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Background: Acute kidney injury (AKI) is a common complication after liver transplantation (LT) that is independently associated with an increased risk of morbidity and mortality. This study aimed to evaluate the effects of administering gelatin-low dose albumin versus albumin on renal function and other early outcomes in LT., Methods: This randomized controlled clinical trial was conducted on 140 patients undergoing LT from brain death donors. Patients were randomly assigned to two groups: albumin or modified gelatin with albumin. Blood samples were collected before (T0) and on the first (T1), second (T2), third (T3), fifth (T4), and last day of hospitalization (T5) after LT for the detection of laboratory parameters, including renal and liver function tests., Results: The incidence of AKT on the basis of RIFLE criteria was 31.42% in the gelatin group (R: 59.10%, I: 36.40%, and F: 4.50%) and 25.71% in the albumin group (R: 66.70%, I: 27.80%, and F: 5.50%) (p = .845). Two patients in the gelatin and one in the albumin groups required renal replacement therapy (RRT). There was no significant difference between groups when the trends of changes in renal and liver function parameters were assessed during the study period (T0-T5). Furthermore, the incidence of complications was similar across groups., Conclusion: This study showed that modified gelatin could be used without inappropriate outcomes on renal function in patients with normal preoperative kidney function tests undergoing LT., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Post reperfusion syndrome (PRS) is a relatively common and life-threatening complication during orthotopic liver transplantation (OLT). It is associated with poor patient and transplanted liver outcomes., Objective: This study aimed to compare the risk factors of PRS during OLT., Design: Clinical-epidemiological observational retrospective study., Setting: We gathered the records of patients who underwent OLT in 3 years, from May 22, 2016, to May 22, 2019, in Namazi and Bu-Ali Sina organ transplantation hospitals., Patients: In this study, we assessed 1182 patients who underwent OLT. Patients were divided into two groups based on the presence or absence of PRS., Main Outcome Measures: Diagnosing the predictors of PRS was the primary outcome of this study., Results: Results showed that age > 60 years, Child-Pugh scores C, higher Model End Stage liver disease score, and preoperative sodium < 130 mmol/l (parameters of the liver recipient), increase in cold ischemic time (the donors' parameters), and the classical technique (the surgical parameters) were the strong predictors of PRS., Conclusions: The results indicated that underlying liver disease was not the predictor of PRS in the presence of other risk factors; therefore, clinicians have to consider these risk factors in patients undergoing OLT., (© 2022. The Author(s).)

Objectives: One of the most prevalent complications of orthotopic liver transplant is primary graft dysfunction. Recent studies have shown the preconditioning effect of remifentanil on animal livers but not human livers. Here, we compared the preconditioning effects of remifentanil and fentanyl in orthotopic liver transplant in human patients., Materials and Methods: In this double-blind clinical trial, 100 patients who underwent liver transplant from deceased donors were randomly allocated into 2 groups. Patients in the remifentanil group received remifentanil infusion, and those in the fentanyl group received fentanyl infusion during maintenance of anesthesia. Serum aminotransferase levels, prothrombin time (international normalized ratio), partial thrombin time, arterial blood gas levels, and renal function tests were evaluated over 7 days posttransplant. Intensive care unit stay and hospitalization were also recorded., Results: The median peak alanine aminotransferase level during 7 days after transplant was 2100 U/L (interquartile range, 1230-3220) in the remifentanil group and 3815 U/L (interquartile range, 2385-5675) in the fentanyl group (P = .048). Metabolic acidosis, renal state, prothrombin time (international normalized ratio), and partial thrombin time were similar in both groups (P > .05). Durations of stay in the intensive care unit and hospital were not significantly different between the 2 groups (P = .75 and P = .23, respectively). Overall, the clinical outcomes were similar in the remifentanil and fentanyl groups (P > .05)., Conclusions: We found that remifentanil and fentanyl were not different with regard to their preconditioning effects and graft protection in orthotopic liver transplant recipients.

