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Tseng HY, Lin YH, Lin CC, Chen CL, Yong CC, Lin LM, Wang CC, Chan YC. Long-term renal outcomes comparison between patients with chronic kidney disease and hepatorenal syndrome after living donor liver transplantation. Front Surg 2023; 10:1116728. [PMID: 37077866 PMCID: PMC10106629 DOI: 10.3389/fsurg.2023.1116728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/27/2023] [Indexed: 04/05/2023] Open
Abstract
Background and aimsHepatorenal syndrome (HRS) is a disastrous renal complication of advanced liver disease with a poor prognosis. Restoring normal liver function through liver transplantation (LT) is a standardized treatment with favorable short-term survival. However, the long-term renal outcomes in patients with HRS receiving living donor LT (LDLT) are controversial. This study aimed to investigate the prognostic impact of LDLT in patients with HRS.MethodsWe reviewed adult patients who underwent LDLT between July 2008 and September 2017. Recipients were classified into 1) HRS type 1 (HRS1, N = 11), 2) HRS type 2 (HRS2, N = 19), 3) non-HRS recipients with pre-existing chronic kidney disease (CKD, N = 43), and 4) matched normal renal function (N = 67).ResultsPostoperative complications and 30-day surgical mortality were comparable among the HRS1, HRS2, CKD, and normal renal function groups. The 5-year survival rate was >90% and estimated glomerular filtration rate (eGFR) transiently improved and peaked at 4 weeks post-transplantation in patients with HRS. However, renal function deteriorated and resulted in CKD stage ≥ III in 72.7% of HRS1 and 78.9% of HRS2 patients (eGFR <60 ml/min/1.73 m2). The incidence of developing CKD and end-stage renal disease (ESRD) was similar between the HRS1, HRS2, and CKD groups, but significantly higher than that in the normal renal function group (both P < 0.001). In multivariate logistic regression, pre-LDLT eGFR <46.4 ml/min/1.73 m2 predicted the development of post-LDLT CKD stage ≥ III in patients with HRS (AUC = 0.807, 95% CI = 0.617–0.997, P = 0.011).ConclusionsLDLT provides a significant survival benefit for patients with HRS. However, the risk of CKD stage ≥ III and ESRD among patients with HRS was similar to that in pre-transplant CKD recipients. An early preventative renal-sparing strategy in patients with HRS is recommended.
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Affiliation(s)
- Hsiang-Yu Tseng
- Liver Transplantation Center, and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Hung Lin
- Liver Transplantation Center, and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Che Lin
- Liver Transplantation Center, and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chao-Long Chen
- Liver Transplantation Center, and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chee-Chien Yong
- Liver Transplantation Center, and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Li-Man Lin
- Department of Early Childhood Care and Education, Cheng Shiu University, Kaohsiung, Taiwan
| | - Chih-Chi Wang
- Liver Transplantation Center, and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Chia Chan
- Liver Transplantation Center, and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Correspondence: Yi-Chia Chan
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Pedro RADM, Scharranch BC, Araújo LDO, Brandão LS, Andrade LDC, Andraus W, D’Albuquerque LAC, Malbouisson LMS. High versus low mean arterial pressure target in liver transplant patients. An open, controlled, single-center, randomized clinical trial - Protocol and methods (LIVER-PAM). CRITICAL CARE SCIENCE 2023; 35:11-18. [PMID: 37712725 PMCID: PMC10275307 DOI: 10.5935/2965-2774.20230336-en] [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: 10/01/2022] [Accepted: 01/29/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE To explain the rationale and protocol of the methods and analyses to be used in the LIVER-PAM randomized clinical trial, which seeks to understand whether a higher mean arterial pressure is capable of reducing the incidence of renal dysfunction postoperatively after liver transplantation. METHODS LIVER-PAM is an open-label, randomized, controlled, singlecenter clinical trial. Patients randomized to the intervention group will have a mean arterial pressure of 85 - 90mmHg in the initial 24 hours of postoperative management, while patients in the control group will have a mean arterial pressure of 65 - 70mmHg in the same period. A sample of 174 patients will be required to demonstrate a 20% reduction in the absolute incidence of renal dysfunction, with a power of 80% and an alpha of 0.05. CONCLUSION If a 20% reduction in the absolute incidence of renal dysfunction in the postoperative period of liver transplantation is achieved with higher target mean arterial pressure in the first 24 hours, this would represent an inexpensive and simple therapy for improving current outcomes in the management of liver transplant patients.ClinicalTrials.gov Registry: NCT05068713.
