1
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McGinn R, McCluskey SA, Sayed BA, Goto T, Chan CT, Murphy P. Intraoperative hemodialysis with supra- and infradiaphragmatic catheters for liver transplantation. Can J Anaesth 2024; 71:1165-1171. [PMID: 38877135 DOI: 10.1007/s12630-024-02777-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 06/16/2024] Open
Abstract
PURPOSE The benefits of intraoperative dialysis during orthotopic liver transplantation remain controversial. In patients with anuric renal failure and portopulmonary hypertension, maintaining venous return during caval clamping and unclamping along with minimizing fluid overload is critical to avoiding right ventricular strain and failure. CLINICAL FEATURES We present the case of a 54-yr-old female who underwent orthotopic liver transplantation for alcohol-related liver disease with acute decompensation including severe hepatorenal syndrome (anuric requiring dialysis), probable hepatopulmonary syndrome, moderate pulmonary hypertension (right ventricular systolic pressure, 44 mm Hg), hepatic encephalopathy (grade 2), and esophageal varices. Prior to incision, pulmonary arterial pressures were 48/28 (mean, 35) mm Hg with a central venous pressure of 30 mm Hg, cardiac output of 7.4 L·min-1, and pulmonary vascular resistance of 98 dynes·sec·cm-5. In the context of right ventricular strain and volume overload observed on transthoracic echocardiography, we inserted an additional dialysis catheter into the right femoral vein. We initiated dialysis using the two catheters as a circuit (femoral line to the dialysis machine; blood was reinjected via the subclavian line) acting as a limited venovenous bypass, allowing right ventricular offloading and hemodialysis throughout the case. We removed 4.5 L via hemodialysis during the surgery, while avoiding acidosis, hyperkalemia, and sodium shifts. The patient tolerated reperfusion adequately despite pre-existing right ventricular dilation and dysfunction. CONCLUSION We report on the use two hemodialysis catheters in a patient undergoing orthotopic liver transplantation as a circuit for simultaneous anuric hepatorenal syndrome and moderate pulmonary hypertension with right ventricular dilation and dysfunction. We believe this technique was instrumental in the patient's successful transplant.
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Affiliation(s)
- Ryan McGinn
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Stuart A McCluskey
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Blayne A Sayed
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Toru Goto
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | | | - Patricia Murphy
- Department of Anesthesiology and Pain Management, Toronto General Hospital, University of Toronto, Toronto, ON, Canada.
- Department of Anesthesia and Pain Management, Toronto General Hospital, 200 Elizabeth St, 3EN-464, Toronto, ON, M5G 2C4, Canada.
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2
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Karvellas CJ, Bajaj JS, Kamath PS, Napolitano L, O'Leary JG, Solà E, Subramanian R, Wong F, Asrani SK. AASLD Practice Guidance on Acute-on-chronic liver failure and the management of critically ill patients with cirrhosis. Hepatology 2024; 79:1463-1502. [PMID: 37939273 DOI: 10.1097/hep.0000000000000671] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023]
Affiliation(s)
- Constantine J Karvellas
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
| | - Jasmohan S Bajaj
- Virginia Commonwealth University, Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | - Patrick S Kamath
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | | | - Jacqueline G O'Leary
- Department of Medicine, Dallas Veterans Medical Center, University of Texas Southwestern Medical Center Dallas, Texas, USA
| | - Elsa Solà
- Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford, California, USA
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3
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Henderson D, Gupta A, Menon S, Deep A. Intraoperative kidney replacement therapy in acute liver failure. Pediatr Nephrol 2024:10.1007/s00467-023-06272-7. [PMID: 38526761 DOI: 10.1007/s00467-023-06272-7] [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: 10/10/2023] [Revised: 12/16/2023] [Accepted: 12/18/2023] [Indexed: 03/27/2024]
Abstract
