Acute kidney injury after pediatric liver transplantation: incidence, risk factors, and association with outcome

Postoperative hypoalbuminemia and outcomes of pediatric liver transplantation

BACKGROUND

Hypoalbuminemia after liver transplantation (LT) is associated with acute kidney injury (AKI) and poor outcomes in adult LT recipients. This study was performed to examine the association between the postoperative serum albumin level and early postoperative outcomes of LT in children.

METHODS

This single-center retrospective review involved pediatric LT recipients (0-18 years old) treated from January 2013 to June 2020. All patients were admitted to PICU and received standard post-LT care protocol. We divided patients into low (< 30 g/L) and normal (> 30 g/L) groups based on postoperative albumin day 1 to 3.

RESULTS

Among 108 LT recipients, most had biliary atresia. The median age at the time of LT was 1.8 years [interquartile range (IQR), 1.5-5.7]. There were 18 patients in low albumin group [median albumin level, 27.9 g/L (IQR, 25.8-29.6) and 90 patients in normal albumin group [median albumin level, 34.5 g/L (IQR, 32.4-36.9). The low albumin group had significantly higher incidence of AKI, occurring in 20% of patients with a median onset of 2.5 days following LT (IQR, 1-5). Postoperative hypoalbuminemia (OR, 4.94; 95% CI, 1.32-18.47; p = 0.01) and a longer operative time (OR, 1.37; 95% CI, 1.01-1.47; p = 0.02) were independent risk factors for AKI by multivariable analysis. No significant differences between the two groups were found in other early postoperative outcomes.

CONCLUSION

Postoperative hypoalbuminemia was associated with early postoperative AKI following LT in children but not with other worsening outcomes.

Incidence and Risk Factors of Acute Kidney Injury in Pediatric Liver Transplant Patients: A Retrospective Study

Background

Acute kidney injury (AKI) significantly contributes to the mortality and morbidity rates among pediatric liver transplant (LT) recipients.

Objective

Our study aimed to assess the potential factors contributing to AKI in pediatric LT patients and to analyze the impact of AKI on postoperative mortality and hospitalization duration.

Materials and methods

About 235 pediatric LT patients under the age of 18 between the years 2015 and 2021 were evaluated retrospectively. The relationship between preoperative and intraoperative variables of the patients and AKI developed when the early postoperatıve period was assessed.

Results

A correlation was found between the patients' preoperative age, albumin levels, and AKI. AKI was found to be associated with the duration of surgery and intraoperative blood transfusion.

Conclusion

Our findings revealed that the severity of AKI in pediatric LT patients is linked to extended surgical durations and increased blood transfusions resulting from hemodynamically compromised blood loss. Furthermore, independent risk factors for AKI were identified as prolonged warm ischemia and the overall duration of the operation.

How to cite this article

Demiroz D, Colak YZ, Ozdes OO, Ucar M, Ali Erdogan M, Toprak HI, et al. Incidence and Risk Factors of Acute Kidney İnjury in Pediatric Liver Transplant Patients: A Retrospective Study. Indian J Crit Care Med 2024;28(1):75-79.

Transplanting the Liver for a New Life: Can the Kidney Throw in a Spanner?

How to cite this article: Parameswaran N. Transplanting the Liver for a New Life: Can the Kidney Throw in a Spanner? Indian J Crit Care Med 2024;28(1):13-14.

Epidemiology data on the cost and outcomes associated with pediatric acute kidney injury

BACKGROUND

Hospitalized children with acute kidney injury (AKI) have not been extensively studied for clinical outcomes including hospital stay, the need for mechanical ventilation, mortality rates, and healthcare utilization. We hypothesize significant financial costs and increased morbidity and mortality associated with pediatric AKI.

METHODS

This is a retrospective study of pediatric patients (age ≤18 years) included in the Kids' Inpatient Database (KID) between January 1, 2016, and December 31, 2021. The results of the data analysis were utilized for comparative testing between the AKI and non-AKI cohorts.

