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Kim J, Kwon JH, Kim GS. Changes in Blood Potassium after Reperfusion during Living-Donor Liver Transplantation: An Exploratory Study. Diagnostics (Basel) 2021; 11:diagnostics11122248. [PMID: 34943485 PMCID: PMC8700509 DOI: 10.3390/diagnostics11122248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/26/2021] [Accepted: 11/27/2021] [Indexed: 11/17/2022] Open
Abstract
The incidence of hyperkalemia (>5.5 mEq/L) or high blood potassium (5–5.5 mEq/L) during living-donor liver transplantation (LDLT) is reported to be more than 10%. It occurs more frequently in the early post-reperfusion period and is a major cause of post-reperfusion arrhythmia and cardiac arrest. Unlike deceased-donor liver transplantation, the pattern of blood potassium changes immediately after reperfusion has not been described in LDLT. From January 2021 to March 2021, fifteen consecutive patients were enrolled. Baseline blood potassium was measured from blood samples obtained 10-min (T-10) and immediately before (T0) reperfusion. During the first 5 min after reperfusion, blood potassium measurements were conducted every one minute (T1–T5). The blood potassium levels at T-10 and T0 were 3.8 ± 0.4 and 3.9 ± 0.4 mEq/L, respectively. After reperfusion, mean increases (95% CI) in blood potassium from T-10 and T0 were 0.5 (0.4–0.6) and 0.4 (0.3–0.5) mEq/L, respectively. Blood potassium peaked at T1, returned to baseline at T3, and fell below the baseline at T5. Peak blood potassium after reperfusion showed strong correlations with blood potassium measured at T-10 (p < 0.001) and T0 (p < 0.0001). These findings can support the establishment of future research plans and perioperative management of blood potassium in LDLT.
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Affiliation(s)
| | | | - Gaab Soo Kim
- Correspondence: ; Tel.: +82-2-34100360; Fax: +82-2-34100361
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Lin J, Zhang Y, Chen M, Dai J, Song A, Chen J, Tao X. The Association Between Variability in Electrolytes and the In-Hospital Mortality in Critically Ill Children in Pediatric Intensive Care Units. Front Pediatr 2021; 9:692894. [PMID: 34414145 PMCID: PMC8368981 DOI: 10.3389/fped.2021.692894] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 07/06/2021] [Indexed: 02/05/2023] Open
Abstract
Objective: This study aimed to explore the association between the variability in electrolytes and the in-hospital mortality in critically ill children admitted into intensive care units (ICUs). Design: This is a retrospective case-control study. Setting and Participants: Total of 11,245 children have been admitted to ICUs of Children's Hospital of Zhejiang University from 2010 to 2018. Methods: The coefficient of variation (CV), standard deviation (SD), and variability independent of the mean (VIM) were calculated as variability indices. High variability was defined as having values in the highest quartile for each parameter. Age, sex, diagnoses of disease, and surgical treatment were adjusted in the multivariable-adjusted logistic regression model. Results: A total of 11,245 children were included, and 660 patients died in the hospital. The median (P25, P75) potassium, sodium, and chloride of all patients were 3.8 (3.58, 4.09), 136.83 (135.11, 138.60), and 108.67 (105.71, 111.17), respectively. U-shaped relationships between the mean, lowest, and highest levels of potassium, sodium, and chloride and the in-hospital mortality were observed. The lowest mortality was noted when serum potassium, sodium, and chloride were between ~3.5 and 5.0, 135 and 145, and 105 and 115 mmol/l, respectively. The areas under the curve (AUCs) of three indices of variability in electrolytes were larger than those of the mean and lowest levels of electrolytes in predicting the in-hospital mortality. In the multivariable-adjusted model, the odds ratios and 95% confidence interval (CI) of the in-hospital mortality were 3.14 (2.44-4.04) for one parameter, 5.85 (4.54-7.53) for two parameters, and 10.32 (7.81-13.64) for three parameters compared with subjects having no parameters of high variability measured as the CV. The results were consistent when the variability was determined using the SD and VIM (all P for trend <0.001). Consistent results were noted in various subgroup analyses. Conclusions: This study showed that individuals with higher variability of each parameter were related with higher risk of in-hospital mortality. There was a linear association between the number of high variability parameters and the in-hospital mortality. The variability of electrolytes might be a good predictor for in-hospital mortality of children in ICUs.
