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Raja K, Panackel C. Post Liver Transplant Renal Dysfunction-Evaluation, Management and Immunosuppressive Practice. J Clin Exp Hepatol 2024; 14:101306. [PMID: 38274509 PMCID: PMC10806298 DOI: 10.1016/j.jceh.2023.101306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 11/21/2023] [Indexed: 01/27/2024] Open
Abstract
Liver transplantation (LT) is an effective and lifesaving treatment for patients with end-stage liver disease and hepatocellular carcinoma. Significant improvement in intermediate and long-term survival has been possible due to advancements in immunosuppressive therapy, perioperative care, and surgical techniques. Despite these advances, metabolic complications, including diabetes mellitus, cardiovascular diseases, malignancies, and renal dysfunction, are challenging issues after LT. Acute kidney injury (AKI) and chronic kidney disease (CKD) after LT are common and result in significant morbidity and mortality. Early diagnosis of kidney injury after LT is challenging, and no technique has yet proven effective in prediction of renal dysfunction. The methods for assessing renal function range from formulas that predict glomerular filtration rate to non-invasive biomarkers. The universal adoption of the model for end-stage liver disease has a direct impact on the incidence of peri-transplant AKI and development of CKD in the long-term. Post-LT renal dysfunction is multifactorial and is usually a result of pre-transplantation comorbidities, occurrence of renal dysfunction on the waiting list, perioperative events, and post-transplant nephrotoxic immunosuppressive medication use. Early identification of patients at risk for renal dysfunction and adoption of preventive measures are crucial in the pre-transplant period. No data are currently available to suggest a surgical technique that reliably demonstrates renal protection. Nephroprotective strategies during LT follow accepted surgical practice guidelines, such as maintenance of intravascular volume and mean arterial pressure. The management of kidney disease following LT is challenging, as by the time the serum creatinine is significantly elevated, few interventions impact the course of progression. Early nephroprotective measures are strongly advised and they mostly center on delaying the administration of calcineurin inhibitors (CNIs) during the initial postoperative period, lowering CNI dosage and combining CNI with mycophenolate mofetil and everolimus. The reasons for renal failure following LT, the techniques used to diagnose it, and the therapies designed to preserve renal function both immediately and late after LT are all critically evaluated in this review.
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Affiliation(s)
- Kaiser Raja
- Department of Gastroenterology and Hepatology, King's College Hospital London, Dubai, United Arab Emirates
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Chadha R, Sakai T, Rajakumar A, Shingina A, Yoon U, Patel D, Spiro M, Bhangui P, Sun LY, Humar A, Bezinover D, Findlay J, Saigal S, Singh S, Yi NJ, Rodriguez-Davalos M, Kumar L, Kumaran V, Agarwal S, Berlakovich G, Egawa H, Lerut J, Clemens Broering D, Berenguer M, Cattral M, Clavien PA, Chen CL, Shah S, Zhu ZJ, Ascher N, Bhangui P, Rammohan A, Emond J, Rela M. Anesthesia and Critical Care for the Prediction and Prevention for Small-for-size Syndrome: Guidelines from the ILTS-iLDLT-LTSI Consensus Conference. Transplantation 2023; 107:2216-2225. [PMID: 37749811 DOI: 10.1097/tp.0000000000004803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND During the perioperative period of living donor liver transplantation, anesthesiologists and intensivists may encounter patients in receipt of small grafts that puts them at risk of developing small for size syndrome (SFSS). METHODS A scientific committee (106 members from 21 countries) performed an extensive literature review on aspects of SFSS with proposed recommendations. Recommendations underwent a blinded review by an independent expert panel and discussion/voting on the recommendations occurred at a consensus conference organized by the International Liver Transplantation Society, International Living Donor Liver Transplantation Group, and Liver Transplantation Society of India. RESULTS It was determined that centers with experience in living donor liver transplantation should utilize potential small for size grafts. Higher risk recipients with sarcopenia, cardiopulmonary, and renal dysfunction should receive small for size grafts with caution. In the intraoperative phase, a restrictive fluid strategy should be considered along with routine use of cardiac output monitoring, as well as use of pharmacologic portal flow modulation when appropriate. Postoperatively, these patients can be considered for enhanced recovery and should receive proactive monitoring for SFSS, nutrition optimization, infection prevention, and consideration for early renal replacement therapy for avoidance of graft congestion. CONCLUSIONS Our recommendations provide a framework for the optimal anesthetic and critical care management in the perioperative period for patients with grafts that put them at risk of developing SFSS. There is a significant limitation in the level of evidence for most recommendations. This statement aims to provide guidance for future research in the perioperative management of SFSS.
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Affiliation(s)
- Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Akila Rajakumar
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Alexandra Shingina
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN
| | - Uzung Yoon
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Dhupal Patel
- Department of Anesthesia and Intensive Care Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Michael Spiro
- Department of Anaesthesia, Royal Devon and Exeter and Department of Anaesthesia and Intensive Care Medicine, The Royal Free Hospital, London, United Kingdom
| | - Pooja Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India
| | - Li-Ying Sun
- Department of Critical Liver Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Abhinav Humar
- Division of Transplantation, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - James Findlay
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Sanjiv Saigal
- Centre of Liver and Biliary Sciences, Centre of Gastroenterology, Hepatology and Endoscopy, Max Super Specialty Hospital, New Delhi, India
| | - Shweta Singh
- Department of Anesthesiology and Critical Care, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Nam-Joon Yi
- Division of HBP Surgery, Department of Surgery, Seoul National University, College of Medicine, Seoul, Korea
| | - Manuel Rodriguez-Davalos
- Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Lakshmi Kumar
- Department of Anesthesiology, Amrita Hospital, Kochi, India
| | - Vinay Kumaran
- Division of Transplant Surgery, Department of Surgery, VCU Medical Center, Richmond, VA
| | - Shaleen Agarwal
- Centre of Liver and Biliary Sciences, Centre of Gastroenterology, Hepatology and Endoscopy, Max Super Specialty Hospital, New Delhi, India
| | | | - Hiroto Egawa
- Department of Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Jan Lerut
- Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Dieter Clemens Broering
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Marina Berenguer
- Liver Transplantation and Hepatology Unit, La Fe University Hospital and IISLaFe and Ciberehd, Valencia, Spain
| | - Mark Cattral
- Ajmera Transplant Center, University of Toronto, Toronto, ON, Canada
| | | | - Chao-Long Chen
- Liver Transplantation Centre, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Samir Shah
- Department of Hepatology, Institute of Liver Disease, HPB Surgery and Transplant, Global Hospitals, Mumbai, India
| | - Zhi-Jun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Nancy Ascher
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi, NCR, India
| | - Ashwin Rammohan
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Jean Emond
- Liver and Abdominal Transplant Surgery, Columbia University Irving Medical Center, New York, NY
| | - Mohamed Rela
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
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Martín LG, Vázquez-Garza JN, Grande AM, González MCM, Martín CF, Polo IDLH, Roux DP, Rojo MG, García FL. Postreperfusion Syndrome in Liver Transplant: A Risk Factor for Acute Kidney Failure: A Retrospective Analysis. Transplant Proc 2022; 54:2277-2284. [PMID: 36192211 DOI: 10.1016/j.transproceed.2022.08.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 07/29/2022] [Accepted: 08/26/2022] [Indexed: 10/07/2022]
Abstract
The maximum expression of hemodynamic instability during liver transplant is the so-called postreperfusion syndrome (PRS) that increases both overall mortality and postoperative complications. It was first defined by Aggarwal et al in 1987, but the results are still conflicting when establishing the relationship between PRS and acute kidney failure (AKF). We conducted a retrospective observational study of transplant recipients with deceased-donor liver grafts between January 2002 and December 2018. We analyzed the incidence of PRS and its potential negative impact over kidney function. A total of 551 transplants were analyzed. PRS was recorded in 130 patients (23.6%). The incidence of AKF was 61.5%. A total of 111 patients required kidney replacement therapy (32.7%). Regarding the severity of AKF, 128 patients were classified as acute kidney injury (AKI) 1 (23.2%), 76 as AKI 2 (13.8%), and 135 as AKI 3 (24.5%). In the group with PRS, 75.4% (n = 98) developed AKF vs 57.2% (n = 241) in the group without PRS. In the multivariate analysis we found a relationship between PRS and AKF with an odds ratio of 2.18 (95% CI, 1.30-3.64; P = .003), once adjusted by the length of the anhepatic phase, donor age, Model for End-Stage Liver Disease score, history of ascites, and need for early surgical reintervention. The incidence of AKF decreased (44.5%) ever since the implementation of delayed calcineurin inhibitors therapy and piggyback surgical technique, but a clear influence of the occurrence of PRS on the development of AKF is still observed, with an OR of 3.78 (95% CI, 1.92-7.43; P < .001), once adjusted by albumin and hemoglobin levels, Model for End-Stage Liver Disease score, and Child classification.
