The effectiveness and impact of 10 gram glucose and 10 units insulin in treating hyperkalemia during living donor liver transplantation.

BACKGROUND: The aim of this retrospective observational study is to evaluate the effectiveness and impact on glycemia of the administration of 10 gram glucose and 10 units insulin in treating hyperkalemia during living donor liver transplantation (LDLT). METHODS: In LDLT, patients whose serum potassium exceeded 5.4 mEq/L and were treated with 10 gram glucose and 10 U regular insulin were included in this study. The descriptive statistics summarize the demographic data, baseline laboratory values, and intra-operative parameters of the treated patients. The changes of the serum potassium and serum glucose levels after treatment were analyzed by the paired Student's t-test. All the data were given as means ± SD. A P value < 0.05 was regarded as statistically significant. RESULTS: After administration of 10 gram glucose and 10 units regular insulin bolus intravenously, a drastic and significant decreased of serum potassium from 5.73 ± 0.44 to 4.48 ± 0.06 mEq/L was noted. The serum glucose level was slightly higher after the treatment (166.6 ± 32.1 and 196.8 ± 44.3 mg/dl respectively, p = 0.05). CONCLUSIONS: An intravenous bolus of 10 units regular insulin with 10 gram glucose was able to decrease the serum -potassium level effectively and additionally increase serum glucose in LDLT patients.

Vascular stents in the management of portal venous complications in living donor liver transplantation.

To evaluate the efficacy of stent placement in the treatment of portal vein (PV) stenosis or occlusion in living donor liver transplant (LDLT) recipients, 468 LDLT records were reviewed. Sixteen (10 PV occlusions and 6 stenoses) recipients (age range, 8 months-59 years) were referred for possible interventional angioplasty (dilatation and/or stent) procedures. Stent placement was attempted in all. The approaches used were percutaneous transhepatic (n = 10), percutaneous transsplenic (n = 4), and intraoperative (n = 2). Technical success was achieved in 11 of 16 patients (68.8%). The sizes of the stents used varied from 7 mm to 10 mm in diameter. In the five unsuccessful patients, long-term complete occlusion of the PV with cavernous transformation precluded catherterization. The mean follow-up was 12 months (range, 3-24). The PV stent patency rate was 90.9% (10/11). Rethrombosis and occlusion of the stent and PV occurred in a single recipient who had a cryoperserved vascular graft to reconstruct the PV during the LDLT operation. PV occlusion of >1 year with cavernous transformation seemed to be a factor causing technical failure. In conclusion, early treatment of PV stenosis and occlusion by stenting is an effective treatment in LDLT. Percutaneous transhepatic and transsplenic, and intraoperative techniques are effective approaches depending on the situation.

Liver graft regeneration in right lobe adult living donor liver transplantation.

Optimal portal flow is one of the essentials in adequate liver function, graft regeneration and outcome of the graft after right lobe adult living donor liver transplantation (ALDLT). The relations among factors that cause sufficient liver graft regeneration are still unclear. The aim of this study is to evaluate the potential predisposing factors that encourage liver graft regeneration after ALDLT. The study population consisted of right lobe ALDLT recipients from Chang Gung Memorial Hospital-Kaohsiung Medical Center, Taiwan. The records, preoperative images, postoperative Doppler ultrasound evaluation and computed tomography studies performed 6 months after transplant were reviewed. The volume of the graft 6 months after transplant divided by the standard liver volume was calculated as the regeneration ratio. The predisposing risk factors were compiled from statistical analyses and included age, recipient body weight, native liver disease, spleen size before transplant, patency of the hepatic venous graft, graft weight-to-recipient weight ratio (GRWR), posttransplant portal flow, vascular and biliary complications and rejection. One hundred forty-five recipients were enrolled in this study. The liver graft regeneration ratio was 91.2 +/- 12.6% (range, 58-151). The size of the spleen (p = 0.00015), total portal flow and GRWR (p = 0.005) were linearly correlated with the regeneration rate. Patency of the hepatic venous tributary reconstructed was positively correlated to graft regeneration and was statistically significant (p = 0.017). Splenic artery ligation was advantageous to promote liver regeneration in specific cases but splenectomy did not show any positive advantage. Spleen size is a major factor contributing to portal flow and may directly trigger regeneration after transplant. Control of sufficient portal flow and adequate hepatic outflow are important factors in graft regeneration.

