Modeling hepatitis C virus kinetics during liver transplantation reveals the role of the liver in virus clearance

While the liver, specifically hepatocytes, are widely accepted as the main source of hepatitis C virus (HCV) production, the role of the liver/hepatocytes in clearance of circulating HCV remains unknown. Frequent HCV kinetic data were recorded and mathematically modeled from 5 liver-transplant patients throughout the anhepatic (absence of liver) phase and for 4 hours post-reperfusion. During the anhepatic phase, HCV remained at pre-anhepatic levels (n=3) or declined (n=2) with t1/2~1h. Immediately post-reperfusion, virus declined in a biphasic manner in 4 patients consisting of a rapid decline (t1/2=5min) followed by a slower decline (t1/2=67min). Consistent with the majority of patients in the anhepatic phase, when we monitored HCV clearance at 37°C from culture medium in the absence/presence of chronically infected hepatoma cells that were inhibited from secreting HCV, the HCV t1/2 in cell culture was longer in the absence of chronically HCV-infected cells. The results suggest that the liver plays a major role in the clearance of circulating HCV and that hepatocytes may be involved.

Tachycardia-polyuria syndrome after swan-ganz catheterization in liver transplant patient - A case report -

Background: Tachycardia-polyuria syndrome is characterized by polyuria occurring because of tachycardia with a heart rate of ≥ 120 beats/min lasting ≥ 30 min. We report such a case occurring after swan-ganz catheterization.Case: A 41-year-old male was scheduled for living-donor liver transplantation. After general anesthesia, atrial fibrillation occurred during swan-ganz catheterization, and polyuria developed 1 h later. During the anhepatic phase, the patient’s heart rate increased further, and cardioversion was performed. After a normal sinus rhythm was achieved, the patient’s urine output returned to normal.Conclusions: The patient’s polyuria seemed related to the iatrogenic atrial fibrillation occurring during swan-ganz catheterization. Although we did not measure atrial natriuretic peptide, an increase in its concentration may have been the main mechanism of polyuria, as natriuresis was observed.

Successful resuscitation after hyperkalemic cardiac arrest during liver transplantation by converting veno-venous bypass to veno-arterial ECMO

Introduction: Intraoperative cardiac arrest (ICA) is a feared complication during liver transplantation (LTx), typically occurring during reperfusion. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been used for post-reperfusion cardiac arrest. Case report: We present a case of successful resuscitation after hyperkalemic ICA during the pre-anhepatic phase of a second liver transplantation by converting veno-venous bypass (VVB) to VA-ECMO. Discussion: While this technique has been recommended for ICA during reperfusion, it has never been reported during the pre-anhepatic phase. VA-ECMO can be a lifesaving extension to cardiopulmonary resuscitation for ICA during LTx with beneficial neurological outcome by providing perfusion while the cause of ICA is reversed. Conclusion: Conversion of VVB to VA-ECMO should be considered in all patients who suffer from ICA during LTx with use of VVB. With VVB installed, conversion to VA-ECMO is fast and effective. If VVB is not used, early VA-ECMO should be considered for ICA.

Intraoperative Hepatic Blood Inflow Can Predict Early Acute Kidney Injury following DCD Liver Transplantation: A Retrospective Observational Study

