Volumetric graft changes after liver transplantation: evidence of adaptation to recipient body size.

It is believed that whole liver grafts adjust their size to fit the body size of the recipient after transplantation, despite a lack of evidence. The aim of this study was to test this hypothesis. This was a retrospective cohort study of 113 liver transplantations performed at Karolinska University Hospital. The cohort was divided based on graft volume-to-standard liver volume ratio (GV/SLV) into quartiles of small, mid, and large grafts. Serial volumetric assessment was performed on the day of transplantation and at posttransplant check-ups early (<2 mo) and late (9-13 mo) after transplantation using computed tomography (CT) volumetry. Change in GV/SLV ratio over time was analyzed with ANOVA repeated measures. A multiple regression model was used to investigate the influence of intraoperative blood flow, recipient body size, age, and relative sickness on graft volume changes. Between the three time points, mean GV/SLV ratio adapted to 0.55-0.94-1.00 in small grafts (n = 29, P < 0.001); 0.87-1.18-1.13 in midgrafts (n = 56, P < 0.001); 1.11-1.51-1.18 in large grafts (n = 28, P < 0.001). Regression analysis showed a positive correlation between posttransplant graft growth and portal flow (ß = 1.18, P = 0.005), arterial flow (ß = 0.17, P = 0.001), and recipient body surface area (ß = 59.85, P < 0.001). A negative correlation was observed for graft weight-to-recipient weight ratio (GRWR; ß = -33.12, P < 0.001). Grafts with initial GV/SLV-ratio < 0.6 adapt toward the ideal volume for recipient body size 1 year after transplantation. The disparity between graft size relative to recipient body size, and the portal and arterial perfusion, influence volumetric graft changes.NEW & NOTEWORTHY This is the first and largest human study to verify the hypothesis that whole liver grafts adjust their size to match recipient body size 1 year after transplantation-a phenomenon that has previously only been observed in experimental animal studies and human case reports. The direction of volumetric changes is driven by the disparity between graft size relative to recipient body surface area and weight, as well as the intraoperative portal- and arterial graft perfusion.

Novel Benchmark Values for Redo Liver Transplantation: Does the Outcome Justify the Effort?

OBJECTIVE: To define benchmark cutoffs for redo liver transplantation (redo-LT). BACKGROUND: In the era of organ shortage, redo-LT is frequently discussed in terms of expected poor outcome and wasteful resources. However, there is a lack of benchmark data to reliably evaluate outcomes after redo-LT. METHODS: We collected data on redo-LT between January 2010 and December 2018 from 22 high-volume transplant centers. Benchmark cases were defined as recipients with model of end stage liver disease (MELD) score ≤25, absence of portal vein thrombosis, no mechanical ventilation at the time of surgery, receiving a graft from a donor after brain death. Also, high-urgent priority and early redo-LT including those for primary nonfunction (PNF) or hepatic artery thrombosis were excluded. Benchmark cutoffs were derived from the 75th percentile of the medians of all benchmark centers. RESULTS: Of 1110 redo-LT, 373 (34%) cases qualified as benchmark cases. Among these cases, the rate of postoperative complications until discharge was 76%, and increased up to 87% at 1-year, respectively. One-year overall survival rate was excellent with 90%. Benchmark cutoffs included Comprehensive Complication Index CCI ® at 1-year of ≤72, and in-hospital and 1-year mortality rates of ≤13% and ≤15%, respectively. In contrast, patients who received a redo-LT for PNF showed worse outcomes with some values dramatically outside the redo-LT benchmarks. CONCLUSION: This study shows that redo-LT achieves good outcome when looking at benchmark scenarios. However, this figure changes in high-risk redo-LT, as for example in PNF. This analysis objectifies for the first-time results and efforts for redo-LT and can serve as a basis for discussion about the use of scarce resources.

Liver Transplantation for Acute Intermittent Porphyria.