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Affiliation(s)
- Rodolpho Augusto de Moura Pedro
- Department of Gastroenterology, Hospital das Clínicas,
Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP),
Brazil
| | - Bruna Carla Scharranch
- Department of Gastroenterology, Hospital das Clínicas,
Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP),
Brazil
| | - Lucas de Oliveira Araújo
- Department of Gastroenterology, Hospital das Clínicas,
Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP),
Brazil
| | - Luciana Severo Brandão
- Department of Gastroenterology, Hospital das Clínicas,
Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP),
Brazil
| | - Lúcia da Conceição Andrade
- Department of Nephrology, Hospital das Clínicas, Faculdade
de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil
| | - Wellington Andraus
- Department of Gastroenterology, Hospital das Clínicas,
Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP),
Brazil
| | | | - Luíz Marcelo Sá Malbouisson
- Discipline of Anesthesiology, Department of Surgery, Hospital das
Clínicas, Faculdade de Medicina de São Paulo - São Paulo (SP),
Brazil
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3
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Flamm SL, Wong F, Ahn J, Kamath PS. AGA Clinical Practice Update on the Evaluation and Management of Acute Kidney Injury in Patients With Cirrhosis: Expert Review. Clin Gastroenterol Hepatol 2022; 20:2707-2716. [PMID: 36075500 DOI: 10.1016/j.cgh.2022.08.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/15/2022] [Accepted: 08/18/2022] [Indexed: 02/07/2023]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available published evidence and expert advice regarding the clinical management of patients with suspected acute kidney injury in patients with cirrhosis. METHODS This article provides practical advice for the management of patients with cirrhosis and acute kidney injury based on the best available published evidence. This best practice document is not based on a formal systematic review. This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through the standard procedures of Clinical Gastroenterology & Hepatology. These Best Practice Advice (BPA) statements were drawn from a review of the published literature and from expert opinion. Since systematic reviews were not performed, these BPA statements do not carry formal ratings of the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE 1: Acute kidney injury (AKI) should be diagnosed when the serum creatinine increases by ≥0.3 mg/dL within 48 hours or is ≥50% from baseline or when the urine output is reduced below 0.5 mL/kg/h for >6 hours. BEST PRACTICE ADVICE 2: Preventive measures against the development of AKI in cirrhosis include (1) avoidance of potentially nephrotoxic medications like nonsteroidal anti-inflammatory drugs (NSAIDs), (2) avoidance of excessive or unmonitored diuretics or nonselective beta-blockade, (3) avoidance of large-volume paracentesis without albumin replacement, and (4) counseling patients to avoid alcohol use. BEST PRACTICE ADVICE 3: (A) Investigation is directed to determining the cause of AKI, which can be due to hypovolemic causes (volume responsive, and the most common cause of AKI in patients with cirrhosis); acute tubular necrosis; hepatorenal syndrome with AKI (HRS-AKI) (a functional renal failure that persists despite volume repletion); HRS with acute kidney disease, a type of functional renal failure of <3 months- duration in which criteria for HRS-AKI are not met; or postrenal, which occurs only rarely. (B) The specific type of AKI should be identified through a careful history, physical examination, blood biochemistry, urine microscopic examination, urine chemistry (Na+ and urea) and selected urinary biomarkers, and renal ultrasound. BEST PRACTICE ADVICE 4: A rigorous search for infection is required in all patients with AKI. A diagnostic paracentesis should be carried out to evaluate for spontaneous bacterial peritonitis; blood and urine cultures and chest radiograph are also required. There is no role for routine prophylactic antibiotics in patients with AKI, but broad-spectrum antibiotics should be started whenever infection is strongly suspected. BEST PRACTICE ADVICE 5: When AKI is diagnosed, diuretics and nonselective beta-blockers should be held, NSAIDs discontinued, the precipitating cause of AKI treated, and fluid losses replaced, administering albumin 1 g/kg/d for 2 days if the serum creatinine shows doubling from baseline. Urine output, vital signs, and when indicated, echocardiography or CVP (if there is a pre-existing central line) should be used to monitor fluid status. BEST PRACTICE ADVICE 6: When the serum creatinine remains higher than twice the baseline value despite these measures, treatment of HRS-AKI should be initiated with albumin at a dose of 1 g/kg intravenously on day 1 followed by 20-40 g daily along with vasoactive agents (terlipressin; if terlipressin is not available, either a combination of octreotide and midodrine; or norepinephrine, depending on institutional preferences) and continued either until 24 hours following the return of the serum creatinine level to within ≤0.3 mg/dL of baseline for 2 consecutive days or for a total of 14 days of therapy. BEST PRACTICE ADVICE 7: Terlipressin should be initiated as a bolus dose of 1 mg every 4-6 hours (total 4-6 mg/d). The dose should be increased to a maximum of 2 mg every 4-6 hours (total 8-12 mg/d) if there is no reduction in serum creatinine at day 3 of therapy by at least 25% compared to the baseline value. Alternatively, clinicians can administer terlipressin by continuous intravenous infusion at a lower starting dose of 2 mg/d, which may reduce ischemic side effects and increase the dose gradually every 24-48 hours up to a maximum dose of 12 mg/d, or reversal of HRS. As per Food and Drug Administration restrictions, terlipressin should not be used in patients with a serum creatinine ≥5 mg/dL, or oxygen saturation of <90%. BEST PRACTICE ADVICE 8: Oral midodrine when used should be initiated at doses of 7.5 mg and titrated upward to 12.5 mg 3 times daily with octreotide (starting with 100 μg and titrating upward to 200 μg subcutaneously 3 times daily). BEST PRACTICE ADVICE 9: Norepinephrine should be used as a continuous intravenous infusion at a starting dose of 0.5 mg/h and the dose increased every 4 hours by 0.5 mg/h to a maximum of 3 mg/h with the goal of increasing the mean arterial pressure by ≥10 mm Hg and/or the urine output to >50 mL/h for at least 4 hours. BEST PRACTICE ADVICE 10: The risks of ischemic side effects of terlipressin and norepinephrine include angina and ischemia of fingers, skin, and intestine. These side effects may be lowered by starting at the lowest dose and gradually titrating upward. BEST PRACTICE ADVICE 11: Fluid status should be closely monitored because of the risk of pulmonary edema with excessive use of albumin. BEST PRACTICE ADVICE 12: Renal replacement therapy (RRT) may be used in the management of (A) AKI secondary to acute tubular necrosis; (B) HRS-AKI in potential candidates for liver transplantation (that is, RRT should not be used in patients with HRS-AKI who are not candidates for liver transplantation); and (C) AKI of uncertain etiology in which the need for RRT may be considered on an individual basis. BEST PRACTICE ADVICE 13: Transjugular intrahepatic portosystemic shunts should not be used as a specific treatment of HRS-AKI. BEST PRACTICE ADVICE 14: Liver transplantation is the most effective treatment for HRS-AKI. Pharmacotherapy for HRS-AKI before proceeding with liver transplantation may be associated with better post-liver transplantation outcomes. Selected patients with HRS-AKI may require simultaneous liver kidney transplantation based on updated Organ Procurement and Transplantation Network listing criteria.
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Affiliation(s)
- Steven L Flamm
- Division of Gastroenterology and Hepatology, Rush University Medical College, Chicago, Illinois
| | - Florence Wong
- Division of Gastroenterology and Hepatology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Joseph Ahn
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota.
