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October 13, 2007
2:00 PM - 4:00 PM
Room Hall D, Area J,
Endotoxin Levels as Marker for Liver Graft Performance in Patients Undergoing Liver Transplantation
Ibtesam A. Hilmi, M.B., C.H.B., FRCA, Raymond M. Planinsic, M.D., Daneila Damian, M.D., Testsuro Sakai, M.D., Nizar Moayeri, M.D.
Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Introduction: The liver plays a pivotal role in removing endotoxin, a function which is impaired in liver failure. In orthotopic liver transplant (OLT) recipients the sources of endotoxinemia may include porto-systemic shunting from the gut to the circulation and liver failure leading to impaired clearance of endotoxin. The Endotoxin Activity Assay (EAA) is a novel new in-vitro method for endotoxin measurement. We sought to use this new method to determine whether EAA is a senstivite marker for graft performance.

Methods: This pilot study of 20 subjects, that was performed as a prospective observational, double-blinded study to investigate EAA levels of patients during and after OLT. EAA levels were compared with those for 10 healthy volunteers. EAA was measured intraoperativly at 4 time-points; 1-baseline (on induction), 2-anhepatic phase, 3-post-reperfusion (PR), 4-end of surgery. EAA was subsequently measured every day for the 1st postoperative week and then weekly for 3 weeks. Data collection included: patient demographics, etiology of liver failure, type of graft/graft characteristics, acute physiology measurements, Model for End-Stage Liver Disease (MELD) score, liver function tests, renal function tests, liver graft survival rate, patient survival rate, sites and type of infections, and duration of hospital and ICU stay.

Interpretation of EAA results: The EAA reports a range from 0.00 to 1.00 units. EAA values <0.40= low; 0.40-0.59=intermediate and ≥0.60 EA units indicate high endotoxin activity.

Results: The median/range EAA for the control group was 0.21(0.16-0.27). In the OLT patients, the median/range baseline EAA was 0.4 (0.10-0.70). There was positive correlation between increasing EAA and increasing MELD score, Graph-2. From 20 OLT patients, 6 recipients received live-donor livers, 14 received cadaveric livers. The EAA at the PR in the cadaveric group is 0.50(0.18-0.83) and the live-donor group is 0.40 (0.19-0.81). The intraoperative EAA correlated with lactate levels consistent with gut hypoperfusion as a source of lactate and endotoxin. While EAA decreased over time in most patients, it remained elevated after 4 weeks post-OLT in the majority of cases, Graph-1.

Conclusion: Endotoxemia as measured by EAA is common in OLT patients. EAA correlates with severity of liver disease as scored by MELD. EAA is still moderately elevated 4 weeks post-OLT in many patients. Further study is necessary to determine the utility of measurement of EAA levels in OLT patients to further understand the relationship between EAA and graft recovery as well as possible ongoing portosystemic shunting.[figure1][figure2]

Anesthesiology 2007; 107: A312
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