Korean J Transplant.  2023 Dec;37(4):221-228. 10.4285/kjt.23.0061.

An overview of unresolved issues in the perioperative management of liver transplant patients

Affiliations
  • 1Department of Organ Transplant Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Hospital, Jaipur, India
  • 2Department of Neuro-Anaesthesia, Mahatma Gandhi Medical College and Hospital, Jaipur, India
  • 3Department of Anaesthesia, Mahatma Gandhi Medical College and Hospital, Jaipur, India

Abstract

Over the past decade, the field of solid organ transplantation has undergone significant changes, with some of the most notable advancements occurring in liver transplanta- tion. Recent years have seen substantial progress in preoperative patient optimization protocols, anesthesia monitoring, coagulation management, and fluid management, among other areas. These improvements have led to excellent perioperative outcomes for all surgical patients, including those undergoing liver transplantation. In the last few decades, there have been numerous publications in the field of liver transplantation, but controversies related to perioperative management of liver transplant recipients persist. In this review article, we address the unresolved issues surrounding the anesthetic management of patients scheduled for liver transplantation.

Keyword

Coronary artery disease; End-stage liver disease; Intracranial pressure; Liver transplantation; Pulmonary hypertension

Reference

1. Fede G, Privitera G, Tomaselli T, Spadaro L, Purrello F. 2015; Cardiovascular dysfunction in patients with liver cirrhosis. Ann Gastroenterol. 28:31–40.
2. Kaur H, Premkumar M. 2022; Diagnosis and management of cirrhotic cardiomyopathy. J Clin Exp Hepatol. 12:186–99. DOI: 10.1016/j.jceh.2021.08.016. PMID: 35068798. PMCID: PMC8766707.
3. Shin WJ, Kwon HM, Kim SH, Jang HY, Kim JY, Kim JH, et al. 2023; Characterizing heart failure with preserved ejection fraction in end-stage liver disease and liver transplant outcomes. JACC Asia. 3:506–17. DOI: 10.1016/j.jacasi.2023.03.007. PMID: 37396430. PMCID: PMC10308113.
4. Salah HM, Pandey A, Soloveva A, Abdelmalek MF, Diehl AM, Moylan CA, et al. 2021; Relationship of nonalcoholic fatty liver disease and heart failure with preserved ejection fraction. JACC Basic Transl Sci. 6:918–32. DOI: 10.1016/j.jacbts.2021.07.010. PMID: 34869957. PMCID: PMC8617573.
5. VanWagner LB, Lapin B, Levitsky J, Wilkins JT, Abecassis MM, Skaro AI, et al. 2014; High early cardiovascular mortality after liver transplantation. Liver Transpl. 20:1306–16. DOI: 10.1002/lt.23950. PMID: 25044256. PMCID: PMC4213202.
6. Główczyńska R, Galas M, Ołdakowska-Jedynak U, Peller M, Tomaniak M, Raszeja-Wyszomirska J, et al. 2018; Pretransplant QT interval: the relationship with severity and etiology of liver disease and prognostic value after liver transplantation. Ann Transplant. 23:622–30. DOI: 10.12659/AOT.908769. PMID: 30177675. PMCID: PMC6248058.
7. Harinstein ME, Iyer S, Mathier MA, Flaherty JD, Fontes P, Planinsic RM, et al. 2012; Role of baseline echocardiography in the preoperative management of liver transplant candidates. Am J Cardiol. 110:1852–5. DOI: 10.1016/j.amjcard.2012.08.021. PMID: 23021513.
8. Kwon HM, Moon YJ, Kim KS, Shin WJ, Huh IY, Jun IG, et al. 2021; Prognostic value of B-type natriuretic peptide in liver transplant patients: implication in posttransplant mortality. Hepatology. 74:336–50. DOI: 10.1002/hep.31661. PMID: 33249627.
9. Lentine KL, Costa SP, Weir MR, Robb JF, Fleisher LA, Kasiske BL, et al. 2012; Cardiac disease evaluation and management among kidney and liver transplantation candidates: a scientific statement from the American Heart Association and the American College of Cardiology Foundation. J Am Coll Cardiol. 60:434–80. DOI: 10.1016/j.jacc.2012.05.008. PMID: 22763103.