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Asch WS. Is Prioritization of Kidney Allografts to Combined Liver-Kidney Recipients Appropriate? COMMENTARY. KIDNEY360 2022; 3:999-1002. [PMID: 35849645 PMCID: PMC9255872 DOI: 10.34067/kid.0005042021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/14/2021] [Indexed: 01/10/2023]
Affiliation(s)
- William S. Asch
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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5
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Januszko-Giergielewicz B, Kobryń A, Donderski R, Trzcinska J, Theda-Pawelska J, Romaszko-Wojtowicz A, Shevchuk A, Słupski M. Hepatorenal Syndrome and Other Post-Liver Transplantation Complications: Case Studies and Literature Review. Transplant Proc 2022; 54:1029-1036. [PMID: 35760626 DOI: 10.1016/j.transproceed.2022.03.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/05/2022] [Accepted: 03/14/2022] [Indexed: 01/09/2023]
Abstract
Hepatorenal syndrome (HRS) was originally defined as a renal dysfunction caused by a decreased renal perfusion due to hemodynamic disturbances in the arterial circulation and an excessive activity of endogenous vasoactive systems in the course of cirrhosis. Considering the latest research, this syndrome may have a more complex pathomechanism. Equally often as in cirrhosis, HRS develops after orthotopic liver transplantation (OLTx) and worsens the prognosis significantly increasing mortality rates in this patient population. The prevalence of renal complications after OLTx and their negative prognostic impact on the survival of both the graft and the recipient prompted the authors of this work to analyze in detail 2 cases of HRS after OLTx to indicate the multiplicity of factors contributing to the pathophysiology of this syndrome. Attention was paid to risk factors for HRS found in the anamnesis before OLTx, especially a pre-existing renal dysfunction. In both cases early post-OLTx complications associated with the transplantation procedure were described: destabilization of the circulatory system, transfusions of blood products, prolonged stay at an intensive care unit, and necessity of introducing continuous renal replacement therapy. In the later period after the OLTx, infections (bacterial, fungal, viral) and drug nephrotoxicity, including the activity of immunosuppressants (tacrolimus), contributed primarily to the renal function impairment.
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Affiliation(s)
- Beata Januszko-Giergielewicz
- Clinic of General, Liver and Transplant Surgery, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland.
| | - Andrzej Kobryń
- Clinic of General, Liver and Transplant Surgery, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland
| | - Rafał Donderski
- Department of Nephrology, Internal Diseases and Hypertention, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland
| | - Joanna Trzcinska
- Clinic of General, Liver and Transplant Surgery, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland
| | - Joanna Theda-Pawelska
- Clinic of General, Liver and Transplant Surgery, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland
| | - Anna Romaszko-Wojtowicz
- Department of Pulmonology, Faculty of Public Health, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Poland
| | - Andii Shevchuk
- Clinic of General, Liver and Transplant Surgery, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland
| | - Maciej Słupski
- Clinic of General, Liver and Transplant Surgery, University Hospital No 1 in Bydgoszcz named after Dr A. Jurasz, Collegium Medicum, Nicolaus Copernicus University in Toruń, Poland
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6
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Intraoperative dialysis with the use of a mobile dialysis system during liver transplantation. Adv Med Sci 2022; 67:208-215. [PMID: 35568010 DOI: 10.1016/j.advms.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 03/22/2022] [Accepted: 04/29/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE Over the last few years, transplant centers have started to use various intraoperative renal replacement therapy (ioRRT) modalities during liver transplantation (LT) in patients with pre-existing renal impairment. Here, we present a study on the safety and clinical outcomes of intraoperative hemodialysis (ioHD) performed using a mobile dialysis system during LT. PATIENTS AND METHODS We retrospectively analyzed 102 adult patients undergoing LT with ioHD; pre-existing renal failure and/or intraoperative metabolic derangement were ioHD treatment indications. RESULTS Our study cohort consisted of three groups: LT with preoperative serum creatinine (sCr) < 2 mg/dL (Group 1:n = 22), LT with preoperative sCr ≥2 mg/dL (Group 2:n = 73), and simultaneous liver-kidney transplantation (Group 3:n = 7). Among the procedures, 30% were re-transplantations. The mean calculated Model for End-stage Liver Disease score in Group 2 was 39.2, and 67% of patients were hospitalized in the intensive care unit. Patients in Group 1 were less acutely ill but developed severe intraoperative derangements and, therefore, underwent urgent ioHD intraoperatively. However, it was delayed when compared to Group 2. All groups achieved post-reperfusion potassium levels <4 mmol/L and a decrease in central venous pressure. No serious procedural complications occurred. Post-reperfusion syndrome occurred in 12.7% of patients. Elevated mortality was likely due to the high illness severity in the cohort. CONCLUSIONS Performing ioHD with a mobile dialysis system during LT was safe and effective, while being easier to perform than continuous techniques. Its effect on intra- and postoperative outcomes should be addressed in a study with a control group.
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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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8
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Estimation of glomerular filtration rate in patients with cirrhosis: evaluation of equations currently used in clinical practice and validation of Royal Free Hospital cirrhosis glomerular filtration rate. Eur J Gastroenterol Hepatol 2022; 34:84-91. [PMID: 32956187 DOI: 10.1097/meg.0000000000001935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Conventional creatinine-based glomerular filtration rate (GFR) equations have been reported to overestimate renal function in patients with cirrhosis. The Royal Free Hospital (RFH) cirrhosis GFR equation was developed to accurately estimate GFR in this population. The aim of this study was to evaluate the ability of widely available equations [Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI), Modification of Diet in Renal Disease equations (MDRD-4, MDRD-6)] and the RFH equation to correctly estimate the GFR of patients with cirrhosis. METHODS We retrospectively analyzed data from patients with cirrhosis who underwent measurement of GFR with the use of 51Cr-EDTA (GFR-M). The CKD-EPI, MDRD-4, MDRD-6 and RFH equations were calculated, while bias, precision and accuracy were estimated for each one of them and then compared with paired t-tests. Bias was defined as the mean difference between the GFR-M and the result of each equation; precision was defined as the SD of the differences and accuracy was defined as the square root of the mean squared error (mean of the squared differences). Higher values are associated with worse bias and better precision/accuracy. RESULTS One-hundred and thirty-four cirrhotic patients were included. Bias was estimated for CKD-EPI, MDRD-4, MDRD-6 and RFH at -5.91, -3.13, 0.92 and 18.24, respectively. Significant differences were observed between all equations (P < 0.001). Regarding precision, only the comparison between MDRD-4 (20.81) and RFH (16.6) yielded a statistically significant result (P = 0.037). Finally, CKD-EPI (19.32) and MDRD-6 (18.81) exhibited better accuracy than GFR-RFH (24.61) (P = 0.006 and 0.001). CONCLUSION RFH demonstrates inferior accuracy in predicting renal function in patients with cirrhosis, in comparison to conventional equations.
