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BACKGROUND AND AIMS Despite frequent cirrhotic cardiomyopathy or subclinical heart failure (HF), the prognostic value of peri-liver transplant (LT) B-type natriuretic peptide (BNP) has been poorly studied in advanced liver disease. We examined the association between BNP and mortality in a large cohort of LT patients and identified risk factors for peri-LT BNP increase. APPROACH AND RESULTS Using prospectively collected data from the Asan LT Registry between 2008 and 2019, 3,811 patients who measured serial pretransplant BNP (preBNP) and peak BNP levels within the first 3 posttransplant days (postBNPPOD3 ) were analyzed. Thirty-day all-cause mortality predicted by adding preBNP and/or postBNPPOD3 to the traditional Revised Cardiac Risk Index (RCRI) was evaluated. PreBNP > 400 pg/mL (known cutoff of acute HF) was found in 298 (7.8%); however, postBNPPOD3 > 400 pg/mL was identified in 961 (25.2%) patients, specifically in 40.4% (531/1,315) of those with a Model for End-Liver Disease score (MELDs) > 20. Strong predictors of postBNPPOD3 > 400 pg/mL were preBNP, hyponatremia, and MELDs, whereas those of preBNP > 400 pg/mL were MELDs, kidney failure, and respiratory failure. Among 100 (2.6%) post-LT patients who died within 30 days, patients with postBNPPOD3 ≤ 150 pg/mL (43.1%, reference group), 150-400 pg/mL (31.7%), 400-1,000 pg/mL (18.5%), 1,000-2,000 pg/mL (4.7%), and >2,000 pg/mL (2.0%) had 30-day mortalities of 0.9%, 2.2%, 4.0%, 7.7%, and 22.4%, respectively. Adding preBNP, postBNPPOD3 , and both BNP to RCRI improved net reclassification index to 22.5%, 29.5%, and 33.1% of 30-day mortality, respectively. CONCLUSIONS PostBNPPOD3 > 400 pg/mL after LT was markedly prevalent in advanced liver disease and mainly linked to elevated preBNP. Routine monitoring of peri-LT BNP provides incremental prognostic information; therefore, it could help risk stratification for mortality as a practical and useful biomarker in LT.

Background: Given the severe shortage of donor liver grafts, coupled with growing proportion of cardiovascular death after liver transplantation (LT), precise cardiovascular risk assessment is pivotal for selecting recipients who gain the greatest survival benefit from LT surgery. We aimed to determine the prognostic value of pre-LT combined measurement of B-type natriuretic peptide (BNP) and high-sensitivity troponin I (hsTnI) in predicting early post-LT mortality. Methods: We retrospectively evaluated 2,490 consecutive adult LT patients between 2010 and 2018. Cut-off values of BNP and hsTnI for predicting post-LT 90-day mortality were calculated. According to the derived cut-off values of two cardiac biomarkers, alone and in combination, adjusted hazard ratios (aHR) of post-LT 90-day mortality were determined using multivariate Cox regression analysis.Results: Mortality rate after 90 days was 2.9% (72/2,490). Rounded cut-off values for post-LT 90-day mortality were 400 pg/ml for BNP (aHR 2.02 [1.15, 3.52], P = 0.014) and 60 ng/L for hsTnI (aHR 2.65 [1.48, 4.74], P = 0.001), respectively. Among 273 patients with BNP ≥ 400 pg/ml, 50.9% of patients were further stratified into having hsTnI ≥ 60 ng/L. Combined use of pre-LT cardiac biomarkers predicted post-LT 90-day mortality rate; both non-elevated: 1.0% (21/2,084), either one is elevated: 9.0% (24/267), and both elevated: 19.4% (27/139, log-rank P < 0.001; aHR vs non-elevated 4.23 [1.98, 9.03], P < 0.001).Conclusions: Concomitant elevation of both cardiac biomarkers posed significantly higher risk of 90-day mortality after LT. Pre-LT assessment cardiac strain and myocardial injury, represented by BNP and hsTnI values, would contribute to prioritization of LT candidates and help administer target therapies that could modify early mortality.

Background More than 400 liver transplants were performed at Asan Medical Center (AMC) in 2011, and over 500 liver transplants including 420 living-donor liver transplants (LDLTs) were performed in 2019. Herein, we report the methodology of these procedures. Methods Since the first adult LDLTs at AMC using the left and right lobes were successfully performed, various innovative techniques and approaches have been developed: modified right lobe, dual graft, donor exchange for ABO incompatibility, expansion of indications and no-touch techniques for hepatocellular carcinoma, intraoperative cine-portogram and additional intervention for large collaterals, management of portal vein thrombosis (PVT) and stenosis, salvage LDLT after major hepatectomy, and timely LDLT for patients with acute-on-chronic liver failure. Results Four hundred twenty LDLTs in 403 adult and 17 pediatric patients and 85 deceased-donor liver transplants in 74 adult and 11 pediatric patients were performed. The number of deceased-donor liver transplants remained constant since 2011, but the number of LDLTs increased steadily. One hundred thirty patients (25.7%) required urgent liver transplantations and 24 patients with acute-on-chronic liver failure underwent LDLT. PVT including grade 1,2,3, and 4 was reported in 91 patients (18.0%), and Yerdel’s grade 2, 3, and 4 PVT was reported in 47 patients (51.6%); all patients with PVT were successfully treated. Adult LDLTs for hepatocellular carcinoma and ABO incompatibility accounted for 52.6% and 24.3% of the cases, respectively. In-hospital mortality in 2019 was 2.97%. Conclusion Continual efforts to overcome challenging problems in LDLT with various innovations and dedication of the team members during the perioperative period to improve patient outcomes were crucial in increasing the number of liver transplantations at Asan Medical Center.

Introduction Early allograft dysfunction (EAD) is known to be a prototype of graft failure and ultimately influences long-term graft failure or death. We hypothesized that pretransplant thrombogenicity evaluated by procoagulant and anticoagulant, von Willebrand factor (vWF), factor Ⅷ (FⅧ), protein C (PC) and their imbalance ratio of vWF-to-PC (vWFPCR) and FVIII-to-PC (FⅧPCR), is associated with EAD and 90-day graft failure after living-related liver transplantation (LDLT) and contributes to further exacerbation of graft dysfunction when coexists with systemic inflammation. Material and methods Of 1199 prospectively registered LDLT patients, 698 with measurements of each thrombogenicity parameters were analyzed. Risk factors for EAD development were searched and subsequent best cut-offs was calculated according to the receiver operator characteristic curve analysis. When comparing the outcome, multivariable regression analysis and inverse probability of treatment weighting (IPTW) of the propensity score were performed. Results The prevalence of EAD was 10.7% (n = 75/698) after LDLT. Of parameters, vWFPCR had highest predictivity potential of EAD with the best cut-off of 8.06. The relationship between vWFPCR≥8.06 showed significant association with EAD development (OR [95%CI], 2.55[1.28–5.09], P = 0.008) and 90-day graft failure (HR [95%CI], 2.24 [1–4.98], P = 0.043) after IPTW-adjustment. Furthermore, risk of EAD increased proportionally with increasing C-reactive protein as a continuous metric of systemic inflammation, and more steeply in those with higher thrombogenicity (i.e., higher vWFPCR). Adding vWFPCR to MELD score improved EAD risk prediction by 21.9%. Conclusions Pretransplant thrombogenicity assessed by imbalance of pro- and anticoagulant, was significantly associated with EAD and 90-day graft failure after LDLT and this association was worsened by systemic inflammation.

Background and aim The proportional increase of corrected QT interval (QTc) along end-stage liver disease (ESLD) severity may lead to inconsistent outcome reporting if based on conventional threshold of prolonged QTc. We investigated the comprehensive QTc distribution among ESLD patients and assessed the association between QTc > 500 ms, a criterion for diagnosing severe long-QT syndrome, and the 30-day major adverse cardiovascular event (MACE) after liver transplantation (LT) and identified the risk factors for developing QTc > 500 ms. Methods Data were collected prospectively from the Asan LT Registry between 2011 and 2018, and outcomes were retrospectively reviewed. Multivariable analysis and propensity score-weighted adjusted odds ratios (ORs) were calculated. Thirty-day MACEs were defined as the composite of cardiovascular mortality, arrhythmias, myocardial infarction, pulmonary thromboembolism, and/or stroke. Results Of 2579 patients, 194 (7.5%) had QTc > 500 ms (QTc500_Group), and 1105 (42.8%) had prolonged QTc (QTcP_Group), defined as QTc > 470 ms for women and >450 ms for men. The 30-day MACE occurred in 336 (13%) patients. QTc500_Group showed higher 30-day MACE than did those without (20.1% vs 12.5%, P = 0.003), with corresponding adjusted OR of 1.24 (95% CI: 1.06-1.46, P = 0.007). However, QTcP_Group showed comparable 30-day MACE (13.3% vs 12.8% without prolonged QTc, P = 0.764). Significant risk factors for QTc > 500 ms development were advanced liver disease, female sex, hypokalemia, hypocalcemia, high left ventricular end-diastolic volume, and tachycardia. Conclusion Our results revealed that, among ESLD patients, a novel threshold of QTc > 500 ms was associated with post-LT 30-day MACE but not with conventional threshold, indicating that a longer QTc threshold should be considered for this unique patient population.

