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Predictive factors of short term outcome after liver transplantation: A review

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World Journal of Gastroenterology 2016年第26期22卷 5936-5949页

作者： Giuliano Bolondi Federico Mocchegiani Roberto Montalti Daniele Nicolini Marco Vivarelli lesley de pietri Anaesthesiology Intensive Care and Pain Therapy Medical Residency University of Modena and Reggio Emilia Division of Hepatobiliary and Transplant Surgery Department of Experimental Medicine Polytechnic University of Marche Division of Anaesthesiology and Intensive Care Unit Department of Cardiology Thoracic and Vascular Surgery Critical Care Medicine Arcispedale Santa Maria Nuova-IRCCS

Liver transplantation represents a fundamental therapeutic solution to end-stage liver disease. The need for liver allografts has extended the set of criteria for organ acceptability, increasing the risk of adverse outcomes. Little is known about the early postoperative parameters that can be used as valid predictive indices for early graft function, retransplantation or surgical reintervention, secondary complications, long intensive care unit stay or death. In this review, we present state-of-the-art knowledge regarding the early post-transplantation tests and scores that can be applied during the first postoperative week to predict liver allograft function and patient outcome, thereby guiding the therapeutic and surgical decisions of the medical staff. Post-transplant clinical and biochemical assessment of patients through laboratory tests (platelet count, transaminase and bilirubin levels, INR, factor V, lactates, and Insulin Growth Factor 1) and scores (model for end-stage liver disease, acute physiology and chronic health evaluation, sequential organ failure assessment and model of early allograft function) have been reported to have good performance, but they only allow late evaluation of patient status and graft function, requiring days to be quantified. The indocyanine green plasma disappearance rate has long been used as a liver function assessment technique and has produced interesting, although not univocal, results when performed between the 1th and the 5th day after transplantation. The liver maximal function capacity test is a promising method of metabolic liver activity assessment, but its use is limited by economic cost and extrahepatic factors. To date, a consensual definition of early allograft dysfunction and the integration and validation of the above-mentioned techniques, through the development of numerically consistent multicentric prospective randomised trials, are necessary. The medical and surgical management of trans

关键词： Liver transplant Liver failure Early allograft dysfunction Primary non-function Initial poor function Outcome predictors Post operative Scoring system Indocyanine green Liver maximal functional capacity

Perioperative thromboprophylaxis in liver transplant patients

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World Journal of Gastroenterology 2018年第27期24卷 2931-2948页

作者： lesley de pietri Roberto Montalti Daniele Nicolini Roberto Ivan Troisi Federico Moccheggiani Marco Vivarelli Division of Anaesthesiology and Intensive Care Unit Department of General SurgeryAUSL Reggio Emilia-IRCCSReggio Emilia 42123Italy Hepatobiliary and Abdominal Transplantation Surgery Department of Experimental and Clinical MedicinePolytechnic University of MarcheAncona 60126Italy department of General Hepatobiliary and Liver Transplantation SurgeryGhent University Hospital Medical SchoolGhent 185 3K3 9000Belgium

Improvements in surgical and anesthetic procedures have increased patient survival after liver transplantation(LT). However, the perioperative period of LT can still be affected by several complications. Among these, thromboembolic complications(intracardiac thrombosis, pulmonary embolism, hepatic artery and portal vein thrombosis) are relatively common causes of increased morbidity and mortality. The benefit of thromboprophylaxis in general surgical patients has already been established, but it is not the standard of care in LT recipients. LT is associated with a high bleeding risk, as it is performed in a setting of already unstable hemostasis. For this reason, the role of routine perioperative prophylactic anticoagulation is usually restricted. However, recent data have shown that the bleeding tendency of cirrhotic patients is not an expression of an acquired bleeding disorder but rather of coexisting factors(portal hypertension, hypervolemia and infections). Furthermore, in cirrhotic patients, the new paradigm of ‘‘rebalanced hemostasis' ' can easily tip towards hypercoagulability because of the recently described enhanced thrombin generation, procoagulant changes in fibrin structure and platelet hyperreactivity. This new coagulation balance, along with improvements in surgical techniques and critical support, has led to a dramatic reduction in transfusion requirements, and the intraoperative thromboembolic-favoring factors(venous stasis, vessels clamping, surgical injury) have increased the awareness of thrombotic complications and led clinicians to reconsider the limited use of anticoagulants or antiplatelets in the postoperative period of LT.

