Intraoperative blood loss in orthotopic liver transplantation:The predictive factors

Liver transplantation has been associated with massive blood loss and considerable transfusion requirements. Bleeding in orthotopic liver transplantation is multifactorial. Technical difficulties inherent to this complex surgical procedure and pre operative derangements of the primary and secondary coagulation system are thought to be the principal causes of perioperative hemorrhage. Intraoperative practices such as massive fluid resuscitation and resulting hypothermia and hypocalcemia secondary to citrate toxicity further aggravate the preexisting coagulopathy and worsen the perioperative bleeding. Excessive blood loss and transfusion during orthotopic liver transplant are correlated with diminished graft survival and increased septic episodes and prolonged ICU stay. With improvements in surgical skills, anesthetic technique, graft preservation, use of intraoperative cell savers and overall perioperative management, orthotopic liver transplant is now associated with decreased intra operative blood losses. The purpose of this review is to discuss the risk factors predictive of increased intra operative bleeding in patients undergoing orthotopic liver transplant.

Source of blood supply of liver cavernous hemangioma and sclerosis and embolization treatment

AIM To investigate the source of blood supply of carvenous hemangioma of liver (CHL) and provide a feasibile treatment for CHL via hepatic artery. METHODS Ⅰ. Origin of blood supply of CHL: portovenography, hepatic arteriography and portal vein staining were performed in 5 patients. Two casts of hepatic blood vessels from resected specimen were observed. Ⅱ. Clinical data: Among 75 patients (30 males, 45 females, aged 25～57 years with a mean of 37 4). 56 were of solitary type (44 on the right lobe, 12 on the left with 4 having intraparenchymatoma) and 19 were of multiple type (9 on the right, 2 the left, 8 whole liver). Twenty two patients were treated by sclerosis, 50 by embolization via hepatic artery and 3 were excised. RESULTS In 5 cases with portography, the contrast medium did not enter the tumor, the tumor appeared as low denty area and the intrahepatic branches of portal vein were pushed aside. In 5 cases with portal vein staining, the normal liver parenchyma was stained deep blue, and the tumor was not stained. The tumor area appeared as a round vacant cavity in 2 specimen casts. In 72 patients treated with sclerosis a or embolization via hepatic artery or through interventional method, the tumors diminished by 10%～30% in diameter and no tumors grew larger. CONCLUSION The blood supply of CHL originates from the hepatic artery. Tumors treated with sclerosis and emblization decreased in size or got fiberized.

Predictive roles of intraoperative blood glucose for posttransplant outcomes in liver transplantation

Diabetogenic traits in patients undergoing liver transplantation(LT) are exacerbated intraoperatively by exogenous causes, such as surgical stress, steroids,blood transfusions, and catecholamines, which leadto intraoperative hyperglycemia. In contrast to the strict glucose control performed in the intensive care unit, no systematic protocol has been developed for glucose management during LT. Intraoperative blood glucose concentrations typically exceed 200 mg/dL in LT, and extreme hyperglycemia(> 300 mg/dL) is common during the neohepatic phase. Only a few retrospective studies have examined the relationship between intraoperative hyperglycemia and posttransplant complications, with reports of infectious complications or mortality. However, no prospective studies have been conducted regarding the influence of intraoperative hyperglycemia in LT on post-transplant outcome. In addition to absolute blood glucose values,the temporal patterns in blood glucose levels during LT may serve as prognostic features. Persistent neohepatic hyperglycemia(without a decline) throughout LT is a useful indicator of early graft dysfunction. Moreover,intraoperative variability in glucose levels may predict the need for reoperation for hemorrhage after LT.Thus, there is an urgent need for guidelines for glucose control in these patients, as well as prospective studies on the impact of glucose control on various posttransplant complications. This report highlights some of the recent studies related to perioperative blood glucose management focused on LT and liver disease.

The origin of blood supply for cavernous hemangioma of the liver

OBJECTIVE: To investigate the origin of blood supply to cavernous hemangioma of the liver (CHL). METHODS: To observe the relation of cavernous hemangioma of the liver to the hepatic artery and portal vein, we performed serial selective hepatic arteriography in 22 patients. Five patients after ligation of the right hepatic arteries underwent portography and liver staining by in jection of methylene blue into the portal veins and 2 patients had hepatic specimens resected, which were made into a model cast by filling the hepatic veins (yellow) and portal venous branches (blue) with methyl methacrylate after vascular lavage. RESULTS: Serial selective hepatic arteriography showed that hepatic arteries and hemangioma were displayed simultaneously, and that hemangioma was supplied by one to numerous arterial branches. In the portal phase of portography, contrast medium failed to enter the tumor and the intrahepatic branches of the portal vein were pushed aside by the tumor; in the liver parenchymal phase, however, the tumor appeared to be a low-density area. Hepatic arteriography and portography revealed that the fistula between the artery and portal vein may not be existed. The liver stained with methylene blue showed that the normal hepatic parenchyma could be stained with deep blue; in contrast, the tumor was not stained at all. The casting specimens showed that the eroded tumor left a round vacant area because of its total shedding, and no blue stained branches of the portal vein extended into the tumor. CONCLUSION: Blood supply of CHL may originate from the hepatic artery.

