Evaluation of the effects of n-acetylcysteine treatment in adult liver transplant recipients

Background: N-acetylcysteine (NAC) has been used in post-orthotopic liver transplant (OLT) patients for the proposed mechanism of preventing tissue damage of the newly transplanted organ from reactive oxygen species. This in turn may reduce cytokines and inflammation making oxygen delivery to the newly transplanted organ easier, which can lead to decreased reperfusion injury. Objective: To evaluate the efficacy and safety of NAC use in patients post-OLT. Graft survival was examined as the primary outcome with post-operative bleeding requiring an exploratory laparotomy, biliary complications, and length of hospitalization. Methods: The study is a retrospective review of the impact of NAC on solitary livers transplanted between January 2010 and June 2014. Student\u27s t-test was used to compare continuous variables and Chi-Square test was used to compare categorical variables. Kaplan-Meier Method and Cox Proportional Hazards model were used to analyze outcomes post-OLT. Results:118 solitary livers were included with 50 (42%) receiving NAC post-OLT and 68 (58%) not receiving NAC. Those who received NAC had similar MELD at transplant, weight, age, and gender compared to those who did not. The average length of hospitalization post-OLT in the NAC group was 19.5 +/- 26.4 days vs. 14.1 +/- 11.0 days in the no NAC group (p=0.13.) Post-operative bleeding was similar between groups. A higher percent of those who received NAC had a DCD organ (32% vs. 15%, p=0.02). NAC patients had higher initial post-OLT AST and ALT compared to those who did not receive NAC (2604 +/- 1761 vs. 1192 +/- 1026, p Conclusion: Further examination of association between biliary outcomes and NAC in a multivariable model also did not reach statistical significance. This could be due to our limited sample size, or overshadowed by more important variables like year of transplant or donor status. These results support the further need for research to fully understand the role of NAC use in post-operative liver transplant patients

En bloc Liver kidney transplantation using donor splenic artery as inflow to the kidney. Report of two cases

The number of simultaneous liver kidney transplant has been increasing. This surgery is associated with an increased risk of complications, longer duration of surgery and longer ischemia time to the renal allograft. Two patients listed for liver-kidney transplant at our center underwent en bloc combined liver kidney transplantation using donor splenic artery as inflow. Patient 1 previously underwent cardiac catheterization which was complicated by a bleeding pseudo-aneurysm of the right external iliac artery, which required endovascular stenting of the external iliac artery and embolization of the inferior epigastric artery. Patient 2 was on vasopressor support and continuous renal replacement therapy at the time of transplant. We describe a novel technique of en bloc liver-kidney transplant with simultaneous reperfusion of both allografts using the donor splenic artery for renal inflow. This technique is useful in decreasing cold ischemia time and total operative time by simultaneous reperfusion of both allografts. It is a useful technical variant which can be used in patients with severe disease of the iliac arteries. This article is protected by copyright. All rights reserved

Recurrent liver failure caused by IgG4 associated cholangitis

Immunoglobulin G4 associated cholangitis (IAC) is an autoimmune disease associated with autoimmune pancreatitis (AIP). It presents with clinical and radiographic findings similar to primary sclerosing cholangitis (PSC). IAC commonly has a faster, more progressive onset of symptoms and it is more common to see obstructive jaundice in IAC patients compared to those with PSC. One of the hallmarks of IAC is its responsiveness to steroid therapy. Current recommendations for treatment of AIP demonstrate excellent remission of the disease and associated symptoms with initiation of steroid therapy followed by steroid tapering. If untreated, it can progress to irreversible liver failure. This report describes a 59 year-old female with un-diagnosed IAC who previously had undergone a pancreaticoduodenectomy for a suspected pancreatic cancer and later developed liver failure from presumed PSC. The patient underwent an uncomplicated liver transplantation at our institution, but experienced allograft failure within five years due to progressive and irreversible bile duct injury. Radiology and histology suggested recurrence of PSC, but the diagnosis of IAC was suspected based on her past history and confirmed when IgG4 positive cells were found within the intrahepatic bile duct walls on a liver biopsy. A successful liver retransplantation was performed and the patient is currently on triple immunosuppressive therapy. Our experience in this case and review of the current literature regarding IAC management suggest that patients with suspected or recurrent PSC with atypical features including history of pancreatitis should undergo testing for IAC as this entity is highly responsive to steroid therapy

Evaluation of Preoperative Anemia and Transfusion Requirements in Adult Liver Transplant Recipients

Conclusion: Lower preoperative hemoglobin was associated with increased preoperative and intraoperative transfusion requirements as well as increased postoperative infection. More preoperative cryoprecipitate units, fewer postoperative cryoprecipitate units, and more FFP units were independent predictors of infection