Arterial Liver Insufficiency After Liver Transplantation Due to a Reactive Intrahepatic Vasoconstriction (original) (raw)
Related papers
Intraoperative Blood Flow Measurements and Liver Allograft Function: Preliminary Results
Transplantation Proceedings, 2006
Our previous studies showed a correlation of intraoperative renal allograft blood flow and immediate functions. A similar relation is not well established for liver transplantation. The aim of this study was to assess the relation between hepatic blood flow on revascularization and immediate liver graft function (IF).
Echocardiography, 2019
Objectives: The authors devised a hepatic vein flow index (HVFi), using intraoperative transesophageal echocardiography and graft weight, and investigated its predictive value for postoperative graft function in orthotopic liver transplant. Design: Prospective clinical trial. Setting,: Single-center tertiary academic hospital. Participants: Ninety-seven patients who had orthotopic liver transplant with the piggy-back technique between February 2018 and December 2019. Measurements and Main Results: HVFi was defined with HV flow/graft weight. Patients who developed early graft dysfunction (EAD) had low HVFi in systole (HVFi sys, 1.23 v 2.19 L/min/kg, p < 0.01), low HVFi in diastole (HVFi dia, 0.87 v 1.54 L/min/kg, p < 0.01), low hepatic vein flow (HVF) in systole (HVF sys, 2.04 v 3.95 L/min, p < 0.01), and low HVF in diastole (HVF dia, 1.44 v 2.63 L/min, p < 0.01). More cardiac death, more vasopressors at the time of measurement, more acute rejection, longer time to normalize total bilirubin (TIME t-bil), longer surgery time, longer neohepatic time, and more packed red blood cell transfusion were observed in the EAD patients. All HVF parameters were negatively correlated with TIME t-bil (HVFi sys R = À0.406, p < 0.01; HFVi dia R = À0.442, p < 0.01; HVF sys R = À0.44, p < 0.01; HVF dia R = À0.467, p < 0.01). The receiver operating characteristic curve analysis determined the best cutoff levels of HVFi to predict occurrence of EAD (HVFi sys <1.608, HVFi dia <0.784 L/min/kg), acute rejection (HVFi sys <1.388, HVFi dia <1.077 L/min/kg), and prolonged high total bilirubin (HVFi sys <1.471, HVFi dia <1.087 L/min/kg). Conclusions: The authors' devised HVFi has the potential to predict the postoperative graft function.
Arterial blood flow predicts graft survival in liver transplant patients
Liver Transplantation, 2011
Proper liver perfusion is essential for sufficient organ function after liver transplantation. The aim of this study was to determine the effects of portal and arterial blood flow on liver function and organ survival after liver transplantation. The arterial and portal venous blood flow was measured intraoperatively by transit time flow measurement after reperfusion for 290 consecutive liver transplants. The graft survival, hepatic cell damage (alanine aminotransferase and aspartate aminotransferase), and liver function (prothrombin ratio and bilirubin) were determined. Grafts were stratified into groups according to arterial blood flow measurements [<100 mL/minute for arterial blood flow group I (ART I), 100-240 mL/minute for ART II, and 240 mL/minute for ART III] and portal venous blood flow measurements (<1300 mL/minute for portal venous blood flow group I and 1300 mL/minute for portal venous blood flow group II). With multivariate analysis, the impact of blood flow on graft survival was determined, and potential confounders were considered. Decreased portal venous blood flow was associated with significantly less organ survival in univariate analysis but not in multivariate analysis. In contrast, the arterial blood flow was significantly correlated with organ survival after liver transplantation in univariate and multivariate analyses [hazard rate ratio ¼ 2.5, confidence interval ¼ 1.6-4.1, P < 0.001, median survival ¼ 56.6 (ART I), 82.7 (ART II), or 100.7 months (ART III)]. Moreover, low arterial blood flow resulted in impaired postoperative organ function and higher rates of primary nonfunction. Biliary complications were not affected by blood flow. Other risk factors for graft failure that were identified by multivariate analysis included retransplantation, histidine tryptophan ketoglutarate solution versus University of Wisconsin solution, and donor treatment with epinephrine. Impaired arterial blood flow after reperfusion represents a significant predictor of primary graft nonfunction and is associated with impaired graft survival. Whether the intraoperative measurement of hepatic arterial flow is predictive of graft survival should be evaluated in a prospective trial.
