Maximilian Jara

Recipient and donor body mass index as important risk factors for delayed kidney graft function.

Background. Obesity is increasingly impacting the overall health status and the global costs for health care. The increase in body mass index (BMI) is also observed in kidney allograft recipients and deceased organ donors. Methods. In a retrospective single-center study, we analyzed 1132 deceased donor kidney grafts, transplanted at our institution between 2000 and 2009 for recipient and donor BMI and its correlation with delayed graft function (DGF). Recipients/donors were classified according to their BMI (<18.5, 18.5–24.9, 25–29.9, and >30 kg/m2). DGF was defined as requirement for one dialysis within the first week after transplantation. Results. Overall DGF rate was 32.4%, mean recipient BMI was 23.64±3.75 kg/m2, and mean donor BMI was 24.69±3.44 kg/m2. DGF rate was 25.2%, 29.8%, 40.9%, and 52.6% in recipients with BMI less than 18.5, 18.5 to 24.9, 25 to 29.9, and more than 30 kg/m2, respectively (P<0.0001). Donor BMI less than 18.5, 18.5 to 24.9, 25 to 29.9, more than 30 kg/m2 resulted in a DGF rate of 22.5%, 31.0%, 37.3%, and 51.2% (P<0.0001). Multivariate analysis revealed recipient BMI and dialysis duration as independent risk factors for DGF. DGF results in inferior 1- and 5-year graft and patient survival. Conclusion. Recipient and donor BMI correlate with the incidence of DGF. Awareness thereof should have an impact on peri- and posttransplant measures in renal transplant recipients.

Reductions in post-hepatectomy liver failure and related mortality after implementation of the LiMAx algorithm in preoperative work-up: a single-centre analysis of 1170 hepatectomies of one or more segments

OBJECTIVES Post-hepatectomy liver failure has a major impact on patient outcome. This study aims to explore the impact of the integration of a novel patient-centred evaluation, the LiMAx algorithm, on perioperative patient outcome after hepatectomy. METHODS Trends in perioperative variables and morbidity and mortality rates in 1170 consecutive patients undergoing elective hepatectomy between January 2006 and December 2011 were analysed retrospectively. Propensity score matching was used to compare the effects on morbidity and mortality of the integration of the LiMAx algorithm into clinical practice. RESULTS Over the study period, the proportion of complex hepatectomies increased from 29.1% in 2006 to 37.7% in 2011 (P = 0.034). Similarly, the proportion of patients with liver cirrhosis selected for hepatic surgery rose from 6.9% in 2006 to 11.3% in 2011 (P = 0.039). Despite these increases, rates of post-hepatectomy liver failure fell from 24.7% in 2006 to 9.0% in 2011 (P < 0.001) and liver failure-related postoperative mortality decreased from 4.0% in 2006 to 0.9% in 2011 (P = 0.014). Propensity score matching was associated with reduced rates of post-hepatectomy liver failure [24.7% (n = 77) versus 11.2% (n = 35); P < 0.001] and related mortality [3.8% (n = 12) versus 1.0% (n = 3); P = 0.035]. CONCLUSIONS Postoperative liver failure and postoperative liver failure-related mortality decreased in patients undergoing hepatectomy following the implementation of the LiMAx algorithm.

Prognostic value of enzymatic liver function for the estimation of short-term survival of liver transplant candidates: a prospective study with the LiMAx test

LiMAx has been recently proposed as a new quantitative liver function test. Thus, we aimed to evaluate the diagnostic ability of LiMAx to assess short‐term survival in liver transplant candidates and compare its performance to the model for end‐stage liver disease (MELD) and indocyanine green plasma disappearance rate (ICG‐PDR). Liver function of 167 chronic liver failure patients without hepatocellular carcinoma was prospectively investigated when they were evaluated for liver transplantation. Primary study endpoints were liver‐related death within 6 months of follow‐up. Within 6 months of follow‐up, 18 patients died and 36 underwent liver transplantation. Median LiMAx results on evaluation day were significantly lower in patients who died (99 μg/kg/h vs. 55 μg/kg/h; P = 0.024), while median ICG‐PDR results did not differ within both groups (4.4%/min vs. 3.5%/min; P = 0.159). LiMAx showed a higher negative predictive value (NPV: 0.93) as compared with ICG‐PDR (NPV: 0.90) and the MELD (NPV: 0.91) in predicting risk of death within 6 months. In conclusion, LiMAx provides good prognostic information of liver transplant candidates. In particular, patients who are not at risk of death can be identified reliably by measuring actual enzymatic liver function capacity.