RESULTS

The study included 4842 children [with AKI (n = 2424) and without AKI (n = 2418)]. The odds of mortality (p = 0.004) and mechanical ventilation (p < 0.001) were observed to be significantly higher among those with AKI as compared to those without AKI. Additionally, the median (IQR) duration of stay in the hospital (p < 0.001) and total cost (p < 0.001) were significantly higher among those with AKI vs. those without AKI.

CONCLUSIONS

AKI in children was associated with higher odds of mortality, longer duration of hospital stay, increased requirement of mechanical ventilation, and increased hospital expenditure. The scientific community can utilize this information to better understand the outcomes associated with this disease process in this patient population.

IMPACT

This article has thoroughly evaluated epidemiologic data associated with pediatric acute kidney injury (AKI) in hospitalized patients This study assesses mortality, hospital expenditure, and other factors to strengthen single-center and few multi-center studies and provides novel data regarding insurance and cost associated with pediatric AKI With increased knowledge of current epidemiology and risk factors, the scientific community can better understand prevention and outcomes in hospitalized children with AKI.

Posttransplant renal replacement therapy is an alarm signal for survival outcomes in pediatric liver transplantation

BACKGROUND

The impact of renal replacement therapy (RRT) on the long-term survival outcomes of pediatric liver recipients remains controversial.

METHODS

A total of 224 patients aged <18 years, who underwent liver transplantation (LT), were divided into two groups: patients who underwent renal replacement therapy (RRT) (group R, n = 25, 11.2%) and those who did not (group N, n = 199, 88.8%). The posttransplant patient survival outcomes according to RRT use constituted the primary end-point. RRT was initiated preoperatively in 12 patients (48.0%) and postoperatively in 13 [early: <6 months after LT (n = 5, 20.0%) and late: ≥6 months after LT (n = 8, 32.0%)]. The indications for RRT included liver disease involving the kidney (44.0%) and hepatorenal syndrome (56.0%).

RESULTS

The age at the time of LT (71.6 vs. 19.1 months) was higher, the pediatric end-stage liver disease score was lower (9.9 vs. 21.2), and the duration of hospitalization posttransplantation (41.0 vs. 27.0 days) was longer, while the rates of hepatic artery thrombosis (8.0% vs. 3.5%) were higher in group R (p < .05). The number of patients (60.0% vs. 93.0%; p < .001) and graft survival rates (68.0% vs. 93.0%; p < .001) were significantly lower in group R. Multivariate analysis revealed that posttransplant RRT and hepatic artery complications were risk factors for patient survival outcomes. Renal function was recovered in 7 patients (28.0%) in group R, and 9 (36.0%) eventually underwent kidney transplantation.

CONCLUSION

The survival outcomes of children requiring posttransplant RRT were significantly worse than those of children, who did not undergo RRT. Physicians should pay meticulous attention to patients requiring post-LT RRT.

Successful use of intra-operative continuous renal replacement therapy in pediatric liver transplant recipients: Single center case series

BACKGROUND

Acute kidney injury (AKI) is common in pediatric patients undergoing liver transplantation (LT), with an incidence 17%-55%. Fluid, metabolic, and acid-base aberrancies are often pronounced pre-operatively and further worsened by events during LT, making intra-operative continuous renal replacement therapy (CRRT) an option for critically ill LT recipients.

METHODS

All pediatric LT performed at our institution who underwent intra-operative CRRT between January 2017 and August 2021 were included. Patient demographics and clinical data including graft outcomes, intra-operative findings, and timing and indications for CRRT were collected from the electronic medical record.

RESULTS

CRRT was used in nine of the 76 (12%) pediatric LT performed at our center during the study period. Ages at LT ranged from 39 to 17.7 years. Recipients requiring CRRT were more likely to have acute liver failure, status 1A, and higher calculated MELD/PELD scores. CRRT was initiated pre-transplant in three recipients and continued post-transplant in six recipients. Median duration of CRRT was two (range 0-14) days. Indications included hyperammonemia (3/9), acidosis (3/9), fluid overload (6/9), and hyperkalemia (2/9). The CRRT group had a significantly longer post-transplant intensive care unit length of stay in comparison to those that did not require CRRT (median 6, range 3-40 days vs. median 3, range 0-121 days, p = .02], but there were no significant differences in reoperations, hospital length of stay, or recipient or graft survival.