This study aimed to assess the effects of remote ischemic preconditioning (RIPC) on liver function in donors and recipients after living donor liver transplantation (LDLT).Ischemia reperfusion injury (IRI) is known to be associated with graft dysfunction after liver transplantation. RIPC is used to lessen the harmful effects of IRI.A total of 148 donors were randomly assigned to RIPC (n = 75) and control (n = 73) groups. RIPC involves 3 cycles of 5-minute inflation of a blood pressure cuff to 200 mm Hg to the upper arm, followed by 5-minute reperfusion with cuff deflation. The primary aim was to assess postoperative liver function in donors and recipients and the incidence of early allograft dysfunction and graft failure in recipients.RIPC was not associated with any differences in postoperative aspartate aminotransferase (AST) and alanine aminotransferase levels after living donor hepatectomy, and it did not decrease the incidence of delayed graft hepatic function (6.7% vs 0.0%, P = 0.074) in donors. AST level on postoperative day 1 [217.0 (158.0, 288.0) vs 259.5 (182.0, 340.0), P = 0.033] and maximal AST level within 7 postoperative days [244.0 (167.0, 334.0) vs 296.0 (206.0, 395.5), P = 0.029) were significantly lower in recipients who received a preconditioned graft. No differences were found in the incidence of early allograft dysfunction (4.1% vs 5.6%, P = 0.955) or graft failure (1.4% vs 5.6%, P = 0.346) among recipients.RIPC did not improve liver function in living donor hepatectomy. However, RIPC performed in liver donors may be beneficial for postoperative liver function in recipients after living donor liver transplantation.

Background Although, living donor liver transplantation (LDLT) is the standard treatment option for patients with end-stage liver disease, it always entails ethical concerns about the risk of living donors. Recent studies have reported a correlation between sarcopenia and surgical prognosis in recipients. However, there are few studies of donor sarcopenia and the surgical prognosis of donors. This study investigated the association between sarcopenia and postoperative acute kidney injury in liver donors. Methods This retrospective study analyzed 2,892 donors who underwent donor hepatectomy for LDLT between January 2008 and January 2018. Sarcopenia was classified into pre-sarcopenia and severe sarcopenia, which were determined to be -1 standard deviation (SD), and -2 SD from the mean baseline of the skeletal muscle index, respectively. Multivariate regression analysis was performed to evaluate the association between donor sarcopenia and postoperative AKI. Additionally, we assessed the association between donor sarcopenia and delayed recovery of liver function (DRHF). Results In the multivariate analysis, donor sarcopenia was significantly associated a higher incidence of postoperative AKI (adjusted odds ratio [OR]: 2.65, 95% confidence interval [CI]: 1.15-6.11, P=0.022 in pre-sarcopenia, OR: 5.59, 95% CI: 1.11-28.15, P=0.037 in severe sarcopenia, respectively). Additionally, hypertension, and synthetic colloid use were significantly associated with postoperative AKI. In the multivariate analysis, risk factors of DRHF were male gender, indocyanine green retention rate at 15 minutes, and graft type, however, donor sarcopenia was not a risk factor. Conclusions Donor sarcopenia is associated with postoperative AKI following donor hepatectomy.

Background: PNI is significantly associated with surgical outcomes, however, the association between PNI and intraoperative transfusions is unknown. Methods: This study retrospectively analyzed 1065 patients who underwent hepatectomy. We divided patients into two groups according to the PNI (&lt, 44 and &gt, 44) and compared their transfusion rates and surgical outcomes. We performed multivariate logistic and Cox regression analysis to determine risk factors for transfusion and the 5-year survival. Additionally, we found the net reclassification index (NRI) to validate the discriminatory power of PNI. Results: The PNI &lt, 44 group had higher transfusion rates (adjusted odds ratio [OR]: 2.20, 95%CI: 1.06–4.60, p = 0.035) and poor surgical outcomes, such as post hepatectomy liver failure (adjusted [OR]: 3.02, 95%CI: 1.87–4.87, p &lt, 0.001), and low 5-year survival (adjusted OR: 1.68, 95%CI: 1.17–2.24, p &lt, 0.001). On multivariate analysis, PNI &lt, 44, age, hemoglobin, operation time, synthetic colloid use, and laparoscopic surgery were risk factors for intraoperative transfusion. On Cox regression analysis, PNI &lt, 44, MELD score, TNM staging, synthetic colloid use, and transfusion were associated with poorer 5-year survival. NRI analysis showed significant improvement in the predictive power of PNI for transfusion (p = 0.002) and 5-year survival (p = 0.004). Conclusions: Preoperative PNI &lt, 44 was significantly associated with higher transfusion rates and surgical outcomes.

Various biological indicators are reportedly associated with postoperative acute kidney injury (AKI) in the surgical treatment of hepatocellular carcinoma (HCC). However, only a few studies have evaluated the association between the preoperative prognostic nutritional index (PNI) and postoperative AKI. This study evaluated the association of the preoperative PNI and postoperative AKI in HCC patients. We retrospectively analyzed 817 patients who underwent open hepatectomy between December 2007 and December 2015. Multivariate regression analysis was performed to evaluate the association between the PNI and postoperative AKI. Additionally, we evaluated the association between the PNI and outcomes such as postoperative renal replacement therapy (RRT) and mortality. Cox regression analysis was performed to assess the risk factors for one-year and five-year mortality. In the multivariate analysis, high preoperative PNI was significantly associated with a lower incidence of postoperative AKI (odds ratio (OR): 0.92, 95% confidence interval (CI): 0.85 to 0.99, p = 0.021). Additionally, diabetes mellitus and the use of synthetic colloids were significantly associated with postoperative AKI. PNI was associated with postoperative RRT (OR: 0.76, 95% CI: 0.60 to 0.98, p = 0.032) even after adjusting for other potential confounding variables. In the Cox regression analysis, high PNI was significantly associated with low one-year mortality (Hazard ratio (HR): 0.87, 95% CI: 0.81 to 0.94, p &lt, 0.001), and five-year mortality (HR: 0.93, 95% CI: 0.90–0.97, p &lt, 0.001). High preoperative PNI was significantly associated with a lower incidence of postoperative AKI and low mortality. These results suggest that the preoperative PNI might be a predictor of postoperative AKI and surgical prognosis in HCC patients undergoing open hepatectomy.

We aimed to determine if the severity of computed tomographic coronary angiography (CTCA)-diagnosed coronary artery disease (CAD) is associated with postliver transplantation (LT) myocardial infarction (MI) within 30 days and early mortality. We retrospectively evaluated 2118 consecutive patients who underwent CAD screening using CTCA. Post-LT type-2 MI, elicited by oxygen supply-and-demand mismatch within a month after LT, was assessed according to the severity of CTCA-diagnosed CAD. Obstructive CAD (>50% narrowing, 9.2% prevalence) was identified in 21.7% of patients with 3 or more known CAD risk factors of the American Heart Association. Post-LT MI occurred in 60 (2.8%) of total patients in whom 90-day mortality rate was 16.7%. Rates of post-LT MI were 2.1%, 3.1%, 3.4%, 4.3%, and 21.4% for normal, nonobstructive CAD, and 1-, 2-, and 3-vessel obstructive CAD, respectively. Two-vessel or 3-vessel obstructive CAD showed a 4.9-fold higher post-LT MI risk compared to normal coronary vessels. The sensitivity and negative predictive value of obstructive CAD in detecting post-LT MI were, respectively, 20% and 97.5%. In conclusion, negative CTCA finding in suspected patients can successfully exclude post-LT MI, whereas proceeding with invasive angiography is needed to further risk-stratify in patients with significant CTCA-diagnosed CAD. Prognostic role of CTCA in predicting post-LT MI needs further research.