Controversy over the use of intraoperative blood salvage autotransfusion during liver transplantation for hepatocellular carcinoma patients

Intraoperative blood salvage autotransfusion (IBSA) is used in various surgical procedures. However, because of the risk of reinfusion of salvaged blood contaminated by tumor cells, the use of IBSA in hepatocellular carcinoma (HCC) patients undergoing liver transplantation (LT) is controversial. The critical points include whether tumor cells can be cleared by IBSA, whether IBSA increases the risk of recurrence or metastasis, and what are the indications for IBSA. Moreover, is it warranted to take the risk of tumor dissemination by using IBSA to avoid allogeneic blood transfusion? Do the remaining tumor cells after additional filtration by leukocyte depletion filters still possess potential tumorigenicity? Does IBSA always work well? We have reviewed the literature and tried to address these questions. The available data indicate that IBSA is safe in LT for HCC, but randomized, controlled and prospective trials are urgently required to clarify the uncertainty.

Correlation between hepatic blood flow and liver function in alcoholic liver cirrhosis

AIM: To elucidate the correlation between hepatic blood flow and liver function in alcoholic liver cirrhosis (AL-LC).

Therapeutic potential of menstrual blood stem cells in treating acute liver failure

BACKGROUND Acute liver failure(ALF)is a significant and complex hepatic insult that may rapidly progress to life-threatening conditions.Recently,menstrual blood stem cells(MenSCs)have been identified as a group of easily accessible mesenchymal stem cells with the advantages of non-invasive acquisition,low immunogenicity,a greater capacity of self-renewal and multi-lineage differentiation,making them promising candidates for stem cell-based therapy to revolutionize the treatment strategies for liver failure.AIM To investigate the therapeutic potential of MenSCs for treating ALF in pigs and to dynamically trace the biodistribution of transplanted cells.METHODS MenSCs were labeled in vitro with PKH26,a lipophilic fluorescent dye.The treatment group received immediate transplantation of PKH26-labelled MenSCs(2.5×106/kg)via the portal vein after D-galactosamine injection,and the control group underwent sham operation.The survival time,liver function,and hepatic pathological changes were compared between the two groups.Three major organs(liver,lungs and spleen)were extracted from animals and imaged directly with the In vivo Imaging System(IVIS)at the predetermined time points.The regions of interest were drawn to quantify the cell uptake in different organs.RESULTS The labelling procedure did not affect the morphology,viability or multipotential differentiation of MenSCs.Biochemical analysis showed that the levels of alanine aminotransferase(ALT),aspartate aminotransferase(AST),total bilirubin(TBIL)and prothrombin time(PT)measured at selected time points 24 h after transplantation were significantly decreased in the treatment group(P<0.05).The survival time of ALF animals was prolonged in the treatment group compared with the control group(75.75±5.11 h vs 53.75±2.37 h,log rank,P<0.001).The liver pathological tissue in the MenSC treatment group showed obviously increased numbers of remaining hepatocytes and a comparatively slight necrotic degree and area.In addition,the IVIS imaging revealed that PKH26-positive MenSCs were clearly retained in the liver initially and then diffused through the systemic circulation.Interestingly,the signal intensity in the liver increased obviously at 36 h,which corresponded to the biochemical result that liver function deteriorated most rapidly at 24-36 h.CONCLUSION Our study demonstrates the therapeutic efficacy and homing ability of transplanted MenSCs in a large animal model of ALF and suggests that MenSC transplantation could be a promising strategy for treating ALF.

Alterations of ATPase activity and erythrocyte oxygen consumption in patients with liver-blood deficiency syndrome

ＡｌｔｅｒａｔｉｏｎｓｏｆＡＴＰａｓｅａｃｔｉｖｉｔｙａｎｄｅｒｙｔｈｒｏｃｙｔｅｏｘｙｇｅｎｃｏｎｓｕｍｐｔｉｏｎｉｎｐａｔｉｅｎｔｓｗｉｔｈｌｉｖｅｒｂｌｏｏｄｄｅｆｉｃｉｅｎｃｙｓｙｎｄｒｏｍｅＳＨＩＬｉｎＪｉｅ１，ＬＩＵＪｕｎＦａｎ２...