International journal of surgery, 2013
Background: Sometimes even in adequate graft to recipient weight ratio (GRWR) settings and after ruling out all other causes, recipients still show features of the small for size syndrome. The purpose of this study was to evaluate all causative factors responsible for early graft dysfunction fulfilling the definition of the small for size syndrome, regardless of the GRWR status, and with particular emphasis on portal flow (ml/min/100 g). We also tried to establish whether a high portal flow on intraoperative Doppler study immediately after reperfusion can predict graft dysfunction. Material and methods: Early graft dysfunction was defined according to the definitions given for the small for size syndrome by the Kyushu University Group. Patients undergone living donor liver trans-plantations between January 2010 and December 2012 were analyzed. We routinely do Doppler ultra-sound (USG) immediately after reperfusion and daily for 5 days. The portal vein flow after routine Doppler examination immediately after reperfusion was noted as the portal vein flow at day 0. Results: 19 of 134 patients showed features of early graft dysfunction as defined. On univariate analysis, hepatitis C virus (HCV) and portal vein flow immediately after reperfusion were significant predictors of postoperative graft dysfunction. (p ¼ 0.008 and p < 0.0001). On multivariate logistic regression, only portal vein flow after reperfusion (p ¼ 0.002) remained as the significant predictor of postoperative graft dysfunction. A portal flow of greater than 190 (ml/min/100 g) was significant in predicting graft dysfunction (p < 0.0001) with an AUROC of 0.709. GRWR was not a significant predictor. Conclusion: A portal vein flow immediately after reperfusion >190/ml/min/100 g. reliably predicted whether a graft would behave as small for size or not, regardless of the GRWR status. Portal vein flow was the most significant predictor of graft dysfunction.
Hepatology, 2002
Information on changes in splanchnic hemodynamics after liver transplantation is incomplete. In particular, data on long-term changes are lacking, and the relationship between changes in arterial and portal parameters is still under debate. The effect of liver transplantation on splanchnic hemodynamics was analyzed with echo-Doppler in 41 patients with cirrhosis who were followed for up to 4 years. Doppler parameters were also evaluated in 7 patients transplanted for acute liver failure and in 35 controls. In cirrhotics, portal blood velocity and flow increased immediately after transplantation (from 9.1 ؎ 3.7 cm/sec to 38.3 ؎ 14.6 and from 808 ؎ 479 mL/min to 2,817 ؎ 1,153, respectively, P < .001). Hepatic arterial resistance index (pulsatility index) also augmented (from 1.36 ؎ 0.32 to 2.34 ؎ 1.29, P < .001) and was correlated with portal blood velocity and flow. The early changes in these parameters were related, in agreement with the hepatic buffer response theory. Portal flow returned to normal values after 2 years. Superior mesenteric artery flow normalized after 3 to 6 months. Splenomegaly persisted after 4 years, when spleen size was related to portal blood flow. In 7 patients transplanted for acute liver failure, portal flow, and hepatic arterial resistance index were normal after transplantation.
Intraoperative Blood Flow Measurements in Organ Allografts Can Predict Postoperative Function
Transplantation Proceedings, 2007
A reliable method to recognize the extent of ischemia/reperfusion injury in transplantation is needed in order to tailor the immunosuppressive scheme to the needs of a damaged organ. This study sought to assess the correlation between the total and the parenchymal blood flow into a transplanted kidney (n ϭ 71) or liver (n ϭ 15) shortly after revascularization with the early function of the organ after transplantation. The total blood flow in the renal artery in kidney recipients or in the hepatic artery and portal vein in liver recipients was measured by an electromagnetic flowmeter. The parenchymal blood flow (in several parts of the transplanted organ) was assessed using a laser-Doppler flowmeter. Two measurements were always taken after revascularization (5 to 60 minutes apart). Vascular resistance (VR) as calculated by the difference between the mean arterial pressure (MAP) and the central venous pressure (CVP) was correlated with immediate kidney or liver function parameters. Neither total renal blood flow (RBF) nor VR was different between the immediate function (IF) and delayed graft function (DGF) groups of kidney transplant patients. However, the cortical (parenchymal) blood flow was significantly greater in the IF than the DGF group at 5 minutes: 29.98 Ϯ 6.13 mL/min/100 g vs 23.56 Ϯ 6.46 mL/min/100 g (P Ͻ .001). The difference was even more significant at 35 minutes: 33.94 Ϯ 7.47 mL/min/100 g vs 15.47 Ϯ 3.34 mL/min/100 g (P Ͻ .0001). Among liver transplant patients, the results suggested a correlation between hepatic arterial blood flow and early graft viability and function. The most reliable predictor of early graft function was the portal blood flow, which correlated with the volume of secreted bile as well as the bilirubin, and transaminase levels and coagulation profile. Further studies must confirm the value of measurements of total and parenchymal blood flow in organ transplant recipients.
