Liver transplantation in patients with acute liver failure - Criteria and results

Objective. Evaluation of the results of emergency liver transplantation in patients with acute liver failure. Design. Analysis of 25 patients with acute liver failure. Setting. University Hospital Rotterdam Dijkzigt. Method. Twenty-five patients with acute liver failure were admitted to the Intensive Care Unit in January 1989-May 1993. Patients were selected for emergency liver transplantation according to the Clichy criteria (presence of confusion or coma and factor V activity less than 20-30%). Results. Liver transplantation was indicated in 17 patients and performed in 13. The 1-year survival rate in patients with a liver transplant was 85%. Four patients with an indication for liver transplantation, but who could not be transplanted died. All 8 patients without an indication for emergency liver transplantation survived. Conclusion. Survival after liver transplantation for acute hepatic failure is now about 80%; the Clichy criteria appear to be helpful in selecting patients with acute hepatic failure for liver transplantation.</p

Liver transplantation in patients with acute liver failure - Criteria and results

Objective. Evaluation of the results of emergency liver transplantation in patients with acute liver failure. Design. Analysis of 25 patients with acute liver failure. Setting. University Hospital Rotterdam Dijkzigt. Method. Twenty-five patients with acute liver failure were admitted to the Intensive Care Unit in January 1989-May 1993. Patients were selected for emergency liver transplantation according to the Clichy criteria (presence of confusion or coma and factor V activity less than 20-30%). Results. Liver transplantation was indicated in 17 patients and performed in 13. The 1-year survival rate in patients with a liver transplant was 85%. Four patients with an indication for liver transplantation, but who could not be transplanted died. All 8 patients without an indication for emergency liver transplantation survived. Conclusion. Survival after liver transplantation for acute hepatic failure is now about 80%; the Clichy criteria appear to be helpful in selecting patients with acute hepatic failure for liver transplantation.</p

Aprotinin in orthotopic liver transplantation: Evidence for a prohemostatic, but not a prothrombotic, effect

Aprotinin reduces blood transfusion requirements in orthotopic liver transplantation (OLT). Concern has been voiced about the potential risk for thrombotic complications when aprotinin is used. The aim of this study is to evaluate the effects of aprotinin on the two components of the hemostatic system (coagulation and fibrinolysis) in patients undergoing OLT. As part of a larger, randomized, double-blind, placebo-controlled study, we compared coagulation (fibrinogen level, activated partial thromboplastin time [aPTT], prothrombin time, and platelet count) and fibrinolytic variables (tissue-type plasminogen activator [tPA] antigen and activity, plasminogen activator inhibitor activity, and D-dimer), as well as thromboelastography (reaction time [r], clot formation time, and maximum amplitude) in 27 patients administered either high-dose aprotinin (2 ! 106 kallikrein inhibitor units [KIU] at induction, continuous infusion of 1 ! 106 KIU/h, and 1 ! 106 KIU before reperfusion; n " 10), regular-dose aprotinin (2 ! 106 KIU at induction and continuous infusion of 0.5 ! 106 KIU/h; n " 8), or placebo (n " 9) during OLT. Blood samples were drawn at seven standardized intraoperative times. Baseline characteristics were similar for the three groups. During the anhepatic and postreperfusion periods, fibrinolytic activity (plasma D-dimer and tPA antigen levels) was significantly lower in aprotinin-treated patients compared with the placebo group. Interestingly, coagulation times (aPTT and r) were significantly more prolonged in aprotinintreated patients than the placebo group. No difference was seen in the incidence of perioperative thrombotic complications in the entire study population (n " 137). Aprotinin has an anticoagulant rather than a procoagulant effect. Its blood-sparing (prohemostatic) effect appears to be the overall result of a strong antifibrinolytic and a weaker anticoagulant effect. These findings argue against a prothrombotic effect of aprotinin in patients undergoing OLT. (Liver Transpl 2001;7:896-903.

