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Objective:To explore the risk factors affecting the incidence of acute kidney injury(AKI)after liver transplantation(LT).Methods:From November 2019 to November 2022, clinical data were retrospectively reviewed for 105 recipients of classic orthotopic LT.There are 89 males and 16 females with an age range of(50.52±10.35)years.They are assigned into two groups of AKI(66 cases)and non-AKI(39 cases)according to the AKI diagnostic and staging criteria of Global Kidney Disease Prognosis Organization in 2012.General profiles and clinical data(e.g.previous medical history, MELD score, total bilirubin, albumin, serum creatinine level, coagulation function, anhepatic phase and time to surgery)of two groups of recipients are compared.The factors with statistically significant differences are included into multivariate Logistic regression analysis for obtaining independent risk factors for early AKI post-LT.Results:Among them, 66 patients developed AKI within 7 days post-operation with an incidence rate of 62.86%(66/105).The clinical stages of AKI are Ⅰ(46 cases, 69.70%), Ⅱ(10 cases, 15.15%)and Ⅲ(10 cases, 15.15%).Statistically significant inter-group differences exists in age, abdominal surgery history, preoperative serum level of creatinine, operative duration, anhepatic phase and intraoperative plasma transfusion(all P<0.05).Multivariate Logistic regression analysis indicated that abdominal surgery history( OR=5.803, 95% CI: 1.008~33.401, P=0.049), anhepatic phase( OR=1.054, 95% CI: 1.008~1.101, P=0.020)and preoperative serum level of creatinine( OR=0.968, 95% CI: 0.943~0.994, P=0.016)are independent risk factors for early AKI after classical orthotopic LT recipients. Conclusions:Abdominal surgery history, anhepatic phase, and preoperative serum level of creatinine are independent risk factors for early AKI in classic orthotopic LT recipients.
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With persistent advancement of surgical instruments, methods and techniques, clinical efficacy of liver transplantation has been steadily enhanced. However, the length of anhepatic phase is still an important factor affecting the efficacy of liver transplantation. Rat is one of the major animal models for liver transplantation-related basic research. In this article, multiple approaches for prolonging the anhepatic phase and shortening the operation time during anhepatic phase in rat liver transplantation were reviewed, which consisted of sevoflurane inhalation anesthesia, intravenous infusion via jugular vein indwelling needle, clamping of the abdominal aorta before anhepatic phase, injection of normal saline into portal vein before anhepatic phase, subcutaneous transposition of the spleen, electrocoagulation of hepatic esophageal artery, magnetic ring anastomosis of the superior and inferior hepatic vena cava, cannula anastomosis of the superior and inferior hepatic vena cava, stent anastomosis of the superior and inferior hepatic vena cava, rapid connection device and cannula of portal vein, and ring-shaped cannula of hepatic tissue-preserving inferior hepatic vena cava, aiming to add evidence for prolonging the duration of anhepatic phase, improving the operation efficiency during anhepatic phase and elevating the success rate of rat liver transplantation.
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Objective To analyze the risk factors and predictors related to postoperative delirium(POD) in liver transplantation. Methods The clinical data of 232 liver transplant recipients were retrospectively analyzed. Recipients were assigned to POD group (n=60) and non-POD (n=172) group according to the presence of POD. The intra- and post-operative conditions were compared between the two groups of liver transplant recipients. The risk factors for occurrence of POD in liver transplant recipients were analyzed using multifactorial analysis. And the value of predicting the occurrence of POD in liver transplant recipients according to the risk factors were assessed. Results The incidence of POD in liver transplant recipients was 25.9%. The operation time and anhepatic phase in the POD group were longer than those in the non-POD group. Intraoperative infusion of erythrocyte, infusion of cryoprecipitate, and lactic acid level were higher than those in the non-POD group (all P < 0.05). The levels of postoperative alanine aminotransferase (ALT), aspartate aminotransferase (AST), prothrombin time international normalized ratio (PT-INR), and plasma fibrinogen in the POD group were significantly higher than those in the non-POD group (all P < 0.05). Preoperative hepatic encephalopathy, elevated blood ammonia, high score of model for end-stage liver disease (MELD), elevated postoperative AST level and long intraoperative anhepatic phase were the independent risk factors for POD in liver transplant recipients (all P < 0.05). Preoperative elevated blood ammonia and high MELD score showed profound value in predicting the occurrence of POD in liver transplant recipients, with best cut-off values of 42.6 μmol/L and 18 points, sensitivity of 0.650 and 0.767 as well as specificity of 0.826 and 0.727, respectively. Conclusions The incidence of POD is high in liver transplant recipients. Preoperative hepatic encephalopathy, elevated blood ammonia, high MELD score, elevated postoperative AST level, and long intraoperative anhepatic phase are independent risk factors for liver transplant POD. Preoperative elevated blood ammonia and high MELD score are predictors of POD in transplant recipients.
