Selection and preparation of candidates for combined liver-kidney transplantation: experience at a single center-two case reports.

BACKGROUND: The published experiences of combined liver-kidney transplantation (LKT) are favorable, but there is still no uniformity concerning the impact on hepatorenal syndrome, or in cases of symptomatic hepatorenal polycystic disease. Herein we describe our experience with two LKTs, with particular reference to the selection and preparation of the candidates, and the surgical approach. METHODS: Between 1996 and June 2003, we performed 430 liver transplants in 398 recipients, including two LKTs: one in a patient with hepatorenal polycystic disease (case 1) and the other in a patient with HBV(+) cirrhosis undergoing dialysis after a previous isolated kidney transplant (case 2). RESULTS: In case 1, LKT and right nephrectomy were performed 2 months after a left lumbar nephrectomy. In case 2, LKT was performed 10 months after an isolated kidney transplant, without removing the first graft, which recovered function after 3 months. Both patients are now in good health with functioning grafts. CONCLUSIONS: LKT requires careful selection and preparation of candidates to optimize the probability of success. In well-compensated dialyzed patients with cirrhosis due to viral hepatitis, we believe that a combined approach is indicated after antiviral therapy. In cases of hepatorenal cystic disease, a two-stage surgical approach makes it possible to eliminate the risk of infection and intracyst hemorrhage in nonfunctioning polycystic kidneys.

Hepatic resection after liver transplantation as a graft-saving procedure: indication criteria, timing and outcome.

BACKGROUND: Hepatic resection is uncommon after liver transplantation (LT), but can be a graft-saving procedure in selected cases. Herein we describe the criteria, outcome, and timing of this procedure in our series. METHODS: Between January 1996 and December 2002, 397 LTs were performed in 367 recipients, of whom 12 patients (3.2%) subsequently underwent liver graft resections because of ischemic-type biliary lesions (ITBLs) (n = 5, 41.6%), segmental hepatic artery thrombosis (S-HAT)(n = 3, 25%), recurrent hepatocellular carcinoma (HCC) (n = 2, 16.6%), liver abscess (n = 1, 8.3%), or liver trauma (n = 1, 8.3%). The patients were divided into group 1 (n = 3 all with S-HAT) who underwent early resections (within 3 months of LT), and group 2 (n = 9) who underwent late resections (after 3 months). The outcomes and postoperative mortality ratio (within 30 days) were compared. RESULTS: The resections consisted of four left lobectomies, three right hepatectomies, two extended right hepatectomies, one segmentectomy, one anterior trisegmentectomy, and one right lateral sectoriectomy. The perioperative mortality rate was 66.6% in group 1 (one case of myocardial infarction and one of sepsis), and 22% in group 2 (one case of sepsis and one of hepatic failure). CONCLUSIONS: Late resections in stable patients with damage confined to the graft yield good prognosis. Even major resections are feasible graft-saving procedures. In contrast, early hepatic resections in S-HAT are associated with a worse outcome. Retransplantation should be considered the first-choice option. Sepsis significantly affects the postsurgical course.

Intraabdominal pressure in liver transplant recipients: incidence and clinical significance.

BACKGROUND: The incidence and clinical relevance of increased intraabdominal pressure after orthotopic liver transplantation (OLT) has not yet been evaluated despite the finding that occurrence of this condition in postsurgical critically ill patients may impair various organ functions. The aim of this study was to assess whether the occurrence of abdominal hypertension among a population of OLT recipients was an important cofactor producing early postoperative complications. METHOD: This prospective clinical study measured abdominal pressure every 6 hours during the intensive care unit (ICU) stay using the urinary bladder method. A value of >/=25 mm Hg was considered high. Hemodynamic status was simultaneously evaluated and renal function assessed based on the hourly urinary output, and by calculating serum creatinine on postoperative days 2 and 4. Renal failure was defined as a serum creatinine level of >1.5 mg/dL, or an increase in peak of >1 mg/L within 72 hours of surgery. The filtration gradient and patient outcomes were also considered. RESULTS: Intraabdominal hypertension was observed in 32% of cases. The subjects displaying high IAP showed significantly lower artery pressure values (P <.01), but did not differ in terms of central venous pressure or cardiac output. High intraabdominal pressure was more frequently associated with renal failure (P <.01), a lower filtration gradient (P <.001), delayed postsurgical weaning from the ventilation (P <.001), and increased ICU mortality (P <.05). A receiver operator characteristic curve analysis showed that the critical IAP values, namely those with the best sensitivity/specificity, were 23 mm Hg for postoperative ventilatory delayed weaning (P <.05), 24 mm Hg for renal dysfunction (P <.05), and 25 mm Hg for death (P <.01). CONCLUSIONS: Abdominal hypertension occurs frequently after OLT and may be associated with a complicated postoperative course.

