Intractable ascites without mechanical vascular obstruction after orthotopic liver transplantation: etiology and clinical outcome of sinusoidal obstruction syndrome

Abstract

Intractable ascites after orthotopic liver transplantation (OLT) is a relatively rare complication. However, it often takes a life threatening course, which requires re-transplantation. In previous studies, several reports gave hepatic sinusoidal obstruction syndrome (SOS) as one of the causes of refractory ascites. However, the detailed etiology of SOS after OLT and its association with clinical consequences remain unclear because there have been few studies to date. We report two recent cases with rapidly progressive refractory ascites associated with SOS, following completely different clinical courses. In case 1, the first episode of acute allograft rejection triggered SOS and subsequent intractable ascites, while the second acute rejection worsened his clinical status. A transjugular intrahepatic portosystemic stent-shunt (TIPS) was placed and this procedure resulted in complete disappearance of ascites and of renal dysfunction. In contrast, refractory ascites in case 2, who had neither rejection nor mechanical outlet obstruction, worsened despite TIPS stent placement, and re-transplantation was necessary. We speculate that the pre-existing diseased liver of the cadaver donor caused this serious complication, necessitating a second graft.

Transjugular intrahepatic portosystemic shunt for the treatment of sinusoidal obstruction syndrome in a liver transplant recipient and review of the literature

“…In agreement with other authors, 16,27,28 we believe that when there is no response to medical treatment, prompt TIPS placement should be contemplated. When multiorgan failure ensues, the window of opportunity may close.…”

“…We carried out a MEDLINE search with the terms sinusoidal obstruction syndrome after liver transplant, veno-occlusive disease after liver transplant, and transjugular intrahepatic portosystemic shunt, and we found 6 additional cases of TIPS-treated SOS among LT recipients. 8,26,27 The clinical characteristics and outcomes of these patients and our case are listed in Table 1. Only 1 patient received azathioprine, and 3 of the 7 received mycophenolate mofetil.…”

Acute Cellular Rejection Resulting in Sinusoidal Obstruction Syndrome and Ascites Postliver Transplantation

“…More recently, Kitajima et al (9) described two patients developing intractable ascites post-LT as a result of SOS, one arising in the setting of a previous episode of mild ACR. This episode of SOS occurred 180 days post-LT in a patient having sepsis who conceivably may have also had small-for-size syndrome.…”

Devastating outflow obstruction after pediatric split liver transplantation

“…Most of the previously reported cases with SOS after LT were adults (5, 6, 12, 13, 14, 15). To the best of our knowledge, only one case demonstrating SOS to occur after LT in a small child has been previously reported (16).…”