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BACKGROUND Acute kidney injury (AKI) after liver transplantation is associated with increased morbidity and mortality. It remains controversial whether the choice of vena cava reconstruction technique impacts AKI. METHODS This is a single-center retrospective cohort of 897 liver transplants performed between June 2009 and September 2018 using either the vena cava preserving piggyback technique or caval replacement technique without veno-venous bypass or shunts. The association between vena cava reconstruction technique and stage of postoperative AKI was assessed using multivariable ordinal logistic regression. Causal mediation analysis was used to evaluate warm ischemia time as a potential mediator of this association. RESULTS The incidence of AKI (AKI stage ≥2) within 48 h after transplant was lower in the piggyback group (40.3%) compared to the caval replacement group (51.8%, P < 0.001). Piggyback technique was associated with a reduced risk of developing a higher stage of postoperative AKI (odds ratio, 0.49; 95% confidence interval, 0.37-0.65, P < 0.001). Warm ischemia time was shorter in the piggyback group and identified as potential mediator of this effect. There was no difference in renal function (estimated glomerular filtration rate and the number of patients alive without dialysis) 1 y after transplant. CONCLUSIONS Piggyback technique, compared with caval replacement, was associated with a reduced incidence of AKI after liver transplantation. There was no difference in long-term renal outcomes between the 2 groups.

Author(s): Syed, Shareef M; Gardner, James; Roll, Garrett; Webber, Allison; Mehta, Neil; Shoji, Jun; Adelmann, Dieter; Niemann, Claus; Braun, Hillary J; Mello, Anna; Yao, Francis; Posselt, Andrew; Kang, Sang-Mo; Hirose, Ryutaro; Roberts, John; Feng, Sandy; Ascher, Nancy; Stock, Peter; Freise, Chris | Abstract: BackgroundThe novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) disease has transformed innumerable aspects of medical practice, particularly in the field of transplantation.Main bodyHere we describe a single-center approach to creating a generalizable, comprehensive, and graduated set of recommendations to respond in stepwise fashion to the challenges posed by these conditions, and the underlying principles guiding such decisions.ConclusionsCreation of a stepwise plan will allow transplant centers to respond in a dynamic fashion to the ongoing challenges posed by the COVID-19 pandemic.

Acute kidney injury (AKI) after liver transplantation is associated with increased morbidity and mortality. It remains controversial whether the choice of vena cava reconstruction technique impacts AKI.This is a single-center retrospective cohort of 897 liver transplants performed between June 2009 and September 2018 using either the vena cava preserving piggyback technique or caval replacement technique without veno-venous bypass or shunts. The association between vena cava reconstruction technique and stage of postoperative AKI was assessed using multivariable ordinal logistic regression. Causal mediation analysis was used to evaluate warm ischemia time as a potential mediator of this association.The incidence of AKI (AKI stage ≥2) within 48 h after transplant was lower in the piggyback group (40.3%) compared to the caval replacement group (51.8%, P0.001). Piggyback technique was associated with a reduced risk of developing a higher stage of postoperative AKI (odds ratio, 0.49; 95% confidence interval, 0.37-0.65, P0.001). Warm ischemia time was shorter in the piggyback group and identified as potential mediator of this effect. There was no difference in renal function (estimated glomerular filtration rate and the number of patients alive without dialysis) 1 y after transplant.Piggyback technique, compared with caval replacement, was associated with a reduced incidence of AKI after liver transplantation. There was no difference in long-term renal outcomes between the 2 groups.

In liver transplantation, both cold and warm ischemia times are known to impact early graft function. The extraction time is a period during the initial phase of organ cooling which occurs during deceased donor procurement. During this time, the organ is at risk of suboptimal cooling. Whether donor extraction time, the time from donor aortic cross-clamp to removal of the donor organ from the body cavity has an effect on early graft function is not known.We investigated the effect of donor extraction time on early graft function in 292 recipients of liver grafts procured locally and transplanted at our center between June 2012 and December 2016. Early graft function was assessed using the model of early allograft function score in a multivariable regression model including donor extraction time, cold ischemia time, warm ischemia time, donor risk index, and terminal donor sodium.Donor extraction time had an independent effect on early graft function measured by the model of early allograft function score (coefficient, 0.021; 95% confidence interval, 0.007-0.035; P0.01; for each minute increase of donor extraction time). Besides donor extraction time, cold ischemia time, warm ischemia time, and donor risk index had a significant effect on early graft function.We demonstrate an independent effect of donor extraction time on graft function after liver transplantation. Efforts to minimize donor extraction time could improve early graft function in liver transplantation.