Objectives: Liver transplant traditionally and potentially is associated with the risk of massive blood loss and transfusion, which can adversely affect transplant outcomes. Many variables influence the amount of bleeding, and these can be categorized as patient related, surgery related, and graft related. We aimed to assess the effects of these variables on the amount of bleeding and transfusion during liver transplant; predicting the risk of massive blood loss can help transplant teams to select and manage patients more effectively., Materials and Methods: We retrospectively studied 754 patients who underwent liver transplant from 2013 to 2016 and analyzed more than 20 variables that could influence the volume of blood loss and packed cell transfusion., Results: We found that at least 4 variables are strongly and independently correlated with blood loss volume: age, Model for End-Stage Liver Disease score, warm ischemia time, and total bilirubin. Furthermore, intraoperative blood loss had a weak but clinically important correlation with the underlying disease (ie, the cause of liver cirrhosis). Some variables, including international normalized ratio, platelet count, albumin, serum urea nitrogen, creatinine level, sodium level, and the amount of ascites, could be considered as 'dependent' and weak predictors of massive blood loss. Sex of patient, cold ischemia time, surgery technique, and history of previous abdominal surgery were not correlated with the amount of bleeding., Conclusions: With the use of the variables identified, we can properly select patients and surgical teams and promptly use modalities for decreasing and managing blood loss.

Background: Iran's experience with liver transplantation (LT) began more than two decades ago. The purpose of this article is to present the status of LT in Iran, review specific characteristics of the programs, their outcomes, and their growth to become one of the largest LT programs in the world., Methods: A questionnaire, asking for data on the number of transplants performed and specifics of the recipients and type of donors with focus on indications and outcomes was sent to LT programs., Results: During a period of 23 years, 4,485 LTs were performed at 6 centers in the country. Of these, 4106 were from deceased donors and 379 were from living donors. There were 3553 adults and 932 pediatric recipients. Hepatitis B and biliary atresia were the most common etiologies in adult and pediatric patients, respectively. Overall survival rates at 1, 5, and 10 years were 85%, 77%, and 71% for adults and 76%, 67% and 56% for pediatric patients, respectively., Conclusion: Approval of the brain death law in Iran and coordinated efforts by the transplant centers to build comprehensive LT programs has resulted in the ability to procure more than 700 deceased donors per year with acceptable long-term survival., (© 2018 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Brain death is associated with increased inflammatory cytokines levels and poor graft quality to transplant. We aimed to evaluate the impact of Ascorbic Acid (AA) on the inflammatory status of Brain-Dead Donors (BDDs). Forty BDDs were randomly divided into two groups. Donor treatment (n=20) consisted of 100 mg/kg AA infusion 6 hours before donor operation and subsequent infusion of 100 mg/kg/p6h until organ removal. Blood samples were taken at three times, 6 hours before donor surgery (TP(1)), immediately after laparotomy (TP(2)), and before organ removal (TP(3)). Gene expression level and serum concentration of IL-6 and TNF-α cytokines were assessed by real-time PCR and ELISA methods. To investigate transplanted liver function, serum values of Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT), and Billirubin-Total were evaluated on the 1(st), 3(rd), and 10(th) postoperative days. We found a significant reduction in IL-6 mRNA expression ratio of TP(3) to TP(1) following AA application among BDDs. Despite the considerable decrease in treated donors regarding IL-6 mRNA expression ratio of TP(2) to TP(1), TP(3) to TP(2), and also TNF-α variations in these periods, the results were not significant. Regarding serum concentration of these cytokines, particularly IL-6, there was a decrease between TP(2) and TP(3) following AA application in the treated donors. Furthermore, a significant reduction was found in serum AST and ALT levels in the recipients of treated group on the 3(rd) day compared to the 1(st) day after transplantation. It seems that AA beneficially affects the inflammatory status of BDDs, resulting in improved primary allograft function.