Pleural effusion and hypoalbuminaemia frequently occur after hepatectomy. Despite the emphasis on the safety of donors, little is known about the impact of postoperative albumin level on pleural effusion in liver donors. We retrospectively assessed 2316 consecutive liver donors from 2004 to 2014. The analysis of donors from 2004 to 2012 showed that postoperative pleural effusion occurred in 47.4% (970/2046), and serum albumin levels decreased until postoperative day 2 (POD2) and increased thereafter. In multivariable analysis, the lowest albumin level within POD2 (POD2ALB) was inversely associated with pleural effusion (OR 0.28, 95% CI 0.20–0.38; P P P P = 0.024), compared with synthetic colloid infusion after PS matching (193 pairs). In conclusion, our data showed that POD2ALB is inversely associated with pleural effusion, and that intraoperative albumin infusion is associated with a lower incidence of pleural effusion when compared to synthetic colloid infusion in liver donors.

Background: Living donor liver transplantation (LDLT) has been associated with massive bleeding and increased blood transfusion requirements. However, information on indicators predicting bleeding and transfusion in LDLT is limited. Recent studies have reported a correlation between red cell distribution width (RDW) and bleeding risk. This study investigates the association between RDW and intraoperative blood transfusion in patients receiving LDLT.Methods: This retrospective study analyzed 2548 patients who underwent LDLT between January 2010 and October 2019. The patients were divided into four groups based on preoperative RDW quartiles: Q1 ( The risk factors for intraoperative transfusion were evaluated by multivariate regression analysis. The predictive power of RDW was assessed through receiver operating characteristic (ROC) and integrated discrimination improvement (IDI) analysis.Results: There were significant differences in incidence of intraoperative transfusion according to preoperative RDW quartile (Q1 vs Q2 vs Q3 vs Q4: 47.3% vs. 78.1% vs. 91.8% vs. 96.2%, P<0.001). Q4 had poor surgical outcomes, such as acute kidney injury (adjusted odds ratio [OR]: 1.91, 95% CI: 1.44–2.54, P<0.001). In the multivariate logistic analysis, RDW, age, sex, diabetes mellitus, coronary artery disease, model for end-stage liver disease scores, and total ischemic time were risk factors for transfusion. In ROC and IDI analysis, RDW had predictive power for intraoperative transfusion (P=0.023 in IDI).Conclusions: Preoperative RDW is a potential predictor of intraoperative transfusion and postoperative acute kidney injury in patients receiving LDLT.

Postoperative hemorrhagic stroke (HS) is a rare yet devastating complication after liver transplantation (LT). Unruptured intracranial aneurysm (UIA) may contribute to HS, however, related data are limited. We investigated UIA prevalence and aneurysmal subarachnoid hemorrhage (SAH) and HS incidence post-LT. We identified risk factors for 1-year HS and constructed a prediction model. This study included 3544 patients who underwent LT from January 2008 to February 2019. Primary outcomes were incidence of SAH, HS, and mortality within 1-year post-LT. Propensity score matching (PSM) analysis and Cox proportional hazard analysis were performed. The prevalence of UIAs was 4.63% (n = 164, 95% confidence interval (CI), 3.95–5.39%). The 1-year SAH incidence was 0.68% (95% CI, 0.02–3.79%) in patients with UIA. SAH and HS incidence and mortality were not different between those with and without UIA before and after PSM. Cirrhosis severity, thrombocytopenia, inflammation, and history of SAH were identified as risk factors for 1-year HS. UIA presence was not a risk factor for SAH, HS, or mortality in cirrhotic patients post-LT. Given the fatal impact of HS, a simple scoring system was constructed to predict 1-year HS risk. These results enable clinical risk stratification of LT recipients with UIA and help assess perioperative HS risk before LT.

Background Gastric cancer is a common but lethal cancer owing to deficient in effective treatment. Substantial evidences have proved that immune infiltration plays a key role in progression of gastric cancer. This study aimed to establish a signature based on immune related genes that can predict clinical outcomes and therapeutic efficacy. Methods The expression data from The Cancer Genome Atlas database and 4617 immune related genes from previously published 160 immune gene sets were collected for development and validation of the signature. Cox proportional hazard regression model was used to construct the signature. The reliability and forecasting ability were evaluated by two independent datasets from GEO. Results A gene model consisting of 47 immune related genes was used as our signature. Risk scores were calculated based on the coefficient and the expression level of each gene in this model. The low risk score group had an obviously favorable prognosis than the other group in all cohorts. Both of univariate and multivariate analysis suggested that our immune gene signature was an independent prognostic factor. Single sample gene Set Enrichment Analysis (ssGSEA) revealed that high risk score was associated with high Th17 cell infiltration, low mast cell and pro- angiogenesis immune cell infiltration. More importantly, patients with high risk score presented high tumor mutation burden (TMB), which is an essential element for predicting therapeutic efficacy of immune check point inhibitor. Conclusion This signature is a promising tool to predict prognosis and screen out population who can get benefit from immune check point inhibitor.

Although the revised cardiac risk index (RCRI) is a useful tool for estimating the risk of postoperative cardiac events, whether it improves the prediction of cardiac events in patients undergoing liver transplantation (LT) has not been sufficiently demonstrated.We retrospectively analyzed 1429 patients who underwent LT. Cardiac events were defined as myocardial infarction, death, or combined events within 30 days after surgery. The RCRI was defined as the number of independent predictors including high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin treatment, and creatinine level2 mg/dL. Multivariate logistic regression analysis was performed to identify factors independently associated with cardiac events. The additive predictability of RCRI for the Model for End-Stage Liver Disease (MELD) score was assessed using receiver operating characteristic curve analysis.Forty-four (3.1%) cardiac events occurred within 30 days after surgery. Both the MELD score (adjusted odds ratio [aOR], 1.05; P = .005) and RCRI (aOR, 4.35; P .001 for RCRI score 2; aOR, 6.27; P = .009 for RCRI score 3 compared with RCRI score 1) independently predicted postoperative 30-day cardiac events. The model with MELD score plus RCRI was significantly more predictive for postoperative 30-day cardiac events than the model with MELD score alone (C-statistics 0.800 vs 0.757; P = .030).For preoperative risk stratification, RCRI showed additive value to MELD score in predicting postoperative 30-day cardiac events after LT.

Background Antiphospholipid antibodies (aPL), including anticardiolipin (aCL), anti-β2-glycoprotein I (anti-β2GPI), and lupus anticoagulant (LA) antibodies, are frequently found in liver cirrhosis and associated with splanchnic vein thrombosis. Although the risk factors of early allograft dysfunction (EAD) are known, the association between EAD and aPL has been poorly investigated. We hypothesized that LA, potent aPL with thrombotic potential, may be associated with EAD development after living donor liver transplantation (LDLT). Methods Data of 719 patients who underwent LDLT from February 2014 to June 2016 at our center were retrospectively collected and analyzed. Patients were divided into 2 groups according to the positivity of LA screening test (LA group [n = 148] vs no-LA group [n = 571]). Risk factors for EAD were investigated using multivariable regression analysis and inverse probability of treatment weighting (IPTW) of propensity scores. Results The prevalence of LA screening positivity, confirmatory test positivity, and EAD was 20.6%, 1.1%, and 11.3%, respectively. aCL positivity rate was 7.5% and anti-β2GPI positivity rate was 7.0%. The EAD prevalence in LA and no-LA group was 25.7% and 7.5%, respectively. However, multivariable and IPTW analyses showed no association between EAD and LA screening positivity (P = .263 and P = .825, respectively), although a significant association was found in univariate analysis (odds ratio, 4.242; P Conclusion A positive LA screening test result was associated with EAD only in the univariate analysis. Inflammation, based on C-reactive protein level, was more important for EAD development.

