Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society
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Editorial Comment Review
Transplantation: impact of pretransplant renal insufficiency.
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Pre-liver transplant renal dysfunction is associated with decreased survival following transplantation and is also a prognostic indicator of posttransplant chronic kidney disease. Selection of patients for combined liver/kidney transplantation versus orthotopic liver transplantation alone (OLTa) is often difficult given the lack of a reliable method to predict which patients will have ongoing severe renal dysfunction in the absence of concomitant kidney transplantation. We hypothesized that most patients with pretransplant renal dysfunction (serum creatinine > or = 1.5 mg/dL for at least 2 weeks prior to and at time of transplant) will not experience a rapid decline in estimated glomerular filtration rates (eGF) post-OLTa to the point of necessitating consideration for kidney transplantation, even in the setting of calcineurin inhibitor-based immunosuppression. ⋯ Patients with pretransplant kidney dysfunction > 12 weeks were at increased risk for eGFR < 20 mL/minute (hazard ratio = 5.3, P = 0.04), a risk that escalated after adjustment for age and serum creatinine at transplant (hazard ratio = 8.9, P = 0.01). Significant predictors of eGFR < 20 mL/minute post-OLTa in this patient cohort were the presence of diabetes and the serum creatinine level at transplant. In conclusion, few patients with preexisting renal dysfunction, especially if <12 weeks duration, experience a significant drop in eGFR post-OLTa.
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Comparative Study
Ischemic cholangiopathy following liver transplantation from donation after cardiac death donors.
The use of donation after cardiac death (DCD) donor hepatic allografts is becoming more widespread; however, there have been published reports of increased graft failure from specific complications associated with this type of allograft. The complication of ischemic cholangiopathy (IC) has been reported to occur more frequently after the use of DCD hepatic allografts. We report the results of 52 liver transplants from DCD donors and the factors that influenced the development of IC. ⋯ Donor weight >100 kg and total ischemia times > or =9 hours, in donors older than 50 years of age, predicted the development of IC in the DCD group. In conclusion, there is a higher incidence of IC in recipients receiving DCD donor livers; however, patient and graft outcomes with DCD donors remain comparable to those with DBD donors. Careful donor selection may improve utilization of these grafts.
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Acute hypotensive transfusion reactions are newly characterized transfusion reactions in which hypotension is the prominent feature. The pathophysiology of acute hypotensive transfusion reactions is related to the bradykinin function and its metabolism. A liver transplant recipient on treatment with an angiotensin converting enzyme inhibitor developed sudden hypotension, that is, systolic pressure of 60 mm Hg, after receiving 200 mL of a blood product mixture without significant surgical blood loss. ⋯ We hypothesized that the patient had an acute hypotensive transfusion reaction due to disordered bradykinin metabolism. Analysis of his blood showed low levels of both angiotensin converting enzyme and aminopeptidase P enzyme activity, confirming that the patient experienced an acute hypotensive transfusion reaction that was due to the use of the angiotensin converting enzyme inhibitor and was precipitated by an abnormality in the metabolic enzyme pathway. It is recommended to discontinue angiotensin converting enzyme inhibitors and switch to a different class of antihypertensive medications for patients with a high Model for End-Stage Liver Disease score on the waiting list for liver transplantation.
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The purpose of this study is to review the clinical experience with sirolimus immunosuppression in liver transplant patients with calcineurin inhibitor-induced chronic renal insufficiency. The study design is a case-control retrospective series. Fifty-seven liver transplant patients with renal insufficiency that were started on sirolimus at greater than 90 days postoperatively and treated for more than 90 days were identified. ⋯ Progression to renal replacement therapy, episodes of acute and chronic rejection, and death were similar between the sirolimus and control groups. The overall prevalence of side effects was significantly higher in the sirolimus group compared with the control group, although these were generally tolerable in most patients. In conclusion, this study suggests that conversion to sirolimus in liver transplant patients with chronic renal insufficiency is associated with stabilization of renal function but confers no additional benefit to low-dose calcineurin inhibitor regimens and may in fact be disadvantageous in patients with a creatinine clearance of less than 30 mL/minute.