Geraldine C. Diaz

Donor Health Assessment After Living-Donor Liver Transplantation

ObjectiveTo elicit donor opinions on liver living donation through use of a survey that protected the anonymity of the respondent and to assay long-term (follow-up > 1 year) donor health by a widely recognized instrument for health assessment. Summary Background DataLiving-donor liver transplantation is an accepted technique for children that has recently been extended to adults. Limited donor outcomes data suggest favorable results, but no outcomes data have been reported using an instrument that elicits an anonymous response from the donor or employs a widely recognized health survey. MethodsForty-one living-donors between June 1992 and June 1999 were identified and included in this study, regardless of specific donor or recipient outcome. Each donor received a 68-question survey and a standard McMaster Health Index. ResultsSurvey response was 80%. All donors were satisfied with the information provided to them before donation. Eighty-eight percent of donors initially learned of living donation only after their child had been diagnosed with liver disease: 44% through the transplant center, 40% by popular media, 12% by their pediatrician, and 4% by their primary care physician. Physical symptoms, including pain and the surgical wound, were recurrent items of concern. Perception of time to “complete” recovery were less than 3 months (74%), 3 to 6 months (16%), and more than 6 months (10%). Donors’ return to physical activities was shown by above-mean McMaster physical scores; scores for social and emotional health were not different from population data. There were no reported changes in sexual function or menstruation after donation, and five of six donors procreated. ConclusionsDonors overwhelmingly endorsed living donation regardless of recipient outcome or the occurrence of a complication. Eighty-nine percent advocated “increased” application of living donation beyond “emergency situations,” and no donor responded that living donation should be abandoned or that he or she felt “forced” to donate.

Transplantation-mediated alloimmune thrombocytopenia: Guidelines for utilization of thrombocytopenic donors†

Transplantation‐mediated alloimmune thrombocytopenia (TMAT) is donor‐derived thrombocytopenia following solid‐organ transplantation. To date, no clear consensus on the appropriateness of organ utilization from cadaver donors with a history of idiopathic thrombocytopenia purpura (ITP) has emerged. Herein is reported a devastating case of TMAT following liver transplantation utilizing an allograft from a donor with ITP that resulted in allograft failure. The literature is reviewed in this context to propose preliminary guidelines regarding utilization of allografts from cadaver donors with a history of ITP. Liver Transpl 2008;14:1803–1809.

Hepatic and renal protection during cardiac surgery.

Hepatic injury in cardiac surgery is a rare complication but is associated with significant morbidity and mortality. A high index of suspicion postoperatively will lead to earlier treatment directed at eliminating or minimizing ongoing hepatic injury while preventing additional metabolic stress from ischemia, hemorrhage, or sepsis. The evidence-basis for perioperative renal risk factors remains hampered by the inconsistent definitions for renal injury. Although acute kidney injury (as defined by the Risk, Injury, Failure, Loss, End-stage criteria) has become accepted, it does not address pathogenesis and bears little relevance to cardiac surgery. Although acute renal failure requiring renal replacement therapy after cardiac surgery is rare, it has a devastating impact on morbidity and mortality, and further studies on protective strategies are essential.

Survival of Clostridium perfringens sepsis in a liver transplant recipient

Clostridium perfringens sepsis following orthotopic liver transplantation (OLT) is a rare but reported complication that historically results in mortality or emergent retransplantation (ReTx). 1–7 Complications from C. perfringens emphysematous gastritis have contributed to the death of a healthy live liver donor as well. 8 Herein, we describe the first documented survivor of C. perfringens sepsis following OLT managed without laparotomy or emergent ReTx. Liver Transpl 15:1469–1472, 2009.

Postoperative Care/Critical Care of the Transplant Patient

Critical care of the general surgical patient requires synthesis of the patients physiology, intraoperative events, and preexisting comorbidities. Evaluating an abdominal solid-organ transplant recipient after surgery adds a new dimension to clinical decisions because the transplanted allograft has undergone its own physiologic challenges and now must adapt to a new environment. This donor-recipient interaction forms the foundation for assessment of early allograft function (EAF). The intensivist must accurately assess and support EAF within the context of the recipients current physiology and preexisting comorbidities. Optimizing EAF is essential because allograft failure is a significant predictor of recipient morbidity and mortality.