BACKGROUND As end-stage liver disease progresses, renal blood flow linearly correlates with mean arterial blood pressure (MBP) due to impaired autoregulation. We investigated whether the lower degree of postoperative MBP would predict the occurrence of postoperative acute kidney injury (AKI) after liver transplantation. MATERIAL AND METHODS This retrospective study enrolled 1,136 recipients with normal preoperative kidney function. Patients were categorized into two groups according to the averaged postoperative MBP

We aimed to determine the association between the preoperative antithrombin III (ATIII) level and postoperative acute kidney injury (AKI) after LT (post-LT AKI). We retrospectively evaluated 2395 LT recipients between 2010 and 2018 whose data of perioperative ATIII levels were available. Patients were divided into two groups based on the preoperative level of ATIII (ATIII &lt, 50% vs. ATIII ≥ 50%). Multivariable regression analysis was performed to assess the risk factors for post-LT AKI. The mean preoperative ATIII levels were 30.2 ± 11.8% in the ATIII &lt, 50% group and 67.2 ± 13.2% in the ATIII ≥ 50% group. The incidence of post-LT AKI was significantly lower in the ATIII ≥ 50% group compared to that in the ATIII &lt, 50% group (54.7% vs. 75.5%, p &lt, 0.001), odds ratio (OR, per 10% increase in ATIII level) 0.86, 95% confidence interval (CI) 0.81–0.92, p &lt, 0.001. After a backward stepwise regression model, female sex, high body mass index, low albumin, deceased donor LT, longer duration of surgery, and high red blood cell transfusion remained significantly associated with post-LT AKI. A low preoperative ATIII level is associated with post-LT AKI, suggesting that preoperative ATIII might be a prognostic factor for predicting post-LT AKI.

Background: Sarcopenia contributes to increased morbidity and mortality in patients undergoing surgery for abdominal aortic aneurysms (AAA). However, few reports have demonstrated whether sarcopenia would affect the development of postoperative acute kidney injury (AKI) in these patients. This study aimed to examine whether sarcopenia is associated with AKI and morbidity and mortality after infrarenal AAA operation. Methods: We retrospectively analysed 379 patients who underwent infrarenal AAA surgery. The diagnosis of sarcopenia was performed using the skeletal muscle index, which was calculated from axial computed tomography at the level of L3. The patients were separated into those with sarcopenia (n = 104) and those without sarcopenia (n = 275). We applied multivariable and Cox regression analyses to evaluate the risk factors for AKI and overall mortality. A propensity score matching (PSM) evaluation was done to assess the postoperative results. Results: The incidence of AKI was greater in sarcopenia than non-sarcopenia group before (34.6% vs. 15.3%, p &lt, 0.001) and after the PSM analysis (34.6% vs. 15.4%, p = 0.002). Multivariable analysis revealed sarcopenia to be associated with AKI before (p = 0.010) and after PSM (p = 0.016). Sarcopenia was also associated with overall mortality before (p = 0.048) and after PSM (p = 0.032). A Kaplan–Meier analysis revealed that overall mortality was elevated patients with sarcopenia before and after PSM than in those without (log-rank test, p &lt, 0.001, p = 0.022). Conclusions: Sarcopenia was associated with increased postoperative AKI incidence and overall mortality among individuals who underwent infrarenal AAA operation.

Background & Aims Ventriculo-arterial coupling (VAC) reflects the interaction between ventricular performance and effective arterial load. Current criteria for cirrhotic cardiomyopathy focus only on cardiac function without addressing the effect of hyperdynamic, low-resistance circulation. We investigated alterations in VAC in cirrhotic patients and their associations with post-liver transplant all-cause mortality. Methods In this single institution cohort study, cirrhotic patients who underwent liver transplantation (LT) (n=914) were retrospectively compared with healthy matched controls using noninvasively measured end-systolic ventricular elastance (Ees), arterial elastance (Ea), and VAC (Ea/Ees). All-cause mortality based on VAC values were investigated using a Cox hazard model with the inverse probability treatment weighting (IPTW) of propensity score. Results Cirrhotic patients had significantly lower Ees, Ea and VAC values than controls. Over a median of 30months, 96 patients died after LT. In patients with a high model for end-stage liver disease score (⩾25), VAC of >0.61 (highest tertile) had poorer survival outcomes than patients with VAC of ⩽0.50 (lowest tertile) (66.0% vs. 91.8%; Log-rank p =0.001), and was independently associated with risk of mortality (hazard ratio, 2.44; 95% CI, 1.10–5.39; p =0.028) compared with VAC of ⩽0.61 after IPTW adjustment. Conclusions In cirrhotic patients, ventricular elastance and VAC values are lower than those in controls. However, in advanced cirrhotic patients, an increase in VAC value is associated with all-cause mortality after LT, suggesting that this non-invasive estimation of ventriculo-arterial uncoupling is an additional novel prognosticator in cirrhotic cardiovascular disorders. Lay summary In cirrhotic patients, cardiac dysfunction is latent and only manifests under stressful conditions because of arterial vasodilation. In this study, based on the pressure-volume curve of cardiac function, we investigated characteristics of the ventricular-arterial coupling in cirrhotic patients and further found that disparities in the ventriculo-arterial relationship are associated with graft failure and all-cause mortality after liver transplantation.

Although left ventricular diastolic dysfunction (LVDD) is a pronounced feature of adult cirrhotic cardiomyopathy and a major predictor of poor outcomes following liver transplantation (LT), little is known about if pretransplant cardiac dysfunction affects perioperative outcomes in pediatric LT.We retrospectively evaluated pretransplant clinical and Doppler echocardiographic data for 45 consecutive pediatric LT recipients who were treated between 2007 and 2013 (median age = 15 months; interquartile range = 9 to 78 months). LVDD was defined according to the cirrhotic cardiomyopathy criteria, and the myocardial performance index (MPI) was measured using tissue Doppler imaging. Intraoperative data and hospitalization days following LT were compared.LVDD and MPI ≥0.5 (defined as a z score ≥2) were observed in 13% and 27% of patients, respectively. Patients with an MPI ≥0.5 demonstrated the increased accumulation of lactate at the end of their LT operation (mean = 2.48 vs 0.82; P = .026) compared with patients with an MPI 0.5. The hospital stay was longer in patients with LVDD (median = 46 days vs 30 days; P = .041) and patients with an MPI ≥0.5 (median = 38 days vs 29 days; P = .014) compared with patients without LVDD and MPI 0.5, respectively.LVDD might be less prevalent (13%) in pediatric patients compared with adults. However, pretransplant cardiac dysfunction in patients with LVDD and an MPI ≥0.5 adversely affects perioperative outcomes, necessitating that such pediatric LT recipients be cautiously observed perioperatively.

Fluid overload (FO) has been shown to adversely affect multiple organs and survival in critically ill patients. Liver transplantation (LT) carries the risk of massive transfusion, which frequently results in FO. We investigated the association of postoperative weight gain with graft failure, early allograft dysfunction (EAD), and overall mortality in LT. 1833 living donor LT (LDLT) recipients were retrospectively analysed. Patients were divided into 2 groups according to postoperative weight gain (P = 0.001). When postoperative weight change was used as a continuous variable, the aHR for each 1% increase in postoperative weight was 1.045 (95% CI, 1.009–1.082; P = 0.015). In addition, the ≥3% group was associated with EAD (adjusted OR [aOR], 1.553; 95% CI, 1.024–2.356; P = 0.038) and overall mortality (aHR, 1.731; 95% CI, 1.182–2.535; P = 0.005). In conclusion, postoperative weight gain may be independently associated with increased risk of graft failure, EAD, and mortality in LDLT recipients.

Background This study aims to investigate the noninferiority of Enhanced Recovery After Surgery (ERAS) for pancreaticoduodenectomy (PD). Methods In this single-center trial, we randomly assigned 276 adult patients who underwent open PD into ERAS and conventional groups with 138 patients in each, from 2015 through 2017. The primary endpoint was the incidence of overall morbidity until postoperative 3 months. The secondary endpoints were in-hospital or 30-day mortality, postoperative length of stay (LOS), nutritional status and overall hospital costs. Results Overall morbidity was reported in 64 patients (52.0%, ERAS group) and in 68 patients (54.8%, conventional group) (risk difference [RD] -2.81 percentage points (pp); 90% two-sided confidence interval -13.24 to 7.63). Mortality did not occur in any patients. The two groups did not differ significantly in median postoperative LOS (both 11 days; RD -8.46 pp), body mass index (22.4 ± 2.75 vs. 22.4 ± 2.65 kg/m2 ; RD -3.48 pp), Patient-Generated Subjective Global Assessment score over 4 (45 [40.5%] vs. 50 [43.1%] patients; RD -2.56 pp), and median overall hospital cost (15.61 vs. 16.04, ×106 KRW; RD -6.08 pp). Conclusions Even in PD, modified ERAS protocol was not inferior to conventional protocol, while reducing treatment burden.