10. Sharma V, Kleb C, Sheth C, Verma BR, Jain V, Sharma R, et al. 2022; Cardiac considerations in liver transplantation. Cleve Clin J Med. 89:46–55. DOI: 10.3949/ccjm.89a.21006. PMID: 34983801.
11. Sussman N, Kaza V, Barshes N, Stribling R, Goss J, O'Mahony C, et al. 2006; Successful liver transplantation following medical management of portopulmonary hypertension: a single-center series. Am J Transplant. 6:2177–82. DOI: 10.1111/j.1600-6143.2006.01432.x. PMID: 16796721.
12. De Maria S Jr, Nürnberg J, Lin HM, Contreras-Saldivar AG, Levin M, Flax K, et al. 2013; Association of intraoperative blood pressure instability with adverse outcomes after liver transplantation. Minerva Anestesiol. 79:604–16.
13. Mizota T, Hamada M, Matsukawa S, Seo H, Tanaka T, Segawa H. 2017; Relationship between intraoperative hypotension and acute kidney injury after living donor liver transplantation: a retrospective analysis. J Cardiothorac Vasc Anesth. 31:582–9. DOI: 10.1053/j.jvca.2016.12.002. PMID: 28216198.
14. Smoter P, Nyckowski P, Grat M, Patkowski W, Zieniewicz K, Wronka K, et al. 2014; Risk factors of acute renal failure after orthotopic liver transplantation: single-center experience. Transplant Proc. 46:2786–9. DOI: 10.1016/j.transproceed.2014.09.044. PMID: 25380918.
15. Costa MG, Chiarandini P, Della Rocca G. 2007; Hemodynamics during liver transplantation. Transplant Proc. 39:1871–3. DOI: 10.1016/j.transproceed.2007.05.002. PMID: 17692637.
16. Rocca GD, Costa MG, Feltracco P, Biancofiore G, Begliomini B, Taddei S, et al. 2008; Continuous right ventricular end diastolic volume and right ventricular ejection fraction during liver transplantation: a multicenter study. Liver Transpl. 14:327–32. DOI: 10.1002/lt.21288. PMID: 18306366.
17. Biancofiore G, Critchley LA, Lee A, Bindi L, Bisà M, Esposito M, et al. 2009; Evaluation of an uncalibrated arterial pulse contour cardiac output monitoring system in cirrhotic patients undergoing liver surgery. Br J Anaesth. 102:47–54. DOI: 10.1093/bja/aen343. PMID: 19059920.
18. Krejci V, Vannucci A, Abbas A, Chapman W, Kangrga IM. 2010; Comparison of calibrated and uncalibrated arterial pressure-based cardiac output monitors during orthotopic liver transplantation. Liver Transpl. 16:773–82. DOI: 10.1002/lt.22056. PMID: 20517912.
19. Su BC, Tsai YF, Cheng CW, Yu HP, Yang MW, Lee WC, et al. 2012; Stroke volume variation derived by arterial pulse contour analysis is a good indicator for preload estimation during liver transplantation. Transplant Proc. 44:429–32. DOI: 10.1016/j.transproceed.2011.12.037. PMID: 22410035.
20. Kim SH, Hwang GS, Kim SO, Kim YK. 2013; Is stroke volume variation a useful preload index in liver transplant recipients? A retrospective analysis. Int J Med Sci. 10:751–7. DOI: 10.7150/ijms.6074. PMID: 23630440. PMCID: PMC3638299.
21. Dalia AA, Flores A, Chitilian H, Fitzsimons MG. 2018; A comprehensive review of transesophageal echocardiography during orthotopic liver transplantation. J Cardiothorac Vasc Anesth. 32:1815–24. DOI: 10.1053/j.jvca.2018.02.033. PMID: 29573952.
22. Khurmi N, Seman M, Gaitan B, Young S, Rosenfeld D, Giorgakis E, et al. 2019; Nontraditional use of TEE to evaluate hepatic vasculature and guide surgical management in orthotopic liver transplantation. Case Rep Transplant. 2019:5293069. DOI: 10.1155/2019/5293069. PMID: 31321114. PMCID: PMC6607703.
23. Pantham G, Waghray N, Einstadter D, Finkelhor RS, Mullen KD. 2013; Bleeding risk in patients with esophageal varices undergoing transesophageal echocardiography. Echocardiography. 30:1152–5. DOI: 10.1111/echo.12274. PMID: 23742625.