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Affiliation(s)
- L Gajate Martín
- Department of Anesthesiology and Critical Care, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | | | - A Martín Grande
- Department of Anesthesiology and Critical Care, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - M C Martín González
- Department of Anesthesiology and Critical Care, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - C Fernández Martín
- Department of Anesthesiology and Critical Care, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - I De la Hoz Polo
- Department of Anesthesiology and Critical Care, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - D Parise Roux
- Department of Anesthesiology and Critical Care, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - M Gómez Rojo
- Department of Anesthesiology and Critical Care, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - F Liaño García
- Department of Anesthesiology and Critical Care, Hospital Universitario Ramón y Cajal, Madrid, Spain; Department of Nephrology, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Chan YC, Yeh CH, Li LC, Chen CL, Wang CC, Lin CC, Ong AD, Chiou TY, Yong CC. Excess Risk of Major Adverse Cardiovascular and Kidney Events after Acute Kidney Injury following Living Donor Liver Transplantation. J Clin Med 2022; 11:jcm11113100. [PMID: 35683487 PMCID: PMC9181469 DOI: 10.3390/jcm11113100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/26/2022] [Accepted: 05/29/2022] [Indexed: 12/01/2022] Open
Abstract
Acute kidney injury (AKI) is a well-known risk factor for major adverse kidney events (MAKE) and major adverse cardiovascular events (MACE) in nontransplant settings. However, the association between AKI after liver transplantation (LT) and MACE/MAKE is not established. A retrospective cohort analysis including 512 LT recipients was conducted. The incidence of post-LT AKI was 35.0% (n = 179). In total, 13 patients (2.5%) developed de novo coronary artery disease (CAD), 3 patients (0.6%) diagnosed with heart failure (HF), and 11 patients (2.1%) had stroke. The post-LT AKI group showed a higher incidence of CAD and HF than the no post-LT AKI group (4.5% versus 1.5%, p = 0.042; 1.7% versus 0%, p = 0.018; respectively), while there was no significant difference in the stroke events (2.8% versus 1.8%, p = 0.461). Through Cox regression analysis, history of cardiovascular disease (HR 6.51, 95% CI 2.43–17.46), post-LT AKI (HR 3.06, 95% CI 1.39–6.75), and pre-LT diabetes (HR 2.37, 95% CI 1.09–5.17) were identified as independent predictors of MACE; pre-LT chronic kidney disease (HR 9.54, 95% CI 3.49–26.10), pre-LT diabetes (HR 3.51, 95% CI 1.25–9.86), and post-LT AKI (HR 6.76, 95% CI 2.19–20.91) were risk factors for end-stage renal disease. Post-LT AKI is predictive for the development of MACE and MAKE.
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Affiliation(s)
- Yi-Chia Chan
- Liver Transplantation Center, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-C.C.); (C.-H.Y.); (C.-L.C.); (C.-C.W.); (C.-C.L.); (A.D.O.)
| | - Cheng-Hsi Yeh
- Liver Transplantation Center, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-C.C.); (C.-H.Y.); (C.-L.C.); (C.-C.W.); (C.-C.L.); (A.D.O.)
| | - Lung-Chih Li
- Liver Transplantation Center, Department of Internal Medicine, Division of Nephrology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (L.-C.L.); (T.-Y.C.)
| | - Chao-Long Chen
- Liver Transplantation Center, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-C.C.); (C.-H.Y.); (C.-L.C.); (C.-C.W.); (C.-C.L.); (A.D.O.)
| | - Chih-Chi Wang
- Liver Transplantation Center, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-C.C.); (C.-H.Y.); (C.-L.C.); (C.-C.W.); (C.-C.L.); (A.D.O.)
| | - Chih-Chi Lin
- Liver Transplantation Center, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-C.C.); (C.-H.Y.); (C.-L.C.); (C.-C.W.); (C.-C.L.); (A.D.O.)
| | - Aldwin D. Ong
- Liver Transplantation Center, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-C.C.); (C.-H.Y.); (C.-L.C.); (C.-C.W.); (C.-C.L.); (A.D.O.)
| | - Ting-Yu Chiou
- Liver Transplantation Center, Department of Internal Medicine, Division of Nephrology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (L.-C.L.); (T.-Y.C.)
| | - Chee-Chien Yong
- Liver Transplantation Center, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (Y.-C.C.); (C.-H.Y.); (C.-L.C.); (C.-C.W.); (C.-C.L.); (A.D.O.)
- Correspondence: ; Tel.: +886-7-7317123 (ext. 8093)
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[Kidney failure after liver transplantation]. Nephrol Ther 2022; 18:89-103. [PMID: 35151596 DOI: 10.1016/j.nephro.2021.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/11/2021] [Accepted: 11/06/2021] [Indexed: 02/06/2023]
Abstract
One third of cirrhotic patients present impaired kidney function. It has multifactorial causes and has a harmful effect on patients' morbi-mortality before and after liver transplant. Kidney function does not improve in all patients after liver transplantation and liver-transplant recipients are at high risk of developing chronic kidney disease. Causes for renal dysfunction can be divided in three groups: preoperative, peroperative and postoperative factors. To date, there is no consensus for the modality of evaluation the risk for chronic kidney disease after liver transplantation, and for its prevention. In the present review, we describe the outcome of kidney function after liver transplantation, and the prognostic factors of chronic kidney disease to determine a risk stratification for each patient. Furthermore, we discuss therapeutic options to prevent kidney dysfunction in this setting, and highlight the indications of combined liver-kidney transplantation.
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Park J, Jung S, Na S, Choi HJ, Shim JW, Lee HM, Hong SH, Chae MS. Clinical application of intraoperative somatic tissue oxygen saturation for detecting postoperative early kidney dysfunction patients undergoing living donor liver transplantation: A propensity score matching analysis. PLoS One 2022; 17:e0262847. [PMID: 35061855 PMCID: PMC8782411 DOI: 10.1371/journal.pone.0262847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/06/2022] [Indexed: 01/17/2023] Open
Abstract
Background Somatic tissue oxygen saturation (SstO2) is associated with systemic hypoperfusion. Kidney dysfunction may lead to increased mortality and morbidity in patients who undergo living donor liver transplantation (LDLT). We investigated the clinical utility of SstO2 during LDLT for identifying postoperative kidney dysfunction. Patients and methods Data from 304 adults undergoing elective LDLT between January 2015 and February 2020 at Seoul St. Mary’s Hospital were retrospectively collected. Thirty-six patients were excluded based on the exclusion criteria. In total, 268 adults were analyzed, and 200 patients were 1:1 propensity score (PS)-matched. Results Patients with early kidney dysfunction had significantly lower intraoperative SstO2 values than those with normal kidney function. Low SstO2 (< 66%) 1 h after graft reperfusion was more highly predictive of early kidney dysfunction than the values measured in other intraoperative phases. A decline in the SstO2 was also related to kidney dysfunction. Conclusions Kidney dysfunction after LDLT is associated with patient morbidity and mortality. Our results may assist in the detection of early kidney dysfunction by providing a basis for analyzing SstO2 in patients undergoing LDLT. A low SstO2 (< 66%), particularly 1 h after graft reperfusion, was significantly associated with early kidney dysfunction after surgery. SstO2 monitoring may facilitate the identification of early kidney dysfunction and enable early management of patients.
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Affiliation(s)
- Jaesik Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sangmin Jung
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sanghoon Na
- Department of Anesthesiology and Pain Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jung-Woo Shim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyung Mook Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- * E-mail:
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Park J, Kim SU, Choi HJ, Hong SH, Chae MS. Predictive Role of the D-Dimer Level in Acute Kidney Injury in Living Donor Liver Transplantation: A Retrospective Observational Cohort Study. J Clin Med 2022; 11:450. [PMID: 35054144 PMCID: PMC8779454 DOI: 10.3390/jcm11020450] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 02/01/2023] Open
Abstract
This study aimed to determine the association between serum D-dimer levels and the risk of acute kidney injury (AKI) in patients undergoing living donor liver transplantation (LDLT). Clinical data of 675 patients undergoing LDLT were retrospectively analyzed. The exclusion criteria included a history of kidney dysfunction, emergency cases, and missing data. The final study population of 617 patients was divided into the normal and high D-dimer groups (cutoff: 0.5 mg/L). After LDLT, 145 patients (23.5%) developed AKI. A high D-dimer level (>0.5 mg/L) was an independent predictor of postoperative development of AKI in the multivariate analysis when combined with diabetes mellitus [DM], platelet count, and hourly urine output. AKI was significantly higher in the high D-dimer group than in the normal D-dimer group (odds ratio [OR], 2.792; 95% confidence interval [CI], 1.227-6.353). Patients with a high D-dimer exhibited a higher incidence of early allograft dysfunction, longer intensive care unit stay, and a higher mortality rate. These results could improve the risk stratification of postoperative AKI development by encouraging the determination of preoperative D-dimer levels in patients undergoing LDLT.