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Fabrizi F, Donato MF, Cerutti R, Invernizzi F, Porata G, Frontini G, Raffiotta F, De Feo T, Alfieri CM, Lampertico P, Rossi G, Messa P. Acute kidney injury and chronic kidney disease after liver transplant: A retrospective observational study. Nefrologia 2022; 42:41-49. [PMID: 36153898 DOI: 10.1016/j.nefroe.2021.01.003] [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: 08/30/2020] [Accepted: 01/24/2021] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND AND RATIONALE Chronic kidney disease remains an important risk factor for morbidity and mortality among LT recipients, but its exact incidence and risk factors are still unclear. MATERIAL AND METHODS We carried out a retrospective cohort study of consecutive adults who underwent liver transplant (January 2009-December 2018) and were followed (at least 6 months) at our institution. CKD was defined following the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guidelines. Long-term kidney function was classified into 4 groups: no CKD (eGFR, ≥60mL/min/1.73m2), mild CKD (eGFR, 30-59mL/min/1.73m2), severe CKD (eGFR, 15-29mL/min/1.73m2), and end-stage renal disease (ESRD). RESULTS We enrolled 410 patients followed for 53.2±32.6 months. 39 had CKD at baseline, and 95 developed de novo CKD over the observation period. There were 184 (44.9%) anti-HCV positive, 47 (11.5%) HBsAg positive, and 33 (8.1%) HBV/HDV positive recipients. Recipient risk factors for baseline CKD were advanced age (P=0.044), raised levels of serum uric acid (P<0.0001), and insulin dependent DM (P=0.0034). Early post-transplant AKI was common (n=95); logistic regression analysis found that baseline serum creatinine was an independent predictor of early post-LT AKI (P=0.0154). According to our Cox proportional hazards model, recipient risk factors for de novo CKD included aging (P<0.0001), early post-transplant AKI (P=0.007), and baseline serum creatinine (P=0.0002). At the end of follow-up, there were 116 LT recipients with CKD - 109 (93.9%) and 7 (6.1%) had stage 3 and advanced CKD, respectively. Only two of them are undergoing long-term dialysis. CONCLUSION The incidence of CKD was high in our cohort of LT recipients, but only a slight decline in kidney function over time was recorded. Prevention of post-transplant AKI will improve kidney function in the long run. We need more studies to analyze the function of kidneys among LT recipients over extended follow-ups and their impact on mortality.
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Affiliation(s)
- Fabrizio Fabrizi
- Division of Nephrology, Dialysis and Renal Transplantation, Maggiore Policlinico Hospital and Cà Granda IRCCS Foundation, Milano, Italy.
| | - Maria F Donato
- Division of Gastroenterology and Hepatology, Maggiore Policlinico Hospital and Ca' Granda IRCCS Foundation , Milano, Italy
| | - Roberta Cerutti
- Division of Nephrology, Dialysis and Renal Transplantation, Maggiore Policlinico Hospital and Cà Granda IRCCS Foundation, Milano, Italy
| | - Federica Invernizzi
- Division of Gastroenterology and Hepatology, Maggiore Policlinico Hospital and Ca' Granda IRCCS Foundation , Milano, Italy
| | - Giulia Porata
- Division of Nephrology, Dialysis and Renal Transplantation, Maggiore Policlinico Hospital and Cà Granda IRCCS Foundation, Milano, Italy
| | - Giulia Frontini
- Division of Nephrology, Dialysis and Renal Transplantation, Maggiore Policlinico Hospital and Cà Granda IRCCS Foundation, Milano, Italy
| | - Francesca Raffiotta
- Division of Nephrology, Dialysis and Renal Transplantation, Maggiore Policlinico Hospital and Cà Granda IRCCS Foundation, Milano, Italy
| | - Tullia De Feo
- North Italy Transplant Program, Organ and Tissue Transplantation Immunology, Maggiore Policlinico Hospital and Cà Granda IRCCS Foundation, Milano, Italy
| | - Carlo M Alfieri
- Division of Nephrology, Dialysis and Renal Transplantation, Maggiore Policlinico Hospital and Cà Granda IRCCS Foundation, Milano, Italy; University School of Medicine, Milano, Italy
| | - Pietro Lampertico
- Division of Gastroenterology and Hepatology, Maggiore Policlinico Hospital and Ca' Granda IRCCS Foundation , Milano, Italy; University School of Medicine, Milano, Italy
| | - Giorgio Rossi
- Hepatobiliary and Liver Transplant Unit, Maggiore Policlinico Hospital and Cà Granda IRCCS Foundation, Milano, Italy; University School of Medicine, Milano, Italy
| | - Piergiorgio Messa
- Division of Nephrology, Dialysis and Renal Transplantation, Maggiore Policlinico Hospital and Cà Granda IRCCS Foundation, Milano, Italy; University School of Medicine, Milano, Italy
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10
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Improvement of renal function prior to liver transplantation is not associated with better long-term renal outcome or survival. Ann Hepatol 2021; 26:100559. [PMID: 34656773 DOI: 10.1016/j.aohep.2021.100559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/04/2021] [Accepted: 06/22/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Since MELD implementation renal impairment in liver transplant (LT) recipients has become of increasing importance. This is the first study evaluating the course of renal function immediately prior to LT as predictor for long-term renal and overall outcome. PATIENTS AND METHODS In this retrospective study, 226 adults undergoing LT at the University Medical Center Hamburg-Eppendorf (2011-2015) were included. The impact of renal function over a period of 3 months prior to LT compared to renal function at the day of LT on long-term renal outcome and survival was assessed. RESULTS According to GFR at day of LT renal function improved (≥1 CKD stage) in 64 patients (28%), remained stable in 144 (64%) or deteriorated in 18 (8%). Improvement of renal function prior to LT did neither significantly affect 90-day (13% vs. 14%, p = 0.83), nor 5-year post-LT mortality (35% vs. 41%, p = 0.57). 50 patients (22%) with hepatorenal syndrome (HRS) received terlipressin prior to LT, but only 18 (37%) showed prolonged stabilization of renal function (improvement ≥1 CKD stage). Response to terlipressin did neither improve 90-day (p=1), 5-year mortality (p = 0.52) nor long-term renal function (p = 0.843). Nevertheless, need for dialysis pre-LT (59% vs. 34%, p = 0.005) and post-LT (62% vs. 17%, p<0.001) was associated with increased 5-year mortality. CONCLUSIONS Improvement of renal function immediately prior to LT, either spontaneously or following terlipressin therapy, did neither ameliorate long-term renal outcome nor survival in LT recipients. Future studies need to clarify the impact of terlipressin in HRS on the transplant waiting time in LT candidates.
