Liver transplantation in Jehovah’s witnesses: 13 consecutive cases at a single Institution

Abstract Background . Jehovah's Witnesses represent a tremendous clinical challenge when indicated to liver transplantation because they refuse blood transfusion on religious grounds and the procedure is historically associated with potential massive peri-operative blood loss. We herein describe a peri-operative management pathway with strategies toward a transfusion-free environment with the aim not only of offering liver transplant to selected Jehovah's Witnesses patients but also, ultimately, of translating this practice to all general surgical procedures. Methods . This is a retrospective review of prospective medical records of JW patients who underwent LT at our Institution. The peri-operative multimodal strategy to liver transplantation in Jehovah's Witnesses includes a pre-operative red cell mass optimization package and the intra-operative use of normovolemic haemodilution, veno-venous bypass and low central venous pressure. Results In a 9-year period, 13 Jehovah’s Witness patients received liver transplantation at our centre representing the largest liver transplant program from deceased donors in Jehovah's Witnesses patients reported so far. No patient received blood bank products but 3 had fibrinogen concentrate and one tranexamic acid to correct ongoing hyper-fibrinolysis. There were 4 cases of acute kidney injury (one required extracorporeal renal replacement treatment) and one patient needed vasoactive medications to support blood pressure for the first 2 postoperative days. Two patients underwent re-laparotomy. Finally, of the 13 recipients, 12 were alive at the 1 year follow-up interview and 1 died due to septic complications. Conclusions . Our experience confirms that liver transplantation in selected Jehovah's Witnesses patients can be feasible and safe provided that it is carried out at a very experienced centre and according to a multidisciplinary approach

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Liver transplantation in Jehovah’s witnesses: 13 consecutive cases at a single Institution

10.21203/rs.2.10672/v4 ◽

2019 ◽

Author(s):

Diego Costanzo ◽

Maria Bindi ◽

Davide Ghinolfi ◽

Massimo Esposito ◽

Francesco Corradi ◽

...

Keyword(s):

Liver Transplantation ◽

Liver Transplant ◽

Venous Pressure ◽

Cell Mass ◽

Kidney Injury ◽

Operative Management ◽

Jehovah’S Witnesses ◽

Septic Complications ◽

Jehovah's Witnesses ◽

Free Environment

Abstract Background. Jehovah's Witnesses represent a tremendous clinical challenge when indicated to liver transplantation because they refuse blood transfusion on religious grounds and the procedure is historically associated with potential massive peri-operative blood loss. We herein describe a peri-operative management pathway with strategies toward a transfusion-free environment with the aim not only of offering liver transplant to selected Jehovah's Witnesses patients but also, ultimately, of translating this practice to all general surgical procedures. Methods. This is a retrospective review of prospective medical records of JW patients who underwent LT at our Institution. The peri-operative multimodal strategy to liver transplantation in Jehovah's Witnesses includes a pre-operative red cell mass optimization package and the intra-operative use of normovolemic haemodilution, veno-venous bypass and low central venous pressure. Results In a 9-year period, 13 Jehovah’s Witness patients received liver transplantation at our centre representing the largest liver transplant program from deceased donors in Jehovah's Witnesses patients reported so far. No patient received blood bank products but 3 had fibrinogen concentrate and one tranexamic acid to correct ongoing hyper-fibrinolysis. There were 4 cases of acute kidney injury (one required extracorporeal renal replacement treatment) and one patient needed vasoactive medications to support blood pressure for the first 2 postoperative days. Two patients underwent re-laparotomy. Finally, of the 13 recipients, 12 were alive at the 1 year follow-up interview and 1 died due to septic complications. Conclusions. Our experience confirms that liver transplantation in selected Jehovah's Witnesses patients can be feasible and safe provided that it is carried out at a very experienced centre and according to a multidisciplinary approach

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Liver transplantation in Jehovah’s witnesses: 13 consecutive cases at a single Institution

10.21203/rs.2.10672/v3 ◽

2019 ◽

Author(s):

Diego Costanzo ◽

Maria Bindi ◽

Davide Ghinolfi ◽

Massimo Esposito ◽

Francesco Corradi ◽

...