The role of a nuclear protein, histone H1, on signalling pathways for the maturation of dendritic cells.

We have demonstrated previously that liver allograft tolerance is associated with the immunosuppressive activity of anti-histone H1 autoreactive antibodies induced in the serum of liver transplantation. Furthermore, we and others have shown that nuclear proteins such as histone H1 and high mobility group box 1 play an important role in maturation of dendritic cells (DCs), although the precise mechanisms are still unknown. In the present study, we focus upon the significance of histone H1 on DCs in terms of the intracellular signalling pathway of DCs. Our immunostaining and immunoblot studies demonstrated that histone H1 was detected in cytoplasm and culture supernatants upon the activation of DCs. Histone H1 blockage by anti-histone H1 antibody down-regulated the intracellular activation of mitogen-activated protein kinases (MAPKs) (p38) and IkappaBalpha of DCs, and inhibited DC activity in the proliferation of CD4+ T cells. On the other hand, the addition of histone H1 without endotoxin stimulation up-regulated major histocompatibility complex class II, the CD80 and CD86 surface markers of DCs and the activation of MAPKs (p38 and extracellular-regulated kinase 1/2) and IkappaBalpha. These results suggest that the translocation of histone H1 from nuclei to cytoplasm and the release of their own histone H1 are necessary for the maturation of DCs and the activation for T lymphocytes.

High-mobility group box 1 protein activates hepatic stellate cells in vitro.

OBJECTIVES: Our previous study noticed remarkably elevated titers of anti-high-mobility group box 1 (HMGB1) antibodies in sera during the tolerance induction phase of a rat tolerogenic orthotopic liver transplantation (OLT) as well as in sera of clinically drug-free patients. We hypothesized that the release of nonhistone nuclear protein HMGB1 during rejection may play a pathogenic role in deteriorating post-OLT graft functions, such as inducing liver fibrosis. This study sought to investigate whether HMGB1 can directly activate hepatic stellate cells (HSCs) and drive them toward fibrogenesis. METHODS: The cultured HSCs were treated with recombinant HMGB1. RT-PCR and Western blotting analysis were used to measure alpha-smooth muscle actin (alpha-SMA) expression. Conditioned media were collected for gelatin zymography to monitor the activities of collagen-degrading matrix metalloproteinases (MMPs). RESULTS: HMGB1 at concentrations > 1 ng/mL significantly stimulated HSC growth as revealed by proliferation and BrdU assays. alpha-SMA gene and protein expression were significantly up-regulated by HMGB1, whereas the MMP-2, but not MMP-9, activity was suppressed by HMGB1 treatment. CONCLUSION: Our data suggested that HMGB1 protein, once released during the rejection phase of OLT, activated HSCs and exhibited profibrogenic effects on liver grafts either by increasing the HSC population and extracellular matrix content in liver grafts, or by transforming HSCs into myofibroblasts. Neutralization with anti-HMGB1 antibody was suggested to be a therapeutic modality applicable to prevent fibrogenesis in post-OLT liver grafts.

Induction of indoleamine 2,3-dioxygenase in livers following hepatectomy prolongs survival of allogeneic hepatocytes after transplantation.