CONCLUSIONS

We demonstrate that CRRT can be safely performed in pediatric LT recipients, including young infants through adolescents.

Comparing the effect of administering gelatin-low dose albumin versus albumin on renal function in liver transplantation: A randomized clinical trial

BACKGROUND

Acute kidney injury (AKI) is a common complication after liver transplantation (LT) that is independently associated with an increased risk of morbidity and mortality. This study aimed to evaluate the effects of administering gelatin-low dose albumin versus albumin on renal function and other early outcomes in LT.

METHODS

This randomized controlled clinical trial was conducted on 140 patients undergoing LT from brain death donors. Patients were randomly assigned to two groups: albumin or modified gelatin with albumin. Blood samples were collected before (T0) and on the first (T1), second (T2), third (T3), fifth (T4), and last day of hospitalization (T5) after LT for the detection of laboratory parameters, including renal and liver function tests.

RESULTS

The incidence of AKT on the basis of RIFLE criteria was 31.42% in the gelatin group (R: 59.10%, I: 36.40%, and F: 4.50%) and 25.71% in the albumin group (R: 66.70%, I: 27.80%, and F: 5.50%) (p = .845). Two patients in the gelatin and one in the albumin groups required renal replacement therapy (RRT). There was no significant difference between groups when the trends of changes in renal and liver function parameters were assessed during the study period (T0-T5). Furthermore, the incidence of complications was similar across groups.

CONCLUSION

This study showed that modified gelatin could be used without inappropriate outcomes on renal function in patients with normal preoperative kidney function tests undergoing LT.

Risk Factors and Consequences of Acute Kidney Injury After Noncardiac Surgery in Children

BACKGROUND

Postoperative acute kidney injury (AKI) is a serious complication that is associated with prolonged hospital stay, high risk of short-term postsurgical mortality, need for dialysis, and possible progression to chronic kidney disease. To date, very little data exist on the risk of postoperative AKI among children undergoing noncardiac surgical procedures. We used data from a large multicenter cohort to determine the factors associated with AKI among children who underwent inpatient noncardiac surgical procedures and its impact on the postoperative course.

METHODS

We utilized the National Surgical Quality Improvement Program Pediatric participant user files to identify a cohort of children who underwent inpatient surgery between 2012 and 2018 (n = 257,439). We randomly divided the study population into a derivation cohort of 193,082 (75%) and a validation cohort of 64,357 (25%), and constructed a multivariable logistic regression model to identify independent risk factors for AKI. We defined AKI as the occurrence of either acute renal failure or progressive renal insufficiency within the 30 days after surgery.

RESULTS

The overall rate of postoperative AKI was 0.10% (95% confidence interval [CI], 0.09-0.11). In a multivariable model, operating times longer than 140 minutes, preexisting hematologic disorder, and preoperative sepsis were the strongest independent predictors of AKI. Other independent risk factors for AKI were American Society of Anesthesiologists (ASA) physical status ≥III, preoperative inotropic support, gastrointestinal disease, ventilator dependency, and corticosteroid use. The 30-day mortality rate was 10.1% in children who developed AKI and 0.19% in their counterparts without AKI (P < .001). Children who developed AKI were more likely to require an extended hospital stay (≥75th percentile of the study cohort) relative to their peers without AKI (77.4% vs 21.0%; P < .001).

CONCLUSIONS

Independent preoperative risk factors for AKI in children undergoing inpatient noncardiac surgery were hematologic disorder, preoperative sepsis, ASA physical status ≥III, inotropic support, gastrointestinal disease, ventilator dependency, and steroid use. Children with AKI were 10 times more likely to die and nearly 3 times more likely to require an extended hospital stay, relative to their peers without AKI.

