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Rabbit antithymocyte globulin (ATG) is commonly used as an induction therapy in renal transplant recipients, but the ideal dosage in tacrolimus-based early steroid withdrawal protocols has not been established. The purpose of this pilot study was to determine the immunophenotyping and efficacy of lower dose ATG in low immunological-risk kidney transplant recipients. In this prospective study, 45 patients were randomized (1∶1) to our standard dose ATG (total dose 3.75 mg/kg)(sATG) vs. lower dose 2.25 mg/kg (lowATG). All patients underwent early steroid withdrawal within 7 days. The primary end point was biopsy-proven acute rejection at 12 months. Prospective immunophenotyping of freshly isolated PBMCs was performed at baseline, 3, 6, 12 months post-transplant. The rate of acute rejection was 17% and 10% in the sATG and lowATG, respectively. Effector memory T cells, Tregs and recent thymic emigrants T cells had similar kinetics post-transplant in both groups. No statistically significant differences were found in graft survival, patient survival or infections between the two groups, though there was a non-significant increase in leukopenia (43%v s. 30%), CMV (8% vs. 0) and BK (4% vs. 0) infections in sATG group vs. lowATG. In sum, in low immunological risk kidney recipients undergoing steroid withdrawal, low dose ATG seems to be efficacious in preventing acute rejection and depleting T cells with potentially lower infectious complications. A larger study is warranted to confirm these findings. ClinicalTrials.gov NCT00548405.

Patients with low MELD scores remain at substantial risk for waitlist removal. We investigated modern outcomes and graft utilization for low MELD patients undergoing liver transplant (LT) in the US. Adult LT recipients with low MELD scores (match MELD≤20) from 2022 to 2023 were identified from the UNOS database and stratified by receipt of a donation-after-circulatory-death (DCD), donation-after-brain-death (DBD), or living donor (LD) graft. Demographic and outcome data were compared. Of 5946 recipients, 21.7 ​% underwent DCD transplant and 15.7 ​% LDLT. Both LD and DCD recipients spent less time on waitlist compared to DBD recipients (LD 4.4, DCD 5.0 months vs. DBD 6.0 months, p ​< ​0.001). Only DCD grafts preserved with static-cold-storage (SCS) had lower 1-year graft survival rates. Male sex led to higher odds of DCD-LT, while female sex and diagnosis of malignancy or cholestatic disease increased odds of LDLT. Both LD and DCD LT should be nationally encouraged to increase LT access for low MELD patients. •Only 35% of low MELD patients undergo liver transplant with a DCD or LD graft.•DCD and LD transplants result in shorter waitlist times than DBD.•Both LD and DCD should be pursued to increase LT access for low MELD patients.

Creatinine, bilirubin, and fibrinolysis resistance are associated with multi-organ dysfunction and likely risk factors for prolonged intensive care unit (pICU) stay following liver transplantation (LT). We hypothesize postoperative day-1 (POD-1) labs will predict pICU. LT recipients had clinical laboratories and viscoelastic testing with tissue plasminogen activator thrombelastography (tPA TEG) to quantify fibrinolysis resistance (LY30) on POD-1. pICU was defined as one week or longer in the ICU. Logistic regression was used to identify the relationship between POD-1 labs and pICU. Of 304 patients, 50% went to the ICU, with 15% experiencing pICU. Elevated creatinine (OR 6.6, P ​< ​0.001) and low tPA TEG LY30 (OR 3.7, P ​= ​0.004) were independent predictors of pICU after controlling for other risk factors. A 9-fold increase in the rate of 90-day graft loss (19% vs 2% p ​< ​0.001) was observed patients who had these risk factors for pICU. Elevated creatine and fibrinolysis resistance are associated with pICU and poor outcomes following LT. •The risk for prolonged ICU utilization following liver transplant patients is associated with postoperative day 1 creatine or dialysis use.•Liver transplant patients with fibrinolysis resistance postoperative day 1 also have increased risk of prolong ICU utilization independent of creatinine.•If both risk factors are present these patient have a 9 fold increase rate of 90-day graft loss.

