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Abstract
Combined liver and kidney transplantation is a highly demanding and challenging procedure
for anesthesiologists due to the lengthy and complicated nature of the procedure, the critical patient
condition and the need to balance the intravascular volume to maintain the venous outflow of the
hepatic allograft and also the diuresis of the renal allograft. Intravascular volume management
and coagulation control, seem to be the most important issues during combined liver and kidney
transplantation. There is sparsity of data in the literature concerning the anesthetic and fluid
management in CLKT. We present and discuss the anesthetic management in a case series in three
patients, who underwent combined liver and kidney transplantation in our institution during the
last two years.
1 Department of Anesthesia, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Kingdom of Saudi
Arabia:
* Consultant, Department of Anesthesia, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
** FRCPC, Assistant Professor, Department of Anesthesiology, King Saud University for Health Sciences, Deputy Chairman,
Department of Anesthesia, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
*** Associate Consultant, Department of Anesthesia, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
**** Assistant Consultant, Department of Anesthesia, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
***** Staff Physician, Department of Anesthesia, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
****** Professor of Anesthesia, Consultant, Department of Anesthesia, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
2 Department of Hepatobilliary Science and Liver Transplant, King Abdulaziz Medical City, National Guard Health Affairs,
Riyadh, Kingdom of Saudi Arabia:
* Consultant, Department of Hepatobiliary Surgery and Organ Transplantation, King Abdulaziz Medical City, Riyadh,
Saudi Arabia.
** Chairman, Department of Hepatobiliary Surgery and Organ Transplantation, King Abdulaziz Medical City, Riyadh, Saudi
Arabia
*** Deputy Chairman, Department of Hepatobiliary Surgery and Organ Transplantation, King Abdulaziz Medical City,
Riyadh, Saudi Arabia.
Corresponding author: Vassilios Dimitriou, Professor of Anesthesia, Consultant, Department of Anesthesia, King
Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia. P.O Box: 22490, Riyadh
11426 Phone: +9661180111 ext 19432. E-mail address: vaskdimi58@gmail.com
Continuous veno-venous hemodialysis with an procedure. During kidney transplant the CVP was
output of 250 ml/hour was initiated with the start of allowed to rise gradually till it reached 17 mmHg,
surgery. The baseline CVP reading was 9 mm Hg. before renal allograft reperfusion with crystalloid
It was maintained between 5 - 8 mmHg during the fluid administration. The CVP was kept at this level
preanhepatic, anhepatic phase and neohepatic phases until urine output was noted and then it was allowed
of liver transplant till the start of the renal transplant to decrease to 12 mmHg till the end of the procedure.
procedure. Then the continuous veno-venous Blood loss was 500 ml. Patient received one liter of
hemodialysis was stopped and the CVP was slowly 5% Albumin, 4 liters of normal saline and no blood
increased to 15 mmHg until renal allograft reperfusion products. Pharmacologic coagulation management
using crystalloid hydration with normal saline, and
was achieved with 1gr of tranexamic acid.
it was kept at this value until urine production was
noted. CVP was then gradually decreased again to
approximately 10 mmHg until completion of the Case 3
surgery. Total blood loss was 14 liters. Throughout
the surgery, the patient received 21 units (7350 ml) Male patient (61 years, weight 65 kg, height
of packed red blood cells, 17 units (3400 ml) of fresh 168 cm, BMI 23 Kg/m2) with ESLD secondary to
frozen plasma(FFP), 18 units (1260 ml) of platelets, cryptogenic cirrhosis, ESRD on hemodialysis for
50 units (1500 ml) of cryoprecipitate, 2500 ml of 3years, type 2 diabetes mellitus and hypertension.
cell saver blood and 15 liters of normal saline, and The patient’s MELD score was 23. The laboratory
produced 120 ml of urine. Additional coagulation evaluation showed hemoglobin 107 g/L, platelets
management was achieved with single doses of count 183,000/mm3, INR 1.3, fibrinogen 2.5 g/L, PTT
desmopressin (0.3 mcg/kg) and recombinant factor 37.3, electrolytes (K+, Na+, Cl-) within normal range,
VIIa (rFVIIa) (90 mcg/kg). fasting blood sugar 7.4 mmol/l and creatinine 476
µmol/l. The patient had mild mitral valve regurgitation
Case 2 and mild left atrial dilatation on echocardiographic
examination.
Female patient (54 years, weight70 kg, height Continuous veno-venous hemodialysis was on
154cm, BMI 29.5 kg/m2) with ESLD secondary to standby. The baseline CVP was 7 mmHg. CVP was
cryptogenic cirrhosis, type 2 diabetes mellitus (insulin maintained between 7-10 mmHg throughout the 3
treated), hypertension, dyslipidemia, hypothyroidism
phases of liver transplant. Then CVP was gradually
and end stage renal disease (ESRD). The patient’s
increased to 18 mmHg one hour before kidney allograft
MELD score was 25. The laboratorary evaluation
reperfusion and remained at this level till the end of
showed hemoglobin 128 g/L, platelet count 103,000/
surgery. Blood loss was 3 liters. The patient received 8
mm3, fibrinogen 2.1 g/L, INR 1.1, PTT 30.9, albumin
units (2800 ml) of packed red blood cells, 4 units (800
31 g/l, electrolytes (K+, Na+, Cl-) within normal
ml) of FFP, 10 units (300 ml) of cryoprecipitate, 500
range, fasting blood sugar 5.3 mmol/l and creatinine
ml of albumin 5%, and 13 liters of plasmalyte. Two
738 µmol/l. Electrocardiogram showed prolonged
QT interval, and echocardiography showed a right grams of tranexamic acid were given intraoperatively.
