Modifiable risk factors of acute kidney injury after liver transplantation: a systematic review and meta-analysis

Low preoperative serum uric acid is associated with early acute kidney injury after living donor liver transplantation

BACKGROUND

Liver transplantation is treatment option for patients with end-stage liver disease and hepatocellular carcinoma. Renal function deterioration significantly impacts the survival rates of liver recipients, and serum uric acid (SUA) is associated with both acute and chronic renal function disorders. Thus, our study aimed to assess the relationship and predictive value of preoperative SUA level and postoperative acute kidney injury (AKI) in living donor liver transplantation (LDLT).

METHODS

We conducted a prospective observational study on 87 patients undergoing LDLT. Blood samples were collected immediately before LDLT, and renal function status was followed up for 3 consecutive days postoperatively.

RESULTS

Low SUA levels (cutoff value 4.15 mg/dL) were associated with a high risk of early posttransplantation AKI. The area under the curve was 0.73 (sensitivity, 79.2%; specificity, 59.4%). Although not statistically significant, there were no deaths in the non-AKI group but two in the early AKI group secondary to liver graft dysfunction in addition to early AKI within the first month after LDLT.

CONCLUSION

AKI after liver transplantation may lead to a deterioration of patient status and increased mortality rates. We determined low preoperative SUA levels as a possible risk factor for early postoperative AKI.

Intraoperative kidney replacement therapy in acute liver failure

Paediatric acute liver failure (PALF) is often characterised by its rapidity of onset and potential for significant morbidity and even mortality. Patients often develop multiorgan dysfunction/failure, including severe acute kidney injury (AKI). Whilst the management of PALF focuses on complications of hepatic dysfunction, the associated kidney impairment can significantly affect patient outcomes. Severe AKI requiring continuous kidney replacement therapy (CKRT) is a common complication of both PALF and liver transplantation. In both scenarios, the need for CKRT is a poor prognostic indicator. In adults, AKI has been shown to complicate ALF in 25-50% of cases. In PALF, the incidence of AKI is often higher compared to other critically ill paediatric ICU populations, with reports of up to 40% in some observational studies. Furthermore, those presenting with AKI regularly have a more severe grade of PALF at presentation. Observational studies in the paediatric population corroborate this, though data are not as robust-mainly reflecting single-centre cohorts. Perioperative benefits of CKRT include helping to clear water-soluble toxins such as ammonia, balancing electrolytes, preventing fluid overload, and managing raised intracranial pressure. As liver transplantation often takes 6-10 h, it is proposed that these benefits could be extended to the intraoperative period, avoiding any hiatus. Intraoperative CKRT (IoCKRT) has been shown to be practicable, safe and may help sicker recipients tolerate the operation with outcomes analogous with less ill patients not requiring IoCKRT. Here, we provide a comprehensive guide describing the rationale, practicalities, and current evidence base surrounding IoCKRT during transplantation in the paediatric population.

Post Liver Transplant Renal Dysfunction-Evaluation, Management and Immunosuppressive Practice

Liver transplantation (LT) is an effective and lifesaving treatment for patients with end-stage liver disease and hepatocellular carcinoma. Significant improvement in intermediate and long-term survival has been possible due to advancements in immunosuppressive therapy, perioperative care, and surgical techniques. Despite these advances, metabolic complications, including diabetes mellitus, cardiovascular diseases, malignancies, and renal dysfunction, are challenging issues after LT. Acute kidney injury (AKI) and chronic kidney disease (CKD) after LT are common and result in significant morbidity and mortality. Early diagnosis of kidney injury after LT is challenging, and no technique has yet proven effective in prediction of renal dysfunction. The methods for assessing renal function range from formulas that predict glomerular filtration rate to non-invasive biomarkers. The universal adoption of the model for end-stage liver disease has a direct impact on the incidence of peri-transplant AKI and development of CKD in the long-term. Post-LT renal dysfunction is multifactorial and is usually a result of pre-transplantation comorbidities, occurrence of renal dysfunction on the waiting list, perioperative events, and post-transplant nephrotoxic immunosuppressive medication use. Early identification of patients at risk for renal dysfunction and adoption of preventive measures are crucial in the pre-transplant period. No data are currently available to suggest a surgical technique that reliably demonstrates renal protection. Nephroprotective strategies during LT follow accepted surgical practice guidelines, such as maintenance of intravascular volume and mean arterial pressure. The management of kidney disease following LT is challenging, as by the time the serum creatinine is significantly elevated, few interventions impact the course of progression. Early nephroprotective measures are strongly advised and they mostly center on delaying the administration of calcineurin inhibitors (CNIs) during the initial postoperative period, lowering CNI dosage and combining CNI with mycophenolate mofetil and everolimus. The reasons for renal failure following LT, the techniques used to diagnose it, and the therapies designed to preserve renal function both immediately and late after LT are all critically evaluated in this review.

