Gaab Soo Kim

The changes in coagulation profile and epidural catheter safety for living liver donors: A report on 6 years of our experience

The use of epidural catheters has been a subject of active debate in living liver donors because of the possible postoperative coagulation derangement and the subsequent risk of epidural hematoma. The aim of this study was to evaluate the safety of epidural catheters in relation to the changes in coagulation profile based on a review of previously published literature and the results of our 360 donors. In both the literature and in our cases, platelet count, prothrombin time (PT), and activated partial thromboplastin time (aPTT) in cases of heparin administration showed significant changes (P < 0.05), especially after right lobectomy. Platelet count reached its nadir on postoperative day (POD) 2–3, while PT and aPTT reached their peaks on POD 1–2 and at the end of the operation, respectively. In our donors, the ranges of platelet count, PT, and aPTT for the first 3 PODs were 54–359 ×10/μL, 0.99–2.38 international normalized ratio (INR), and 25.9–300 seconds, respectively, and of note, 5 donors (1.4%) had a platelet count of <80 × 10/μL and 9 donors (2.5%) had a PT of >2.0 INR. Epidural catheterizations were performed in 242 donors, and the catheters were removed on POD 3–4 in 177 donors (73.1%). Mean (range) of platelet count, PT, and aPTT on the day of catheter removal were 168.4 ± 42.9 (82–307) × 10/μL, 1.33 ± 0.18 (0.99–1.93) INR, and 40.9 ± 4.8 (32.0–70.6) seconds, respectively. No epidural hematoma was observed in this study. In conclusion, the discreet use of epidural catheters in live liver donors, in spite of postoperative coagulation derangements, appears to be safe regardless of the type of hepatectomy performed. Liver Transpl 13:62–70, 2007.

A Correlation between Low Back Pain and Associated Factors: A Study Involving 772 Patients who Had Undergone General Physical Examination

Many factors are associated with the development of low back pain. Among them, exercise, obesity, smoking, age, educational level and stress are the most common. This study examined the association of these factors with low back pain. An additional aim was to determine a procedure for preventing low back pain. This study analyzed the responses to a questionnaire sent to 772 individuals who had undergone a medical examination at this hospital in 2003 and excluded the individuals who had shown symptoms or their test results indicated a particular disease. Assuming that there were no variables, individuals who exercised regularly 3-4 times per week would have a lower chance of having low back pain than those who did not exercise regularly. The analysis revealed that individuals with a college degree or higher education have a lower chance of experiencing low back pain than those with only a high school education or even college drop-outs. When the other variables were constant, age, extent of obesity (body mass index), smoking and level of stress were not found to affect the development of low back pain. The level of education was associated with the development of low back pain. However, regular exercise 3-4 times per week or more would be most effective in reducing the incidence and duration of low back pain.

The effects of desflurane and propofol‐remifentanil on postoperative hepatic and renal functions after right hepatectomy in liver donors

Various volatile anesthetics have been used in hepatectomy in living donors, and their effects on major organs have been extensively evaluated. However, the impact of total intravenous anesthesia (TIVA) on postoperative liver and renal functions after large liver resections has been less extensively investigated than that of volatile agents. The aim of this study was to compare the postoperative hepatic and renal functions between volatile anesthesia with desflurane and TIVA with propofol‐remifentanil in living donors undergoing right hepatectomy. Seventy adult patients were randomly allocated into 2 groups: the desflurane group (n = 35) and TIVA group (n = 35). Aspartate aminotransferase, alanine aminotransferase, prothrombin time (PT), albumin, total bilirubin (TB), blood urea nitrogen (BUN), creatinine (Cr), BUN/Cr ratio, estimated glomerular filtration rate (GFR), platelet count, and hemoglobin levels were analyzed in the preoperative period, immediately after the operation, and on the first, second, third, fifth, seventh, and thirtieth postoperative days (PODs). Most of the liver function test results were not significantly different between the 2 groups. However, PT (international normalized ratio) and TB were significantly greater on POD 5 in the TIVA group. Among the renal function tests, Cr was significantly higher and estimated GFR was significantly lower on POD 1 in the TIVA group. The platelet counts and hemoglobin levels were similar between the 2 groups. In conclusion, the results of our study suggest that living related donors for liver transplant may have a better outcome following anesthesia with desflurane. However, further testing will be necessary to prove this hypothesis. Liver Transpl 14:1150–1158, 2008.