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Affiliation(s)
- Jaesik Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (J.P.); (S.H.H.)
| | - Sung Un Kim
- Department of Anesthesiology and Pain Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea;
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (J.P.); (S.H.H.)
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (J.P.); (S.H.H.)
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Fabes J, Ambler G, Shah B, Williams NR, Martin D, Davidson BR, Spiro M. Protocol for a prospective double-blind, randomised, placebo-controlled feasibility trial of octreotide infusion during liver transplantation. BMJ Open 2021; 11:e055864. [PMID: 34857585 PMCID: PMC8640665 DOI: 10.1136/bmjopen-2021-055864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Liver transplantation is a complex operation that can provide significant improvements in quality of life and survival to the recipients. However, serious complications are common and include major haemorrhage, hypotension and renal failure. Blood transfusion and the development of acute kidney injury lead to both short-term and long-term poor patient outcomes, including an increased risk of death, graft failure, length of stay and reduced quality of life. Octreotide may reduce the incidence of renal dysfunction, perioperative haemorrhage and enhance intraoperative blood pressure. However, octreotide does have risks, including resistant bradycardia, hyperglycaemia and hypoglycaemia and QT prolongation. Hence, a randomised controlled trial of octreotide during liver transplantation is needed to determine the cost-efficacy and safety of its use; this study represents a feasibility study prior to this trial. METHODS AND ANALYSIS We describe a multicentre, double-blind, randomised, placebo-controlled feasibility study of continuous infusion of octreotide during liver transplantation surgery. We will recruit 30 adult patients at two liver transplant centres. A blinded infusion during surgery will be administered in a 2:1 ratio of octreotide:placebo. The primary outcomes will determine the feasibility of this study design. These include the recruitment ratio, correct administration of blinded study intervention, adverse event rates, patient and clinician enrolment refusal and completion of data collection. Secondary outcome measures of efficacy and safety will help shape future trials by assessing potential primary outcome measures and monitoring safety end points. No formal statistical tests are planned. This manuscript represents study protocol number 1.3, dated 2 June 2021. ETHICS AND DISSEMINATION This study has received Research Ethics Committee approval. The main study outcomes will be submitted to an open-access journal. TRIAL SPONSOR The Joint Research Office, University College London, UK.Neither the sponsor nor the funder have any role in study design, collection, management, analysis and interpretation of data, writing of the study report or the decision to submit the report for publication. TRIAL REGISTRATION The study is registered with ClinicalTrials.gov (NCT04941911) with recruitment due to start in August 2021 with anticipated completion in July 2022. CLINICAL TRIALS UNIT Surgical and Interventional Group, Division of Surgery & Interventional Science, University College London.
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Affiliation(s)
- Jeremy Fabes
- Peninsula Medical School, University of Plymouth, Plymouth, Devon, UK
- Department of Anaesthesia, Royal Free London NHS Foundation Trust, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Bina Shah
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Norman R Williams
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Daniel Martin
- Peninsula Medical School, University of Plymouth, Plymouth, Devon, UK
| | - Brian R Davidson
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Michael Spiro
- Division of Surgery & Interventional Science, University College London, London, UK
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Bittermann T, Abt PL, Olthoff KM, Kaur N, Heimbach JK, Emamaullee J. Impact of Advanced Renal Dysfunction on Posttransplant Outcomes After Living Donor Liver Transplantation in the United States. Transplantation 2021; 105:2564-2570. [PMID: 33660658 PMCID: PMC8410875 DOI: 10.1097/tp.0000000000003728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Survival after living donor liver transplantation (LDLT) in the United States is excellent. However, the significance of pretransplant kidney disease on outcomes in this population is poorly understood. METHODS This was a retrospective cohort study of 2806 LDLT recipients nationally between January 2010 and June 2020. Recipients with estimated glomerular filtration rate <40 mL/min/1.73 m2 (eGFR-low) or requiring dialysis were compared. Multivariable survival analyses evaluated (1) eGFR-low as a predictor of post-LDLT survival and (2) the survival of LDLT versus deceased donor liver transplant (DDLT) alone with eGFR-low. RESULTS From 2010 to 2020, 140 (5.0%) patients had eGFR-low and 18 (0.6%) required dialysis pre-LDLT. The number of LDLTs requiring dialysis between 2017 and 2020 outnumbered the prior 7 y. Overall LDLT experience was greater at centers performing LDLT in recipients with renal dysfunction (P < 0.001). LDLT recipients with eGFR-low had longstanding renal dysfunction: mean eGFR 3-6 mo before LDLT 42.7 (±15.1) mL/min/1.73 m2. Nearly half (5/12) of eGFR-low recipients with active kidney transplant (KT) listing at LDLT experienced renal recovery. Five patients underwent early KT after LDLT via the new "safety net" policy. Unadjusted survival after LDLT was worse with eGFR-low (hazard ratio 2.12 versus eGFR ≥40 mL/min/1.73 m2; 95% confidence interval, 1.47-3.05; P < 0.001), but no longer so when accounting for mean eGFR 3-6 mo pre-LDLT (hazard ratio, 1.27; 95% confidence interval, 0.82-1.95; P = 0.3). The adjusted survival of patients with eGFR-low receiving LDLT versus deceased donor liver transplant alone was not different (P = 0.08). CONCLUSIONS Overall, outcomes after LDLT with advanced renal dysfunction are acceptable. These findings are relevant given the recent "safety net" KT policy.
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Affiliation(s)
- Therese Bittermann
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA
- Division of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Peter L. Abt
- Division of Transplant Surgery, University of Pennsylvania, Philadelphia, PA
| | - Kim M. Olthoff
- Division of Transplant Surgery, University of Pennsylvania, Philadelphia, PA
| | - Navpreet Kaur
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Julie K. Heimbach
- Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN
| | - Juliet Emamaullee
- Department of Surgery, University of Southern California, Los Angeles, CA
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10
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Dong V, Nadim MK, Karvellas CJ. Post-Liver Transplant Acute Kidney Injury. Liver Transpl 2021; 27:1653-1664. [PMID: 33963666 DOI: 10.1002/lt.26094] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/19/2021] [Accepted: 04/26/2021] [Indexed: 12/13/2022]
Abstract
Acute kidney injury (AKI) is a common condition following liver transplantation (LT). It negatively impacts patient outcomes by increasing the chances of developing chronic kidney disease and reducing graft and patient survival rates. Multiple definitions of AKI have been proposed and used throughout the years, with the International Club of Ascites definition being the most widely now used for patients with cirrhosis. Multiple factors are associated with the development of post-LT AKI and can be categorized into pre-LT comorbidities, donor and recipient characteristics, operative factors, and post-LT factors. Many of these factors can be optimized in an attempt to minimize the risk of AKI occurring and to improve renal function if AKI is already present. A special consideration during the post-LT phase is needed for immunosuppression as certain immunosuppressive medications can be nephrotoxic. The calcineurin inhibitor tacrolimus (TAC) is the mainstay of immunosuppression but can result in AKI. Several strategies including use of the monoclonoal antibody basilixamab to allow for delayed initiation of tacrolimus therapy and minimization through combination and minimization or elimination of TAC through combination with mycophenolate mofetil or mammalian target of rapamycin inhibitors have been implemented to reverse and avoid AKI in the post-LT setting. Renal replacement therapy may ultimately be required to support patients until recovery of AKI after LT. Overall, by improving renal function in post-LT patients with AKI, outcomes can be improved.
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Affiliation(s)
- Victor Dong
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Alberta, Canada.,Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, University of Southern California, Los Angeles, CA
| | - Constantine J Karvellas
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada.,Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
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11
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Abstract
One-third of patients with cirrhosis present kidney failure (AKI and CKD). It has multifactorial causes and a harmful effect on morbidity and mortality before and after liver transplantation. Kidney function does not improve in all patients after liver transplantation, and liver transplant recipients are at a high risk of developing chronic kidney disease. The causes of renal dysfunction can be divided into three groups: pre-operative, perioperative and post-operative factors. To date, there is no consensus on the modality to evaluate the risk of chronic kidney disease after liver transplantation, or for its prevention. In this narrative review, we describe the outcome of kidney function after liver transplantation, and the prognostic factors of chronic kidney disease in order to establish a risk categorization for each patient. Furthermore, we discuss therapeutic options to prevent kidney dysfunction in this context, and highlight the indications of combined liver–kidney transplantation.