Impact of renal recovery on in-hospital and post-discharge mortality

OBJECTIVE

To verify the impact of renal recovery on mortality in non-critically ill patients with acute kidney injury.

METHOD

A prospective cohort study was carried out in a public hospital in the Federal District with patients with acute kidney injury admitted to a non-critical care unit. Renal recovery was assessed based on the ratio of serum creatinine to baseline creatinine and the patient was followed up for 6 months. Mortality was assessed during hospitalization and after discharge.

RESULTS

Of the 90 patients with hospital-acquired kidney injury, renal recovery was identified in 34.1% to 75% of cases, depending on the time of assessment, considering a follow-up period of up to 6 months. Recovery of renal function during follow-up had an impact on in-hospital mortality [95% CI 0.15 (0.003 - 0.73; p = 0019).

CONCLUSION

Recovery of renal function has been shown to be a protective factor for mortality in patients admitted to the non-critical care unit. Early identification of kidney damage and monitoring of physiological and laboratory variables proved to be fundamental in identifying the severity of the disease and reducing mortality.

Impact of patent foramen ovale on short-term outcomes in children with biliary atresia undergoing living donor liver transplantation: a retrospective cohort study

OBJECTIVE

To investigate the impact of patent foramen ovale (PFO) on the short-term outcomes of living donor liver transplantation (LDLT) in children with biliary atresia.

METHODS

With the approval of the hospital ethics committee, 304 children with biliary atresia who underwent LDLT in our center from January 2020 to December 2021 were enrolled. According to the results of echocardiography before the operation, the subjects were divided into the PFO group (n = 73) and the NoPFO group (n = 231). The baseline characteristics; intraoperative recipient-related data and donor-related data; incidence of postreperfusion syndrome (PRS); postoperative mechanical ventilation time; ICU stay duration; postoperative hospital stay duration; liver function index; incidences of postoperative complications including acute renal injury (AKI), graft dysfunction, hepatic artery thrombosis (HAT) and portal vein thrombosis (PVT); and one-year survival rate were compared between the two groups.

RESULTS

The median age in the PFO group was 6 months and that in the NoPFO group was 9 months (P < 0.001), and the median height (65 cm) and weight (6.5 kg) in the PFO group were significantly lower than those in the NoPFO group (68 cm, 8.0 kg) (P < 0.001). The preoperative total bilirubin level (247 vs. 202 umol/L, P = 0.007) and pediatric end-stage liver disease (PELD) score (21 vs. 16, P = 0.001) in the PFO group were higher than those in the NoPFO group. There were no significant differences in the intraoperative PRS incidence (46.6% vs. 42.4%, P = 0.533 ), postoperative mechanical ventilation time (184 vs. 220 min, P = 0.533), ICU stay duration (3.0 vs. 2.5 d, P = 0.267), postoperative hospital stay duration (22 vs. 21 d, P = 0.138), AKI incidence (19.2% vs. 24.7%, P = 0.333), graft dysfunction incidence (11.0% vs. 12.6%, P = 0.716), HAT incidence (5.5% vs. 4.8%, P = 0.762), PVT incidence (2.7% vs. 2.2%, P = 0.675) or one-year survival rate (94.5% vs. 95.7%, P = 0.929) between the two groups.

CONCLUSION

The presence of PFO has no negative impact on short-term outcomes in children with biliary atresia after LDLT.