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11
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Teo VXY, Heng RRY, Tay PWL, Ng CH, Tan DJH, Ong Y, Tan EY, Huang D, Vathsala A, Muthiah M, Tan EXX. A meta-analysis on the prevalence of chronic kidney disease in liver transplant candidates and its associated risk factors and outcomes. Transpl Int 2021; 34:2515-2523. [PMID: 34773291 DOI: 10.1111/tri.14158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 10/20/2021] [Accepted: 11/07/2021] [Indexed: 12/15/2022]
Abstract
Pre-liver transplant (LT) chronic kidney disease (CKD) has emerged as a leading cause of post-operative morbidity. We aimed to report the prevalence, associated risk factors, and clinical outcomes in patients with pre-LT CKD. Meta-analysis and systematic review were conducted for included cohort and cross-sectional studies. Studies comparing healthy and patients with s pre-LT CKD were included. Outcomes were assessed with pooled hazard ratios. 15 studies were included, consisting of 82,432 LT patients and 26,754 with pre-LT CKD. Pooled prevalence of pre-LT CKD was 22.35% (CI: 15.30%-32.71%). Diabetes mellitus, hypertension, viral hepatitis, and non-alcoholic fatty liver disease, and older age were associated with increased risk of pre-LT CKD: (OR 1.72 CI: 1.15-2.56, P = 0.01), (OR 2.23 CI: 1.76-2.83, P < 0.01), (OR 1.09; CI: 1.05-1.13, P < 0.01), (OR 1.73; CI: 1.10-2.71 P = 0.03), and (MD: 2.92 years; CI: 1.29-4.55years; P < 0.01) respectively. Pre-LT CKD was significantly associated with increased mortality (HR 1.38; CI: 1.2-1.59; P < 0.01), post-LT end-stage renal disease and post-LT CKD. Almost a quarter of pre-LT patients have CKD and it is significantly associated with post-operative morbidity and mortality. However, long-term outcomes remain unclear due to a lack of studies reporting such outcomes.
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Affiliation(s)
- Vanessa Xin Yi Teo
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Ryan Rui Yang Heng
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Phoebe Wen Lin Tay
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Yuki Ong
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - En Ying Tan
- Department of Medicine, National University Hospital, Singapore
| | - Daniel Huang
- Yong Loo Lin School of Medicine, National University Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore.,Liver Transplantation, National University Centre for Organ Transplantation, National University Hospital, Singapore
| | - Anantharaman Vathsala
- Yong Loo Lin School of Medicine, National University Singapore, Singapore.,Division of Nephrology, Department of Medicine, National University Hospital, Singapore.,Kidney and Pancreas Transplantation, National University Centre for Organ Transplantation, National University Hospital, Singapore
| | - Mark Muthiah
- Yong Loo Lin School of Medicine, National University Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore.,Liver Transplantation, National University Centre for Organ Transplantation, National University Hospital, Singapore
| | - Eunice Xiang Xuan Tan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore.,Liver Transplantation, National University Centre for Organ Transplantation, National University Hospital, Singapore
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12
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Chopinet S, Bobot M, Reydellet L, Bollon E, Gérolami R, Decoster C, Blasco V, Moal V, Grégoire E, Hardwigsen J. Peri-operative risk factors of chronic kidney disease after liver transplantation. J Nephrol 2021; 35:607-617. [PMID: 34426948 DOI: 10.1007/s40620-021-01127-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 06/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a frequent long-term complication after liver transplantation (LT) and is associated with poor long-term survival. The aim of our study was to identify the risk factors of developing post-transplant CKD at 1 year, during the pre-operative, peri-operative, and post-LT phases. METHODS All consecutive patients who underwent primary LT between July 2013 and February 2018 were analyzed. To assess the impact of peri- and post-operative factors on renal function at 1 year we performed a propensity score matching on gender, age of the recipient, Model for End-Stage Liver Disease (MELD) score, etiology of the hepatic disease, and estimated Glomerular Filtration Rate (eGFR) at baseline. RESULTS Among the 245 patients who underwent LT, 215 had available data at one year (Y1), and 46% of them had CKD. Eighty-three patients in the CKD group and 83 in the normal renal function group were then matched. The median follow-up was 35 months (27-77). Patients with CKD at Y1 had a decreased 5-year survival compared to patients with normal renal function at one year: figures were 62% and 90%, respectively, p = 0.001. The independent predictors of CKD at Y1 were major complications (OR = 2.2, 95% CI [1.2-4.2]), p = 0.015, intensive care unit (ICU) stay > 5 days (OR = 2.2, 95% CI [1.3-5.1]), p = 0.046, ICU serum lactate level at 24 h ≥ 2.5 mmol/L (OR = 3.8 95% CI [1.1-8]), p = 0.034, need for post-LT renal replacement therapy (OR = 6.4 95% CI [1.4-25]), and MELD score ≥ 20 (OR = 2.1 95% CI [1.1-3.9]), p = 0.019. CONCLUSIONS The peri-operative period has a major impact on CKD incidence. Early recognition of patients at high risk of CKD may be critical for implementation of nephroprotective measures.
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Affiliation(s)
- Sophie Chopinet
- Department of Digestive Surgery and Liver Transplantation, Hôpital la Timone, 264 Rue Saint-Pierre, 13385, Marseille Cedex 05, France. .,European Center for Medical Imaging Research CERIMED/LIIE, Université Aix-Marseille, Marseille, France. .,Aix-Marseille Université, 27 Boulevard Jean Moulin, 13385, Marseille, France.