Improved early graft survival in patients receiving aprotinin during orthotopic liver transplantation

REPERFUSION injury contributes to hepatic dysfunc- tion and may play a role in the initiation of acute and chronic rejection after orthotopic liver transplantation (OLT). Injury that occurs during reperfusion has been described as an injury of the sinusoidal endothelial cells (SEC). Proteolytic enzymes, such as cysteine- and serine- proteases and matrix metalloproteinases, have been shown to play a role in this process.1 Aprotinin is an inhibitor of serine-proteases and has wide-acting, antiproteolytic prop- erties. In the European Multicenter Study on the Use of Aprotinin in Liver Transplantation (EMSALT) we recently showed that aprotinin significantly reduces hyperfibrinoly- sis, thereby reducing blood loss and transfusion require- ments during OLT by 50% and 30%, respectively.2 Besides its blood-sparing effect it has been suggested that aprotinin ameliorates reperfusion injury. Based on these properties, we studied early graft function after OLT in patients who received aprotinin or placebo during transplantation

Intravascular coagulation in liver transplantation - is it present or not?: A comparison between orthotopic and heterotopic liver transplantation

It is still not clear whether disseminated intravascular coagulation (DIC) contributes to the hemostatic disturbances in orthotopic liver transplantation (OLT). Theoretically the lack of hepatic clearance of procoagulant factors during the anhepatic period and the release of thromboplastic material from the graft might trigger DIC. During heterotopic liver transplantation (HLT) the host liver is left in situ and procoagulant factors may still be cleared; DIC, if present, may not occur until after reperfusion. The aim of the present study was to gain more insight into the underlying mechanism of the coagulation changes during liver transplantation by comparison of OLT and HLT. Thrombin-antithrombin-III complexes (TAT), and indicator of thrombin generation, fibrin degradation products (FbDP) and routine clotting times were assayed in 12 OLTs, 18 HLTs and in a control group of 10 partial hepatic resections (PHR). TAT increased dramatically after reperfusion to 136 μg/l in OLT and to 94 μg/l in HLT (p n.s.). In contrast, FbDP levels increased only in OLT, to a maximum of 13.8 μg/ml. Routine clotting times changed mildly and similarly in both OLT and HLT. Conclusions: Graft reperfusion triggers excessive thrombin formation, but there are no other signs of subsequent DIC. Any thrombin formed is probably rapidly inhibited by antithrombin-III. The rise in FbDP during OLT is the result of increased fibrinolysis, which occurred only in OLT and not in HLT.</p

Intravascular coagulation in liver transplantation - is it present or not?: A comparison between orthotopic and heterotopic liver transplantation

It is still not clear whether disseminated intravascular coagulation (DIC) contributes to the hemostatic disturbances in orthotopic liver transplantation (OLT). Theoretically the lack of hepatic clearance of procoagulant factors during the anhepatic period and the release of thromboplastic material from the graft might trigger DIC. During heterotopic liver transplantation (HLT) the host liver is left in situ and procoagulant factors may still be cleared; DIC, if present, may not occur until after reperfusion. The aim of the present study was to gain more insight into the underlying mechanism of the coagulation changes during liver transplantation by comparison of OLT and HLT. Thrombin-antithrombin-III complexes (TAT), and indicator of thrombin generation, fibrin degradation products (FbDP) and routine clotting times were assayed in 12 OLTs, 18 HLTs and in a control group of 10 partial hepatic resections (PHR). TAT increased dramatically after reperfusion to 136 μg/l in OLT and to 94 μg/l in HLT (p n.s.). In contrast, FbDP levels increased only in OLT, to a maximum of 13.8 μg/ml. Routine clotting times changed mildly and similarly in both OLT and HLT. Conclusions: Graft reperfusion triggers excessive thrombin formation, but there are no other signs of subsequent DIC. Any thrombin formed is probably rapidly inhibited by antithrombin-III. The rise in FbDP during OLT is the result of increased fibrinolysis, which occurred only in OLT and not in HLT.</p