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Affiliation(s)
- Jilei Lin
- Department of Respiratory Medicine, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yin Zhang
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Meng Chen
- Department of Pediatrics, Meitan People's Hospital, Zunyi, China
| | - Jihong Dai
- Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, Department of Respiratory Disease, National Clinical Research Center for Child Health and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Anchao Song
- School of Public Health and Management, Chongqing Medical University, Chongqing, China
| | - Jianchuan Chen
- Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, Department of Respiratory Disease, National Clinical Research Center for Child Health and Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xingping Tao
- Department of Pediatrics, Kaiyuan People's Hospital, Kaiyuan, China
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de Vries BCS, Berger SP, Bakker SJL, de Borst MH, de Jong MFC. Pre-Transplant Plasma Potassium as a Potential Risk Factor for the Need of Early Hyperkalaemia Treatment after Kidney Transplantation: A Cohort Study. Nephron Clin Pract 2020; 145:63-70. [PMID: 33212442 DOI: 10.1159/000511404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 09/05/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Plasma potassium (K+) abnormalities are common among patients with chronic kidney disease and are associated with higher rates of death, major adverse cardiac events, and hospitalization in this population. Currently, no guidelines exist on how to handle pre-transplant plasma K+ in renal transplant recipients (RTR). OBJECTIVE The aim of this study is to examine the relation between pre-transplant plasma K+ and interventions to resolve hyperkalaemia within 48 h after kidney transplantation. METHODS In a single-centre cohort study, we addressed the association between the last available plasma K+ level before transplantation and the post-transplant need for dialysis or use of K+-lowering medication to resolve hyperkalaemia within 48 h after renal transplantation using multivariate logistic regression analysis. RESULTS 151 RTR were included, of whom 51 (33.8%) patients received one or more K+ interventions within 48 h after transplantation. Multivariate regression analysis revealed that a higher pre-transplant plasma K+ was associated with an increased risk of post-transplant intervention (odds ratio 2.2 [95% CI: 1.1-4.4]), independent of donor type (deceased or living) and use of K+-lowering medication within 24 h prior to transplantation). CONCLUSIONS This study indicates that a higher pre-transplant plasma K+ is associated with a higher risk of interventions necessary to resolve hyperkalaemia within 48 h after renal transplantation. Further research is recommended to determine a cutoff level for pre-transplant plasma K+ that can be used in practice.
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Affiliation(s)
- Bram C S de Vries
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Stefan P Berger
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Stephan J L Bakker
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin H de Borst
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Margriet F C de Jong
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands,
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A Systematic Review for Variables to Be Collected in a Transplant Database for Improving Risk Prediction. Transplantation 2020; 103:2591-2601. [PMID: 30768569 DOI: 10.1097/tp.0000000000002652] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND This systematic review was commissioned to identify new variables associated with transplant outcomes that are not currently collected by the Organ Procurement and Transplantation Network (OPTN). METHODS We identified 81 unique studies including 1 193 410 patients with median follow-up of 36 months posttransplant, reporting 108 unique risk factors. RESULTS Most risk factors (104) were recipient related; few (4) were donor related. Most risk factors were judged to be practical and feasible to routinely collect. Relative association measures were small to moderate for most risk factors (ranging between 1.0 and 2.0). The strongest relative association measure for a heart transplant outcome with a risk factor was 8.6 (recipient with the previous Fontan operation), for a kidney transplant 2.8 (sickle cell nephropathy as primary cause of end-stage renal disease), for a liver transplant 14.3 (recipient serum ferritin >500 µg/L), and for a lung transplant 6.3 (Burkholderia cepacia complex infection for 1 y or less). OPTN may consider some of these 108 variables for future collection to enhance transplant research and clinical care. CONCLUSIONS Evidence-based approaches can be used to determine variables collected in databases and registries. Several candidate variables have been identified for OPTN.