Paediatric acute liver failure (PALF) is often characterised by its rapidity of onset and potential for significant morbidity and even mortality. Patients often develop multiorgan dysfunction/failure, including severe acute kidney injury (AKI). Whilst the management of PALF focuses on complications of hepatic dysfunction, the associated kidney impairment can significantly affect patient outcomes. Severe AKI requiring continuous kidney replacement therapy (CKRT) is a common complication of both PALF and liver transplantation. In both scenarios, the need for CKRT is a poor prognostic indicator. In adults, AKI has been shown to complicate ALF in 25-50% of cases. In PALF, the incidence of AKI is often higher compared to other critically ill paediatric ICU populations, with reports of up to 40% in some observational studies. Furthermore, those presenting with AKI regularly have a more severe grade of PALF at presentation. Observational studies in the paediatric population corroborate this, though data are not as robust-mainly reflecting single-centre cohorts. Perioperative benefits of CKRT include helping to clear water-soluble toxins such as ammonia, balancing electrolytes, preventing fluid overload, and managing raised intracranial pressure. As liver transplantation often takes 6-10 h, it is proposed that these benefits could be extended to the intraoperative period, avoiding any hiatus. Intraoperative CKRT (IoCKRT) has been shown to be practicable, safe and may help sicker recipients tolerate the operation with outcomes analogous with less ill patients not requiring IoCKRT. Here, we provide a comprehensive guide describing the rationale, practicalities, and current evidence base surrounding IoCKRT during transplantation in the paediatric population.
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Affiliation(s)
- Daniel Henderson
- Division of Liver Transplant, Anaesthetic Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Anish Gupta
- Division of Liver Transplant, Anaesthetic Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Shina Menon
- Division of Nephrology, Department of Paediatrics, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Akash Deep
- Paediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK.
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK.
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4
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Abstract
In recent years there has been a significant increase in the incidence of acute-on-chronic liver failure (ACLF). This syndrome is characterized by infections, organ failures, and high short-term mortality. Although progress in the management of these sick patients has been evident, liver transplantation (LT) remains the best treatment modality to date. Several studies have reported LT as a feasible option, despite organ failures. The outcomes following LT are inversely related to the grade of ACLF. This review discusses the current literature on the feasibility, futility, timing, and outcomes of LT in patients with ACLF.
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Affiliation(s)
- Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad-500032, India
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, 2 Dulles, Liver Transplant Office 3400 Spruce Street, Philadelphia, PA 19104, USA.
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5
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Bohorquez H, Koyner JL, Jones CR. Intraoperative Renal Replacement Therapy in Orthotopic Liver Transplantation. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:378-386. [PMID: 37657884 DOI: 10.1053/j.akdh.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 03/09/2023] [Accepted: 03/09/2023] [Indexed: 09/03/2023]
Abstract
Acute kidney injury in patients admitted to the hospital for liver transplantation is common, with up to 80% of pretransplant patients having some form of acute kidney injury. Many of these patients start on dialysis prior to their transplant and have it continued intraoperatively during their surgery. This review discusses the limited existing literature and expert opinion around the indications and outcomes around intraoperative dialysis (intraoperative renal replacement therapy) during liver transplantation. More specifically, we discuss which patients may benefit from intraoperative renal replacement therapy and the impact of hyponatremia and hyperammonemia on the dialysis prescription. Additionally, we discuss the complex interplay between anesthesia and intraoperative renal replacement therapy and how the need for clearance and ultrafiltration changes throughout the different phases of the transplant (preanhepatic, anhepatic, and postanhepatic). Lastly, this review will cover the limited data around patient outcomes following intraoperative renal replacement therapy during liver transplantation as well as the best evidence for when to stop dialysis.
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Affiliation(s)
- Humberto Bohorquez
- Surgical director, Pancreas Transplantation, Section of Abdominal Organ Transplantation, Department of Surgery, Ochsner Health, New Orleans, LA
| | - Jay L Koyner
- Medical Director Acute Dialysis Services, Section of Nephrology, Department of Medicine, University of Chicago, Chicago IL.
