Analysis of critical issues in case management for liver retransplantation

doi:10.4236/crcm.2013.29133

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Vol.2, No.9, 508-512 (2013) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2013.29133

Analysis of critical issues in case management for

liver retransplantation

Marina Moguilevitch*, Ellise Delpin

Montefiore Medical Center, Bronx, NY, USA; *Corresponding Author: [email protected]

Received 8 October 2013; revised 7 November 2013; accepted 6 December 2013

bution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly

ABSTRACT

We report a case of a patient who underwent

successful combined liver-kidney transplant af-

ter two prior liver transplantations. The topic of

liver retransplantation is very controversial. Gi-

ven the critical organ shortage, the question ari-

ses as to wheth er hepa tic retransplant atio n should

be offered liberally despite its greater cost, and

inevitable denial of access to primary transplan-

tation for the other patients on the waiting list.

We suggest that careful selection of the retrans-

plant candidates will improve outcomes and al-

low rational use of the limited organ supply. Ana-

lysis of the available literature allows us to iden-

tify the main predictors of morbidity and mortal-

ity for this patient population. It also enables de-

velopment of a detailed plan for perioperative

management. The role of transesophageal echo-

cardiography (TEE) as a monitor in the complex

liver transplant cases is also discussed. Our re-

port is a significant contribution to the very lim-

ited data available on the subject of multiple

liver retransplants.

Keywords: Liver Retransplantation; TEE in Liver

Transplantati o n; M oni tor ing in Liver

Retransplantation; Anesthetic Manage ment Liver

Retransplantation

1. INTRODUCTION

Liver transplantation is currently the life-saving thera-

peutic modality for treatment of the end-stage liver dis-

ease. With significant advances in antiviral therapy, pos-

toperative immunosuppression and improved surgical

technique today’s 5 and 10 year survival rates after or-

thotopic liver transplant are over 70% and 65% respec-

tively [1]. However, the survival rates of retransplanted

livers among different centers in the United States vary

from 10.0% to 19.4% [2,3] and in the world from 5% to

22% [4,5].

Retransplantation carries greater surgical risks, longer

ICU and hospital stay and significantly poorer outcome

in terms of graft and patients survival. The 5 and 10 year

survival rates range from 47% to 63% and 45% to 62%

respectively [6,7]. The medical problems related to re-

transplantation are compounded by rising financial bur-

den and multiple ethical issues. In an era of extreme or-

gan shortage, the practice of liver retransplantation can

deny access to transplantation to patients waiting for

their first transplant. Additionally, the annual death rate

per 1000 patient has been 2 to 3 times higher for recipi-

ents of multiple liver procedures versus recipients of

primary transplants over the past 9 years [8].

Careful selection of patients for retransplantation and

especially for the repeated retransplantation is extremely

important. The decision regarding this high-risk surgery

should be individualized and based on specific patient

risk factors and the chances for long-term survival.

2. CASE PRESENTATION

The patient is a 29-year-old female with end stage

liver d isease ca used by graft failu re seco ndary to ch ronic

rejection and recurrent autoimmune hepatitis. She had a

history of two prior liver transplants, 16 and 12 years ago.

She presented with clinical symptoms of ascites, severe

portal hypertension and chronic kidney disease requiring

hemodialysis. Her past medical history also included

hypertension, diabetes, and depression. Her medications

include novolog insulin, spironolactone, furosemide, pre-

dnisone, prograft and lactulose. Physical examination

showed significant ascites and jaundice, normal airway,

normal cardiac and pulmonary functions.

Her laboratory studies revealed: Hgb 8.2 mg/dl, total

M. Moguilevitch, E. Delpin / Case Reports in Clinical Medicine 2 (2013) 508-51 2 509

bilirubin/direct bilirubin 54/23.9 mg/dl respectively,

BUN 26 mg/dl, Creatinine 6.4 mg/dl, potassium 4.1

mEq/l, INR 4.8, PT 29 sec, PTT 56 sec, Platelets 39,000.

Transthoracic echocardiogram (TEE) demonstrated

normal left ventricular function with an ejection fraction

of 60% and mild tricuspid valve regurgitation. When an

ABO compatible donor became available the patient was

scheduled for a combined liver-kidney transplant.

