The impact of late liver allograft dysfunction on physical activity of liver transplant recipients

Introduction. Liver transplantation restores patients' physical and social life, and its quality. The prevalence of low physical activity in liver recipients is unknown as well as the impact of late liver allograft dysfunction on it. Liver transplantation enhances patient's return to the usual physical and social activity and improves the quality of life. However, the prevalence of low physical activity among liver recipients and the impact of the late allograft dysfunction on it, which is a risk factor for obesity and cardiovascular diseases, require studying.The aim of the study was to identify whether the late liver allograft dysfunction influences the physical activity of recipients.Material and methods. The study included 87 liver recipients. We measured anthropometric parameters, physical performance (SPPB, LFI, 6-min walk test), mean step count per day. Late liver allograft dysfunction was determined if elevated transaminases and/or cholestatic enzymes or hepatic failure have been diagnosed later than 3 months posttransplant. Activity trackers were provided to assess physical activity.Results. Median age was 54 years [45;61], 33% were men. The median follow-up period was 36 months [16;64]. The median of the average steps count was 5.9 [4.1;8.7] thousand per day. 60.5% of recipients were sedentary and low active, 24.4% were somewhat active, 15.1% were active. In cases of liver allograft dysfunction, the mean step count was significantly lower than in patients with normal liver function: 4.1 thousand [2.6;5.3] versus 6.8 thousand [4.2;9.4], p=0.003, despite no differences in the physical activity test results.Conclusion. In case of a late liver allograft dysfunction, the physical activity can decrease; 60.5% of liver recipients, in the absence of pathological restriction of movement, have a sedentary and low active lifestyle. Activity trackers may allow identifying patients who need additional check-up or physical training.

Emergency interventional endovascular treatment for early disorder of arterial blood flow in the liver graft

Introduction. Liver transplantation is considered the most effective treatment for patients with end-stage liver disease. X-ray endovascular interventions show good results in the treatment of vascular complications after transplantation. The timing, indications and choice of treatment methods require clarification.Objective. To evaluate the safety and efficacy of emergency X-ray endovascular interventions for arterial complications in the early period after liver transplantation.Material and methods. In the period from October 2016 by July 2021, 88 liver transplants were performed. The graft was obtained from a posthumous donor in 75 cases, and from a living donor (right lobe of the liver) in 13 cases. Arterial complications were registered in 10 cases: thrombosis of the hepatic artery in 7 (8.0%), constriction in 3 (3.4%); 4 patients underwent retransplantation due to thrombosis. This analysis included 6 patients aged 27 to 51 years, including 4 men and 2 women. In the early postoperative period (0–14 days), according to laboratory parameters, ultrasound Doppler, and computed tomography with a contrast agent, an impairment of the arterial blood supply of the graft was revealed, for which the patients underwent emergency X-ray image-guided surgical endovascular interventions.Results. Restoration of adequate arterial blood supply to the liver graft was achieved in all six patients. At the time of this writing, the graft function and patency of the hepatic artery were preserved at follow-up periods of 6, 11, 12, 22 (in two patients), and 26 months with a median of 17 months. Four patients developed biliary complications that required surgical correction.Conclusion. X-ray image-guided endovascular interventions can be considered effective and relatively safe in the treatment of patients with arterial complications after liver transplantation. The period of graft arterial ischemia should be minimized as much as possible in order to prevent biliary complications.

Chronic kidney disease as a risk factor for acute stroke

One of the most relevant issues of nephrology, neurology, and cardiology is the management and treatment of patients with chronic kidney disease and stroke. Patients with chronic kidney disease have a risk of both thrombotic complications and bleeding, and they have a high risk of both ischemic and hemorrhagic stroke. Chronic kidney disease significantly worsens the outcome of stroke by limiting the treatment due to reduced drug clearance and side effects. Hemodialysis which causes drastic hemodynamic and biochemical changes leads to the "stress" of the cerebral vascular system, increasing the risk of stroke; kidney transplantation reduces the risk of stroke due to functional recovery. Chronic kidney disease and stroke have significant socio-economic consequences. Patients with end-stage chronic kidney disease, as a rule, are not included in clinical trials; and stroke treatment tactics have not been developed for them. This review examines the interaction between kidneys and brain, the pathophysiology and epidemiology of stroke in all stages of chronic kidney disease, after kidney transplantation and discusses the management and treatment of chronic kidney disease patients with stroke.The investigation of the factors responsible for the high prevalence of brain lesions in chronic kidney disease will allow developing new treatment methods.