BACKGROUND & AIMS Early allograft dysfunction (EAD) is predictive of poor graft and patient survival following living donor liver transplantation (LDLT). Considering the impact of the inflammatory response on graft injury extent following LDLT, we investigated the association between neutrophil-to-lymphocyte ratio (NLR) and EAD, 1-year graft failure, and mortality following LDLT, and compared it to C-reactive protein (CRP), procalcitonin, platelet-to-lymphocyte ratio and the Glasgow prognostic score. METHODS A total of 1960 consecutive adult LDLT recipients (1531/429 as development/validation cohort) were retrospectively evaluated. Cut-offs were derived using the area under the receiver operating characteristic curve (AUROC), and multivariable regression and Cox proportional hazard analyses were performed. RESULTS The risk of EAD increased proportionally with increasing NLR, and the NLR AUROC was 0.73, similar to CRP and procalcitonin and higher than the rest. NLR ≥ 2.85 (best cut-off) showed a significantly higher EAD occurrence (20.5% vs 5.8%, P

Cerebral air embolism is a rare but potentially life-threatening complication. We experienced a living-donor liver transplant recipient who presented with unexpected cerebral air embolism and transient neurologic abnormalities that subsequently developed just after the removal of the pulmonary artery catheter from the central venous access device. One day after the initial event, the patient's neurologic status gradually improved. The patient was discharged 30 days after liver transplantation without neurologic sequelae.

A higher visit-to-visit variability in low-density lipoprotein cholesterol (LDL-C) is associated with an increased frequency of cardiovascular events. We investigated the association between the visit-to-visit LDL-C variability and all-cause mortality, myocardial infarction (MI), and coronary revascularization in a population with non-obstructive coronary artery disease (CAD).From this retrospective cohort of individuals who underwent coronary angiography from 2006 to 2010, a total of 2.012 consecutive patients with non-obstructive CAD, who underwent three or more LDL-C determinations during the first 2 years, were identified and followed up for 5 years. The variability in the visit-to-visit LDL-C was measured by standard deviation (SD) and coefficient of variation (CV). The risk of all-cause mortality and composite endpoints, MI, and coronary revascularization were evaluated by a multivariable Cox regression analysis.During a 5-year follow-up, a total of 99 (4.92%) mortality cases and 154 (7.65%) cases of composite endpoints were observed. The percentage of subjects who experienced mortality or composite endpoints was higher in those with a higher LDL-C-SD or LDL-C-CV level. The association between the LDL-C variability and clinical endpoints was regardless of possible confounding factors.Among the patients with non-obstructive CAD, a higher visit-to-visit LDL-C variability is associated with increasing all-cause mortality or composite endpoints during the long-term follow-up.

BACKGROUND Postreperfusion syndrome (PRS) has been shown to be related to postoperative morbidity and graft failure in orthotopic liver transplantation. To date, little is known about the impact of PRS on the prevalence of postoperative acute kidney injury (AKI) and the postoperative outcomes after living donor liver transplantation (LDLT). The purpose of our study was to determine the impact of PRS on AKI and postoperative outcomes after LDLT surgery. METHODS Between January 2008 and October 2015, we retrospectively collected and evaluated the records of 1865 patients who underwent LDLT surgery. We divided the patients into 2 groups according to the development of PRS: PRS group (n = 715) versus no PRS group (n = 1150). Risk factors for AKI and mortality were investigated by multivariable logistic and Cox proportional hazards regression model analysis. Propensity score (PS) analysis (PS matching and inverse probability of treatment weighting analysis) was designed to compare the outcomes between the 2 groups. RESULTS The prevalence of PRS and the mortality rate were 38% and 7%, respectively. In unadjusted analyses, the PRS group showed more frequent development of AKI (P < .001), longer hospital stay (P = .010), and higher incidence of intensive care unit stay over 7 days (P < .001) than the no PRS group. After PS matching and inverse probability of treatment weighting analysis, the PRS group showed a higher prevalence of postoperative AKI (P = .023 and P = .017, respectively) and renal dysfunction 3 months after LDLT (P = .036 and P = .006, respectively), and a higher incidence of intensive care unit stay over 7 days (P = .014 and P = .032, respectively). CONCLUSIONS We demonstrated that the magnitude and duration of hypotension caused by PRS is a factor contributing to the development of AKI and residual renal dysfunction 3 months after LDLT.

BACKGROUND Enhanced Recovery After Surgery (ERAS) program is a standardized, multimodal perioperative management plan that integrates various evidence-based interventions. We aimed to investigate the noninferiority of ERAS for pancreaticoduodenectomy (PD), one of the most complex abdominal surgeries. METHODS In this single-center trial, we randomly assigned 276 adult patients who underwent open pancreaticoduodenectomy into ERAS and conventional groups with 138 patients in each, from Mar 2, 2015 through January 11, 2017. In ERAS group, the modified ERAS Guidelines were applied, and the conventional group received the conventional perioperative management of our center. The primary endpoint was the incidence of overall operation-related morbidity until postoperative 3 months, with a noninferiority margin of 15*0 percentage points (pp). The secondary endpoints were in-hospital or 30-day mortality, postoperative length of stay, nutritional status and overall hospital costs. FINDINGS Overall morbidity was reported in 64 patients (52*0%, ERAS group) and in 68 patients (54*8%, conventional group) (risk difference (RD), -2*81 pp; 90% two-sided confidence interval, -13*24 to 7*63). Mortality did not occur in any patients. The two groups did not differ significantly in terms of median postoperative length of stay (both 11 days; RD, -8*46 pp), body mass index (22*4 ± 2*75 vs. 22*4 ± 2*65 kg/m2; RD, -3*48 pp), albumin level (2*6 ± 0*34 vs. 2*6 ± 0*33 g/dl; RD, 1*27 pp), Patient-Generated Subjective Global Assessment score over 4 (45 (40*5%) vs. 50 (43*1%) patients; RD, -2*56 pp), and median overall hospital cost (15*61 versus 16*04, x 106 KRW; RD, -6*08 pp). INTERPRETATION Even in pancreaticoduodenectomy, the modified ERAS protocol was not inferior to the conventional protocol regarding the postoperative morbidity, mortality, postoperative length of stay and hospital cost, while reducing treatment burden. Trial Registration Number: ClinicalTrials.gov number NCT02372331 Funding: Funded by the Asan Institute for Life Sciences (2014-0961). Declaration of Interest: We declare no competing interests Ethical Approval: The protocol was approved by the institutional review board of the Asan Medical Center (2014-0961).

The connection between renal dysfunction and cardiovascular dysfunction has been consistently shown. In patients with liver cirrhosis, renal dysfunction shows a tight correlation with prognosis after liver transplantation (LT); therefore, precise renal assessment is mandatory. Cystatin C, a sensitive biomarker for assessing renal function, has shown superiority in detecting mild renal dysfunction compared to classical biomarker creatinine. In this study, we aimed to compare cystatin C and creatinine in predicting 30-day major cardiovascular events (MACE) and all-cause mortality in LT recipients with normal serum creatinine levels.Between May 2010 and October 2015, 1181 LT recipients (mean Model for End-stage Liver Disease score 12.1) with pretransplantation creatinine level ≤1.4 mg/dL were divided into tertiles according to each renal biomarker. The 30-day MACE was a composite of troponin I0.2 ng/mL, arrhythmia, congestive heart failure, death, and cerebrovascular events.The highest tertile of cystatin C (≥0.95 mg/L) was associated with a higher risk for a 30-day MACE event (odds ratio: 1.62; 95% confidence interval: 1.07 to 2.48) and higher risk of death (hazard ratio: 1.96; 95% confidence interval: 1.04 to 3.67) than the lowest tertile (0.74 mg/L) after multivariate adjustments. However, the highest tertile of creatinine level showed neither increasing MACE event rate nor worse survival rate compared with the lowest tertile (both insignificant after multivariate adjustment).Pretransplantation cystatin C is superior in risk prediction of MACE and all-cause mortality in LT recipients with normal creatinine, compared to creatinine. It would assist further risk stratification which may not be detected with creatinine.

