Factors affecting complications development and mortality after single lung transplant

Lung transplantation(LT)is a life-saving therapeutic procedure that prolongs survival in patients with end-stage lung disease.Furthermore,as a therapeutic option for high-risk candidates,single LT(SLT)can be feasible because the immediate morbidity and mortality after transplantation are lower compared to sequential single(double)LT(SSLTx).Still,the long-term overall survival is,in general,better for SSLTx.Despite the great success over the years,the early post-SLT period remains a perilous time for these patients.Patients who undergo SLT are predisposed to evolving early or late postoperative complications.This review emphasizes factors leading to post-SLT complications in the early and late periods including primary graft dysfunction and chronic lung allograft dysfunction,native lung complications,anastomosis complications,infections,cardiovascular,gastrointestinal,renal,and metabolite complications,and their association with morbidity and mortality in these patients.Furthermore,we discuss the incidence of malignancy after SLT and their correlation with immunosuppression therapy.

Role for contrast-enhanced ultrasound in assessing complications after kidney transplant

Kidney transplantation(KT)is an effective treatment for end-stage renal disease.Despite their rate has reduced over time,post-transplant complications still represent a major clinical problem because of the associated risk of graft failure and loss.Thus,post-KT complications should be diagnosed and treated promptly.Imaging plays a pivotal role in this setting.Grayscale ultrasound(US)with color Doppler analysis is the first-line imaging modality for assessing complications,although many findings lack specificity.When performed by experienced operators,contrast-enhanced US(CEUS)has been advocated as a safe and fast tool to improve the accuracy of US.Also,when performing CEUS there is potentially no need for further imaging,such as contrast-enhanced computed tomography or magnetic resonance imaging,which are often contraindicated in recipients with impaired renal function.This technique is also portable to patients’bedside,thus having the potential of maximizing the cost-effectiveness of the whole diagnostic process.Finally,the use of blood-pool contrast agents allows translating information on graft microvasculature into time-intensity curves,and in turn quantitative perfusion indexes.Quantitative analysis is under evaluation as a tool to diagnose rejection or other causes of graft dysfunction.In this paper,we review and illustrate the indications to CEUS in the post-KT setting,as well as the main CEUS findings that can help establishing the diagnosis and planning the most adequate treatment.

Early post-operative complications in living donor liver transplantation:prevention,detection and management

Living donor liver transplantation (LDLT) is now performed with high rates of success due to judicious recipient and donor selection,careful preoperative planning, excellent anesthesia management, and prompt detection and treatment of complications. The indications for LDLT for adult and pediatric recipients should be the same as for deceased donor liver transplantation. Early postoperative complications are often defined as complications occurring within the first 3 months

Imaging features of intrathoracic complications of lung transplantation:What the radiologists need to know

Lung transplantation has been a method for treating end stage lung disease for decades. Despite improvements in the preoperative assessment of recipients and donors as well as improved surgical techniques, lung transplant recipients are still at a high risk of developing postoperative complications which tend to impact negatively the patients' outcome if not recognised early. The recognised complications post lung transplantation can be broadly categorised into acute and chronic complications. Recognising the radiological features of these complications has a significant positive impact on patients' survival post transplantation. This manuscript provides a comprehensive review of the radiological features of post lung transplantations complications over a time continuum.

Incidence, risk factors and clinical outcome of multidrug-resistant organisms after heart transplantation

BACKGROUND Transplant recipients commonly harbor multidrug-resistant organisms(MDROs),as a result of frequent hospital admissions and increased exposure to antimi-crobials and invasive procedures.AIM To investigate the impact of patient demographic and clinical characteristics on MDRO acquisition,as well as the impact of MDRO acquisition on intensive care unit(ICU)and hospital length of stay,and on ICU mortality and 1-year mortality post heart transplantation.METHODS This retrospective cohort study analyzed 98 consecutive heart transplant patients over a ten-year period(2013-2022)in a single transplantation center.Data was collected regarding MDROs commonly encountered in critical care.RESULTS Among the 98 transplanted patients(70%male),about a third(32%)acquired or already harbored MDROs upon transplantation(MDRO group),while two thirds did not(MDRO-free group).The prevalent MDROs were Acinetobacter baumannii(14%),Pseudomonas aeruginosa(12%)and Klebsiella pneumoniae(11%).Compared to MDRO-free patients,the MDRO group was characterized by higher body mass index(P=0.002),higher rates of renal failure(P=0.017),primary graft dysfunction(10%vs 4.5%,P=0.001),surgical re-exploration(34%vs 14%,P=0.017),mechanical circulatory support(47%vs 26%P=0.037)and renal replacement therapy(28%vs 9%,P=0.014),as well as longer extracorporeal circulation time(median 210 vs 161 min,P=0.003).The median length of stay was longer in the MDRO group,namely ICU stay was 16 vs 9 d in the MDRO-free group(P=0.001),and hospital stay was 38 vs 28 d(P=0.006),while 1-year mortality was higher(28%vs 7.6%,log-rank-χ2:7.34).CONCLUSION Following heart transplantation,a predominance of Gram-negative MDROs was noted.MDRO acquisition was associated with higher complication rates,prolonged ICU and total hospital stay,and higher post-transplantation mortality.