Fabrication and data harvesting of casting sample of rat liver blood vessels

BACKGROUND: The configuration and course of liver blood vessels (LBVs) are involved in the study of patho-genesis of hepatic diseases including liver cirrhosis, tissue engineering of the liver and surgical treatment of diseases of the liver and gallbladder. In the study of vascularization in tissue engineering of the liver in particular, the work we should do is to get the anatomy data of LBVs for computer-aided reconstruction of digital model of LBVs. In doing so, the casting sample of rat liver blood vessels (RLBVs) is fabricated and the data of each section of the sample is harvested. METHODS: Liquid polymer preparation (8%-10%), which was made of chlorinated poly vinyl chloride ( CPVC) as a solute, acetone as solvent and pigment, was injected into the RLBVs of 40 rats. Once acetone evaporated, the preparation solidified. When the cells and connective tissue were dissolved by hydrochloric acid, a casting sample of RLBV was left. The sample was embedded in paraffin and cut into sections. The data of each section of RLBVs was collected by digital camera. RESULTS: In 36 rats, the casting sample of RLBVs was made successfully by this method. The diameter of the hepatic arteries varied from 0. 8 to 0.2 mm, the portal veins from 2.0 to 0.1 mm, and the hepatic veins from 2.2 to 0.2 mm. In each rat, about 150 photographs of the sections of RLBVs were taken. CONCLUSION: The method described above is feasible for getting experimental data for computer-aided reconstruction of the digital model of RLBVs.

Plasma leucine enkephalin content in patients with “Liver-blood deficiency” syndrome and clinical significance

Ｐｌａｓｍａｌｅｕｃｉｎｅｅｎｋｅｐｈａｌｉｎｃｏｎｔｅｎｔｉｎｐａｔｉｅｎｔｓｗｉｔｈ“Ｌｉｖｅｒｂｌｏｏｄｄｅｆｉｃｉｅｎｃｙ”ｓｙｎｄｒｏｍｅａｎｄｃｌｉｎｉｃａｌｓｉｇｎｉｆｉｃａｎｃｅＳＨＩＬｉｎＪｉｅ１，ＣＨＥＮＧｕｏＬｉｎ１，Ｌ...

Pharmacological effects of Paeoniflorin and Albiflorin on IL-3, GM-CSF, IL-6 and TNF-α in the rats of syndrome of stagnation of liver qi and blood deficiency

Objective： To observe the effect of paeoniflorin （PF）, albiflorin （AF） on the hemogram, visceral index and hematopoiesis cytokine in the rats of syndrome of stagnation of liver qi and blood deficiency, and to discuss the material base and mechanism of effect of nourishing blood and smoothing the liver of Baishao （Radix Paeoniae Alba）. Methods： Male SD rats were randomly divided into groups according to the sucrose preference test and body weight （n = 12）. Except the normal control, the other groups were treated with the chronic stress stimulation combined with radiation respectively to establish the model of syndrome of stagnation of liver qi and blood deficiency. The body weight, visceral index and the quantity of Leucocyte, Red Blood Cells, Hemoglobin in peripheral hemogram were monitored, then plasma and serum were separated. Radioimmunoassay was used to analyze the levels of Lnterleukin-3, Granulocyte-macrophage Colony-stimulating Factor, Lnterleukin-6 and Tumor Necrosis Factor-α in plasma. Results： Compared with that of model group, 30 mg·kg^-1 PF and 30 mg·kg^-1 AF of the weight, spleen index, quantity of Leucocyte were increased significantly （P 〈 0.05, P 〈 0.01）. The results of Radioimmunoassay showed that the levels of Interleukin-3 increased （P 〈 0.05, P 〈 0.05） and the levels of Tumor Necrosis Factor-α decreased in both 30 mg·kg^-1 PF and 30 mg·kg^-1 AF groups （P 〈 0.05, P 〈 0.05）. Conclusion： The effect of PF and AF on the regulation of bone marrow hematopoietic system and immune system play a role in the blood of rats with syndrome of stagnation of liver qi and blood deficiency, which suggests that both of them are the main active ingredients of nourishing blood and smoothing the liver of Baishao.