OBJECTIVES: Indoleamine 2,3-dioxygenase (IDO), which catalyzes the breakdown of tryptophan into kyneurenine, has immunologic significance for the induction of maternal tolerance and liver allograft tolerance by inhibiting T-cell activation. In the present study, we compared survival of syngeneic or allogeneic hepatocytes in livers with or without hepatectomy. Subsequently, we investigated gene expression and localization of IDO in the recipient liver. METHODS: DA and Fisher 344 rats were used in the following experimental groups: group 1, DA hepatocytes transplanted into hepatectomized Fisher 344 rats; group 2, Fisher 344 hepatocytes transplanted into hepatectomized Fisher 344 rats; group 3, DA hepatocytes transplanted into nonhepatectomized Fisher 344 rats; and group 4, Fisher 344 hepatocytes transplanted into nonhepatectomized Fisher 344 rats. After transplantation, the surviving cells were evaluated on day 5. The IDO signal of the recipient liver was detected by reverse transcriptase polymerase chain reaction (RT-PCR) and immunohistochemistry. RESULTS: In the hepatectomized groups subjected to allogeneic or syngeneic hepatocyte transplantation, the number of surviving hepatocytes was greater than in the nonhepatectomized group after transplantation. The IDO signals (RT-PCR) in the hepatectomized groups were stronger than those in the nonhepatectomized groups. Immunohistochemistry demonstrated that the IDO signal is located in liver antigen-presenting cells, such as Kupffer cells or dendritic cells, and not expressed in hepatocytes. CONCLUSIONS: Our results demonstrated that IDO is induced in antigen-presenting cells of hepatectomized livers by which subsequently transplanted cells may be protected from rejection by inhibiting indirect or direct recognition of donor antigen and further T-cell activation.

The reaction of posttransplant denervated liver on the hemorrhagic shock in rats.

OBJECTIVE: The aims of the study were to determine the effects of denervation on the function of the liver transplantation as a blood reservoir and to define its vulnerability to ischemic-reperfusion (I/R) injury after hemorrhagic shock. MATERIALS AND METHODS: Hemorrhagic shock with a mean arterial blood pressure (MAP) of 40 to 50 mm Hg was induced by withdrawing blood at a rate of approximately 1 mL/min among 10 posttransplant denervated rats and 10 sham rats for 1 hour. The rats were then resuscitated by retransfusing the drawn blood with sacrifice under deep anesthesia at 1 hour after resuscitation. The total amount of blood required to achieve hemorrhagic shock was compared between groups as well as the vulnerability and reactions of the posttransplant denervated liver to I/R injury after hemorrhagic shock as assessed by gene expressions of c-jun, c-fos, tumor necrosis factor (TNF)-alpha, interleukin (IL)6, IL-10, and heat-shock protein 70 (HSP70). RESULTS: The volume of blood that had to be drawn to reach a MAP of 40 to 50 mm Hg was not significantly different between the groups. One hour of hemorrhagic shock followed by resuscitation resulted in significant increases in the genes expression of c-fos, TNF-alpha, IL-6, IL-10, and HSP70 in comparison to the control values, but no difference was observed between experimental and sham groups. CONCLUSION: We suggest that the function of the liver as a blood reservoir and the gene expressions of c-fos and pro- and anti-inflammatory cytokines, as well as the protective protein HSP70 in response to I/R injury, were not altered by liver transplantation.

Effects of different operating room temperatures on the body temperature undergoing live liver donor hepatectomy.

OBJECTIVE: We sought to compare the effects of operation room temperature (ORT) at typical ambient environment (19-21 degrees C) and ORT at 24 degrees C on the core temperature of patients undergoing living donor hepatectomy. METHODS AND PATIENTS: Sixty-two patients undergoing living donor hepatectomy were divided into 2 groups. In group I (n = 31), surgery was performed at typical ambient ORT, and in group II (n = 31) in ORT at 24 degrees C. Anesthesia and measures to prevent heat loss, except ORT, were all the same. Nasopharyngeal temperature (NT) was recorded after anesthesia induction, then hourly until completion of the operation. Changes in NTs were analyzed as well as patient age, weight, anesthetic duration, blood loss, intravenous fluids, total urine output, and pre- and postoperative hemoglobin and hematocrit values. The Mann-Whitney U test was used for comparisons between groups. RESULTS: The patient's characteristics between groups were not statistically different. However, a significantly higher core temperature was noted in group II compared with group I. Increased ORT from 19 to 21 degrees C to 24 degrees C resulted in an increased core temperature of at least 0.5 degrees C during living donor hepatectomy.

Bispectral index monitoring in healthy, cirrhotic, and end-stage liver disease patients undergoing hepatic operation.