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12
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Kim KS, Moon YJ, Kim SH, Kim B, Jun IG, Kwon HM, Song JG, Hwang GS. Low Preoperative Antithrombin III Level Is Associated with Postoperative Acute Kidney Injury after Liver Transplantation. J Pers Med 2021; 11:jpm11080716. [PMID: 34442360 PMCID: PMC8401622 DOI: 10.3390/jpm11080716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/21/2021] [Accepted: 07/23/2021] [Indexed: 12/17/2022] Open
Abstract
We aimed to determine the association between the preoperative antithrombin III (ATIII) level and postoperative acute kidney injury (AKI) after LT (post-LT AKI). We retrospectively evaluated 2395 LT recipients between 2010 and 2018 whose data of perioperative ATIII levels were available. Patients were divided into two groups based on the preoperative level of ATIII (ATIII < 50% vs. ATIII ≥ 50%). Multivariable regression analysis was performed to assess the risk factors for post-LT AKI. The mean preoperative ATIII levels were 30.2 ± 11.8% in the ATIII < 50% group and 67.2 ± 13.2% in the ATIII ≥ 50% group. The incidence of post-LT AKI was significantly lower in the ATIII ≥ 50% group compared to that in the ATIII < 50% group (54.7% vs. 75.5%, p < 0.001); odds ratio (OR, per 10% increase in ATIII level) 0.86, 95% confidence interval (CI) 0.81–0.92; p < 0.001. After a backward stepwise regression model, female sex, high body mass index, low albumin, deceased donor LT, longer duration of surgery, and high red blood cell transfusion remained significantly associated with post-LT AKI. A low preoperative ATIII level is associated with post-LT AKI, suggesting that preoperative ATIII might be a prognostic factor for predicting post-LT AKI.
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Affiliation(s)
| | | | | | | | | | | | - Jun-Gol Song
- Correspondence: ; Tel.: +82-2-3010-3869; Fax: +82-2-470-1363
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13
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Park J, Joo MA, Choi HJ, Hong SH, Park CS, Choi JH, Chae MS. Predictive utility of fibrinogen in acute kidney injury in living donor liver transplantation: A propensity score-matching analysis. PLoS One 2021; 16:e0252715. [PMID: 34086798 PMCID: PMC8177619 DOI: 10.1371/journal.pone.0252715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 05/20/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND This study investigated the association between the fibrinogen level and the risk of acute kidney injury (AKI) in patients who have undergone living donor liver transplantation (LDLT). PATIENTS AND METHODS A total of 676 patients who underwent LDLT were analyzed retrospectively. Exclusion criteria included a history of severe kidney dysfunction, emergency operation, deceased donor, ABO-incompatible transplantation, and missing data. The study population was divided into low and normal fibrinogen groups. A 1:1 propensity score (PS) matching analysis was used to evaluate the association between a low fibrinogen level (< 160 mg/dL) and postoperative development of AKI. RESULTS In total, 142 patients (23.1%) developed AKI after LDLT. The PS matching analysis showed that the probability of AKI was two-fold higher in the low fibrinogen group than in the normal fibrinogen group. In addition, patients with AKI had poorer postoperative outcomes such as longer hospitalization, longer ICU stay, and higher mortality than patients without AKI. CONCLUSIONS The preoperative fibrinogen level may be useful for risk stratification of patients undergoing LDLT in terms postoperative development of AKI.
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Affiliation(s)
- Jaesik Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min A. Joo
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul Soo Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong Ho Choi
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Perioperative ABO Blood Group Isoagglutinin Titer and the Risk of Acute Kidney Injury after ABO-Incompatible Living Donor Liver Transplantation. J Clin Med 2021; 10:jcm10081679. [PMID: 33919744 PMCID: PMC8070732 DOI: 10.3390/jcm10081679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/04/2021] [Accepted: 04/10/2021] [Indexed: 01/28/2023] Open
Abstract
For ABO-incompatible liver transplantation (ABO-i LT), therapeutic plasma exchange (TPE) is performed preoperatively to reduce the isoagglutinin titer of anti-ABO blood type antibodies. We evaluated whether perioperative high isoagglutinin titer is associated with postoperative risk of acute kidney injury (AKI). In 130 cases of ABO-i LT, we collected immunoglobulin (Ig) G and Ig M isoagglutinin titers of baseline, pre-LT, and postoperative peak values. These values were compared between the patients with and without postoperative AKI. Multivariable logistic regression analysis was used to evaluate the association between perioperative isoagglutinin titers and postoperative AKI. Clinical and graft-related outcomes were compared between high and low baseline and postoperative peak isoagglutinin groups. The incidence of AKI was 42.3%. Preoperative baseline and postoperative peak isoagglutinin titers of both Ig M and Ig G were significantly higher in the patients with AKI than those without AKI. Multivariable logistic regression analysis showed that preoperative baseline and postoperative peak Ig M isoagglutinin titers were significantly associated with the risk of AKI (baseline: odds ratio 1.06, 95% confidence interval 1.02 to 1.09; postoperative peak: odds ratio 1.08, 95% confidence interval 1.04 to 1.13). Cubic spline function curves show a positive relationship between the baseline and postoperative peak isoagglutinin titers and the risk of AKI. Clinical outcomes other than AKI were not significantly different according to the baseline and postoperative peak isoagglutinin titers. Preoperative high initial and postoperative peak Ig M isoagglutinin titers were significantly associated with the development of AKI. As the causal relationship between high isoagglutinin titers and risk of AKI is unclear, the high baseline and postoperative isoagglutinin titers could be used simply as a warning sign for the risk of AKI after liver transplantation.
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15
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Shankar V, Raj A, Singhal S, Sahni R, Goyal N, Venuthurimilli A, Olson MT, Chatterji C. Doppler-derived renal resistive index helps predict acute kidney injury in patients undergoing living-related liver transplantation. Clin Transplant 2021; 35:e14263. [PMID: 33608962 DOI: 10.1111/ctr.14263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/24/2021] [Accepted: 02/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is commonly associated with increased postoperative morbidity in liver transplant (LT) recipients. The aim of this study was to identify the role of renal resistive index (RRI) in predicting AKI and to study the factors associated with AKI in LT recipients. PATIENTS AND METHODS We performed a single-center, prospective study, including adult living donor LT recipients at our center between January 2018 and September 2019 with no preoperative renal dysfunction. RRI was calculated on ultrasound doppler once preoperatively, and once daily in the postoperative period through postoperative day (POD) six. Patients were grouped into AKI and non-AKI groups for comparison. RESULTS Fifty patients were included in the study (mean age, 44 years; 20% females). AKI developed in 25 patients (50%). Both groups were similar in baseline characteristics. RRI of ≥ 0.69 on POD 2 predicted AKI (sensitivity 88%; specificity 92%). RRI on the day before AKI diagnosis (0.71 vs. 0.65) and on the day of diagnosis (0.72 vs. 0.65) were significantly increased relative to preoperative baseline. CONCLUSIONS Doppler-derived RRI is a rapid, non-invasive, and bedside procedure capable of predicting the occurrence of postoperative AKI in LT recipients.
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Affiliation(s)
- Vijay Shankar
- Department of Anesthesiology and Critical Care, Indraprastha Apollo Hospital, New Delhi, India
| | - Anupam Raj
- Department of Anesthesiology and Critical Care, Indraprastha Apollo Hospital, New Delhi, India
| | - Saurabh Singhal
- Liver Transplant and Hepatopancreaticobiliary Unit, Indraprastha Apollo Hospital, New Delhi, India
| | - Reeti Sahni
- Department of Radiology, Indraprastha Apollo Hospital, New Delhi, India
| | - Neerav Goyal
- Liver Transplant and Hepatopancreaticobiliary Unit, Indraprastha Apollo Hospital, New Delhi, India
| | - Arun Venuthurimilli
- Liver Transplant and Hepatopancreaticobiliary Unit, Indraprastha Apollo Hospital, New Delhi, India
| | - Michael T Olson
- Department of Surgery, University of Arizona College of Medicine -Phoenix Campus, Phoenix, AZ, USA
| | - Chitra Chatterji
- Department of Anesthesiology and Critical Care, Indraprastha Apollo Hospital, New Delhi, India
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16
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Park J, Cho S, Cho YJ, Choi HJ, Hong SH, Chae MS. Predictive Utility of Antithrombin III in Acute Kidney Injury in Living-Donor Liver Transplantation: A Retrospective Observational Cohort Study. Transplant Proc 2020; 53:111-118. [PMID: 33272652 DOI: 10.1016/j.transproceed.2020.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/07/2020] [Accepted: 10/01/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION This study was performed to determine the association between the serum level of antithrombin III (ATIII) level and the risk of acute kidney injury (AKI) in patients undergoing living-donor liver transplantation (LDLT). PATIENTS AND METHODS A total of 591 patients undergoing LDLT were retrospectively investigated and 14 patients were excluded because of a history of kidney dysfunction or missing data; 577 patients were finally enrolled in the study. The study population was divided into normal and low ATIII groups. Data on all laboratory variables, including ATIII, were collected on the day before surgery. RESULTS After LDLT, 143 patients developed AKI (24.8%). A lower ATIII was independently associated with postoperative AKI along with preoperative (diabetes mellitus) and intraoperative (mean heart rate, hourly urine output) factors. Based on the standard cutoff for normal ATIII (<70%), the probability of AKI was 2.8-fold higher in the low ATIII group than in the normal ATIII group. In addition, patients with low ATIII received blood transfusion products during the operation and underwent longer duration mechanical ventilation. CONCLUSIONS Preoperative ATIII measurement will help improve risk stratification for postoperative AKI development in patients undergoing LDLT.