Context: Attenuating postreperfusion syndrome during orthotopic liver transplant is very important for transplant anesthesiologists because of the syndrome's complications. Oxygen-derived free radicals play an important role in the genesis of postreperfusion syndrome, but the effect of mannitol (a free radical scavenger) on attenuating the syndrome is unclear.OBJECTIVES-To investigate the effectiveness of infusing mannitol during the anhepatic phase in preventing postreperfusion syndrome, as indicated by postreperfusion cardiac output and central venous oxygen saturation., Design: In a randomized clinical trial, 53 patients who had undergone orthotopic liver transplant were allocated to 2 groups. During the anhepatic phase, patients in the mannitol group received 1g/kg mannitol, whereas those in the control group received physiological saline. Mean arterial pressure, cardiac output, and central venous oxygen saturation were measured before and after the portal vein was declamped. Serum levels of sodium and potassium were recorded at baseline and after portal vein declamping.Setting-Shiraz Organ Transplant Center, Shiraz, Iran., Results: In the mannitol group, no significant change was found in mean arterial pressure, cardiac output, and central venous oxygen saturation before and after declamping of the portal vein (P= .78, P= .59, and P= .83, respectively). However, after declamping in the control group, mean arterial pressure, cardiac output, and central venous oxygen saturation were significantly lower than before declamping (P=.003, P=.001, and P<.001, respectively). No significant change in serum levels of sodium and potassium from baseline to after declamping were found in either group., Conclusion: Infusion of mannitol 1 g/kg during the anhepatic phase was effective in attenuating postreperfusion syndrome without stress about hyperkalemia or hyponatremia during anesthesia.

Objectives: Uncorrected hypernatremia in organ donors has been associated with poor graft or patient survival during liver transplants. However, recent studies have found no association between the donor serum sodium and transplant outcome. This study sought to show the negative effect donor hypernatremia has on initial liver allograft function. This is the first study to investigate international normalized ratio and renal factors of patients with normal and those with hypernatremic donor livers., Materials and Methods: This study was conducted at the Shiraz Transplant Research Center in Shiraz, Iran, between May 2009, and July 2011. Four hundred seven consecutive adult orthotopic liver transplants were performed at the University of Shiraz Medical Center., Results: There were 93 donors in the group with hypernatremia with terminal serum sodium of 155 mEq/L or greater (group 1), and 314 with terminal serum sodium less than 155 mEq/L (group 2). Posttransplant data after 5 days showed that aspartate aminotransferase, alanine aminotransferase, international normalized ratio, and kidney function did not differ between the groups., Conclusions: Hypernatremia is the most important complication after brain death. Previous studies have suggested donor hypernatremia results in a greater incidence of early postoperative graft dysfunction in liver transplant and is considered one of the extended criteria donor. However, in recent years, this hypothesis has been questioned. Our study shows no difference between patients' initial results of liver and kidney functioning with normal and hypernatremic donor livers. This is the first study to investigate international normalized ratio as a fundamental factor in defining early allograft dysfunction and renal factors between patients with normal and hypernatremic donor's livers.

Background: Patients with end-stage liver diseases who undergo liver transplantation may suffer from hypotension related to the liver disease itself or related to the surgical procedure. Because electro-acupuncture (EA) at the Neiguan (PC-6) and the Jianshi (PC-5) points influences hemodynamics, we hypothesize that electro-acupuncture at the traditionally used acupuncture points will reduce the severity of hypotension in patients who undergo liver transplantation., Methods: Forty patients with end-stage liver disease who underwent orthotropic deceased donor liver transplantation were randomized into two groups. The norepinephrine (NE) group received norepinephrine as a vasoconstrictor, and the electro-acupuncture group received EA at the PC-5 and the PC-6 points for treatment of hypotension during anesthesia for the liver transplantation. The patients were monitored, during the three stages of liver transplantation by using hemodynamic parameters., Results: During the three stages of liver transplantation, there were no significant differences in the hemodynamic measurements including the mean arterial pressure, heart rate and central venous pressure between the two groups (p>0.05)., Conclusions: Electro-acupuncture at the acupuncture points reduced the severity and the incidence of hypotension during anesthesia for liver transplantation., (Copyright © 2012. Published by Elsevier B.V.)