Incidence of severe ventricular arrhythmias during pulmonary artery catheterization in liver allograft recipients

Liver allograft recipients may develop a hyperdynamic circulation and cardiac electrophysiologic abnormalities. The incidence of severe ventricular arrhythmias in liver allograft recipients during pulmonary artery (PA) catheterization was determined. One hundred five liver allograft recipients were studied prospectively; 5 of the patients with preexisting valvular heart disease, ischemic heart disease, or arrhythmias were excluded. Severe ventricular arrhythmia, defined as 3 or more consecutive ventricular premature beats occurring at a rate of >100 per minute, was observed in 37.0% of the patients during insertion of the catheter and in 25.0% of the patients during removal of the catheter. Two patients developed ventricular tachycardia, and 2 developed ventricular fibrillation; the arrhythmias in these 4 patients did not respond to appropriate pharmacological treatment but resolved promptly after removal of the PA catheter. The catheter transit time from the right ventricle to the pulmonary capillary wedge position was longer in patients with severe ventricular arrhythmia than in those without this arrhythmia (91.6 ± 103.6 s versus 53.3 ± 18.4 s, P < 0.05). In conclusion, patients undergoing liver transplantation have a high risk of developing a ventricular arrhythmia during PA catheterization. Liver Transpl 13:1451–1454. 2007.

Incidence and predictors of post-reperfusion syndrome in living donor liver transplantation.

Chung IS, Kim HY, Shin YH, Ko JS, Gwak MS, Sim WS, Kim GS, Lee S‐K. Incidence and predictors of post‐reperfusion syndrome in living donor liver transplantation.

Is cytomegalovirus infection dangerous in cytomegalovirus-seropositive recipients after liver transplantation?

Cytomegalovirus (CMV) infections contracted after liver transplantation put patients at an increased risk of morbidity and mortality. We analyzed the effects of CMV infection by time of onset, mortality, and graft failure risk factors in liver recipients who were CMV donor‐positive/recipient‐positive (D+/R+). We reviewed 618 medical records for consecutive adult liver transplant cases. CMV pp65 antigenemia assays to determine patient CMV status were administered monthly. The incidences of CMV infection and disease were 55.7% (344 of 618 records) and 5.5% (34 of 618 records), respectively. The differences in patient survival and graft failure rates for CMV‐infected and CMV‐uninfected patients were not significant (P = 0.707 and P = 0.973), but the rates were lower in patients with CMV disease than in CMV‐uninfected patients (P = 0.005 and P = 0.030, respectively). The recurrence of hepatitis B virus and hepatocellular carcinoma, hepatic dysfunction, infection, numerous pp65‐staining cells, and CMV disease were found to be the risk factors for mortality and graft failure in CMV D+/R+ adult liver transplant patients. In conclusion, the occurrence of CMV disease, and not asymptomatic CMV infection, was a risk factor for mortality and graft failure in adult liver transplant recipients with CMV D+/R+. Liver Transpl, 2011.

Intrathecal morphine combined with intravenous patient‐controlled analgesia is an effective and safe method for immediate postoperative pain control in live liver donors

The healthy condition of living donors makes their tolerance to pain particularly low, and clinicians are often challenged to come up with an analgesic technique that is effective yet ensures donor safety. This study compared, in donor right hepatectomy, the efficacy and safety of preoperative intrathecal morphine (ITM) combined with intravenous patient‐controlled analgesia (IV‐PCA) with IV‐PCA alone. Forty adult patients were randomly allocated into 2 groups: ITM+IV‐PCA group (n = 20) and IV‐PCA‐only group (n = 20). Patients in the ITM+IV‐PCA group received morphine sulfate (400 μg). The visual analog scale (VAS) at rest and when coughing and supplementary meperidine and IV‐PCA (fentanyl) consumption were assessed at 2, 4, 6, 8, 10, 12, 18, 24, 30, 36, 42, 48 56, 64, and 72 hours after surgery. Also, side effects such as sedation, dizziness, nausea, vomiting, pruritus, and respiratory depression were evaluated. The ITM+IV‐PCA group showed significantly less pain at rest and when coughing for up to 30 hours and 24 hours, respectively. Cumulative postoperative consumption of meperidine and IV‐PCA (fentanyl) were significantly less in the ITM+IV‐PCA group. The incidence of side effects were comparable between the 2 groups except for pruritus; its incidence was significantly higher in the ITM+IV‐PCA group during the first 24 hours, but no treatment was required due to its mild severity. The results of our study suggest that preoperative ITM combined with IV‐PCA may be considered as an effective and safe pain management regimen in living liver donors who have characteristics of low tolerance to pain and postoperative coagulation derangement. Liver Transpl 15:381–389, 2009.