Bovine Pericardium for Portal Vein Reconstruction in Abdominal Surgery: A Surgical Guide and First Experiences in a Single Center

Background: Resection and reconstruction of infiltrated vessels achieve resectability of extended pancreatic tumors. The aim of the present study was to assess the feasibility of bovine pericardium as graft material for the individualised portal vein reconstruction and demonstrate a surgical technique for abdominal vein repair. Methods: We performed a MEDLINE search to review the methods for complex abdominal vein reconstruction in the course of extended pancreatectomy. Moreover, clinical data of patients receiving portal vein reconstruction using a bovine pericardial patch at our institution were retrospectively analyzed. Results: Based on the results of a review of the literature, autologous venous grafts using the internal jugular vein represent the most popular option for segmental portal vein reconstruction in case of impossible direct suture. At our center, segmental portal vein reconstruction with bovine pericardial patch in course of pancreatic surgery was performed in 4 patients. No case of vascular complications such as occlusion, segmental stenosis or thrombosis occurred. Conclusions: Our experience suggests a surgical procedure for an individual size-matched portal vein reconstruction using bovine pericardium. Although first results appear promising, prospective studies are required to objectively assess the patency of bovine pericardium compared with autologous and synthetic interposition grafts for portal vein reconstruction.

Risk factors of metabolic disorders after liver transplantation: an analysis of data from fasted patients.

Background Metabolic disorders are common complications after orthotopic liver transplantation (OLT) and may lead to increased morbidity and mortality. Methods Fasting glucose and lipid metabolism, and body weight of 81 patients undergoing primary OLT were prospectively analyzed. Patients were investigated preoperatively, on postoperative days 1, 3, 5, 10, 14, 28 as well as 6 months and 1 year after OLT. Data of nonfasted patients were excluded from the analysis. Standardized definitions and classifications for diabetes mellitus (DM), body mass index (BMI), and dyslipidemia were used. Results Prevalence of new-onset diabetes after transplantation was 9.3%, and obesity was its only independent risk factor (odds ratio [OR], 16.5). Preoperative impaired glucose homeostasis (OR, 10.8) and initial poor graft function (OR, 6.89) were independent risk factors for postoperative DM. Maximum prevalence of hypertriglyceridemia and hypercholesterolemia was found on postoperative day 10 and 6 months post-OLT, respectively. Risk factors for hypercholesterolemia at 1 year were patient age (OR, 1.17) and postoperative renal dysfunction (OR, 16.33). Higher preoperative BMI was a risk factor for postoperative hypertriglyceridemia (OR, 1.17). Overall body weight and BMI significantly decreased over 1 year (P < 0.05). Prevalence of obesity was 22.2% before and 20.9% after OLT. Conclusion For the first time, initial poor graft function was identified as a risk factor for post-OLT DM. By ruling out any exogenous factors influencing metabolism, we believe we were able to show the true prevalence of metabolic disorders and therefore provided a valuable contribution to the identification of potential risk factors.

Noninvasive diagnosis of chemotherapy induced liver injury by LiMAx test – two case reports and a review of the literature

BackgroundChemotherapy-induced liver injury is a well-known phenomenon after neoadjuvant therapy of liver metastasis and contributes to postoperative morbidity and mortality. Still there is no suitable test available to reliably determine functional impairment and hepatic regeneration after chemotherapy.Case presentationWe report two cases of caucasian patients who underwent repeated liver function assessments using LiMAx (maximum liver function capacity), Indocyanine plasma disappearance rate and biochemical liver function parameters in the course of adjuvant oxaliplatin-based chemotherapy.Both patients yielded a decrease from their initial liver function determined by LiMAx. Liver regeneration assessed functional recovery within 4 weeks in case of mild functional impairment after cessation of chemotherapy or within 8 weeks in case of major functional deterioration. Indocyanine plasma disappearance rate and biochemical parameters remained stable or without a clear trend in case of minor functional impairment. This is the first report using a dynamic liver function test to evaluate the impact and recovery from chemotherapy associated liver injury.ConclusionsThe LiMAx test might be a sensitive tool to diagnose mild functional impairment after chemotherapy when standard liver function tests have remained within normal ranges and might be capable to assess the course of regeneration after chemotherapy. This could be useful to optimize individual chemotherapy-free interval before liver surgery can be carried out safely.

Predictors of quality of life in patients evaluated for liver transplantation

Health‐related quality of life (HRQOL) is severely impaired in advanced liver disease. The purpose of this study was to evaluate the impact of actual liver function and disease‐specific factors on HRQOL of patients evaluated for liver transplantation.

