Arterial ketone body ratio (AKBR) was measured sequentially in 84 liver transplantations (OLTx). These transplantation procedures were classified into 3 groups with respect to graft survival and patient condition at the end of the first month (Group A, the grafts survived longer than 1 month with satisfactory patient condition; Group B, the grafts survived longer than 1 month but the patients were ICU-bound; Group C, the grafts were lost and the patients died or underwent re-OLTx). In Group A, the AKBR was elevated to above 1.0 by the second postoperative day. In Group B, the AKBR was elevated to above 0.7 but stayed below 1.0 during this period. In Group C, the AKBR remained below 0.7 longer than 2 days after operation. Although conventional liver function tests showed significant increases in Groups B and C as compared with Group A, they were less specific in predicting ultimate graft survival.
Liver transplantation is now the treatment of choice for many patients with end-stage liver disease.1–3 Since the introduction of the immunosuppressive agent cyclosporine in 1978,4 organ replacement has gained acceptance as the only intervention that can cure this relentless, chronic process and offer the chance of complete rehabilitation.
One-year survival rates of 70% or better have been reported for many groups of patients.5,6 The majority can look forward to long, productive lives. The operation now can be recommended to persons formerly thought to be at prohibitively high risk because of their particular disease, prior abdominal surgery, extreme youth, or advanced age. The youngest and oldest recipients of successful transplants at our institutions were 3½ weeks and 76 years old.
Refinements in surgical technique have contributed to these improved results, particularly the introduction of the venovenous bypass,7 improvements in biliary tract reconstruction,8 and the development of methods for multiple organ procurement.9–11 For a description of how the operations on donor and recipient are done, see “Current surgical technique,” page 78.
The effect of endotoxemia on renal function was studied in 76 orthotopic liver transplant patients. In the preoperative period, a high preoperative serum creatinine level (> 2.0 mg/dl) was significantly associated with postoperative endotoxemia. The serum total bilirubin level was significantly greater in the patients with high serum creatinine levels than in those with lower serum creatinine levels (< 2.0 mg/dl). On the 7th postoperative day (POD), the serum creatinine level was significantly associated with an increased plasma endotoxin level. The serum total bilirubin and AST levels did not differ significantly between the patients with high and those with low serum creatinine levels. Based upon these data postoperative endotoxemia is suspected as being the principal cause of early postoperative renal dysfunction. A synergistic effect on renal function between cyclosporine and endotoxin may be important in the pathogenesis of the renal dysfunction seen after successful liver transplantation.
