Development of AKI within the first 72 h after transplant impacted short-term and long-term graft survival.

The greatest part of liver allograft injury occurs during reperfusion, not during the cold ischemia phase. The aim of this study, therefore, was to investigate how the severity of postreperfusion syndrome (PRS) influences short-term outcome for the patient and for the liver allograft. Over a 2-year period, 338 consecutive patients who presented for orthotopic liver transplantation (OLT) were included in this retrospective study. They were divided into 2 groups according to the severity of the PRS they experienced. The first group comprised 152 patients with mild or no PRS; the second group comprised 186 patients with significant PRS. Perioperative hemodynamic parameters, coagulation profiles, blood product requirements, incidence of infection, incidence of rejection and outcome data for both groups were collected and analyzed. There was no demographic difference between the groups except for age; group 2 had older patients than group 1 (54.94 Ϯ 9.07 versus 51.52 Ϯ 9.91, P ϭ 0.001). Compared to group 1, group 2 patients required more red blood cell transfusions (11.31 Ϯ 10.90 versus 8.08 Ϯ 7.89 units, P ϭ 0.002), more fresh frozen plasma transfusions (10.25 Ϯ 10.96 versus 7.03 Ϯ 7.64 units, P ϭ 0.002), more cryoprecipitate (1.88 Ϯ 4.72 units versus 0.61 Ϯ 1.80 units, P ϭ 0.001), and were more likely to suffer from fibrinolysis (52.7% versus 41.4%, P ϭ 0.041). Interestingly, group 2 had a shorter average warm ischemia time than group 1 (33.19 Ϯ 8.55 versus 36.21 Ϯ 11.83 minutes, P ϭ 0.01). Group 2 also required longer, on average, mechanical ventilation (14.95 Ϯ 29.79 versus 8.55 Ϯ 17.79 days, P ϭ 0.015), remained in the intensive care unit longer (17.65 Ϯ 31.00 versus 11.49 Ϯ 18.67 days, P ϭ 0.025), and had a longer hospital stay (27.29 Ϯ 32.35 versus 20.85 Ϯ 21.08 days, P ϭ 0.029). Group 2 was more likely to require retransplantation (8.6% versus 3.3%, P ϭ 0.044). In conclusion, the severity of PRS during OLT appears to be related to the outcome of patient and liver allograft.

Introduction Dexmedetomidine is a highly selective α2-adrenoceptor agonist with sedative, anxiolytic and analgesic properties that has minimal effects on respiratory drive. Its sedative and hypotensive effects are mediated via central α2A and imidazoline type 1 receptors while activation of peripheral α2B–adrenoceptors result in an increase in arterial blood pressure and systemic vascular resistance (SVR). In this randomized, prospective, clinical study we attempted to quantify the short-term hemodynamic effects resulting from a rapid IV bolus administration of dexmedetomidine in pediatric cardiac transplant patients. Methods Twelve patients, aged ≤10 years of age, weighing ≤40kg, presenting for routine surveillance of right and left heart cardiac catheterization after cardiac transplantation were enrolled. After an inhaled or IV induction, the tracheas were intubated and anesthesia was maintained with 1 minimum alveolar concentration of isoflurane in room air, fentanyl (1mcg/kg) and rocuronium (1mg/kg). At the completion of the planned cardiac catheterization, 100% oxygen was administered. After recording a set of baseline values that included heart rate (HR), systolic blood pressure, diastolic blood pressure, central venous pressure, systolic pulmonary artery pressure, diastolic pulmonary artery pressure, pulmonary artery wedge pressure and thermodilution-based cardiac output, a rapid IV dexmedetomidine bolus of either 0.25mcg/kg or 0.5mcg/kg was administered over 5 seconds. The hemodynamic measurements were repeated at 1 min and 5 mins. Results There were 6 patients in each group. Investigation suggested that systolic blood pressure, diastolic blood pressure, systolic pulmonary artery pressure, diastolic pulmonary artery pressure, pulmonary artery wedge pressure and systemic vascular resistance all increased at 1 minute after rapid IV bolus for both doses, and decreased significantly to near baseline for both doses by 5 minutes. The transient increase in pressures was more pronounced in the systemic system than in the pulmonary system. In the systemic system there was a larger percent increase in the diastolic pressures than the systolic pressures. Cardiac output, CVP and pulmonary vascular resistance did not change significantly. HR decreased at 1 min for both doses and was, within the 0.5 mcg/kg group, the only hemodynamic variable still changed from baseline at the 5 min time point Conclusion Rapid IV bolus administration of dexmedetomidine in this small sample of children having undergone heart transplants was clinically well tolerated, although it resulted in a transient but significant increase in systemic and pulmonary pressure and a decrease in HR. In the systemic system there is a larger percent increase in the diastolic pressures than the systolic pressures, and furthermore these transient increases in pressures were more pronounced in the systemic system than in the pulmonary system.

