Katherine Klingenberg, PA-C, MHS
Senior Instructor
University of Colorado School of Medicine, United States
Disclosure information not submitted.
Hunter Moore, MD, PhD
Transplant Surgery Fellow
University of Colorado School of Medicine, United States
Disclosure information not submitted.
Yanik Bababekov, MD
Transplant Surgery Fellow
University of Colorado School of Medicine, United States
Disclosure information not submitted.
Trevor Nydam, MD
Associate Professor of Transplant Surgery
University of Colorado School of Medicine, United States
Disclosure information not submitted.
Title: Direct Peritoneal Resuscitation Prior to Liver Retransplantation For Primary Graft Nonfunction
Case Report Body
Introduction: Early allograft dysfunction (EAD) after orthotopic liver transplantation (OLT) manifests in a spectrum of complications associated with early graft loss and mortality. Primary nonfunction (PNF) of the graft, the most extreme form of EAD, requires emergent retransplantation with mortality rates > 75%. Bridging individuals with EAD or PNF to retransplantation is challenging due to organ availability and coagulopathy with metabolic derangements. Direct peritoneal resuscitation (DPR), used in trauma patients to decrease intra-abdominal edema and inflammation while simultaneously increasing microvascular circulation, poses therapeutic benefits to patients with EAD. We present the case of utilizing DPR prior to retransplantation for PNF after OLT.
Description: A 59-year-old male with ESLD who underwent OLT was admitted to the ICU with hemorrhagic shock and vasoplegia. On post-operative day (POD) #1, his AST/ALT were >10,000 with ongoing transfusion requirements warranting emergent reoperation for abdominal compartment syndrome. The liver was rigid with patchy necrosis with edematous distended bowel. Unable to close the abdomen, DPR was initiated to improve microcirculation of the liver and reduce liver and bowel edema. DPR inflow was placed at the liver hilum with drainage around the lateral edges. DPR was initiated per our trauma protocol with temporary abdominal closure. He returned to the OR POD#2 finding reduced bowel edema and liver firmness. His acidosis and coagulopathy resolved while continuing DPR. On POD#3, despite trends in improving graft function, there were concerns that the liver would not recover, he underwent a redo liver transplant without complication.
Discussion: DPR successfully bridged a OLT patient with PNF to retransplantation. After the sentinel 2010 publications of DPR, subsequent evaluations demonstrated reductions in inflammation and improved outcomes in hemorrhagic shock in clinical trials. DPR has also been utilized to improve graft function prior to organ procurement, but there is limited data regarding the utilization of DPR post engraftment. As there is no alternative treatment of PNF beyond supportive care and retransplantation DPR demonstrated utility as an adjunct salvage therapy until the patient’s retransplant. The patient is home with normal liver function.