function tests were also normal. The graft-to-recipient weight ratio was 1% using a left lobe graft. After transplant, serum ceruloplasmin levels on day 15 and month 1 were 14 and 19 mg/dL. At month 1, liver function tests were normal. Doppler ultrasonography showed normal vascular flow of the native liver and the graft. The patient's neurologic symptoms were progressively reduced. Progressive neurologic deterioration with no hepatic insufficiency is considered a suitable indication for auxiliary partial orthotopic liver transplant; this procedure is suggested before the neurologic and liver failure symptoms of Wilson disease occur.

The efficacy of intra-articular lidocaine administration in chronic knee pain due to osteoarthritis: A randomized, double-blind, controlled study.

BACKGROUND: Intra-articular injections for the treatment of knee pain due to osteoarthritis are performed when conservative therapies have failed. The intra-articular injection of lidocaine may be an effective treatment modality due to its neuronal membrane-stabilizing effect and long-lasting anti-inflammatory action. In this study, we compared the efficacy of intra-articular 0.5% lidocaine versus saline injection on pain, stiffness and physical function in patients with osteoarthritis. METHODS: Patients with osteoarthritis were randomly allocated to two groups. Group I (n=26) received 7mL 0.5% lidocaine and group II (n=26) received 7mL saline into the painful knee for a series of three injections spaced by 1 week intervals under ultrasound guidance. Knee pain was measured with a numeric rating score (NRS) at baseline and 3 months after the 3rd injection. WOMAC scales, including pain (WOMAC-P), stiffness (WOMAC-S) and physical function (WOMAC-F), were assessed and recorded at baseline, 30minutes after the 1st injection, immediately prior to the 2nd and 3rd injections and 3 months after the 3rd injection. RESULTS: Demographic data were comparable between groups. The NRS after 3 months was significantly lower in group I (P=0.001). The WOMAC-P, immediately prior to the 3rd injection and 3 months afterwards, was significantly lower in group I (P=0.006, P=0.001, respectively). The WOMAC-S was improved prior to the 3rd injection and sustained until 3 months in group I (P=0.035, P=0.004, respectively). The WOMAC-F was improved after the 1st injection and sustained until 3 months in group I (P=0.002, P<0.0001 and P<0.0001, respectively). CONCLUSIONS: Intra-articular 0.5% lidocaine injection under ultrasound guidance has a potential role in the management of chronic knee pain due to osteoarthritis for a 3-month period.

EVALUATION AND MANAGEMENT OF DIFFICULT AIRWAY IN OBESITY A SINGLE CENTER RETROSPECTIVE STUDY.

The primary aim of this single center retrospective study was to evaluate difficult mask ventilation (DMV) and difficult laryngoscopy (DL) in a unique group of obese patients. A total of 427 adult patients with body mass index (BMI) ≥ 25 and surgically treated for endometrial cancer from 2011 to 2014 were assessed. Additional increase in BMI, comorbidities, bedside screening tests for risk factors, and the tools used to manage the patients were noted and their effects on DMV and/or DL investigated. Every escalation in the number of risk factors increased the probability of DMV 2.2-fold, DL 1.8-fold and DMV+DL 3.0-fold. Among bedside tests, limited neck movement (LNM), short neck (SN) and absence of teeth were significant for DMV (p < 0.05), LNM, SN and obstructive sleep apnea for DL (p < 0.05), and LNM and SN for DMV+DL (p < 0.05). However, a 10-point increase of BMI was not an independent risk factor when patients with BMI > 25% were considered. In conclusion, LNM and SN are independent risk factors for developing DMV and/or DL in obese endometrial cancer patients, while BMI increase over 30 was not additionally affecting difficult airway.

Anesthesia Management of a Deceased Cadaveric-Donor Combined Liver and Kidney Transplant for Primary Hyperoxaluria Type 1: Report of a Case.

Primary hyperoxaluria type 1 is an autosomal recessive disorder that is responsible for the overproduction of oxalate and has an incidence of 1 in 120 000 live births. Indications for combined liver and kidney transplant are still debated. However, combined liver and kidney transplant is preferred in various conditions, including primary hyperoxaluria, liver-based metabolic abnormalities affecting the kidney, and structural diseases affecting both the liver and the kidney, such as congenital hepatic fibrosis and polycystic kidney disease. When compared with sequential liver and kidney transplant, the rejection rate of both liver and kidney allografts was reported to be lower than with combined liver and kidney transplant. With proper anesthesia management, the probable increased complications with combined liver and kidney transplant can be prevented. In this report, we present the anesthesia care of a 22-year-old patient with primary hyperoxaluria type 1 who had deceased-donor combined liver and kidney transplant.