Purpose. Acute kidney injury (AKI) is a major and severe complication following donation-after-circulatory-death (DCD) liver transplantation (LT) and is associated with increased postoperative morbidity and mortality. However, the risk factors and the prognosis factors of AKI still need to be further explored, and the relativity of intraoperative hepatic blood inflow (HBI) and AKI following LT has not been discussed yet. The purpose of this study was to investigate the correlation between HBI and AKI and to construct a prediction model of early acute kidney injury (EAKI) following DCD LT with the combination of HBI and other clinical parameters. Methods. Clinical data of 132 patients who underwent DCD liver transplantation at the first hospital of China Medical University from April 2005 to March 2017 were analyzed. Data of 105 patients (the first ten years of patients) were used to develop the prediction model. Then we assessed the clinical usefulness of the prediction models in the validation cohort (27 patients). EAKI according to Kidney Disease Improving Global Outcomes (KDIGO) criteria based on serum creatinine increase during 7-day of postoperative follow-up. Results. After Least Absolute Shrinkage and Selection Operator (LASSO) regression and simplification, a simplified prediction model consisting of the Child-Turcotte-Pugh (CTP) score (p=0.033), anhepatic phase (p=0.014), packed red blood cell (pRBC) transfusion (p=0.027), and the HBI indexed by height (HBI/h) (p=0.002) was established. The C-indexes of the model in the development and validation cohort were 0.823 [95% CI, 0.738-0.908] and 0.921 [95% CI, 0.816-1.000], respectively. Conclusions. In this study, we demonstrated the utility of HBI/h as a predictor for EAKI following DCD LT, as well as the clinical usefulness of the prediction model through the combination of the CTP score, anhepatic phase, pRBC transfusion and HBI/h.

Blood pressure monitoring during liver transplantation: the method of measurement does matter

Introduction. Accurate blood pressure (BP) measurements are the mainstay for the efficient management of abrupt changes of hemodynamics and perfusion during orthotopic liver transplantation (OLT).Material and methods. The prospective study included 39 patients. We compared the BP values measured in the femoral and radial arteries during the different phases of the OLT.Results. The central systolic arterial pressure (SAP) and mean arterial pressure (MAP) measured invasive in the femoral artery were significantly higher than those measured in the peripheral artery during the anhepatic phase (95.1±10.6 vs. 84.5±9.9 mm Hg, and 66±8.8 vs. 59.7±7.1 mm Hg, respectively), after 5 minutes of reperfusion (91.1±17.3 vs. 78.5±18.4 mm Hg, and 63.9±13.1 vs. 57.7±13.6 mm Hg, respectively), and after 15 minutes of reperfusion (102.2±16.8 vs. 88.1±14.4 mm Hg, and 67.7±10.7 vs. 62.5±10.4 mm Hg, respectively). We found a strong correlation between the differences of SAP and MAP and the dose of norepinephrine administered during the anhepatic phase (r=0.76 and r=0.77 for SAP and MAP, respectively), and after 5 minutes of reperfusion (r=0.71 and r=0.52 for SAP and MAP, respectively). The difference between central and peripheral BPs after 15 minutes of reperfusion mainly depended on the changes in the potassium concentration (r=0.55 for SAP and MAP) and base deficiency (r=0.73 and r=0.82 for SAP and MAP, respectively).Conclusion. Thus, it was proved that the invasive measurement of BP in the femoral artery is a more accurate method compared with that in the radial artery as it is less exposed to high doses of vasopressors and variations in the acid-base state during OLT.

The efficiency of low-dose Hepatitis B Immunoglobulin plus nucleos(t)ide analogs in preventing post-transplant HBV recurrence

Background/aim: In this study, the efficiency of using low-dose HBIG plus antiviral treatment according to individual needs have been evaluated in post-transplant HBV patients. Material and methods: We retrospectively evaluated 179 patients who admitted between 2009-2014. Five thousand IU IV HBIG was given in anhepatic phase, and 400 IU/day IM HBIG was given in the post-transplant period. After HBsAg seroconversion 400 IU IM HBIG every two weeks as prophylaxis was continued. Results: Average follow-up period was 26 (2-65) months. Seventy patients had hepatocellular carcinoma (HCC). The HBV recurrence was 4.5% in the 1st year, and 5.8% in the 3rd year. The HBsAg became negative in 11 (2-63) days, and anti-HBs became positive in 9 (1-31) days. HBsAg positivity occurred in 6 patients during the follow-up period. Five of these patients were those who were transplanted due to HCC. In 5 of the HCC patients whose HBsAg became positive, tumor recurrence was observed after 0.3-9.9 months. HBsAg positivity was more frequently detected in patients with HCC (p=0.009). Conclusion: The HBV recurrence should be evaluated as a predictor of HCC recurrence in patients who were transplanted due to HCC.