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  • Yl MK
  • Patil NS
  • Mohapatra N
  • Sindwani G
  • Dhingra U
  • et al.
Ann Surg. 2024 Jan 12; doi: 10.1097/SLA.0000000000006200.
CET Conclusion
Reviewer: Mr Keno Mentor, Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences University of Oxford
Conclusion: Temporary portocaval shunt (TPCS) formation is a frequently utilised in liver transplantation to reduce portal hypertension and blood loss during the hepatectomy phase. The benefit of this technique has been proven in acute liver failure, where physiological portosystemic shunts are not well developed, but the benefit in cases of chronic liver disease with cirrhosis is less clear. This unblinded randomised trial investigated the efficacy of TPCS in chronic liver patients undergoing live donor liver transplant. Intra-operative parameters including inotrope requirement, blood loss and renal function were significantly improved in the TPCS group. However, these superior haemodynamic parameters did not result in meaningful post-operative benefit, with no significant differences in key clinical parameters including morbidity, mortality and length of stay between the two groups. The technique should thus continue to be utilised on a case by case basis.
Aims: This study aimed to investigate the role of temporary portocaval shunt (TPCS) during recipient hepatectomy in live donor liver transplant recipients.
Interventions: Participants were randomised to TPCS versus no TPCS.
Participants: 60 live donor liver transplantation (LDLT) recipients.
Outcomes: The primary outcomes are intraoperative haemodynamic parameters (systolic blood pressure, diastolic blood pressure, mean arterial pressure), blood loss, transfusion requirement, renal function, and duration of surgery. The secondary outcomes include early graft dysfunction, morbidity, mortality, total ICU and hospital stay.
Follow Up: 90 days
OBJECTIVE:

The primary objectives were to compare intra operative hemodynamic parameters, blood loss, renal function, and duration of surgery with and without TPCS in live donor liver transplantation (LDLT) recipients. Secondary objectives were post-operative early graft dysfunction (EGD), morbidity, mortality, total ICU and hospital stay.

BACKGROUND:

Blood loss during recipient hepatectomy for liver transplantation (LT) remains a major concern. Routine use of temporary portocaval shunt (TPCS) during LT is not yet elucidated.

METHODS:

A single centre, open label, randomized control trial. The sample size was calculated based on intraoperative blood loss. After exclusion, a total of 60 patients, 30 in each arm (TPCS versus no TPCS) were recruited in the trial.

RESULTS:

The baseline recipient and donor characteristics were comparable between the groups. The median intra-operative blood loss (P = 0.004) and blood product transfusions (P<0.05) were significantly less in TPCS group. TPCS group had significantly improved intraoperative hemodynamics in anhepatic phase as compared to no-TPCS group (P<0.0001), requiring significantly less vasopressor support. This led to significantly better renal function as evidenced by higher intraoperative urine output in TPCS group (P=0.002). Because of technical simplicity, TPCS group had significantly fewer IVC injuries (3.3 vs. 26.7%, P=0.026) and substantially shorter hepatectomy time and total duration of surgery (529.4 ± 35.54 vs. 606.83 ± 48.13 mins, P<0.0001). ). Time taken for normalisation of lactate in the immediate post-operative period was significantly shorter in TPCS group (median, 6 h vs. 13 h; P=0.04). Although post-operative endotoxemia, major morbidity, 90day mortality, total ICU and hospital stay were comparable between both the groups, tolerance to enteral feed was earlier in the TPCS group.

CONCLUSION:

In LDLT, TPCS is a simple and effective technique that provides superior intraoperative hemodynamics and reduces blood loss and duration of surgery.