Perioperative Characteristics of Siblings Undergoing Liver or Kidney Transplant.

OBJECTIVES: Reasons for chronic liver and kidney failure may vary; sometimes more than 1 family member may be affected, and may require a transplant. The aim of this study was to examine the similarities or differences between the perioperative characteristics of siblings undergoing liver or kidney transplant. MATERIALS AND METHODS: The medical records of 6 pairs of siblings who underwent liver transplant and 4 pairs of siblings who underwent kidney transplant at Baskent University Hospital between 1989 and 2014 were retrospectively analyzed. Collected data included demographic features; comorbidities; reasons for liver and kidney failure; perioperative laboratory values; intraoperative hemodynamic parameters; use and volume of crystalloids, colloids, blood products, cell saver system, and albumin; duration of anesthesia; urine output; and postoperative follow-up data. RESULTS: The mean age of the 6 sibling pairs who underwent liver transplant was 16.3 ± 12.2 years. All 12 patients had Child-Pugh grade B cirrhosis, with mean disease duration of 7.8 ± 3.9 years. There were no significant differences between siblings with respect to intraoperative blood product transfusion, crystalloid and colloid fluid replacements, hypotension frequency, blood gas analyses, urinary output, duration of anhepatic phase, inotropic agent administration, postoperative laboratory values, need for mechanical ventilation and vasopressors, occurrence of acute renal failure and infections, and duration intensive care unit stay (P > .05). The mean age of the 4 sibling pairs who underwent kidney transplant was 21.3 ± 6.4 years, with mean duration of renal insufficiency of 2.2 ± 1.6 years. There were no significant differences between siblings with respect to intraoperative crystalloid and colloid fluid administration, duration of anesthesia, intraoperative mannitol and furosemide administration, and postoperative laboratory values (P > .05). CONSLUSIONS: In conclusion, the 6 sibling pairs who underwent liver transplant and 4 sibling pairs who underwent kidney transplant in our cohort had similar perioperative characteristics.

Accuracy of continuous noninvasive arterial pressure monitoring in living-liver donors during transplantation.

OBJECTIVES: Hemodynamic monitoring is vital during liver transplant surgeries because distinct hemodynamic changes are expected. The continuous noninvasive arterial pressure (CNAP) monitor is a noninvasive device for continuous arterial pressure measurement by a tonometric method. This study compared continuous noninvasive arterial pressure monitoring with invasive direct arterial pressure monitoring in living-liver donors during transplant. MATERIALS AND METHODS: There were 40 patients analyzed while undergoing hepatic lobectomy for liver transplant. Invasive pressure monitoring was established at the radial artery and continuous noninvasive arterial pressure monitoring using a finger sensor was recorded simultaneously from the contralateral arm. Systolic, diastolic, and mean arterial pressures from the 2 methods were compared. Correlation between the 2 methods was calculated. RESULTS: A total of 5433 simultaneous measurements were obtained. For systolic arterial blood pressure, 55% continuous noninvasive arterial pressure measurements were within 10% direct arterial measurement; the correlation was 0.479, continuous noninvasive arterial pressure bias was -0.3 mm Hg, and limits of agreement were 32.0 mm Hg. For diastolic arterial blood pressure, 50% continuous noninvasive arterial pressure measurements were within 10% direct arterial measurement; the correlation was 0.630, continuous noninvasive arterial pressure bias was -0.4 mm Hg, and limits of agreement were 21.1 mm Hg. For mean arterial blood pressure, 60% continuous noninvasive arterial pressure measurements were within 10% direct arterial measurement; the correlation was 0.692, continuous noninvasive arterial pressure bias was +0.4 mm Hg, and limits of agreement were 20.8 mm Hg. CONCLUSIONS: The 2 monitoring techniques did not show acceptable agreement. Our results suggest that continuous noninvasive arterial pressure monitoring is not equivalent to invasive arterial pressure monitoring in donors during living-donor liver transplant.

Postoperative effects of intraoperative hyperglycemia in liver transplant patients.