Factors influencing hypertrophy of the left lateral liver lobe after portal vein embolization

PurposePortal vein embolization (PVE) before extended right hepatectomy leads to an increase of the future liver remnant (FLR) volume, but predictive factors for sufficient hypertrophy are still unclear. The purpose of this study was to investigate parameters influencing the growth of FLR.MethodsPatients undergoing PVE prior hepatic resection were evaluated. PVE was done using polyvinyl alcohol particles only. Volumetric analysis was performed before embolization and before hepatectomy. Success of PVE was determined as percental growth of the future liver remnant.ResultsSeventy-seven patients were included, and three cohorts were formed according to the hypertrophy of FLR. FLR increased from 448.2 ± 187 to 475.5 ± 191 in the poor, from 315.3 ± 86 to 469.1 ± 142 in the moderate, and from 283.4 ± 68 to 400.4 ± 110 in the good hypertrophy group. More cases of recanalization of the portal vein were observed in patients with poor hypertrophy (p = 0.016). Small FLR before PVE predict higher growth of the FLR (p = 0.006). Duration between PVE and surgery differed significantly: 22 (poor) vs. 32 (good) days (p = 0.040).DiscussionNo recanalization, small initial FLR and longer time were assessed with better FLR hypertrophy. More sufficient PVE techniques and postponed hepatectomy might improve the outcome. Small initial FLR should not be a disclosure for curative hepatectomy.

Der LiMAx-Test: ein neuer diagnostischer Test zur Messung der aktuellen Leberfunktionskapazität

Hintergrund ▼ Fortschritte in der chirurgischen, anästhesiologischen und intensivmedizinischen Behandlung konnten die perioperative Morbidität und Mortalität nach großen Leberteilresektionen innerhalb der letzten Jahrzehnte erheblich reduzieren. Trotzdem beträgt die Rate an postoperativer Leberinsuffizienz mit entsprechend hoher Mortalität nach großen Resektionen je nach Definitionen und Literatur bis zu 32 % [8]. Hauptindikation für Leberteilresektionen sind maligne Tumore sekundären sowie primären Ursprungs. So ist das hepatozelluläre Karzinom die häufigste zum Tod führende Erkrankung bei Patienten mit Leberzirrhose in Europa [24]. Besonders bei ausgedehnten radikal onkologischen Resektionen ist die Einschätzung der verbleibenden Leberfunktion zur Minimierung des perioperativen Risikos bedeutend. Während bei einer gesunden Leber Resektionen von bis zu 80 % möglich sind, besteht bei vorgeschädigter Leber (Zirrhose, Hepatitis, Steatosis, Cholestase, Chemotherapie) selbst nach kleinen Leberteilresektionen das Risiko für eine bedrohliche Leberinsuffizienz [25].

Liver Transplantation and Liver Resection for Cirrhotic Patients with Hepatocellular Carcinoma: Comparison of Long-Term Survivals

BackgroundBoth liver transplantation (LT) and liver resection (LR) represent curative treatment options for hepatocellular carcinoma (HCC) in patients with liver cirrhosis. In this study, we have compared outcomes between historical and more recent patient cohorts scheduled either for LT or LR, respectively.MethodsClinicopathological data of all patients with HCC and cirrhosis who underwent LT or LR between 1989 and 2011 were evaluated. Overall survival of patients with HCC within the Milan criteria (MC) was analyzed focusing on changes between different time periods.ResultsIn total, 364 and 141 patients underwent LT and LR for HCC in cirrhosis, respectively. Among patients with HCC within MC, 214 and 59 underwent LT and LR, respectively. Postoperative morbidity (37 vs. 11%, P < .0001), but not mortality (3 vs. 1%, P = .165), was higher after LR than after LT for HCC within MC. In the period 1989–2004, overall survival (OS) was significantly higher in patients who underwent LT compared to LR for HCC within MC (5-year OS: 77 vs. 36%, P < .0001). Interestingly, in the more recent period 2005–2011, OS was comparable between LT and LR for HCC within MC (5-year OS: 73 vs. 61%, P = .07).ConclusionWe have noted an improvement of outcomes among patients selected for partial hepatectomy in recent years that were comparable to stable results after LT in cirrhotic patients with HCC. Whether those improvements are due to advances in liver surgery, optimized perioperative managament for patients with liver cirrhosis, and the development of modern multimodal treatment strategies for the recurrent lesions appears plausible.