Post-operative imaging in liver transplantation: State-of-the-art and future perspectives

Orthotopic liver transplantation(OLT)represents a major treatment for end-stage chronic liver disease,as well as selected cases of hepatocellular carcinoma and acute liver failure.The ever-increasing development of imaging modalities significantly contributed,over the last decades,to the management of recipients both in the pre-operative and post-operative period,thus impacting on graft and patients survival.When properly used,imaging modalities such as ultrasound,multidetector computed tomography,magnetic resonance imaging(MRI)and procedures of direct cholangiography are capable to provide rapid and reliable recognition and treatment of vascular and biliary complications occurring after OLT.Less defined is the role for imaging in assessing primary graft dysfunction(including rejection)or chronic allograft disease after OLT,e.g.,hepatitis C virus(HCV)recurrence.This paper:(1)describes specific characteristic of the above imaging modalities and the rationale for their use in clinical practice;(2)illustrates main imaging findings related to post-OLTcomplications in adult patients;and(3)reviews future perspectives emerging in the surveillance of recipients with HCV recurrence,with special emphasis on MRI.

Donor safety and remnant liver volume in living donor liver transplantation

AIM:To evaluate the relationship between donor safety and remnant liver volume in right lobe living donor liver transplantation(LDLT).METHODS:From July 2001 to January 2009,our liver transplant centers carried out 197 LDLTs.The clinical data from 151 cases of adult right lobe living donors(not including the middle hepatic vein) were analyzed.The conditions of the three groups of donors were well matched in terms of the studied parameters.The donors' preoperative data,intraoperative and postoperative data were calculated for the three groups:Group 1 remnant liver volume(RLV) < 35%,group 2 RLV 36%-40%,and group 3 RLV > 40%.Comparisons included the different remnant liver volumes on postoperative liver function recovery and the impact of systemic conditions.Correlations between remnant liver volume and post-operative complications were also analyzed.RESULTS:The donors' anthroposomatology data,op-eration time,and preoperative donor blood test indicators were calculated for the three groups.No significant differences were observed between the donors' gender,age,height,weight,and operation time.According to the Chengdu standard liver volume formula,the total liver volume of group 1 was 1072.88 ± 131.06 mL,group 2 was 1043.84 ± 97.11 mL,and group 3 was 1065.33 ± 136.02 mL.The three groups showed no statistically significant differences.When the volume of the remnant liver was less than 35% of the total liver volume,the volume of the remnant had a significant effect on the recovery of liver function and intensive care unit time.In addition,the occurrence of complications was closely related to the remnant liver volume.When the volume of the remnant liver was more than 35% of the total liver volume,the remnant volume change had no significant effect on donor recovery.CONCLUSION:To ensure donor safety,the remnant liver volume should be greater than the standard liver volume(35%) in right lobe living donor liver transplantation.

Approach to persistent ascites after liver transplantation

Persistent ascites(PA)after liver transplantation(LT),commonly defined as ascites lasting more than 4 wk after LT,can be expected in up to 7%of patients.Despite being relatively rare,it is associated with worse clinical outcomes,including higher 1-year mortality.The cause of PA can be divided into vascular,hepatic,or extrahepatic.Vascular causes of PA include hepatic outflow and inflow obstructions,which are usually successfully treated.Regarding modifiable hepatic causes,recurrent hepatitis C and acute cellular rejection are the leading ones.Considering predictors for PA,the presence of ascites,refractory ascites,hepatorenal syndrome type 1,spontaneous bacterial peritonitis,hepatic encephalopathy,and prolonged ischemic time significantly influence the development of PA after LT.The initial approach to patients with PA should be to diagnose the treatable cause of PA.The stepwise approach in evaluating PA includes diagnostic paracentesis,ultrasound with Doppler,and an echocardiogram when a cardiac cause is suspected.Finally,a percutaneous or transjugular liver biopsy should be performed in cases where the diagnosis is unclear.PA of unknown cause should be treated with diuretics and paracentesis,while transjugular intrahepatic portosystemic shunt and splenic artery embolization are treatment methods in patients with refractory ascites after LT.

Adult to adult living related liver transplantation: Where do we currently stand?

Adult to adult living donor liver transplantation (AALDLT) was first preformed in the United States in 1997. The procedure was rapidly integrated into clinical practice, but in 2002, possibly due to the first widely publicized donor death, the number of living liver donors plummeted. The number of donors has since reached a steady plateau far below its initial peak. In this review we evaluate the current climate of AALDLT. Specifically, we focus on several issues key to the success of AALDLT: determining the optimal indications for AALDLT, balancing graft size and donor safety, assuring adequate outflow, minimizing biliary complications, and maintaining ethical practices. We conclude by offering suggestions for the future of AALDLT in United States transplantation centers.

