[Volume-based haemostasis reserves in blood product free liver transplantations]. / Térfogatalapú haemostasistartalékok vérmentes májtranszplantációk során.

Introduction: During liver transplantation, haemostasis is typically assessed by means of standard laboratory tests and viscoelastic tests, while dynamic monitoring of coagulation factor specific blood losses is an unusual, yet established approach. Aim: Our aim was to evaluate the volume-based haemostasis reserves in blood product free liver transplants in the first perioperative 48 hours, in association with the Child-Pugh score. Method: Data of 59 blood product free liver transplanted patients' coagulation factor levels, viscoelastic parameters and coagulation factor specific blood losses according to Gross methodological, baseline and 'coagulopathic' trigger levels were analysed. The haemostasis reserves were estimated according to the Child-Pugh classification. Laboratory tests and the calculation of haemostasis reserves were carried out before liver transplantation (T1), at the end of the surgery (T2) and also 12-24-48 hours postoperatively (T3-T4-T5). The viscoelastic tests were performed before liver transplantation (T1) and at the end of the surgery (T2). Results: Fibrinogen levels decreased by 1.2 g/L. Factor II, V, VII, X levels decreased by 26-40%. From T2 to T4, fibrinogen increased by 0.9 ± 0.6 g/L over 24 h (p<0.001). Factor II, V, VII, X levels increased by 12-30% between T3 to T5 (p<0.001). The viscoelastic parameters remained in the normal range during liver transplantation (T1-T2). Haemostasis reserves decreased by 61% at the end of surgery (p<0.001), but reached 88% of the preoperative value on the second postoperative day. The initial reserves of Child B and C groups were 36-41% lower than Child A, nevertheless, these differences were not significant at 48 hours. Conclusion: The volume-based haemostasis approach supplements the standard laboratory and viscoelastic tests. This unusual approach dynamically indicates the actual reserve of haemostasis and shows the 'weakest link' within the system. Orv Hetil. 2020; 161(7): 252-262.

Liver Transplant for Metastatic Neuroendocrine Tumors: A Single-Center Experience in Hungary.

Unresectable liver metastases of gastroenteropancreatic neuroendocrine tumors are an accepted indication for liver transplant. Patients undergoing liver transplant because of neuroendocrine tumor liver metastases have similar long-term survival compared with hepatocellular carcinoma; however, recurrence rates are reported to be higher. METHODS: We performed a retrospective analysis of medical records of patients who received transplants for neuroendocrine tumor liver metastases in the Department of Transplantation and Surgery of Semmelweis University between January 1995 and August 2018. The median follow-up period was 33 months. RESULTS: Ten liver transplants have been performed because of neuroendocrine tumor liver metastases during the observed period. Recurrence occurred in 5 cases, and 3 patients died. Estimated 1- and 5-year patient survival rates after transplant were 89% and 71%, respectively. Estimated 1- and 5-year recurrence-free rates were 80% and 43%, respectively. Every patient whose primary tumor was of pancreatic origin or those recipients who had Ki67 index values in the explanted liver higher than 5% had disease recurrence. CONCLUSION: Patient survival and recurrence rates after liver transplant were comparable with the results reported by other centers. In line with previous findings, primary pancreatic neuroendocrine tumors and higher Ki67 index values in the explanted livers were both associated with higher recurrence rates. We believe that an international registry would be helpful to better understand factors leading to tumor recurrence in these cases.

MARS therapy, the bridging to liver retransplantation - Three cases from the Hungarian liver transplant program.

Besides orthotopic liver transplantation (OLT) there is no long-term and effective replacement therapy for severe liver failure. Artificial extracorporeal liver supply devices are able to reduce blood toxin levels, but do not replace any synthetic function of the liver. Molecular adsorbent recirculating system (MARS) is one of the methods that can be used to treat fulminant acute liver failure (ALF) or acute on chronic liver failure (AoCLF). The primary non-function (PNF) of the newly transplanted liver manifests in the clinical settings exactly like acute liver failure. MARS treatment can reduce the severity of complications by eliminating blood toxins, so that it can help hepatic encephalopathy (HE), hepatorenal syndrome (HRS), and the high rate mortality of cerebral herniation. This might serve as a bridging therapy before orthotopic liver retransplantation (reOLT). Three patients after a first liver transplantation became candidate for urgent MARS treatment as a bridging solution prior to reOLT in our center. Authors report these three cases, fo-cusing on indications, MARS sessions, clinical courses, and final outcomes.

[The first successful adult right-lobe living donor liver transplantation in Hungary]. / Az elsô sikeres élô donoros felnôttkori jobb lebenyes májtranszplantáció Magyarországon.