| | - Mickaël Bobot
- Department of Nephrology, Hôpital de la Conception, Marseille, France.,C2VN, INSERM 1263 INRAE 1260 Aix-Marseille Université, Marseille, France.,Aix-Marseille Université, 27 Boulevard Jean Moulin, 13385, Marseille, France
| | - Laurent Reydellet
- Department of Anesthesiology, Hôpital la Timone, Marseille, France.,Aix-Marseille Université, 27 Boulevard Jean Moulin, 13385, Marseille, France
| | - Emilie Bollon
- Department of Digestive Surgery and Liver Transplantation, Hôpital la Timone, 264 Rue Saint-Pierre, 13385, Marseille Cedex 05, France.,Aix-Marseille Université, 27 Boulevard Jean Moulin, 13385, Marseille, France
| | - René Gérolami
- Department of Hepatology Gastroenterology, Hôpital la Timone, Marseille, France.,Aix-Marseille Université, 27 Boulevard Jean Moulin, 13385, Marseille, France
| | - Claire Decoster
- Department of Hepatology Gastroenterology, Hôpital la Timone, Marseille, France.,Aix-Marseille Université, 27 Boulevard Jean Moulin, 13385, Marseille, France
| | - Valéry Blasco
- Department of Anesthesiology, Hôpital la Timone, Marseille, France.,Aix-Marseille Université, 27 Boulevard Jean Moulin, 13385, Marseille, France
| | - Valérie Moal
- Department of Nephrology, Hôpital de la Conception, Marseille, France.,Aix-Marseille Université, 27 Boulevard Jean Moulin, 13385, Marseille, France
| | - Emilie Grégoire
- Department of Digestive Surgery and Liver Transplantation, Hôpital la Timone, 264 Rue Saint-Pierre, 13385, Marseille Cedex 05, France.,European Center for Medical Imaging Research CERIMED/LIIE, Université Aix-Marseille, Marseille, France.,Aix-Marseille Université, 27 Boulevard Jean Moulin, 13385, Marseille, France
| | - Jean Hardwigsen
- Department of Digestive Surgery and Liver Transplantation, Hôpital la Timone, 264 Rue Saint-Pierre, 13385, Marseille Cedex 05, France.,Aix-Marseille Université, 27 Boulevard Jean Moulin, 13385, Marseille, France
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13
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Fabrizi F, Donato MF, Cerutti R, Invernizzi F, Porata G, Frontini G, Raffiotta F, De Feo T, Alfieri CM, Lampertico P, Rossi G, Messa P. Acute kidney injury and chronic kidney disease after liver transplant: A retrospective observational study. Nefrologia 2021; 42:S0211-6995(21)00092-8. [PMID: 34112530 DOI: 10.1016/j.nefro.2021.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/26/2020] [Accepted: 01/24/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND AND RATIONALE Chronic kidney disease remains an important risk factor for morbidity and mortality among LT recipients, but its exact incidence and risk factors are still unclear. MATERIAL AND METHODS We carried out a retrospective cohort study of consecutive adults who underwent liver transplant (January 2009-December 2018) and were followed (at least 6 months) at our institution. CKD was defined following the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guidelines. Long-term kidney function was classified into 4 groups: no CKD (eGFR, ≥60mL/min/1.73m2), mild CKD (eGFR, 30-59mL/min/1.73m2), severe CKD (eGFR, 15-29mL/min/1.73m2), and end-stage renal disease (ESRD). RESULTS We enrolled 410 patients followed for 53.2±32.6 months. 39 had CKD at baseline, and 95 developed de novo CKD over the observation period. There were 184 (44.9%) anti-HCV positive, 47 (11.5%) HBsAg positive, and 33 (8.1%) HBV/HDV positive recipients. Recipient risk factors for baseline CKD were advanced age (P=0.044), raised levels of serum uric acid (P<0.0001), and insulin dependent DM (P=0.0034). Early post-transplant AKI was common (n=95); logistic regression analysis found that baseline serum creatinine was an independent predictor of early post-LT AKI (P=0.0154). According to our Cox proportional hazards model, recipient risk factors for de novo CKD included aging (P<0.0001), early post-transplant AKI (P=0.007), and baseline serum creatinine (P=0.0002). At the end of follow-up, there were 116 LT recipients with CKD - 109 (93.9%) and 7 (6.1%) had stage 3 and advanced CKD, respectively. Only two of them are undergoing long-term dialysis. CONCLUSION The incidence of CKD was high in our cohort of LT recipients, but only a slight decline in kidney function over time was recorded. Prevention of post-transplant AKI will improve kidney function in the long run. We need more studies to analyze the function of kidneys among LT recipients over extended follow-ups and their impact on mortality.
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Affiliation(s)
- Fabrizio Fabrizi
- Division of Nephrology, Dialysis and Renal Transplantation, Maggiore Policlinico Hospital and Cà Granda IRCCS Foundation, Milano, Italy.
| | - Maria F Donato
- Division of Gastroenterology and Hepatology, Maggiore Policlinico Hospital and Ca' Granda IRCCS Foundation , Milano, Italy
| | - Roberta Cerutti
- Division of Nephrology, Dialysis and Renal Transplantation, Maggiore Policlinico Hospital and Cà Granda IRCCS Foundation, Milano, Italy
| | - Federica Invernizzi
- Division of Gastroenterology and Hepatology, Maggiore Policlinico Hospital and Ca' Granda IRCCS Foundation , Milano, Italy
| | - Giulia Porata
- Division of Nephrology, Dialysis and Renal Transplantation, Maggiore Policlinico Hospital and Cà Granda IRCCS Foundation, Milano, Italy
| | - Giulia Frontini
- Division of Nephrology, Dialysis and Renal Transplantation, Maggiore Policlinico Hospital and Cà Granda IRCCS Foundation, Milano, Italy
| | - Francesca Raffiotta
- Division of Nephrology, Dialysis and Renal Transplantation, Maggiore Policlinico Hospital and Cà Granda IRCCS Foundation, Milano, Italy
| | - Tullia De Feo
- North Italy Transplant Program, Organ and Tissue Transplantation Immunology, Maggiore Policlinico Hospital and Cà Granda IRCCS Foundation, Milano, Italy
| | - Carlo M Alfieri
- Division of Nephrology, Dialysis and Renal Transplantation, Maggiore Policlinico Hospital and Cà Granda IRCCS Foundation, Milano, Italy; University School of Medicine, Milano, Italy
| | - Pietro Lampertico
- Division of Gastroenterology and Hepatology, Maggiore Policlinico Hospital and Ca' Granda IRCCS Foundation , Milano, Italy; University School of Medicine, Milano, Italy
| | - Giorgio Rossi
- Hepatobiliary and Liver Transplant Unit, Maggiore Policlinico Hospital and Cà Granda IRCCS Foundation, Milano, Italy; University School of Medicine, Milano, Italy
| | - Piergiorgio Messa
- Division of Nephrology, Dialysis and Renal Transplantation, Maggiore Policlinico Hospital and Cà Granda IRCCS Foundation, Milano, Italy; University School of Medicine, Milano, Italy
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14
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Molinari M, Fernandez-Carrillo C, Dai D, Dana J, Clemente-Sanchez A, Dharmayan S, Kaltenmeier C, Liu H, Behari J, Rachakonda V, Ganesh S, Hughes C, Tevar A, Al Harakeh H, Emmanuel B, Humar A, Bataller R. Portal vein thrombosis and renal dysfunction: a national comparative study of liver transplant recipients for NAFLD versus alcoholic cirrhosis. Transpl Int 2021; 34:1105-1122. [PMID: 33780554 PMCID: PMC8360094 DOI: 10.1111/tri.13873] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/08/2021] [Accepted: 03/19/2021] [Indexed: 12/13/2022]
