Early allograft dysfunction after living donor liver transplantation—current concepts and future directions

Agrawal, Dhiraj; Saigal, Sanjiv

doi:10.1097/lvt.0000000000000173

Liver Transplantation

2023

DOI: 10.1097/lvt.0000000000000173

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Early allograft dysfunction after living donor liver transplantation—current concepts and future directions

Dhiraj Agrawal¹,

Sanjiv Saigal

Abstract: Early allograft dysfunction (EAD) after liver transplantation is a significant clinical problem that negatively impacts graft and patient outcomes. The rising incidence of EAD and what it means concerning living donor liver transplantation (LDLT) is an area of great interest. However, EAD after LDLT is a complex research topic yet to be reviewed comprehensively. Most of the literature on EAD is based on experience in deceased donor liver transplantation, and limited information is available in the context of L… Show more

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Cited by 2 publications

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Dexmedetomidine use during orthotopic liver transplantation surgery on early allograft dysfunction: a randomized controlled trial

Yang,

Zhu,

et al. 2024

International Journal of Surgery

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Background: Previous studies have shown a protective effect of dexmedetomidine use in kidney transplantation. In contrast, it is not known whether intraoperative administration of dexmedetomidine can reduce early allograft dysfunction incidence following liver transplantation. Objective: To investigate the effect of dexmedetomidine use during surgery on early allograft dysfunction following orthotopic liver transplantation (OLT). Study design: This is a single-center, double-blinded, placebo-controlled randomized clinical trial. 330 adult patients undergoing orthotopic liver transplantation were enrolled from Jan 14th, 2019 to May 22nd, 2022. Patients received dexmedetomidine or normal saline during surgery. 1 year follow-ups were recorded. Methods: Patients were randomized to two groups receiving either dexmedetomidine or normal saline intraoperatively. For patients in the dexmedetomidine group, a loading dose (1 μg/kg over 10 min) of dexmedetomidine was given after induction of anesthesia followed by a continuous infusion (0.5 μg/kg /h) until the end of surgery. For patients in the normal saline group, an equal volume loading dose of 0.9% saline was given after the induction of anesthesia followed by an equal volume continuous infusion until the end of surgery. The primary outcome was early allograft dysfunction. Secondary outcomes included primary graft non-function, acute kidney injury and acute lung injury/ acute respiratory distress syndrome. Results: Of 330 patients included in the intention-to-treat analysis, 165 were in the dexmedetomidine group (mean [SD] age, 49 [10] years; 117 [70.9%] men), and 165 were in the normal saline group (mean SD age, 49 [9] years; 118 [74%] men). 39 (24.4%) patients in the dexmedetomidine group and 31 (19.4%) in normal saline group developed early allograft dysfunction and the difference was statistically insignificant (P=0.28). Secondary outcomes including primary graft non-function and acute kidney injury was similar between the two groups. Conclusion: Intraoperative administration of dexmedetomidine did not reduce early allograft dysfunction rate after orthotopic liver transplantation.

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Dexmedetomidine use during orthotopic liver transplantation surgery on early allograft dysfunction: a randomized controlled trial

Yang,

Zhu,

et al. 2024

International Journal of Surgery

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Letter to the Editor: Small-for-size syndrome is the predominant form of early allograft dysfunction in living donor liver transplantation

Gupta,

Agarwal

2023

Liver Transplantation

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To the editor, We read with interest the review article on early allograft dysfunction (EAD) by Agrawal and Saigal. [1] The authors need to be congratulated for their extensive literature review and attempt at separating small-for-size syndrome (SFSS) as a subset of EAD. Further, they suggest separating technical issues before defining EAD.However, the authors do not make a recommendation for using any of the existing definitions or suggest a new one for which consensus could be built. The definition suggested by Olthoff seems, at the moment, to be most appropriate.In our experience of over 4000 living donor liver transplant (LDLT), EAD and technical issues often go hand in hand. For example, massive intraoperative blood loss will result in poor graft function. [2] In the right lobe LDLT, with multiple venous and biliary anastomoses, subtle technical deficiencies in the form of narrowing or leaks are inevitable. Major attention has focused on MHV thrombosis, which is notorious for graft dysfunction. [3] Similarly, small inferior hepatic veins may have an important role. [4] Increased ascites drainage following LDLT may be from subtle outflow obstruction, which only becomes clear from HPVG studies. Minor bile leaks will result in cholestasis, which will not improve without drainage. Segmental dysfunction by virtue of inflammation adversely impacts overall graft function.SFSS is a distinct clinical entity and perhaps is the only true form of EAD. Ischemia-reperfusion injury is extremely rare when cold ischemic times are so short. Even with other factors, such as graft steatosis and older donors, ischemiareperfusion alone is unlikely to be a cause of major graft dysfunction. One must remember that donors part with 60% to 70% liver volume without deleterious effects on liver function. If SFSS sets in even with adequate graft volume, it is more likely that functioning liver volume may not be adequate, rather than from another cause for EAD.Certainly, the incidence of SFSS decreases with experience. [5] Therefore, we strongly feel that SFSS and EAD are interlinked, and to suggest that there are other forms of EAD in LDLT would take away the focus from the importance of the technical integrity of LDLT.

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Early allograft dysfunction after living donor liver transplantation—current concepts and future directions

Cited by 2 publications

References 78 publications

Dexmedetomidine use during orthotopic liver transplantation surgery on early allograft dysfunction: a randomized controlled trial

Dexmedetomidine use during orthotopic liver transplantation surgery on early allograft dysfunction: a randomized controlled trial

Letter to the Editor: Small-for-size syndrome is the predominant form of early allograft dysfunction in living donor liver transplantation

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