Surgical complications after liver transplantation.

AIM: The number of liver transplantations in Italy has steadily increased over the last 10 years as a result of the use of donors aged more than 60 years. The use of organs with a reduced functional reserve has been compensated for by improvements in immunosuppressive therapy, surgical techniques and the management of postoperative complications. This article describes the incidence and treatment of the main surgical complications after liver transplantation. METHODS: Between January 1996 and June 2003, 398 patients received 430 transplants at our Centre. Thirty-seven early relaparotomies were performed (8.6%), including 12 retransplantation (2.8%). The 1-, 3- and 5-year actuarial survival of the patients was 79.8%, 72.2% and 67.5%, and that of the grafts was 75.9%, 68% and 63.4%. Perioperative mortality was 10.5% (with no intraoperative deaths). RESULTS: The overall incidence of biliary complications was 31.6%, 9.1% of which were due to the removal of the Kehr tube. There were 42 (9.8%) anastomotic stenoses, 5 (1.2%) extra-anastomotic stenoses, 1 (0.2%) anastomotic leak, 5 (1.2%) extra-anastomotic leaks, and 19 (4.4%) ischemic-type biliary lesions. The overall incidence of vascular complications was 6.9%: 7 (1.6%) cases of hepatic artery thrombosis, 17 (4.0%) arterial stenoses, 1 (0.2%) arterial pseudoaneurysm, 4 (0.9%) cases of portal thromboses and 1 (0.2%) case of caval laminar thrombosis. Eight patients (1.9%) developed massive and persistent post-transplant ascites and/or hydrothorax. CONCLUSION: The use of donors aged more than 60 years makes it possible to maintain high standards of patient and graft survival that is not only due to the optimisation of immunosuppressive protocols, but also to improvements in surgical techniques, intensive care and the management of surgical complications.

Regional filter heparinization for continuous veno-venous hemofiltration in liver transplant recipients.

AIM: To study safety, clinical and operative feasibility of continuous veno-venous hemofiltration (CVVH) with anticoagulation only of the filter in patients at risk for bleeding. METHODS: This prospective, comparative, non randomised study was completed at an intensive care unit of a teaching NHS hospital. Sixteen liver transplant (LT) recipients with acute renal failure needing CVVH were treated with a regional anticoagulation protocol (heparin and protamine were administered respectively pre- and post-filter) and compared to 11 critically ill subjects who received a standard low-heparin treatment. Activated coagulation time (ACT) monitoring was used to adjust anticoagulation and heparin neutralization. RESULTS: Mean circuit life was 35.8+/-13.6 hours (95% CI 28.5-43.1) in patients receiving regional anticoagulation and 34.4+/-14 hours in controls (95% CI 25.5-43.3; p=0.7). Fourty-eight circuits (47.5% of the total) in the heparin-protamine group had a life-span longer than 30 hours and other 22 (21.7%) were changed intentionally after 24 hours of use in absence of clots. None of the patients in both the studied groups had bleeding or hemodynamic complications and their azotemic control was always satisfactory. CONCLUSION: In LT recipients, regional anticoagulation can achieve a circuits life-span comparable to that from systemic anticoagulation with satisfactory safety and simplicity of use.

Very early tracheal extubation without predetermined criteria in a liver transplant recipient population.

This study of all patients undergoing orthotopic liver transplantation (OLT) at our center between January 1997 and December 1999 evaluated the feasibility and safety of very early tracheal extubation without previous selection. Anesthetic management was the same in all cases, and tracheal extubation was performed on the basis of standardized criteria routinely adopted in operating rooms throughout the world, i.e., no residual curarization or anesthetic action, ability to swallow efficiently, and stable hemodynamics. One hundred sixty-nine patients underwent 181 OLTs during the study period. Tracheal extubation was performed within 3 hours of surgery in 115 cases, 8 hours in 19 cases, and 8 to 24 hours in 10 cases. In 36 cases, artificial ventilation was required for more than 24 hours or weaning was not possible. One patient died of primary graft nonfunction within 24 hours and was excluded from the analysis. The feasibility of early extubation was influenced by the amount of intraoperative transfused blood; efficacy of kidney, cardiac, and pulmonary function; and presence of encephalopathy (P <.001). No correlation was found with age or pre-OLT severity of hepatic disease, and the postoperative period was not compromised by early weaning. Very early extubation was feasible and safe in a large number of unselected transplant recipients, thus suggesting that the definition of early tracheal extubation should be changed from 8 to 3 hours after surgery.

