To investigate whether early postoperative changes in blood lactate concentration indicate the functional recovery of the newly grafted liver, changes in oxygen supply, oxygen consumption, acid-base equilibrium, and blood lactate concentrations were prospectively studied in a group of 53 postnecrotic cirrhotic patients during the various phases of orthotopic liver transplantation (preanhepatic, anhepatic, neohepatic) and for the first 48 h following reperfusion. The patients were divided into two groups according to the quality of the early graft function, as indicated by alanine aminotransferase, bile flow, and prothrombin activity: group A (49 patients), good immediate graft function and group B (4 patients), immediate graft non-function. Lactate levels rose in the same manner during the preanhepatic and anhepatic stages and peaked after revascularization of the graft. Following reperfusion, however, distinctly different blood lactate profiles were recorded in the two groups of patients. A fall in lactate concentration was recorded in group A patients, whereas a continuous rise occurred in group B patients: the difference becoming significant by the end of surgery (P<-0.05). During the first 48 h following revascularization of the graft, opposite trends in lactate concentration, bile flow, alanine aminotransferase, and prothrombin activity were evident in the two groups of patients: 24 h after reperfusion, lactate levels were below 2 mmol/1 in 47 of 49 patients from group A, while they plateaued above 4 mmol/1 in all patients from group B. Group A patients had lower alanine aminotransferase levels (P<-0.001), higher prothrombin activity, (P<-0.01), and greater bile flow (P<-0.02). If validated in larger series, the blood lactate profile, probably more than the absolute level, appears to be a useful indicator of the early recovery of liver metabolic capacities in the immediate postoperative period of orthotopic liver transplantation.

Lactate blood levels in the perioperative period of orthotopic liver transplantation.

Background. Acute renal failure occurring immediately after liver transplantation and requiring hemodialysis is a major problem resulting in a poor prognosis. We investigated the efficacy of human atrial natriuretic peptide, which has potent natriuretic effects and unique protective effects for glomeruli in preventing acute renal failure after liver transplantation. Methods. Thirty-seven patients who underwent live donor liver transplantation with model for end-stage liver disease scores greater than 15 were the subjects of the study. Subjects were prospectively randomized into two groups: patients that received synthetic human atrial natriuretic peptide infusion (Group H: n=19) and those that received conventional diuretics, furosemide and potassium canrenoate (Group C: n=18). The peri- and postoperative changes in hemodynamic status and renal function were compared between the two groups. Results. There were no statistical differences in the changes in hemodynamic status between groups. Hemodialysis was required after liver transplantation in nine patients, two in Group H and seven in Group C (P=0.04). Postoperative creatinine clearance was higher in Group H (P=0.03). Aldosterone level was suppressed in group H (P=0.006). Conclusions. Continuous infusion of synthetic human atrial natriuretic peptide might be effective for preventing acute renal failure requiring hemodialysis after liver transplantation.

Prevention of renal impairment by continuous infusion of human atrial natriuretic peptide after liver transplantation.

The significance of serum levels of glycosaminoglycans (GAGs) and insulin like growth factor-1 (IGF-1) in early screening of hepatocellular carcinoma in cirrhotic patients was evaluated. The effect of diabetes on GAGs and IGF-1 levels was also estimated. Fifty cirrhotic patients with early stage Hepatocellular carcinoma (HCC) (22 were diabetic), thirty control cirrhotic patients without HCC (11 were diabetic) and twenty normal control subjects, were enrolled to the study. Serum α-fetoprotein (AFP), the commonly used marker for HCC, was measured in all HCC patients. Serum GAGs increased significantly, while IGF-1 was reduced in patients with cirrhosis and early stage HCC compared to normal control (P < 0.001). There was a significant reduction in GAGs and IGF-1 levels in control cirrhotic group compared to HCC group (P < 0.05). HCC patients who had normal AFP showed significantly increased GAGs and reduced IGF-1 levels compared to normal control. In comparison with corresponding non-diabetic patients, diabetic patients showed a significant increase in serum GAGs in both cirrhotic control and HCC (P < 0.01), while a significant decrease was observed in serum IGF-1 only in HCC (P < 0.05). Concomitant determination and monitoring of serum GAGs and IGF-1 could be used as a simple, low cost and non-invasive marker for HCC in cirrhotic patients.