Standard ASA monitors were placed. After pre-oxy-

genation, anesthesia was induced with midazolam 2 mg,

fentanyl 150 mcg, propofol 150 mg, and cisatracurium

18 mg. The patient was intubated orally with 7.5 cuffed

endotracheal tube. Subsequently, two large bore periph-

eral intravenous lines, an ar terial line, and a right intern al

jugular 8.5 French introducer catheter were placed. Mul-

tiple attempts to float a Swan Ganz catheter were unsuc-

cessful. A TEE probe was inserted. The examination re-

vealed significant tricuspid valve regurgitation with dila-

tation of the right atrium. Right and left ventricular func-

tion was preserved. The calculated pulmonary artery

pressure was 45/25 mm Hg (Figure 1).

Surgery was planned with the use of veno-venous by-

pass and TEE.

An outflow 21 French heparin coated bypass cannula

was placed in left femoral vein and inflow 19 French

cannula was placed in internal jugular vein under ultra-

sound guidance. The bypass flow through the case was

1.6 - 1.7 L/min. Cell saver and Belmont rapid infuser

were utilized during the surgery. Inferior vena cava cross

clamp time was 27 minutes. There were moderate hemo-

dynamic changes after reperfusion necessitating vaso-

pressin and norepinephrine infusions. The patient was

coagulopathic requiring 45 units of PRBC, 20 liters of

cell saver blood, 37 units of FFP, 5 units of cryoprecipi-

tate and 5 units of platelets.

Thromboelastography was utilized to guide the treat-

ment of the coagulopathy. Surgery lasted 10 hours and

the patient was transferred to the ICU in tubated in stable

condition. The postoperative course was uncomplicated,

except for the need for several hemodialysis sessions.

She was extubatedon postoperative day 2. The patient-

was discharged from the ICU after 5 days and left the

hospital 2 weeks after surgery. Ten months after the

transplant the patient is doing well.

3. DISCUSSION

Transplantation is often the best option for patients

faced with organ failure. Although the results following

primary transplantation have improved, allog raft loss is a

problem confronted by many patients and their physi-

cians. While retransplantation offers hope for good

health and better survival, previous studies have demon-

strated inferior outcomes after repeat liver transplanta-

tion [1,7] .

In a time of extremely limited organ supply, retrans-

plantation remains to be very controversial on ethical,

economic and medical grounds. Therefore, it is particu-

larly important to identify th e group of patients who will

definitely benefit from retransplantation , and to delineate

major donor risk factors that potentially can lead to poor

outcomes and coordinate the work of the multiple ser-

vices involved in these high-risk procedures. The key to

the growing success of liver retransplantation is in care-

ful selection and strategic planning of this operation.

It is very important to be aware of the multiple risk

factors affecting the outcome of the procedure. In the past,

technical complications were the main ind ication for ear-

ly retransplantion, while chronic rejection was the most

important cause for late retransplantation. At the present

time, the scarcity of donor organs necessitates the accep-

tance of subopti mal donor grafts for primary transplan ta-

tion. This practice, in turn, contributes to the fact that

primary graft dysfunction has become the leading indica-

Figure 1. Mid esophageal right ventricle inflow-outflow view. Tricuspid regurgitation.

M. Moguilevitch, E. Delpin / Case Reports in Clinical Medicine 2 (2013) 508-51 2

510

tion for liver retransplantation within the first year after

primary transplantation. Also, the use of more potent im-

munosuppression has decreased chronic rejection but has

increased recurrent hepatitis C in grafts as the primary

cause for retransplantation on e year after primary surgery

[9].

Although retransplantation in general has poorer out-

comes in terms of survival, multiple studies have shown

that patients having elective retransplantation exhibited

survival curves indistinguishable from those of the single

transplant group [1,10,11]. In spite of a trend towards

longer hospital stay and higher charges in the retrans-

plantpatients, retransplantation is fully justifiable when

performed electively [12]. Outcomes are worse for emer-

gency retransplants, especially those performed within 8

to 30 days of the initial transplantation [13]. However,

despite its inferior results, hepatic retransplantation can

not be abandoned just for practical and ethical reasons.