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Affiliation(s)
- Jaesik Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seunghee Cho
- Department of Anesthesiology and Pain Medicine, Incheon St. Marys Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yun Jeong Cho
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Park J, Choi JH, Choi HJ, Hong SH, Park CS, Choi JH, Chae MS. Predictive role of vitamin B 12 in acute kidney injury in living donor liver transplantation: a propensity score matching analysis. BMJ Open 2020; 10:e038990. [PMID: 33191257 PMCID: PMC7668363 DOI: 10.1136/bmjopen-2020-038990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES We examine the association between vitamin B12 level and risk for acute kidney injury (AKI) in patients undergoing living donor liver transplantation (LDLT). DESIGN Retrospective observational cohort study. SETTING University hospital, from January 2009 to December 2018. PARTICIPANTS A total of 591 patients who underwent elective LDLT were analysed in this study. Those with a preoperative history of kidney dysfunction, vitamin B12 supplementation due to alcoholism, low vitamin B12 (<200 pg/mL) or missing laboratory data were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES The population was classified into AKI and non-AKI groups according to Kidney Disease Improving Global Outcomes (KDIGO) criteria, and associations between perioperative factors and AKI were analysed. After 1:1 propensity score (PS) matching, the association between high vitamin B12 (>900 pg/mL) and postoperative AKI was evaluated. RESULTS Preoperative vitamin B12 was higher in the AKI group. Potentially significant perioperative factors from univariate analyses were entered into multivariate analyses, including preoperative factors (vitamin B12, diabetes), intraoperative factors (hourly urine output) and donor graft fatty change in LDLT patients. PS matching analyses with adjustment using PS revealed that high serum vitamin B12 (>900 pg/mL) was associated with risk for AKI, and the risk was 2.8-fold higher in patients with high vitamin B12 than in those with normal vitamin B12. Higher vitamin B12 was also related to a higher AKI stage. In addition, inflammatory factors (C reactive protein, white blood cells and albumin) were associated with vitamin B12 level. CONCLUSIONS Our study may improve the accuracy of predicting postoperative AKI by introducing preoperative vitamin B12 into risk assessments for patients undergoing LDLT.
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Affiliation(s)
- Jaesik Park
- Anesthesiology and Pain Medicine, Catholic University of Korea College of Medicine, Seoul, The Republic of Korea
| | - Jung Hee Choi
- Anesthesiology and Pain Medicine, Catholic University of Korea College of Medicine, Seoul, The Republic of Korea
| | - Ho Joong Choi
- Surgery, Catholic University of Korea College of Medicine, Seoul, The Republic of Korea
| | - Sang Hyun Hong
- Anesthesiology and Pain Medicine, Catholic University of Korea College of Medicine, Seoul, The Republic of Korea
| | - Chul Soo Park
- Anesthesiology and Pain Medicine, Catholic University of Korea College of Medicine, Seoul, The Republic of Korea
| | - Jong Ho Choi
- Anesthesiology and Pain Medicine, Catholic University of Korea College of Medicine, Seoul, The Republic of Korea
| | - Min Suk Chae
- Anesthesiology and Pain Medicine, Catholic University of Korea College of Medicine, Seoul, The Republic of Korea
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Intraoperative Hemodynamic Parameters and Acute Kidney Injury After Living Donor Liver Transplantation. Transplantation 2020; 103:1877-1886. [PMID: 30720690 DOI: 10.1097/tp.0000000000002584] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) after living donor liver transplantation (LDLT) is associated with increased mortality. We sought to identify associations between intraoperative hemodynamic variables and postoperative AKI. METHODS We retrospectively reviewed 734 cases of LDLT. Intraoperative hemodynamic variables of systemic and pulmonary arterial pressure, central venous pressure (CVP), and pulmonary artery catheter-derived parameters including mixed venous oxygen saturation (SvO2), right ventricular end-diastolic volume (RVEDV), stroke volume, systemic vascular resistance, right ventricular ejection fraction, and stroke work index were collected. Propensity score matching analysis was performed between patients with (n = 265) and without (n = 265) postoperative AKI. Hemodynamic variables were compared between patients with AKI, defined by Kidney Disease Improving Global Outcomes criteria, and those without AKI in the matched sample. RESULTS The incidence of AKI was 36.1% (265/734). Baseline CVP, baseline RVEDV, and SvO2 at 5 minutes before reperfusion were significantly different between patients with and without AKI in the matched sample of 265 pairs. Multivariable logistic regression analysis revealed that baseline CVP, baseline RVEDV, and SvO2 at 5 minutes before reperfusion were independent predictors of AKI (CVP per 5 cm H2O increase: odds ratio [OR], 1.20; 95% confidence interval [CI], 1.09-1.32; SvO2: OR, 1.45; 95% CI, 1.27-1.71; RVEDV: OR, 1.48; 95% CI, 1.24-1.78). CONCLUSIONS The elevated baseline CVP, elevated baseline RVEDV after anesthesia induction, and decreased SvO2 during anhepatic phase were associated with postoperative AKI. Prospective trials are required to evaluate whether the optimization of these variables may decrease the risk of AKI after LDLT.
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Kim WH, Lee HJ, Yoon HC, Lee KH, Suh KS. Intraoperative Oxygen Delivery and Acute Kidney Injury after Liver Transplantation. J Clin Med 2020; 9:E564. [PMID: 32092886 PMCID: PMC7073538 DOI: 10.3390/jcm9020564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/02/2020] [Accepted: 02/17/2020] [Indexed: 01/04/2023] Open
Abstract
Although intraoperative hemodynamic variables were reported to be associated with acute kidney injury (AKI) after liver transplantation, the time-dependent association between intraoperative oxygen delivery and AKI has not yet been evaluated. We reviewed 676 cases of liver transplantation. Oxygen delivery index (DO2I) was calculated at least ten times during surgery. AKI was defined according to the Kidney Disease Improving Global Outcomes criteria. The area under the curve (AUC) was calculated as below a DO2I of 300 (AUC < 300), 400 and 500 mL/min/m2 threshold. Also, the cumulative time below a DO2I of 300 (Time < 300), 400, and 500 mL/min/m2 were calculated. Multivariable logistic regression analysis was performed to evaluate whether AUC < 300 or time < 300 was independently associated with the risk of AKI. As a sensitivity analysis, propensity score matching analysis was performed between the two intraoperative mean DO2I groups using a cutoff of 500 ml/min/m2, and the incidence of AKI was compared between the groups. Multivariable analysis showed that AUC < 300 or time < 300 was an independent predictor of AKI (AUC < 300: odds ratio [OR] = 1.10, 95% confidence interval [CI] 1.06-1.13, time < 300: OR = 1.10, 95% CI 1.08-1.14). Propensity score matching yielded 192 pairs of low and high mean DO2I groups. The incidence of overall and stage 2 or 3 AKI was significantly higher in the lower DO2I group compared to the higher group (overall AKI: lower group, n = 64 (33.3%) vs. higher group, n = 106 (55.2%), P < 0.001). In conclusion, there was a significant time-dependent association between the intraoperative poor oxygen delivery <300 mL/min/m2 and the risk of AKI after liver transplantation. The intraoperative optimization of oxygen delivery may mitigate the risk of AKI.
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Affiliation(s)
- Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-J.L.); (H.-C.Y.); (K.H.L.)
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-J.L.); (H.-C.Y.); (K.H.L.)
| | - Hee-Chul Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-J.L.); (H.-C.Y.); (K.H.L.)
| | - Kook Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea; (H.-J.L.); (H.-C.Y.); (K.H.L.)