Phenomenon of Demikhov. At N.V. Sklifosovsky Institute (1960–1986). V.P. Demikhov and world transplantology in 1968-1969

The article has reviewed the advances of Soviet and world Transplantology in the field of heart and other organ transplantation achieved by the end of the 1960s. It is shown that there were several groups of doctors and scientists who worked in the USSR dealing with the problem of experimental organ transplantation and trying to bring this experience into clinic. The group of surgeons and urologists (B.V. Petrovsky, Y.M. Lopukhin, etc.) from the Research Institute of Clinical and Experimental Surgery and the 2nd MOLGMI named after N.I. Pirogov, which had the greatest administrative resources and technical capabilities, was successfully implementing kidney transplantation into clinic. The staff of the Faculty Surgery Department (V.S. Savelyev and others) of the 2nd MOLGMI named after N.I. Pirogov developed experimental approaches to heart and liver transplantation. Surgeons from the Tuberculosis Research Institute (N.I. Gerasimenko and others) were dealing with in lung auto- and homotransplats in experiment. All those studies were conducted in close contact with the Department of Operative Surgery and Topographic Anatomy of the 2nd MOLGMI named after N.I. Pirogov (G.E. Ostroverkhov) and the Research Laboratory for Organ Transplantation established at that Department (Y.M. Lopukhin). The leading position in heart transplantation in the country belonged to the Vishnevsky Institute of Surgery (A.A. Vishnevsky, etc.). Surgeons of the MMA named after S.M. Kirov (I.S. Kolesnikov, etc.) rendered a great assistance to the Institute. Apart from these institutions, the Organ Transplantation Laboratory (headed by V.P. Demikhov) worked at N.V. Sklifosovsky Research Institute for Emergency Medicine; it had gained a huge experimental experience, but had very modest opportunities to purchase equipment and pharmaceuticals, to conduct laboratory and morphological studies, having practically no prospects for introducing the results of its research into clinic. Meanwhile, the world clinical Transplantation continued to develop successfully, which was reflected in the materials of the 2nd International Symposium on Heart Transplantation held in 1969 in Montreal (Canada).

The impact of desflurane and sevoflurane on the intraoperative and early postoperative period in liver transplantation

Background. A pressing issue is the choice of an anesthetic agent for liver transplantation. The mechanism of the organprotective properties of desflurane and sevoflurane is not fully understood. It is important to understand the effects of desflurane and sevoflurane on the severity of ischemia-reperfusion injury of the liver graftAim. To study the effect of desflurane and sevoflurane on the intraoperative and early postoperative period in liver transplantation.Material and methods. The study included 47 patients with liver cirrhosis of various etiologies who underwent cadaveric liver transplantation between February and December 2020. The groups compared in the study included 24 patients who received desflurane and 23 patients who received sevoflurane.Results. There were no statistically significant differences in the effect of desflurane and sevoflurane on hemodynamic parameters, on the need for vasopressor drugs. Episodes of bradycardia and cardiac arrhythmias were significantly more frequent when using sevoflurane. Patients were extubated significantly faster after surgery in the desflurane group. In the early postoperative period, desflurane and sevoflurane did not adversely affect significantly the liver graft function and the degree of its ischemia-reperfusion injury. The groups appeared comparable in rates of using the renal replacement therapy, the incidence of the graft dysfunction development in the postoperative period, and the surgery outcomes.Conclusions. The use of modern inhalation anesthetics desflurane and sevoflurane to maintain anesthesia during liver transplantation does not adversely affect the course of the intraoperative and early postoperative period.

Clinical characteristics and outcomes of COVID-19 in kidney transplant recipients

