Five-year experience with intraoperative extracorporeal membrane oxygenation in lung transplantation: Indications and midterm results.

BACKGROUND: Since April 2010, extracorporeal membrane oxygenation (ECMO) has replaced cardiopulmonary bypass for intraoperative support during lung transplantation at our institution. The aim of this study was to present our 5-year experience with this technique. METHODS: Records of patients who underwent transplantation between April 2010 and January 2015 were retrospectively reviewed. Patients who underwent transplantation without ECMO formed Group A. Patients in whom the indication for ECMO support was set a priori before the beginning of the operation formed Group B. The remaining patients in whom the indication for ECMO support was set during transplantation formed Group C. RESULTS: Among 595 patients, 425 (71%) patients (Group A) did not require intraoperative ECMO; the remaining 170 (29%) patients did. Among these patients, 95 (56%) patients formed Group B, and the remaining 75 (44%) patients comprised Group C. Pulmonary fibrosis and pre-operative dilated or hypertrophied right ventricle emerged as risk factors for the indication of non-a priori intraoperative ECMO. Patients in Groups B and C showed a higher pre-operative risk profile and higher prevalence of post-operative complications than patients in Group A. Overall survival at 1 year was 93%, 83%, and 82% and at 4 years was 73%, 68%, and 69% in Groups A, B, and C (p = 0.11). The intraoperative use of ECMO did not emerge as a risk factor for in-hospital mortality or mortality after hospital discharge. CONCLUSIONS: Intraoperative ECMO filled the gap between pre-operative and post-operative ECMO in lung transplantation. Although complications and in-hospital mortality were higher in patients who received ECMO, survival was similar among patients who underwent transplantation with or without ECMO.

Acupuncture induces a pro-inflammatory immune response intensified by a conditioning-expectation effect.

BACKGROUND: In a previous study it has been shown that acupuncture activates the respiratory burst (RB) of neutrophils as measured by the differences to baseline of the mean channel number of fluorescence intensity (mfi) in volunteers. Since this result could have been affected by a placebo effect, a study has been designed that controls for the different facets of placebo mechanisms such as expectancy, suggestibility, and conditioning. PARTICIPANTS AND METHODS: 60 healthy volunteers were randomized either to acupuncture of the acupoint Large Intestine 11 (LI 11) (groups 1 and 2) or relaxation (group 3) twice a week for 4 weeks. Only acupuncture group 1 and the relaxation group were provided with the additional suggestion that the treatment may strengthen the immune system. RESULTS: The repeated measurement analysis for differences of follow-ups to baseline showed significantly different treatment effects for neutrophils but not for monocytes (unprimed neutrophils: p = 0.004; neutrophils primed with TNF-alpha/FMLP or with FMLP only: p = 0.026 and p = 0.019, respectively) between groups. For both cell types post-hoc Dunnett's t-tests using the relaxation group as control showed significantly stronger treatment effects for acupuncture group 1. Combining all priming procedures, the average increase in mfi for both cell types was about 30% greater in acupuncture group 1 than in the relaxation group. Plasma concentrations of pro-inflammatory cytokines only increased significantly in the acupuncture groups. CONCLUSION: Repetitive acupuncture increases the cytotoxicity of leukocytes in healthy volunteers, which might be intensified by a conditioning-expectation effect.

The role of portal vein clamping for cytokine release and neutrophils activity during liver resection and transplant.