Keyword(s):

Liver Transplantation ◽

Liver Transplant ◽

Venous Pressure ◽

Cell Mass ◽

Kidney Injury ◽

Operative Management ◽

Jehovah’S Witnesses ◽

Septic Complications ◽

Jehovah's Witnesses ◽

Free Environment

Abstract Background. Jehovah's Witnesses represent a tremendous clinical challenge when indicated to liver transplantation because they refuse blood transfusion on religious grounds and the procedure is historically associated with potential massive peri-operative blood loss. We herein describe a peri-operative management pathway with strategies toward a transfusion-free environment with the aim not only of offering liver transplant to selected Jehovah's Witnesses patients but also, ultimately, of translating this practice to all general surgical procedures.Methods. This is a retrospective review of prospective medical records of JW patients who underwent LT at our Institution. The peri-operative multimodal strategy to liver transplantation in Jehovah's Witnesses includes a pre-operative red cell mass optimization package and the intra-operative use of normovolemic haemodilution, veno-venous bypass and low central venous pressure. Results In a 9-year period, 13 Jehovah’s Witness patients received liver transplantation at our centre representing the largest liver transplant program from deceased donors in Jehovah's Witnesses patients reported so far. No patient received blood bank products but 3 had fibrinogen concentrate and one tranexamic acid to correct ongoing hyper-fibrinolysis. There were 4 cases of acute kidney injury (one required extracorporeal renal replacement treatment) and one patient needed vasoactive medications to support blood pressure for the first 2 postoperative days. Two patients underwent re-laparotomy. Finally, of the 13 recipients, 12 were alive at the 1 year follow-up interview and 1 died due to septic complications. Conclusions. Our experience confirms that liver transplantation in selected Jehovah's Witnesses patients can be feasible and safe provided that it is carried out at a very experienced centre and according to a multidisciplinary approach

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Liver transplantation in Jehovah’s witnesses: 13 consecutive cases at a single Institution

10.21203/rs.2.10672/v1 ◽

2019 ◽

Author(s):

Diego Costanzo ◽

Maria Bindi ◽

Davide Ghinolfi ◽

Massimo Esposito ◽

Francesco Forfori ◽

...

Keyword(s):

Liver Transplantation ◽

Venous Pressure ◽

Cell Mass ◽

Kidney Injury ◽

Operative Management ◽

Jehovah’S Witnesses ◽

Septic Complications ◽

Jehovah's Witnesses ◽

Replacement Treatment ◽

Free Environment

Abstract Jehovah's Witnesses represent a tremendous clinical challenge when indicated to liver transplantation because they refuse blood transfusion on religious grounds and the procedure is historically associated with potential massive peri-operative blood loss. We developed a peri-operative management pathway with strategies toward a transfusion-free environment in the respect of the patients’ religious beliefs. Briefly, our peri-operative multimodal strategy to liver transplantation in Jehovah's Witnesses includes a pre-operative red cell mass optimization package and the intra-operative use of normovolemic haemodilution, veno-venous bypass and low central venous pressure. In a 9-year period, 13 Jehovah’s Witness patients received liver transplantation at our centre representing the largest LT program from deceased donors in JW patients that has been reported so far. No patient received blood bank products but 3 had fibrinogen concentrate and one tranexamic acid to correct ongoing hyper-fibrinolysis. There were 4 cases of acute kidney injury (one required extracorporeal renal replacement treatment) and one patient needed vasoactive medications to support blood pressure for the first 2 postoperative days. Two patients underwent re-laparotomy. Finally, of the 13 recipients, 12 were alive at the 1 year follow-up interview and 1 died due to septic complications. Our experience confirms that liver transplantation in selected Jehovah's Witnesses patients can be feasible and safe provided that it is carried out at a very experienced centre and according to a multidisciplinary approach

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Liver transplantation in Jehovah’s witnesses: 13 consecutive cases at a single Institution

10.21203/rs.2.10672/v2 ◽

2019 ◽

Author(s):

Diego Costanzo ◽

Maria Bindi ◽

Davide Ghinolfi ◽

Massimo Esposito ◽

Francesco Corradi ◽

...

Keyword(s):

Liver Transplantation ◽

Venous Pressure ◽

Cell Mass ◽

Kidney Injury ◽

Operative Management ◽

Jehovah’S Witnesses ◽

Septic Complications ◽

Jehovah's Witnesses ◽

Replacement Treatment ◽

Free Environment

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Liver transplantation in Jehovah's Witnesses: a case series

Colombian Journal of Anesthesiology ◽

10.1097/cj9.0000000000000132 ◽

1969 ◽

Vol 48 (2) ◽

pp. 85-90

Author(s):

Fredy Ariza ◽

Daniel Arboleda-Palacios ◽

Sebastian Rosales Hooker-Herrera ◽

Eliana Manzi-Tarapués ◽

Luis Armando Caicedo-Rusca

Keyword(s):