Abstract
The prevalence of portal vein thrombosis (PVT), renal dysfunction (RD), and simultaneous PVT/RD in liver transplantation (LT) is poorly understood. We analyzed the prevalence of PVT, RD, simultaneous PVT/RD, and the outcomes of adult recipients of LT for nonalcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD) between 2006 and 2016 in the United States. We found that the prevalence of PVT (7.2% → 11.3%), RD (33.8% → 39.2%), and simultaneous PVT/RD (2.4% → 4.5%) has increased significantly over the study period (all P‐values <0.05). NAFLD patients had a higher proportion of PVT (14.8% vs. 9.2%), RD (45.0% vs. 42.1%), and simultaneous PVT/RD (6.5% vs. 3.9%; all P‐values <0.05). 90‐day mortality was 3.8%, 6.3%, 6.8%, and 9.8% for PVT(−)/RD(−), PVT(−)/RD(+), PVT(+)/RD(−), and PVT(+)/RD(+) recipients, respectively (P < 0.01). 5‐year survival was 82.1%, 75.5%, 74.8%, and 71.1% for PVT(−)/RD(−), PVT(−)/RD(+), PVT(+)/RD(−), and PVT(+)/RD(+) recipients, respectively (P < 0.05). In conclusion, the prevalence of PVT, RD, and simultaneous PVT/RD has increased among LT recipients, especially for those with NAFLD. The short‐ and long‐term outcomes of recipients with PVT, RD, and simultaneous PVT/RD were inferior to patients without those risk factors irrespective of their indication for LT. No differences in patient outcomes were found between ALD and NAFLD recipients after stratification by risk factors.
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Affiliation(s)
- Michele Molinari
- Department of Surgery, UPMC Montefiore Hospital, Pittsburgh, PA, USA
| | - Carlos Fernandez-Carrillo
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Surgery, University of Leeds, Leeds, UK
| | - Dongling Dai
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jorgensen Dana
- Department of Surgery, UPMC Montefiore Hospital, Pittsburgh, PA, USA
| | - Ana Clemente-Sanchez
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Stalin Dharmayan
- Department of Surgery, UPMC Montefiore Hospital, Pittsburgh, PA, USA
| | | | - Hao Liu
- Department of Surgery, UPMC Montefiore Hospital, Pittsburgh, PA, USA
| | - Jaideep Behari
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Vikrant Rachakonda
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Swaytha Ganesh
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Amit Tevar
- Department of Surgery, UPMC Montefiore Hospital, Pittsburgh, PA, USA
| | - Hasan Al Harakeh
- Department of Surgery, UPMC Montefiore Hospital, Pittsburgh, PA, USA
| | - Bishoy Emmanuel
- Department of Surgery, UPMC Montefiore Hospital, Pittsburgh, PA, USA
| | - Abhinav Humar
- Department of Surgery, UPMC Montefiore Hospital, Pittsburgh, PA, USA
| | - Ramon Bataller
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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15
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Pena Polanco NA, Martin P, Carrion AF. Advances in the Management of Renal Dysfunction in Patients With Cirrhosis. Gastroenterol Hepatol (N Y) 2021; 17:211-220. [PMID: 34924889 PMCID: PMC8667379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Renal dysfunction frequently develops in patients with advanced liver disease. Renal dysfunction in this setting is associated with adverse outcomes and an unfavorable prognosis. Hepatorenal syndrome (HRS), defined as worsening renal function in patients with advanced cirrhosis that can present either acutely (<3 months) or more indolently in the absence of other etiologies, remains a common cause of acute kidney injury. If reversal is not promptly achieved, rapid decline to mortality is common. Volume expansion and vasoconstrictors are the mainstays of therapy. Terlipressin, a vasopressin analogue licensed in several countries but not in the United States, is currently used for the treatment of HRS. Timely liver transplantation remains the only effective therapeutic option for a large group of patients with persistent renal dysfunction despite pharmacotherapy. In patients with underlying chronic renal dysfunction, simultaneous liver-kidney transplantation should be considered. The aim of this article is to present an overview of renal dysfunction in patients with cirrhosis, including diagnosis and management.
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Affiliation(s)
- Nathalie A Pena Polanco
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Paul Martin
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Andres F Carrion
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida
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16
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17
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Niewiński G, Smyk W, Graczyńska A, Kostrzewa K, Raszeja-Wyszomirska J, Ołdakowska-Jedynak U, Małyszko J, Wójcicki M, Zieniewicz K. Kidney Function After Liver Transplantation in a Single Center. Ann Transplant 2021; 26:e926928. [PMID: 33619240 PMCID: PMC7911851 DOI: 10.12659/aot.926928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Renal dysfunction in the peri-transplant period appears to complicate both short- and long-term outcome of liver transplantation (LT). The aim of this study was to analyze the impact of selected clinical features in the peri-liver transplant period, as well calcineurin inhibitor, particularly tacrolimus given after LT, on kidney function in a single liver transplant center’s experience. Material/Methods A total 125 consecutive liver-grafted individuals (82 M, 43 F), mean age 50±13 y (with alcohol-related liver disease in 48 (38%) patients) were included into the study. Their clinical data were collected in the database until 46 months of follow-up, and the Python packages Pandas (version 0.22.0) and scikit-learn (version 0.21.3) were used for data analysis. Results More advanced liver disease as judged by Child-Pugh class and MELD score differed significantly patients with preserved (serum creatinine SCr <1.5 mg/dL) and impaired (SCr ≥1.5 mg/dL) kidney function before LT. Older age and higher SCr pre-LT were associated with higher levels of SCr after LT in 2 time-points. SCr before LT was correlated with delta SCr for the highest and last recorded value (P<0.0001). Higher amounts of transfused colloids during surgery were associated with increased delta SCr for the highest value (P=0.019) after grafting in logistic regression analysis. There were no associations between SCr after LT and duration of anhepatic phase, urine output ≤100 mL/h, or post-reperfusion syndrome during transplantation (all P>0.05). There were no associations between SCr after LT and tacrolimus trough levels in analyses of correlations and linear regression analyses (all P>0.05). Conclusions We found that pretransplant serum creatinine was the only factor affecting kidney function after LT in our liver transplant center. The restricted fluid policy was safe and effective in terms of long-term renal function. The role of kidney-saving immunosuppressive protocols in preserving renal function long-term after LT was also confirmed.