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Weinberg L, Lee DK, Koshy AN, Leong KW, Tosif S, Shaylor R, Pillai P, Miles LF, Drucker A, Pearce B. Potassium levels after liver reperfusion in adult patients undergoing cadaveric liver transplantation: A retrospective cohort study. Ann Med Surg (Lond) 2020; 55:111-118. [PMID: 32477508 PMCID: PMC7251297 DOI: 10.1016/j.amsu.2020.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/29/2020] [Accepted: 05/04/2020] [Indexed: 01/20/2023] Open
Abstract
Background Hyperkalemia is a common cause of arrhythmias in patients undergoing liver transplantation. We examined the pattern of change of potassium levels during and immediately after reperfusion of the donor liver. Materials and methods Potassium levels of 30 consecutive adult patients undergoing cadaveric liver transplantation were assessed before and after liver reperfusion. Changes in potassium levels over 13 predefined timepoints were analyzed. Primary aim: to describe the pattern of change of potassium levels during the reperfusion period. Correlation between changes in potassium levels during reperfusion and a-priori variables were investigated. Results Baseline median (IQR) potassium levels were 4.1 (3.8:4.5) mmol/L. Thirteen patients (43%) developed hyperkalemia, 10 (33%) of whom developed severe hyperkalemia. Potassium levels peaked at 80 s post reperfusion, plateaued until 2 min, before returning toward baseline values at 5 min. There was a strong association between pre-reperfusion/baseline potassium levels and peak potassium values during reperfusion (95%CI: 0.26 to 0.77, p < 0.001). A baseline potassium level of 4.45 mmol/L was a good predictor of reperfusion hyperkalemia with a sensitivity of 69.2% and specificity of 94.1% (AUC = 0.894, 95%CI: 0.779 to 1.000, p < 0.001). Conclusion Hyperkalemia during cadaveric liver transplantation is common affecting almost 1 in 2 patients during reperfusion. During reperfusion potassium levels peaked within 2 min and over a third of patients developed severe hyperkalemia. Higher peak potassium levels correlated strongly with higher pre-reperfusion potassium values. These findings guide clinicians with timing of sampling of blood to check for hyperkalemia and identify modifiable factors associated with the development of hyperkalemia. Hyperkalemia during the reperfusion phase of cadaveric liver transplantation is common. Potassium levels peaked at 80 s post reperfusion, plateaued for 2 min, and returned to baseline at 5 min. There was a strong association between pre-reperfusion potassium levels and peak potassium values during reperfusion. Timing of blood sampling to check for hyperkalemia is paramount. A baseline potassium level of greater than 4.45 mmol/L was a good predictor of reperfusion hyperkalemia.
