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Urokinase as a protective factor against ischaemic type biliary lesions in liver transplantation
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Abstracts
Methods: The procurement and transplantation quality forms from March 2012 till August 2013 were analyzed. The forms were categorized by using a scoring system based on five categories. A (no remarks at procurement or transplantation level), B (a deviation remarked by the transplantation surgeon), C (a possibly avoidable damage of the organ) defined as a C1 score (damaged but transplantable) or a C2 score (damaged and discarded). A D score (an unavoidable damage of the organ) also subdivided in a D1 (damaged but transplantable) and a D2 (damaged and not transplantable). And an E score for all other remarks. Results: 420 of 563 (74.6%) sets of kidney QFs and 133 of 158 (84.2%) sets of liver QF's were completed and analyzed. On average in 24.3% (14.5%–60%) of the kidneys and in 27.8% (21.6%–40%) of the livers a possibly avoidable damage of the organ was found. 1.4% of the kidneys was discarded caused by a possibly avoidable injury. For the liver less than 1% was discarded partly caused by a possibly avoidable injury. In 22.1% a deviation between the transplant and procurement was found in the analyzed kidney forms and 21.8% of the liver forms. This means that the transplanting surgeon noted damage to the organ that was not seen or differently assessed by the procuring surgeon Conclusion: This research shows the percentages of ‘possibly avoidable damage’ during organ procurement, and although these seem rather high, these are comparable to the (few) literature about this subject. There was a trend between procurement center volume and organ damage; the higher the number of procurements per center, the lower the percentage of possibly avoidable damages. Feedback on this research to the centers will hopefully lead to further improve quality of procurements. doi:10.1016/j.trim.2014.11.153
B14-1158 Urokinase as a protective factor against ischaemic type biliary lesions in liver transplantation L.C. Pietersena,b, A.C. Den Dulkc, A.E. Braata, A.O. Rahmelb, J.J. Bloka, B. van Hoekc, J. Ringersa a
Department of Transplant Surgery, Leiden University Medical Center, Leiden, The Netherlands b Eurotransplant International Foundation, Leiden, The Netherlands c Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands Introduction: Ischemic injury of the peribiliary vascular plexus plays a critical role in the occurrence of ischemic-type biliary lesions (ITBL) after liver transplantation. Flushing the graft with a thrombolytic agent may solve this problem. This may cause more bleeding due to its effect on the clotting system. The aim of the present study was to assess whether flushing the donor liver with urokinase, prior to transplantation, has a positive effect on reducing the number of ITBL, without a higher risk of bleeding. Patients and Methods: Between January 2005 and October 2012, with a follow-up through October 2013, all patients receiving a liver transplantation were included. Exclusion criteria were patients who received a domino liver, a split liver or auxiliary liver transplant, or unknown data. Clinical information was obtained from a prospectively collected database. Results: A total of 205 patients were operated in the given period of which 21 were excluded. Of the 184 patients included, 122 did not receive urokinase (control group) and 62 patients received urokinase (study group). Basic donor characteristics (ET-DRI) and recipient characteristics (age, BMI, lab MELD) did not significantly differ in both groups.
