title: Clinical update in liver transplantation.
abstract: There has been considerable recent progress liver transplantation (LTX). The postreperfusion syndrome has clearly defined and typically responds to vasopressin and/or methylene blue when refractory to catecholamine therapy. Diastolic dysfunction and cirrhotic cardiomyopathy are prevalent and important in LTX recipients. The high cardiovascular risk and the increasing medical complexity of the current liver transplant recipient have stimulated the publication of guidelines for cardiovascular assessment before LTX. Cardiac surgery is increasingly more successful in patients with cirrhosis, including simultaneous heart-liver transplantation. Cardiopulmonary bypass in LTX is indicated for hemodynamic rescue and, at some centers, serves as the hemodynamic platform for liver implantation. Although acute renal injury is common after LTX, early diagnosis is now possible with novel biomarkers. Earlier detection of postoperative renal dysfunction may prompt intervention for renal rescue. The metabolic milieu in LTX remains critical. Regular insulin therapy may be more effective than infrequent large bolus therapy for potassium homeostasis. Careful titration of insulin therapy may improve freedom from severe hyperglycemia to decrease morbidity. Since the organization of dedicated anesthesia care teams for LTX improves perioperative outcome, this aspect of perioperative care is receiving systematic attention to optimize safety and quality. The specialty of LTX is likely to continue to flourish even more, given these pervasive advances.
authors.affiliation: Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104-4283, USA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Valentine
authors.forename: Madeline
authors.initials: M
authors.lastname: Gregorits
authors.forename: Jacob T
authors.initials: JT
authors.lastname: Gutsche
authors.forename: Lourdes
authors.initials: L
authors.lastname: Al-Ghofaily
authors.forename: John G T
authors.initials: JG
authors.lastname: Augoustides
mesh_terms: D000758:Anesthesia; D006348:Cardiac Surgical Procedures / Q000379:methods; D006801:Humans; D007674:Kidney Diseases / Q000209:etiology; D016031:Liver Transplantation / Q000379:methods* / Q000639:trends; D008751:Methylene Blue / Q000627:therapeutic use; D011183:Postoperative Complications / Q000517:prevention & control / Q000628:therapy; D015427:Reperfusion Injury / Q000517:prevention & control; D014662:Vasoconstrictor Agents / Q000627:therapeutic use; D056987:Vasoplegia / Q000209:etiology / Q000628:therapy; D014667:Vasopressins / Q000627:therapeutic use
chemical_list: D014662:Vasoconstrictor Agents; D014667:Vasopressins; D008751:Methylene Blue
keywords: acute kidney injury; anesthesia team; biomarkers; cardiac arrest; cardiac surgery; cardiopulmonary bypass; cardiovascular risk; cirrhotic cardiomyopathy; creatinine; delivery of anesthetic care; diastolic dysfunction; graft rejection; heart transplantation; hyperglycemia; hyperkalemia; insulin; liver transplantation; methylene blue; mortality; neutrophil gelatinase-associated lipocalin; postreperfusion syndrome; surgical site infection; vasoplegia