  • Yadav A
  • Caldararo K
  • Singh P
J Telemed Telecare. 2022 Aug;28(7):530-532 doi: 10.1177/1357633X20942632.
  • Katz-Greenberg G
  • Yadav A
  • Gupta M
  • Martinez-Cantarin MP
  • Gulati R
  • et al.
Clin Nephrol. 2020 Dec;94(6):318-321 doi: 10.5414/CN110311.
  • Bansal D
  • Yadav AK
  • Kumar V
  • Minz M
  • Sakhuja V
  • et al.
PLoS One. 2013 Oct 11;8(10):e75591 doi: 10.1371/journal.pone.0075591.
CET Conclusion
Reviewer: Mr Simon Knight, Centre for Evidence in Transplantation, The Royal College of Surgeons of England.
Conclusion: This well-written manuscript details the results of a small open-label randomised controlled trial of long-term CNI versus switch to sirolimus from 2 months following renal transplantation. The population is a low-risk living-donor population on CNI, MMF and steroids, the majority of who received no antibody induction. The authors demonstrate a significant improvement in GFR at 180 days following switch in the sirolimus group compared to the CNI maintenance group, as well as an increased population of regulatory T cells. There are a few of aspects of this trial that are worth highlighting. The first is the relatively high withdrawal of consent rate from the trial (20%), which was higher in the sirolimus group (22.5 vs 13.8%). Despite this the authors report no difference in adverse event rates between the two cohorts. Secondly, despite the target trough levels for tacrolimus (the majority of patients) being 8-10ng/ml, the mean trough level in both groups was around 13 ng/ml at randomisation. Finally, the length of follow-up is very short; one would like to see longer-term results to confirm if the lower GFR is maintained in the sirolimus cohort.
Aims: To investigate the effect on glomerular filtration rate (GFR) and Treg frequency by switching renal transplant patients from calcineurin inhibitor therapy (CNI) to sirolimus therapy (SRI).
Interventions: Participants were randomised to continue with CNI-therapy (tacrolimus or cyclosporine) or to receive SRI-therapy. All patients were administered with mycophenolate mofetil and prednisolone.
Participants: 60 living donor kidney transplant recipients.
Outcomes: The primary endpoint was renal function assessed by serum-creatinine based GFR. Secondary endpoints included Treg population at 6 months, incidence of biopsy proven acute rejection, patient and graft survival, incidence of hyperlipidemia, new onset diabetes after transplantation, hypertension and infections.
Follow Up: 6 months
BACKGROUND:

Measures to prevent chronic calcineurin inhibitor (CNI) toxicity have included limiting exposure by switching to sirolimus (SIR). SIR may favorably influence T regulator cell (T(reg)) population. This randomized controlled trial compares the effect of switching from CNI to SIR on glomerular filtration rate (GFR) and T(reg) frequency.

METHODS:

In this prospective open label randomized trial, primary living donor kidney transplant recipients on CNI-based immunosuppression were randomized to continue CNI or switched to sirolimus 2 months after surgery; 29 were randomized to receive CNI and 31 to SIR. All patients received mycophenolate mofetil and steroids. The main outcome parameter was estimated GFR (eGFR) at 180 days. T(reg) population was estimated by flowcytometry.

RESULTS:

Baseline characteristics in the two groups were similar. Forty-eight patients completed the trial. At six months, patients in the SIR group had significantly higher eGFR as compared to those in the CNI group (88.94 ± 11.78 vs 80.59 ± 16.51 mL/min, p = 0.038). Patients on SIR had a 12 mL/min gain of eGFR of at the end of six months. Patients in the SIR group showed significant increase in T(reg) population at 30 days, which persisted till day 180. There was no difference in the adverse events in terms of number of acute rejection episodes, death, infections, proteinuria, lipid profile, blood pressure control and hematological parameters between the two groups. Four patients taking SIR developed enthesitis. No patient left the study or switched treatment because of adverse event.

CONCLUSIONS:

A deferred pre-emptive switch over from CNI to SIR safely improves renal function and T(reg) population at 6 months in living donor kidney transplant recipients. Registered in Clinical Trials Registry of India (CTRI/2011/091/000034).