Thirty-five patients developed ITBL. In the control group 23 (18%) and 12 patients in the study group (17%), resulting in a not-significant difference (p = 0.94). Comparing only DCD-donors from both groups also does not show a significant decrease in ITBL (P = 0.53). Autologous blood transfusion did not differ significantly between both groups (p = 0.82). Heterologous blood transfusion differed significantly between both groups (p b 0.01), with surprisingly more need for packed cells in the control group. Discussion: Contrary to previous studies, this (small) pilot study could not find a decrease in the prevalence of ITBL in patients treated with urokinase before implantation. The moment of intervention, before implantation versus during organ procurement, could be an explanation. A larger prospective study with administration of a thrombolytic agent during organ procurement of may clarify this issue. Further, flushing with urokinase before implantation does not lead to more bleeding and is therefore safe for the patient. doi:10.1016/j.trim.2014.11.154
Abstracts basic research B14-1045 Effect of cessation of cotrimoxazole on serum creatinine in kidney transplant recipients I.S. Muskens, C.E. Hensen, A.D. Van Zuilen Department of Nephrology, UMC Utrecht, The Netherlands Background: Kidney function is an independent predictor for graft survival after transplantation. Cotrimoxazole (400 mg sulfamethoxazole and 80 mg trimethoprim (CTM)), used as prophylaxis for PJP-pneumonia, is known to increase serum creatinine-levels by inhibiting tubular excretion of creatinine, resulting in a pseudodecline of eGFR. In our centre CTM is stopped on protocol four months after kidney transplantation upon achieving minimal immunosuppression. We investigated the effect of cessation of CTM on serum creatinine in kidney transplant recipients. Methods: All recipients, transplanted between 01-01-2010 and 0106-2013 (n = 220) were included. CTM prescription and reason for cessation were derived from medical records. The last three creatinine values prior to cessation and two after were averaged. Additionally, the age of the recipient and tacrolimus level around the time of cessation were recorded. We performed analysis both on all patients (group A) and on patients who stopped CTM according to protocol (group B). Univariate analysis was done with paired student t-test, multivariate analysis through linear regression. Outcomes: Of 220 patients 133 stopped on protocol (mean duration of CTM: 132 (sd:54) days and 87 patients stopped early (mean 102 (sd:89) days). Reasons for cessation were among others hematologic abnormalities (N = 37 (16.8%)), liver dysfunction (N = 4 (1.8%)), suspected tubule interstitial nephritis (N = 10 (4.5%)). In group A mean creatinine after cessation was 150 (sd:92) μmol/l. This was 11.6 μmol/ lower than prior to cessation (p b 0.0005). In group B, mean decrease in creatinine was 13 μmol/l (P b 0.0005). In adjusted analysis we found that serum tacrolimus and age did not affect creatinine reduction. However, the higher the creatinine was prior to cessation the bigger the absolute and relative reduction in creatinine. Conclusion: Sulfamethoxazole affects tubular secretion of creatinine. Only limited data on the effect of CTM in prophylactic dosage on serum creatinine is available. We illustrated that cessation of 480 mg of CTM daily results in a reduction of creatinine of 13 μmol/l or 8%. The fact that this effect cannot be observed in patients who are
Abstracts
Methods: The procurement and transplantation quality forms from March 2012 till August 2013 were analyzed. The forms were categorized by using a scoring system based on five categories. A (no remarks at procurement or transplantation level), B (a deviation remarked by the transplantation surgeon), C (a possibly avoidable damage of the organ) defined as a C1 score (damaged but transplantable) or a C2 score (damaged and discarded). A D score (an unavoidable damage of the organ) also subdivided in a D1 (damaged but transplantable) and a D2 (damaged and not transplantable). And an E score for all other remarks. Results: 420 of 563 (74.6%) sets of kidney QFs and 133 of 158 (84.2%) sets of liver QF's were completed and analyzed. On average in 24.3% (14.5%–60%) of the kidneys and in 27.8% (21.6%–40%) of the livers a possibly avoidable damage of the organ was found. 1.4% of the kidneys was discarded caused by a possibly avoidable injury. For the liver less than 1% was discarded partly caused by a possibly avoidable injury. In 22.1% a deviation between the transplant and procurement was found in the analyzed kidney forms and 21.8% of the liver forms. This means that the transplanting surgeon noted damage to the organ that was not seen or differently assessed by the procuring surgeon Conclusion: This research shows the percentages of ‘possibly avoidable damage’ during organ procurement, and although these seem rather high, these are comparable to the (few) literature about this subject. There was a trend between procurement center volume and organ damage; the higher the number of procurements per center, the lower the percentage of possibly avoidable damages. Feedback on this research to the centers will hopefully lead to further improve quality of procurements. doi:10.1016/j.trim.2014.11.153
B14-1158 Urokinase as a protective factor against ischaemic type biliary lesions in liver transplantation L.C. Pietersena,b, A.C. Den Dulkc, A.E. Braata, A.O. Rahmelb, J.J. Bloka, B. van Hoekc, J. Ringersa a
Department of Transplant Surgery, Leiden University Medical Center, Leiden, The Netherlands b Eurotransplant International Foundation, Leiden, The Netherlands c Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands Introduction: Ischemic injury of the peribiliary vascular plexus plays a critical role in the occurrence of ischemic-type biliary lesions (ITBL) after liver transplantation. Flushing the graft with a thrombolytic agent may solve this problem. This may cause more bleeding due to its effect on the clotting system. The aim of the present study was to assess whether flushing the donor liver with urokinase, prior to transplantation, has a positive effect on reducing the number of ITBL, without a higher risk of bleeding. Patients and Methods: Between January 2005 and October 2012, with a follow-up through October 2013, all patients receiving a liver transplantation were included. Exclusion criteria were patients who received a domino liver, a split liver or auxiliary liver transplant, or unknown data. Clinical information was obtained from a prospectively collected database. Results: A total of 205 patients were operated in the given period of which 21 were excluded. Of the 184 patients included, 122 did not receive urokinase (control group) and 62 patients received urokinase (study group). Basic donor characteristics (ET-DRI) and recipient characteristics (age, BMI, lab MELD) did not significantly differ in both groups.
