RESUMO
Purpose: The influence of allograft ischemic time (IT) on short- and long-term mortality remains under debate in lung transplantation (LTx). Due to a scarcity in donors, better understanding of IT might improve the outcome after LTx. Methods: Between January 1990 and June 2016; 307 patients underwent LTx at Lund university hospital, Sweden. The end-point used was death/Re-LTx assessed by Cox regression and Kaplan-Meier survival. Results: Kaplan-Meier survival for mean IT (min) between subgroups ≤120, 121-240, 241-360 and 361+ showed significant difference for pairwise-comparisons with superior outcome for IT between ≤120 and 240 min. Cox regression analyses for each hour of IT in patients with a limited survival up to 1- and 5-year had a hazard ratio (HR) of 1.119 and 1.063 respectively (p < .05). Conclusions: In LTx, every 2-hour increase of IT is equivalent to an increased mortality of up to 24% within 5 years. LTx with an IT of ≤120 min had a superior survival in both 1- and 5 years in comparison to an IT of up to 360 min. Better application of IT provides a key role in improving LTx outcome.
Assuntos
Isquemia Fria/mortalidade , Transplante de Pulmão/mortalidade , Isquemia Quente/mortalidade , Adolescente , Adulto , Idoso , Criança , Isquemia Fria/efeitos adversos , Feminino , Humanos , Transplante de Pulmão/efeitos adversos , Masculino , Pessoa de Meia-Idade , Reoperação/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Suécia , Fatores de Tempo , Resultado do Tratamento , Isquemia Quente/efeitos adversos , Adulto JovemRESUMO
OBJECTIVES: Organ donation after brain death followed by circulatory death is practiced in China. This study evaluated the application of normothermic regional perfusion to protect the liver grafts from these donors from warm ischemia in a large transplant center in China. MATERIALS AND METHODS: This prospective study involved 19 liver transplants from brain death followed by circulatory death donors that were conducted between December 2014 and June 2017. We evaluated the baseline characteristics of the donors and recipients and compared outcomes of both groups. Graft and recipient survival and postoperative complications were also analyzed. RESULTS: Although the normothermic regional perfusion group consisted of marginal donors with prolonged warm ischemia and recipients with higher Model for End-Stage Liver Disease scores (P < .05), postoperative tests indicated no differences in liverfunction recovery in both groups. Furthermore, total bilirubin decreased significantly faster in the normothermic regional perfusion group than in the control group (P < .05). Both groups showed similar 1-year recipient survival rates. No recipients in the normothermic regional perfusion group had any biliary complications, whereas 2 recipients in the control group developed ischemic cholangiopathy and received invasive treatment during follow-up. CONCLUSIONS: In situ normothermic regional perfusion demonstrated a significant benefit in grafts from brain death followed by circulatory death donors and could potentially increase both the number and quality of donated organs.
Assuntos
Morte Encefálica , Transplante de Fígado , Perfusão , Doadores de Tecidos , Isquemia Quente , Adulto , China , Feminino , Sobrevivência de Enxerto , Humanos , Testes de Função Hepática , Transplante de Fígado/efeitos adversos , Transplante de Fígado/mortalidade , Masculino , Pessoa de Meia-Idade , Perfusão/efeitos adversos , Perfusão/mortalidade , Complicações Pós-Operatórias/mortalidade , Estudos Prospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Isquemia Quente/efeitos adversos , Isquemia Quente/mortalidadeRESUMO
Warm ischemia time is a potentially modifiable insult to transplanted kidneys, but little is known about its effect on long-term outcomes. Here we conducted a study of United States kidney transplant recipients (years 2000-2013) to determine the association between warm ischemia time (the time from organ removal from cold storage to reperfusion with warm blood) and death/graft failure. Times under 10 minutes were potentially attributed to coding error. Therefore, the 10-to-under-20-minute interval was chosen as the reference group. The primary outcome was mortality and graft failure (return to chronic dialysis or preemptive retransplantation) adjusted for recipient, donor, immunologic, and surgical factors. The study included 131,677 patients with 35,901 events. Relative to the reference patients, times of 10 to under 20, 20 to under 30, 30 to under 40, 40 to under 50, 50 to under 60, and 60 and more minutes were associated with hazard ratios of 1.07 (95% confidence interval, 0.99-1.15), 1.13 (1.06-1.22), 1.17 (1.09-1.26), 1.20 (1.12-1.30), and 1.23 (1.15-1.33) for the composite event, respectively. Association between prolonged warm ischemia time and death/graft failure persisted after stratification by donor type (living vs. deceased donor) and delayed graft function status. Thus, warm ischemia time is associated with adverse long-term patient and graft survival after kidney transplantation. Identifying strategies to reduce warm ischemia time is an important consideration for future study.