Kidney disease in children with heart or liver transplant

Over the past few decades, there has been increasing recognition of kidney disease in children with non-kidney solid organ transplantation. The risk of kidney disease in children undergoing heart or liver transplantation is higher than the general population as the underlying disease and its associated management may directly impair kidney function. Both heart and liver failures contribute to hypoperfusion and kidney ischemia before patients reach the point of transplant. The transplant surgery itself can often be complicated by acute kidney injury (AKI), which may be further exacerbated by a complicated postoperative course. In the short- and long-term post-transplant period, these children are at risk of acute illness, exposed to nephrotoxic medications, and susceptible to rare but severe infections and immunologic insults that may contribute to AKI and chronic kidney disease (CKD). In some, CKD can progress to kidney failure with replacement therapy (KFRT). CKD and KFRT are associated with increased morbidity and mortality in this patient population. Therefore, it is critical to monitor for and recognize the risk factors for kidney injury in this population and mitigate these risks. In this paper, the authors provide an overview of kidney disease pertaining to heart and liver transplantation in children with guidance on monitoring, diagnosis, prevention, and management.

Artificial neural network for prediction of acute kidney injury after liver transplantation for cirrhosis and hepatocellular carcinoma

Acute kidney injury (AKI) has serious consequences on the prognosis of patients undergoing liver transplantation (LT) for liver cancer and cirrhosis. Artificial neural network (ANN) has recently been proposed as a useful tool in many fields in the setting of solid organ transplantation and surgical oncology, where patient prognosis depends on a multidimensional and nonlinear relationship between variables pertaining to the surgical procedure, the donor (graft characteristics), and the recipient comorbidities. In the specific case of LT, ANN models have been developed mainly to predict survival in patients with cirrhosis, to assess the best donor-to-recipient match during allocation processes, and to foresee postoperative complications and outcomes. This is a specific opinion review on the role of ANN in the prediction of AKI after LT for liver cancer and cirrhosis, highlighting potential strengths of the method to forecast this serious postoperative complication.

Patient blood management in India - Review of current practices and feasibility of applying appropriate standard of care guidelines. A position paper by an interdisciplinary expert group

In a developing country like India, with limited resources and access to healthcare facilities, dealing with massive hemorrhage is a major challenge. This challenge gets compounded by pre-existing anemia, hemostatic disorders, and logistic issues of timely transfer of such patients from peripheral hospitals to centers with adequate resources and management expertise. Despite the awareness amongst healthcare providers regarding management modalities of bleeding patients, no uniform Patient Blood Management (PBM) or perioperative bleeding management protocols have been implemented in India, yet. In light of this, an interdisciplinary expert group came together, comprising of experts working in transfusion medicine, hematology, obstetrics, anesthesiology and intensive care, to review current practices in management of bleeding in Indian healthcare institutions and evaluating the feasibility of implementing uniform PBM guidelines. The specific intent was to perform a gap analysis between the ideal and the current status in terms of practices and resources. The expert group identified interdisciplinary education in PBM and bleeding management, bleeding history, viscoelastic and platelet function testing, and the implementation of validated, setting-specific bleeding management protocols (algorithms) as important tools in PBM and perioperative bleeding management. Here, trauma, major surgery, postpartum hemorrhage, cardiac and liver surgery are the most common clinical settings associated with massive blood loss. Accordingly, PBM should be implemented as a multidisciplinary and practically applicable concept in India in a timely manner in order to optimize the use the precious resource blood and to increase patients' safety.

Acute Kidney Injury Following Pediatric Liver Transplant

OBJECTIVE

To determine the incidence, severity, and risk factors of postoperative acute kidney injury in pediatric liver transplant patients with and without inborn errors of metabolism.

DESIGN

Retrospective cohort study.

SETTING

Single-center PICU.

PATIENTS

All children less than or equal to 18 years old who received a liver transplant between January 2009 and July 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Following exclusion criteria there were 92 transplant encounters. After excluding patients who received combined kidney-liver transplantation, acute kidney injury occurred in 57% of patients (N = 49), with 25.6% (N = 22) stage 1, 15.1% (N = 13) stage 2, and 16.3% (N = 14) stage 3. In an adjusted analysis, metabolic indication for transplant was not significantly associated with presence of acute kidney injury (p = 0.45). For the subset of patients without inborn errors of metabolism, the odds of having acute kidney injury was 1.50 (95% CI: 1.00-2.26) for each 1-unit increase in preoperative INR after adjusting for the covariates of age, preoperative albumin, CMV status of donor, and preoperative creatinine. In the full cohort, as well as the sample of children without inborn errors of metabolism, presence of acute kidney injury was associated with longer total hospital stay as well as number of ICU days.

