Ischaemic preconditioning for liver transplantation

  • Review
  • Intervention

Authors


Abstract

Background

Ischaemic preconditioning is a mechanism for reducing organ ischaemia reperfusion injury by a brief period of organ ischaemia.

Objectives

To assess the advantages and disadvantages of ischaemic preconditioning during donor hepatectomy for liver transplant recipients.

Search methods

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until June 2008.

Selection criteria

We included only randomised clinical trials comparing ischaemic preconditioning versus no ischaemic preconditioning during donor liver retrievals performed in humans in this review (irrespective of language or publication status).

Data collection and analysis

Two authors independently identified the trials for inclusion and independently collected the data on the characteristics of the trial, bias-risk of the trials, mortality, initial poor function, primary graft non-function, re-transplantation, intensive therapy unit stay, hospital stay, and liver function tests. We analysed the data with both the fixed-effect and the random-effects models. For each binary outcome we calculated the risk ratio (RR) with 95% confidence intervals (CI) based on available case analysis. For continuous outcomes, we calculated the mean difference (MD) with 95% CI.

Main results

In four trials, 270 cadaveric liver donor retrievals were randomised; 131 to ischaemic preconditioning and 139 to no ischaemic preconditioning. In one trial, 15 living donor liver retrievals were randomised; 10 to ischaemic preconditioning and 5 to no ischaemic preconditioning. All trials were high bias-risk trials. There was no statistically significant difference in mortality, initial poor function, primary graft non-function,re-transplant, intensive therapy unit stay, or hospital stay between the liver transplant recipients belonging to the two groups. There was no consistent pattern noted in the transaminase activity. There was no statistically significant difference in the bilirubin level or prothrombin activity.

Authors' conclusions

There is currently no evidence to support or refute the use of ischaemic preconditioning in donor liver retrievals. Further studies are necessary to identify the optimal ischaemic preconditioning stimulus.

摘要

背景

肝移植的缺血預處理

缺血預處理是一種讓器官在短時間內缺血,使器官減少受到缺血再灌注損傷的一種治療機制。

目標

評估缺血預處理在取肝過程中,對於肝移植受體的利弊。

搜尋策略

我們搜尋2007年3月以前的The Cochrane HepatoBiliary Group Controlled Trials Register, Cochrane Library的Cochrane Central Register of Controlled Trials (CENTRAL),MEDLINE、EMBASE和Science Citation Index Expanded。

選擇標準

我們僅包括文獻回顧,比較在取肝臟過程中,缺血預處理和非缺血預處理的隨機臨床試驗 (不受語言或出版狀態的限制)。

資料收集與分析

我們收集了有關試驗特徵,試驗研究方法學品質、死亡率、初期肝功能不良、初期移植肝無功能、再次肝移植、肝功能檢驗、嗜中性白血球活化的標記,細胞凋亡和重症治療單位的住院時間等資料。我們使用固定效果和隨機效果模式分析資料。根據治療意向分析,我們計算每個結果的危險比 (RR) ,及其95%信賴區間 (CI)。對於持續性結果,我們計算了加權平均差(WMD),95% CI。

主要結論

共檢索了3個試驗,共有162位屍體捐肝者,78位接受缺血預處理,84位沒有接受缺血預處理。另一個試驗中,在15位活體捐肝者中隨機分配,10位接受缺血預處理,5位沒有接受缺血預處理。4個試驗有3個試驗的偏差屬於低風險。死亡率、初期肝功能不良、初期移植肝無功能、再次肝移植等方面沒有統計顯著差異。轉氨?活性、膽紅素值、凝血素活性、平均髓過氧化物?活性值,平均 CD8淋巴球的表現,平均誘導一氧化氮合成?,以及細胞凋亡方面沒有統計學意義上的顯著差異。接受肝移植病人的重症治療單位住院時間沒有顯著差異。

作者結論

目前沒有證據支持或反對捐肝者取肝過程中使用缺血預處理。 未來需要進一步研究,確定最佳的缺血預處理刺激物。未來需要隨機臨床試驗來評估取肝過程中,缺血預處理的角色,這牽涉到執行缺血預處理,再使用溫血再灌注的時間。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

沒有證據支持或反對肝移植使用缺血預處理。缺血預處理是一種讓器官在短時間內缺血,使器官減少受到缺血再灌注損傷的一種治療機制,例如,一段時間減少血液供應或不供應血液, 讓器官在短時間內處於血液下降的狀態,降低由於血液回流至器官造成的損傷。是否於取肝過程中使用缺血預處理對肝移植產生有利的結果仍有爭議。本次系統性文獻回顧包括四個隨機臨床試驗,評估在摘除捐獻者肝臟時,對肝移植受體實施缺血預處理的利弊。3個試驗納入162位屍體捐肝;隨機將78 位接受缺血預處理,84位沒有接受缺血預處理;另一個試驗納入15位活體捐肝;隨機將10位接受缺血預處理,5位沒有接受缺血預處理。4個試驗有3個試驗屬於偏誤風險較低。死亡率、初期肝功能不良、初期移植肝無功能、再次肝移植、任何其他顯示肝臟受損的指標等方面,於統計學上均無顯著差異,而不同的試驗中有不同的方向。目前沒有證據支持或反對取肝過程中使用缺血預處理。需要透過研究,以確定最佳的缺血預處理刺激物。未來需要隨機臨床試驗來評估取肝過程中,缺血預處理的角色,這牽涉到執行缺血預處理,再使用溫血再灌注的時間。

Plain language summary

No evidence to support or refute the use of ischaemic preconditioning in liver transplantation

Ischaemic preconditioning is a mechanism for reducing organ ischaemia reperfusion injury by a brief period of organ ischaemia, ie, decrease the injury caused by return of blood supply to the organ after a period of decreased or absent blood supply by exposing the organ to shorter periods of decreased blood supply. There is considerable controversy regarding whether ischaemic preconditioning during donor liver retrieval has beneficial effect on the outcome of liver transplantation. This systematic review includes five randomised clinical trials assessing the advantages and disadvantages of ischaemic preconditioning during donor hepatectomy for liver transplant recipients. In four trials, 270 cadaveric liver donor retrievals were randomised; 131 to ischaemic preconditioning and 139 to no ischaemic preconditioning; and in one trial, 15 living donor liver retrievals were randomised; 10 to ischaemic preconditioning and 5 to no ischaemic preconditioning. All the trials were high bias-risk trials. There was no statistically significant difference in mortality, initial poor function, re-transplant, primary graft non-function, or in any other outcome other than enzyme markers of liver injury, which was in different directions in different trials. There is currently no evidence to support or refute the use of ischaemic preconditioning in donor liver retrievals. Further studies are necessary to identify the optimal ischaemic preconditioning stimulus.

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