Vol.2, No.9, 508-512 (2013) Case Reports in Clinical Medicine
http://dx.doi.org/10.4236/crcm.2013.29133
Analysis of critical issues in case management for
liver retransplantation
Marina Moguilevitch*, Ellise Delpin
Montefiore Medical Center, Bronx, NY, USA; *Corresponding Author: [e-mail]
Received 8 October 2013; revised 7 November 2013; accepted 6 December 2013
Copyright © 2013 Marina Moguilevitch, Ellise Delpin. This is an open access article distributed under the Creative Commons Attri-
bution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited. In accordance of the Creative Commons Attribution License all Copyrights © 2013 are reserved for SCIRP and the owner of
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ABSTRACT
We report a case of a patient who underwent
successful combined liver-kidney transplant af-
ter two prior liver transplantations. The topic of
liver retransplantation is very controversial. Gi-
ven the critical organ shortage, the question ari-
ses as to wheth er hepa tic retransplant atio n should
be offered liberally despite its greater cost, and
inevitable denial of access to primary transplan-
tation for the other patients on the waiting list.
We suggest that careful selection of the retrans-
plant candidates will improve outcomes and al-
low rational use of the limited organ supply. Ana-
lysis of the available literature allows us to iden-
tify the main predictors of morbidity and mortal-
ity for this patient population. It also enables de-
velopment of a detailed plan for perioperative
management. The role of transesophageal echo-
cardiography (TEE) as a monitor in the complex
liver transplant cases is also discussed. Our re-
port is a significant contribution to the very lim-
ited data available on the subject of multiple
liver retransplants.
Keywords: Liver Retransplantation; TEE in Liver
Transplantati o n; M oni tor ing in Liver
Retransplantation; Anesthetic Manage ment Liver
Retransplantation
1. INTRODUCTION
Liver transplantation is currently the life-saving thera-
peutic modality for treatment of the end-stage liver dis-
ease. With significant advances in antiviral therapy, pos-
toperative immunosuppression and improved surgical
technique today’s 5 and 10 year survival rates after or-
thotopic liver transplant are over 70% and 65% respec-
tively [1]. However, the survival rates of retransplanted
livers among different centers in the United States vary
from 10.0% to 19.4% [2,3] and in the world from 5% to
22% [4,5].
Retransplantation carries greater surgical risks, longer
ICU and hospital stay and significantly poorer outcome
in terms of graft and patients survival. The 5 and 10 year
survival rates range from 47% to 63% and 45% to 62%
respectively [6,7]. The medical problems related to re-
transplantation are compounded by rising financial bur-
den and multiple ethical issues. In an era of extreme or-
gan shortage, the practice of liver retransplantation can
deny access to transplantation to patients waiting for
their first transplant. Additionally, the annual death rate
per 1000 patient has been 2 to 3 times higher for recipi-
ents of multiple liver procedures versus recipients of
primary transplants over the past 9 years [8].
Careful selection of patients for retransplantation and
especially for the repeated retransplantation is extremely
important. The decision regarding this high-risk surgery
should be individualized and based on specific patient
risk factors and the chances for long-term survival.
2. CASE PRESENTATION
The patient is a 29-year-old female with end stage
liver d isease ca used by graft failu re seco ndary to ch ronic
rejection and recurrent autoimmune hepatitis. She had a
history of two prior liver transplants, 16 and 12 years ago.
She presented with clinical symptoms of ascites, severe
portal hypertension and chronic kidney disease requiring
hemodialysis. Her past medical history also included
hypertension, diabetes, and depression. Her medications
include novolog insulin, spironolactone, furosemide, pre-
dnisone, prograft and lactulose. Physical examination
showed significant ascites and jaundice, normal airway,
normal cardiac and pulmonary functions.
Her laboratory studies revealed: Hgb 8.2 mg/dl, total

M. Moguilevitch, E. Delpin / Case Reports in Clinical Medicine 2 (2013) 508-51 2 509
bilirubin/direct bilirubin 54/23.9 mg/dl respectively,
BUN 26 mg/dl, Creatinine 6.4 mg/dl, potassium 4.1
mEq/l, INR 4.8, PT 29 sec, PTT 56 sec, Platelets 39,000.