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Affiliation(s)
- Laurence Weinberg
- Austin Health, Victoria, Australia.,Department of Surgery, Austin Health, University of Melbourne, Victoria, Australia
| | - Dong-Kyu Lee
- Department of Anesthesiology and Pain Medicine, Korea University, Guro Hospital, Guro-Gu, Seoul, Republic of Korea
| | | | - Kai Wen Leong
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - Shervin Tosif
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - Ruth Shaylor
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - Param Pillai
- Department of Anesthesia, Austin Health, Victoria, Australia
| | | | | | - Brett Pearce
- Department of Anesthesia, Austin Health, Victoria, Australia
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Manning MW, Kumar PA, Maheshwari K, Arora H. Post-Reperfusion Syndrome in Liver Transplantation—An Overview. J Cardiothorac Vasc Anesth 2020; 34:501-511. [DOI: 10.1053/j.jvca.2019.02.050] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 02/15/2019] [Accepted: 02/28/2019] [Indexed: 01/13/2023]
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Yoon U, Gerney G, Hsu G, Elia E, Kang Y. Exchange Autotransfusion for Rapid Correction of Hyperkalemia During Liver Transplantation: A Case Report. A A Pract 2019; 12:15-18. [PMID: 29985842 DOI: 10.1213/xaa.0000000000000831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 46-year-old woman with alcoholic cirrhosis and hepatorenal syndrome requiring hemodialysis presented with hyperkalemia (5.5 mEq/L) immediately before liver transplantation. For correction of hyperkalemia, an exchange transfusion began by removing her blood into an autotransfusion system to wash out noncellular components while maintaining normovolemia. Additionally, she received washed homologous red blood cells, insulin, and glucose to minimize or reduce the degree of hyperkalemia. Serum potassium level decreased to 4.0 mEq/L within 3 hours and was 5.0 mEq/L 30 seconds after reperfusion of the grafted liver. Postreperfusion syndrome was not observed. In summary, exchange transfusion was used successfully for rapid correction of hyperkalemia, showing the value of its application in liver transplantation.
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Affiliation(s)
- Uzung Yoon
- From the Department of Anesthesiology, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
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Joseph TT, DiMeglio M, Huffenberger A, Laudanski K. Behavioural patterns of electrolyte repletion in intensive care units: lessons from a large electronic dataset. Sci Rep 2018; 8:11915. [PMID: 30093668 PMCID: PMC6085366 DOI: 10.1038/s41598-018-30444-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 07/26/2018] [Indexed: 11/29/2022] Open
Abstract
Repletion of electrolytes often depends on provider-specific behavior and hospital policy. We examined the pattern of electrolyte repletion across several intensive care units (ICU) in a large healthcare system from 2010–2015. This included 109 723 potassium repletions, 51 833 magnesium repletions, 2 306 calcium repletions, 8 770 phosphate repletions, and 3 128 249 visit-days over 332 018 visits. Potassium, magnesium, and calcium were usually repleted within the institutional reference range. In contrast, the bulk of phosphate repletion was done with pre-repletion serum level below the reference range. The impact of repletion on post-repletion levels was significant but uniformly small. The pre-repletion serum level had a significant inverse correlation with the post-repletion level of each electrolyte. Potassium, magnesium and phosphate follow-up labs were scheduled in 9–10 hours after their repletion. In contrast, calcium was rechecked in less than 20 minutes. Routine repletion of potassium, magnesium and calcium had no effect on the incidence of tachyarrhythmias. We estimated the expense from electrolyte repletion within the reference range was approximately $1.25 million. Absent a specific clinical indication, repleting electrolytes when the serum concentration are within normative values may represent an avenue for cost savings, staff burden unload and potential reduction in frequency of complications in the ICUs.
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Affiliation(s)
- Thomas T Joseph
- Department of Anaesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Matthew DiMeglio
- Center for Connected Medicine, University of Pennsylvania Health system, Philadelphia, USA
| | | | - Krzysztof Laudanski
- Department of Anaesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.