Thirty-five patients developed ITBL. In the control group 23 (18%) and 12 patients in the study group (17%), resulting in a not-significant difference (p = 0.94). Comparing only DCD-donors from both groups also does not show a significant decrease in ITBL (P = 0.53). Autologous blood transfusion did not differ significantly between both groups (p = 0.82). Heterologous blood transfusion differed significantly between both groups (p b 0.01), with surprisingly more need for packed cells in the control group. Discussion: Contrary to previous studies, this (small) pilot study could not find a decrease in the prevalence of ITBL in patients treated with urokinase before implantation. The moment of intervention, before implantation versus during organ procurement, could be an explanation. A larger prospective study with administration of a thrombolytic agent during organ procurement of may clarify this issue. Further, flushing with urokinase before implantation does not lead to more bleeding and is therefore safe for the patient. doi:10.1016/j.trim.2014.11.154
Abstracts basic research B14-1045 Effect of cessation of cotrimoxazole on serum creatinine in kidney transplant recipients I.S. Muskens, C.E. Hensen, A.D. Van Zuilen Department of Nephrology, UMC Utrecht, The Netherlands Background: Kidney function is an independent predictor for graft survival after transplantation. Cotrimoxazole (400 mg sulfamethoxazole and 80 mg trimethoprim (CTM)), used as prophylaxis for PJP-pneumonia, is known to increase serum creatinine-levels by inhibiting tubular excretion of creatinine, resulting in a pseudodecline of eGFR. In our centre CTM is stopped on protocol four months after kidney transplantation upon achieving minimal immunosuppression. We investigated the effect of cessation of CTM on serum creatinine in kidney transplant recipients. Methods: All recipients, transplanted between 01-01-2010 and 0106-2013 (n = 220) were included. CTM prescription and reason for cessation were derived from medical records. The last three creatinine values prior to cessation and two after were averaged. Additionally, the age of the recipient and tacrolimus level around the time of cessation were recorded. We performed analysis both on all patients (group A) and on patients who stopped CTM according to protocol (group B). Univariate analysis was done with paired student t-test, multivariate analysis through linear regression. Outcomes: Of 220 patients 133 stopped on protocol (mean duration of CTM: 132 (sd:54) days and 87 patients stopped early (mean 102 (sd:89) days). Reasons for cessation were among others hematologic abnormalities (N = 37 (16.8%)), liver dysfunction (N = 4 (1.8%)), suspected tubule interstitial nephritis (N = 10 (4.5%)). In group A mean creatinine after cessation was 150 (sd:92) μmol/l. This was 11.6 μmol/ lower than prior to cessation (p b 0.0005). In group B, mean decrease in creatinine was 13 μmol/l (P b 0.0005). In adjusted analysis we found that serum tacrolimus and age did not affect creatinine reduction. However, the higher the creatinine was prior to cessation the bigger the absolute and relative reduction in creatinine. Conclusion: Sulfamethoxazole affects tubular secretion of creatinine. Only limited data on the effect of CTM in prophylactic dosage on serum creatinine is available. We illustrated that cessation of 480 mg of CTM daily results in a reduction of creatinine of 13 μmol/l or 8%. The fact that this effect cannot be observed in patients who are