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Introduction Acute kidney injury (AKI) is a common complication after liver transplantation (LT). Few studies investigating the incidence and risk factors for AKI after live donor LT (LDLT) have been published. Hypothesis LDLT recipients have a lower risk for post-LT AKI than cadaveric donor LT (CDLT) recipients due to higher quality liver grafts. Methods We retrospectively reviewed LDLTs and CDLTs performed at the University of Pittsburgh Medical Center between Jan. 2006 and Dec. 2011. AKI was defined as a 50% increase in serum creatinine (SCr) from baseline (preoperative) values within 48 hours (1). One hundred LDLT and 424 CDLT recipients were included in the propensity score matching logistic model based on age, gender, MELD score, Child score, pre-transplant SCr, and pre-existing diabetes mellitus. Eighty-six pairs were created after one-to-one propensity-matching. The binary outcome of AKI was analyzed using mixed effects logistic regression, incorporating the main exposure of interest (LDLT versus CDLT) with the aforementioned matching criteria and post-reperfusion syndrome, number of units of packed red cells, and donor age as fixed effects. Results In the corresponding matched dataset, the incidence of AKI at 72 hours was 23.3% in the LDLT group, significantly lower than 44.2% in the CDLT group (p=0.004). Multivariable mixed effects logistic regression showed that live donor liver allografts were significantly associated with reduced odds of AKI at 72 hours post-LT (p=0.047, OR=0.307; 95% CI 0.096–0.984). The matched patients had lower body weights, better-preserved liver functions, and more stable intraoperative hemodynamic parameters. The donors were also younger for the matched patients than for the un-matched patients. Conclusion Receiving a graft from live donor has a protective effect against early post-LT AKI.

IV NAC was not effective in reducing renal or hepatic injury in the setting of liver transplantation. The dose and duration of NAC used, though higher than most renal protection studies, may have been ineffective for raising GSH levels in some patients.

Introduction: Liver transplant anesthesiology is an evolving and expanding subspecialty, and programs have, in the past, exhibited significant variations of practice at transplant centers across the United States. In order to explore current practice patterns, the Quality & Standards Committee from the Society for the Advancement of Transplant Anesthesia (SATA) undertook a survey of liver transplant anesthesiology program directors. Methods: Program directors were invited to participate in an online questionnaire. A total of 110 program directors were identified from the 2018 Scientific Registry of Transplant Recipients (SRTR) database. Replies were received from 65 programs (response rate of 59%). Results:Our results indicate an increase in transplant anesthesia fellowship training and advanced training in transesophageal echocardiography (TEE). We also find that the use of intraoperative TEE and viscoelastic testing is more common. However, there has been a reduction in the use of veno-venous bypass, routine placement of pulmonary artery catheters and the intraoperative use of anti-fibrinolytics when compared to prior surveys. Conclusion:The results show considerable heterogeneity in practice patterns across the country that continues to evolve. However, there appears to be a movement towards the adoption of specific structural and clinical practices.

BACKGROUND: Liver transplantation in children is often associated with coagulopathy and significant blood loss. Available data are limited. In this observational retrospective study, we assessed transfusion practices in pediatric patients undergoing liver transplantation at a single institution over the course of 9 years. METHODS: Data were retrospectively collected from patient medical records at the Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center. All patients who underwent liver transplantation from January 2008 to June 2017 were included. Primary and secondary outcomes were volume of red blood cells (RBCs) transfused and mortality, respectively. RESULTS: From January 2008 to June 2017, there were 278 liver transplants in 271 patients. The number of primary transplants were 259, second retransplants 15, and third retransplants 4. Average age at transplantation was 6.9 years. Biliary atresia, maple syrup urine disease, urea cycle defect, and liver tumor were the leading indications accounting for 66 (23.7%), 45 (16.2%), 24 (8.6%), and 23 (8.3%) of transplants, respectively. Seventy-six cases (27.3%) did not require RBC transfusions. Among those transfused, 181 (89.6%) of the cases required <1 blood volume (BV). The median BV transfused among all cases was 0.21 (range, 0–9; Q1, 0; Q3, 0.45). There is a trend toward higher volume transfusions among infants (median, 0.46 BV) compared to children >12 months of age (0.12 BV). By diagnosis, the group requiring the highest median volume transfusion was patients with total parenteral nutrition–related liver failure (3.41 BV) followed by patients undergoing repeat transplants (0.6 BV). Comparison of primary versus repeat transplants shows a trend toward higher volume transfusions in third transplants (median, 2.71 BV), compared to second transplants (0.43 BV) and primary transplants (0.18 BV). Four of 271 patients (1.5%) died during admission involving liver transplantation. Nine of 271 patients (3.3%) died subsequently. Total mortality was 4.8%. CONCLUSIONS: In contrast to historically reported trends, evaluation of current transfusion practices reveals that most patients undergoing liver transplantation receive <1 BV of packed RBCs. More than 1 in 4 transplantations require no transfusion at all. Risk factors for greater transfusion need include younger age, total parenteral nutrition–related liver failure, and repeat transplantation.