The purpose of this study was to assess factors influencing the end-tidal concentrations of isoflurane within a bispectral index (BIS) range of 45-55 among healthy live liver donors (n = 11), chronic hepatitis B patients undergoing hepatectomy hepatocellular carcinoma (n = 10), and end-stage liver disease patients undergoing liver transplantation (n = 7). Patients data collected prospectively were compared among the groups using one-way analysis of variance as well as univariate and multivariate techniques. The results showed that end-stage liver disease patients required the least end-tidal isoflurane concentration. Patients with hepatocellular carcinoma with cirrhosis required intermediate end-tidal isoflurane concentrations; healthy live liver donors required the highest end-tidal isoflurane concentrations to provide sufficient anesthetic depth, as monitored by a target BIS (range, 45-55). Upon multivariate analysis, liver function was the only significant factor influencing the likelihood of lowering the end-tidal isoflurane concentration by 4 hours after anesthesia induction (P = .026). In conclusion, we recommend a preset target BIS within the range of 45-55 to monitor the depth of anesthesia during partial hepatectomy and liver transplantation because end-tidal isoflurane concentration requirements are different for patients with various liver status. This strategy may protect the patients from intraoperative recall or anesthesia over-depth as a consequence of insufficient or overdose of anesthesia, respectively.

Rhabdomyolysis after liver transplantation: a case report.

Our aim was to present the case of a pediatric biliary atresia patient who experienced rhabdomyolysis with severe cardiac arrhythmias associated with hyperkalemia, metabolic acidosis, and myoglobulinemia during liver transplantation. A 5-year-old girl, weighing 16.5 kg, with end-stage liver disease due to biliary atresia underwent living donor liver transplantation. A sudden onset of atrial fibrillation with rapid ventricular response was noted during the transplantation. The cardiac arrhythmia was associated with hyperkalemia, metabolic acidosis, and myoglobulinemia. Rhabdomyolysis was suspected. Hyperkalemia and metabolic acidosis were not corrected despite treatment with 10 mL of 50% glucose plus 6 U of regular insulin in 4 succeeding boluses and 110 mEq sodium bicarbonate before sending the patient to the intensive care unit. A corresponding decrease and normalization in serum potassium and correction of metabolic acidosis were noted as responses to a single dose of intravenous (20 mg) dantrolene. The patient was extubated 5 days after transplantation. The kidney function remained within normal limits during the rhabdomyolysis and the entire hospital stay. The patient was discharged 7 weeks later and is surviving with the original liver graft and satisfactory kidney function to date.

Anesthesia management in a patient with an abdominal aortic aneurysm undergoing liver transplantation: a case report.

We describe the anesthetic management in a 56-year old man with hepatocellular carcinoma and cirrhosis who underwent liver transplantation (LT). Pretransplantation workup showed a 3-cm wide by 10-cm long infrarenal abdominal aortic aneurysm (AAA) with chronic dissection. He subsequently underwent living donor LT. The total operative time was 12 hours. The systolic blood pressure was maintained at normal levels. Severe hypertension was not noted. Hypotension noted during the anhepatic phase was managed with increased volume infusion and small doses (0.1 mg) of intravenous phenylephrine. Metabolic acidosis and ionized hypocalcemia were corrected accordingly. Total blood loss was 460 mL. Blood or blood products were not given. The intravascular volume was replaced with 1400 mL of 5% albumin and 10,610 mL of crystalloid. Extubation was performed in the intensive care unit at 12 hours after the operation. The postoperative course was unremarkable. The patient is alive at 3 years after LT. Patients with AAA undergoing LT present a challenge to the anesthesiologist because among the risk factors for rupture, blood pressure is the only factor under his or her control during the operation. If blood loss can be kept to a minimum and hemodynamic stability achieved, a chronically small dissected AAA may not be a contraindication to LT.

Correlation Between Blood Transfusion and Blood Glucose Levels in Adult Living Donor Liver Transplantation.