Liver Transplantation ◽

Cell Mass ◽

Case Series ◽

Graft Dysfunction ◽

Post Transplantation ◽

Jehovah’S Witnesses ◽

Intraoperative Bleeding ◽

Jehovah's Witnesses ◽

End Stage ◽

To Receive

Introduction: Orthotopic liver transplantation (OLT) is a procedure characterized by high bleeding rates and a significant likelihood of exposure to blood products. Objectives: This case series shows the experience at a referral center for Jehovah's Witnesses (JW) with end-stage liver disease, undergoing OLT. Materials and methods: A search was conducted in our database of JW undergoing OLT between July 2007 and August 2012. The information about their pre-operative condition and progress up to 30 days post-transplantation. Results: Four subjects were identified (3F/1M) with an average age of 42 years (range 22-55). All of them received a multidisciplinary management which included pre-operative optimization of red cell mass, antifibrinolytic prophylaxis, and cell salvage (mean volume of 344mL [range 113-520]). The average intraoperative bleeding volume was of 625mL (range 300-1000). One of the patients presented with a primary graft dysfunction and died, while the rest had a normal postoperative course. Conclusion: It is possible to offer OLT to patients who refuse to receive allogeneic blood transfusions, through a comprehensive approach that includes perioperative hematologic optimization and the use of blood conservation measures, without a significant impact on the outcomes.

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Orthotopic liver transplantation in Jehovah's Witnesses

Current Anaesthesia and Critical Care ◽

10.1016/j.cacc.2007.09.001 ◽

2008 ◽

Vol 19 (1) ◽

pp. 34-41

Author(s):

Lucy Yang ◽

Zorica Jankovic

Keyword(s):

Liver Transplantation ◽

Orthotopic Liver Transplantation ◽

Jehovah’S Witnesses ◽

Jehovah's Witnesses

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Nutrition of Liver Transplant Patients

Canadian Journal of Gastroenterology ◽

10.1155/2000/919737 ◽

2000 ◽

Vol 14 (suppl d) ◽

pp. 85D-88D ◽

Cited By ~ 3

Author(s):

Arved Weimann ◽

Mathias Plauth ◽

Stefan C Bischoff ◽

Ernst R Kuse

Keyword(s):

Glucose Tolerance ◽

Liver Transplant ◽

Impaired Glucose Tolerance ◽

Nutritional Assessment ◽

Negative Impact ◽

Cell Mass ◽

Graft Function ◽

Early Postoperative Period ◽

Anthropometric Parameters ◽

Septic Complications

Good cooperation between the hepatologist, surgeon and anesthesiologist is required to determine the appropriate perioperative nutritional management for the liver transplant patient. For preoperative risk stratification, nutritional assessment according to resting energy expenditure by indirect calorimetry, and body cell mass by bioelectrical impedence analysis, may be superior to anthropometric parameters. When considering impaired glucose tolerance in the early postoperative period, requirements of energy intake and macronutrients are no different from those established in major abdominal surgery. Preference should be made to use the enteral route whenever possible. Fat emulsions containing medium- and long-chain triglycerides have neither a negative impact on reticulo-endothelial system recovery of the graft, nor any obvious metabolic advantages. There is no evidence for the routine use of branched-chain amino acids. Even in the case of good graft function, long term dietary evaluation and counselling may be useful. Impaired glucose tolerance, hyperlipidemia and hypercholesterolemia should be considered carefully. The role of preoperative nutritional therapy using oral supplements and the value of immune-enhancing substrates should be evaluated with special regard to a decrease in postoperative septic complications and for possible impact on immune tolerance after transplantation.

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A97 TACROLIMUS-ASSOCIATED HEMOLYTIC UREMIC SYNDROME IN A PEDIATRIC LIVER TRANSPLANT RECIPIENT

Journal of the Canadian Association of Gastroenterology ◽

10.1093/jcag/gwz047.096 ◽

2020 ◽

Vol 3 (Supplement_1) ◽

pp. 113-114

Author(s):

K W Wong ◽

S Gilmour

Keyword(s):