OBJECTIVES: Uncontrolled release of cytokines has been linked to graft dysfunction or rejection and contributes to an increase in mortality and morbidity. We argue that temporary vascular clamping of the hepatic pedicle during major hepatic surgery is a potential stimulus for an excessive release of cytokines and the activity of neutrophils. MATERIALS AND METHODS: Thirty patients underwent partial liver resection or transplant. Samples were drawn preoperatively, immediately before portal vein clamping, at the early reperfusion period, and on days 1, 3, 5, and 7 after the operation. Central venous plasma concentrations of IL-6, IL-8, and TNF- a were compared to portal venous plasma. The influence of neutrophils on metabolic activity was measured by flow cytometry. RESULTS: In both patient groups, no significant differences in cytokine concentrations between central and portal venous plasma were found. However, significant differences of neutrophils activity were observed in patients undergoing partial liver resection compared to patients after transplant. CONCLUSION: Portal vein stasis induced by clamping the hepatic pedicle has no influence on the local release of IL-6, IL-8, and TNF-a. However, preoperatively increased plasma levels of TNF-a play a decisive role in the metabolic activity of neutrophils in patients with final-stage liver disease.

Ex vivo microvesicle formation after prolonged ischemia in renal transplantation.

INTRODUCTION: Patients with chronic renal failure suffer from dysfunction in coagulation. Kidney transplantation induces inflammatory reactions and thus activation of platelets. Activated platelets, in turn, form microvesicles by shedding. These microvesicles have been shown to have coagulant activities. Activated platelets in prolonged cold ischemia were associated with delayed graft function and inferior survival. We investigated ex vivo formation of microvesicles in kidney transplantation and the influence of cold graft storage on microvesicles. METHODS: 20 patients (47.4+/-10.6 years (mean+/-SD)) undergoing transplantation were included in the study after written informed consent. Dependent on cold preservation time of transplanted kidneys, recipients were allocated into two groups with 10.4+/-6.1 h (group 1) and 23.7+/-3.8 h (group 2) preservation time, respectively. Blood samples were drawn before anesthesia, 12 h, 2, 7 and 14 days after transplantation. To evaluate microvesicle release, samples were activated with thrombin-receptor-activating-peptide-6 (TRAP) or adenosine-di-phosphate. Microvesicles were counted as percentage of platelets smaller than a predetermined size in flow cytometry. RESULTS: Platelet derived ex vivo microvesicle formation was significantly higher up to 48 h after transplantation when stimulated with TRAP in group 1. Platelet count was significantly higher compared to baseline values in the short-term ischemia group but not with long-term ischemia. Creatinine was significantly lower at study end compared to baseline with no differences between both groups. CONCLUSIONS: Lower platelet microvesicle formation after ex vivo stimulation with TRAP was associated with longer graft ischemia time. This may be a sign of former activation of platelets which could influence graft function and survival.

Reduced P-selectin expression on circulating platelets after prolonged cold preservation in renal transplantation.

The uremic state in patients with terminal renal insufficiency is accompanied by a bleeding tendency connected with platelet dysfunction. Prolonged cold ischemia and inflammatory interactions between leukocytes, platelets and endothelial cells contribute to ischemia-/reperfusion (I/R) injury and may impair long-term graft survival. We evaluated the influence of the duration of cold preservation time on the expression of platelet GPIIb/IIIa and P-selectin and on the formation of leukocyte-platelet complexes after kidney transplantation. Fourteen patients undergoing kidney transplantation were divided into group I with long preservation time (26.6 +/- 1.9 h) and group II with short preservation time (8 +/- 6.1 h). Five venous blood samples (3 ml) were taken before induction of anesthesia, 12 h, 2, 7 and 14 d after transplantation. Surface expression of the GPIIb/IIIa, P-selectin and the percentage of platelet-granulocyte complexes were quantified by flow cytometry. Additionally blood from seven healthy volunteers was analyzed. GPIIb/IIIa and P-selectin expression on circulating platelets were significantly decreased in the long and the short-term graft preservation group compared with healthy volunteers. A significantly reduced P-selectin expression was found in the long-term preservation group compared with the short-term group. The percentage of platelet-granulocyte complexes also decreased in both preservation groups in the first 2 d after reperfusion and remained in this state in the long-term preservation group. Reduced expression of P-selectin on circulating platelets may be an indicator of I/R injury after prolonged kidney graft preservation.