The clinical relevance of the anhepatic phase during liver transplantation

Abstract

This study assesses the relation between the anhepatic phase duration and the outcome after liver transplantation. Of 645 patients who underwent transplantation between 1994 and 2006, 194 were recipients of consecutive adult primary piggyback liver transplants using heart-beating donors. The anhepatic phase was defined as the time from the physical removal of the liver from the recipient to recirculation of the graft. Other noted study variables were the cold and warm ischemia times, donor and recipient age, donor and recipient body mass index, perioperative red blood cell (RBC) transfusion, indication for transplantation, and Model for End-Stage Liver Disease score. The primary outcome parameter was graft dysfunction, which was defined as either primary nonfunction or initial poor function according to the Ploeg-Maring criteria. The median anhepatic phase was 71 minutes (37-321 minutes). Graft dysfunction occurred in 27 patients (14%). Logistic regression analysis showed an anhepatic phase over 100 minutes [odds ratio (OR), 4.28], a recipient body mass index over 25 kg/m 2 (OR, 3.21), and perioperative RBC transfusion (OR, 3.04) to be independently significant predictive factors for graft dysfunction. One-year patient survival in patients with graft dysfunction was 67% versus 92% in patients without graft dysfunction (P Ͻ 0.001). A direct relation between the anhepatic phase duration and patient survival could, however, not be established. In conclusion, this study shows that liver transplant patients with an anhepatic phase over 100 minutes have a higher incidence of graft dysfunction. The shortage of donor organs, in combination with an increasing number of patients on the waiting list for transplantation, urges professionals involved in liver transplantation to strive for optimal utilization of liver grafts. An important issue in this process is minimizing the amount of damage induced during the cold ischemia time (CIT), warm ischemia time (WIT), and reperfusion, which are indissolubly connected to transplantation of a liver graft.Immediately after procurement of the liver of a deceased donor, cold storage is used to minimize ischemic injury. This cold ischemia phase usually lasts for several hours and ends the moment that the graft is taken from ice for implantation. Additionally, during the subsequent warm ischemia phase, the graft is extremely susceptible to ischemic injury. 1 The influence of the length of both CIT and WIT on the outcome of liver transplantation has been extensively studied.1-3 Recent studies even show a cumulative negative effect induced by prolonged CIT and WIT. 2,4 The length of the CIT is mainly determined by logistic factors, such as the distance and availability of operation facilities and personnel. The length of the WIT is less variable. It is mainly dependent on the quality and configuration of the recipient vessels and to a lesser extent the experience of the surgeon.The influence of the length of the anhepatic phase on the outcome of transplantation is less well studied. The ...

Initial Poor Graft Dysfunction and Primary Graft Non-Function After Orthotopic Liver Transplantation

“…Delva et al thought that rewarm ischemia time should not exceed 60 minutes (Delva et al, 1989). Recently, in a logistic regression analysis by Ijtsma et al, the anhepatic phase over 100 minutes [odds ratio (OR), 4.28] was an independent predictive factor for graft dysfunction (Ijtsma et al, 2009). These results suggested that extended rewarming ischemia time is an important risk factor for IPGF.…”

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“…Many variables, such as massive blood loss and secondary hypotension, a prolonged anhepatic phase, and intraoperative electrolyte and acid-base disorders, may cause acute kidney injury or further impairment of the renal function. [16][17][18] Several investigations have reported that massive intraoperative allogeneic red blood cell transfusions have a negative effect on liver transplant recipient outcomes. [19][20][21] Ramos and associates 22 confirmed that massive red blood cell transfusions are associated with longer hospital stays, and decreased postoperative survival for liver transplant recipients.…”

Development of an improved rat model of dual graft liver transplantation with long-term survival

“…An anhepatic phase time of not more than 26 min has been considered to be safe for liver transplantation (Kamada and Calne, 1979), whereas a longer anhepatic phase time has been proven to be negatively associated with graft survival after transplantation (Ijtsma et al, 2009). In our study, the connection between the SHIVC and PV was prepared during the plasty of the donor liver grafts, significantly shortening the time of the anhepatic phase, so that the anhepatic phase time of the DLTs were all within 25 min.…”