Transthoracic echocardiogram (TEE) demonstrated
normal left ventricular function with an ejection fraction
of 60% and mild tricuspid valve regurgitation. When an
ABO compatible donor became available the patient was
scheduled for a combined liver-kidney transplant.
Standard ASA monitors were placed. After pre-oxy-
genation, anesthesia was induced with midazolam 2 mg,
fentanyl 150 mcg, propofol 150 mg, and cisatracurium
18 mg. The patient was intubated orally with 7.5 cuffed
endotracheal tube. Subsequently, two large bore periph-
eral intravenous lines, an ar terial line, and a right intern al
jugular 8.5 French introducer catheter were placed. Mul-
tiple attempts to float a Swan Ganz catheter were unsuc-
cessful. A TEE probe was inserted. The examination re-
vealed significant tricuspid valve regurgitation with dila-
tation of the right atrium. Right and left ventricular func-
tion was preserved. The calculated pulmonary artery
pressure was 45/25 mm Hg (Figure 1).
Surgery was planned with the use of veno-venous by-
pass and TEE.
An outflow 21 French heparin coated bypass cannula
was placed in left femoral vein and inflow 19 French
cannula was placed in internal jugular vein under ultra-
sound guidance. The bypass flow through the case was
1.6 - 1.7 L/min. Cell saver and Belmont rapid infuser
were utilized during the surgery. Inferior vena cava cross
clamp time was 27 minutes. There were moderate hemo-
dynamic changes after reperfusion necessitating vaso-
pressin and norepinephrine infusions. The patient was
coagulopathic requiring 45 units of PRBC, 20 liters of
cell saver blood, 37 units of FFP, 5 units of cryoprecipi-
tate and 5 units of platelets.
Thromboelastography was utilized to guide the treat-
ment of the coagulopathy. Surgery lasted 10 hours and
the patient was transferred to the ICU in tubated in stable
condition. The postoperative course was uncomplicated,
except for the need for several hemodialysis sessions.
She was extubatedon postoperative day 2. The patient-
was discharged from the ICU after 5 days and left the
hospital 2 weeks after surgery. Ten months after the
transplant the patient is doing well.
3. DISCUSSION
Transplantation is often the best option for patients
faced with organ failure. Although the results following
primary transplantation have improved, allog raft loss is a
problem confronted by many patients and their physi-
cians. While retransplantation offers hope for good
health and better survival, previous studies have demon-
strated inferior outcomes after repeat liver transplanta-
tion [1,7] .
In a time of extremely limited organ supply, retrans-
plantation remains to be very controversial on ethical,
economic and medical grounds. Therefore, it is particu-
larly important to identify th e group of patients who will
definitely benefit from retransplantation , and to delineate
major donor risk factors that potentially can lead to poor
outcomes and coordinate the work of the multiple ser-
vices involved in these high-risk procedures. The key to
the growing success of liver retransplantation is in care-
ful selection and strategic planning of this operation.
It is very important to be aware of the multiple risk
factors affecting the outcome of the procedure. In the past,
technical complications were the main ind ication for ear-
ly retransplantion, while chronic rejection was the most
important cause for late retransplantation. At the present
time, the scarcity of donor organs necessitates the accep-
tance of subopti mal donor grafts for primary transplan ta-
tion. This practice, in turn, contributes to the fact that
primary graft dysfunction has become the leading indica-
Figure 1. Mid esophageal right ventricle inflow-outflow view. Tricuspid regurgitation.

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510
tion for liver retransplantation within the first year after
primary transplantation. Also, the use of more potent im-
munosuppression has decreased chronic rejection but has
increased recurrent hepatitis C in grafts as the primary
cause for retransplantation on e year after primary surgery
[9].
Although retransplantation in general has poorer out-
comes in terms of survival, multiple studies have shown
that patients having elective retransplantation exhibited
survival curves indistinguishable from those of the single
transplant group [1,10,11]. In spite of a trend towards
longer hospital stay and higher charges in the retrans-
plantpatients, retransplantation is fully justifiable when
performed electively [12]. Outcomes are worse for emer-
gency retransplants, especially those performed within 8
to 30 days of the initial transplantation [13]. However,
despite its inferior results, hepatic retransplantation can
not be abandoned just for practical and ethical reasons.
