Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society
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Comparative Study
Association between plasma cyclic guanosine monophosphate levels and hemodynamic instability during liver transplantation.
The activation of cyclic guanosine monophosphate (cGMP) production in patients with end-stage liver disease (ESLD) has been associated with hemodynamic instability during orthotopic liver transplantation (OLT). The aim of this prospective, observational study was to investigate the involvement of cGMP in the mediation of profound hypotension during liver graft reperfusion. An additional objective was to determine whether preoperative cGMP levels are associated with intraoperative hemodynamic instability. ⋯ We also demonstrated a significantly higher intraoperative catecholamine requirement (P < 0.001) and a prolonged postoperative ICU stay (P = 0.02) in group 1 patients versus group 2 patients. In conclusion, this study demonstrates increased baseline cGMP production in patients with ESLD, which is significantly associated with severe hypotension during OLT. We suggest that preoperative levels of cGMP correlate with hemodynamic instability during liver graft reperfusion.
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Adult living donor liver transplantation (aLDLT) is associated with surgical risks for the donor and with the possibility of small-for-size syndrome (SFSS) for the recipient, with both events being of great importance. An excessively small liver graft entails a relative increase in the portal blood flow during reperfusion, and this factor predisposes the recipient to an increased risk of SFSS in the postoperative period, although other causes related to recipient, graft, and technical factors have also been reported. ⋯ The identification of patients at risk for excessive portal hyperflow will allow its modulation before reperfusion. This could favor the use of smaller grafts and ultimately lead to a reduction in donor complications because it would allow more limited hepatectomies to be performed.
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In the United States, livers for transplantation are distributed within donation service areas (DSAs). In DSAs with multiple transplant centers, competition among centers for organs and recipients may affect recipient selection and outcomes in comparison with DSAs with only 1 center. The objective of this study was to determine whether competition within a DSA is associated with posttransplant outcomes and variations in patients wait-listed within the DSA. ⋯ In comparison with DSAs without competition, the low-, mid-, and high-competition DSAs (1) performed transplantation for patients with a higher risk of graft failure [hazard ratio (HR) = 1.24, HR = 1.26, and HR = 1.34 (P < 0.001 for each)] and a higher risk of death [HR = 1.21, HR = 1.23, and HR = 1.34 (P < 0.001 for each)] and for a higher proportion of sicker patients as quantified by the Model for End-Stage Liver Disease (MELD) score [10.0% versus 14.8%, 20.1%, and 28.2% with a match MELD score of 31-40 (P < 0.001 for each comparison)], (2) were more likely to use organs in the highest risk quartile as quantified by the DRI [18.3% versus 27.6%, 20.4%, and 31.7% (P ≤ 0.001 for each)], and (3) listed more patients per million population [18 (median) versus 34 (P = not significant), 37 (P = 0.005), and 45 (P = 0.0075)]. Significant variability in patient selection for transplantation is associated with market variables characterizing competition among centers. These findings suggest both positive and negative effects of competition among health care providers.
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It is believed that antiviral prophylaxis decreases the incidence of cytomegalovirus (CMV) reactivation and disease. There are few data regarding weekly assays for CMV DNA after transplantation and the subsequent management of CMV. Here we report a cohort of living related liver transplantation (LRLT) patients who were treated for invasive CMV disease or for CMV infections if they were receiving steroids for rejection. ⋯ In conclusion, CMV reactivation is common after LRLT (13%), but the disease is rare (2.9%) without prophylaxis in CMV immunoglobulin G-positive recipients. The administration of steroids for ACR strongly correlates with CMV reactivation and disease. CMV reactivation and disease did not affect survival in our patient cohort.
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Randomized Controlled Trial Comparative Study
Epinephrine and phenylephrine pretreatments for preventing postreperfusion syndrome during adult liver transplantation.
Acute hypotension after reperfusion of the liver graft occurs frequently during liver transplantation. A randomized, prospective trial was performed to test the effects of epinephrine and phenylephrine pretreatments for attenuating postreperfusion syndrome (PRS). Ninety-three adult liver recipients were randomly allocated to receive an intravenous bolus of 10 μg of epinephrine, 100 μg of phenylephrine, or normal saline (the control group) at the time of graft reperfusion. ⋯ The intraoperative epinephrine and dopamine requirements were significantly lower in both pretreatment groups. Perioperative laboratory data, postoperative stays, and in-hospital mortality rates were similar for the 3 groups. In conclusion, pretreatment with 10 μg of epinephrine or 100 μg of phenylephrine significantly reduces the occurrence of PRS and vasopressor requirements without immediate or delayed adverse effects in adult liver transplantation.