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Kim HY, Lee JE, Ko JS, Gwak MS, Lee SK, Kim GS. Intraoperative management of liver transplant recipients having severe renal dysfunction: results of 42 cases. Ann Surg Treat Res 2018; 95:45-53. [PMID: 29963539 PMCID: PMC6024087 DOI: 10.4174/astr.2018.95.1.45] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 01/19/2018] [Accepted: 01/30/2018] [Indexed: 12/26/2022] Open
Abstract
Purpose Whereas continuous renal replacement therapy (CRRT) has been utilized during liver transplantation (LT), there was a lack of evidence to support this practice. We investigated the adverse events at the perioperative periods in recipients of LT who received preoperative CRRT without intraoperative CRRT. Methods We retrospectively reviewed medical records of adult patients (age ≥ 18 years) who received LT between December 2009 and May 2015. Perioperative data were collected from the recipients, who received preoperative CRRT until immediately before LT, because of refractory renal dysfunction. Results Of 706 recipients, 42 recipients received preoperative CRRT. The mean (standard deviation) Model for end-stage liver disease score were 49.6 (13.4). Twenty-six point two percent (26.2%) of recipients experienced the serum potassium > 4.5 mEq/L before reperfusion and treated with regular insulin. Thirty-eight point one percent (38.1%) of recipients were managed with sodium bicarbonate because of acidosis (base excess < −10 mEq/L throughout LT). All patients finished their operations without medically uncontrolled complications such as severe hyperkalemia (serum potassium > 5.5 mEq/L), refractory acidosis, or critical arrhythmias. Mortality was 19% at 30 day and 33.3% at 1 year. Conclusion Although intraoperative CRRT was not used in recipients with severe preoperative renal dysfunction, LT was safely performed. Our experience raises a question about the need for intraoperative CRRT.
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Affiliation(s)
- Ha Yeon Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Ja Eun Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Justin S Ko
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mi Sook Gwak
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Suk-Koo Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Jiménez JV, Carrillo-Pérez DL, Rosado-Canto R, García-Juárez I, Torre A, Kershenobich D, Carrillo-Maravilla E. Electrolyte and Acid-Base Disturbances in End-Stage Liver Disease: A Physiopathological Approach. Dig Dis Sci 2017; 62:1855-1871. [PMID: 28501971 DOI: 10.1007/s10620-017-4597-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 04/26/2017] [Indexed: 12/17/2022]
Abstract
Electrolyte and acid-base disturbances are frequent in patients with end-stage liver disease; the underlying physiopathological mechanisms are often complex and represent a diagnostic and therapeutic challenge to the physician. Usually, these disorders do not develop in compensated cirrhotic patients, but with the onset of the classic complications of cirrhosis such as ascites, renal failure, spontaneous bacterial peritonitis and variceal bleeding, multiple electrolyte, and acid-base disturbances emerge. Hyponatremia parallels ascites formation and is a well-known trigger of hepatic encephalopathy; its management in this particular population poses a risky challenge due to the high susceptibility of cirrhotic patients to osmotic demyelination. Hypokalemia is common in the setting of cirrhosis: multiple potassium wasting mechanisms both inherent to the disease and resulting from its management make these patients particularly susceptible to potassium depletion even in the setting of normokalemia. Acid-base disturbances range from classical respiratory alkalosis to high anion gap metabolic acidosis, almost comprising the full acid-base spectrum. Because most electrolyte and acid-base disturbances are managed in terms of their underlying trigger factors, a systematic physiopathological approach to their diagnosis and treatment is required.
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Affiliation(s)
- José Víctor Jiménez
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Diego Luis Carrillo-Pérez
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Rodrigo Rosado-Canto
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Ignacio García-Juárez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Aldo Torre
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - David Kershenobich
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico
| | - Eduardo Carrillo-Maravilla
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, 14080, Mexico City, Mexico.
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Pruinelli L, Monsen KA, Gross CR, Radosevich DM, Simon GJ, Westra BL. Predictors of Liver Transplant Patient Survival. Prog Transplant 2016; 27:98-106. [DOI: 10.1177/1526924816680099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective: Liver transplantation is a costly and risky procedure, representing 25 050 procedures worldwide in 2013, with 6729 procedures performed in the United States in 2014. Considering the scarcity of organs and uncertainty regarding prognosis, limited studies address the variety of risk factors before transplantation that might contribute to predicting patient’s survival and therefore developing better models that address a holistic view of transplant patients. This critical review aimed to identify predictors of liver transplant patient survival included in large-scale studies and assess the gap in risk factors from a holistic approach using the Wellbeing Model and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. Data Source: Search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, and PubMed from the 1980s to July 2014. Study Selection: Original longitudinal large-scale studies, of 500 or more subjects, published in English, Spanish, or Portuguese, which described predictors of patient survival after deceased donor liver transplantation. Data Extraction: Predictors were extracted from 26 studies that met the inclusion criteria. Data Synthesis: Each article was reviewed and predictors were categorized using a holistic framework, the Wellbeing Model (health, community, environment, relationship, purpose, and security dimensions). Conclusions: The majority (69.7%) of the predictors represented the Wellbeing Model Health dimension. There were no predictors representing the Wellbeing Dimensions for purpose and relationship nor emotional, mental, and spiritual health. This review showed that there is rigorously conducted research of predictors of liver transplant survival; however, the reported significant results were inconsistent across studies, and further research is needed to examine liver transplantation from a whole-person perspective.