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Objective To establish a non-venous bypass orthotopic liver transplantation model in Bama miniature pigs with high repeatability and stability. Methods Twelve Bama miniature pigs were randomly divided into the donor group (n=6) and recipient group (n=6). Pigs underwent non-venous bypass orthotopic liver transplantation. The time of anhepatic phase during operation was shortened, blood pressure during anhepatic phase was stably maintained, and management of anesthesia and body fluid during operation were strengthened. The operation time, anhepatic phase and survival status of the recipients were observed and recorded. The intraoperative heart rate, mean arterial pressure (MAP) and changes in arterial blood gas analysis were monitored. The perioperative liver function was evaluated. Results Among 6 Bama miniature pigs, 1 died from transplantation failure intraoperatively. The operation time of the remaining 5 pigs was (247±27) min and the time of anhepatic phase was (46±4) min. Three animals survived for more than 2 weeks. Compared with the preanhepatic phase, the heart rate of the animals was significantly faster, MAP was considerably reduced to (46±6) mmHg, blood pH value, base excess (BE) and HCO3- level were all significantly decreased and serum level of K+ was significantly elevated during the anhepatic phase (all P < 0.05). In the neohepatic phase, MAP of Bama miniature pigs was significantly increased, heart rate was dramatically slower.Blood pH value, BE, HCO3- level were significantly increased and serum level of K+ was significantly declined (all P < 0.05). During abdominal closure, MAP, blood gas indexes and serum level of K+ were almost recovered to those in the preanhepatic phase. Compared with preoperative levels, the levels of alanine aminotransferase(ALT), aspartate aminotransferase(AST), lactate dehydrogenase(LDH)and alkaline phosphatase(ALP)were significantly increased after operation (all P < 0.05), the change in AST was the most obvious, and it gradually decreased at postoperative 2 d. The level of γ-gutamyl transferase(GGT) did not significantly elevated. The level of total bilirubin (TB) was evidently elevated at postoperative 5 d. Compared with the preoperative levels, the levels of total protein (TP) and albumin (ALB) were significantly decreased after operation (both P < 0.05), and began to gradually increase at postoperative 1 d. Conclusions The non-venous bypass orthotopic liver transplantation model of Bama miniature pig is convenient, with highly reproducible and survival rate, which can be utilized as a standardized liver transplantation model.
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Objective To explore the skills and summarize the experience in the establishment of orthotopic liver transplantation rat models from donation after cardiac death (DCD). Methods According to the time of warm ischemia, 120 rats were divided into 3 groups: group A (warm ischemia for 0 min, n=40 pairs), group B (warm ischemia for 10 min, n=40 pairs) and group C (warm ischemia for 20 min, n=40 pairs). Orthotopic liver transplantation was performed by the modified two-cuff technique in 3 groups. The time of each stage of surgery was recorded in 3 groups. The survival rate at the end of surgery, 24 h, 72 h and 7 d after surgery was recorded in 3 groups. The dead rats were immediately subject to anatomical examination to identify the cause of death. Results The cold ischemia time of donor liver, anhepatic phase and operation time of the recipients did not significantly differ among three groups (all P>0.05). In groups A, B and C, the survival rate at the end of surgery was 97%, 97%, and 100% respectively. The survival rate at postoperative 24 h was 92%, 90% and 92% respectively. The survival rate at postoperative 72 h was 90%, 80% and 77% respectively. The survival rate at postoperative 7 d was 85%, 70% and 57% respectively. The survival rate at the end of surgery, postoperative 24 h and 72 h did not significantly differ among 3 groups (all P>0.05). At postoperative 7 d, the survival rate in group C was significantly lower than that in group A (P<0.05). Surgical operation was the major cause of intraoperative and postoperative 24 h death. Bile leakage and ischemic hepatic failure were the causes of death at postoperative 72 h. Biliary duct complications were the main causes of death at postoperative 7 d. The quantity of rats developing with biliary duct complications was increased along with the prolongation of warm ischemic time. Conclusions The success of stable establishment of rat models with orthotopic liver transplantation from DCD depends upon the protection of the liver and biliary function. The difficulty lies in the anastomosis of the suprahepatic inferior vena cava and the shortening of anhepatic phase.