Background Measuring activated clotting time (ACT) is widely performed to monitor heparin therapy. Regardless of anticoagulant use, ACT is affected by coagulopathies such as coagulation factor deficiency and thrombocytopenia. However, its use in end-stage liver disease (ESLD) with complex coagulopathy is not well characterized. We evaluated whether ACT could be used to detect innate coagulopathy in ESLD patients. Methods We retrospectively assessed Hemochron (International Technidyne, Edison, NJ, USA) ACT (FTCA 510, normal range 105–167 seconds) and INTEM clotting time (CT) of rotational thromboelastometry (ROTEM; ROTEM delta, Pentapharm GmbH, Munich, Germany) (100–240 seconds) in 366 liver transplantation (LT) recipients, simultaneously measured before anesthetic induction for LT. Multiple linear regression analyses helped identify the factors related to ACT in ESLD patients. The relationship between ACT and INTEM CT was evaluated by Spearman rank correlation analysis and receiver operating characteristic curve. Results Median ACT was 143 seconds (range 73–295 seconds), and 60 patients (16.4%) had ACTs of >167 seconds. Multiple regression analyses revealed that prolonged prothrombin time, activated partial thromboplastin time, low antithrombin III, and young age were associated with high ACT levels. INTEM CT was associated with ACT independent of liver disease severity, while EXTEM CT was not. ACT was moderately correlated with INTEM CT ( r = 0.535), and the optimal cutoff value of ACT for predicting INTEM CT >240 seconds was 151 seconds (area under the curve = 0.787). Conclusions In ESLD patients, ACT is effective in detecting prolonged INTEM CT. Therefore, ACT may be used to predict intrinsic pathway defects with a cutoff value of 151 seconds, suggesting feasibility when ROTEM is unavailable.

Background The importance of heart rate (HR) measurement as a prognostic factor has been recognized in many clinical conditions, such as hypertension, coronary artery disease, or heart failure. Patients with liver cirrhosis tend to have increased resting HR as consequence of hyperdynamic circulation. In the current study, we examined whether pretransplant resting increased HR is associated with overall mortality in cirrhotic patients following liver transplantation (LT). Patients and Methods We retrospectively collected and analyzed the data of 881 liver recipients who underwent LT surgery between October 2009 and September 2012. Patients were categorized into 3 groups by tertile of resting HR as follows: tertile 1 group, HR ≤ 65 beats per minute (bpm); tertile 2 group, HR 66 to 80 bpm; and tertile 3 group, HR > 80 bpm. Results Kaplan-Meier analysis showed that the all-cause mortality rate was significantly different according to tertiles of HR ( P = .016, log-rank test). The multivariate Cox regression analysis showed that tertile 3 group was significantly associated with higher risk for all-cause mortality (hazard ratio 1.83, 95% confidence interval, 1.10–3.07; P = .021) compared with tertile 1 group, after adjusting for clinically significant variables in univariate analysis. Conclusions Our results demonstrate that pretransplant resting tachycardia can identify patients at high risk of death in cirrhotic patients following LT, suggesting that further study will be need to clarify relationship between HR burden and sympathetic cardiac neuropathy.

Background Regional oxygen saturation (rSO2) is a sensitive marker of cerebral hypoperfusion during liver transplantation. However, bilirubin absorbs near-infrared light, resulting in falsely low rSO2 values. We sought to determine whether rSO2 values vary in response to bilirubin concentrations during liver transplantation and to assess whether rSO2 changes were associated with factors reflecting cerebral oxygen delivery in patients with hyperbilirubinemia. Methods Measurements of rSO2 values continuous cardiac output (CO), mean arterial pressure, central venous pressure, body temperature, arterial blood gas analysis, and laboratory parameters were simultaneously performed at 1 hour after the surgical incision (baseline) and at 3 predetermined times during the anhepatic and neohepatic phases in 95 end-stage liver disease patients including 67 males of Child A/B/C/29/29/37 categories respectively. Relationships between changes in parameters were evaluated by correlation and multivariate regression analyses. Results The 273 measurements revealed changes in rSO2 (range, −18% to 40%) to correlate significantly with alterations in hemoglobin (Hb), serum glucose, lactate, prothrombin time, pH, partial arterial CO2 pressure (PaCO2), and CO, but not with serum total bilirubin (TB). Multivariate linear regression analysis revealed that changes in Hb, CO, PaCO2, and pH were independent of rSO2 changes during liver transplantation. Conclusions Our findings showed that rSO2 changes were independently associated with factors reflecting cerebral oxygen delivery, such as Hb, CO, PaCO2, and pH, whereas rSO2 values did not correlate with changes in bilirubin concentrations, indicating that rSO2 changes reveal cerebral oxygen balance regardless of TB levels among patients undergoing liver transplantation.

The anti-CD20 monoclonal antibody rituximab has significantly decreased the prevalence of antibody-mediated rejection of ABO-incompatible (ABOi) living donor liver transplantation (LDLT). However, little is known about acute kidney injury (AKI) following ABOi LDLT. The aim of this study was to identify the incidence of AKI in ABOi LDLT and compare it with that of ABO-compatible (ABOc) LDLT. We retrospectively collected and analyzed the data of 1617 patients who underwent liver transplant surgery from November 2008 to December 2014. Risk factors for AKI were investigated using multivariate regression analysis. In 271 ABOi LDLTs, AKI occurred in 184 (67.9%) according to Kidney Disease: Improving Global Outcomes criteria. After propensity score matching, the incidence of AKI was significantly higher after ABOi LDLT than after ABOc LDLT (67.0% versus 48.2%; P 0.001). Furthermore, the intensive care unit stay (P = 0.01) was significantly prolonged, but there were no significant differences in mortality (P = 0.74), graft failure (P = 0.32), and postoperative dialysis (P = 0.74) between the 2 groups. Hemoglobin level and operation time were independent risk factors for AKI following ABOi LDLT. In conclusion, the incidence of AKI is higher in ABOi LDLT than ABOc LDLT. However, the impact of AKI on postoperative outcomes was not marked in our study. Therefore, ABOi LDLT in selected patients is promising with apparent good graft and survival outcomes. Liver Transplantation 22 1656-1665 2016 AASLD.

Objective: The present study is an exploration of the dynamic changes of plasma mitochondrial deoxyribonucleic acid (mtDNA) and inflammatory level in patients with acute myocardial infarction (MI). Methods: Thirty-eight patients with acute MI and 33 control participants were included in the study. Blood samples were collected on admission, 12 hours post-percutaneous coronary intervention (PCI), 24 hours post-PCI, and 48 hours post-PCI. White blood cell (WBC) count and C-reactive protein (CRP) level were determined. Plasma was isolated from whole blood. Plasma mtDNA was measured using real-time polymerase chain reaction, and tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) were measured using enzyme-linked immunosorbent assay kits. Bivariate correlation analysis was used to find correlation between plasma mtDNA and inflammatory level on admission. Results: Plasma mtDNA was significantly higher in patients with acute MI than controls on admission (p

Cardiac dysfunction may be present in patients with liver cirrhosis. Brain natriuretic peptide (BNP) concentration is a widely used biomarker for heart failure. We evaluated whether elevated BNP reflects cardiac dysfunction, as assessed by preoperative echocardiography, in liver transplant recipients.We assessed 122 liver transplant recipients (94 males, 28 females; age, 50 ± 8 years). All underwent preoperative echocardiography, including measurements of heart chamber size, mass, ejection fraction, systolic pressure gradient between right ventricle and right atrium (PGsys [RV - RA]), mitral inflow velocities including early (E) and late (A) transmitral flow velocities, E/A, and deceleration time of E. Tissue Doppler imaging (TDI) was also performed to evaluate systolic (S'), early diastolic (E'), and late diastolic (A') myocardial velocities, E'/A', EAS index: E'/(A' × S'), and E/E'. Univariate and multivariate logistic regression analyses were performed to determine echocardiographic indices for predicting BNP ≥ 100 pg/mL.Of 122 recipients, 87 (71%) had BNP100 pg/mL (median, 32.0 pg/mL; interquartile range [IQR], 18.0-50.0), and 35 (29%) had BNP ≥ 100 pg/mL (median, 163.0 pg/mL; IQR, 136.0-479.0). Univariate analysis showed that E (P.001), PGsys (RV-RA) (P.001), and E/E' (P = .038) were significantly associated with BNP ≥ 100 pg/mL. Multivariate analysis showed that PGsys (RV - RA) was the only independent predictor of BNP ≥ 100 pg/mL (odds ratio, 1.171; 95% confidence interval, 1.091-1.258; P.001).PGsys (RV - RA) is an echocardiographic index independently associated with BNP ≥ 100 pg/mL, suggesting that elevated BNP in patients with end-stage liver disease may reflect increased pulmonary arterial pressure, rather than systolic and diastolic dysfunction assessed by TDI.