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Affiliation(s)
| | - Karen A. Monsen
- School of Nursing, University of Minnesota, Minneapolis, MN, USA
| | - Cynthia R. Gross
- School of Nursing and College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - David M. Radosevich
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - György J. Simon
- Department of Health Science Research, Mayo Clinic Rochester, Rochester, MN, USA
| | - Bonnie L. Westra
- School of Nursing and Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
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12
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Jeong SM. Postreperfusion syndrome during liver transplantation. Korean J Anesthesiol 2015; 68:527-39. [PMID: 26634075 PMCID: PMC4667137 DOI: 10.4097/kjae.2015.68.6.527] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 07/31/2015] [Accepted: 08/07/2015] [Indexed: 02/07/2023] Open
Abstract
As surgical and graft preservation techniques have improved and immunosuppressive drugs have advanced, liver transplantation (LT) is now considered the gold standard for treating patients with end-stage liver disease worldwide. However, despite the improved survival following LT, severe hemodynamic disturbances during LT remain a serious issue for the anesthesiologist. The greatest hemodynamic disturbance is postreperfusion syndrome (PRS), which occurs at reperfusion of the donated liver after unclamping of the portal vein. PRS is characterized by marked decreases in mean arterial pressure and systemic vascular resistance, and moderate increases in pulmonary arterial pressure and central venous pressure. The underlying pathophysiological mechanisms of PRS are complex. Moreover, risk factors associated with PRS are not fully understood. Rapid and appropriate treatment with vasopressors, volume replacement, or venesection must be provided depending on the cause of the hemodynamic disturbance when hemodynamic instability becomes profound after reperfusion. The negative effects of PRS on postoperative early morbidity and mortality are clear, but the effect of PRS on postoperative long-term mortality remains a matter of debate.
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Affiliation(s)
- Sung-Moon Jeong
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Li C, Wen TF, Yan LN, Li B, Yang JY, Wang WT, Xu MQ, Wei YG. Factors associated with early mortality after living-donor liver transplant. EXP CLIN TRANSPLANT 2014; 13:62-7. [PMID: 25343488 DOI: 10.6002/ect.2014.0031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES We sought to identify the risk factors associated with the early mortality after a living-donor liver transplant. MATERIALS AND METHODS Two hundred eighteen patients were recruited in this study. Potential risk factors were analyzed using univariate and multivariate analyses. A C statistic equivalent to the area under the receiver operating characteristic curve was used to assess the ability of the model to predict mortality risk during the first 3 months after a living-donor liver transplant. RESULTS Twenty-six recipients died within the first 3 months after a living-donor liver transplant. On a multivariate analysis, intraoperative allogeneic red blood cell transfusion and the preoperative creatinine levels were independently associated with early postoperative mortality. A prognostic model was proposed in this study (early mortality risk score = 0.107 × intraoperative allogeneic red blood cells transfusion [U] + 0.005 × preoperative creatinine concentration [μmol/L]). Three-month survival rates of patients with high and low scores were 69.8% and 95.5% (P < .001). CONCLUSIONS Transfusion of intraoperative allogeneic red blood cell and preoperative creatinine levels are associated with the early mortality after living-donor liver transplant. A model to predict early mortality after a living-donor liver transplant based on these risk factors was proposed in this study.