BACKGROUND: To evaluate the effect of dextrose contained in banked blood products on the changes of blood glucose levels in adult living donor liver transplantation patients retrospectively. METHODS: Four hundred seventy-seven patients were divided into a non-blood transfusion (BT) group (G1) and a BT group (G2). The changes in blood glucose levels during the operation were compared using a Mann-Whitney U test, and a P value less than .05 was regarded as significant. RESULTS: No significant changes were detected in blood glucose levels after anesthesia, during dissection phase, in the anhepatic phase, or after reperfusion between the groups. Estimated blood loss for G1 (n = 89) and G2 (n = 388) were 718 ± 514 and 5804 ± 877 mL respectively, G1 had no blood transfusion but G2 had received 4350 ± 6230 mL leukocyte-poor red blood cell transfusion, the pre- and end operation hemoglobin for G1 and G2 were 13.2 ± 2.0, 10.2 ± 1.9 and 10.1 ± 1.6, 10.2 ± 1.9 mg/dL respectively, indicating that they were not under or over transfused. CONCLUSION: When banked blood products are used to replace ongoing blood loss, the dextrose contained in citrate-phosphate-dextrose-adenine seems to have no effect on the changes in the blood glucose levels of the recipients.

Comparison of Core Temperature Changes Between Pediatric Patients Lying on Regular Operating Room Linen Drapes and Water-Repellent Sheepskin Rug in Living Donor Liver Transplantation.

OBJECTIVES: The aims of this study were to compare the core temperature changes between pediatric patients lying on regular operating room linen drapes and a water-repellent sheepskin rug during living donor liver transplantation (LDLT) and to evaluate the effectiveness of using a water-repellent sheepskin rug in preventing profound hypothermia due to fluid overflow from the abdominal cavity during LDLT. PATIENTS AND METHODS: The operative records of pediatric patients who underwent LDLT from June 1994-September 2003 were reviewed retrospectively. The nasopharyngeal temperature (NT) changes during the LDLT procedure between patients lying on regular operating room drapes (GI) and water-repellent sheepskin rug (GII) were compared and analyzed using the Mann-Whitney U test. A P value <.05 was regarded as significant. RESULTS: Thirty-two patients were included in GI and 56 in GII. Profound hypothermia was not observed in any recipients lying on a water-repellent sheepskin rug (GII). The NT after induction and the following 4 hours into the LT procedure were significantly higher in GII than GI. CONCLUSION: Pediatric patients lying on water-repellent sheepskin preserved their core temperature better in comparison to patients lying on linen drapes. The use of a water-repellent sheepskin rug seems to be effective in preventing profound hypothermia related to physical contact with abdominal fluid overflow during the LDLT.

Eye Protection in Liver Transplantation Patients Under General Anesthesia.

BACKGROUND: Opsite (Smith & Nephew, Hull, UK) is widely used in wound care but its use in eye protection against corneal abrasion during major surgery is rarely reported. The purpose of the current study is to compare the effectiveness of using Opsite in eye protection with either wet gauze alone or with wet gauze following application of eye ointment in patients undergoing living donor liver transplantation (LDLT). METHODS: This is a prospective, double-blinded, randomized controlled trial. Forty-one patients undergoing liver transplantation were enrolled. One eye of each patient was protected with sterile gauze soaked with normal saline solution and covered with Opsite. Duratears (ALCON, Fort Worth, Tex, United States) ointment was applied to the other eye before covering it with sterile wet gauze and Opsite (ointment group). The corneal examination was carried out after fluorescein staining before and at the end of surgery by the same doctor. A Student t-test and a χ2 test were used for the statistical analyses. RESULTS: Forty-one patients with 82 eyes were observed in this study. No corneal epithelial defects were found in either the normal saline group or the ointment group. CONCLUSION: Opsite combined with wet gauze with or without additional eye ointment provided 100% protection against corneal abrasion in patients undergoing LDLT.

Anesthesia Management and Fluid Therapy in Right and Left Lobe Living Donor Hepatectomy.