Assuntos
Sobrevivência de Enxerto , Transplante de Rim/efeitos adversos , Transplante de Rim/mortalidade , Complicações Pós-Operatórias/mortalidade , Isquemia Quente/efeitos adversos , Isquemia Quente/mortalidade , Adulto , Função Retardada do Enxerto/etiologia , Função Retardada do Enxerto/mortalidade , Função Retardada do Enxerto/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Sistema de Registros , Diálise Renal , Reoperação , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Adulto JovemRESUMO
INTRODUCTION: The aim of this study is to evaluate the risk factors for acute kidney injury (AKI) and 30-day mortality after liver transplantation. MATERIAL AND METHODS: This is a retrospective cohort of consecutive adults undergoing orthotopic liver transplantation (OLT) at a referral hospital in Brazil, from January 2013 to January 2014. Risk factors for AKI and death were investigated. RESULTS: A total 134 patients were included, with median age of 56 years. AKI was found in 46.7% of patients in the first 72 h after OLT. Risk factors for AKI were: viral hepatitis (OR 2.9, 95% CI = 1.2-7), warm ischemia time (OR 1.1, 95% CI = 1.01-1.2) and serum lactate (OR 1.3, 95%CI = 1.02-1.89). The length of intensive care unit (ICU) stay was longer in AKI group: 4 (3-7) days vs. 3 (2-4) days (p = 0.001), as well as overall hospitalization stay: 16 (9-26) days vs. 10 (8- 14) days (p = 0.001). The 30-day mortality was 15%. AKI was an independent risk factor for mortality (OR 4.3, 95% CI = 1.3-14.6). MELD-Na ≥ 22 was a predictor for hemodialysis need (OR 8.4, 95%CI = 1.5-46.5). Chronic kidney disease (CKD) was found in 36 patients (56.2% of AKI patients). CONCLUSIONS: Viral hepatitis, longer warm ischemia time and high levels of serum lactate are risk factors for AKI after OLT. AKI is a risk factor for death and can lead to CKD in a high percentage of patients after OLT. A high MELD-Na score is a predictor for hemodialysis need.
Assuntos
Injúria Renal Aguda/etiologia , Injúria Renal Aguda/mortalidade , Transplante de Fígado/efeitos adversos , Transplante de Fígado/mortalidade , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/terapia , Biomarcadores/sangue , Brasil , Distribuição de Qui-Quadrado , Feminino , Mortalidade Hospitalar , Humanos , Ácido Láctico/sangue , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Diálise Renal , Insuficiência Renal Crônica/etiologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Regulação para Cima , Isquemia Quente/efeitos adversos , Isquemia Quente/mortalidadeRESUMO
BACKGROUND & AIMS: The growing discrepancy between supply and demand for liver transplantation has necessitated a greater use of higher risk grafts. Donation after Circulatory Death (DCD) liver transplant recipients have an increased frequency of acute kidney injury (AKI). We hypothesised that other higher risk grafts might also impact negatively on renal function. Our aim was to examine the effect of the evolving use of higher risk grafts on the incidence of post liver transplant AKI. METHODS: Single-centre study of 1152 patients undergoing first-single-organ liver transplantation for chronic liver disease 01/2000-12/2011. To assess the impact of the evolution of graft quality over time; donor/graft/recipient variables were compared over three 4-year periods. RESULTS: Pretransplant recipient renal function improved during follow-up (p<0.001), and the median postoperative day-1 (p<0.001), -2 (p<0.001), and -3 (p<0.001) tacrolimus trough levels fell. The proportion of patients receiving a higher risk graft was 31.8% in 2000-2003, 40.9% in 2004-2007, and 59.1% in 2008-2011 (p<0.001). There was a progressive increase in AKI (2000-2003, OR 1.00; 2004-2007, OR 1.43; 2008-2011, OR 2.40, p<0.001). After adjusting for recipient variables increasing recipient warm ischaemic time (p=0.019), DCD transplantation (p<0.001), donor age ≥60 years (p=0.020), and donor body mass index ≥30 kg/m(2) (p<0.001) were independent predictors of AKI. CONCLUSIONS: The increasing use of higher risk liver grafts is associated with an increased incidence of AKI. These findings support the need for therapies that minimise the hepatic ischaemia-reperfusion injury.