Prognostic modeling allowing prediction of mortality
risk and long-term survival of patients after retransplan-
tation is extremely important. Analysis of prognostic
factors confirmed by several studies identified a signifi-
cant correlation between mortality and patient ag e, serum
creatinine level, urgency of the operation, and ICU re-
cipient status before retransplantation [14,15]. Younger
patients with normal creatinine coming for elective pro-
cedures more than a year after previous transplants have
better survival chances [1,12,15]. It is a difficult decision
to identify the optimal time for retransplantation in the
case of chronic progressive graf t rejection . In th is settin g,
there might be a place for living related liver transplanta-
tion. Living related transplant shortens the waiting time,
allows for better preparation of the recipient, and pro-
vides an optimal graft with the sho rtest possible ischemia
time [16].
There are several other measures proposed to improve
the results of retransplantation of the high-risk patients.
One of them is to match the severity of the patient’s con-
dition with the quality of the graft. It is a well-established
fact that the recipients of good quality grafts have better
survival chance compared to those who received ex-
tended criteria grafts [17]. Another area of improvement
in retransplantation identified in the literature is refine-
ment of surgical techniques. The success rate of retrans-
plantation has increased as a growing number of sur-
geons have gained expertise in doing this procedure [18].
Ethical issues related to retrasplantation are also very
important. When a patient receives a repeat transplant,
many people think it is unjust to give them priority over
someone who has never had one before. While the num-
ber of liver transplants performed in United States has
reached over 6000 per year, the demand for donor organs
exceeds the supply. As a result, around 1800 deaths per
year occur on the waiting list. Cu rrently, only 554 out of
16,026 patients nationally listed as candidates are listed
for retransplantation [19]. Statistically, these numbers are
very small, but still can raise many ethical concerns for
the transplant teams, candidates for transplant, and fam-
ily members .
Although the primary goal of organ retransplantation
is the optimal health of the patients, it is realistic to ana-
lyze the financial considerations behind the procedure.
The high cost of retransplantation has been well docu-
mented [7]. The cost of retransplantation is usually twice
that of primary one. Even finances are a driving force in
our society; the question arises if it is eth ically correct to
place monetary value on human life.
In our case, weighing the risks versus benefits for this
particular patient, the team decided that young age, late
graft failure and the non-urgent nature of the operation
would increase the chances of a favorable outcome.
Repeat retransplantation of a patient with chronic kid-
ney failure necessitated to combine liver-kidney trans-
plant which presen ted additional risks. In this setting, the
appropriate choice of the invasive monitoring becomes
extremely important. Our current standard of care for pe-
rioperative hemodynamic monitoring during liver trans-
plantation remains an arterial line an d a pulmonary artery
catheter (PAC). However, perioperative transesophageal
echocardiogram (TEE) has been shown to be helpful in
managing fluid therapy, monitoring myocardial function,
and identifying intraoperative complications [20,21].
In our case, TEE monitoring was imperative as the
presence of the significant tricuspid valve regurgitation
(TR) prevented successful placement of the PAC. The
primary advantage of TEE is real-time assessment of
cardiac function, quantitative and qualitative determina-
tion of right and left ventricular filling and ejection frac-
tion. Right and left ventricular dysfunction can be exac-
erbated during liver transplantation by large fluid shifts
that occur during clamping and unclamping of the major
vascular structures such as the inferior vena cava and the
portal vein. Patients are at particular risk of right ven-
tricular failure during and after the reperfusion phase of
the operation. In the presence of TR, this risk is signifi-
cantly increased. Unlike the PAC, the TEE as an imaging
modality can detect new wall motion abnormalities,
shunting, as well as pulmonary and intracardiac emboli
[22,23]. Previous concerns about possible trauma to eso-
phageal varices during TEE placement were largely un-
founded. A large retrospective cohort study demonstrated
no major bleeding complications, even in higher risk
patients [24].
Our unique experience with a repeat combined liver-
kidney transplant opens a new prospective in the ap-
proach to the problem of liver retransplantation. Careful

M. Moguilevitch, E. Delpin / Case Reports in Clinical Medicine 2 (2013) 508-51 2 511
patient selection, individualized monitoring, manage-
ment plans, and strong team work contribute to making
this high-risk procedu re su cc essful.
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