| | - Courtney R Jones
- Associate Professor of Anesthesiology and Critical Care, Director of Transplant Anesthesia, Division of Transplantation, Department of Anesthesia, University of Cincinnati College of Medicine, Cincinnati, OH
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6
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Karvellas CJ, Gustot T, Fernandez J. Management of the acute on chronic liver failure in the intensive care unit. Liver Int 2023. [PMID: 37365997 DOI: 10.1111/liv.15659] [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: 04/30/2023] [Revised: 06/01/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023]
Abstract
Acute on chronic liver failure (ACLF) reflects the development of organ failure(s) in a patient with cirrhosis and is associated with high short-term mortality. Given that ACLF has many different 'phenotypes', medical management needs to take into account the relationship between precipitating insult, organ systems involved and underlying physiology of chronic liver disease/cirrhosis. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (e.g. infection, severe alcoholic hepatitis and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo liver transplantation or recovery. Management of these patients is complex since they are prone to develop new organ failures and infectious or bleeding complications. ICU therapy parallels that applied in the general ICU population in some complications but differs in others. Given that liver transplantation in ACLF is an emerging and evolving field, multidisciplinary teams with expertise in critical care and transplant medicine best accomplish management of the critically ill ACLF patient. The focus of this review is to identify the common complications of ACLF and to describe the proper management in critically ill patients awaiting liver transplantation in our centres, including organ support, prognostic assessment and how to assess when recovery is unlikely.
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Affiliation(s)
- Constantine J Karvellas
- Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
| | - Thierry Gustot
- Department of Gastroenterology, Hepato-Pancreatology and Digestive Oncology, H.U.B., CUB Hôpital Erasme, Brussels, Belgium
| | - Javier Fernandez
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Barcelona, Spain
- EF CLIF, EASL-CLIF Consortium, Barcelona, Spain
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7
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Bagshaw SM, Neyra JA, Tolwani AJ, Wald R. Debate: Intermittent Hemodialysis versus Continuous Kidney Replacement Therapy in the Critically Ill Patient: The Argument for CKRT. Clin J Am Soc Nephrol 2023; 18:647-660. [PMID: 39074305 DOI: 10.2215/cjn.0000000000000056] [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: 07/31/2024]
Abstract
Continuous kidney replacement therapy (CKRT) is well entrenched as one of the dominant KRT modalities in modern critical care practice. Since its introduction four decades ago, there have been considerable innovations in CKRT machines that have improved precision, safety, and simplicity. CKRT is the preferred KRT modality for critically ill patients with hemodynamic instability. Early physical therapy and rehabilitation can be feasibly and safely provided to patients connected to CKRT, thus obviating concerns about immobility. Although randomized clinical trials have not shown a mortality difference when comparing CKRT and intermittent hemodialysis, CKRT allows precision delivery of solute and fluid removal that can be readily adjusted in the face of dynamic circumstances. Accumulated evidence from observational studies, although susceptible to bias, has shown that CKRT, when compared with intermittent hemodialysis, is associated with better short- and long-term kidney recovery and KRT independence. Critical care medicine encompasses a wide range of sick patients, and no single KRT modality is likely to ideally suit every patient in every context and for every condition. The provision of KRT represents a spectrum of modalities to which patients can flexibly transition in response to their evolving condition. As a vital tool for organ support in the intensive care unit, CKRT enables the personalization of KRT to meet the clinical demands of patients during the most severe phases of their illness.