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Liver transplantation is the main treatment for end-stage liver diseases and liver tumor.To solve the problem of the insufficient donor liver,autologous liver transplantation (ALT) is becoming widely acknowledged,which could serve as a complementary technique for treating unresectable liver space-occupying lesions in routine operation.However,compared with allogeneic liver transplantation,the long anhepatic phase during ALT may influence the outcome of such patients.Veno-venous bypass (VVB) as a technology which can maintain the stability of hemodynamics and internal environment in the anhepatic phase is routinely used in ALT.In this paper,the application of VVB in the ALT was mainly discussed.
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OBJECTIVE: The ideal ratio between liver graft mass and recipient body weight for liver transplantation in small infants is unknown; however, if this ratio is over 4%, a condition called large-for-size may occur. Experimental models of large-for-size liver transplants have not been described in the literature. In addition, orthotopic liver transplantation is marked by high morbidity and mortality rates in animals due to the clamping of the venous splanchnic system. Therefore, the objective of this study was to create a porcine model of large-for-size liver transplantation with clamping of the supraceliac aorta during the anhepatic phase as an alternative to venovenous bypass. METHOD: Fourteen pigs underwent liver transplantation with whole-liver grafts without venovenous bypass and were divided into two experimental groups: the control group, in which the weights of the donors were similar to the weights of the recipients; and the large-for-size group, in which the weights of the donors were nearly 2 times the weights of the recipients. Hemodynamic data, the results of serum biochemical analyses and histological examination of the transplanted livers were collected. RESULTS: The mortality rate in both groups was 16.5% (1/7). The animals in the large-for-size group had increased serum levels of potassium, sodium, aspartate aminotransferase and alanine aminotransferase after graft reperfusion. The histological analyses revealed that there were no significant differences between the groups. CONCLUSION: This transplant method is a feasible experimental model of large-for-size liver transplantation. .
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Animales , Trasplante de Hígado/métodos , Hígado/anatomía & histología , Aspartato Aminotransferasas/sangre , Peso Corporal , Estudios de Factibilidad , Hemodinámica , Modelos Animales , Tamaño de los Órganos , Potasio/sangre , Reproducibilidad de los Resultados , Porcinos , Sodio/sangre , Factores de TiempoRESUMEN
Two-stage liver transplantation, involving a total hepatectomy with a temporary portocaval shunt followed by liver transplantation, requires intensive perioperative care, especially during the prolonged anhepatic period. The pathophysiology and management of this prolonged anhepatic state is not fully elucidated and the proper management during this period is a great challenge to clinicians in the intensive care unit and anesthesiologists. We report a case and management of a total hepatectomy with a temporary portocaval shunt followed by living-donor liver transplantation in a patient with a surgically complicated liver failure after a hepatic tumor resection.
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Humanos , Hepatectomía , Unidades de Cuidados Intensivos , Hígado , Fallo Hepático , Trasplante de Hígado , Atención PerioperativaRESUMEN
Objective To study the changes and management of systemic and pulmonary hemodynamics during anhepatic period in patients undergoing orthotopic liver transplantation without veno-venous bypass.Methods Sixty-eight patients with end-stage liver disease undergoing orthotopic liver transplantation were enrolled in this research. Monitoring and recoding CVP, MAP, CI, HR, MPAP, PAWP PVR, SVR at different time points: preincision, before anhepatic, 5, 30 min of anhepatic, 5, 30, 60 min of neohepatic,ending of operation, 12 h and 24 h after operation. All the patients were divided into three groups according CVP during anhepatic period: group A(CVP <4 mmHg) ,group B(4 mm Hg≤CVP≤6 mmHg) ,group C (CVP>6 mmHg). Besides, calculating the concentration of dopamine, norepinephrine ,epinephrine and the volume of urine during of operation. Results There were different changes during different operation periods. During anhepatic period, HR, PVR and SVR increased, while CVP, CI, MAP, PAP, PAWP decreased(P<0.05). At early neohepatic period, HR decreased and CVP,PAWP, MPAP,CI,PVR SVR increased ,At the beginning of neohepatic period, MAP dacreased or increased quickly, and became steadily after 5 min. Among the three groups, the changes of hemodynamics in group B was slightest,and the concentration of dopamine, norepinephrine and epinephrine was smallest (P< 0.05 ). Conclusions The systemic and pulmonary emodynamics fluctuated sharply during anhepatic and early neohepatic period. It is important and useful to manage CVP 4 -6 mmHg, MABP ≥ 60 mmHg by infusing liquid and vasoconstrictors,such as dopamine, norepinephrine or epinephrine during anhepatic period.