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Affiliation(s)
- Chuan Li
- From the Division of Liver Transplantation, West China Hospital of Sichuan University, Chengdu (610041), China
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14
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Wingo CS. Introduction: potassium homeostasis in humans: our current understanding. Semin Nephrol 2013; 33:205-6. [PMID: 23953796 DOI: 10.1016/j.semnephrol.2013.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Valentine E, Gregorits M, Gutsche JT, Al-Ghofaily L, Augoustides JG. Clinical Update in Liver Transplantation. J Cardiothorac Vasc Anesth 2013; 27:809-15. [DOI: 10.1053/j.jvca.2013.03.031] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Indexed: 02/08/2023]
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Agrawal S, Dhiman RK. Answers to multiple choice questions. J Clin Exp Hepatol 2012; 2:401-6. [PMID: 25755463 PMCID: PMC3940550 DOI: 10.1016/j.jceh.2012.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | - Radha K. Dhiman
- Address for correspondence: Radha K. Dhiman, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
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Singh S, Nasa V, Tandon M. Perioperative monitoring in liver transplant patients. J Clin Exp Hepatol 2012; 2:271-8. [PMID: 25755443 PMCID: PMC3940305 DOI: 10.1016/j.jceh.2012.06.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 06/26/2012] [Indexed: 02/06/2023] Open
Abstract
Liver transplant (LT) is a major surgical undertaking involving major fluid shifts, hemodynamic instability and metabolic derangements in a patient with preexisting liver failure and multisystemic derangements. Monitoring and organ support initiated in the preoperative phase is continued intraoperatively and into the postoperative phase to ensure an optimal outcome. As cardiovascular events are the leading cause of non-graft related death among LT recipients, major emphasis is placed on cardiovascular monitoring. The other essential monitoring are the continuous assessment of coagulapathy, extent of metabolic derangements, dyselectrolytemis and intracranial pressure monitoring in patients with fulminant hepatic failure. The type and extent of monitoring differs with need according to preexisting child status of the patient and the extent of systemic derangements. It also varies among transplant centers and is mainly determined by individual or institutional practices.
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Key Words
- ACT, activated clotting time
- ALF
- ALF, acute liver failure
- APTT, activated partial thromboplastin time
- ARDS, acute respiratory distress syndrome
- CCO, continuous CO
- CCTs, conventional coagulation tests
- CI, cardiac index
- CL, clot lysis
- CO, cardiac output
- CR, clot rate
- CVP, central venous pressure
- ESLD, end stage liver disease
- EVLWI, extra vascular lung water index
- ICG, indocyanine green
- ICH, intracranial hypertension
- ICP, intracranial pressure
- LT, liver transplant
- MA, maximum amplitude
- ONSD, optic nerve sheath diameter
- PAC, pulmonary artery catheter
- PAOP, pulmonary arterial occlusion pressure
- PF, platelet function
- PI, pulsatility index
- PT, prothrombin time
- ROTEM, rotation thrombelastometry
- RVEDV, right ventricular end-diastolic volume
- SV, stroke volume
- SVR, systemic vascular resistance
- TCD, transcranial Doppler
- TDCO, thermodilution principle
- TEE, transesophageal echocardiography
- TEG, thrombelastography
- cirrhosis
- coagulopathy
- intracranial pressure monitoring
- liver transplant
- mPAP, mean pulmonary artery pressure
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Affiliation(s)
- Shweta Singh
- Address for correspondence: Shweta Singh, Associate Professor, Dept. of Anesthesiology and Critical Care, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi 110070, India. Tel.: +91 9810625177.