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Affiliation(s)
- Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, Alberta, Canada
| | - Javier A Neyra
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ashita J Tolwani
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ron Wald
- Division of Nephrology, St. Michael's Hospital and the University of Toronto and the Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
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8
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Monard C, Tresson P, Lamblin A, Benatir F, Taverna XJ, Rimmelé T. Intraoperative extracorporeal blood purification therapy during major septic vascular surgery. Crit Care 2022; 26:404. [PMID: 36575522 PMCID: PMC9795654 DOI: 10.1186/s13054-022-04284-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 12/16/2022] [Indexed: 12/28/2022] Open
Affiliation(s)
- Céline Monard
- grid.413852.90000 0001 2163 3825Service d’Anesthésie-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France ,grid.7849.20000 0001 2150 7757EA 7426, PI3 (Pathophysiology of Injury-Induced Immunosuppression), Université Claude Bernard Lyon 1-Biomérieux-Hospices Civils de Lyon, Lyon, France
| | - Philippe Tresson
- grid.413852.90000 0001 2163 3825Service de Chirurgie Vasculaire et Endovasculaire, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France ,grid.413852.90000 0001 2163 3825Centre de Référence des Infections Vasculaire Complexes (CRIVasc Network), Hospices Civils de Lyon, Lyon, France
| | - Antoine Lamblin
- grid.413852.90000 0001 2163 3825Service d’Anesthésie-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Farida Benatir
- grid.413852.90000 0001 2163 3825Service d’Anesthésie-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Xavier-Jean Taverna
- grid.413852.90000 0001 2163 3825Service d’Anesthésie-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Thomas Rimmelé
- grid.413852.90000 0001 2163 3825Service d’Anesthésie-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France ,grid.7849.20000 0001 2150 7757EA 7426, PI3 (Pathophysiology of Injury-Induced Immunosuppression), Université Claude Bernard Lyon 1-Biomérieux-Hospices Civils de Lyon, Lyon, France
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9
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Minjares RO, Martin P, Carrion AF. Chronic Kidney Disease After Liver Transplantation. Clin Liver Dis 2022; 26:323-340. [PMID: 35487614 DOI: 10.1016/j.cld.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Improved survival after liver transplantation has led to an aging cohort of recipients at risk of renal dysfunction. The etiology of renal dysfunction is typically multifactorial; calcineurin inhibitors nephrotoxicity, pretransplant renal dysfunction, and perioperative acute kidney injury are important risk factors. Metabolic complications such as hypertension, diabetes mellitus, and metabolic-associated fatty liver disease also contribute to the development of renal disease. Most LT recipients will eventually develop some degree of renal dysfunction. Criteria to select candidates for simultaneous liver and kidney transplantation have been established. Both delayed introduction of CNIs and renal-sparing immunosuppressive regimens may reduce progression of renal dysfunction.
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Affiliation(s)
- Ramon O Minjares
- Department of Internal Medicine, University of Miami Miller School of Medicine, 1611 NW 12th Avenue, Suite 600-D, Miami, FL 33136, USA.
| | - Paul Martin
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, 1611 NW 12th Avenue, Suite 600-D, Miami, FL 33136, USA
| | - Andres F Carrion
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, 1611 NW 12th Avenue, Suite 600-D, Miami, FL 33136, USA
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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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Cronin B, O'Brien EO. Intraoperative Renal Replacement Therapy: Practical Information for Anesthesiologists. J Cardiothorac Vasc Anesth 2021; 36:2656-2668. [PMID: 34750060 DOI: 10.1053/j.jvca.2021.10.002] [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: 06/27/2021] [Revised: 09/02/2021] [Accepted: 10/01/2021] [Indexed: 11/11/2022]
Abstract
Previous publications regarding perioperative renal replacement therapy (RRT) have focused on the general care of the RRT-dependent patient and provided a broad overview of the various RRT modalities. The goal of this review article is to provide anesthesiologists with specific practical information regarding the possible intraoperative advantages and limitations of each modality, mandatory equipment to institute intraoperative therapy, and background knowledge necessary to communicate effectively with nephrologists and/or support staff regarding the intraoperative RRT goals.
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Affiliation(s)
- Brett Cronin
- Department of Anesthesiology, University of California, San Diego, UCSD Medical Center, San Diego, CA.
| | - E Orestes O'Brien
- Department of Anesthesiology, University of California, San Diego, UCSD Medical Center, San Diego, CA.
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12
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Abstract
Liver transplantation (LT) has revolutionized outcomes for cirrhotic patients. Current liver allocation policies dictate patients with highest short-term mortality receive the highest priority, thus, several patients become increasingly ill on the waitlist. Given cirrhosis is a progressive disease, it can be complicated by the occurrence of acute-on-chronic liver failure (ACLF), a syndrome defined by an acute deterioration of liver function associated with extrahepatic organ failures requiring intensive care support and a high short-term mortality. Successfully bridging to transplant includes accurate prognostication and prioritization of ACLF patients awaiting LT, optimizing intensive care support pre-LT, and tailoring immunosuppressive and anti-infective therapies post-LT. Furthermore, predicting futility (too sick to undergo LT) in ACLF is challenging. In this review, we summarize the role of LT in ACLF specifically highlighting (a) current prognostic scores in ACLF, (b) critical care management of the ACLF patient awaiting LT, (c) donor issues to consider in transplant in ACLF, and (d) exploring of recent post-LT outcomes in ACLF and potential opportunities to improve outcomes including current care gaps and unmet research needs.