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea;
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20
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Yu JH, Kwon Y, Kim J, Yang SM, Kim WH, Jung CW, Suh KS, Lee KH. Influence of Transfusion on the Risk of Acute Kidney Injury: ABO-Compatible versus ABO-Incompatible Liver Transplantation. J Clin Med 2019; 8:jcm8111785. [PMID: 31731500 PMCID: PMC6912207 DOI: 10.3390/jcm8111785] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/17/2019] [Accepted: 10/23/2019] [Indexed: 01/28/2023] Open
Abstract
ABO-incompatible liver transplantation (ABO-i LT) is associated with a higher risk of acute kidney injury (AKI) compared to ABO-compatible liver transplantation (ABO-c LT). We compared the risk of AKI associated with transfusion between ABO-c and ABO-i living donor liver transplantation (LDLT). In 885 cases of LDLT, we used a propensity score analysis to match patients who underwent ABO-c (n = 766) and ABO-i (n = 119) LDLT. Baseline medical status, laboratory findings, and surgical- and anesthesia-related parameters were used as contributors for propensity score matching. AKI was defined according to the "Kidney Disease Improving Global Outcomes" criteria. After 1:2 propensity score matching, a conditional logistic regression analysis was performed to evaluate the relationship between the intraoperative transfusion of packed red blood cells (pRBCs) and fresh frozen plasma (FFP) on the risk of AKI. The incidence of AKI was higher in ABO-i LT than in ABO-c LT before and after matching (after matching, 65.8% in ABO-i vs 39.7% in ABO-c, p < 0.001). The incidence of AKI increased in direct proportion to the amount of transfusion, and this increase was more pronounced in ABO-i LT. The risk of pRBC transfusion for AKI was greater in ABO-i LT (multivariable adjusted odds ratio (OR) 1.32 per unit) than in ABO-c LT (OR 1.11 per unit). The risk of FFP transfusion was even greater in ABO-i LT (OR 1.44 per unit) than in ABO-c LT (OR 1.07 per unit). In conclusion, the association between transfusion and risk of AKI was stronger in patients with ABO-i LT than with ABO-c LT. Interventions to reduce perioperative transfusions may attenuate the risk of AKI in patients with ABO-i LT.
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Affiliation(s)
- Je Hyuk Yu
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea; (J.H.Y.); (Y.K.); (J.K.); (S.-M.Y.); (C.-W.J.); (K.H.L.)
| | - Yongsuk Kwon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea; (J.H.Y.); (Y.K.); (J.K.); (S.-M.Y.); (C.-W.J.); (K.H.L.)
| | - Jay Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea; (J.H.Y.); (Y.K.); (J.K.); (S.-M.Y.); (C.-W.J.); (K.H.L.)
| | - Seong-Mi Yang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea; (J.H.Y.); (Y.K.); (J.K.); (S.-M.Y.); (C.-W.J.); (K.H.L.)
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea; (J.H.Y.); (Y.K.); (J.K.); (S.-M.Y.); (C.-W.J.); (K.H.L.)
- Correspondence: ; Tel.: +82-2-2072-2462; Fax: +82-2-747-5639
| | - Chul-Woo Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea; (J.H.Y.); (Y.K.); (J.K.); (S.-M.Y.); (C.-W.J.); (K.H.L.)
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul 03080, Korea;
| | - Kook Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea; (J.H.Y.); (Y.K.); (J.K.); (S.-M.Y.); (C.-W.J.); (K.H.L.)
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Incidence and Impact of Acute Kidney Injury after Liver Transplantation: A Meta-Analysis. J Clin Med 2019; 8:jcm8030372. [PMID: 30884912 PMCID: PMC6463182 DOI: 10.3390/jcm8030372] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/05/2019] [Accepted: 03/14/2019] [Indexed: 02/06/2023] Open
Abstract
Background: The study’s aim was to summarize the incidence and impacts of post-liver transplant (LTx) acute kidney injury (AKI) on outcomes after LTx. Methods: A literature search was performed using the MEDLINE, EMBASE and Cochrane Databases from inception until December 2018 to identify studies assessing the incidence of AKI (using a standard AKI definition) in adult patients undergoing LTx. Effect estimates from the individual studies were derived and consolidated utilizing random-effect, the generic inverse variance approach of DerSimonian and Laird. The protocol for this systematic review is registered with PROSPERO (no. CRD42018100664). Results: Thirty-eight cohort studies, with a total of 13,422 LTx patients, were enrolled. Overall, the pooled estimated incidence rates of post-LTx AKI and severe AKI requiring renal replacement therapy (RRT) were 40.7% (95% CI: 35.4%–46.2%) and 7.7% (95% CI: 5.1%–11.4%), respectively. Meta-regression showed that the year of study did not significantly affect the incidence of post-LTx AKI (p = 0.81). The pooled estimated in-hospital or 30-day mortality, and 1-year mortality rates of patients with post-LTx AKI were 16.5% (95% CI: 10.8%–24.3%) and 31.1% (95% CI: 22.4%–41.5%), respectively. Post-LTx AKI and severe AKI requiring RRT were associated with significantly higher mortality with pooled ORs of 2.96 (95% CI: 2.32–3.77) and 8.15 (95%CI: 4.52–14.69), respectively. Compared to those without post-LTx AKI, recipients with post-LTx AKI had significantly increased risk of liver graft failure and chronic kidney disease with pooled ORs of 3.76 (95% CI: 1.56–9.03) and 2.35 (95% CI: 1.53–3.61), respectively. Conclusion: The overall estimated incidence rates of post-LTx AKI and severe AKI requiring RRT are 40.8% and 7.0%, respectively. There are significant associations of post-LTx AKI with increased mortality and graft failure after transplantation. Furthermore, the incidence of post-LTx AKI has remained stable over the ten years of the study.
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Lee HC, Yoon SB, Yang SM, Kim WH, Ryu HG, Jung CW, Suh KS, Lee KH. Prediction of Acute Kidney Injury after Liver Transplantation: Machine Learning Approaches vs. Logistic Regression Model. J Clin Med 2018; 7:jcm7110428. [PMID: 30413107 PMCID: PMC6262324 DOI: 10.3390/jcm7110428] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 10/29/2018] [Accepted: 11/06/2018] [Indexed: 12/15/2022] Open
Abstract
Acute kidney injury (AKI) after liver transplantation has been reported to be associated with increased mortality. Recently, machine learning approaches were reported to have better predictive ability than the classic statistical analysis. We compared the performance of machine learning approaches with that of logistic regression analysis to predict AKI after liver transplantation. We reviewed 1211 patients and preoperative and intraoperative anesthesia and surgery-related variables were obtained. The primary outcome was postoperative AKI defined by acute kidney injury network criteria. The following machine learning techniques were used: decision tree, random forest, gradient boosting machine, support vector machine, naïve Bayes, multilayer perceptron, and deep belief networks. These techniques were compared with logistic regression analysis regarding the area under the receiver-operating characteristic curve (AUROC). AKI developed in 365 patients (30.1%). The performance in terms of AUROC was best in gradient boosting machine among all analyses to predict AKI of all stages (0.90, 95% confidence interval [CI] 0.86–0.93) or stage 2 or 3 AKI. The AUROC of logistic regression analysis was 0.61 (95% CI 0.56–0.66). Decision tree and random forest techniques showed moderate performance (AUROC 0.86 and 0.85, respectively). The AUROC of support the vector machine, naïve Bayes, neural network, and deep belief network was smaller than that of the other models. In our comparison of seven machine learning approaches with logistic regression analysis, the gradient boosting machine showed the best performance with the highest AUROC. An internet-based risk estimator was developed based on our model of gradient boosting. However, prospective studies are required to validate our results.
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Affiliation(s)
- Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
| | - Soo Bin Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
| | - Seong-Mi Yang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Ho-Geol Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Chul-Woo Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Kook Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul 03080, Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul 03080, Korea.
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Lemon K, Al-Khafaji A, Humar A. Critical Care Management of Living Donor Liver Transplants. Crit Care Clin 2018; 35:107-116. [PMID: 30447773 DOI: 10.1016/j.ccc.2018.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This article represents a review of the postoperative management of donors and recipients after living donor liver transplant, including monitoring, liberation from mechanical ventilation, nutritional support, and pain control. Vascular complications, such as biliary and sepsis, and bleeding are also discussed. Finally, commonly used immunosuppression and antimicrobial prophylaxes are reviewed.
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Affiliation(s)
- Kristina Lemon
- Department of Surgery, University of Pittsburgh Medical Center, Thomas E. Starzl Transplantation Institute, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - Ali Al-Khafaji
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, 3550 Terrace Street, Scaife 613, Pittsburgh, PA 15261, USA.
| | - Abhinav Humar
- Department of Surgery, University of Pittsburgh Medical Center, Thomas E. Starzl Transplantation Institute, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA
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Jun IG, Kwon HM, Jung KW, Moon YJ, Shin WJ, Song JG, Hwang GS. The Impact of Postreperfusion Syndrome on Acute Kidney Injury in Living Donor Liver Transplantation. Anesth Analg 2018; 127:369-378. [DOI: 10.1213/ane.0000000000003370] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Abstract
The development of acute kidney injury in the setting of liver disease is a significant event both before and after liver transplant. Whether acute kidney injury is the cause of or merely associated with worse outcomes, the development of renal failure is significant from a prognostic as well as from a diagnostic and therapeutic standpoint. Although not every etiology is reversible, there are number of etiologies that are correctable, to include hypovolemia, nephrotoxic medications, and acute tubular necrosis. In the post-liver transplant period, renal failure is associated with graft failure as well as worse outcomes overall. Prompt recognition, workup, and intervention can significantly impact outcomes and survival both before and after liver transplant.
