Abstract Purpose Although liver transplantation (LT) outcomes have improved significantly over the last decades, early post-transplant vascular complications are still associated with an elevated risk of graft failure. Doppler ultrasound (DUS) enables detection of vascular complications and provides hepatic artery Resistive Index (RI). The aim of our study was to evaluate the association of the RI parameters of DUS performed in the first post-transplant week with post-transplant outcomes. Methods All consecutive patients undergoing a first LT between 2001 and 2019 at a single center were included. P were divided into three groups: RI < 0.55, RI 0.55–0.85 and RI > 0.85. Patients were also divided according to the presence or absence of hepatic artery thrombosis (HAT). Graft survival was compared among groups. Results Three hundred and forty-four patients were included. HAT occurred in 23 patients (6.7%), of which 7 were partial and 16 were complete. Biliary complications were more common in patients with HAT (11 [47.8%]) vs. 44 [13.4%] [p < 0.001]). There was no statistically significant difference in graft survival between patients with and without HAT. Patients with RI < 0.55 on post-operative day 1 had worse graft survival compared to patients with RI 0.55–0.85 and RI > 0.85. RI on post-operative day 3 and 5 was not predictive of graft survival. Conclusions The use of DUS on liver transplant recipients in the early post-transplant period offers the possibility of early diagnosis of vascular complications. Additionally, according to our data, low RI (< 0.55) on the first postoperative day also provides prognostic information regarding graft-survival.

PURPOSE:Although liver transplantation (LT) outcomes have improved significantly over the last decades, early vascular complications are still associated with elevated risks of graft failure. Doppler ultrasound (DUS) enables detection of vascular complications, provides hepatic artery Resistive Index (RI). The aim of our study was to evaluate the association of the RI parameters of DUS performed in the first post-transplant week with post-transplant outcomes. METHODS:All consecutive patients undergoing a first LT between 2001 and 2019 at a single center were included. Patients were divided into two groups: RI < 0.55 and RI ≥ 0.55. Patients were also divided according to the presence or absence of hepatic artery thrombosis (HAT). Graft survival was compared between groups. RESULTS:Overall, 338 patients were included. HAT occurred in 23 patients (6.8%), of which 7 were partial and 16, complete. Biliary complications were more common in patients with HAT (10 [43.5%]) vs. 38 [12.1%] [p < 0.001]). Graft survival was lower for patients with HAT (p = 0.047). Also, RI < 0.55 was associated with increased incidence of HAT (p < 0.001). Additionally, patients with RI < 0.55 on post-operative day 1 had decreased graft survival as compared to patients with RI > 0.55 (p = 0.041). RI on post-operative day 3 and 5 was not predictive of inferior graft outcomes. CONCLUSIONS:Intensive use of DUS in the early post-LT period offers the possibility of early diagnosis of vascular complications, guiding medical and surgical management of HAT. Additionally, according to our data, low RI (< 0.55) on the first postoperative day also is a predictor of HAT and decreased graft-survival.

Presenter: Cleber Kruel MD, PhD | Universidade Federal do Rio Grande do Sul Background: Intraoperative recovery devices (DRIS) (Cell Saver (R) and others) allow the blood lost by the patient to be reinfused into himself. DRIS are often used in major surgeries, reducing the need for blood transfusions. There is no consensus whether or not it is safe to use these devices in oncological patients. The aim of the present study is to evaluate the impact of DRIS in patients with hepatocellular carcinoma (HCC) submitted to liver transplantation . Methods: Adults patients undergoing a first liver transplantation for HCC in a single center from 2002 to 2018 were included. Patients transfused with blood recovered form DRIS, were compared to patients who did not receive autologous blood. Survival was calculated using the Kaplan-Meier Method, and comparison between the two groups was performed using the Log-Rank test (p value < 0.05 was considered statistically significant). Results: A total of 155 patients were included in this study. In 121 patients, DRIS were used intraoperatively, and in 34 patients these devices were not required due to minor blood loss. For the DRIS group survival at 1, 3 and 5 years was 84.8%, 76.9% and 68.2% vs. 85.3%, 71.5% and 67.5% for the control group (p = 0.82). Patients who did not use DRIS or received blood transfusion had no better survival than the others (p = 0.48). Transfusion was not associated with poor survival (p = 0.55). Conclusion: The use of DRIS seems to have no impact in tumor recurrence in HCC patients submitted to liver transplantation.