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Objective To observe the changes of propofol blood concentrations in rats during anhepatic phase by continuous constant-speed infusion of propofol and to investigate the extrahepatic metabolism of propofol and the effects of lungs on the extrahepatic metabolism of propofol. Methods When the continuous constant-speed transfusion of propofol was carrying out through the left deep cervical vein, the blood samples of 100 ?l were withdrawn simultaneously from the right deep cervical artery and vein at the flowing time points: 5 min before the dissociation of hepatic portal, immediate devascularization of the hepatic portal, 15 min, 30 min and 60 min after devascularization of the hepatic portal. The propofol blood concentrations were analyzed by HPLC. Results At 15 min, 30 min and 60 min after the devascularization of the hepatic portal, the propofol blood concentrations in the right deep cervical artery and vein were significantly higher than that at 5 min before the dissociation of hepatic portal and immediate devascularization of the hepatic portal (P
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Objective To investigate the gene expression variation of rat kidney uridine diphosphate glucuronatetransferase ugt1a6 related to propofol metabolism in anhepatic phase and to primarily explain the reasons of extrahepatic metabolism characteristic of propofol. Methods A total of 15 male SD rats were distributed randomly to 3 groups (n=5 in each group): control group (group A), devascularization of the hepatic portal for 30 min (group B) and 60 min (group C). Kidney tissues of rats were taken and ugt1a6 mRNA were detected by RT-PCR. Results Gene expression levels of kidney ugt1a6 of groups B and C were significantly higher than group A (P
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Objective To investigate the variation of fentanyl concentration and the gene expression and activity of rat intestinal cytochrome P450 3A1 in anhepatic phase. Methods The experiment was comprised of 2 steps. Step 1: The rats were randomly divided into experimental group (group A2, underwent occlusion of the hepatic portal) and control group (group A1), with 10 rats in each group. Fentanyl blood concentration was analyzed by LC/MS/MS. Step 2: The rats were randomly divided into group B1 (control), group B2 and group B3 (the rats underwent devascularization of the hepatic portal for 30 or 60 min). The levels of CYP3A1 in rat small intestine were assessed with RT-PCR and the enzymic activity of CYP3A1 was detected by fluorometry. Results Fentanyl concentration in anhepatic phase dropped more slowly in group A2 than group A1 (P
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Objective To investigate the expression variation of kidney OATP-3 in rats relating to rocuronium metabolism in anhepatic phase and to primarily explain the reason of extrahepatic metabolism characters of rocuronium. Methods Twelve rats were distributed to 2 groups randomly with 6 in each: Group A (control group) and Group B in which the hepatic portal devascularization was performed for 60 min. Kidney tissues of the rats were taken. oatp-3 mRNA was detected by RT-PCR and OATP-3 protein by Western blotting. Results The expression levels of kidney OATP-3 mRNA and protein in Group B were significantly higher than those in Group A(P
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BACKGROUND: In patients of sepsis, especially combined with multiple organ failure syndrome, the whole body oxygen consumption is delivery dependent even above the critical oxgen delivery. This phenomenon is named as 'pathologic oxygen delivery dependency'. Multiple organ failure syndrome is characterized by maldistribution of oxygen delivery, tissue oxygen diffusion disturbance and inability of oxidative phosphorylation of anaerobic metabolites owing to hepatic failure. In liver transplantation, the anhepatic phase is characterized by uneven microperfusion due to surgical manipulation and 'total hepatic failure'. We hypothesized that there might be oxygen delivery dependency in anhepatic phase of liver transplantation. METHODS: In 14 canine orthotopic liver transplantations, whole body oxygen delivery (DO2) and oxygen consumption (VO2) were calculated as the product of cardiac output and, arterial oxygen content and arterial-venous oxygen content difference, respectively, according to the operative phases. Then the relationship between DO2 and VO2 was analyzed by correlation analysis in each operative phases. RESULTS: In control and four reperfusion phases no significant correlation was found. But in two anhepatic phases (10 minutes after inferior vena cava cross clamping, 5 minutes before reperfusion), significant correlation was found (R=0.79, 0.72, p<0.005, 0.01 repectively). In postinduction phase (50 minutes after induction), significant correlation was found (R=0.62, p<0.05), but strength of correlation was lower. CONCLUSIONS: This study showed the oxygen delivery dependency in anhepatic phase of liver transplantation. Therefore supranormal oxygen supply advocated in multiple organ failure syndrome and sepsis might be applicable to management of anhepatic phase of selected recipients.