24. Schroeder RA, Collins BH, Tuttle-Newhall E, Robertson K, Plotkin J, Johnson LB, et al. 2004; Intraoperative fluid management during orthotopic liver transplantation. J Cardiothorac Vasc Anesth. 18:438–41. DOI: 10.1053/j.jvca.2004.05.020. PMID: 15365923.
25. Feng ZY, Xu X, Zhu SM, Bein B, Zheng SS. 2010; Effects of low central venous pressure during preanhepatic phase on blood loss and liver and renal function in liver transplantation. World J Surg. 34:1864–73. DOI: 10.1007/s00268-010-0544-y. PMID: 20372900.
26. Morkane CM, Sapisochin G, Mukhtar AM, Reyntjens KM, Wagener G, Spiro M, et al. 2022; Perioperative fluid management and outcomes in adult deceased donor liver transplantation: systematic review of the literature and expert panel recommendations. Clin Transplant. 36:e14651. DOI: 10.1111/ctr.14651. PMID: 35304919.
27. Finfer S, Micallef S, Hammond N, Navarra L, Bellomo R, Billot L, et al. 2022; Balanced multielectrolyte solution versus saline in critically ill adults. N Engl J Med. 386:815–26. DOI: 10.1056/NEJMoa2114464. PMID: 35041780.
28. Hartmann M, Szalai C, Saner FH. 2016; Hemostasis in liver transplantation: pathophysiology, monitoring, and treatment. World J Gastroenterol. 22:1541–50. DOI: 10.3748/wjg.v22.i4.1541. PMID: 26819521. PMCID: PMC4721987.
29. Schumacher C, Eismann H, Sieg L, Friedrich L, Scheinichen D, Vondran FW, et al. 2019; Use of rotational thromboelastometry in liver transplantation is associated with reduced transfusion requirements. Exp Clin Transplant. 17:222–30. DOI: 10.6002/ect.2017.0236. PMID: 30295585.
30. De Pietri L, Ragusa F, Deleuterio A, Begliomini B, Serra V. 2015; Reduced transfusion during OLT by POC coagulation management and TEG functional fibrinogen: a retrospective observational study. Transplant Direct. 2:e49. DOI: 10.1097/TXD.0000000000000559. PMID: 27500243. PMCID: PMC4946500.
31. Mallett SV. 2015; Clinical utility of viscoelastic tests of coagulation (TEG/ROTEM) in patients with liver disease and during liver transplantation. Semin Thromb Hemost. 41:527–37. DOI: 10.1055/s-0035-1550434. PMID: 26049072.
32. Massicotte L, Beaulieu D, Thibeault L, Roy JD, Marleau D, Lapointe R, et al. 2008; Coagulation defects do not predict blood product requirements during liver transplantation. Transplantation. 85:956–62. DOI: 10.1097/TP.0b013e318168fcd4. PMID: 18408574.
33. Massicotte L, Sassine MP, Lenis S, Roy A. 2004; Transfusion predictors in liver transplant. Anesth Analg. 98:1245–51. DOI: 10.1213/01.ANE.0000111184.21278.07. PMID: 15105195.
34. Goldaracena N, Méndez P, Quiñonez E, Devetach G, Koo L, Jeanes C, et al. 2013; Liver transplantation without perioperative transfusions single-center experience showing better early outcome and shorter hospital stay. J Transplant. 2013:649209. DOI: 10.1155/2013/649209. PMID: 24455193. PMCID: PMC3876589.
35. Scott TR, Kronsten VT, Hughes RD, Shawcross DL. 2013; Pathophysiology of cerebral oedema in acute liver failure. World J Gastroenterol. 19:9240–55. DOI: 10.3748/wjg.v19.i48.9240. PMID: 24409052. PMCID: PMC3882398.
36. Bernal W, Hall C, Karvellas CJ, Auzinger G, Sizer E, Wendon J. 2007; Arterial ammonia and clinical risk factors for encephalopathy and intracranial hypertension in acute liver failure. Hepatology. 46:1844–52. DOI: 10.1002/hep.21838. PMID: 17685471.
37. Vaquero J, Chung C, Blei AT. 2003; Brain edema in acute liver failure. A window to the pathogenesis of hepatic encephalopathy. Ann Hepatol. 2:12–22. DOI: 10.1016/S1665-2681(19)32153-2. PMID: 15094701.
