Early diagnosis of primary nonfunction and indication for reoperation after liver transplantation

Abstract

Initial graft function is a major factor influencing the clinical outcome after liver transplantation (LTX), but a reliable method for assessing and predicting graft dysfunction directly after LTX is not available. Ninety-nine patients undergoing deceaseddonor LTX were studied in a prospective pilot study to evaluate the LiMAx test, the indocyanine green test, and conventional biochemical parameters with respect to their sensitivity and prognostic power for the diagnosis of initial graft dysfunction. Patients suffering from initial graft dysfunction (defined as technical complications or primary nonfunction (n ¼ 8)) had significantly decreased LiMAx readouts (43 6 18 versus 184 6 98 lg/kg/hour, P < 0.001) immediately after LTX. Univariate analysis also showed significant differences for serum bilirubin, ammonia, glutamate dehydrogenase, and the international normalized ratio (P < 0.05), but multivariate analysis revealed LiMAx as the single independent predictor of initial dysfunction (P ¼ 0.008) with an area under the receiver operating characteristic curve (AUROC) of 0.960 (95% confidence interval ¼ 0.921-0.998, P < 0.001). In addition, the diagnosis of primary nonfunction (n ¼ 3) was evaluated with LiMAx and aspartate aminotransferase (AST) activity on the first postoperative day. The calculated AUROC values were 0.992 (0.975-1.0, P ¼ 0.004) for LiMAx and 0.967 (0.929-1.0, P ¼ 0.006) for AST. By a combination of test results obtained directly after LTX and on the first day, LiMAx indicated primary nonfunction with a sensitivity of 1.0 (0.31-1.0) and a positive predictive value of 1.0 (0.31-1.0), whereas AST classification showed a sensitivity of 0.67 (0.13-0.98) and a positive predictive value of 0.29 (0.05-0.70). In conclusion, the assessment of initial graft function using the LiMAx test might be effective for identifying critical complications that could threaten graft survival within 24 hours after LTX. Liver Transpl 16:172-180,

Primary graft dysfunction of the liver: definitions, diagnostic criteria and risk factors

“…Direct liver function assessment tests, such as indocianine green clearance, can be employed for early graft dysfunction diagnosis. (22) The application of the liver function test LiMAx (maximal liver function capacity) (22)(23)(24) 24 hours following transplant was reported by Lock et al (22) This test reflects real-time liver function and was shown to be successful in graft function assessment immediately after surgery. (22) The main definitions of EAD are given on chart 1.…”

Liver Status Assessment by Spectrally and Time Resolved IR Detection of Drug Induced Breath Gas Changes

“…The predicted LiMAx value after surgery is approximately 31% of 639 µ g/kg/h. This value of 198 µ g/kg/h is below the normal liver capacity, but in a range in which the recovery of the liver is expected without complications [21,30,[32][33][34][35][36]. Thus, it is possible to predict this operation is safe.…”

“…The DOB kinetics were measured with the described certificated FLIP device (Humedics GmbH, Berlin, Germany). A number of clinical trails have been published [4,[21][22][23][24][25][26][27][28].…”

“…The liver resections are often the exclusive curative treatment. The liver can recover completely after operation, if the remaining metabolic liver function remains above a certain threshold [21,30]. Three additional DOB kinetics are plotted in Figure 5.…”

Evaluation of early liver graft performance by the indocyanine green plasma disappearance rate

“…5 Interestingly, living donor liver grafts also have shown full performance with the indocyanine green (ICG) test directly after LT. 6 In contrast to these findings, a significant effect of ischemia/reperfusion on ICG-PDR readouts has been demonstrated in previous experimental studies, and a posttransplant regeneration of test readouts could be expected. It somehow remains unclear why there is no progression or increase in ICG-PDR readouts in humans.…”