OBJECTIVE: Right lobe living donor hepatectomy poses a greater risk for the donor in relation to blood loss. The aims of this study were to compare anesthetic and intraoperative fluid management in right and left lateral segment living donor hepatectomy. PATIENTS AND METHODS: The anesthesia records of living donor hepatectomy patients were retrospectively reviewed. Donor age and weight, anesthesia time, central venous pressure, blood loss, blood product transfusion, intravenous fluids used, doses of furosemide, and urine output were compared and analyzed between groups using the Mann Whitney U test. RESULTS: Forty-six patients underwent living donor left lateral segment hepatectomy (Group I); while 31 patients underwent right lobe hepatectomy (Group II). The mean blood loss in Group II was significantly higher compared to Group I (118 ± 81 mL vs 68 ± 64 mL), but clinically such amount of blood loss was not high enough to affect the hemodynamics. The fluid management was therefore not meaningfully different between the two groups. No blood transfusions or colloid infusions were required for either group. Urine output, hemoglobin changes, blood urea nitrogen, and serum creatinine pre- and postoperatively were not significantly different between groups. CONCLUSIONS: As long as blood loss is minimal, we found no difference in the anesthetic management and fluid replacements between right and left lateral segment living donor hepatectomy.

The Correlation Between CVP and SVV and Intraoperative Minimal Blood Loss in Living Donor Hepatectomy.

BACKGROUND: Blood loss during liver surgery is found to be correlated with central venous pressure (CVP). The aim of the current retrospective study is to find out the cutoff value of CVP and stroke volume variation (SVV), which may increase the risk of having intraoperative blood loss of more than 100 mL during living liver donor hepatectomies. METHOD AND PATIENTS: Twenty-seven adult living liver donors were divided into 2 groups according to whether they had intraoperative blood loss of less (G1) or more than 100 mL (G2). The mean values of the patients' CVP and SVV at the beginning of the transaction of the liver parenchyma was used as the cutoff point. Its correlation to intraoperative blood loss was evaluated using the χ2 test; P < .001 was regarded as significant. RESULTS: The cutoff points of CVP and SVV were 8 mm Hg and 13% respectively. The odds ratio of having blood loss exceeding 100 mL was 91.25 (P < .001) and 0.36 (P < .001) for CVP and SVV, respectively. CONCLUSION: CVP less than 5 mm Hg, as suggested by most authors, is not always clinical achievable. Our results show that a value of less than 8 mm Hg or SVV 13% is able to achieve a minimal blood loss of 100 mL during parenchyma transaction during a living donor hepatectomy. Measurements used to lower the CVP or increased SVV in our serial were intravenous fluids restriction and the use of a diuretic.

Histone H1 vaccine therapy for overcoming acute rejection in experimental organ transplantation.

OBJECTIVE: In a rat tolerogenic orthotopic liver transplantation (OLT) model, the recipient serum (post-OLT serum) shows strong immunosuppressive activity. In our previous reports, we suggested that autoreactive antibody (Ab) against histone H1 is a major immunosuppressive factor in this serum. The present study sought to determine whether up-regulation of anti-histone H1 Ab by histone H1 vaccination led to tolerance. MATERIALS AND METHODS: Using mixed lymphocyte reactions (MLR) and heterotopic heart transplantations (HHT), the alloreactive T-cell responses and allograft survivals of histone H1-immunized rats were compared with those of control rats. Cytokine and cellular profiles were determined by enzyme-linked immunosorbent assay (ELISA) and flow cytometry. RESULTS: The alloreactive T-cell response of histone H1-immunized rats was significantly lower than that of control rats, although there was no difference in nonspecific T-cell activation between the 2 groups. The allograft survival of histone H1-immunized rats was significantly prolonged after HHT. The major histocompatibility complex (MHC) class II and CD25 molecules of histone H1-immunized rats were significantly down-regulated compared with those of control rats. Moreover, the serum cytokine profile was modified by the immunization with histone H1. CONCLUSIONS: These results suggest that histone H1 vaccination of transplant recipients leads to the production of immunosuppressive factors and the modification of cytokine/cellular profiles.

Role of antinuclear antibodies in experimental and clinical liver transplantation.