ventricular systolic pressure of 40-50 mm Hg with After completion of the surgery, the patients
mild tricuspid valve regurgitation. were transferred to surgical intensive care unit in a
Continuous veno-venous hemodialysis was on stable condition. They all had a smooth post-operative
standby. The baseline CVP reading was 12 mmHg. course,with good function of the liver and kidney
Despite fluid restriction, diuresis with mannitol and grafts,except case 2 whose kidney graft did not
initial temporary use nitroglycerin infusion, which work properly requiring hemodialysis, but she was
was stopped due to development of hypotension, CVP discharged home,and only comes to the hospital for
remained 10-12mmHg throughout liver transplant her dialysis sessions.
M.E.J. ANESTH 23 (5), 2016
552 Amr E. K. et. al
volume replacement in cases 1 and 2, and Plasmalyte catastrophic bleeding, when coagulopathy is evident.
in case 3. There is a report comparing normal saline, Although the available data on safety in this population
lactated Ringer's and Plasmalyte, in kidney transplants does not suggest an increased risk of thrombotic,
of living related donors. The conclusion was that all thromboembolic and ischaemic events associated with
three crystalloid solutions can be safely used during PCC and fibrinogen concentrate use, the data are scarce
uncomplicated, short-duration renal transplants; and need to be confirmed in large trials35,36. Currently
however, better metabolic profile was maintained in the first two multicentre, randomized, double-blinded
patients who received Plasmalyte27. trial comparing the routine use of prothrombin complex
Transfusion and coagulation management during concentrate (PCC) or fibrinogen concentrate with a
CLRT is challenging and coagulopathy is usually placebo in patients undergoing LT are still pending37,38.
multifactorial28. Clinical strategies to reduce blood Recombinant factor VIIa (rFVIIa) was used
loss during CLRT include the use of blood products by Busani et al., in a series of seven patients with
to correct pre-existing or intraoperative coagulopathy. persistent severe bleeding after application of a standard
This is achieved by transfusion of fresh frozen plasma transfusion protocol, in a dose similar to what we
(FFP), platelet concentrate, cryoprecipitate and used in case 1 (90 mcg/kg). Blood losses and need for
antifibrinolytic agents to correct hyperfibrinolysis platelets transfusion significantly decreased after rFVIIa
that may occur during the procedure28. In our administration; a non-significant decrease in red blood
cases the coagulation management was guided by cell and fresh frozen plasma transfusions also occurred.
thromboelastography (TEG), performed hourly In six patients treatment with rFVIIa was effective;
during the surgical procedure, as well as conventional only one patient died because of haemorrhagic shock,
coagulation parameters. The use of TEG for coagulation and no thromboses were detected among the treated
management constitutes the more recent trend in patients. The study suggested that in some challenging
coagulation monitoring29-31. A major disadvantage of cases of massive bleeding rFVIIa should be considered
transfusion of blood products such as FFP is volume
as a useful option to control bleeding39.
overload. To correct a prolonged PT during CLRT
several units of FFP are needed, which will result in an Tranexamic acid was administrated in case
increase in CVP and portal (splanchnic) venous blood 2, it was given also in case 3. It seems to be the
pressure and in fact will increase the bleeding risk. antifibrinolytic agent of choice in liver transplantation,
being equally efficacious as the currently unavailable
Prothrombin complex concentrate (PCC) are
aprotinin. As opposed to a blind prophylaxis with
hemostatically active highly purified concentrates,
antifibrinolytics in liver transplantation a goal directed
prepared from pooled plasma32. They contain all four
therapy, by using thrombelastometry to assess
vitamin K-dependent clotting factors (II, VII, IX and
fibrinolysis, has been suggested31,40.
X). In contrast to the traditional infusion of FFP to
stimulate coagulation in cirrhotic patients, PCC does Desmopressin acetate (DDAVP) was used in case
not add to the intravascular volume and therefore may 1.Desmopressin increases the levels of factor VIII,
be, theoretically, more effective in reducing bleeding vWF, and plasminogen. DDAVP appears to improve
complications than FFP infusion32. blood coagulability during liver transplantation in vitro,
possibly by activating coagulation factors and platelets41.
It has been demonstrated that hypofibrinogenemia
is associated with increased hemorrhage during liver In conclusion, CLKT is a highly demanding and
transplantation28. Fibrinogen concentrate is also challenging procedure for anesthesiologists due to the
produced from pooled human plasma. It is stored as lengthy and complicated nature of the procedure, the
a lyophilised powder at room temperature and can be critical patient condition and the need to balance the
reconstituted quickly with sterile water and infusion intravascular volume to maintain the venous outflow
volumes are low, allowing for rapid administration of the hepatic allograft and also the diuresis of the renal
without delays for thawing or cross-matching33,34. In allograft. Appropriate intraoperative fluid management
many centers, PCC and fibrinogen concentrate are tailored to each phase of CLRT surgery and targeted
used “off-label” during LT as a rescue therapy during coagulation management may have favorable results.
M.E.J. ANESTH 23 (5), 2016
554 Amr E. K. et. al
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