Liver Transplantation ◽

Liver Transplant ◽

Hemolytic Uremic Syndrome ◽

Kidney Injury ◽

Solid Organ ◽

Post Transplantation ◽

Atypical Hus ◽

Pediatric Liver ◽

Uremic Syndrome ◽

Pediatric Liver Transplant

Abstract Background Tacrolimus associated hemolytic uremic syndrome (HUS) has been reported in renal and pediatric cardiac transplantation. Furthermore, in adults receiving liver transplant, there are reports of multiorgan failure, death, and end stage renal failure secondary to tacrolimus induced HUS [J NEPHROL 2003; 16: 580–585]. Although tacrolimus is commonly used in pediatric liver transplantation, there are no reports of the same entity. Aims To describe a case of tacrolimus induced HUS in a pediatric liver transplant patient and subsequent re-initiation of tacrolimus. Methods The patient was followed during his hospital admission and after discharge. Results An 8-year-old male with Progressive Familial Intrahepatic Cholestasis (PFIC) Type III, diagnosed at age 2, presents for living unrelated donor liver transplantation. He was previously well compensated but began to deteriorate in the months leading up to transplant with rising liver enzymes, ascites, and mild encephalopathy after presumed viral gastroenteritis. He receives a left lateral segment liver transplantation and is started on tacrolimus immunosuppression post liver transplant as per protocol. On initiation of tacrolimus, the patient’s hemoglobin trends downward to a trough of 59 g/L four days post transplantation. Concurrently, his haptoglobin is <0.10g/L, total bilirubin peaks at 708 umol/L, creatinine rises to a peak of 71 umol/L, urea peaks at 23.0 mmol/L. Platelets reach a nadir at 27x10^9/L, seven days post transplantation. Direct antibody test was negative, and blood cultures remained negative. Given the constellation of hemolytic anemia, thrombocytopenia, and acute kidney injury following initiation of tacrolimus, a diagnosis of atypical HUS is made. Tacrolimus is discontinued, intravenous methylprednisolone is started and the patient is switched to cyclosporine immunosuppression. Both the hemolysis and kidney injury resolve gradually. The patient develops side effects from cyclosporine including hypertension and excessive hair growth. One month post discontinuation of tacrolimus, he is started on sirolimus, while weaning steroids and cyclosporine. Seven weeks post discontinuation of tacrolimus, he is restarted on tacrolimus and is currently tolerating dual immunosuppression with no signs of HUS recurrence. Conclusions Atypical HUS secondary to tacrolimus post liver transplant in children is a rare entity. In the acute period, discontinuation of tacrolimus is essential to preserve renal function given potentially devastating outcomes seen in adults. Cyclosporine is an alternative immunosuppressive agent used in pediatric solid organ transplantation, although it has also been implicated in causing HUS. Funding Agencies None

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Neutrophil Gelatinase-Associated Lipocalin Is Not Associated with Tacrolimus-Induced Acute Kidney Injury in Liver Transplant Patients Who Received Mycophenolate Mofetil with Delayed Introduction of Tacrolimus

International Journal of Molecular Sciences ◽

10.3390/ijms20123103 ◽

2019 ◽

Vol 20 (12) ◽

pp. 3103 ◽

Cited By ~ 1

Author(s):

Mio Fukuda ◽

Kimitaka Suetsugu ◽

Soichiro Tajima ◽

Yurie Katsube ◽

Hiroyuki Watanabe ◽

...

Keyword(s):

Liver Transplantation ◽

Acute Kidney Injury ◽

Mycophenolate Mofetil ◽

Liver Transplant ◽

Kidney Injury ◽

Transplant Recipients ◽

Fatty Acid Binding ◽

Neutrophil Gelatinase Associated Lipocalin ◽

Neutrophil Gelatinase ◽

Liver Transplant Recipients

Tacrolimus is widely used as an immunosuppressant in liver transplantation, and tacrolimus-induced acute kidney injury (AKI) is a serious complication. The urinary neutrophil gelatinase-associated lipocalin (NGAL) level has been linked to tacrolimus-induced AKI in patients starting tacrolimus treatment the morning after liver transplantation. Here we tested this association using a different immunosuppression protocol: Mycophenolate mofetil administration beginning on Postoperative Day 1 and tacrolimus administration beginning on Postoperative Day 2 or 3. Urine samples were collected from 26 living donor liver transplant recipients before (Postoperative Day 1) and after (Postoperative Day 7 or 14) tacrolimus administration. NGAL levels were measured via enzyme-linked immunosorbent assays, as were those of three additional urinary biomarkers for kidney diseases: Monocyte chemotactic protein-1 (MCP-1), liver-type fatty acid-binding protein (L-FABP), and human epididymis secretory protein 4 (HE4). HE4 levels after tacrolimus administration were significantly higher in patients who developed AKI (n = 6) than in those who did not (n = 20), whereas NGAL, MCP-1, and L-FABP levels did not differ significantly before or after tacrolimus administration. These findings indicate that NGAL may not be a universal biomarker of AKI in tacrolimus-treated liver transplant recipients. To reduce the likelihood of tacrolimus-induced AKI, our immunosuppression protocol is recommended.

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