关键词： Anticoagulation Liver transplantation Antiplatelets Thrombosis Coagulation Heparin Thromboelastography Thromboprophylaxis Hepatic artery thrombosis Portal vein thrombosis

Intraoperative thromboelastography as a tool to predict postoperative thrombosis during liver transplantation

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World Journal of Transplantation 2020年第11期10卷 345-355页

作者： lesley de pietri Roberto Montalti Giuliano Bolondi Valentina Serra Fabrizio Di Benedetto department of General Surgery Division of Anaesthesiology and Intensive Care UnitNuovo Ospedale Civile di SassuoloSassuolo 41049ModenaItaly department of Public Health Hepato-Pancreato-Biliary Surgery SectionFederico II University of NaplesNapoli 80138Italy Surgery and Trauma department Intensive Care UnitOspedale Bufalini CesenaCesena 47521Italy Surgery department Hepato-Pancreato-Biliary SurgerySurgical Oncology and Liver Transplantation UnitAzienda Ospedaliero Universitaria di ModenaUniversity of Modena and Reggio EmiliaModena 41125Italy

BACKGROUND Thromboembolic complications are relatively common causes of increased morbidity and mortality in the perioperative period in liver transplant *** postoperative portal vein thrombosis(PVT,incidence 2%-2.6%)and early hepatic artery thrombosis(HAT,incidence 3%-5%)have a poor prognosis in transplant patients,having impacts on graft and patient *** the present study,we attempted to identify the predictive factors of these complications for early detection and therefore monitor more closely the patients most at risk of thrombotic *** To investigate whether intraoperative thromboelastography(TEG)is useful in detecting the risk of early postoperative HAT and PVT in patients undergoing liver transplantation(LT).METHODS We retrospectively collected thromboelastographic traces,in addition to known risk factors(cold ischemic time,intraoperative requirement for red blood cells and fresh-frozen plasma transfusion,prolonged operating time),in 27 patients,selected among 530 patients(≥18 years old),who underwent their first LT from January 2002 to January 2015 at the Liver University Transplant Center and developed an early PVT or HAT(case group).Analyses of the TEG traces were performed before anesthesia and 120 min after *** retrospectively compared these patients with the same number of nonconsecutive control patients who underwent LT in the same study period without developing these complications(1:1 match)(control group).The chosen matching parameters were:Patient graft and donor characteristics[age,sex,body mass index(BMI)],indication for transplantation,procedure details,United Network for Organ Sharing classification,BMI,warm ischemia time(WIT),cold ischemia time(CIT),the volume of blood products transfused,and conventional laboratory coagulation *** distributed continuous data are reported as the mean±SD and compared using one-way Analysis of Variance(ANOVA).Nonnormally distributed continuous data are rep

关键词： Thromboelastography Hepatic artery thrombosis Portal vein thrombosis Liver transplantation Risk factors Cirrhosis

Transoesophageal echocardiography during liver transplantation

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World Journal of Hepatology 2015年第23期7卷 2432-2448页

作者： lesley de pietri Federico Mocchegiani Chiara Leuzzi Roberto Montalti Marco Vivarelli Vanni Agnoletti Division of Anaesthesiology and Intensive Care Unit Azienda Ospedaliero-Universitaria di Modena-Policlinico Transplantation Unit Polytechnic University of Marche Unit of Interventional Cardiology Arcispedale Santa Maria Nuova IRCCS Division of Anaesthesiology and Intensive Care Unit Arcispedale Santa Maria Nuova IRCCS

Liver transplantation(LT) has become the standard of care for patients with end stage liver disease. The allocation of organs, which prioritizes the sickest patients, has made the management of liver trans-plant candidates more complex both as regards their comorbidities and their higher risk of perioperative complications. Patients undergoing LT frequently display considerable physiological changes during the pro-cedures as a result of both the disease process and the surgery. Transoesophageal echocardiography(TEE), which visualizes dynamic cardiac function and overall contractility, has become essential for perioperative LT management and can optimize the anaesthetic management of these highly complex patients. More-over, TEE can provide useful information on volume status and the adequacy of therapeutic interventions and can diagnose early intraoperative complications, such as the embolization of large vessels or development of pulmonary hypertension. In this review, directed at clinicians who manage TEE during LT, we show why the procedure merits a place in challenging anaesthetic environment and how it can provide essential information in the perioperative management of compromised patients undergoing this very complex surgical procedure.