CONCLUSIONS

Acute kidney injury in the early postoperative period is common in pediatric liver transplant patients (57%), 31.4% of whom had severe disease. In patients without inborn errors of metabolism, each unit increase in preoperative INR suggests a higher risk of acute kidney injury after adjusting for covariates including preoperative creatinine. This finding suggests an association between the severity of preoperative synthetic liver function and the risk of developing postoperative acute kidney injury which requires further investigation.

Acute and chronic kidney disease after pediatric liver transplantation: An underestimated problem

Acute and chronic kidney injuries represent critical issues after liver transplantation (LTx), but whereas renal dysfunction in adult transplant patients is well documented, little is known about its prevalence in childhood. It is a challenge to accurately evaluate renal function in patients with liver disease, due to several confounding factors. Creatinine-based equations estimating glomerular filtration rate, validated in nephropathic patients without hepatic issues, are frequently inaccurate in end-stage liver disease, underestimating the real impact of renal disease. Moreover, whereas renal issues observed within 1 year from LTx were often related to acute injuries, kidney damage observed after 5-7 years from LTx, is due to chronic, irreversible mechanisms. Most immunosuppression protocols are based on calcineurin inhibitors (CNIs) and corticosteroids, but mycophenolate mofetil or sirolimus could play significant roles, also in children. Early diagnosis and personalized treatment represent the bases of kidney disease management, in order to minimize its close relation with increased mortality. This review analyzed acute and chronic kidney damage after pediatric LTx, also discussing the impact of pre-existent renal disease. The main immunosuppressant strategies have been reviewed, highlighting their impact on kidney function. Different methods assessing renal function were reported, with the potential application of new renal biomarkers.

The Epidemiology and Management of Pediatric AKI in Asia

Because of the lack of early recognition and referral, the incidence of pediatric acute kidney injury (AKI) in Asia still is underestimated. Although each diagnostic criteria has its own merits, the Kidney Disease Improving Global Outcomes classification now is widely accepted. In Asia, the spectrum of pediatric AKI is wide-ranging, from pediatric AKI in highly sophisticated tertiary-care pediatric intensive care units in resource-rich regions due to advanced procedures such as transplantation, cardiac surgery, and other hospital-acquired causes, to primary care preventable causes, such as infectious diseases, snakebite, and so forth in rural parts of the developing world. The development and application of novel biomarkers, concepts such as the Renal Angina Index and advanced renal replacement therapy have revolutionized the era of treating AKI, but the cost and feasibility are the key determinants, especially in rural areas. In view of availability and expenses, peritoneal dialysis should be the first choice in less-developed areas, however, because of various barriers, it still needs more effort. Effective educational steps to both medical carers and families are needed urgently.

Acute Kidney Injury in Hospitalized Pediatric Patients: A Review of Research

INTRODUCTION

Pediatric patients who develop acute kidney injury (AKI) while hospitalized have longer hospital stays, increased morbidity and mortality, and are at an increased risk for developing chronic kidney disease. Early recognition of AKI is becoming a major clinical focus. There is little research focusing on nursing interventions that may affect a pediatric patient's risk for developing AKI. The purpose of this review is to summarize reported predictors of AKI to improve its early recognition and treatment among hospitalized pediatric patients.

METHODS

A review of research was conducted to further identify risk factors of AKI among noncritically ill hospitalized pediatric patients.

RESULTS

The current literature demonstrated inconsistent findings in early recognition of AKI among hospitalized pediatric patients.

DISCUSSION

Interventions for early recognition and treatment of AKI should consider other variables, such as previous history of AKI and fluid status as risk factors, warranting additional research.