Intraoperative blood salvage (IBS) with autologous blood transfusion is controversial in liver transplantation (LT) for hepatocellular carcinoma (HCC). This study evaluated the role of IBS usage in LT for HCC. In a retrospective cohort study at a single center from 2002 to 2018, the outcomes of LT surgery for HCC were analyzed. Overall survival and disease-free survival of patients who received IBS were compared with those who did not receive IBS. Cancer recurrence, length of hospital stay, post-transplant complications, and blood loss also were evaluated. The primary aim of this study was to evaluate overall mid-term and long-term survival (4 and 6 years, respectively). Of the total 163 patients who underwent LT for HCC in the study period, 156 had complete demographic and clinical data and were included in the study. IBS was used in 122 and not used in 34 patients. Ninety-five (60.9%) patients were men, and the mean patient age was 58.5 ± 7.6 years. The overall 1-year, 5-year, and 7-year survival in the IBS group was 84.2%, 67.7%, and 56.8% vs. 85.3%, 67.5%, and 67.5% in the non-IBS group (p = 0.77). The 1-year, 5-year, and 7-year disease-free survival in the IBS group was 81.6%, 66.5%, and 55.4% vs. 85.3%, 64.1%, and 64.1% in the non-IBS group (p = 0.74). For patients without complete HCC necrosis (n = 121), the 1-year, 5-year, and 7-year overall survival rates for those who received IBS (n = 95) were 86.2%, 67.7%, and 49.6% vs. 84.6%, 70.0%, and 70.0% for 26 patients without IBS (p = 0.857). For the same patients, the 1-year, 5-year, and 7-year disease-free survival in the IBS group was 84.0%, 66.8%, and 64.0% vs. 88.0%, 72.8%, and 72.8% in the non-IBS group (p = 0.690). IBS does not appear to be associated with worse outcomes in patients undergoing LT for HCC, even in the presence of viable HCC in the explant. There seems to be no reason to contraindicate the use of IBS in LT for HCC.

Although MELD score is a reliable tool for estimating mortality in the waiting list, criteria for preoperative prediction of survival after liver transplantation (LT) are lacking. ALBI score was validated as a prognostic marker for hepatocellular carcinoma patients undergoing transarterial chemoembolization, hepatic resection, and sorafenib treatment but not for LT outcomes yet. This study aimed to evaluate ALBI score as a prognostic factor in LT. This is a single-center analysis of patients undergoing LT between October 2001 and June 2017. Primary endpoint was overall post-LT mortality. Secondary endpoint was 90-day mortality. Of all 301 patients included in this study, 185 (61.5%) were males. The median age was 54.1 ± 11.3 years. Univariate and multivariate analysis revealed that ALBI grade 3 (HR 1.836, 95% CI 1.154–2.921, p = 0.010), low serum albumin (HR 0.628, 95% CI 0.441–0.893, p = 0.010), black race (HR 2.431, 95% CI 1.160–5.092, p = 0.019), and elevated body mass index (HR 1.061, 95% CI 1.022–1.102, p = 0.002) all were associated with decreased overall survival following LT. Patients with both ALBI grade 3 (n = 25) and calculated MELD score ≥ 25 had the lowest overall survival (p < 0.001). ALBI grade 3 was related to lower post-LT survival and can be utilized as a tool for risk stratification in LT.

Shunts between the superior mesenteric vein (SMV) and the right renal vein (RRV) are very rare. Here, we describe and depict the rare case of a liver transplant (LT) in the setting of shunt between SMV and RRV. A 67-year-old white man presenting with Child C cirrhosis secondary to hemochromatosis and persistent encephalopathy was listed for LT. Preoperative abdominal angiotomography revealed the presence of a large spontaneous shunt between the SMV and the RRV. The patient underwent LT by receiving a liver from a 17-year-old brain-dead deceased donor victim of trauma. A large shunt between the SMV and the RRV was confirmed intraoperatively. Although there was no portal vein (PV) thrombosis, the PV was atrophic and had a reduced flow. PV pressure was 22mmHg (an arterial line was inserted inside the PV stump, and this line was connected to a common pressure transducer, the pressure readings was expressed in the anesthesia monitor). After shunt ligation PV pressure increased to 32mmHg. There were no post-transplant vascular complications, and the patient was discharged home in good health. Preoperative study of all LT candidates with angio CT scan is mandatory. Whenever there is PV thrombosis, an attempt to remove the entire thrombus is warranted. After thrombectomy or whenever there is not PV thrombosis, all large shunts should be ligated. PV pressure and flow should be measured before and after shunt ligation. In the absence of PV thrombosis, ligation of the shunt should enable an increase in PV flow and pressure, as reported herein.