Protein C activity and postoperative metabolic liver function after liver transplantation.

BACKGROUND Protein C is a natural thrombin antagonist produced by hepatocytes. Its levels are low in liver failure and predispose patients to increased risk for thrombosis. Little is known about the relationship between protein C activity and hepatic function after orthotopic liver transplantation (OLT). METHODS We measured protein C activity of 41 patients undergoing liver transplantation by the Staclot method (normal range, 70%-130%) preoperatively and then daily on postoperative days (POD) 0-5. RESULTS The mean protein C activity was low before OLT (34.3 ± 4.3%) and inversely correlated with the preoperative Model for End-Stage Liver Disease score (Spearmans r = -0.643; P < .0001). Mean activity increased significantly on POD 1 (58.9 ± 4.5%), and remained above preoperative levels through POD 5. Ten patients developed metabolic liver dysfunction defined by a serum total bilirubin >5 mg/dL on POD 7. These patients had significantly lower protein C activity from POD 3 (47.2 ± 9.6% vs 75.9 ± 5.8%; P = .01) to POD 5. Preoperative protein C activity correlated inversely with the severity of liver failure as indicated by preoperative MELD score. CONCLUSION Protein C activity recovered rapidly in patients with good allograft function but remained significantly lower in patients who had limited metabolic function as evidenced by increased total bilirubin levels.

Combined Solid Organ Transplantation Involving the Liver

The number of orthotopic liver transplants performed (OLT) in combination with transplantation of other solid organs has increased [1], and multiple factors have contributed to this. First, the last decade has seen a dramatic improvement in the medical management of patients with cirrhosis. The introduction of beta-blockade to decrease portal hypertension, widespread application of endoscopic modalities to treat esophageal varices, use of TIPS (transjugular intrahepatic portosystemic shunt), and effective medications to control hepatitis B viral replication have increased the life expectancy of patients with cirrhosis. As a result of improved life expectancy, patients with end-stage liver disease at times present with additional organ-system failures. A second contributing factor for increasing combined organ transplantation is the dramatic improvement in the outcomes of single-organ transplantation. The natural progression of these successes in abdominal and thoracic solid organ transplantation is the extension of these techniques to the arena of dual-organ transplantation.

The impact of adult‐to‐adult living donor liver transplantation on transplant center outcomes reporting

The Scientific Registry of Transplant Recipients (SRTR) has released a 5‐tier performance ranking system based upon results of deceased‐donor and living‐donor liver transplantation.

Massive Hepatic Infarction Caused by HELLP Syndrome

A healthy, 30-year-old woman at 32 weeks gestation presented to the emergency department with sudden-onset headache and abdominal pain. On physical exam, she was hypertensive (188/69 mm Hg) and had mild tenderness to palpation in the right upper quadrant. Initial laboratory studies revealed proteinuria, aspartate aminotransferase at 730 U/L, and alanine aminotransferase at 478 U/L. She was diagnosed with severe preeclampsia, and an emergent cesarean section was performed.

Anesthesia for Patients with Concomitant Hepatic and Pulmonary Dysfunction

Hepatic function and pulmonary function are interrelated with failure of one organ system affecting the other. With improved therapies, patients with concomitant hepatic and pulmonary failure increasingly enjoy a good quality of life and life expectancy. Therefore, the prevalence of such patients is increasing with more presenting for both emergent and elective surgical procedures. Hypoxemia requires a thorough evaluation in patients with end-stage liver disease. The most common etiologies respond to appropriate therapy. Portopulmonary hypertension and hepatopulmonary syndrome are associated with increased perioperative morbidity and mortality. It is incumbent on the anesthesiologist to understand the physiology of liver failure and its early effect on pulmonary function to ensure a successful outcome.