Introduction. The pandemic caused by the SARS-CoV-2 coronavirus is characterized by significant morbidity and mortality. Kidney transplant recipients are at high risk of a more severe course of coronavirus infection due to ongoing immunosuppression, a high comorbidity index, and elder age.Aim. To investigate the features of the clinical course, the treatment applied and also the outcomes of the new coronavirus infection in patients after kidney transplantation.Material and methods. The retrospective study included 69 adult kidney transplant recipients continuously followed-up by our transplant nephrology service and who fell ill with COVID-19 from April 2020 till February 2021. The comparison study of the clinical pattern, laboratory and instrumental test results, treatment features and outcomes was made.Results. The most common clinical symptoms were hyperthermia (85.5%, n= 59), weakness (65.2%, n=45) and cough (52.2%, n=36), other symptoms were significantly less common. In 89.5% of cases (n=60), the virus ribonucleic acid was detected at least once by polymerase chain reaction; in 10.5% of cases (n=7), the polymerase chain reaction results were negative. According to CT, the extent of lung tissue lesion was identified as CT1 stage in 28 patients (46.7%), CT2 stage in 24 (40%); and only in 8 (13%) patients the lesion was assessed as CT3. Later on the number of patients with more than 50% lung damage increased to 16 (26.7%) and in 1 case the severity of lung tissue damage was consistent with CT4. Typical features for all patients were anemia and lymphopenia of varying severity, hypoproteinemia, increased serum creatinine and urea, C-reactive protein, ferritin, procalcitonin and D-dimer in the laboratory test results. The treatment included antiviral, antibacterial, anticoagulant therapy, corticosteroids, biological anti-cytokine drugs. In 95% of cases (n=66), the maintenance immunosuppressive therapy was changed up to complete withdrawal of the certain components. The patient survival rate with a functioning graft was 76.8% (n=53), the graft loss was observed in 4.3% of cases (n=3), and the lethal outcome was reported in 18.8% (n=13). The cause of death was a severe respiratory distress syndrome with multiple organ dysfunction complicated by sepsis and septic shock in 8 patients (61.5%). Invasive ventilation and hemodialysis were associated with 17.2 (p<0.00001) and 21.5 (p<0.0006) times higher risk of death, respectively.Conclusions. Severe lymphopenia is associated with a clinical worsening of the COVID-19 course. Predictors of fatal outcome were identified as follows: bacterial sepsis, invasive ventilation, the need for renal replacement therapy (p<0.00001). Immunosuppression adjustment should be personalized considering the severity of infection, age, comorbidities, post-transplant timeframe, and the risk of rejection.><0.00001). Immunosuppression adjustment should be personalized considering the severity of infection, age, comorbidities, post-transplant timeframe, and the risk of rejection.

Results of using L-ornitin-L-aspartate in the treatment of hepatic encephalopathy in liver transplantation

The aim was to study the results of using various treatment regimens for hepatic encephalopathy for patients with liver cirrhosis before and after liver transplantation and the effect on the incidence and severity of hepatic encephalopathy in the perioperative period, and on the posttransplantation course.Material and methods. Fifty four patients with cirrhosis of various etiologies and the presence of significant hepatic encephalopathy undergoing living donor liver transplantation were included in the study. In the comparison group, patients took lactulose and rifaximin. In the main group, patients took lactulose and rifaximin in combination with L-ornithine-L-aspartate in the preoperative period, and L-ornithine-L-aspartate after liver transplantation for 5 days.Results. The use of L-ornithine-L-aspartate in the complex therapy of hepatic encephalopathy led to significantly reduced time of performing the Number Connection Test, the improvement of cognitive functions in patients by the Montreal Cognitive Assessment, a decreased incidence of stage II–III hepatic encephalopathy and an increased incidence of stage 0-I hepatic encephalopathy in the preoperative period. In the postoperative period, patients of the main group showed a rapid decrease in the severe stages of hepatic encephalopathy (stage II–III) towards less severe forms (stage 0–I) on the 3rd, 5th and 7th days after liver transplantation, and also a faster recovery of cognitive functions, an earlier adequate recovery of consciousness, muscle tone, an earlier possibility of extubation, a shorter length of stay in the intensive care unit, and a decreased postoperative hospital length of stay relatively to the patients of the comparison group.Conclusion. The use of L-ornithine-L-aspartate in the combination therapy for hepatic encephalopathy in the peritransplantation period leads to a significant decrease of the incidence and severity of hepatic encephalopathy, accelerates rehabilitation of patients, reduces postoperative hospital length of stay.