Recurrent attacks of acute intermittent porphyria (AIP) result in poor quality of life and significant risks of morbidity and mortality. Liver transplantation (LT) offers a cure, but published data on outcomes after LT are limited. We assessed the pretransplant characteristics, complications, and outcomes for patients with AIP who received a transplant. Data were collected retrospectively from the European Liver Transplant Registry and from questionnaires sent to identified transplant and porphyria centers. We studied 38 patients who received transplants in 12 countries from 2002 to 2019. Median age at LT was 37 years (range, 18-58), and 34 (89%) of the patients were women. A total of 9 patients died during follow-up, and 2 patients were retransplanted. The 1-year and 5-year overall survival rates were 92% and 82%, which are comparable with other metabolic diseases transplanted during the same period. Advanced pretransplant neurological impairment was associated with increased mortality. The 5-year survival rate was 94% among 19 patients with moderate or no neuropathy at LT and 83% among 10 patients with severe neuropathy (P = 0.04). Pretransplant renal impairment was common. A total of 19 (51%) patients had a GFR < 60 mL/minute. Although few patients improved their renal function after LT, neurological impairments improved, and no worsening of neurological symptoms was recorded. No patient had AIP attacks after LT, except for a patient who received an auxiliary graft. LT is a curative treatment option for patients with recurrent attacks of AIP. Severe neuropathy and impaired renal function are common and increase the risk for poor outcomes. If other treatment options fail, an evaluation for LT should be performed early.

Is primary hepatic angiosarcoma in children an indication for liver transplantation?-A single-centre experience and review of the literature.

PHA in the paediatric population is an extremely rare and aggressive malignant soft tissue neoplasm, with less than 50 cases published worldwide. The prognosis is dismal. If the tumour is unresectable, one treatment option is LT. In this article, the current available literature is reviewed and additionally, three cases of paediatric patients with PHA who underwent LT at Karolinska University Hospital, Sweden, are presented. Based on the literature and our own experience, there is undoubtedly possible good outcome of LT due to PHA. On the contrary, no patients have survived PHA without LT. PHA in paediatric patients should be recommended to LT in selected patients. Effect of modern adjuvant chemo and RT should be evaluated further based on international registry for such rare cases of PHA.

Impact of Hepatic Artery Variations and Reconstructions on the Outcome of Orthotopic Liver Transplantation.

BACKGROUND: Donor variational arteries often require complex reconstruction. METHODS: We analysed the incidence of different variations, types of arterial reconstructions and their impact on post-operative results from 409 patients undergoing liver transplantation at Karolinska Institute between 2007 and 2015. RESULTS: A total of 292 (71.4%) liver grafts had a standard hepatic artery (SHA), and 117 (28.6%) showed hepatic artery variants (HAV). 58% of HAV needed reconstruction. The main variations were variant left hepatic artery (45.3%) from the gastric artery; variant right hepatic artery (38.5%); and a triple combination of variant right and left hepatic artery and the proper hepatic artery from the common hepatic artery (12.8%); other 3.4%. Patients/graft survival and arterial complications were not different between SHA and HAV. Incidence of biliary stricture was numerically higher in left hepatic artery variants (p = 0.058) and in variants where no arterial reconstruction was performed (p = 0.001). Operation and arterial warm ischaemia time were longer in the HAV group. The need for intraoperative re-reconstruction was higher in the HAV group (p = 0.04). Intraoperative bleeding was larger after back-table reconstruction than with intraoperative reconstruction (p = 0.04). CONCLUSION: No overall differences were found between the HAV and the SHA groups. Occurrence of a variant left hepatic artery and HAV with no reconstruction seems to increase the risk of biliary strictures.

Association of post-reperfusion syndrome and ischemia-reperfusion injury with acute kidney injury after liver transplantation.

BACKGROUND: Acute kidney injury (AKI) is frequently observed after orthotopic liver transplantation (OLT) even in patients with previously normal renal function. In this study, we investigated the impact of factors such graft steatosis, post-reperfusion syndrome (PRS), and hepatic ischemia reperfusion injury (HIRI) on the development of AKI after OLT in adult patients. METHODS: We retrospectively examined consecutive adult patients who underwent OLT at our institution between July 2011 and June 2017. AKI was diagnosed based on the criteria proposed by the International Kidney Disease Improving Global Outcomes (KDIGO) workgroup. Peak aspartate aminotransferase (AST) level within 72 hours after OLT was used as a surrogate marker for HIRI. Graft steatosis was diagnosed by histopathological examination using specimens biopsied intraoperatively at the end of transplantation procedure and categorized as <10%, 10%-20%, 20%-30%, and ≥30% of hepatic steatosis. RESULTS: Out of 386 patients, 141 (37%) developed AKI (KDIGO stage 1:71 patients; stage 2:29 patients; stage 3:41 patients). Multivariable logistic regression analysis revealed that cold ischemic time (P = .012) and HIRI (P = .007) were independent risk factors for post-OLT AKI. Multivariable analysis also revealed that graft steatosis was associated with HIRI but not directly with AKI. PRS was not associated with HIRI or AKI in the multivariable analyses. CONCLUSION: Our results indicate that greater severity of liver graft injury during transplantation negatively affects renal function after OLT. As expected, the severity of liver graft steatosis contributes to accelerated liver injury occurring during the transplantation procedure.