Risk factors and associated outcomes of early acute kidney injury in pediatric liver transplant recipients: A retrospective study

BACKGROUND

Acute kidney injury (AKI) may contribute to high mortality rates after liver transplantation. Few studies have investigated AKI in pediatric liver transplantation. This retrospective study was conducted to investigate the risk factors for and associated outcomes of AKI in pediatric liver transplant recipients.

METHODS

Eighty pediatric liver transplant patients were included. The occurrence of AKI was defined by the KDIGO Clinical Practice Guidelines for Acute Kidney Injury. A multivariate regression analysis model was used to investigate risk factors for AKI in the pediatric liver recipients.

RESULTS

The final multivariable regression model showed that biliary atresia (odds ratio [OR] = 0.097, p = 0.03), increased time of the anhepatic phase (OR = 0.871, p = 0.005) and lower postoperative jaundice clearance (OR = 13.936, p = 0.02) were independently associated with the development of AKI in pediatric patients. Additionally, cumulative 3-year patient (p = 0.15) and graft (p = 0.26) survival rates between the non-acute kidney injury (NAKI) and AKI groups were 95.2% vs 86.8% and 90.5% vs 84.2%, respectively.

CONCLUSION

Pediatric liver transplant recipients with a presence of biliary atresia, increased time of anhepatic phase, and a lower postoperative jaundice clearance had an increased risk of AKI. The long-term outcomes of patients who developed AKI appears to be worse compared with those having NAKI.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

Level III.

The use of urinary biomarkers to predict acute kidney injury in children after liver transplant

BACKGROUND

AKI after pediatric liver transplantation is associated with increased morbidity and mortality. The role of urinary biomarkers for the prediction of AKI in pediatric patients after liver transplantation has not been previously reported. The primary objective of this prospective pilot study was to determine the predictive capabilities of urinary KIM-1, NGAL, TIMP-2, and IGFBP7 for diagnosing AKI.

METHODS

Sixteen children undergoing liver transplantation were enrolled in the study over a 19-month time period. The Kidney Disease Improving Outcomes criteria for urine output and serum creatinine were used to define AKI. Predictive ability was evaluated using the area under the curve obtained by ROC analysis.

RESULTS

AKI occurred in 6 (37.5%) of the patients between 2 and 4 days after transplant. There were no differences in any of the biomarkers prior to transplant. When obtained within 6 hours after transplant, the area under the ROC curve for predicting AKI was 0.758 (95% CI: 0.458-1.00) for KIM-1, 0.900 (95% CI: 0.724-1.00) for NGAL, and 0.933 (95% CI: 0.812-1.00) for the product of TIMP-2 and IGFBP7 ([TIMP-2]·[IGFBP7]).

CONCLUSIONS

Our results show that both NGAL and [TIMP-2]·[IGFBP7] provide significant discrimination for AKI risk following liver transplant in children. Larger studies are needed to determine the optimal time point for measuring these biomarkers and to validate our findings.

Acute Kidney Injury and Renal Regional Oxygen Saturation During Pediatric Liver Transplantation

Background

Kidney injury is a complication among children undergoing liver transplantation (pLTx). Cystatin C serum concentration seems to be superior to creatinine-based determination of kidney injury in adults and children. Near-infrared spectroscopy (NIRS) technology provides non-invasive and real-time measurement of renal tissue oxygenation. Here, we compared renal tissue oximetry (rSrO₂) with conventional diagnostic criteria cystatin C and creatinine concentration in children undergoing pLTx.

Material/Methods

rSrO₂ was measured intraoperatively in children undergoing pLTx over the left kidney, and was statistically compared with pre- and postoperative serum creatinine and cystatin C concentrations.

Results

rSrO₂ was affected by hemoglobin concentration, bilirubin concentration, and FiO₂. Statistical analysis demonstrated that rSrO₂ was significantly reduced in children with preoperative pathologic increased cystatin C concentrations compared to children without (63.7±4.3 vs. 53.4±4.9, p<0.05). We did not detect a significant difference in rSrO₂ between children who developed postoperative renal impairment, either determined by increased postoperative cystatin C concentration, creatinine concentration, or the pRIFLE criteria. Intraoperative increase or decrease in rSrO₂ did not predict the development of postoperative kidney injury.