Prognostic modeling allowing prediction of mortality

risk and long-term survival of patients after retransplan-

tation is extremely important. Analysis of prognostic

factors confirmed by several studies identified a signifi-

cant correlation between mortality and patient ag e, serum

creatinine level, urgency of the operation, and ICU re-

cipient status before retransplantation [14,15]. Younger

patients with normal creatinine coming for elective pro-

cedures more than a year after previous transplants have

better survival chances [1,12,15]. It is a difficult decision

to identify the optimal time for retransplantation in the

case of chronic progressive graf t rejection . In th is settin g,

there might be a place for living related liver transplanta-

tion. Living related transplant shortens the waiting time,

allows for better preparation of the recipient, and pro-

vides an optimal graft with the sho rtest possible ischemia

time [16].

There are several other measures proposed to improve

the results of retransplantation of the high-risk patients.

One of them is to match the severity of the patient’s con-

dition with the quality of the graft. It is a well-established

fact that the recipients of good quality grafts have better

survival chance compared to those who received ex-

tended criteria grafts [17]. Another area of improvement

in retransplantation identified in the literature is refine-

ment of surgical techniques. The success rate of retrans-

plantation has increased as a growing number of sur-

geons have gained expertise in doing this procedure [18].

Ethical issues related to retrasplantation are also very

important. When a patient receives a repeat transplant,

many people think it is unjust to give them priority over

someone who has never had one before. While the num-

ber of liver transplants performed in United States has

reached over 6000 per year, the demand for donor organs

exceeds the supply. As a result, around 1800 deaths per

year occur on the waiting list. Cu rrently, only 554 out of

16,026 patients nationally listed as candidates are listed

for retransplantation [19]. Statistically, these numbers are

very small, but still can raise many ethical concerns for

the transplant teams, candidates for transplant, and fam-

ily members .

Although the primary goal of organ retransplantation

is the optimal health of the patients, it is realistic to ana-

lyze the financial considerations behind the procedure.

The high cost of retransplantation has been well docu-

mented [7]. The cost of retransplantation is usually twice

that of primary one. Even finances are a driving force in

our society; the question arises if it is eth ically correct to

place monetary value on human life.

In our case, weighing the risks versus benefits for this

particular patient, the team decided that young age, late

graft failure and the non-urgent nature of the operation

would increase the chances of a favorable outcome.

Repeat retransplantation of a patient with chronic kid-

ney failure necessitated to combine liver-kidney trans-

plant which presen ted additional risks. In this setting, the

appropriate choice of the invasive monitoring becomes

extremely important. Our current standard of care for pe-

rioperative hemodynamic monitoring during liver trans-

plantation remains an arterial line an d a pulmonary artery

catheter (PAC). However, perioperative transesophageal

echocardiogram (TEE) has been shown to be helpful in

managing fluid therapy, monitoring myocardial function,

and identifying intraoperative complications [20,21].

In our case, TEE monitoring was imperative as the

presence of the significant tricuspid valve regurgitation

(TR) prevented successful placement of the PAC. The

primary advantage of TEE is real-time assessment of

cardiac function, quantitative and qualitative determina-

tion of right and left ventricular filling and ejection frac-

tion. Right and left ventricular dysfunction can be exac-

erbated during liver transplantation by large fluid shifts

that occur during clamping and unclamping of the major

vascular structures such as the inferior vena cava and the

portal vein. Patients are at particular risk of right ven-

tricular failure during and after the reperfusion phase of

the operation. In the presence of TR, this risk is signifi-

cantly increased. Unlike the PAC, the TEE as an imaging

modality can detect new wall motion abnormalities,

shunting, as well as pulmonary and intracardiac emboli

[22,23]. Previous concerns about possible trauma to eso-

phageal varices during TEE placement were largely un-

founded. A large retrospective cohort study demonstrated

no major bleeding complications, even in higher risk

patients [24].

Our unique experience with a repeat combined liver-

kidney transplant opens a new prospective in the ap-

proach to the problem of liver retransplantation. Careful

M. Moguilevitch, E. Delpin / Case Reports in Clinical Medicine 2 (2013) 508-51 2 511

patient selection, individualized monitoring, manage-

ment plans, and strong team work contribute to making

this high-risk procedu re su cc essful.

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