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13
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Expert consensus on perioperative management of liver transplantation in adults with acute-on-chronic liver failure. LIVER RESEARCH 2021. [DOI: 10.1016/j.livres.2021.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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14
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Abstract
Development of acute kidney injury in patients with chronic liver disease is common and portends a poor prognosis. Diagnosis remains challenging, as traditional markers, such as serum creatinine, are not reliable. Recent development of novel biomarkers may assist with this. Pathophysiology of this condition is multifactorial, relating to physiologic changes associated with portal hypertension, kidney factors, and systemic inflammatory response. Mainstay of treatment remains use of vasoconstrictors along with albumin. Recent guidelines streamline the selection of patients that will require simultaneous liver and kidney transplantation. Posttransplant kidney injury is common relating to multiple factors.
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Affiliation(s)
- Saro Khemichian
- Division of Gastroenterology/Liver, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Los Angeles, CA 90033, USA
| | - Claire Francoz
- Hepatology and Liver Intensive Care, Hospital Beaujon, 100 Boulevard Du General Leclerc, Clichy 92110, France
| | - Francois Durand
- Hepatology and Liver Intensive Care, Hospital Beaujon, University of Paris, 100 Boulevard Du General Leclerc, Clichy 92110, France
| | - Constantine J Karvellas
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, 1-40 Zeidler Ledcor Building, Edmonton, Alberta T6G 2X8, Canada
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, 1520 San Pablo Street, Suite 4300, Los Angeles, CA 90033, USA.
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15
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Zaccherini G, Weiss E, Moreau R. Acute-on-chronic liver failure: Definitions, pathophysiology and principles of treatment. JHEP Rep 2020; 3:100176. [PMID: 33205036 PMCID: PMC7652714 DOI: 10.1016/j.jhepr.2020.100176] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/29/2020] [Accepted: 08/18/2020] [Indexed: 12/11/2022] Open
Abstract
The term acute-on-chronic liver failure (ACLF) defines an abrupt and life-threatening worsening of clinical conditions in patients with cirrhosis or chronic liver disease. In recent years, different definitions and diagnostic criteria for the syndrome have been proposed by the major international scientific societies. The main controversies relate to the type of acute insult (specifically hepatic or also extrahepatic), the stage of underlying liver disease (cirrhosis or chronic hepatitis) and the concomitant extrahepatic organ failure(s) that should be considered in the definition of ACLF. Therefore, different severity criteria and prognostic scores have been proposed and validated. Current evidence shows that the pathophysiology of ACLF is closely associated with an intense systemic inflammation sustained by circulating pathogen-associated molecular patterns and damage-associated molecular patterns. The development of organ failures may be a result of a combination of tissue hypoperfusion, direct immune-mediated damage and mitochondrial dysfunction. Management of ACLF is currently based on the supportive treatment of organ failures, mainly in an intensive care setting. For selected patients, liver transplantation is an effective treatment that offers a good long-term prognosis. Future studies on potential mechanistic treatments that improve patient survival are eagerly awaited.