One in four liver transplants (LT) require return to the operating room(R-OR) within 48 h of surgery. We hypothesize that donor, recipient, and intraoperative factors will predict R-OR. LT recipients were enrolled in an observational study to measure coagulation with thrombelastography (TEG) were assessed with transplant recipient and donor variables for risk of R-OR. 160 recipients with a median age of 55 years and a MELD-Na of 22 were analyzed. R-OR occurred in 22%. Recipient BMI (p = 0.006), donor heavy alcohol use (p = 0.017), TEG MA (p = 0.013) during the anhepatic phase of surgery, TEG MA at anhepatic and 30-min after reperfusion (p < 0.05), and red blood cell transfusions (p < 0.001) were associated with R-OR. The vexing triad of recipient obesity, heavy donor alcohol use, and low TEG MA were associated with a high rate of R-OR. Strategies to reduce this sub-optimal combination of risk factors could reduce the frequency of unplanned re-operations. •Liver transplant recipient BMI greater than 30 and donor history of heavy alcohol use is associated with an 80% return rate to the operating room.•During liver transplantation, clot strength less than 45 mm during the anheptic and early reperfusion is associated with greater than 20 units of intraoperative blood loss and 80% return rate to the operating room.•The combination of coagulopathy, obesity, and donor alcohol heavy use is associated with an 100% rate of return to the operating room.

Liver transplantation is the gold standard treatment for end-stage liver disease. This study evaluates post-transplantation survival compared with the general population by quantifying standardized mortality ratios in a nested case-control study. Controls were noninstitutionalized United States inhabitants from the National Longitudinal Mortality Study. Cases underwent liver transplantation from 1990 to 2007 identified through the Organ Procurement and Transplantation Network database. Propensity matching (5:1, nearest neighbor, caliper 0.1) identified controls based on age, sex, race, and state. The primary endpoint was 10-year survival. 62,788 cases were matched to 313,381 controls. The overall standardized mortality ratio was 2.46 (95% CI ​= ​2.44–2.48). The standardized mortality ratio was higher for males (2.59 vs. 2.25) and Hispanic patients (4.80). Younger patients and those transplanted earlier (1990–1995) had higher standardized mortality ratios. Liver recipients have a standardized mortality ratio 2.46 times higher than the general population. Long-term mortality has declined over time. •Standardized mortality was higher for males, Hispanic patients, and earlier eras.•Standardized mortality decreased proportionally with increasing age.•Liver transplant recipients had lower incidence of death from cardiovascular causes.

Direct peritoneal resuscitation (DPR) is associated with improved outcomes in trauma. Animal models suggest DPR has favorable effects on the liver. We sought to evaluate its safety and assess for improved outcomes in liver transplantation (LT). LT patients with renal dysfunction and/or obesity were enrolled in a phase-I clinical trial. DPR lasted 8–24 ​h depending on postoperative disposition. Primary outcome was percent of patients completing DPR. Secondary outcomes evaluated complications. Controls with either obesity (control-1) or both risk factors (obesity ​+ ​renal dysfunction, control-2) were analyzed. Fifteen patients were enrolled (seven with both criteria and eight with obesity alone). DPR was completed in 87 ​% of patients, with one meeting stopping criteria. Controls included 45 (control-1) and 24 (control-2) patients. Return to operating room, graft loss, and late infections were lower with DPR. DPR appears to be safe in closed abdomens following LT, warranting a follow-up phase-II trial to assess efficacy. [Display omitted] •Direct peritoneal resuscitation was utilized high risk patients following liver transplant.•Direct peritoneal resuscitation appears to be a safe and feasible intervention in liver transplant recipients with temporary and definitively closed abdomens.•There may be some potential benefits of utilizing direct peritoneal resuscitation in individuals with obesity and renal dysfunction undergoing liver transplantation.•A phase II clinical trial is warranted to evaluate the efficacy and potential benefits of direct peritoneal resuscitation.

Objectives: To determine the relationship between perioperative glucose control and postoperative nosocomial infection rate in 100 consecutive diabetic patients undergoing elective surgery. Design and Patients: One hundred initially uninfected diabetic patients undergoing elective surgery were prospectively monitored for perioperative glucose control and postoperative nosocomial infection rate. Glucose control was determined by the attending surgeon or diabetologist. Setting: A large tertiary care hospital that serves as the in-patient facility for a local diabetes center. Main Outcome Measures: All patients were screened for infection preoperatively. Only initially uninfected patients were enrolled, and all patients received perioperative antibiotic coverage. Perioperative glucose control and postoperative nosocomial infection rate were monitored prospectively. APACHE II scores were determined on all patients. Patients were stratified into two groups: those with relatively \"good\" perioperative glucose control (all values ≤220 mg/dL) and those with \"poor\" control (at least one value >220 mg/dL). Contingency tables were generated, comparing nosocomial infection rates vs perioperative glucose control. Correlation coefficients between APACHE II score and maximum and mean glucose values were also determined. Results: A serum glucose >220 mg/dL on postoperative day one (POD 1) was a sensitive (87.5%) but relatively nonspecific (33.3%) predictor of the later development of postoperative nosocomial infection. In patients with hyperglycemia (>220 mg/dL) on POD 1, the infection rate was 2.7 times that observed (31.3% vs 11.5%) in diabetic patients with all serum glucose values <220 mg/dL. When minor infection of the urinary tract was excluded, the relative risk for \"serious\" postoperative infection increased to 5.7 when any POD 1 blood glucose level was >220 mg/dL. On the basis of correlation coefficients between serum glucose values and APACHE II score, only 18% of the variance in the highest serum glucose could be explained by disease severity alone. Conclusions: We conclude that diabetic patients undergoing major cardiovascular or abdominal surgery have an increased risk of infection that is further exacerbated by early postoperative hyperglycemia. The high rate of nosocomial infection observed in diabetic patients with poor glucose control suggests that hyperglycemia itself may be an independent risk factor for the development of infection. Efforts to improve perioperative glucose homeostasis in diabetic patients may reduce the incidence of nosocomial infection and thereby improve outcome. (Journal of Parenteral and Enteral Nutrition 22:77-81, 1998)