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Affiliation(s)
| | - Ali Al-Khafaji
- 2 Department of Critical Care Medicine, The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
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Abstract
PURPOSE OF REVIEW In this review, we discuss the latest updates on perioperative acute kidney injury (AKI) and the specific considerations that are relevant to different surgeries and patient populations. RECENT FINDINGS AKI diagnosis is constantly evolving. New biomarkers detect AKI early and shed a light on the possible cause of AKI. Hypotension, even for a short duration, is associated with perioperative AKI. The debate on the deleterious effects of chloride-rich solutions is still far from conclusion. Remote ischemic preconditioning is showing promising results in the possible prevention of perioperative AKI. No definite data show a beneficiary effect of statins, fenoldepam, or sodium bicarbonate in preventing AKI. SUMMARY Perioperative AKI is prevalent and associated with significant morbidity and mortality. Considering the lack of effective preventive or therapeutic interventions, this review focuses on perioperative AKI: measures for early diagnosis, defining risks and possible mechanisms, and summarizing current knowledge for intraoperative fluid and hemodynamic management to reduce risk of AKI.
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Predictive Role of Serum Cytokine Profiles in Acute Kidney Injury after Living Donor Liver Transplantation. Mediators Inflamm 2018; 2018:8256193. [PMID: 29805315 PMCID: PMC5901815 DOI: 10.1155/2018/8256193] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 03/07/2018] [Indexed: 01/07/2023] Open
Abstract
Introduction Previous studies have shown that a higher serum interleukin- (IL-) 6 level is associated with a higher risk of acute kidney injury (AKI) development after major nontransplant surgery. Our study investigated the potential association of preoperative serum cytokine profiles with new AKI development in patients who underwent living donor liver transplantation (LDLT). Methods Serum levels of cytokines IL-2, IL-6, IL-10, IL-12, and IL-17, interferon-γ, and tumor necrosis factor- (TNF-) α were measured in 226 LDLT recipients preoperatively and analyzed retrospectively. Recipients with a preoperative functional impairment of the kidney were excluded. AKI was defined according to Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Results In a univariate regression model, IL-6, IL-17, and TNF-α levels showed an association with AKI development after LDLT. Multivariate analysis showed an independent association of the preoperative serum IL-6 level with AKI development after LDLT and a significant relationship between higher serum IL-6 levels and a greater likelihood of developing AKI. Serum IL-6 levels were higher in patients with stage 3 AKI than in patients who did not develop AKI. Conclusions Our results support the need for further investigations of IL-6 as a predictor of AKI development in patients undergoing LDLT.
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Kork F, Rimek A, Andert A, Becker NJ, Heidenhain C, Neumann UP, Kroy D, Roehl AB, Rossaint R, Hein M. Visual quality assessment of the liver graft by the transplanting surgeon predicts postreperfusion syndrome after liver transplantation: a retrospective cohort study. BMC Anesthesiol 2018. [PMID: 29523082 PMCID: PMC5845208 DOI: 10.1186/s12871-018-0493-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background The discrepancy between demand and supply for liver transplants (LT) has led to an increased transplantation of organs from extended criteria donors (ECD). Methods In this single center retrospective analysis of 122 cadaveric LT recipients, we investigated predictors of postreperfusion syndrome (PRS) including transplant liver quality categorized by both histological assessment of steatosis and subjective visual assessment by the transplanting surgeon using multivariable regression analysis. Furthermore, we describe the relevance of PRS during the intraoperative and postoperative course of LT recipients. Results 53.3% (n = 65) of the patients suffered from PRS. Risk factors for PRS were visually assessed organ quality of the liver grafts (acceptable: OR 12.2 [95% CI 2.43–61.59], P = 0.002; poor: OR 13.4 [95% CI 1.48–121.1], P = 0.02) as well as intraoperative norepinephrine dosage before reperfusion (OR 2.2 [95% CI 1.26–3.86] per 0.1 μg kg− 1 min− 1, P = 0.01). In contrast, histological assessment of the graft was not associated with PRS. LT recipients suffering from PRS were hemodynamically more instable after reperfusion compared to recipients not suffering from PRS. They had lower mean arterial pressures until the end of surgery (P < 0.001), received more epinephrine and norepinephrine before reperfusion (P = 0.02 and P < 0.001, respectively) as well as higher rates of continuous infusion of norepinephrine (P < 0.001) and vasopressin (P = 0.02) after reperfusion. Postoperative peak AST was significantly higher (P = 0.001) in LT recipients with PRS. LT recipients with intraoperative PRS had more postoperative adverse cardiac events (P = 0.05) and suffered more often from postoperative delirium (P = 0.04). Conclusions Patients receiving ECD liver grafts are especially prone to PRS. Anesthesiologists should keep these newly described risk factors in mind when preparing for reperfusion in patients receiving high-risk organs.
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Affiliation(s)
- Felix Kork
- Department of Anaesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.
| | - Alexandra Rimek
- Department of Anaesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Anne Andert
- Department of General, Visceral and Transplantation Surgery, Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Niklas Jurek Becker
- Department of General, Visceral and Transplantation Surgery, Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Christoph Heidenhain
- Department of General, Visceral and Oncological Surgery, Sana Hospital Gerresheim, Gräulinger Strasse 120, 40625, Düsseldorf, Germany
| | - Ulf P Neumann
- Department of General, Visceral and Transplantation Surgery, Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Daniela Kroy
- Department of Medicine III, Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Anna B Roehl
- Department of Anaesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Rolf Rossaint
- Department of Anaesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Marc Hein
- Department of Anaesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
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Atalan HK, Gucyetmez B, Aslan S, Yazar S, Polat KY. Postoperative acute kidney injury in living donor liver transplantation recipients. Int J Artif Organs 2017; 41:0. [PMID: 28885664 DOI: 10.5301/ijao.5000638] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2017] [Indexed: 01/20/2023]
Abstract
PURPOSE There are many risk factors for postoperative acute kidney injury in liver transplantation. The aim of this study is to investigate the risk factors for postoperative acute kidney injury in living donor liver transplantation recipients. METHODS 220 living donor liver transplantation recipients were retrospectively evaluated in the study. According to the Kidney Disease Improving Global Outcomes Guidelines, acute kidney injury in postoperative day 7 was investigated for all patients. The patient's demographic data, preoperative and intraoperative parameters, and outcomes were recorded. RESULTS Acute kidney injury was found in 27 (12.3%) recipients. In recipients with acute kidney injury, female population, model for end-stage liver disease score, norepinephrine requirement, duration of mean arterial pressure less than 60 mmHg, the usage of gelatin and erythrocyte suspension and blood loss were significantly higher than recipients with nonacute kidney injury (for all p<0.05). In multivariate analyses, the likelihood of acute kidney injury on postoperative day 7 were increased 2.8-fold (1.1-7.0), 2.7-fold (1.02-7.3), 3.4-fold (1.2-9.9) and 5.1-fold (1.7-15.0) by postoperative day 7, serum tacrolimus level ≥10.2 ng dL-1, intraoperative blood loss ≥14.5 mL kg-1, the usage of gelatin >5 mL kg-1 and duration of MAP less than 60 mmHg ≥5.5 minutes respectively (for all p<0.05). CONCLUSIONS In living donor liver transplantation recipients, serum tacrolimus levels, intraoperative blood loss, hypotension period and the usage of gelatin may be risk factors for acute kidney injury in the early postoperative period.