OBJECTIVES: The aim of this study was to determine the effects of intraoperative hyperglycemia on postoperative outcomes in orthotopic liver transplant recipients. MATERIALS AND METHODS: After ethics committee approval was obtained, we retrospectively analyzed the records of patients who underwent orthotopic liver transplant from January 2000 to December 2013. A total 389 orthotopic liver transplants were performed in our center, but patients aged < 15 years (179 patients) were not included in the analyses. Patients were divided into 2 groups based on their maximum intraoperative blood glucose level: group 1 (patients with intraoperative blood glucose level < 200 mg/dL) and group 2 (patients with intraoperative blood glucose level > 200 mg/dL). Postoperative complications between the 2 groups were compared. RESULTS: There were 58 patients (37.6%; group 1, blood glucose < 200 mg/dL) who had controlled blood glucose and 96 patients (62.3%; group 2, blood glucose > 200 mg/dL) who had uncontrolled blood glucose. The mean age and weight for groups 1 and 2 were similar. There were no differences between the 2 groups regarding the duration of anhepatic phase (P = .20), operation time (P = .41), frequency of immediate intraoperative extubation (P = .14), and postoperative duration of mechanical ventilation (P = .06). There were no significant differences in frequency of patients who had postoperative infectious complications, acute kidney injury, or need for hemodialysis. Mortality rates after liver transplant were similar between the 2 groups (P = .81). CONCLUSIONS: Intraoperative hyperglycemia during orthotopic liver transplant was not associated with an increased risk of postoperative infection, acute renal failure, or mortality.

Results of pediatric liver transplant: a single-center experience.

OBJECTIVES: Liver transplant is an established curative therapy for children with chronic end-stage liver disease or acute liver failure. In this study, we aimed to evaluate pediatric liver transplant in terms of outcomes, complications, and long-term followup results. MATERIALS AND METHODS: Pediatric patients who had liver transplant in our institution were included. We retrospectively evaluated demographic features including body weight, Child-Pugh score, etiology of liver disease, graft source, perioperative outcomes, perioperative complications, postoperative complications, and long-term results. Outcomes of treatment of complications and revision transplant were evaluated. RESULTS: Between September 2001 and December 2013, there were 188 pediatric liver transplants performed in our institution. Most grafts (90.9%) were obtained from living-related donors. There were 13 patients (6.9%) who had an intervention because of a hemorrhage postoperatively. Biliary leakage was observed in 33 patients (17.5%) and biliary stricture during follow-up was observed in 32 patients (17%). Thrombosis rates in the hepatic artery and portal vein were 12.3% and 0.5%. Revision transplant was performed in 11 patients (5.8%); reason for revision transplant was rejection in 50% patients. The remaining children were alive with good graft functioning after treatment of complications and revision transplant. The overall 5- and 10-year survival rates were 82.3% and 78.9%. CONCLUSIONS: The overall outcomes of pediatric liver transplant at our center are very promising. With improved care of younger children and the combined efforts of the parents and medical team, the number of the children receiving transplants will increase in the future.

Large-for-size liver transplant: a single-center experience.

OBJECTIVES: The ideal ratio between liver transplant graft mass and recipient body weight is unknown, but the graft probably must weigh 0.8% to 2.0% recipient weight. When this ratio > 4%, there may be problems due to large-for-size transplant, especially in recipients < 10 kg. This condition is caused by discrepancy between the small abdominal cavity and large graft and is characterized by decreased blood supply to the liver graft and graft dysfunction. We evaluated our experience with large-for-size grafts. MATERIALS AND METHODS: We retrospectively evaluated 377 orthotopic liver transplants that were performed from 2001-2014 in our center. We included 188 pediatric transplants in our study. RESULTS: There were 58 patients < 10 kg who had living-donor living transplant with graft-to-bodyweight ratio > 4%. In 2 patients, the abdomen was closed with a Bogota bag. In 5 patients, reoperation was performed due to vascular problems and abdominal hypertension, and the abdomen was closed with a Bogota bag. All Bogota bags were closed in 2 weeks. After closing the fascia, 10 patients had vascular problems that were diagnosed in the operating room by Doppler ultrasonography, and only the skin was closed without fascia closure. No graft loss occurred due to large-for-size transplant. There were 8 patients who died early after transplant (sepsis, 6 patients; brain death, 2 patients). There was no major donor morbidity or donor mortality. CONCLUSIONS: Large-for-size graft may cause abdominal compartment syndrome due to the small size of the recipient abdominal cavity, size discrepancies in vascular caliber, insufficient portal circulation, and disturbance of tissue oxygenation. Abdominal closure with a Bogota bag in these patients is safe and effective to avoid abdominal compartment syndrome. Early diagnosis by ultrasonography in the operating room after fascia closure and repeated ultrasonography at the clinic may help avoid graft loss.

Liver and kidney transplant in primary hyperoxaluria: a single center experience.