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Key Words
- AARC, APASL ACLF Research Consortium
- ACLF, acute-on-chronic liver failure
- AKI, acute kidney injury
- APASL, Asian Pacific Association for the Study of the Liver
- Acute decompensation
- Bacterial infections
- Bacterial translocation
- CLIF, Chronic Liver Failure-Consortium
- COSSH, Chinese Group on the Study of Severe Hepatitis
- DAMPs, damage-associated molecular patterns
- EASL, European Association for the Study of the Liver - Chronic Liver
- ER, endoplasmic reticulum
- HMGB1, high mobility group box 1
- ICU, intensive care unit
- INR, international normalised ratio
- Immunopathology
- Inflammatory response
- MELD, model for end-stage liver disease
- Metabolism
- Multiorgan failure
- NACSELD, North American Consortium for the Study of End-stage Liver Disease
- NO, nitric oxide
- OF, organ failure
- PAMPs, pathogen-associated molecular patterns
- PRR, pattern-recognition receptors
- Sterile inflammation
- TLR, Toll-like receptor
- UNOS, United Network for Organ Sharing
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Affiliation(s)
- Giacomo Zaccherini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain
| | - Emmanuel Weiss
- European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain.,Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Paris, France.,Inserm et Université de Paris, Centre de Recherche sur l'Inflammation (CRI), Paris, France
| | - Richard Moreau
- European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain.,Inserm et Université de Paris, Centre de Recherche sur l'Inflammation (CRI), Paris, France.,Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France
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16
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Huang HB, Xu Y, Zhou H, Zhu Y, Qin JP. Intraoperative Continuous Renal Replacement Therapy During Liver Transplantation: A Meta-Analysis. Liver Transpl 2020; 26:1010-1018. [PMID: 32275802 DOI: 10.1002/lt.25773] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/28/2020] [Accepted: 03/29/2020] [Indexed: 01/01/2023]
Abstract
Continuous renal replacement therapy (CRRT) is frequently used to treat recipients with renal failure before or after liver transplantation (LT), though evidence supporting its use during surgery remains unclear. Therefore, we conducted a quantitative meta-analysis to evaluate the effect of intraoperative continuous renal replacement therapy (IORRT) in recipients with pretransplant severe renal dysfunction. We searched PubMed, Embase, and the Cochrane database for trials focusing on LT recipients supported with or without IORRT. Outcomes assessed were mortality, preoperative characteristics, intraoperative data, and predefined postoperative outcomes. Seven trials with 1051 recipients were eligible. Preoperatively, the IORRT group recipients had higher Model for End-Stage Liver Disease scores (weighted mean difference [WMD], 6.19; 95% confidence interval [CI], 2.51-9.87), Charlson scores (WMD, 0.45; 95% CI, 0.09-0.80), acute liver failure (odds ratio [OR], 1.82; 95% CI, 1.27-2.61), serum creatinine (WMD, 71.33 μmol/L; 95% CI, 1.98-140.69 μmol/L), total bilirubin level (WMD, 5.05 μmol/L; 95% CI, 1.75-8.35 μmol/L), intensive care unit admission (OR, 3.53; 95% CI, 1.23-10.13), vasoactive therapy (OR, 3.80; 95% CI, 2.64-5.46), ventilator care (OR, 2.52; 95% CI, 1.18-5.35), and renal replacement therapy (RRT) (OR, 29.37; 95% CI, 7.66-112.54) compared with control patients. IORRT patients also required more intraoperative blood product transfusion and had more post-LT RRT (OR, 25.67; 95% CI, 4.92-133.85). However, there were no significant differences in short-term mortality (OR, 2.12; 95% CI, 0.82-5.44) between the groups. In addition, worse longterm mortality was seen in the IORRT group. In conclusion, IORRT is feasible and safe and may help sicker recipients tolerate the LT procedure to achieve short-term clinical outcomes comparable with less ill patients without IORRT. More high-quality evidence is needed to verify our conclusion in the future.