Characteristics and risk factors for recurrence of nonalcoholic steatohepatitis following liver transplantation.

OBJECTIVES: Nonalcoholic steatohepatitis (NASH), which is a common and increasing indication for liver transplantation (LT), is known to recur after LT. Since the recurrence of NASH can lead to graft failure, the identification of predictive factors is needed and preventive strategies should be implemented. METHODS: We retrospectively examined 95 patients who had undergone LT for NASH or alcoholic liver disease (ALD) as a primary indication. We evaluated peritransplant characteristics and histological findings 1-year post LT among liver transplant patients due to NASH or ALD. RESULTS: Pre-LT body mass index (BMI) was higher and pre-LT diabetes was more prevalent in NASH patients than in ALD patients (p < .01). The difference of BMI persisted at 3 months and 1 year after LT. There were no differences between the groups regarding histopathological findings including the degree of steatosis and fibrosis in 1-year biopsy. In multivariate analysis, recipient age and 1-year BMI were independent risk factors for post-LT fatty liver disease development. Regarding predictive factors of NASH recurrence, the prevalence of pre-LT insulin-dependent diabetes was significantly higher in patients who developed NASH recurrence than those who did not. The increase of HbA1c at 1-year post-LT checkup was higher in patients who developed recurrence than those who did not, although the difference did not reach statistical significance. CONCLUSIONS: The results of this study suggest that insulin-dependent diabetes has detrimental effects on NASH recurrence following LT. Optimal glycemic control should be recommended, but studies are needed to prove its preventive effect on NASH recurrence.

Defining Benchmarks in Liver Transplantation: A Multicenter Outcome Analysis Determining Best Achievable Results.

: This multicentric study of 17 high-volume centers presents 12 benchmark values for liver transplantation. Those values, mostly targeting markers of morbidity, were gathered from 2024 "low risk" cases, and may serve as reference to assess outcome of single or any groups of patients. OBJECTIVE: To propose benchmark outcome values in liver transplantation, serving as reference for assessing individual patients or any other patient groups. BACKGROUND: Best achievable results in liver transplantation, that is, benchmarks, are unknown. Consequently, outcome comparisons within or across centers over time remain speculative. METHODS: Out of 7492 liver transplantation performed in 17 international centers from 3 continents, we identified 2024 low risk adult cases with a laboratory model for end-stage liver disease score ≤20 points, a balance of risk score ≤9, and receiving a primary graft by donation after brain death. We chose clinically relevant endpoints covering intra- and postoperative course, with a focus on complications graded by severity including the complication comprehensive index (CCI). Respective benchmarks were derived from the median value in each center, and the 75 percentile was considered the benchmark cutoff. RESULTS: Benchmark cases represented 8% to 49% of cases per center. One-year patient-survival was 91.6% with 3.5% retransplantations. Eighty-two percent of patients developed at least 1 complication during 1-year follow-up. Biliary complications occurred in one-fifth of the patients up to 6 months after surgery. Benchmark cutoffs were ≤4 days for ICU stay, ≤18 days for hospital stay, ≤59% for patients with severe complications (≥ Grade III) and ≤42.1 for 1-year CCI. Comparisons with the next higher risk group (model for end stage liver disease 21-30) disclosed an increase in morbidity but within benchmark cutoffs for most, but not all indicators, while in patients receiving a second graft from 1 center (n = 50) outcome values were all outside of benchmark values. CONCLUSIONS: Despite excellent 1-year survival, morbidity in benchmark cases remains high with half of patients developing severe complications during 1-year follow-up. Benchmark cutoffs targeting morbidity parameters offer a valid tool to assess higher risk groups.