关键词： Liver transplantation Transoesophageal echocardiog

Perioperative effects of high doses of intraoperative thymoglobulin induction in liver transplantation

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World Journal of Transplantation 2015年第4期5卷 320-328页

作者： lesley de pietri Valentina Serra Giuseppe Preziosi Gianluca Rompianesi Bruno Begliomini Division of Anaesthesiology and Intensive Care Unit Azienda Ospedaliero-Universitaria di Modena-Policlinico Liver and Multivisceral Transplant Centre Azienda Ospedaliero-Universitaria di Modena-Policlinico Division of General Surgery University College London

AIM:To describe our single-centre experience in liver transplantation(LT)with the infusion of high perioperative thymoglobulin *** optimal dosage and timing of thymoglobulin[antithymocyte globulin(ATG)]administration during LT remains *** release syndrome,haemolytic anaemia,thrombocytopenia,neutropenia,fever and serum sickness are potential adverse effects associated with ATG ***:Between december 2009 and december 2010,16 adult non-randomized patients(ATG group),receiving a liver graft from a deceased donor,received an intraoperative infusion(4-6 h infusion)of thymoglobulin(3 mg/kg,ATG:Thymoglobuline).These patients were compared(case control approach)with 16 patients who had a liver transplant without ATG treatment(control group)to evaluate the possible effects of intraoperative ATG *** matching parameters were:Sex,recipient age(±5 years),LT indication including viral status,MELD score(±5 points),international normalized ratio and platelet count(as close as possible).The exclusion criteria for both groups included the following:Multi-organ or living donor transplant,immunosuppressive therapy before transplantation,contraindications to the administration of any thymocyte globulin,human immunodeficiency virus seropositivity,thrombocytopenia[plateletde effects(haemodynamic alterations,core temperature variations,colloids and crystalloids requirements,and surgical time)possibly related to ATG infusion and the thromboelastographic(TEG)evaluation of the ATG effects on coagulation,blood loss and blood product transfusion were analysed during the operation and the first three postoperative ***:Intraoperative ATG administration was associated with longer surgical procedures[560±88 min vs 480±83 min(control group),P=0.013],an intraoperative core temperature more than 37℃(50%of ATG patients vs 6.2%of control patients,P=0.015),major intraoperative bloo

关键词： Immunosuppression induction Cytokine release Thymoglobulin Thromboelastography Liver transplant

Thromboelastographic reference ranges for a cirrhotic patient population undergoing liver transplantation

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World Journal of Transplantation 2016年第3期6卷 583-593页

作者： lesley de pietri Marcello Bianchini Gianluca Rompianesi Elisabetta Bertellini Bruno Begliomini Division of Anaesthesiology and Intensive Care Unit Department of Cardiology Thoracic and Vascular Surgery Critical Care Medicine Arcispedale Santa Maria Nuova Gastroenterology Unit Department of Internal Medicine Azienda Ospedaliero Universitaria di Modena Liver and Multivisceral Transplant Center Azienda Ospedaliero-Universitaria di Modena Division of Anaesthesiology and Intensive Care Unit Department of Surgery Azienda Ospedaliero Universitaria di Modena

AIM To describe the thromboelastography(TEG) "reference" values within a population of liver transplant(LT) candidates that underline the differences from healthy *** Between 2000 and 2013, 261 liver transplant patients with a model for end-stage liver disease(MELD) score between 15 and 40 were studied. In particular the adult patients(aged 18-70 years) underwent to a first LT with a MELD score between 15 and 40 were included, while all patients with acute liver failure, congenital bleeding disorders, and anticoagulant and/or antiplatelet drug use were excluded. In this population of cirrhotic patients, preoperative haematological and coagulation laboratory tests were collected, and the pretransplant thromboelastographic parameters were studied and compared with the parameters measured in a previously studied population of 40 healthy subjects. The basal TEG parameters analysed in the cirrhotic population of liver candidates were as follows: Reaction time(r), coagulation time(k), Angle-Rate of polymerization of clot(α Angle), Maximum strenght of clot(MA), Amplitudes of the TEG tracing at 30 min and 60 min after MA is measured(A30 and A60), and Fibrinolysis at 30 and 60 min after MA(Ly30 and Ly60). The possible correlation between the distribution of the reference range and the gender, age, MELD score(higher or lower than 20) and indications for transplantation(liver pathology) were also investigated. In particular, a MELD cut-off value of 20 was chosen to verify the possible correlation between the thromboelastographic reference range and MELD score. RESULTS Most of the TEG reference values from patients with end-stage liver disease were significantly different from those measured in the healthy population and were outside the suggested normal ranges in up to 79.3% of subjects. Wide differences were found among all TEG variables, including r(41.5% of the values), k(48.6%), α(43.7%), MA(79.3%), A30(74.4%) and A60(80.9%), indicating a prevailing trend to h

关键词： Thromboelastography Liver cirrhosis Blood coagulation disorder Liver transplantation Reference values