Laparoscopic pylorus-preserving pancreaticoduodenectomy is being performed more frequently because of improved surgical techniques. Although several studies have demonstrated safety and favourable outcomes of laparoscopic pylorus-preserving pancreaticoduodenectomy compared to open pylorus-preserving pancreaticoduodenectomy, few studies have focused on the development of postoperative acute kidney injury. This retrospective study compared the prevalence and risk factors of acute kidney injury following laparoscopic and open pylorus-preserving pancreaticoduodenectomy. Data from 809 patients who underwent pylorus-preserving pancreaticoduodenectomy between February 2012 and September 2016 were analysed. Patients were divided into two groups according to the surgical procedure (open pylorus-preserving pancreaticoduodenectomy [n = 632] vs laparoscopic pylorus-preserving pancreaticoduodenectomy [n = 177]). The Kidney Disease: Improving Global Outcomes criteria were used to define postoperative acute kidney injury and risk factors were investigated using multivariable logistic regression analysis with propensity score matching analysis and standardized mortality ratio weighting to compare outcomes. No significant differences were found in the occurrence of postoperative acute kidney injury and incidence of postoperative ICU admission between open and laparoscopic pylorus-preserving pancreaticoduodenectomy groups after propensity score matching (p = 1.000, p = 0.999, respectivelyand standardized mortality ratio weighted analysis (p = 0.619, p = 0.982, respectively). Hospital stay was significantly shorter in the laparoscopic pylorus-preserving pancreaticoduodenectomy group (propensity matched set, mean [SD], 16.7 [10.0] vs. 18.7 [9.6] days, p = 0.004; standardized mortality ratio, 16.6 [9.9] vs. 18.1 [8.8] days, p = 0.001). There was no significant difference in postoperative acute kidney injury incidence between both groups. Laparoscopic pylorus-preserving pancreaticoduodenectomy is promising with comparable postoperative outcomes to open pylorus-preserving pancreaticoduodenectomy and has the advantage of shorter hospital stay.

Subclavian central venous catheterization is a common procedure for which misplacement of the central venous catheter (CVC) is a frequent complication that can potentially be fatal. The carina is located in the mid-zone of the superior vena cava (SVC) and is considered a reliable landmark for CVC placement in chest radiographs. The C-length, defined as the distance from the edge of the right transverse process of the first thoracic spine to the carina, can be measured in posteroanterior chest radiographs using a picture archiving and communication system. To evaluate the placement of the tip of the CVC in subclavian central venous catheterizations using the C-length, we reviewed the medical records and chest radiographs of 122 adult patients in whom CVC catheterization was performed (from January 2012 to December 2014) via the right subclavian vein using the C-length. The tips of all subclavian CVCs were placed in the SVC using the C-length. No subclavian CVC entered the right atrium. Tip placement was not affected by demographic characteristics such as age, sex, height, weight, and body mass index. The evidence indicates that the C-length on chest radiographs can be used to determine the available insertion length and place the right subclavian CVC tip into the SVC.

Purpose: Patients with relapsed mantle-cell lymphoma have poor prognosis and short survival. Our aim was to determine the efficacy of nonablative allogeneic stem-cell transplantation in patients with relapsed mantle-cell lymphoma. Patients and Methods: Eighteen patients were treated in one of two consecutive trials. Thirteen patients underwent a conditioning regimen of fludarabine (30 mg/m2 daily for 3 days), cyclophosphamide (750 mg/m2 daily for 3 days), and high-dose rituximab. For the remaining five patients, the conditioning regimen consisted of cisplatin (25 mg/m2 daily for 4 days), fludarabine (30 mg/m2 daily for 2 days), and cytarabine (1,000 mg/m2 daily for 2 days). Tacrolimus and methotrexate were used for graft-versus-host disease prophylaxis. Results: The median age was 56.5 years. Patients underwent a median of three prior chemotherapy regimens. Prior autologous transplantation failed in five (28%) patients and 16 (89%) had chemosensitive disease. Donor cell engraftment occurred in all patients. Eight patients (44%) required no platelet or RBC transfusion, and acute graft-versus-host disease of greater than grade 2 did not develop in any patient. The day-100 mortality was 0%. Complete remission (CR) occurred in 17 patients. Three patients progressed, and one was reinduced into continuous CR with donor lymphocyte infusion. With a median follow-up period of 26 months, the actuarial probability of current-event-free-survival at 3 years was 82% (95% CI, 65% to 99%). Conclusion:Our data suggest that nonablative allogeneic transplantation is a safe and potentially effective strategy for patients with relapsed and chemosensitive mantle-cell lymphoma.

Objective: To compare the effect of Keyin Decoction with retinoic acid in treating psoriasis.Methods: One hundred and six patients were randomly divided by paired grouping into the KYD group and the all-trans retinoic acid (RA) group, 53 in each group with 19 cases belonging to Wind-Heat Syndrome type and 34 to Wind-Dryness type. The Wind-Heat Syndrome type in the KYD group was treated with KYD I (with the action of clearing Heat, removing Dampness, cooling blood and dispelling Wind), and the Wind-Dryness type with KYDII (with the action of nourishing blood, moistening skin and dredging Qi-blood circulation). The RA group was treated with RA. Sequential analysis was adopted to observe the effect. At the same time, the adverse reaction was observed.Results: When the test got to the 44th pair of patients, the scription of result reached the UA line of sequential chart, suggesting that the efficacy of KYD was superior to that of RA. Skin lesion subsidence rate in the KYD group and the RA group was 39.6% and 20.8% respectively with significant difference (P

Background Early detection of coagulopathy is important to prevent bleeding during liver transplantation (LT). Rotation thromboelastometry (ROTEM ® ) provides the earliest parameter of clot amplitudes at 5 min (A5). We evaluated whether A5 correlates with platelet count (PLT) and fibrinogen concentration (Fib) and can predict thrombocytopenia and hypofibrinogenaemia in hypocoagulable patients undergoing living-donor LT (LDLT). Methods A total of 3446 retrospective ROTEM ® measurements, including 1139 EXTEM, 1182 INTEM, and 1125 FIBTEM, with simultaneously measured PLT and Fib, were analysed during LDLT in 239 patients. The correlations between A5 and maximum clot firmness (MCF) index, PLT, and Fib were calculated. Receiver operating characteristic analysis with area under the curve (AUC) was used to assess A5 thresholds predictive of PLT and Fib. Results The median PLT was 47 000 mm −3 and the median Fib was 100 mg dl −1 during LDLT. The A5 parameters of EXTEM (A5 EXTEM ) and INTEM (A5 INTEM ) were highly correlated with MCF ( r =0.96 and r =0.95, respectively), PLT ( r =0.76 and r =0.77, respectively), and Fib ( r =0.63 and r =0.64, respectively). A5 of FIBTEM (A5 FIBTEM ) was also correlated with MCF ( r =0.91) and Fib ( r =0.75). A5 EXTEM thresholds of 15 and 19 mm predicted PLT −3 (AUC=0.90) and −3 (AUC=0.87), respectively, whereas A5 FIBTEM 4 mm predicted Fib −1 (AUC=0.86). Biases from A5 EXTEM and A5 FIBTEM to their MCFs were 16.4 and 1.3 mm, respectively. Conclusions A5 as an early variable of clot firmness is effective in detecting critically low PLT and Fib. A5 can therefore be a reliable fast index guiding transfusion therapy in hypocoagulable patients undergoing LDLT.

BACKGROUND The safety of healthy living donors undergoing hepatic resection for living-donor liver transplantation is of paramount concern. Although blood transfusions have been associated with morbidity and mortality after hepatectomy, there is limited information about the risk factors associated with blood transfusion in living liver donors. METHODS We retrospectively analyzed 2344 donors who underwent a hepatectomy for living-donor liver transplantation. Logistic regression analysis was performed to determine blood transfusion predictors in living-donor hepatectomy. RESULTS Of these donors, 48 (2.0%) and 97 (4.1%) were transfused with packed red blood cell (PRBC) and fresh-frozen plasma (FFP), respectively. The amount of PRBC and FFP administered to donors transfused with blood products were 1.9±0.8 and 3.7±2.5 units, respectively. In multivariate logistic regression analysis, a low preoperative hemoglobin level was found to be an independent predictor of PRBC transfusion in donor hepatectomy (odds ratio=0.585; 95% confidence interval=0.451-0.758; P

A 55-year-old man with end-stage renal disease had severe left ventricular dysfunction and a history of deep vein thrombosis. He underwent renal transplantation, during which a central venous catheter was inserted into the right jugular vein. The central venous pressure (CVP) exceeded 20 mmHg throughout the operation but there was no other adverse event. After surgery, although the left ventricular dysfunction improved, the CVP remained high. On postoperative day 10, the patient presented with cyanosis of the arms and redness of the face and was diagnosed with superior vena cava (SVC) syndrome, for which he underwent emergency thrombectomy and SVC reconstruction. The clinical course of this patient suggests that his end-stage renal disease-associated hypercoagulable state may have promoted thrombus formation. Moreover, placing the central venous catheter tip too deep may have encouraged thrombus formation. Repositioning the tip may have prevented this complication.