Assuntos
Injúria Renal Aguda/etiologia , Doença Hepática Terminal/cirurgia , Transplante de Fígado/efeitos adversos , Injúria Renal Aguda/mortalidade , Adulto , Índice de Massa Corporal , Doença Hepática Terminal/mortalidade , Feminino , Seguimentos , Sobrevivência de Enxerto , Humanos , Incidência , Transplante de Fígado/mortalidade , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Morbidade , Obesidade/mortalidade , Traumatismo por Reperfusão/mortalidade , Fatores de Risco , Doadores de Tecidos , Resultado do Tratamento , Isquemia Quente/mortalidadeRESUMO
BACKGROUND: Recent studies investigating early graft function (EGF) after living donor kidney transplantation (LDKT) identified prolonged warm ischemia time (WIT) as a risk factor for the occurrence of poor EGF. The latter is associated with long-term graft loss; therefore the question arises whether prolonged WIT affects long-term outcomes in LDKT. METHODS: Data were collected on 472 consecutive adult LDKTs. Patients were divided according to the total WIT into 3 groups with short (<30 minutes), intermediate (30-45 minutes), or prolonged (>45 minutes) WIT. RESULTS: Of all patients, 193 (40.9%) experienced short, 249 (52.8%) intermediate, and 30 (6.4%) prolonged WIT. Prolonged WIT was a significant risk factor for the occurrence of poor EGF with an adjusted odds ratio of 4.252 (95% confidence interval [CI), 1.914 -9.447). Long-term graft survival was impaired in patients with prolonged WIT, with an adjusted hazard ratio of 3.163 (95% CI, 1.202-8.321). Multivariate analysis revealed determinants of prolonged WIT, including laparoscopic procurement, recipient overweight, right donor kidney, and multiple renal arteries. CONCLUSION: Prolonged WIT impairs long-term graft survival in LDKT. This finding underlines the need to develop strategies to avoid the occurrence of prolonged WIT in LDKT.
Assuntos
Transplante de Rim/efeitos adversos , Doadores Vivos , Disfunção Primária do Enxerto/etiologia , Isquemia Quente/efeitos adversos , Adulto , Distribuição de Qui-Quadrado , Feminino , Sobrevivência de Enxerto , Humanos , Estimativa de Kaplan-Meier , Transplante de Rim/métodos , Transplante de Rim/mortalidade , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Países Baixos , Razão de Chances , Disfunção Primária do Enxerto/mortalidade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Isquemia Quente/mortalidadeRESUMO
BACKGROUND: There is little data available on the specific effects of warm ischemia time (WIT) as opposed to cold ischemia or storage time. With current research endeavors focusing on warm continuous perfusion, storage of donor hearts, and utilization of hearts from non-heart-beating donors, the impact of WIT on outcomes is increasingly relevant. The aim of this study was to analyze our results in cardiac transplantation with specific focus on the impact of WIT. METHODS: A retrospective review of 206 patients who underwent orthotopic heart transplantation at our institution between June 2001 and November 2010 was performed. Donor, recipient, and operative factors were analyzed. The main outcome variables were all cause mortality, survival, and primary graft failure. RESULTS: WIT of >80 minutes was associated with reduced survival compared with a shorter WIT of <60 minutes. Multivariate analysis showed increasing donor age to be the most significant variable associated with increased risk of mortality (hazard ratio 1.04; P = .004) per year of increasing donor age. CONCLUSIONS: This study has demonstrated a reduced survival in heart transplant recipients with increased WIT. This finding may be of particular relevance to potential future heart transplantation using organs procured from non-heart-beating donors.
Assuntos
Transplante de Coração/mortalidade , Isquemia Quente/mortalidade , Adulto , Distribuição de Qui-Quadrado , Feminino , Transplante de Coração/efeitos adversos , Humanos , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Vitória , Isquemia Quente/efeitos adversos , Adulto JovemRESUMO
BACKGROUND: Ischemia-reperfusion injury (IRI) can occur during hepatic surgery and transplantation. IRI causes hepatic mitochondrial and microcirculatory impairment, resulting in acute liver dysfunction and failure. We proposed a novel strategy of regulated hepatic reperfusion (RHR) to reverse the cellular metabolic deficit that incurred during organ ischemia by using a substrate-enriched, oxygen-saturated, and leukocyte-depleted perfusate delivered under regulated reperfusion pressure, temperature, and pH. We investigate the use of RHR in mitigating IRI after a prolonged period of warm ischemia. METHODS: Using a 2-hour liver warm ischemia swine model, 2 methods of liver reperfusion were compared. The control group (n = 6) received conventional reperfusion with unmodified portal venous blood under unregulated reperfusion pressure, temperature, and pH. The experimental group (n = 6) received RHR. We analyzed the effects of RHR on post-reperfusion hemodynamic changes, liver function, and 7-day animal survival. RESULTS: RHR resulted in 100% survival compared with 50% in the control group (p = 0.05). Post-reperfusion syndrome was not observed in the RHR group, but it occurred in 83% of the control group. RHR resulted in a lesser degree of change from baseline serum alanine aminotransferase levels, aspartate aminotransferase, and lactate dehydrogenase after reperfusion compared with the control group. Histopathologic evaluation showed minimal ischemic changes in the RHR group, whereas a considerable degree of coagulative hepatocellular necrosis was observed in the control group. CONCLUSIONS: Regulated hepatic reperfusion mitigates IRI, facilitates liver function recovery, and improves survival after a prolonged period of hepatic warm ischemia. This novel strategy has potential applicability to clinical hepatic surgery and liver transplantation when marginal grafts are used.