The effects of desflurane and sevoflurane on hepatic and renal functions after right hepatectomy in living donors

We compared postoperative hepatic and renal functions between the two inhalational anesthetics, desflurane and sevoflurane in living donors undergoing right hepatectomy. Seventy‐four adult donors were randomly allocated into Des group (n = 37) and sevo group (n = 37). Before the induction of anesthesia, morphine sulfate 400 μg was injected intrathecally. Anesthesia was maintained with one minimum alveolar concentration (MAC) of deflurane or sevoflurane plus continuous intravenous remifentanil. Liver and renal function tests were performed and analysed at preoperative period, immediately after operation, and on 1st, 2nd, 3rd, 5th, 7th, and 30th postoperative days (PODs). Aspartate aminotransferase (AST) showed significant elevations from the day of surgery to POD 3 and alanine aminotransferase (ALT) was significantly elevated on POD 1 and POD 3 in the sevo group. Albumin level was significantly lower on POD 2 in the sevo group. Creatinine was significantly higher on POD 3 and POD 30 and estimated glomerular filtration ratio was significantly lower on POD 3 and POD 30 in the sevo group. No patient developed hepatic or renal failures. The results of our study showed better postoperative hepatic and renal function test with desflurane than sevoflurane at equivalent dose of 1 MAC in living donors undergoing right hepatectomy, but further study is required to evaluate clinical importance.

Long‐term results for living donor liver transplant recipients with hepatocellular carcinoma using intraoperative blood salvage with leukocyte depletion filter

Massive intraoperative bleeding during liver transplantation often requires large amounts of blood products. The goal of this study was to investigate long‐term outcomes of living donor liver transplantation (LDLT) recipients with hepatocellular carcinoma (HCC) who underwent intraoperative use of intraoperative blood salvage (IBS) and leukocyte depletion filter (LDF). In this study, we included 230 LDLT recipients with HCC from two transplantation centers, between February 2002 and December 2007. Group 1 patients (n = 121) underwent intraoperative IBS with LDF and group 2 patients (n = 109) did not. The amount of autotransfused, filtered red blood cells (RBCs) in group 1 was 1590.2 ± 1486.8 ml, which corresponded to 5.9 units of allogenic leukocyte‐depleted RBCs saved. The incidences of renal dysfunction, postoperative bleeding, and urinary tract infection in group 2 were higher than in group 1 (P < 0.05). Recurrence‐free survival rates for 1, 3, and 5 years were 91.3%, 83.3%, and 83.3%, respectively, in group 1, and 84.6%, 79.0%, and 77.4%, respectively, in group 2 (P = 0.314). IBS using LDF does not increase the risk of cancer recurrence during LDLT for recipients with HCC. Therefore, the use of IBS with LDF appears to be safe for LDLT recipients with HCC.

Clinical Risk Scoring Models for Prediction of Acute Kidney Injury after Living Donor Liver Transplantation: A Retrospective Observational Study.

Acute kidney injury (AKI) is a frequent complication of liver transplantation and is associated with increased mortality. We identified the incidence and modifiable risk factors for AKI after living-donor liver transplantation (LDLT) and constructed risk scoring models for AKI prediction. We retrospectively reviewed 538 cases of LDLT. Multivariate logistic regression analysis was used to evaluate risk factors for the prediction of AKI as defined by the RIFLE criteria (RIFLE = risk, injury, failure, loss, end stage). Three risk scoring models were developed in the retrospective cohort by including all variables that were significant in univariate analysis, or variables that were significant in multivariate analysis by backward or forward stepwise variable selection. The risk models were validated by way of cross-validation. The incidence of AKI was 27.3% (147/538) and 6.3% (34/538) required postoperative renal replacement therapy. Independent risk factors for AKI by multivariate analysis of forward stepwise variable selection included: body-mass index >27.5 kg/m2 [odds ratio (OR) 2.46, 95% confidence interval (CI) 1.32–4.55], serum albumin <3.5 mg/dl (OR 1.76, 95%CI 1.05–2.94), MELD (model for end-stage liver disease) score >20 (OR 2.01, 95%CI 1.17–3.44), operation time >600 min (OR 1.81, 95%CI 1.07–3.06), warm ischemic time >40 min (OR 2.61, 95%CI 1.55–4.38), postreperfusion syndrome (OR 2.96, 95%CI 1.55–4.38), mean blood glucose during the day of surgery >150 mg/dl (OR 1.66, 95%CI 1.01–2.70), cryoprecipitate > 6 units (OR 4.96, 95%CI 2.84–8.64), blood loss/body weight >60 ml/kg (OR 4.05, 95%CI 2.28–7.21), and calcineurin inhibitor use without combined mycophenolate mofetil (OR 1.87, 95%CI 1.14–3.06). Our risk models performed better than did a previously reported score by Utsumi et al. in our study cohort. Doses of calcineurin inhibitor should be reduced by combined use of mycophenolate mofetil to decrease postoperative AKI. Prospective randomized trials are required to address whether artificial modification of hypoalbuminemia, hyperglycemia and postreperfusion syndrome would decrease postoperative AKI in LDLT.