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Volume: 12 Issue: 6 December 2014

FULL TEXT

LETTER TO EDITOR
Application of an Artificial Pancreas for a Liver Transplant Recipient

Dear Editor:

To improve the mortality of transplant recipients, it is imperative that we prevent postoperative infections. Because of poor perioperative liver function, liver transplant recipients are especially immuno-compromised. Recent evidence suggests that in general surgery, perioperative hyperglycemia is the major risk factor for postoperative infection.1 Therefore, control of glucose concentrations is necessary for prevent postoperative infection. To accomplish this, we began applying a closed-loop glycemic control system with an artificial pancreas (STG-55, NIKKISO CO., LTD., Tokyo, Japan) to the liver transplant recipient. This is the first report of the use of an artificial pancreas for deceased-donor liver transplant.

We had a 42-year-old man with fulminant hepatitis who was referred from a local hospital for further treatment. Despite conservative treatments, his condition gradually deteriorated; and 10 days after admission, a deceased-donor liver transplant was performed. For perioperative glycemic control, the artificial pancreas was used at the start of the transplant. During the transplant, his blood glucose concentration was stable, despite the surgical invasiveness and unstable liver function (Figure 1). His postoperative course was uneventful, and there were no episodes of infection postoperatively (eg, a surgical site infection).

For transplant recipients, the most common cause of short-term mortality is a postoperative infection.2 Thus, preventing postoperative infection is critical, and many factors contribute to the risk including perioperative glycemic control. For liver transplant recipients specifically, perioperative glycemic control is difficult because liver function is highly involved in glucose metabolism.

In this case, the patient’s intraoperative blood glucose concentration was well controlled. Also, an adequate dose of insulin was given according to changes in blood glucose concentration without hypoglycemia. An artificial pancreas application is safe for glycemic control by insulin/glucose administration, which is based on continuous real-time monitoring of the patient’s blood glucose concentration. According to an earlier study in general surgery, no hypoglycemia has occurred.3 Concerning intraoperative blood glucose concentration, it was slightly low before reperfusion. Contrarily, his blood glucose level was elevated after reperfusion, and a relatively high dose of insulin was administered. These changes reflected glucose metabolic disorders during the transplant operation. Continuous monitoring by an artificial pancreas also is used to understand glucose metabolism.

An artificial pancreas is anticipated to have additional benefits for the liver transplant recipient. To prevent graft injury perioperatively, tight glycemic control is important to reduce the risk of microangiopathic organ injury by preventing endothelial cell injuries.4 Additionally, use of insulin affects liver function in clinical settings. Insulin has an anti-inflammatory effect by suppressing inflammatory cytokines (eg, nuclear factor kappa B).5 Applying an artificial pancreas to the liver transplant recipient was safe and successful. Additionally, the artificial pancreas might have beneficial effects in liver transplant recipients because of the hepatoprotective effects of insulin, including stimulating regeneration and endothelial cell protection. Further studies are required to clarify these issues.


References:

  1. Ramos M, Khalpey Z, Lipsitz S, et al. Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery. Ann Surg. 2008;248(4):585-591.
    PubMed
  2. Kaido T, Egawa H, Tsuji H, Ashihara E, Maekawa T, Uemoto S. In-hospital mortality in adult recipients of living donor liver transplantation: experience of 576 consecutive cases at a single center. Liver Transpl. 2009;15(11):1420-1425.
    CrossRef - PubMed
  3. Hanazaki K, Kitagawa H, Yatabe T, et al. Perioperative intensive insulin therapy using an artificial endocrine pancreas with closed-loop glycemic control system: the effects of no hypoglycemia. Am J Surg. 2014;207(6):935-941.
    CrossRef - PubMed
  4. Tabit CE, Chung WB, Hamburg NM, Vita JA. Endothelial dysfunction in diabetes mellitus: molecular mechanisms and clinical implications. Rev Endocr Metab Disord. 2010;11(1):61-74.
    CrossRef - PubMed
  5. Wang S, Moustaid-Moussa N, Chen L, et al. Novel insights of dietary polyphenols and obesity. J Nutr Biochem. 2014;25(1):1-18.
    CrossRef - PubMed

     


Volume : 12
Issue : 6
Pages : 572 - 573
DOI : 10.6002/ect.2014.0205


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From the 1Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University; and the 2Department of Surgery, Kochi Medical School, Kochi University, Japan
Acknowledgements: Hironori Hayashi would like to express his deep graduate to Dr. Koichi Shimizu and Dr. Takashi Tani for their valuable and constructive suggestions. The authors declare there were no conflicts of interest in this study and no funding given for this study.
Corresponding author: Hironori Hayashi, MD, PhD, Department of Gastroenterologic Surgery, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, 13-1, Takara-machi, Kanazawa, Ishikawa 920-8641, Japan
Phone: +81 76 265 2362
Fax: +81 76 234 4260
E-mail: pwrofdrms2000@staff.kanazawa-u.ac.jp