Anaphylaxis Complicating Graft Reperfusion During Orthotopic Liver Transplantation: A Case Report

Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California 94143, USA.
Transplantation Proceedings (Impact Factor: 0.98). 06/2010; 42(5):1967-9. DOI: 10.1016/j.transproceed.2010.03.135
Source: PubMed


Hemodynamic instability may occur during liver transplantation especially following unclamping the portal vein. A period of hypotension (postreperfusion syndrome) is usually responsive to treatment with fluids, calcium, sodium bicarbonate, and vasoactive drugs, but if hypotension persists, other causes must be sought out. In this report, we present a case in which anaphylaxis, most likely due to a component of the University of Wisconsin preservation solution, occurred coincident with liver reperfusion and severely exacerbated reperfusion hemodynamic instability. To our knowledge, this is the first report of anaphylaxis at the time of reperfusion and may provide an explanation for cases of vasoplegic syndrome associated with graft reperfusion.

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    • "By contrast, anaphylactic reactions (grade 3 parameter for systemic toxicity) are extremely rare in the clinical setting of solid organ transplantation, to our knowledge only one such case has been described in the published literature [32]. When comparing the three modalities, the highest relative frequency of a score of 3 was most often pulmonary-related (day 4 = 3.5%). "
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    ABSTRACT: Background Cellular therapy after organ transplantation is emerging as an intriguing strategy to achieve dose reduction of classical immunosuppressive pharmacotherapy. Here, we introduce a new scoring system to assess treatment-emergent adverse events (TEAEs) of adherent stem cell therapies in the clinical setting of allogeneic liver transplantation (for example, the MiSOT-I trial Eudract CT: 2009-017795-25). Methods The score consists of three independent modalities (set of parameters) that focus on clinically relevant events early after intravenous or intraportal stem cell infusion: pulmonary toxicity, intraportal-infusional toxicity and systemic toxicity. For each modality, values between 0 (no TEAE) and 3 (severe TEAE) were defined. The score was validated retrospectively on a cohort of n=187 recipients of liver allografts not receiving investigational cell therapy between July 2004 and December 2010. These patients represent a control population for further trials. Score values were calculated for days 1, 4, and 10 after liver transplantation. Results Grade 3 events were most commonly related to the pulmonary system (3.5% of study cohort on day 4). Almost no systemic-related TEAEs were observed during the study period. The relative frequency of grade 3 events never exceeded 5% over all modalities and time points. A subgroup analysis for grade 3 patients provided no descriptors associated with severe TEAEs. Conclusion The MiSOT-I score provides an assessment tool to score specific adverse events that may occur after adherent stem cell therapy in the clinical setting of organ transplantation and is thus a helpful tool to conduct a safety study.
    Trials 11/2012; 13(1):211. DOI:10.1186/1745-6215-13-211 · 1.73 Impact Factor
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    ABSTRACT: We present a case in which anaphylaxis on hepatic reperfusion during liver transplantation presented only with hypotension and coagulopathy. There were no cutaneous manifestations or clinical features distinguishing anaphylaxis from postreperfusion syndrome. The recipient regularly consumed seafood, and the organ donor died of anaphylaxis to shellfish. The trigger for anaphylaxis was postulated to be passive transfer of immunoglobulin to the recipient. Anesthesiologists should be notified of donor factors to anticipate anaphylaxis. In this report, we discuss coagulopathy of anaphylaxis and contrast it with disseminated intravascular coagulation.
    Anesthesia and analgesia 06/2012; 115(3):522-5. DOI:10.1213/ANE.0b013e31825d2bf4 · 3.47 Impact Factor
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    ABSTRACT: Patients with end stage liver disease (ESLD) have complex problems such as cirrhotic cardiomyopathy, coronary artery disease, hepatopulmonary syndrome (HPS), portopulmonary hypertension (POPH), hepatic encephalopathy, intracranial hypertension, (ICP), left ventricular outflow tract obstruction (LVOTO), high Model of end liver disease (MELD) scores, hyponatremia, and coagulopathies. The anesthesia management for liver transplantation can be very complex, dynamic and challenging. Anesthesia agents affect hepatic blood flow and anesthetic drug distribution, metabolism and elimination maybe altered in end stage liver disease. Other non-anesthetic agents such as nitric oxide, epoprosterenol, THAM, hypertonic saline, fibrinogen concentrates, fresh frozen plasma, platelets, packed red blood cells, recombinant plasminogen activator, calcium chloride, epinephrine etc. may play a vital role in the perioperative management of these patients. Intraoperative hemostasis and coagulation management can be very arduous as these patients may bleed or be at risk for thrombosis. Monitoring modalities such as Thromboelastography (TEG), Transcranial Doppler (TCD), Transesophageal Echocardiography (TEE), Bispectral Index (BIS) and Optic Nerve Sheath Diameter (ONSD) ultrasound play a significant role in various circumstances. Surgical techniques include complete or partial occlusion of the inferior vena cava (IVC) with or without use of venovenous bypass (VVBP) or portocaval shunts. Post reperfusion syndrome (PRS) is a crucial event in this procedure, where patients may experience arrhythmia and/or cardiac arrest. Anesthetic handling of this phase has been recapitulated in detail. Provision of anesthesia services to the living liver transplant donor and pain management has been outlined. Copyright © 2015. Published by Elsevier Inc.
    Transplantation Reviews 05/2015; DOI:10.1016/j.trre.2015.05.003 · 3.82 Impact Factor

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