Albumin mass balance and kinetics in liver transplantation.

BACKGROUND: In major abdominal surgery albumin is shifted from the circulation, presumably leaking into the interstitial space, contributing to a 30-40% decrease in plasma albumin concentration. During and after liver transplantation exogenous albumin is infused for volume substitution and to maintain plasma albumin concentration. Here we used liver transplantation as a model procedure for the study of albumin mass balance and kinetics during major abdominal surgery with albumin substitution. METHODS: Patients were studied during liver transplantation (n = 16), and until postoperative day 3 (POD 3) (n = 11). Cumulative perioperative albumin shift was assessed by mass balance of albumin and hemoglobin. Synthesis rates of albumin and fibrinogen were estimated by the flooding technique using deuterium-labeled phenylalanine. Albumin distribution was assessed by radioiodinated human serum albumin. RESULTS: At the end of surgery, 37 ± 17 g of albumin (p < 0.0001) had shifted from plasma, and this amount was stable until POD 3 (48 ± 33 g, p = 0.0017 versus baseline). There was 91 ± 37 g exogenous albumin infused peroperatively and another 47 ± 35 g was infused postoperatively until POD 3. Absolute synthesis rates of albumin and fibrinogen on POD 3 were 239 ± 84 mg/kg body weight/day and 33 mg/kg body weight/day (range 5-161), respectively. CONCLUSIONS: Albumin net leakage from plasma progressed until the end of surgery, and was then unaltered until POD 3. This is in contrast with the normalization of the cumulative albumin shift identified at day 3 after non-transplant major abdominal surgery. Liver synthesis of export proteins was high compared to reference values at the third postoperative day, suggesting rapid recovery of synthesis capacity. TRIAL REGISTRATION: Swedish Medical Product Agency, EudraCT 2015-002568-18. Registered on 15 July 2015.

Serial Assessment of Growth Factors Associated with Liver Regeneration in Patients Operated with Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy.

BACKGROUND: There is limited knowledge about the mechanisms behind the unparalleled growth of the future liver remnant (FLR) linked to associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). In this study, liver regenerative markers were examined in patients subjected to ALPPS. METHODS: Ten patients with colorectal liver metastases treated with neoadjuvant chemotherapy and ALPPS were included. Plasma was sampled at 6 time points and biopsies from both liver lobes were collected at both stages of ALPPS. The levels of interleukin (IL)-6, hepatocyte growth factor (HGF), tumor necrosis factor-α, epidermal growth factor, and vascular endothelial growth factor in plasma were measured at each time point. Expression of mRNA for markers of proliferation and apoptosis was studied in the biopsies from both liver lobes taken at both stages. RESULTS: ALPPS resulted in a peak of IL-6 after stage 1 (p = 0.004), which decreased rapidly and did not increase again after stage 2. HGF also increased after stage 1 (p = 0.048), and the HGF levels correlated significantly with the degree of growth of the FLR before stage 2 (p = 0.02, r2 = 0.47). There was a correlation between peak levels of IL-6 and HGF (p = 0.03, r2 = 0.84). CONCLUSIONS: IL-6 and HGF seem to be early mediators of hypertrophy after stage 1 in the ALPPS procedure. The peak HGF plasma level correlates with the degree of FLR growth in patients subjected to ALPPS.

Mortality-related risk factors and long-term survival after 4460 liver resections in Sweden-a population-based study.