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Affiliation(s)
- Hui-Bin Huang
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yuan Xu
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Hua Zhou
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yan Zhu
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jun-Ping Qin
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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17
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Kościelska M, Matuszkiewicz-Rowińska J, Zieniewicz K, Krawczyk M, Giercuszkiewicz D, Sierdziński J, Żebrowski P, Małyszko J. Intraoperative Dialysis During Liver Transplantation. Transplant Proc 2020; 52:2454-2458. [PMID: 32448654 DOI: 10.1016/j.transproceed.2020.01.129] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/26/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Orthotopic liver transplantation (LT) is a technically complex surgical procedure associated with a major risk of hemodynamic instability and metabolic derangement, especially in patients with coexisting renal dysfunction. Some centers have applied intraoperative renal replacement therapy (ioRRT) to support patients with preoperative renal failure and prevent critical complications. Although there is a strong theoretical rationale for this treatment, there remains a paucity of definite data demonstrating its benefits. METHODS This was a retrospective observational study of all adult patients undergoing intraoperative dialysis in our center from January 2010 till December 2016. RESULTS The study group consisted of 88 patients with a mean MELD score of 31.4. Six patients underwent simultaneous liver and kidney transplantation. Forty-four (50%) recipients were admitted to the intensive care unit before transplantation, and 19 (21.6%) needed mechanical ventilation. Twenty-eight (31.8%) of the procedures were retransplantations, and 40 (45.4%) patients had been undergoing renal replacement therapy before LT. The mean preoperative serum creatinine was 2.82 ± 1.13 mg/dL. The majority of patients (54.5%) was operated on using the veno-venous bypass technique. The mean arterial blood pH and potassium levels after reperfusion were 7.2 ± 0.12 and 4.04 ± 0.95 mmol/L, respectively. Postreperfusion syndrome (PRS) occurred in 11 (13.9%) patients in whom dialysis started at least 15 minutes before reperfusion. Dialysis circuit clotting occurred in 9.1% of cases. There were no other adverse events of ioRRT. CONCLUSION Our data suggests that intraoperative dialysis in severely ill patients with a high MELD score is safe and effective. Lower than expected PRS occurrence needs to be confirmed in a study with a control group.
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Affiliation(s)
- Małgorzata Kościelska
- Department of Nephrology, Dialysis, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland.
| | | | - Krzysztof Zieniewicz
- Department of General, Liver, and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Marek Krawczyk
- Department of General, Liver, and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Dorota Giercuszkiewicz
- Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Janusz Sierdziński
- Department of Medical Informatics and Telemedicine, Medical University of Warsaw, Warsaw, Poland
| | - Paweł Żebrowski
- Department of Nephrology, Dialysis, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
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18
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MacDonald AJ, Karvellas CJ. Acute kidney injury: A critical care perspective for orthotopic liver transplantation. Best Pract Res Clin Anaesthesiol 2019; 34:69-78. [PMID: 32334788 DOI: 10.1016/j.bpa.2019.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 12/11/2019] [Indexed: 02/06/2023]
Abstract
Acute kidney injury (AKI) is associated with high perioperative mortality in patients undergoing liver transplantation (LT). In the era of Model of End-stage Liver Disease score-based allocation, more patients with impaired renal function are receiving LT. The majority of preoperative AKI is secondary to azotemia, including hepatorenal syndrome - a progressive form of renal impairment unique to liver failure. Prompt recognition and initiation of cause-directed therapies are central to improving post-transplant survival. Given that, the healthcare providers must develop an expertise in liver failure-related renal complications, specifically their management and perioperative implications. Notably, AKI may complicate intraoperative course, exacerbating hemodynamic instability, metabolic acidosis, and electrolyte and coagulation abnormalities. Adjunctive intraoperative continuous renal replacement therapy has been employed; however, prospective studies remain necessary to validate potential benefits.
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Affiliation(s)
| | - Constantine J Karvellas
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada; Department of Critical Care Medicine, University of Alberta, Edmonton, Canada.
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19
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Clark EG, Hiremath S. INCEPTION: is a larger trial to evaluate intraoperative renal replacement therapy in liver transplant patients more than just a dream? Can J Anaesth 2019; 66:1137-1146. [PMID: 31342273 DOI: 10.1007/s12630-019-01455-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 07/04/2019] [Indexed: 11/25/2022] Open
Affiliation(s)
- Edward G Clark
- The Ottawa Hospital and University of Ottawa, Riverside Campus, 1967 Riverside Drive, Ottawa, ON, K1H 7W9, Canada. .,Kidney Research Centre, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Swapnil Hiremath
- The Ottawa Hospital and University of Ottawa, Riverside Campus, 1967 Riverside Drive, Ottawa, ON, K1H 7W9, Canada.,Kidney Research Centre, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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