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Affiliation(s)
- Hakan K Atalan
- Department of Anesthesiology, Atasehir Memorial Hospital, Istanbul, Turkey
| | - Bulent Gucyetmez
- Department of Anesthesiology and Reanimation, Acibadem University School of Medicine, Istanbul, Turkey
| | - Serdar Aslan
- Department of Transplantation, Atasehir Memorial Hospital, Istanbul, Turkey
| | - Serafettin Yazar
- Department of Transplantation, Atasehir Memorial Hospital, Istanbul, Turkey
| | - Kamil Y Polat
- Department of Transplantation, Atasehir Memorial Hospital, Istanbul, Turkey
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Roller J, Glanemann M. Keep the pressure! Correlation of hemodynamic instability after reperfusion and severity of acute kidney injury following liver transplantation. Transpl Int 2017; 30:658-659. [PMID: 28267230 DOI: 10.1111/tri.12948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 02/28/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Jonas Roller
- Department of General, Visceral, Vascular and Pediatric Surgery, Saarland University, Homburg, Saarland, Germany
| | - Matthias Glanemann
- Department of General, Visceral, Vascular and Pediatric Surgery, Saarland University, Homburg, Saarland, Germany
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Jun IG, Lee B, Kim SO, Shin WJ, Bang JY, Song JG, Song GW, Lee SG, Hwang GS. Comparison of acute kidney injury between ABO-compatible and ABO-incompatible living donor liver transplantation: A propensity matching analysis. Liver Transpl 2016; 22:1656-1665. [PMID: 27595780 DOI: 10.1002/lt.24634] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 08/17/2016] [Indexed: 02/07/2023]
Abstract
The anti-CD20 monoclonal antibody rituximab has significantly decreased the prevalence of antibody-mediated rejection of ABO-incompatible (ABOi) living donor liver transplantation (LDLT). However, little is known about acute kidney injury (AKI) following ABOi LDLT. The aim of this study was to identify the incidence of AKI in ABOi LDLT and compare it with that of ABO-compatible (ABOc) LDLT. We retrospectively collected and analyzed the data of 1617 patients who underwent liver transplant surgery from November 2008 to December 2014. Risk factors for AKI were investigated using multivariate regression analysis. In 271 ABOi LDLTs, AKI occurred in 184 (67.9%) according to Kidney Disease: Improving Global Outcomes criteria. After propensity score matching, the incidence of AKI was significantly higher after ABOi LDLT than after ABOc LDLT (67.0% versus 48.2%; P < 0.001). Furthermore, the intensive care unit stay (P = 0.01) was significantly prolonged, but there were no significant differences in mortality (P = 0.74), graft failure (P = 0.32), and postoperative dialysis (P = 0.74) between the 2 groups. Hemoglobin level and operation time were independent risk factors for AKI following ABOi LDLT. In conclusion, the incidence of AKI is higher in ABOi LDLT than ABOc LDLT. However, the impact of AKI on postoperative outcomes was not marked in our study. Therefore, ABOi LDLT in selected patients is promising with apparent good graft and survival outcomes. Liver Transplantation 22 1656-1665 2016 AASLD.
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Affiliation(s)
- In-Gu Jun
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, University of Ulsan College of Medicine, Seoul, South Korea
| | - Byungdoo Lee
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seon-Ok Kim
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Seoul, South Korea
| | - Won-Jung Shin
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ji-Youn Bang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, University of Ulsan College of Medicine, Seoul, South Korea
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Mizota T, Minamisawa S, Imanaka Y, Fukuda K. Oliguria without serum creatinine increase after living donor liver transplantation is associated with adverse post-operative outcomes. Acta Anaesthesiol Scand 2016; 60:874-81. [PMID: 27027576 DOI: 10.1111/aas.12722] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 02/11/2016] [Accepted: 02/13/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication after liver transplantation and is associated with significant morbidity and mortality. Although clinical guidelines recommend defining AKI based on serum creatinine increase and oliguria, the validity and utility of the oliguric component of AKI definition remains largely unexplored. This study examined the incidence and the impact on clinical outcomes of oliguria meeting the urine output criterion of AKI in patients undergoing liver transplantation. The authors hypothesised that oliguria was an independent risk factor for adverse post-operative outcomes. METHODS This study retrospectively examined 320 patients who underwent living donor liver transplantation at our centre. AKI stages were allocated according to recent guidelines based on serum creatinine or urine output within 7 days of surgery. RESULTS The incidence of oliguria meeting the urine output criterion of AKI was 50.3%. Compared with creatinine criterion alone, incorporating oliguria into the diagnostic criteria dramatically increased the measured incidence of AKI from 39.7% to 62.2%. Compared with patients diagnosed without AKI using either criterion, oliguric patients without serum creatinine increase had significantly longer intensive care unit stays (median: 5 vs. 4 days, P = 0.016), longer hospital stays (median: 60 vs. 49 days, P = 0.014) and lower chronic kidney disease-free survival rate on post-operative day 90 (54.2% vs. 73.3%, P = 0.008). CONCLUSION Oliguria is common after liver transplantation, and incorporating oliguria into the diagnostic criteria dramatically increases the measured incidence of AKI. Oliguria without serum creatinine increase was significantly associated with adverse post-operative outcomes.
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Affiliation(s)
- T. Mizota
- Department of Anaesthesia; Kyoto University Hospital; Sakyo-ku Kyoto Japan
| | - S. Minamisawa
- Department of Healthcare Economics and Quality Management; Graduate School of Medicine; Kyoto University; Sakyo-ku Kyoto Japan
| | - Y. Imanaka
- Department of Healthcare Economics and Quality Management; Graduate School of Medicine; Kyoto University; Sakyo-ku Kyoto Japan
| | - K. Fukuda
- Department of Anaesthesia; Kyoto University Hospital; Sakyo-ku Kyoto Japan
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Lim C, Audureau E, Salloum C, Levesque E, Lahat E, Merle JC, Compagnon P, Dhonneur G, Feray C, Azoulay D. Acute kidney injury following hepatectomy for hepatocellular carcinoma: incidence, risk factors and prognostic value. HPB (Oxford) 2016; 18:540-8. [PMID: 27317959 PMCID: PMC4913133 DOI: 10.1016/j.hpb.2016.04.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 03/19/2016] [Accepted: 04/10/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) following hepatectomy remains understudied in terms of diagnosis, severity, recovery and prognostic value. The aim of this study was to assess the risk factors and prognostic value of AKI on short- and long-term outcomes following hepatectomy for hepatocellular carcinoma (HCC). METHOD This is a retrospective analysis of a single-center cohort of 457 consecutive patients who underwent hepatectomy for HCC. The KDIGO criteria were used for AKI diagnosis. The incidence, risk factors, and prognostic value of AKI were investigated. RESULTS AKI occurred in 67 patients (15%). The mortality and major morbidity rates were significantly higher in patients with AKI (37% and 69%) than in those without (6% and 22%; p < 0.001). Renal recovery was complete in 35 (52%), partial in 25 (37%), and absent in 7 (11%) patients. Advanced age, an increased MELD score, major hepatectomy and prolonged duration of operation were identified as independent predictors of AKI. AKI was identified as the strongest independent predictor of postoperative mortality but did not impact survival. CONCLUSION AKI is a common complication after hepatectomy for HCC. Although its development is associated with poor short-term outcomes, it does not appear to be predictive of impaired long-term survival.
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Key Words
- aki, acute kidney injury
- kdigo, kidney disease improving global outcomes
- hcc, hepatocellular carcinoma
- scr, serum creatinine
- rrt, renal replacement therapy
- cki, chronic kidney injury
- egfr, estimated glomerula filtration rate
- icu, intensive care unit
- auroc, area under the receiver operating curve
- os, overall survival
- meld, model for end stage liver disease
- or, odds ratio
- ci, confidence interval
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Affiliation(s)
- Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France,INSERM, U965, Paris, France
| | - Etienne Audureau
- Department of Public Health, Henri Mondor Hospital, Créteil, France
| | - Chady Salloum
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Eric Levesque
- Department of Anesthesia and Liver Intensive Care Unit, Henri Mondor Hospital, Créteil, France,INSERM, U955, Créteil, France
| | - Eylon Lahat
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Jean Claude Merle
- Department of Anesthesia and Liver Intensive Care Unit, Henri Mondor Hospital, Créteil, France
| | - Philippe Compagnon
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France,INSERM, U955, Créteil, France
| | - Gilles Dhonneur
- Department of Anesthesia and Liver Intensive Care Unit, Henri Mondor Hospital, Créteil, France
| | - Cyrille Feray
- INSERM, U955, Créteil, France,Department of Hepatology, Henri Mondor Hospital, Créteil, France
| | - Daniel Azoulay
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France,INSERM, U955, Créteil, France,Correspondence: Daniel Azoulay, Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Henri Mondor hospital, 51 avenue de Lattre de Tassigny, 94010 Créteil, France. Tel: + 33 1 49 81 25 48. Fax. + 33 1 49 81 24 32.Department of Hepatobiliary and Pancreatic Surgery and Liver TransplantationHenri Mondor hospital51 avenue de Lattre de TassignyCréteil94010France
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Ma G, Jiang H, Zhang X, Zhu T. Acute kidney injury after orthotopic liver transplantation using living donor versus deceased donor grafts: A propensity score-matched analysis. Liver Transpl 2015; 21:1560. [PMID: 26249262 DOI: 10.1002/lt.24224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Accepted: 07/25/2015] [Indexed: 02/05/2023]
Affiliation(s)
- Gang Ma
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - HaiXia Jiang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - XiYang Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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