Liver transplant (LT) is the primary treatment for patients with end-stage liver disease. About 25000 LTs are performed annually in the world. The potential for intraoperative bleeding is quite variable. However, massive bleeding is common and requires blood transfusion. Allogeneic blood transfusion has an immunosuppressive effect and an impact on recipient survival, in addition to the risk of transmission of viral infections and transfusion errors, among others. Techniques to prevent excessive bleeding or to use autologous blood have been proposed to minimize the negative effects of allogeneic blood transfusion. Intraoperative reinfusion of autologous blood is possible through previous self-donation or blood collected during the operation. However, LT does not normally allow autologous transfusion by prior self-donation. Hence, using autologous blood collected intraoperatively is the most feasible option. The use of intraoperative blood salvage autotransfusion (IBSA) minimizes the perioperative use of allogeneic blood, preventing negative transfusion effects without negatively impacting other clinical outcomes. The use of IBSA in patients with cancer is still a matter of debate due to the theoretical risk of reinfusion of tumor cells. However, studies have demonstrated the safety of IBSA in several surgical procedures, including LT for hepatocellular carcinoma. Considering the literature available to date, we can state that IBSA should be routinely used in LT, both in patients with cancer and in patients with benign diseases.

Background: Liver transplantation (LT) is a treatment for terminal chronic liver disease and in Brazil patients are listed based on Model End Liver Disease (MELD). However, when there is no significant increase in MELD, special situations (SS) were created, one of these is refractory ascites (RA). In these cases, patients receive additional score. RA is characterized when maximal doses of diuretics are used without ascites control or when creatinine increases when the dose of diuretics is increased, and the need for recurrent paracentesis. It is necessary to exclude the presence of hepatocellular carcinoma (HCC), and it is required to perform only abdominal ultrasonography (USG) up to 6 months before. Methods: The aim of this study was to evaluate explanted livers of patients submitted to LT in the Unit of Liver Transplantation of the University of Campinas, with RA to verify the presence of HCC, not diagnosed by the preoperative exams; and evaluate if would be useful to include the CT of Abdomen in the preoperative evaluation of these patients. Results: Of the 837 LT performed in this institution, 17 cases was due to SS by RA, with predominance of male (64.7%), mean age 59 years and the main etiology was virus C (47.0%).The mean survival was 238.64 days (0–1562), mean MELD of 15.23 (10–22), mean urinary sodium was 25.18 (1.25–120.4) and mean α-fetoprotein (AFP) of 10.23 (0.78–77.7).HCC was observed in 3 cases (17.6%), with 1, 3 and 6 nodules each of these patients and 8.14, 77.7 and 20.56 of AFP, respectively, with presence of angiolymphatic invasion in two of these cases. Conclusion: In conclusion, 17.6% of the cases of RA, no HCC was diagnosed with the currently required exams: abdominal USG and AFP. Thus, suggesting the need of preoperative abdominal CT in patients with chronic liver disease with RA for better selection to LT and, therefore, longer survival.

BACKGROUND:Factor V has never been compared to a validated early allograft dysfunction (EAD) definition. We aimed to assess factor V as a biomarker of EAD and a predictor of graft loss after liver transplantation (LT). METHODS:We retrospectively assessed the serum factor V levels on postoperative day 1 after LT. Patients were divided according to their factor V levels into the ≤36.1 U/mL and > 36.1 U/mL groups. The primary outcome was graft loss within 1, 3, and 6 months. The secondary outcome was EAD, as defined by Olthoff et al. Predictors of outcomes were identified by multivariable logistic regression. RESULTS:Two hundred twenty-seven patients were included in the study: 74 with factor V of 36.1 U/mL or less and 153 with factor V >36.1 U/mL. EAD was diagnosed in 41 (55.4%) of 74 patients with factor V of 36.1 U/mL or less and in 20/153 (13.1%) patients with factor V >36.1 U/mL (P < 0.001). According to the multivariable regression model, factor V was a continuous marker of EAD (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.94-0.98 per U/mL). Among the study groups, the 1-, 3-, and 6-month graft survival rates were 82%, 74%, and 74%, respectively, for patients with factor V of 36.1 U/mL or less and 98%, 95%, and 95%, respectively, for patients with factor V >36.1 U/mL (P = 0.001). Factor V was a continuous predictor for 3- and 6-month graft losses (OR, 0.96; 95% CI, 0.94-0.99 and OR, 0.97; 95% CI, 0.94-0.99 per U/mL), whereas EAD was not significant when adjusted for factor V. CONCLUSION:Factor V is an early marker for EAD and is a continuous predictor of short-term graft loss after LT.

Background: Factor V is known to be a predictor of death in acute liver failure. However, it has never been tested as a predictor of death after LT. The aim of this study was to assess the role of plasmatic Factor V levels after LT as an predictor of mortality after LT.