[Blood coagulation monitoring during liver transplantation: Sonoclot analysis and laboratory tests]. / Monitorizzazione della coagulazione in corso di trapianto di fegato: validazione dell'analisi tromboelastografica "Sonoclot" attraverso le indagini di laboratorio.

BACKGROUND: Aim of this paper is to validate blood coagulation data obtained using the Sonoclot thromboelastographic analyser (Sienco Inc., Morrison, USA) by means of standard laboratory tests during orthotopic liver transplantation (OLT). DESIGN: comparative study between laboratory data and Sonoclot analysis on simultaneously collected blood samples. SETTING: National Health System Liver Transplantation Center. PATIENTS: fifty-one patients, both males and females, affected by terminal hepatic disease submitted to OLT were enrolled in the study. DATA COLLECTION: simultaneous blood samples were collected during the pre-anhepatic, anhepatic and post-reperfusion phases of OLT; coagulation status was assessed by means of either standard Laboratory tests (INR, aPTT, Fibrinogen, PLT, D-Dimer) and Sonoclot analyser data (SonACT, Rate, Time to Peak, Downward Deflection); a statistical analysis was performed (Pearson s chi(2) test). RESULTS: A statistically significative correlation between the analysed data was found. The Sonoclot analyser was useful in identifying platelets dysfunction and was more sensitive to detect fibrinolysis. CONCLUSIONS: The Sonoclot thromboelastographic analyser is a reliable device for monitoring coagulation during OLT.

[Early tracheal extubation ofter orthotopic liver transplantation]. / Estubazione tracheale precoce dopo trapianto ortotopico di fegato.

BACKGROUND: To evaluate an early tracheal extubation feasibility in previously unselected orthotopic liver transplantation (OLT) patients. DESIGN: retrospective analysis. SETTING: National Health System Intensive Care Unit. PATIENTS: all the patients who underwent OLT during 1997 at our institution were evaluated. The anesthestic management was the same for all of them and a veno-venous bypass was always used during the anhepatic phase. Tracheal extubation was performed when metabolic and haemodynamic parameters were stable; the following extubation criteria were also considered: no residual curarization, normocarbia, ability to keep the airway patent, good respiratory drive, ability to carry out simple orders. No pre- or intraoperative criteria, as previously reported in the literature for OLT patients, were followed to perform tracheal extubation in the postoperative period. RESULTS: During 1997 forty OLTs were performed in 38 patients. Twenty-eight patients were successfully extubated within 3 hours from the end of the surgical procedure; three patients were extubated within 6 hours and three within 24 hours from the end of surgery; four patients needed more then 24 hours of ventilation or were impossible to wean. No patient was re-intubated. A correlation appeared evident between early extubation and the amount of the transfused red cell units, kidneys and lungs function, cardiovascular efficiency; no correlation emerged with patients age or the pre-transplant severity of the hepatic disease. CONCLUSIONS: To perform a safe early tracheal extubation in previously unselected OLT patients is feasible and it can be carried out in a wide number of them. The previously reported timing characterizing as "early" a tracheal extubation should be moved from 8 to 3 hours.

[Orthotopic liver transplant. Analysis of costs related to anesthesiologic and intensive care phases]. / Trapianto ortotopico di fegato. Analisi dei costi relativi alle fasi anestesiologica ed intensivistica.

BACKGROUND: To evaluate anesthesia and Intensive Care Unit (ICU) costs for Orthotopic Liver Transplantation (OLT) through a point by point analysis of the entire process from anesthesia induction to ICU discharge. DESIGN: Retrospective analysis. SETTING: Regional Transplantation Centre participating to the Italian National Health Care System. METHODS: Anesthesia and ICU costs for each OLT performed during 1997 were estimated through the analysis of costs of the following categories: drugs, medical and nurse staff, blood bank, radiology, laboratory, haemoderivates. RESULTS: Forty OLTs were performed in 38 recipients during the study period. The total charges for the anesthesia and ICU management of these patients calculated in US dollars were 583.433,23 (considering the exchange rates valid in January 1998). ICU costs resulted approximately 2.5 times higher than those for anesthesia. Blood bank and drugs were the categories that had the greatest impact on the final expense whereas laboratory had the lowest. The charges referred to medical and nurse staff resulted higher in the ICU than for anesthesia. CONCLUSIONS: The Italian National Health Care System has to deal with limited resources; costs analysis of high-tech procedures as OLT is of basic importance to optimise resources allocation and to enforce money-saving actions.

[Recurrent Salmonella dublin infections]. / Infections récidivantes par Salmonella dublin.

A recurrent septicemia in a 8-year old child is reported. Blood and lymphnode tissue cultures permitte the isolation of Salmonella dublin. Despite the in vitro susceptibility of the isolated bacteria and the prolonged antimicrobial therapy, sepsis had a protracted course with relapses.