PURPOSE: The objectives of this study were to analyze the outcome after hepatectomy and to identify contributing factors to mortality and long-term survival in a population-based setting. METHOD: A retrospective, nationwide register study was performed. All patients who underwent hepatectomy in Sweden between 2002 and 2011 were identified in the Swedish Hospital Discharge Registry using their unique personal identification numbers. This cohort was linked to the National Cancer Registry (cancer diagnosis), the National Registry of Causes of Death, and the Migration Registry. Survival analysis by Kaplan-Meier method was performed to assess long-term outcome. A Cox regression model was used to analyze risk factors affecting long-term survival. RESULTS: Overall, 4460 hepatectomies were performed. The 30- and 90-day mortalities were 1.8 and 3.1 %, respectively. The overall 5- and 10-year survival rates for all diagnoses were 45 and 38 %, respectively. Independent risk factors for 5-year mortality were as follows: patient age, comorbidity, male gender, intrahepatic/extrahepatic cholangiocarcinoma, gallbladder cancer, extent of hepatectomy, and hepatectomies performed at non-university hospitals. Re-resection (78.1 % with diagnosis "metastasis") was performed on 374 patients. In these patients, mortality risk decreased by >50 % (HR 0.42; 95 %, CI 0.33-0.53). CONCLUSION: In a population-based analysis, liver resections are done with a low mortality risk and good long-term outcome. Patients who underwent resection at a University Hospital showed a significant better outcome compared to patients resected at non-University Hospitals. These results support further centralization of liver surgery. Re-resection should be performed if feasible.

Changes in gluconeogenesis and intracellular lipid accumulation characterize uremic human hepatocytes ex vivo.

It is well known that reduced glomerular filtration rate (GFR) leads to an increased risk of dyslipidemia, insulin resistance, and cardiovascular mortality. The liver is a central organ for metabolism, but its function in the uremic setting is still poorly characterized. We used human primary hepatocytes isolated from livers of nine donors with normal renal function to investigate perturbations in key metabolic pathways following exposure to uremic (n = 8) or healthy (n = 8) sera, and to serum-free control medium. Both uremic and healthy elicited consistent responses from hepatocytes from multiple donors and compared with serum-free control. However, at physiological insulin concentrations, uremic cells accumulated 56% more intracellular lipids. Also, when comparing uremic with healthy medium after culture, it contained more very-low-density lipoprotein-triglyceride and glucose. These changes were accompanied by decreased phosphorylation of AktS473 mRNA levels of key regulators of gluconeogenesis in uremic sera-treated hepatocytes such as phosphoenolpyruvate carboxykinase 1 and glucose 6-phosphate were elevated. We also found increased expression of 11ß-hydroxysteroid dehydrogenase mRNA in uremic cells, along with high phosphorylation of downstream p53 and phospholipase C-γ1Y783 Thus our ex vivo data suggest that the uremic hepatocytes rapidly develop a glycogenic and lipogenic condition accompanied by perturbations in a large number of signaling networks.

Liver transplantation in the Nordic countries - An intention to treat and post-transplant analysis from The Nordic Liver Transplant Registry 1982-2013.

AIM AND BACKGROUND: The Nordic Liver Transplant Registry (NLTR) accounts for all liver transplants performed in the Nordic countries since the start of the transplant program in 1982. Due to short waiting times, donor liver allocation has been made without considerations of the model of end-stage liver disease (MELD) score. We aimed to summarize key outcome measures and developments for the activity up to December 2013. MATERIALS AND METHODS: The registry is integrated with the operational waiting-list and liver allocation system of Scandiatransplant (www.scandiatransplant.org) and accounted at the end of 2013 for 6019 patients out of whom 5198 were transplanted. Data for recipient and donor characteristics and relevant end-points retransplantation and death are manually curated on an annual basis to allow for statistical analysis and the annual report. RESULTS: Primary sclerosing cholangitis, acute hepatic failure, alcoholic liver disease, primary biliary cirrhosis and hepatocellular carcinoma are the five most frequent diagnoses (accounting for 15.3%, 10.8%, 10.6%, 9.3% and 9.0% of all transplants, respectively). Median waiting time for non-urgent liver transplantation during the last 10-year period was 39 days. Outcome has improved over time, and for patients transplanted during 2004-2013, overall one-, five- and 10-year survival rates were 91%, 80% and 71%, respectively. In an intention-to-treat analysis, corresponding numbers during the same time period were 87%, 75% and 66%, respectively. CONCLUSION: The liver transplant program in the Nordic countries provides comparable outcomes to programs with a MELD-based donor liver allocation system. Unique features comprise the diagnostic spectrum, waiting times and the availability of an integrated waiting list and transplant registry (NLTR).

Endocardial border delineation capability of a novel multimodal polymer-shelled contrast agent.