The authors report on their experiences related to the first adult live donor liver transplantation performed in Hungary. The transplantation was done between brother and sister on 19th of November, 2007. The right lobe of the 33-year-old healthy male's donor liver (segments 5-8) was removed and implanted into the 23-year-old female suffering from cirrhosis on the ground of autoimmune hepatitis. The implantation of the right liver lobe was done after own hepatectomy in orthotopic position. Liver function has improved rapidly following the transplantation. The donor was discharged on the 10th post-operative day with stable liver function. He had full rehabilitation, got back to work, and control check-ups showed a significant liver regeneration. Two years after transplantation, the recipient also lives an active life with compensated liver function and she is under regular medical check-up. With the case report, authors overview the indications and techniques of living donor right-lobe liver transplantation.

[The role of marginal donors in liver transplantation. The Hungarian experience]. / Marginális donorok szerepe a magyar májátültetési programban.

UNLABELLED: Availability of suitable donor organs has always limited liver transplantations. Use of marginal donors (Extended Donor Criteria) for liver transplantation is an alternative to overcome the organ shortage. The aim of this study was to analyze the characteristics of organ donation in Hungary with special regard to marginal donors. METHODS: We reviewed data from donors and recipients between January 2003 and December 2008 retrospectively. Extended donor criteria were adopted from international recommendations. RESULTS: During this period, 1078 donors were reported to the clinic. 835 (77.4%) donors were excluded from liver transplantation and 243 (22.6%) were implanted. From the 243 transplantations 40 recipients (16%) received marginal graft, 203 (84%) received non-marginal graft. Extended Donor Criteria status had no negative impact on the patient and graft survival, postoperative graft dysfunction, and other complications. Recurrence of Hepatitis C occurred earlier in those patients who received marginal graft. CONCLUSION: There is an increasing number of patients waiting for liver transplantation in Hungary. There is no significant difference in morbidity and mortality of patients receiving marginal or non-marginal graft. Use of marginal grafts should be avoided in Hepatitis C virus positive recipients. Acceptance of older donors for liver transplantation should be considered.

[Surgical aspects of pediatric liver transplantation. Living donor liver transplant program in Hungary]. / A gyermekkori májátültetés sebészeti alapjai. Az élodonor-program elso lépései Magyarországon.

Because of the long waiting time for pediatric liver transplantation, new techniques of liver transplantation were invented. Split and living-donor related liver transplantation are common today and the Kaplan-Meier (3 years) overall survival is over 80%. By splitting the liver, two recipients can be transplanted. In general, the left lobe is used for the pediatric, the right lobe for the adult recipient. There are a lot of combinations depending on the donor and recipient weight. The accepted liver volume is approx. 1% of the recipient body weight. The results of the Hungarian pediatric program improve, 27 transplantations were done using 14 partial liver grafts and living donor program was started. Using strict protocols and improving surgical skills, the overall pediatric survival was over 80% in the last 5 years.

[Evaluation of liver function before living donor liver transplantation and liver resection]. / A májfunkció kiértékelése élo donoros májátültetést és májreszekciót megelozoen.

UNLABELLED: Liver resection is the curative therapeutic option for hepatocellular carcinoma, biliary tumors, metastases of colorectal and other extrahepatic tumors, living donor liver transplantation and other benign liver diseases. AIM OF STUDY: To summarize the evaluation methods of liver function before living donor liver transplantation and liver resection. METHOD: We summarize the literature about the evaluation of liver function. RESULTS: Perioperative mortality is determined mostly by the extent of preoperative evaluation focused on the liver. After resection the remnant liver parenchyma must cope with the challenge caused by increased metabolism, portal overflow, decreased vascular bed and biliary tract and oxidative stress following the operation. If the remnant liver is unable to grow up to this challenge, acute liver failure occurs. This maintains the necessity of determining the hepatic functional reserve and the hepatic remnant volume. Child-Pugh classification is widely spread to predict outcome. Dynamic functional tests such as indocyanine green retention test, galactosyl human serum albumin scintigraphy and aminopyrine breath tests can be used to evaluate hepatic reserve. To determine remnant liver volume modern imaging processes such as CT volumetry and hepatobiliary scintigraphy are available. CONCLUSION: After the detailed evaluation resection can be limited to an extent which is oncologically radical enough (1% remnant liver tissue/kg) and spares parenchyma which can ensure survival yet. With careful preoperative examination mortality can be reduced even to reach zero.

[Liver resection for living-donor liver transplantation: anesthesia and intensive care aspects]. / Májreszekció élôdonoros májtranszplantáció céljából: aneszteziológiai és intenzív terápiás szempontok.