Measurement of Liver Size and Intrahepatic Blood Flow of Red-eared Turtles by Color Doppler Ultrasound

In the study, a total of 20 red-eared turtles （ half male and half female） were selected to conduct the measurement of liver size and intrahepatic blood flow of red-eared turtles by color Doppler ultrasound. The results showed that the fight hepatic lobe could be scanned through the right carotid anterior acoustic win- dow, and the left hepatic lobe could be scanned through the left carotid anterior acoustic window, but the vision would be obstructed by the air in trachea. The liver could also be scanned through the left femoral anterior acoustic window and the fight femoral anterior acoustic window when filling of bladder was good. The correla- tion regression analysis suggested that estimated values of liver showed no linear relationship with weight, the longest back curve and the widest back curve. Through the study, the normal indicators for ultrasound examination of red-eared turtle liver were established, in order to provide a reference for examination of turtle liver.

Causes of Peripheral Blood Cytopenias in Patients with Liver Cirrhosis Portal Hypertension and Clinical Significances

Liver cirrhosis portal hypertension patients to reduce the number of blood cells are common in clinical, and often affect the prognosis. This paper discusses cirrhotic portal hypertension patients complicated by the reason of the decrease in the number of peripheral blood cells and what is the clinical significance of these reasons so as to provide theoretical support for the choice of treatment. Splenomegaly and hypersplenism caused should be the main reason for reducing the number of blood cells, but not all, other reasons are alcohol and virus inhibition of bone marrow, liver function impairment, autoimmune damage and loss of blood, etc. If it is a function of the spleen hyperfunction caused by blood cells decreases, blood should rise to normal after splenectomy, or consider other reason or there are other reasons at the same time.

Collection of Professor Lihong Zhu's Experience in Treating Postpartum Hypogalactia of Blood Deficiency and Liver Depression Type

Professor Lihong Zhu proposed the syndrome type of"blood deficiency and liver depression"in the clinical treatment of postpartum hypogalactia,and discussed its main etiology and pathogenesis as Yin blood deficiency and liver Qi stagnation,with blood deficiency as the basis and liver depression as the standard.She self-made"Shugan Shengru prescription/5*which was added and subtracted with symptoms,with remarkable clinical effect,and widened the thinking of diagnosis and treatment of postpartum hypogalactia.

Rapamycin increased development of CD4^+ CD25~h ighFoxp3^+ T cells of peripheral blood in liver transplant recipients

Objective To investigate the possible influence of immunosuppressive therapy,including sirolimus ( SRL) and calcineurin inhibitors ( CNI,tacrolimus) ,on level of Treg in liver allo - graft recipients. Methods Forty - seven liver transplant recipients with stable liver function were assessed for at least 2 years,and divided into

Silica inflammation modulates lipoperoxide and thi-obarbituric acid reactive substances levels in liver and glucose concentration in blood of alloxan diabetic rats

Inflammatory granulomatous diseases are cha- racterized by a high concentration of granu- lomas in tissue interstitium in which phagocytic cells that produce active oxygen and nitrogen metabolites are accumulated. Because of their high reactivity, free radicals react with unsatu- rated fatty acids that are components of mem- brane phospholipids, activate lipid peroxidation processes (LPP), the products of which have a cytotoxic effect. The role of free radicals in the pathogenesis of diabetes and its complications has been proved. The purpose of the present work was to investigate the activity of lipid peroxidation processes in the liver of rats with silica-induced granulomatous inflammation, allo- xan diabetes and their combination. The expe- riment involved male albino rats divided into four main groups. The first group were rats with silica granulomatous inflammation (SL rats);the second group were alloxan diabetic rats (DB rats);and the third group were alloxan diabetic rats, in which silica granulomatous inflammation was induced 8 days after the disease onset (DB_SL rats), the fourth group were rats that were injected saline physiological solution into the tail vein (control rats). Rats were withdrawn from the experiment within different time pe- riods after the induction of pathological pro- cesses. LPP activity in liver homogenates was determined by the relative concentration of lipo- peroxides in the heptane-isopropanol system and the concentration of products of the reac- tion with 2-thiobarbituric acid-reactive substan- ces (TBARS). The severity of carbohydrate meta- bolism disorders was evaluated through the measurement of the blood level of glucose, daily urine volume and the relative weight of the kindneys. We found that silica administration activated LPP in the liver of SL rats;we ob- served the accumulation of primary products on day 1 after administration and later that of TBA- RS followed by normalization of their concen- tration by day 21 of the experiment. TBARS con- centration was higher in DB rats than in the control at all stages of the experiment indicating the maintenance of high LPP activity in the liver of DB rats. TBARS concentration in the liver of DB_SL rats decreased by 3 times by the end of the experiment compared to DB rats, at the same time, they displayed a decreased blood glucose concentration, reduced diuresis and relative weight of the kidneys caused by hyperglycemia and associated polyuria. We conclude that one of the possible mechanisms of the influence on silica granulomatous inflammation on the cour- se of alloxan diabetes can be 1) a reduced LPO activity in liver cells at the lates stages of gran- ulomagenesis process induced by a single dose of a suspension of silica microparticles and 2) a combined decrease in glucose production in the liver of alloxan diabetics rats.