Complete regression of generalized plasmacytoma of lymph nodes in a liver transplant recipient during the conversion of immunosuppressive therapy from tacrolimus to everolimus

Introduction. One of the serious complications after transplantation of solid organs and bone marrow is the development of post-transplant lymphoproliferative diseases.Clinical case. To evaluate the course of post-transplant lymphoproliferative diseases in the long-term in a liver transplant recipient after conversion of immunosuppressive therapy from tacrolimus to everolimus. We analyze a case of generalized primary plasmacytoma of lymph nodes with bone marrow involvement in a patient after liver transplantation.Results. After conversion of immunosuppression we observed a rapid positive trend: decreasing size of lymph nodes and regression of the level of paraprotein down to its complete disappearance. There were neither adverse events associated with everolimus for four years, nor signs of immunosuppression insufficiency.Conclusion. This Case Report is the first description of a long-term remission of nodal plasmacytoma that developed in a liver transplant recipient after complete withdrawal of calcineurin inhibitors and administration of everolimus. We suggest that the regression of post-transplant lymphoproliferative diseases after replacing calcineurin inhibitors with everolimus is associated not only with the minimization of calcineurin inhibitors exposure, but also with the antitumor effect of the everolimus itself, which prompts us to discuss the possibilities of expanding its clinical application.

Analysis of the results of pancreas transplantation in one transplant center in Russia

Introduction. The total number of pancreas transplantations performed in Russia by the end of 2019 had been 176. There are no detailed reports on the number and results of pancreas transplantation in Russia with analysis of factors that significantly affect outcomes.Material and methods. This article presents a retrospective analysis of 60 pancreas transplantation results, which had been performed from January 2008 to July 2019 at the N.V. Sklifosovsky Research Institute for Emergency Medicine. In addition, the assessment of factors that significantly affect the outcomes of pancreas transplantations was performed.Results. 17 intra-abdominal pancreas transplantations with duodenoejunoanastomosis and 43 retroperitoneal pancreas transplantations with interduodenal anastomosis were performed. In 52 patients, the pancreas graft after vascular reconstruction with a Y-shaped vascular prosthesis was used; in other 8 patients, the pancreas graft with isolated blood flow through the splenic artery was used. The rates of immunological and surgical complications were 23.3% and 56.7%, respectively. In-hospital and 1-year recipient, kidney and pancreas graft survival rates were 88.3%, 86.4%, 83.3% and 86.6%, 84.8%, and 81.7%, respectively. The factors that significantly affected the outcomes of pancreas transplantation were the conversion of the dialysis therapy modality, the development of parapancreatic infection, repeated open surgical interventions, surgical complications of IIIb-IVa severity grades by Clavien-Dindo Classification, some features of basic and induction immunosuppressive therapy.Conclusion. The results of pancreas transplantation at the N.V. Sklifosovsky Research Institute for Emergency Medicine are comparable to the outcomes of pancreas transplantation in most world transplant centers.

Comparative effectiveness of "liberal" and "restrictive" modes of intraoperative infusion-transfusion therapy in lung transplantation

Introduction. Recently, researchers have paid considerable attention to the strategy of intraoperative infusiontransfusion therapy in traumatic surgical interventions. The choice of a “restrictive” regimen during surgery in many studies has reduced the incidence and severity of intra- and postoperative complications.Objective. Comparison of the effectiveness of "liberal" and "restrictive" intraoperative infusion-transfusion therapy in lung transplantation.Material and methods. The study included 58 patients who underwent bilateral lung transplantation at N.V. Sklifosovsky Research Institute for Emergency Medicine in the period 2012-2019. The patients were divided into 2 groups: the comparison group included 31 patients, the total volume of intraoperative infusion-transfusion in whom was 14386.9 ± 1310.0 ml (16.5 ml/kg/h). Group II consisted of 27 patients; their total volume of intraoperative infusion-transfusion during surgery was 10251.3 ± 740.1 ml (12.9 ml/kg/hour). The analysis we performed included the volume and composition of intraoperative infusion-transfusion therapy, the volume of blood loss, clinical and laboratory data, the duration of mechanical ventilation, the frequency of intraoperative use of veno-arterial extracorporeal membrane oxygenation and the duration of its use after surgery, mortality.Results. When using the "restrictive" fluid therapy for lung transplantation, we observed a decrease in the volume of intraoperative blood loss by 1.3 times, the volume of transfusion of blood components, including fresh frozen plasma by 37%, erythrocyte suspension by 3.1 times, and instrumental reinfusion of autoerythrocytes by 1.56 times. At the same time, we revealed a decrease by 2.7 times in the duration of the mechanical ventilation use, a decreased frequency of using veno-arterial extracorporeal membrane oxygenation during surgery by 1.3 times, and a decreased duration of using veno-arterial extracorporeal membrane oxygenation after surgery by 2.3 times. Mortality was 38.7% in group I, and 30.7% in group II.Conclusion. The “restrictive” approach to intraoperative infusion-transfusion therapy in lung transplantation seems a promising new trend requiring further study and gaining the experience.