The living related donor mortality after liver donation could occur as a result of postoperative cardiovascular and thromboembolic complication; which could be minimized by detailed preoperative assessment of the living donor. The preoperative functional tests evaluate the physiological reserve or identify the living donors with limited response to the surgical stress. Based on the results of CT volumetry, MRI and liver functional reserve capacity test (indocyanine green retention ratio) the liver resection can be done safely. The preoperative cytochrome P enzymes tests of donors identify the drugs with abnormal metabolism. Balanced anesthesia combined with thoracic epidural anesthesia is done with liver safe, renal safe and ischemic preconditioning drugs. Normovolemic state is maintained with physiologic extrahepatic perfusion and oxygenation conditions. The central venous and hepatic artery pressure is reduced with the guarantee of optimal hepatic perfusion-oxygenation and better liver resection condition. Intraoperative thrombosis prophylaxis is performed with sequential compression device. After liver resection the donor morbidity can be reduced, effective analgesia, thrombosis prophylaxis, liver safe drug therapy and a tight monitoring. Before the first postoperative mobilization a deep vein Doppler ultrasound control is proposed.

Intramucosal pH monitoring during liver transplantation.

PURPOSE: To apply tonometry as a quick estimation of the early liver graft function. PATIENTS AND METHODS: Forty-five liver-transplanted patients were examined. Data were collected prospectively and analysed retrospectively. According to the early graft function, patients were classified into two groups: in group 1 (n = 28) adequate graft function, in group 2 (n = 17) deteriorated graft function was detected in the early post-operative period. Complete conventional and volumetric haemodynamic monitoring and intramucosal pH (pHi), regional CO2 tension (PrCO2) measurements were performed during surgery and until the 36 hours post-operatively. RESULTS: In group 2 the packed blood cell, fresh frozen plasma consumption intraoperatively, and the time of hepatectomy were significantly higher; ICU treatment days, respiration time was longer and mortality rate was higher. Almost the whole examination period pHi was mostly below 7.3 and PrCO2 above 50 mmHg in group 2. There were significant differences in pHi between the groups from the preparation phase until the 24th post-operative hour. In group 2, there were significantly lower values in cardiac output in the whole examination period and in the mean arterial pressure values in the revascularization phase. In group 1, the oxygen delivery values were significantly higher in the preparation phase and oxygen consumption values after revascularization phase. With regression analysis there were no significant correlations between pHi, PrCO2 and global haemodynamic parameters. CONCLUSION: Regional parameters were completely different from global haemodynamic parameters, therefore pHi and PrCO2 can be a good indicator of the early liver graft dysfunction.

[Liver transplantation after Amanita phalloides poisoning from the viewpoint of anesthesia and intensive care based on three cases]. / Amanita phalloides mérgezést követó májtranszplantáció aneszteziológiai és intenzív terápiás szempontjai három eset kapcsán.

Experiences of liver transplantation after Amanita phalloides poisoning were analysed in anaesthetic and intensive therapist point of view based on 3 cases. Cardiac problems were found at all patients during the postoperative period. Probably the amatoxin has cardiotoxic effect or a part of phallotoxins are absorbed despite cooking and caused reversible cardiac function impairment. Pancreatitis, DIC, gastrointestinal bleeding, acute renal failure were found at all patients, therefore liver transplantation is only a part of the treatment, complex therapy is necessary in this cases.

[Continuous autotransfusion during liver transplantation]. / Folyamatos autotranszfúzió használata májtranszplantáció során.

The advantages and disadvantages of continuous autotransfusion during liver transplantation are investigated in our study compared with blood saving and traditional cell saving techniques. Patients were divided into three groups in this retrospective study; Group 1 (n = 14): continuous autotransfusion was applied; in Group 2 (n = 14): no blood saving technique used; in Group 3 (n = 14): Haemonetics cell saver was used. In Group 1 the number of Child B patients was significantly higher than Child C patients (p < 0.05). The initial values of haemoglobin were significantly lower in Groups 1 and 3 (89 +/- 19 vs. 103 +/- 17 vs. 90 +/- 16.8 g/l; p < 0.03). During hepatectomy in Group 1 lower haemoglobin values were detected than in the other two groups (96 +/- 7 vs. 104 +/- 16 vs. 106 +/- 16.6 g/l; p < 0.05). The quantity of total blood utilisation (donor + autotransfusion) was significantly higher in Group 3 than Group 2 and in Group 1 than Group 2 (21.06 +/- 11.2 vs. 11.07 +/- 3.8 vs. 30.71 +/- 18 U; p < 0.001). Comparing the values of ACT in each group during operation periods no significant difference was found. Treatment time on the ICU of the patients in Group 3 was significantly longer than in the other two groups (11.08 +/- 7.8 vs. 9.17 +/- 3.5 vs. 26.62 +/- 14.6 days; p < 0.03). We found that applying CATS is advantageous during liver transplantation, as the device reduces donor blood requirement. No significant complication was observed.