人工肝支持系统相关血源性病原体感染预防与控制专家共识

人工肝支持系统(简称人工肝)是目前治疗肝衰竭的重要手段,因部分患者为血源性病原体携带者或感染者,在治疗过程中患者及医护人员存在血源性病原体感染的风险。我国人工肝相关血源性病原体感染防控策略相关研究处于起步阶段,缺乏规范性、一致性认识。为此,中华护理学会传染病护理专业委员会、湖南省护理学会传染病护理专业委员会组织国内专家,基于国家医院感染防控的相关法律、法规,参考国内外人工肝治疗及血源性病原体感染防控现状,结合我国临床诊疗指南及最佳临床实践证据要求,经反复讨论、修改形成本共识。共识通过对人工肝治疗各环节的风险评估,制定规避风险的安全操作流程,主要包括人工肝室设置、制度管理要求、治疗过程基于患者及医护人员防控细则、暴露处理流程等25项专家共识内容,为人工肝相关血源性病原体感染预防与控制提供临床指导,规避血源性病原体职业暴露及院内感染风险,保障患者及医护人员安全。

非酒精性脂肪性肝炎患者血清Nrf2、AOPP水平与血脂、肝纤维化的关系

目的探讨非酒精性脂肪性肝炎(NASH)患者血清核因子E2相关因子2(Nrf2)、晚期氧化蛋白产物(AOPP)水平与血脂、肝纤维化的关系。方法选择重庆医科大学附属璧山医院收治的104例NASH患者作为研究组,另选90例体检健康者作为对照组。检测并比较各组血清Nrf2、AOPP水平,采用Pearson或Spearman相关分析NASH患者血清Nrf2、AOPP水平与血脂、肝纤维化的关系,采用受试者工作特征(ROC)曲线评估血清Nrf2、AOPP水平对NASH的诊断价值。结果研究组甘油三酯(TG)、总胆固醇(TC)、低密度脂蛋白胆固醇(LDL-C)、Nrf2、AOPP水平均高于对照组(P<0.05),高密度脂蛋白胆固醇(HDL-C)水平明显低于对照组(P<0.05)。重度组血清Nrf2、AOPP水平高于中度组、轻度组(P<0.05),中度组血清Nrf2、AOPP水平高于轻度组(P<0.05)。相关分析结果显示,NASH患者血清Nrf2、AOPP水平与TG、TC、LDL-C、肝纤维化程度均呈正相关(P<0.05),与HDL-C呈负相关(P<0.05)。血清Nrf2诊断NASH的曲线下面积(AUC)为0.830(95%CI 0.780~0.880),血清AOPP诊断NASH的AUC为0.866(95%CI 0.816~0.916),二者联合诊断NASH的AUC为0.925(95%CI 0.875~0.975)。结论NASH患者血清Nrf2、AOPP水平均升高,且二者水平与血脂、肝纤维化程度均存在密切关系,有望作为诊断NASH发生的有效指标。

他克莫司血药浓度对肾移植术后患者肝肾功能的影响

目的探讨他克莫司(FK506)血药浓度对肾移植术后患者肝肾功能的影响。方法回顾性分析2018年10月至2020年10月在我院行肾移植手术的80例患者的临床资料,根据FK506血药浓度梯度不同分为7组,比较各组的肝肾功能指标水平,分析肝肾功能指标与FK506血药浓度的相关性。结果不同FK506血药浓度患者的血清ALB、UREA、SCr、Cys C及eGFR水平比较,差异有统计学意义(P<0.05);不同FK506血药浓度患者的血清TBIL、AST、ALT水平比较,差异无统计学意义(P>0.05)。Spearman相关分析显示,UREA、SCr、Cys C水平与FK506血药浓度呈正相关(r>0.01,P<0.05),eGFR水平与FK506血药浓度呈负相关(r=-0.385,P<0.05)。结论FK506血药浓度对肾移植术后患者肝功能指标的影响较小,但血药浓度过高可引起肾毒性反应。