38. Rodrigo R, Cauli O, Gomez-Pinedo U, Agusti A, Hernandez-Rabaza V, Garcia-Verdugo JM, et al. 2010; Hyperammonemia induces neuroinflammation that contributes to cognitive impairment in rats with hepatic encephalopathy. Gastroenterology. 139:675–84. DOI: 10.1053/j.gastro.2010.03.040. PMID: 20303348.
39. Zemtsova I, Görg B, Keitel V, Bidmon HJ, Schrör K, Häussinger D. 2011; Microglia activation in hepatic encephalopathy in rats and humans. Hepatology. 54:204–15. DOI: 10.1002/hep.24326. PMID: 21452284.
40. Rai V, Nath K, Saraswat VA, Purwar A, Rathore RK, Gupta RK. 2008; Measurement of cytotoxic and interstitial components of cerebral edema in acute hepatic failure by diffusion tensor imaging. J Magn Reson Imaging. 28:334–41. DOI: 10.1002/jmri.21438. PMID: 18626948.
41. Kale RA, Gupta RK, Saraswat VA, Hasan KM, Trivedi R, Mishra AM, et al. 2006; Demonstration of interstitial cerebral edema with diffusion tensor MR imaging in type C hepatic encephalopathy. Hepatology. 43:698–706. DOI: 10.1002/hep.21114. PMID: 16557540.
42. Raghavan M, Marik PE. 2006; Therapy of intracranial hypertension in patients with fulminant hepatic failure. Neurocrit Care. 4:179–89. DOI: 10.1385/NCC:4:2:179. PMID: 16627910.
43. Vaquero J, Fontana RJ, Larson AM, Bass NM, Davern TJ, Shakil AO, et al. 2005; Complications and use of intracranial pressure monitoring in patients with acute liver failure and severe encephalopathy. Liver Transpl. 11:1581–9. DOI: 10.1002/lt.20625. PMID: 16315300.
44. Rajajee V, Williamson CA, Fontana RJ, Courey AJ, Patil PG. 2018; Noninvasive intracranial pressure assessment in acute liver failure. Neurocrit Care. 29:280–90. DOI: 10.1007/s12028-018-0540-x. PMID: 29948998.
45. Mendoza Vasquez LE, Payne S, Zamper R. 2023; Intracranial pressure monitoring in the perioperative period of patients with acute liver failure undergoing orthotopic liver transplantation. World J Transplant. 13:122–8. DOI: 10.5500/wjt.v13.i4.122. PMID: 37388394. PMCID: PMC10303411.
46. Polson J, Lee WM. American Association for the Study of Liver Disease. 2005; AASLD position paper: the management of acute liver failure. Hepatology. 41:1179–97. DOI: 10.1002/hep.20703. PMID: 15841455.
47. Lee WM, Stravitz RT, Larson AM. 2012; Introduction to the revised American Association for the Study of Liver Diseases Position Paper on acute liver failure 2011. Hepatology. 55:965–7. DOI: 10.1002/hep.25551. PMID: 22213561. PMCID: PMC3378702.
48. Stravitz RT, Kramer AH, Davern T, Shaikh AO, Caldwell SH, Mehta RL, et al. 2007; Intensive care of patients with acute liver failure: recommendations of the U.S. Acute Liver Failure Study Group. Crit Care Med. 35:2498–508. DOI: 10.1097/01.CCM.0000287592.94554.5F. PMID: 17901832.
49. European Association for the Study of the Liver. 2017; EASL clinical practical guidelines on the management of acute (fulminant) liver failure. J Hepatol. 66:1047–81. DOI: 10.1016/j.jhep.2016.12.003. PMID: 28417882.
50. Brustia R, Monsel A, Skurzak S, Schiffer E, Carrier FM, Patrono D, et al. 2022; Guidelines for perioperative care for liver transplantation: enhanced recovery after surgery (ERAS) recommendations. Transplantation. 106:552–61. DOI: 10.1097/TP.0000000000003808. PMID: 33966024.
51. Kumar L, Sahu S, Deo AS, Selvakumar R, Panchwag AA, Pavithran P. 2023; Recent advances in anaesthesia for abdominal solid organ transplantation. Indian J Anaesth. 67:32–8. DOI: 10.4103/ija.ija_1025_22. PMID: 36970473. PMCID: PMC10034936.
52. Biancofiore G, Tomescu DR, Mandell MS. 2018; Rapid recovery of liver transplantation recipients by implementation of fast-track care steps: what is holding us back? Semin Cardiothorac Vasc Anesth. 22:191–6. DOI: 10.1177/1089253218761124. PMID: 29488444.
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