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Efficacy of IgM-enriched Immunoglobulin for Vasopressor-resistant Vasoplegic Shock After Liver Transplantation

Willuweit, Katharina, Dr Med1,2; Bezinover, Dmitri3; Herzer, Kerstin1,2; Nowak, Knut M.1; Paul, Andreas1; Saner, Fuat H., MD1

doi: 10.1097/TP.0000000000002344
Original Clinical Science—Liver

Background Vasoplegia is a clinical condition typically manifested by cardiovascular instability unresponsive to the usual doses of inotropes or vasopressors. It can occur in a variety of clinical settings including liver transplantation (LT). Immunoglobulins have been used to treat sepsis-related vasoplegia. We performed a retrospective study to evaluate the efficacy of IgM-enriched immunoglobulin (IgMIg) on 30-day mortality and its ability to reverse vasoplegia in patients undergoing LT.

Methods Between May 2013 and November 2017, 473 LT were performed at our institution. We identified 21 patients who received IgMIg for 3 days to treat vasoplegia. Patients included in the study met the criteria for having vasoplegia and required noradrenaline administration greater than 1 μg·kg−1·min−1 for more than 24 hours to maintain a mean arterial pressure of 70 mm Hg or greater. Procalcitonin and interleukin-6 (IL-6) levels were used as surrogate markers for inflammation and were measured at the beginning and end of IgM treatment.

Results After IgMIg administration, median noradrenaline infusion rates could be significantly reduced from 1.6 μg·kg−1·min−1 (1.3-2 μg·kg−1·min−1) to 0.16 μg·kg−1·min−1 (0.08-0.34 μg·kg−1·min−1) (P < 0.001). In addition, after treatment, procalcitonin levels decreased significantly from 44 ng/mL (24–158) to 26.1 ng/mL (10.9-48.7) (P < 0.001) and IL-6 levels decreased significantly from 63 pg/mL (29-102) to 20 pg/mL (11-20) (P < 0.001). Thirty-day morality was 14.3%.

Conclusions The administration of IgMIg in patients with vasoplegia after LT is associated with a return of hemodynamic stability. Despite a predicted mortality of over 90% by Sepsis-Related Organ Failure Assessment score, the mortality rate of patients receiving IgMIg in our study was less than 20%.

The administration of immunoglobulin M-enriched immunoglobulin ameliorated refractory hypotension in a subset of liver transplant recipients in a single center pilot study. Mechanistic studies and further validation will be needed.

1 Department of General, Visceral and Transplantation Surgery, Medical Center University of Duisburg-Essen, Essen, Germany.

2 Department of Gastroenterology and Hepatology, Medical Center University of Duisburg-Essen, Essen, Germany.

3 Department of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA.

Received 18 March 2018. Revision received 27 May 2018.

Accepted 17 June 2018.

K. W. received a travel grant from Biotest Fuat H. Saner received honoraria from the Biotest speaker’s bureau.

The authors declare no funding or conflicts of interest.

K.W. participated in data collection and analysis, and article preparation. D.B. participated in research design, data analysis, and article preparation. K.H. participated in data collection. K.N. participated in research design and data collection. A.P. participated in research design and data collection. F.S. participated in research design, data collection and analysis, and article preparation.

Correspondence: Fuat H. Saner, MD, Department of General, Visceral and Transplantation Surgery, Medical Center University of Duisburg- Essen, Hufelandstr. 55 45147, Essen, Germany. (fuat.saner@uni-due.de).

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