Management of intestinal failure in inflammatory bowel disease:Small intestinal transplantation or home parenteral nutrition?

Inflammatory bowel disease and Crohn&#x02019;s disease in particular, is a common cause of intestinal failure. Current therapeutic options include home parenteral nutrition and intestinal transplantation. For most patients, home intravenous therapy including parenteral nutrition, with a good probability of long-term survival, is the favoured choice. However, in selected patients, with specific features that may shorten survival or complicate home parenteral nutrition, intestinal transplantation presents a viable alternative. We present survival, complications, quality of life and economic considerations that currently influence individualised decision-making between home parenteral nutrition and intestinal transplantation.

Liver graft preservation methods during cold ischemia phase and normothermic machine perfusion

The growing demand for donor organs requires measures to expand donor pool.Those include extended criteria donors, such as elderly people, steatotic livers,donation after cardiac death, etc. Static cold storage to reduce metabolic requirements developed by Collins in late 1960 s is the mainstay and the golden standard for donated organ protection. Hypothermic machine perfusion provides dynamic organ preservation at 4°C with protracted infusion of metabolic substrates to the graft during the ex vivo period. It has been used instead of static cold storage or after it as short perfusion in transplant center. Normothermic machine perfusion(NMP) delivers oxygen, and nutrition at physiological temperature mimicking regular environment in order to support cellular function. This would minimize effects of ischemia/reperfusion injury.Potentially, NMP may help to estimate graft functionality before implantation into a recipient. Clinical studies demonstrated at least its non-inferiority or better outcomes vs static cold storage. Regular grafts donated after brain death could be safely preserved with convenient static cold storage. Except for prolonged ischemia time where hypothermic machine perfusion started in transplant center could be estimated to provide possible positive reconditioning effect. Use of hypothermic machine perfusion in regular donation instead of static cold storage or in extended criteria donors requires further investigation. Multicenter randomized clinical trial supposed to be completed in December 2021. Extended criteria donors need additional measures for graft storage and assessment until its implantation. NMP is actively evaluating promising method for this purpose.Future studies are necessary for precise estimation and confirmation to issue clinical practice recommendations.

Experiences relating to management of biliary tract complications following liver transplantation in 96 cases

To investigate best diagnosing methods and therapy for patients with biliary tract complications after liver transplantation and analyze related factors Methods A review was made of data collected from 96 patients, and confirmed by retrospective case notes examination Results A total of 94 patients (97 grafts) survived more than 2 days after transplantation; of whom, 92 had an end to end biliary anastomosis with a T tube The average follow up was 5 8 months (range: 0 3-10 2 months) Among the 94 patients, eight (8 5%, 8/94) had complications: leakage during T tube removal (2 patients), leakage at an earlier stage (2), simultaneous stricture and leak (2) and just stricture (2) Six patients with biliary tract complications had predisposing factors including hepatic artery stenosis (2 patients, including one hepatic artery stenosis combined with severe rejection, hepatic artery thrombosis (3), and donor recipient bile duct mismatch (1) There was no difference in cold ischemic time With hepatic artery thrombosis and/or stenosis 】50%, five patients were re transplanted; without hepatic artery thrombosis and/or stenosis 【50%, three patients required endoscopic stenting and radiological percutaneous drainage of bile collection with or without balloon dilation All patients survived Conclusions Biliary strictures occur later than leaks after surgery Without hepatic artery thrombosis and/or stricture, there is no need for surgery; with hepatic artery thrombosis and/or stricture 】50%, re transplantation is needed as early as possible

Current role in facial allograft transplantation:what have we learned?

Face transplant(FT)has evolved enormously in the last 10 years since the successful completion of the first facial transplant.This procedure has become a new reconstructive option for complex facial deformities to restore the anatomy of patients with severely disfigured faces.The authors review the literature and discuss the main surgical,immunological,and ethical aspects as well as the results described in patients undergoing FT.To date there have been more than thirty FT worldwide.The main indication was post-traumatic deformity.In all cases a standard immunosuppression was performed with three drugs,although acute rejection episodes were observed,that could be controlled with conventional immunosuppressive regimen.Overall,functional and aesthetic results have been excellent at short-term and high satisfaction rate exceeded initial expectations,although long-term data are still scarce.Major complications were opportunistic infections.Five deaths that occurred have reopened the ethical debate about the potential complications and concerns of providing informed consent to recipients.Continuous progresses in microsurgical techniques and preoperative planning have promoted the evolution from partial to full FT.All these are on the basis of accurate and careful selection of well-motivated candidates.The next challenge will be getting new immunosuppressive treatment strategies.Although clinical experience has demonstrated the FT viability,it is still considered an experimental procedure in which we have much to learn to define its true role in the current reconstructive surgery and resolve major technical,medical and ethical problems involved.