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Affiliation(s)
- Grzegorz Niewiński
- II Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Wiktor Smyk
- Liver and Internal Medicine Unit, Medical University of Warsaw, Warsaw, Poland
| | - Agata Graczyńska
- II Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | | | | | | | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Maciej Wójcicki
- Liver and Internal Medicine Unit, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Zieniewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
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18
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Madreseh E, Mahmoudi M, Nassiri-Toosi M, Baghfalaki T, Zeraati H. Post Liver Transplantation Survival and Related Prognostic Factors among Adult Recipients in Tehran Liver Transplant Center; 2002-2019. ARCHIVES OF IRANIAN MEDICINE 2020; 23:326-334. [PMID: 32383617 DOI: 10.34172/aim.2020.22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 01/26/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Liver transplantation is a standard treatment for patients with end-stage liver disease (ESLD). However, with increasing demand for this treatment and limited resources, it is available only to patients who are more likely to survive. The primary aim was to determine prognostic factors for survival. METHODS We collected data from 597 adult patients with ESLD, who received a single organ and initial orthotopic liver transplantation (OLT) in our center between 20 March 2008 and 20 March 2018. In this historical cohort study, univariate and multiple Cox model were used to determine prognostic factors of survival after transplantation. RESULTS After a median follow-up of 825 (0-3889) days, 111 (19%) patients died. Survival rates were 88%, 85%, 82% and 79% at 90 days, 1 year, 3 years, and 5 years, respectively. Older patients (HR = 1.27; 95% CI: 1.01-1.59), presence of pre-OLT ascites (HR = 2.03; 95% CI: 1.16-3.57), pre-OLT hospitalization (HR = 1.88; 95% CI:1.02-3.46), longer operative time (HR = 1.006; 95% CI: 1.004-1.008), post-OLT dialysis (HR = 3.51; 95% CI: 2.07-5.94), cancer (HR = 2.69; 95% CI: 1.23-5.89) and AID (HR = 2.04; 95% CI: 1.17-3.56) as underlying disease versus hepatitis, and higher pre-OLT creatinine (HR = 1.67; 95% CI: 1.10-2.52) were associated with decreased survival. CONCLUSION In this center, not only are survival outcomes excellent, but also younger patients, cases with better pre-operative health conditions, and those without complications after OLT have superior survival.
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Affiliation(s)
- Elham Madreseh
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahmood Mahmoudi
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohssen Nassiri-Toosi
- Liver Transplantation Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Taban Baghfalaki
- Department of Statistics, Faculty of Mathematics sciences, Tarbiat Modares University, Tehran, Iran
| | - Hojjat Zeraati
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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19
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Carrion AF, Radhakrishnan R, Martin P. Diagnosis and management of renal dysfunction in patients with cirrhosis. Expert Rev Gastroenterol Hepatol 2020; 14:1-7. [PMID: 31868027 DOI: 10.1080/17474124.2020.1708190] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Renal dysfunction commonly occurs in patients with cirrhosis and is typically associated with poor prognosis. Several pathophysiologic mechanisms are responsible for renal disease in these patients, prompt identification permits individualized management.Areas covered: Pathophysiology, evaluation and differential diagnosis, management and prognosis of renal disease in patients with cirrhosis. Special focus on management of hepatorenal syndrome and indications for simultaneous liver-kidney transplantation.Literature search methodology: a detailed literature search was performed using PubMed without date restrictions. Published guidelines and position papers were also used and cross-referenced to identify additional studies.Expert opinion: The prognostic significance of renal dysfunction in patients with cirrhosis is highlighted by the inclusion of serum creatinine in the model for end-stage liver disease (MELD). Both acute and chronic renal dysfunction result in increased mortality in patients with cirrhosis, although there are marked differences related to the etiology of renal disease. Early recognition and prompt intervention determined by the most likely etiology are key in the management of these patients. Simultaneous liver-kidney transplantation improves patient survival compared to isolated liver transplantation in patients with cirrhosis and persistent renal impairment; however, selection of candidates must be judicious and individualized due to the ongoing shortage of donor kidneys.
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Affiliation(s)
- Andres F Carrion
- Division of Gastroenterology and Hepatology, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Paul Martin
- Division of Gastroenterology and Hepatology, University of Miami Miller School of Medicine, Miami, FL, USA
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Early Persistent Progressive Acute Kidney Injury and Graft Failure Post Liver Transplantation. Transplant Direct 2019; 5:e429. [PMID: 30882034 PMCID: PMC6411224 DOI: 10.1097/txd.0000000000000868] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 12/17/2018] [Accepted: 01/12/2019] [Indexed: 12/24/2022] Open
Abstract
Background Acute kidney injury (AKI) in the setting of liver transplantation is a common and multifaceted complication. Studies in the general population have demonstrated worse prognosis with AKI episodes that persist for a longer duration. Our primary objective was to evaluate the impact of early AKI episodes that are persistent or progressive in nature, on patient outcomes and graft survival. Methods This was a retrospective cohort study including all patients who received a liver transplant between 2011 and 2015 at our center. Moderate to severe AKI episodes (AKIN II or III) were recorded immediately before transplantation and after surgery until hospital discharge. We evaluated the incidence density rate (IDR) of graft failure and the time to graft failure in patients with persistent or progressive AKI (ppAKI) as compared to controls. Results Two hundred seventy-nine patients received 301 deceased donor liver allografts. Progressive or persistent AKI was documented in more than half of transplant cases (152/301). The rate of graft loss was 3 times higher in the ppAKI group (25%) versus the controls (8.7%). The IDR of graft failure was 13.79 per 100 case-years in the ppAKI group as compared with 3.79 per 100 case-years in the controls (IDR ratio, 3.64; 95 % confidence interval, 1.88–7.50). After adjusting for hepatic artery thrombosis, ischemic cholangiopathy, infectious complications and Model for End-stage Liver Disease, ppAKI was associated with a decreased graft survival time. Conclusions Persistent or progressive AKI after liver transplantation is associated with an increased incidence rate of graft failure and is an independent predictor of decreased graft survival time.
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