Context: Intraoperative transfusion can affect the chance of graft survival in liver transplantation, a complicated operation with massive blood loss. Verification of factors that are predictive of intraoperative blood loss and transfusion increases the quality of anesthesia management., Objective: To assess use of blood and blood products between 2002 and 2008 and to evaluate factors associated with blood loss and requirement for blood products in adult patients undergoing orthotopic liver transplantation via piggyback technique., Design: Medical charts and anesthesia records from 261 eligible adult recipients of an orthotopic liver transplant between March 2002 and May 2008 were reviewed., Setting: Shiraz Liver Transplantation Center, the only active liver transplantation center in Iran., Main Outcome Measures: Potential influencing factors in blood loss and transfusion, including sex, preoperative hemoglobin level, international normalized ratio, primary diagnosis, platelet count, creatinine level, Model for End-Stage Liver Disease (MELD) score, central venous pressure, and total anesthesia time, were measured and subjected to multivariable analysis., Results: Mean blood loss was 54.2 (SD, 47.9) mL/kg, the mean (SD) for amounts of blood products transfused was 25.3 (19.5) mL/kg for packed red blood cells, 2.6 (3.3) units for fresh frozen plasma, and 1.7 (3.1) units for platelets. Seven recipients (2.7%) underwent transplantation without intraoperative transfusion of red blood cells, whereas 25 patients (9.6%) received more than 10 units of red blood cells intraoperatively. Multivariable analysis showed that no preoperative factor was a predictor of blood loss or requirement for intraoperative transfusion. Transfusion of fresh frozen plasma and packed red blood cells was significantly lower in 2005, 2006, 2007, and 2008 than in 2003 to 2004 (P < .001).

Mucormycosis is a rare but highly invasive fungal infection that occurs in transplant recipients. The literature contains descriptions of 12 cases of mucormycosis after orthotopic liver transplantation (OLT). This report describes the fatal courses in four patients at our center who developed mucormycosis after liver transplantation. Of 51 liver transplant recipients who received grafts between December 1993 and April 2003, 4 (7.8%; 3 males and 1 female) developed mucormycosis. The primary liver diseases in the four cases were Wilson's disease, autoimmune hepatitis, primary biliary cirrhosis, and cryptogenic cirrhosis. Three of the transplants were harvested by another team and shipped to our center. We concluded that selection of poor transplant candidates, prolonged antibiotic therapy and/or hospitalization prior to OLT, and breaks in aseptic technique during harvesting, shipping, and during operation are the main reasons for the high incidence of mucormycosis in our OLT patients.

A correction is presented to the article "Risk factors of the post-reperfusion syndrome during orthotopic liver transplantation: a clinical observational study."

A serious hazard to patients during orthotopic liver transplantation is hyperkalemia. Although the most frequent and hazardous hyperkalemia occurs immediately after reperfusion of the newly transplanted liver, morbid hyperkalemia could happen in the other phases during orthotopic liver transplantation. However, pre-anhepatic hyperkalemia during orthotopic liver transplantation is rare. This report describes one such patient, who without transfusion, developed severe hyperkalemia during pre-anhepatic phase. The variations in serum potassium concentration of the present case indicate that it is necessary to take care of the changes of serum potassium concentration not only during reperfusion but also during the other phases of the liver transplantation. [ABSTRACT FROM AUTHOR]

Background: Severe metabolic acidosis occurs during orthotopic liver transplantation (OLT) particularly during the anhepatic phase. Although NaHCO3 is considered as the current standard therapy, there are numerous adverse effects. The aim of this study was to determine whether the restricted use of normal saline during anesthesia could reduce the need for NaHCO3. Methods: In this study we enrolled 75 patients with end-stage liver disease who underwent OLT from February 2010 until September 2010 at the Shiraz Organ Transplantation Center. Fluid management of two different transplant anesthetics were compared. The effect of restricted normal saline fluid was compared with non-restricted normal saline fluid on hemodynamic and acid-base parameters at three times during OLT: after the skin incision (T1), 15 min before reperfusion (T2), and 5 min after reperfusion (T3). Results: There were no significant differences in demographic characteristics of the donors and recipients (P>0.05). In the restricted normal saline group there was significantly lower central venous pressure (CVP) than in the non-restricted normal saline group (P=0.002). No significant differences were noted in the other hemodynamic parameters between the two groups (P>0.05). In the non-restricted normal saline group arterial blood pH (P=0.01) and HCO3 (P=0.0001) were significantly less than the restricted normal saline group. The NaHCO3 requirement before reperfusion was significantly more than with the restricted normal saline group (P=0.001). Conclusion: Restricted normal saline administration during OLT reduced the severity of metabolic acidosis and the need for NaHCO3 during the anhepatic phase. [ABSTRACT FROM AUTHOR]