BACKGROUND: A novel polymer-shelled contrast agent (CA) with multimodal and target-specific potential was developed recently. To determine its ultrasonic diagnostic features, we evaluated the endocardial border delineation as visualized in a porcine model and the concomitant effect on physiological variables. METHODS: Three doses of the novel polymer-shelled CA (1.5 ml, 3 ml, and 5 ml [5 × 10(8) microbubbles (MBs)/ml]) and the commercially available CA SonoVue (1.5 ml [2-5 × 10(8) MBs/ml]) were used. Visual evaluations of ultrasound images of the left ventricle were independently performed by three observers who graded each segment in a 6-segment model as either 0 = not visible, 1 = weakly visible, or 2 = visible. Moreover, the duration of clinically useful contrast enhancement and the left ventricular opacification were determined. During anesthesia, oxygen saturation, heart rate, and arterial pressure were sampled every minute and the effect of injection of CA on these physiological variables was evaluated. RESULTS: The highest dose of the polymer-shelled CA gave results comparable to SonoVue. Thus, no significant difference in the overall segment score distribution (2-47-95 vs. 1-39-104), time for clinically sufficient contrast enhancement (20-40 s for both) and left ventricular overall opacification was found. In contrast, when comparing the endocardial border delineation capacity for different regions SonoVue showed significantly higher segment scores for base and mid, except for the mid region when injecting 1.5 ml of the polymer-shelled CA. Neither high nor low doses of the polymer-shelled CA significantly affected the investigated physiological variables. CONCLUSIONS: This study demonstrated that the novel polymer-shelled CA can be used in contrast-enhanced diagnostic imaging without influence on major physiological variables.

Results of Liver Retransplantation After Rescue Hepatectomy: A Single-Center Study.

BACKGROUND Liver retransplantation (reLT) is a well-accepted treatment for liver graft failure in selected patients. A rescue hepatectomy (RH), on the contrary, is a rare and controversial procedure in which a deteriorating liver graft causing failure of other organ systems is removed to stabilize the patient's condition before a new liver graft is available. MATERIAL AND METHODS In this retrospective cohort study, we evaluated the outcomes of the 104 patients who were listed for a first single-organ reLT in our center during the period 2000-2019, to compare the results after RH to other reLTs. RESULTS In the study population, RH was performed on 8 patients, while 7 of these received a new graft (8% of all first time reLTs) and 1 died before reLT. All RHs were performed within 1 week after the first transplantation. The median anhepatic time after RH was 36 hours (range 14-99). The 1-year patient survival rate was 57% for reLTs with RH and 69% for acute reLTs without RH that were performed within 14 days after the first transplantation (P=0.66). The 5-year survival rate was 50% in the RH and 47% in the non-RH group (P=1.0). CONCLUSIONS The use of RH prior to reLT results in a similar outcome to reLTs without RH. Therefore, RH should be considered in patients with a severe clinical instability caused by a deteriorating liver graft. However, further studies are needed to establish guidelines based on objective parameters for when RH should be performed.

Human resident liver myeloid cells protect against metabolic stress in obesity.

Although multiple populations of macrophages have been described in the human liver, their function and turnover in patients with obesity at high risk of developing non-alcoholic fatty liver disease (NAFLD) and cirrhosis are currently unknown. Herein, we identify a specific human population of resident liver myeloid cells that protects against the metabolic impairment associated with obesity. By studying the turnover of liver myeloid cells in individuals undergoing liver transplantation, we find that liver myeloid cell turnover differs between humans and mice. Using single-cell techniques and flow cytometry, we determine that the proportion of the protective resident liver myeloid cells, denoted liver myeloid cells 2 (LM2), decreases during obesity. Functional validation approaches using human 2D and 3D cultures reveal that the presence of LM2 ameliorates the oxidative stress associated with obese conditions. Our study indicates that resident myeloid cells could be a therapeutic target to decrease the oxidative stress associated with NAFLD.

Prevalence, management and efficacy of treatment in portal vein obstruction after paediatric liver transplantation: protocol of the retrospective international multicentre PORTAL registry.