High output, persistent ascites (PA) is a common complication following liver transplant (LT). Recent work has identified that platelets help maintain endothelial integrity and can decrease leakage in pathological states. We sought to assess the association of PA following LT with platelet count and platelet function. Clot strength (MA) is a measure of platelet function and was quantified using thrombelastography (TEG). Total drain output following surgery was recorded in 24-h intervals during the same time frame as TEG. PA was considered >1 L on POD7, as that much output prohibits drain removal. 105 LT recipients with moderate or high volume preoperative ascites were prospectively enrolled. PA occurred in 28%. Platelet transfusions before and after surgery were associated with PA, in addition to POD5 TEG MA and POD5 MELD score. Patients with PA had a longer hospital length of stay and an increased rate of intraabdominal infections. Persistent ascites following liver transplant is relatively common and associated with platelet transfusions, low clot strength, and graft dysfunction. •High output persistent ascites (PA) occurs in 28% of liver transplant recipients.•Platelet transfusions given preoperatively were a significant and independent predictor of persistent high output ascites.•An increase in POD5 MELD and TEG MA postoperatively were significant predictors of PA.•Post-operative PA was associated with longer hospital stays, higher rates of intraabdominal infection, and graft dysfunction.

An NIH clinical coagulopathy score has been devised for trauma patients, but no such clinical score exists in transplantation surgery. We hypothesize that that this coagulopathy score can effectively identify laboratory defined coagulopathy during liver transplantation and correlates to blood product utilization. TEGs were performed and coagulopathy scores (1, normal bleeding – 5, diffuse coagulopathic bleeding) were assigned by the surgeons at 5 intra-operative time points. Blood products used during the case were recorded between time points. Statistical analyses were performed to identify correlations between coagulopathy scores, TEG-detected abnormalities, and blood product utilization. Transfusions rarely correlated with the appropriate TEG measurements of coagulation dysfunction. Coagulopathy score had significant correlation to various transfusions and TEG-detected coagulopathies at multiple points during the case. High aggregate coagulopathy scores identified patients receiving more transfusions, re-operations, and longer hospital stays The combination of viscoelastic testing and a standardized clinical coagulopathy score has the potential to optimize transfusions if used in tandem as well as standardize communication between surgery and anesthesia teams about clinically evident coagulopathy. •Transfusion practices do not always target TEG abnormalities.•The coagulopathy score correlates with transfusions and TEG abnormalities.•Use of the coagulopathy score with TEG can optimize transfusion practices.

During the anhepatic phase of liver transplantation (LT), fibrinolytic activity increases, since the liver clears tissue plasminogen activator (tPA). We hypothesize that patients who fail to reduce fibrinolytic activity following graft reperfusion will have an increased rate of early allograft dysfunction (EAD). Assessment of fibrinolysis in liver transplant recipients was quantified with thrombelastography (TEG) LY30. Changes in LY30 were assessed after graft reperfusion. The 30-min post-reperfusion LY30 was subtracted from the anhepatic LY30 quantifying fibrinolytic changes (delta-LY30). Seventy-three primary LT patients were included in the analysis. Receiver operating characteristic curve (ROC) analysis identified an inflection point of delta-LY30–5.3% as a risk factor for EAD. EAD occurred in 44% of these patients compared to 5% in high delta-LY30 (p = 0.002). LT recipients that develop hyperfibrinolysis who fail to reduce fibrinolytic activity 30 min after graft reperfusion had an EAD rate 8-fold higher than patients who had a large reduction in LY30 following reperfusion. •Three fibrinolytic responses to liver transplant occur; Hypofibrinolysis, Early Fibrinolysis Shutdown (e-SD) and Delayed Shutdown (d-SD)..•Delayed correction of hyperfibrinolysis (d-SD) hold an 8-fold risk of early allograft function compared to early correction (e-SD).•Hypofibrinolysis (lack of fibrinolytic activation) is also associated with an increased rate of early allograft dysfunction (EAD).