Background Renal failure is common among patients undergoing liver transplantation. Liver allocation based on the model for end-stage liver disease score has increased the number of recipients who require perioperative renal replacement therapy (RRT). Although RRT can be continued intraoperatively, the risks and benefits of intraoperative RRT are not well defined. The aim of this study is to report the intraoperative management of patients with pretransplant renal failure at a transplant center with extremely infrequent utilization of intraoperative RRT. Materials and methods We performed a retrospective analysis of all adult patients undergoing orthotopic liver or simultaneous liver-kidney (SLK) transplantation between June 2009 and December 2015. Patients were divided into 2 groups based on their need for pretransplant RRT. Results A total of 785 patients underwent liver or SLK transplant during the study period. One hundred and seventy-four patients (22.2%) required preoperative dialysis. Only 2 patients required intraoperative RRT. There was no difference in the incidence of acidosis or hyperkalemia between patients who required preoperative dialysis and those who did not. Conclusions We describe the successful management of patients undergoing liver or SLK transplantation almost entirely without the need for intraoperative RRT.

In a recent trial, targeted mild hypothermia in brain-dead organ donors significantly reduced the incidence of delayed graft function after kidney transplantation. This trial was stopped early for efficacy. Here, we report long-term graft survival for all organs along with donor critical care end points.We assessed graft survival through 1 year of all solid organs transplanted from 370 donors who had been randomly assigned to hypothermia (34-35°C) or normothermia (36.5-37.5°C) before donation. Additionally, changes in standardized critical care end points were compared between donors in each group.Mild hypothermia was associated with a nonsignificant improvement in 1-year kidney transplant survival (95% versus 92%; hazard ratio, 0.61 [0.31-1.20]; P = 0.15). Mild hypothermia was associated with higher 1-year graft survival in the subgroup of standard criteria donors (97% versus 93%; hazard ratio, 0.39 [0.15 to -1.00]; P = 0.05). There were no significant differences in graft survival of extrarenal organs. There were no differences in critical care end points between groups.Mild hypothermia in the donor safely reduced the rate of delayed graft function in kidney transplant recipients without adversely affecting donor physiology or extrarenal graft survival. Kidneys from standard criteria donors who received targeted mild hypothermia had improved 1-year graft survival.

In this case report we describe the blood metabolic profile ("metabolomics") by nuclear magnetic resonance (NMR) spectroscopy and principle component analysis (PCA) from a patient who underwent two consecutive liver transplantations. The first graft from a living-related donor failed and was followed by a second successful transplant from a deceased donor. Using quantitative high-resolution 1 H-NMR spectroscopy, 48 endogenous metabolites were analyzed in whole blood samples at baseline and different time points after each transplantation. From 48 analyzed metabolites, six metabolites were identified by PCA as metabolic markers consistent with a non-functional liver after first transplantation. Importantly, this distinctive metabolic profile was present as early as two hours after first transplant surgery when no other variable or conventional laboratory tests indicated poor graft function. This article reports the potential usefulness of quantitative 1 H-NMR based metabolomics to diagnose early graft dysfunction in liver transplantation.

BACKGROUND Sirolimus (SRL) seems to impair renal recovery from ischemic injury in animal models and delayed graft function after clinical renal transplantation. This study determined the impact of SRL on renal recovery after ischemia-reperfusion injury in a rat kidney transplant model. METHODS Syngeneic kidneys were preserved in University of Wisconsin solution before transplantation into bilaterally nephrectomized rats. Recipients received vehicle or SRL targeting for whole-blood trough levels of 10 to 20 ng/mL as measured by high-performance liquid chromatography. Renal function was assessed by animal survival or daily serum creatinine. Tissue samples were collected for histologic examination. RESULTS Median SRL whole-blood concentrations were 16.6 +/- 1.6 ng/mL on postoperative day (POD) 1 and 12.0 +/- 0.9 ng/mL on POD 3. Transplantation of kidneys after 39 hr of cold storage resulted in 30% survival in the SRL-treated group compared with 100% survival in the control group (P=0.002). Transplantation of kidneys after 24 hr of cold storage resulted in no survival differences, but there were significant differences in renal function. Daily serum creatinine (PODs 1-4) was higher in the SRL-treated group compared with the control group (P