INTRODUCTION: Portal vein obstruction (PVO) consists of anastomotic stenosis and thrombosis, which occurs due to a progression of the former. The aim of this large-scale international study is to assess the prevalence, current management practices and efficacy of treatment in patients with PVO. METHODS AND ANALYSIS: The Portal vein Obstruction Revascularisation Therapy After Liver transplantation registry will facilitate an international, retrospective, multicentre, observational study, with 25 centres around the world already actively involved. Paediatric patients (aged <18 years) with a diagnosed PVO between 1 January 2001 and 1 January 2021 after liver transplantation will be eligible for inclusion. The primary endpoints are the prevalence of PVO, primary and secondary patency after PVO intervention and current management practices. Secondary endpoints are patient and graft survival, severe complications of PVO and technical success of revascularisation techniques. ETHICS AND DISSEMINATION: Medical Ethics Review Board of the University Medical Center Groningen has approved the study (METc 2021/072). The results of this study will be disseminated via peer-reviewed publications and scientific presentations at national and international conferences. TRIAL REGISTRATION NUMBER: Netherlands Trial Register (NL9261).

Oxygen-charged HTK-F6H8 emulsion reduces ischemia-reperfusion injury in kidneys from brain-dead pigs.

BACKGROUND: Prolonged cold ischemia is frequently associated with a greater risk of delayed graft function and enhanced graft failure. We hypothesized that media, combining a high oxygen-dissolving capacity with specific qualities of organ preservation solutions, would be more efficient in reducing immediate ischemia-reperfusion injury from organs stored long term compared with standard preservation media. METHODS: Kidneys retrieved from brain-dead pigs were flushed using either cold histidine-tryptophan-ketoglutarate (HTK) or oxygen-precharged emulsion composed of 75% HTK and 25% perfluorohexyloctane. After 18 h of cold ischemia the kidneys were transplanted into allogeneic recipients and assessed for adenosine triphosphate content, morphology, and expression of genes related to hypoxia, environmental stress, inflammation, and apoptosis. RESULTS: Compared with HTK-flushed kidneys, organs preserved using oxygen-precharged HTK-perfluorohexyloctane emulsion had increased elevated adenosine triphosphate content and a significantly lower gene expression of hypoxia inducible factor-1α, vascular endothelial growth factor, interleukin-1α, tumor necrosis factor-α, interferon-α, JNK-1, p38, cytochrome-c, Bax, caspase-8, and caspase-3 at all time points assessed. In contrast, the mRNA expression of Bcl-2 was significantly increased. CONCLUSIONS: The present study has demonstrated that in brain-dead pigs the perfusion of kidneys with oxygen-precharged HTK-perfluorohexyloctane emulsion results in significantly reduced inflammation, hypoxic injury, and apoptosis and cellular integrity and energy content are well maintained. Histologic examination revealed less tubular, vascular, and glomerular changes in the emulsion-perfused tissue compared with the HTK-perfused counterparts. The concept of perfusing organs with oxygen-precharged emulsion based on organ preservation media represents an efficient alternative for improved organ preservation.

Protein intake early after liver transplantation and postoperative outcome: An observational study comparing two nutritional protocols.

OBJECTIVES: Patients undergoing liver transplantation (LT) are at risk for eating difficulties. Adequate nutritional support is important to promote enhanced recovery and to reduce postoperative complications. The aim of this study was to evaluate two nutritional protocols and their effect on total protein intake during the first 7 d after LT. METHODS: Adult patients were monitored daily for energy and protein intake during the first week after LT. Patients with ≥3 d of monitoring were included in the study. Two patient groups were studied: protocol A (pA) based on enteral nutrition (EN) provided from postoperative days 1 through 4 (historical control); and protocol B (pB), which was based on high volume of EN and high-protein oral nutritional supplements (ONS). Outcome measures were hospital length of stay and grade of complications according to Clavien-Dindo within the first 3 mo after transplantation. RESULTS: Seventy patients were included in the study (pA n=34, pB n= 36). The median age was 59 y and 70% were men. During postoperative week 1, patients with pB had a higher daily protein intake (95 g versus 77 g, P < 0.01) and met a higher proportion of estimated protein requirements (80% versus 70%, P < 0.05). There were no differences in severe postoperative outcomes between the two groups. CONCLUSIONS: A nutritional protocol with a higher rate of EN and high-protein ONS resulted in a higher protein intake early after LT. However, there was no difference in severe postoperative outcomes between the two nutritional protocols.