OBJECTIVE: We recently reported that autoreactive antibodies (Abs) against nuclear histone H1 was transiently induced at an early phase after orthotopic liver transplantation (OLT) in a tolerogenic rat OLT model and possessed immunosuppressive activity. It was also reported that nuclear antigen, high-mobility group box 1 (HMGB1) protein was one of the initiators of the immune reaction. The present study sought to evaluate the role of antinuclear Abs in experimental and clinical liver transplantation. MATERIALS AND METHODS: We prepared 3 animal models: natural tolerance model (DA liver into PVG); acute rejection model (DA liver into LEW); and drug-induced tolerance model (acute rejection model + cyclosporine [CsA]). In addition, we examined clinical samples, including 1 drug-free patient, to measure the antihistone H1/HMGB1 titers at various times after OLT. RESULTS: In a natural tolerance model, antihistone H1 and HMGB1 Ab was induced during the rejection and the tolerance induction phases, respectively. Those Ab responses were also confirmed in a drug-induced tolerance model, whereas no such responses were shown in an acute rejection model. In our clinical drug-free patient, antihistone H1/HMGB1 titer was significantly higher after cessation of CsA than that in healthy volunteers. CONCLUSIONS: Antinuclear Ab is actively expressed in accordance with overcoming rejection episodes with subsequent tolerance induction in both a natural tolerance model and a drug-induced tolerance model. We also observed a similar tendency in our clinical drug-free patient. These results suggested that antinuclear Abs may be useful markers to determine the timing to withdraw immunosuppressants.

Anesthetic management of a pregnant living related liver donor.

Pregnancy is often considered a contraindication to living related liver donation. There are serious medical and ethical considerations if a pregnant woman insists on undergoing partial hepatectomy to save her sick child. Herein we report a case of living related liver donation from a pregnant woman at 18 weeks of gestation to her 1-year-old child with decompensated cirrhosis due to biliary atresia. The left lateral segment of the liver was harvested for donation. Meticulous surgical technique and anesthetic management were mandatory in assuring a successful outcome. While this isolated case demonstrated that living related liver donation can be performed successfully with a pregnant donor, it should be undertaken only when there is absolutely no other donor and the recipient is in urgent need.

Predictive Risk Factors in the Development of Intraoperative Hyperkalemia in Adult Living Donor Liver Transplantation.

BACKGROUND: Hyperkalemia, defined as a serum potassium level higher than 5 mEq/L, is common in the liver transplantation setting. Severe hyperkalemia may induce fatal cardiac arrhythmias; therefore, it should be monitored and treated accordingly. The aim of the current retrospective study is to evaluate and indentify the predictive risk factors of hyperkalemia during living-donor liver transplantation (LDLT). METHODS AND PATIENTS: Four hundred eighty-seven adult LDLT patients were included in the study. Intraoperative serum potassium levels were monitored at least five times during LDLT; patients with a potassium level higher than 5 mEq/L were included in group 1, and the others with normokalemia in group 2. Patients' categorical characteristics and intraoperative numeric variables with a P value <.1 were selected into a multiple binary logistic regression model. In multivariate analysis, a P value of <.05 is regarded as a risk factor in the development of hyperkalemia. RESULTS: Fifty-one of 487 (10.4%) patients had hyperkalemia with a serum potassium level higher than 5.0 mEq/L during LDLT. Predictive factors with P < .1 in univariate analysis (Table 1), such as anesthesia time, preoperative albumin level, Model for End-stage Liver Disease score, preoperative bilirubin level, amount of blood loss, red blood cell (RBC) and fresh frozen plasma transfused, 5% albumin administered, hemoglobin at the end of surgery, and the amount of furosemide used, were further analyzed by multivariate binary regression. Results show that the anesthesia time, preoperative serum albumin level, and RBC count are determinant risk factors in the development of the hyperkalemia in our LDLT serials. CONCLUSION: Prolonged anesthesia time, preoperative serum albumin level, and intraoperative RBC transfusion are three determinant factors in the development of intraoperative hyperkalemia, and close monitoring of serum potassium levels in patients with abovementioned risk factors are recommended.