Assuntos
Fígado/cirurgia , Traumatismo por Reperfusão/prevenção & controle , Reperfusão/métodos , Isquemia Quente , Animais , Modelos Animais de Doenças , Estimativa de Kaplan-Meier , Fígado/patologia , Fígado/fisiologia , Testes de Função Hepática , Transplante de Fígado , Projetos Piloto , Reperfusão/efeitos adversos , Ressuscitação , Taxa de Sobrevida , Suínos , Fatores de Tempo , Isquemia Quente/mortalidadeRESUMO
BACKGROUND: Congenital heart disease (CHD) in the adult is an uncommon indication for heart transplantation but has been increasing. We assessed survival and predictors of death after heart transplantation for adults with CHD. METHODS: Adult primary heart transplant recipients (aged > 17 years) reported to the United Network for Organ Sharing (1987 to 2006) were reviewed and categorized by diagnosis of CHD vs other diagnoses. Kaplan-Meier survival analysis and Cox regression modeling were performed. RESULTS: During the study period, 35,334 adults underwent primary heart transplantation, and 689 (2%) had CHD. Adult CHD recipients had longer mean waiting list time (218 vs 195 days; p = 0.004), longer ischemic time (3.5 vs 2.9 hours, p < 0.0001), and were more likely to have pretransplant pulmonary vascular resistance exceeding 4 Woods Units (62% vs 51%, p < 0.0001) vs other recipients. Thirty-day mortality was 16% vs 6% (p < 0.0001), although Kaplan-Meier survival did not differ between groups (p = 0.92) out to 10 years. Ischemic time (hazard ratio [HR], 1.2; 95% confidence interval [CI], 1.02 to 1.35; p = 0.02), African American race (HR, 1.9; 95% CI, 1.04 to 3.58; p = 0.03), and pulmonary vascular resistance exceeding 4 Woods Units (HR, 1.5; 95% CI, 1.01 to 2.19; p = 0.04) were predictors of death for adult CHD recipients. CONCLUSIONS: Heart transplantation for adults with CHD is effective and has good long-term prognosis. The 30-day mortality rate is high, but 5- and 10-year survival is not statistically different from patients without CHD.
Assuntos
Bases de Dados Factuais , Cardiopatias Congênitas/cirurgia , Transplante de Coração/mortalidade , Complicações Pós-Operatórias/mortalidade , Sistema de Registros , Adolescente , Adulto , Causas de Morte , Feminino , Cardiopatias Congênitas/mortalidade , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/mortalidade , Transplante de Coração/tendências , Mortalidade Hospitalar , Humanos , Hipertensão Pulmonar/complicações , Hipertensão Pulmonar/mortalidade , Estimativa de Kaplan-Meier , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Estados Unidos , Resistência Vascular , Listas de Espera , Isquemia Quente/mortalidade , Adulto JovemRESUMO
BACKGROUND: Transplantation is limited by the number of available donor organs. Donor organ maintenance systems are a recent technological advance. These systems may increase the number of donor organs that can be used and improve outcomes by decreasing donor organ ischemic time (IT). The purpose of this study was to determine the potential life-years gained if IT in the United Kingdom were decreased for cardiac transplantation. METHODS: Proportional hazards regression and extrapolation of survival rates beyond 20 years posttransplantation were used to estimate the effect of decreasing total IT on survival and the life-years gained over the lifetime of UK heart transplantation patients. RESULTS: Median survival posttransplantation was 10.4 years (95% CI 9.9 to 10.9). For each additional hour of donor organ IT, patients had a 25% increased risk of death after heart transplantation in the first year after transplant, with a 5% increase thereafter (P<0.001). On average, a recipient surviving 10 years posttransplantation could potentially gain 0.4 (95% CI 0.1 to 0.7) life-years if IT was reduced to 1 hr. The longer the IT, the greater the potential life-years to gain; for example, a recipient of an organ that would have had an IT of 6 hr without the use of an organ maintenance system might expect to gain 2.9 life-years (95% CI -0.6 to 6.4) if IT was reduced to 1 hr. CONCLUSIONS: Use of cardiac donor organ maintenance systems has the potential to increase posttransplantation survival.