	 

	Key words: Hepatocelluar carcinoma, liver cirrhosis, alpha fetoprotein, glycosaminoglycans, insulin like growth factor-1.

/pdf/serum-levels-of-glycosaminoglycans-gags-and-insulin-like-43vmbtk5u2.pdf

Serum levels of glycosaminoglycans (GAGs) and insulin like growth factor-1 (IGF-1) as diagnostic markers for early hepatocellular carcinoma in cirrhotic patients with or without diabetes

The complications concerning liver and intestinal transplant surgery have relevance for the field of intensive care because they share some characteristics with those following complex long-term surgery. Thus, in this article we shall try to describe complications that are specific to liver and multivisceral transplants. A review of the existing literature on this topic reveals a large number of studies dedicated to early as well as late surgical complications, and immunosuppressive treatment, while there are far fewer contributions describing complications exclusively concerning intensive care. We shall thus attempt to focus on certain aspects where, besides the literature data, we have personal experience. In particular we want to underline the implications of failure in the functional recovery of the graft; alterations in water, electrolyte, and glycemic balance; as well as neurological, respiratory, renal, nutritional, and infective complications.

Intensive care complications in liver and multivisceral transplantation.

https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/lt.23922

Growth hormone/insulin-like growth factor 1 dynamics in adult living donor liver transplantation

Atrial natriuretic factor (ANF) is a 28 amino acid peptide secreted by the atrial cardiocytes. Clearance is via the lung (50%) and the liver (25%). The main stimulus to ANF secretion is atrial distension but vasoconstrictors, sympathetic stimulation, catecolamines and tachycardia are able to enhance its circulating blood levels. ANF blood concentrations were measured during orthotopic liver transplantation in six postnecrotic cirrhotic patients. Significant increases in ANF blood levels occurred at the end of the anhepatic phase (P≤ 0.02 vs baseline) associated with low cardiac filling pressures (P≤ 0.02 vs baseline) and increased systemic vascular resistances (P≤ 0.02 vs preanhepatic phase). Aldosterone blood levels showed a similar behaviour, increasing significantly (P≥ 0.001 vs baseline) at the end of the anhepatic phase. ANF fell after reperfusion of the graft and returned towards baseline values at the end of the procedure. Since most of the total body clearance of ANF is performed by the lungs, its sharp increase at the end of the anhepatic phase could be considered a counterregulatory response to vasoconstricting stimulation and to fluid-paring mechanisms in the presence of relative hypovolaemia. Its decrease after reperfusion could be related to volume normalization and partly to the enhanced clearance performed by the newly grafted liver.

Changes in circulating levels of atrial natriuretic factor (ANF) during orthotopic liver transplantation in humans

Insulin-like growth factors [IGF I and II or somatomedins (SMS)] are polypeptides chemically and biologically correlated with insulin. The main source of synthetic activity and secretion is the liver, although many other tissues have been demonstrated to synthesize SMS [5]. In the circulation, they are not present in a free form, but are mostly bound to a specific carrier protein independently synthesized in the liver. Hepatic or extrahepatic storage organs have not been demonstrated; the half life of the SMS-binding protein complex is between 3 and 4 [1]. Synthesis of SMS is regulated by GH, insulin, thyroxine and nutrition (caloric and protein intake, and nitrogen balance). The role of corticosteroids is still a matter of debate: in patients treated with steroids SMS blood levels have been shown to be within normal limits, while biological activity has been demonstrated to be significantly reduced by SMS inhibitors, probably induced by corticosteroid therapy [2].

Somatomedin C (IGF I) plasma levels after orthotopic liver transplantation (OLT) in end-stage cirrhotic patients.

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Changes in circulating levels of atrial natriuretic factor (ANF) during orthotopic liver transplantation in humans

Somatomedin C (IGF I) plasma levels after orthotopic liver transplantation (OLT) in end-stage cirrhotic patients.