The interaction of systemic hemodynamics with hepatic flows at the time of liver transplantation (LT) has not been studied in a prospective uniform way for different types of grafts. We prospectively evaluated intraoperative hemodynamics of 103 whole and partial LT. Liver graft hemodynamics were measured using the ultrasound transit time method to obtain portal (PVF) and arterial (HAF) hepatic flow. Measurements were recorded on the native liver, the portocaval shunt, following reperfusion and after biliary anastomosis. After LT HAF and PVF do not immediately return to normal values. Increased PVF was observed after graft implantation. Living donor LT showed the highest compliance to portal hyperperfusion. The amount of liver perfusion seemed to be related to the quality of the graft. A positive correlation for HAF, PVF and total hepatic blood flow with cardiac output was found (p = 0.001). Portal hypertension, macrosteatosis >30%, warm ischemia time and cardiac output, independently influence the hepatic flows. These results highlight the role of systemic hemodynamic management in LT to optimize hepatic perfusion, particularly in LDLT and split LT, where the highest flows were registered.
Hpb, 2009
Background: We hypothesized that operative variables might predict survival following liver transplantation. Methods: We examined perioperative variables from 469 liver transplants carried out at the University of Washington during 2003-2006. Logistic regression determined the variables' contributions to survival at 30, 90 and 365 days. Results: Portal vein blood flow (>1 l/min) was significant to patient survival at 30, 90 and 365 days. Complete reperfusion was only a significant predictor of survival at 30 days. This provided model receiver operating characteristic (ROC) area under the curve (AUC) statistics of 0.93 and 0.87 for 30 and 90 days, respectively. At 365 days, hepatic artery blood flow (>250 ml/min) combined with portal vein blood flow was significantly predictive of survival, with an AUC of 0.74. A subset analysis of 110 transplants demonstrated improved 1-year survival with more aggressive vascular revisions.
HPB, 2009
Background: We hypothesized that operative variables might predict survival following liver transplantation. Methods: We examined perioperative variables from 469 liver transplants carried out at the University of Washington during 2003-2006. Logistic regression determined the variables' contributions to survival at 30, 90 and 365 days. Results: Portal vein blood flow (>1 l/min) was significant to patient survival at 30, 90 and 365 days. Complete reperfusion was only a significant predictor of survival at 30 days. This provided model receiver operating characteristic (ROC) area under the curve (AUC) statistics of 0.93 and 0.87 for 30 and 90 days, respectively. At 365 days, hepatic artery blood flow (>250 ml/min) combined with portal vein blood flow was significantly predictive of survival, with an AUC of 0.74. A subset analysis of 110 transplants demonstrated improved 1-year survival with more aggressive vascular revisions.
Liver Transplantation, 2003
In adult living donor liver transplantation, using small grafts in cirrhotic patients with severe portal hypertension may have unpredictable consequences. The so-called small-for-size syndrome is present in most series worldwide. The goal of this study was to prospectively evaluate the influence of hemodynamic changes on postoperative liver function and on the percentage of liver volume increase, in the setting of living donor liver transplantation. Twenty-two consecutive adult living donor liver transplantations were performed at our institution in a 2-year period. We measured right portal flow and right hepatic arterial flow with an ultrasonic flow meter in the donor, and then in the recipient 1 hour after reperfusion. Postoperative liver function was measured by daily laboratory work. We also performed duplex ultrasounds on postoperative days 1, 2, and 7. Liver volume increase was estimated by magnetic resonance imaging graft volumetry at 2 months posttransplantation. We compared the blood flow results with the immediate liver function and its liver volume increase rate at 2 months. There was a significant increase in portal flow in the recipients compared with the donors (up to fourfold in some cases). Higher portal flow increase rates significantly correlated with faster prothrombin time normalization and faster liver volume increases. Median graft volume increase at 2 months was 44.9%. The increase in blood flow to the graft is well tolerated by the liver mass not affecting hepatocellular function as long as the graft-to body weight ratio is maintained (>0.8) and adequate outflow is provided. (Liver Transpl 2003;9:564-569.)