OBJECTIVES: Primary hyperoxaluria, especially type 1, is a severe disease with multisystem morbidity and high mortality. We present 3 primary hyperoxaluria type 1 patients who underwent liver transplant, including living-donor liver transplant or combined liver and kidney transplant in our institution. CASE REPORTS: Patients who underwent liver transplant or combined liver/kidney transplant at our institution were evaluated, retrospectively. Between January 2002 and 2013, there were 3 patients who underwent transplant for primary hyperoxaluria. All 3 patients had disease onset in childhood, and the definitive diagnosis was established at age < 1, 6, and 8 years. Although early diagnosis was made, primary hyperoxaluria resulted in end-stage renal disease in 2 patients, and hemodialysis was introduced before liver transplant. All 3 patients underwent living-donor liver transplant. Case 1 was a 10-year-old girl who had an uneventful course after living-donor liver transplant, and she received a living-donor kidney transplant from the same donor 4 months after living-donor liver transplant. Case 2 was a 7-yearold boy who was the younger brother of the first patient; he did not have end-stage renal disease or any renal disorder after successful living-donor liver transplant. Case 3 was a 3-year-old boy who was diagnosed at age 2 months with renal disorders; although he was discharged from the hospital after living-donor liver transplant, he was readmitted because of unconsciousness that developed 1 day after discharge, and he died because of intracranial hemorrhage 2 months after liver transplant, unable to receive a kidney transplant. CONCLUSIONS: Primary hyperoxaluria is a rare disorder that is difficult to diagnose until end-organ damage is severe. Outcomes may be improved with early and accurate diagnosis, aggressive supportive treatment, and correction of the enzyme defect by liver transplant before systemic oxalosis develops. However, kidney transplant or combined liver and kidney transplant is required in many primary hyperoxaluria type 1 patients because of the delayed diagnosis or long organ waiting time.

A Case of Compartment Syndrome in the Hand Secondary to Intravenous Fluid Application.

Compartment syndrome of the extremities is a rare but potentially devastating condition. Anaesthetic and analgesic drugs used in the perioperative period may cause a delayed diagnosis by preventing the symptoms from appearing, and irreversible complications can occur. In this report, a case of compartment syndrome secondary to vascular access and its treatment in a morbidly obese patient who underwent abdominoplasty was presented.

Nonmelanoma skin cancer after kidney transplant.

OBJECTIVES: Solid-organ transplant recipients have a high risk of developing nonmelanoma skin cancers. This study sought to determine the incidence of skin cancer and identify possible risk factors for skin cancer in kidney transplant recipients. MATERIALS AND METHODS: Nonmelanoma skin cancer was diagnosed and confirmed with histology in 33 of 1275 kidney transplant recipients (2.6%). Demographic and clinical findings were reviewed retrospectively. RESULTS: Nonmelanoma skin cancers included squamous cell carcinoma in 10 patients (30%), basal cell carcinoma in 9 patients (27%), Kaposi sarcoma in 9 patients (27%), squamous cell carcinoma in situ in 3 patients (9%), and cutaneous lymphoma in 2 patients (6%). The ratio of squamous cell carcinoma to basal cell carcinoma was 1.1:1. The mean time from transplant to skin cancer diagnosis was 65 ± 55 months (range, 0-180 mo). Immunosuppressive therapy was based on cyclosporine in 22 patients (67%), tacrolimus in 8 patients (24%), and combination therapy (cyclosporine and azathioprine) in 3 patients (9%). CONCLUSIONS: Nonmelanoma skin cancer is an important clinical problem in kidney transplant recipients. Interventions that may benefit kidney transplant recipients may include intensive patient education, protection against sun exposure, and dermatologic screening programs.

Peri- and postanalgesic properties of lidokain, lornoxicam, and nitroglycerine combination at intravenous regional anesthesia.

BACKGROUND: This study was conducted to compare and evaluate the effect of adding lornoxicam or nitroglycerine as adjuncts to lidocaine in intravenous regional anesthesia (IVRA). METHODS: 60 patients were randomly separated into three groups, lidocaine group (group L), lidocaine+lornoxicam group (group LL), and lidocaine+lornoxicam+transdermal nitroglycerine group (group LL-N). Hemodynamic parameters, sensory and motor blocks onset, and recovery times were recorded. Analgesic consumption for tourniquet pain and postoperative period were recorded. RESULTS: Sensory block onset times and motor block onset times were shorter in the LL-N and LL groups compared with L group. Sensory block recovery time and motor block recovery time were prolonged in the LL and LL-N groups compared with group L. The amount of fentanyl required for tourniquet pain was less in group LL and group LL-N when compared with group L. VAS scores of tourniquet pain were higher in group L compared with the other study groups. Postoperative VAS scores were higher for the first 4 hours in group L compared with the other study groups. CONCLUSION: The adjuvant drugs (lornoxicam or TNG) when added to lidocaine in IVRA were effective in improving the overall quality of anesthesia, reducing tourniquet pain, increasing tourniquet tolerance, and improving the postoperative analgesia.