Background Dynamic preload indices such as stroke volume variation (SVV) and pulse pressure variation (PPV) have yielded false-positive results in patients with right ventricular (RV) dysfunction. We therefore assessed the effect of RV dysfunction on dynamic indices to predict the decrease in cardiac output (CO) during liver transplantation. Methods Hemodynamic parameters were measured before and after inferior vena cava (IVC) clamping in 52 recipients. The RV dysfunction was defined as an RV ejection fraction (RVEF) ≤ 30%. The area under the receiver operating characteristic curve (AUC) sufficient to detect changes in CO (ΔCO) ≥ 20% after IVC clamping in recipients was calculated. Results Recipients with RVEF ≤ 30% did not show significant increases in SVV or PPV despite having ΔCO ≥ 20%. In recipients with RVEF > 30%, the threshold value and AUC of SVV predicting a decrease in CO were 10% and 0.755 (compared with an AUC of 0.5, P = .011), respectively, whereas those for PPV were 10% and 0.767 (P = .007), respectively. However, in recipients with RVEF ≤ 30%, the threshold value and AUC of SVV were 10% and 0.638 (P = .305), respectively, whereas those for PPV were 12% and 0.684 (P = .159), respectively. Conclusions These results suggest that dynamic preload indices may not be sufficiently sensitive to detect a CO decrease in liver transplant recipients with RV dysfunction, emphasizing the importance of evaluating RV function when determining the predictability of dynamic indices.

Background Stroke volume variation (SVV) is being increasingly used to predict fluid responsiveness. Since radial arterial pressure (RAP) and femoral arterial pressure (FAP) frequently showing discrepancies during liver transplantation (LT), we sought to investigate the effect of differing arterial waveforms on SVV and cardiac output (CO) derived from the Vigileo device, by comparing SVV and CO values derived from RAP (SVV RAP , CO RAP ) and FAP (SVV FAP , CO FAP ) during LT. Methods The linear associations and agreements between SVV RAP and SVV FAP and between CO RAP and CO FAP were assessed during LT. Hemodynamic variables were measured at nine predefined time points in all 32 recipients, resulting in 288 data pairs. Results Correlations were observed between SVV RAP and SVV FAP ( r = .961) and between CO RAP and CO FAP ( r = .848) at all time points. These correlations between SVV RAP and SVV FAP ( r = .923) and between CO RAP and CO FAP ( r = .902) existed even during the period when mean RAP and FAP values differed (10 minutes after reperfusion). Bland-Altman analysis for SVV RAP versus SVV FAP and for CO RAP versus CO FAP showed weak biases (−0.2% and −0.5 L/min) and reasonable limits of agreement (−2.2 to 1.8% and −1.9 to 0.9 L/min). The percentage errors for SVV and CO values were 27.0% and 22.2%. Conclusions There was no significant difference between SVV RAP and SVV FAP when measured using the Vigileo device during LT. This finding indicated that SVV obtained using the Vigileo device offered relatively consistent information regardless of the catheterization site.

Objective To observe the effect of amlodipine with compound amiloride or telmisartan on non-invasive central aortic blood pressure (CABP) and vascular function, and try to elucidate its internal relations and the possible mechanisms, which might guide the clinical manegment. Methods 76 patients with hypertension were enrolled in this prospective randomised controlled clinical research, then divided into two groups randomly: group of amlodipine with compound amiloride (group A) or group of telmisartan (group B). Following parameters were examinated at admission and after 1 year: blood pressure, central aortic blood pressure, augmentation index, pulse wave conduction velocity, ankle-brachial index, carotid artery intima – media thickness. These patients were followed-up and collected clinical events regularly. Control goals of blood pressure are as following: the blood pressure goal of common hypertension should be lower than 140/90 mm Hg, if the hypertension patients with diabetes or kidney disease, the blood pressure should be lower than 130/80 mm Hg; The SBP goal of older hypertension patients should be lower than 150 mm Hg. Drugs used in this research are as follows: amlodipine (2.5 mg/tablet), compound amiloride (1 tablet: Ami 2. 5 mg/Hydrochlorothiazide 25 mg), telmisartan (40 mg/tablet). Results (1) As compared with admission, the blood pressure of two groups and the pulse pressure of group A decreased significantly (P≤0.010), but the pulse pressure of group B had no difference (p=0.077); No significant differences were showed in two groups about BP and PP (p 0.05) and group B had significant difference (p 0.05). (4) As compared with admission, the carotid intima – media thickness of two groups had increased, but no significant difference (p>0.05) between the two groups there was no significant difference (p>0.05). Conclusion (1) Amlodipine with compound amiloride or telmisartan reduces blood pressure increasing similarly, but on the central arterial pressure and vascular function are different. (2) Amlodipine with compound amiloride or telmisartan can improve arterial compliance and delay the advancing of arteriosclerosis by blood pressure. (3) The group of telmisartan can reduce central aortic blood pressure lower and delay advancing of atherosclerosis more as compared with the group of compound amiloride. (4) With the improvement of PWV, CABP can be decreased. PWV with CABP might be used to estimate the effect of antihypertension.

In pediatric patients, dynamic preload indices to predict fluid responsiveness have conflicting results in comparison with adults. A recent study demonstrated that pulse pressure variation (PPV) ≥16% has provided an accurate method for predicting fluid responsiveness in pediatric congenital heart surgery. We aimed to compare PPV and respiratory systolic, diastolic and pulse transit time interval variation (STV, DTV and PTTV, respectively) as predictors of fluid responsiveness during pediatric liver transplantation.

Lesch-Nyhan syndrome (LNS) is a rare, X-linked recessive inherited disorder caused by a deficiency of the enzyme hypoxanthine-guanine-phophoribosyltransferase, leading to excessive purine production and elevation of uric acid. Clinical manifestations include mental retardation, spasticity, choreathetosis, compulsive self-mutilation, renal calculi followed by obstructive nephropathy, and arthritis. Patient with LNS may have increased risk of aspiration pneumonia, acute renal failure and unexpected sudden death. We accomplished successful general anesthesia in a case of LNS requiring percutaneous nephrolithotomy due to

Background: Liver cirrhosis is associated with several hemodynamic abnormalities, including an impairment of autonomic nervous system reflexes, but very few have compared the disease severity with cardiovascular autonomic dysfunction assessed by spectral analysis of blood pressure and electrocardiogram. The aim of this study was to investigate the relationship between Child-Turcotte-Pugh (CTP) score and autonomic indices in patients with liver cirrhosis using the heart rate variability (HRV), blood pressure variability (BPV) and baroreflex sensitivity (BRS). Methods: Fifty patients scheduled for liver transplantation recipients under general anesthesia were enrolled in the study. Beat-to-beat blood pressure and RR interval were measured for five minutes before anesthesia induction. HRV and BPV were estimated by power spectral analysis of RR interval and systolic blood pressure. BRS was estimated by both the sequence method (Sequence BRS) and high frequency (HF) gain of transfer function analysis (HF BRS). Results: Significant inverse correlations between CTP score and Sequence BRS (r = -0.61), HF BRS (r = -0.59), low frequency (LF) and HF power of HRV (r = -0.57, r = -0.46), LF power of BPV (r = -0.37) were found. However, no significant correlations were observed between CTP score and LF/HF ratio of HRV (r = -0.02) and HF power of BPV (r = 0.27). Conclusions: These results showed that autonomic dysfunction assessed by spectral analysis was associated with increasing severity of liver cirrhosis. Further study will be needed to clarify relationship between our findings and hemodynamic fluctuations during anesthesia for liver transplantation.

Ex situ resection of the liver is an alternative surgical procedure for patients with conventionally unresectable hepatic tumors, and with contraindications to liver transplantation. We experienced a case of ex situ resection of the liver in a 40-year-old female patient suffering from sclerosing hepatocellular carcinoma. Preoperative liver function was normal. The duration of the anhepatic period was 2 hours and 55 minutes. No severe hemodynamic or pulmonary complications, and no significant metabolic or coagulatory disorders occurred. To obtain good results by ex situ resection of the liver, anesthesiologist should understand the physiology of the anhepatic period and guard against possible problems during the operation.