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Gruber M, Breu A, Frauendorf M, Seyfried T, Hansen E. Washing of banked blood by three different blood salvage devices. Transfusion 2012; 53:1001-9. [PMID: 22897672 DOI: 10.1111/j.1537-2995.2012.03853.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Storage lesions in red blood cells (RBCs) lead to an accumulation of soluble contaminants that can compromise the patient. Organ failures, coagulopathies, and cardiovascular events including lethal cardiac arrest have been reported, especially with massive transfusion or in pediatric patients. Washing improves the quality of stored RBCs, and autotransfusion devices have been proposed for intraoperative processing, but these devices were designed for diluted wound blood, and limited data on their performance with RBCs are available. STUDY DESIGN AND METHODS Three autotransfusion devices (Electa, Sorin; CATS, Fresenius; OrthoPAT, Haemonetics) differing in function of their centrifugation chambers were evaluated with RBCs at the end of their shelf life and with dilutions thereof. Elimination rates of potassium, plasma free hemoglobin, total protein, citrate, acid equivalents, and iomeprol added as a marker substance were analyzed, in addition to RBC recoveries. RESULTS Product hematocrit (Hct) levels ranged between 54.8 and 72.6%. RBC recovery rates were between 62.7 and 95.0%, the lowest being with the OrthoPAT processing of undiluted RBCs. Plasma elimination rates increased with predilution and ranged from 46.6% to 99.5%, the lowest being with the CATS and undiluted RBCs. Washing did not change pH and buffering capacity of RBCs. CONCLUSION Autotransfusion devices offer a practical and obviously economical option to wash banked RBCs intraoperatively to prevent hyperkalemia and other disturbances in massive transfusion or pediatric patients. Predilution improves elimination rates, especially in devices that produce high product Hct levels. With a Y-tubing the RBCs should bypass reservoir and vacuum, and the procedure should be guarded by a policy and procedure manual and a quality management system.
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Affiliation(s)
- Michael Gruber
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
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Liu LL, Niemann CU. Intraoperative management of liver transplant patients. Transplant Rev (Orlando) 2011; 25:124-9. [PMID: 21514137 DOI: 10.1016/j.trre.2010.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Accepted: 10/25/2010] [Indexed: 12/13/2022]
Abstract
Liver transplantation for end-stage liver disease results in excellent outcomes. Patient and graft outcome is closely monitored on a national level, and 1-year survival is between 80% and 95%. Liver transplantation relies on a multidisciplinary approach, with close involvement of anesthesiologists and intensivists. However, intraoperative care of these patients remains inconsistent and is highly institution dependent. This brief-review article will focus on controversial topics of intraoperative care. Existing evidence on intraoperative monitoring, intraoperative fluid and transfusion management, electrolyte and glucose management, postoperative patient disposition, and, lastly, anesthesia team management will be reviewed.
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Affiliation(s)
- Linda L Liu
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA 94143, USA
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Abstract
PURPOSE OF REVIEW To present current knowledge about the metabolic management of patients undergoing solid organ transplantation, and potential organ donors. RECENT FINDINGS Appropriate management of electrolytes and glucose improves outcome after transplantation, although conflicting evidence exists. Patients with cirrhosis-induced hyponatremia can be successfully transplanted but are at increased risk of postoperative complications. A new class of drugs, the vaptans, that antagonizes arginine vasopressin may be an effective treatment for hyponatremia in transplant candidates. Recent literature has documented the implications, predictors and potential therapies for perioperative hyperkalemia in the transplant population. The debate over appropriate targets for serum glucose in perioperative and critically ill patients has been lively. The documented risk of hypoglycemia associated with 'intensive insulin therapy' has led to the adoption of more conservative glycemic targets. Studies of glycemic control in transplant recipients are limited. SUMMARY In patients undergoing solid organ transplants, sodium management should aim to minimize an acute change in sodium concentration. Vaptans may be of future use in optimizing patients with cirrhosis prior to transplantation. Pending further studies, a perioperative 'middle ground' target glucose of between 140 and 180 mg/dl seems reasonable at this time.
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