Conclusions

In children with liver failure undergoing pLTx, a preoperative decrease in rSrO₂ indicates compromised renal function. However, intraoperative rSrO₂ is not predictive of postoperative kidney injury.

Effect of sevoflurane and propofol on acute kidney injury in pediatric living donor liver transplantation

Background

Acute kidney injury (AKI) is the primary cause of morbidity and mortality after major abdominal surgery. However, little is known about the effect of anesthetics on the development of AKI after pediatric liver transplantation (LT). This study aimed to compare the effects of propofol and sevoflurane anesthetics on postoperative AKI after LT surgery.

Methods

A total of 120 pediatric patients scheduled for pediatric LT were randomly assigned to receive either continuous infusion of propofol or inhalation of sevoflurane. Serum creatinine (Scr), inflammatory medium and oxidative stress factors and renal biomarkers were measured before surgery (T1), 5 min after anhepatic phase (T2), 10 min after ischemia reperfusion (T3), 2 h after ischemia reperfusion (T4), 24 h after surgery (T5), and 3 d after surgery (T6) to evaluate the effects of anesthetics on the development of postoperative AKI.

Results

The incidence of AKI was lower in patients receiving sevoflurane than those receiving propofol. The mean arterial pressure was changed slightly in sevoflurane group. The inflammatory factors of interleukin-18, tumor necrosis factor-α, and the levels of neutrophil gelatinase-associated lipocalin (NGAL) were lower in sevoflurane group, while no oxidative stress factors [hydrogen peroxide (H₂O₂), malondialdehyde and superoxide dismutase)] and interleukin-10 showed differences between the groups.

Conclusions

Anesthesia with sevoflurane may be associated with a modest decrease in the incidence of AKI when compared with propofol. Further clarification with relevance to such association is warranted.

Incidence and Impact of Acute Kidney Injury after Liver Transplantation: A Meta-Analysis

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.

Early Postoperative Acute Kidney Injury Among Pediatric Liver Transplant Recipients

OBJECTIVES

Acute kidney injury after pediatric liver transplant is associated with increased morbidity and mortality. Here, we evaluated children with acute kidney injury early posttransplant using KDIGO criteria to determine incidence, risk factors, and clinical outcomes.

MATERIALS AND METHODS

In this retrospective cohort study, medical records of all patients < 16 years old who underwent liver transplant from April 2007 to April 2017 were reviewed.

RESULTS

Of 117 study patients, 69 (59%) were male and median age at transplant was 72 months (range, 12-120 mo). Forty children (34.2%) had postoperative acute kidney injury, with most having stage 1 disease (n = 21). Compared with children who had acute kidney injury versus those who did not, preoperative activated partial thromboplastin time (median 35.6 s [interquartile range, 32.4-42.8 s] vs 42.5 s [interquartile range, 35-49 s]; P = .007), intraoperative lactate levels at end of surgery (median 5.3 mmol/L [interquartile range, 3.3-8.6 mmol/L] vs 7.9 mmol/L [interquartile range, 4.3-11.2 mmol/L]; P = .044), and need for open abdomen (3% vs 15%; P= .024) were significantly higher. Logistic regression analysis revealed that preoperative high activated partial thromboplastin time (P= .02), intraoperative lactate levels at end of surgery (P = .02), and need for open abdomen (P = .03) were independent risk factors for acute kidney injury. Children who developed acute kidney injury had significantly longer intensive care unit stay (7.1 ± 8.5 vs 4.4 ± 5.4 days, P= .04) and mortality (12.8% vs 1.8%; P = .01).

CONCLUSIONS

Early postoperative acute kidney injury occurred in 34.2% of pediatric liver transplant recipients, with patients having increased mortality risk. High preoperative activated partial throm-boplastin time, high intraoperative end of surgery lactate levels, and need for open abdomen were shown to be associated with acute kidney injury after pediatric liver transplant.