Risk factors of immune checkpoint inhibitor-associated acute kidney injury: evidence from clinical studies and FDA pharmacovigilance database

BACKGROUND

Several risk factors of immune checkpoint inhibitors (ICIs)-associated acute kidney injury (AKI) have been reported sporadically. To identify the risk factors of ICIs-associated AKI in a large-scale population, therefore we conducted a systematic review and a real-world retrospective study.

METHODS

We search literature concerning risk factors of ICIs-associated AKI in ClinicalTrials.gov and electronic databases (PubMed, Cochrane Library, Embase) up to January 2022. Meta-analysis was performed by using odds ratios (ORs) with 95%CIs. In a separate retrospective pharmacovigilance study by extracting data from US FDA Adverse Event Reporting System (FAERS) database, disproportionality was analyzed using the reporting odds ratio (ROR).

RESULTS

A total of 9 studies (5927 patients) were included in the meta-analysis. The following factors were associated with increased risk of ICIs-associated AKI, including proton pump inhibitors(PPIs) (OR = 2.07, 95%CI 1.78-2.42), angiotensin-converting enzyme inhibitors (ACEIs)/ angiotensin receptor blockers (ARBs) (OR = 1.56, 95%CI 1.24-1.95), nonsteroidal anti-inflammatory drugs (NSAIDs) (OR = 1.29, 95%CI 1.01-1.65), diuretics (OR = 2.00, 95%CI 1.38-2.89), diabetes mellitus (OR = 1.28, 95%CI 1.04-1.57), genitourinary cancer (OR = 1.46, 95%CI 1.15-1.85), combination therapy of ICIs (OR = 1.93, 95%CI 1.25-2.97) and extrarenal immune-related adverse events(irAEs) (OR = 2.51, 95%CI 1.96-3.20). Furthermore, analysis from FAERS database verified that concurrent exposures of PPIs (ROR = 2.10, 95%CI 1.91-2.31), ACEIs/ARBs (ROR = 3.25, 95%CI 2.95-3.57), NSAIDs (ROR = 3.06, 95%CI 2.81-3.32) or diuretics (ROR = 2.82, 95%CI 2.50-3.19) were observed significant signals associated with AKI in ICIs-treated patients.

CONCLUSIONS

Concurrent exposures of PPIs, ACEIs/ARBs, NSAIDs or diuretics, diabetes mellitus, genitourinary cancer, combination therapy, and extrarenal irAEs seem to increase the risk of AKI in ICIs-treated patients.

Lack of furosemide responsiveness predict severe acute kidney injury after liver transplantation

Acute kidney injury (AKI) remains to be a common but severe complication after liver transplantation (LT). However, there are still few clinically validated biomarkers. A total of 214 patients who underwent routine furosemide (1-2 mg/kg) after LT were retrospectively included. The urine output during the first 6 h was recorded to evaluate the predictive value of AKI stage 3 and renal replacement therapy (RRT). 105 (49.07%) patients developed AKI, including 21 (9.81%) progression to AKI stage 3 and 10 (4.67%) requiring RRT. The urine output decreased with the increasing severity of AKI. The urine output of AKI stage 3 did not significantly increase after the use of furosemide. The area under the receiver operator characteristic (ROC) curves for the total urine output in the first hour to predict progression to AKI stage 3 was 0.94 (p < 0.001). The ideal cutoff for predicting AKI progression during the first hour was a urine volume of less than 200 ml with a sensitivity of 90.48% and specificity of 86.53%. The area under the ROC curves for the total urine output in the six hours to predict progression to RRT was 0.944 (p < 0.001). The ideal cutoff was a urine volume of less than 500 ml with a sensitivity of 90% and specificity of 90.91%. Severe AKI after liver transplantation seriously affects the outcome of patients. Lack of furosemide responsiveness quickly and accurately predict AKI stage 3, and patients requiring RRT after the operation.

Prädiktoren für erfolgreiche Lebertransplantationen und Risikofaktoren

Die Lebertransplantation ist die einzige kurative Therapieoption einer chronischen Leberinsuffizienz im Endstadium. Daneben stellen onkologische Lebererkrankungen wie das HCC eine weitere Indikation für die Lebertransplantation dar, ebenso wie das akute Leberversagen.

Seit der ersten erfolgreichen Lebertransplantation durch Professor Thomas E. Starzl im Jahr 1967 haben sich nicht nur die chirurgischen, immunologischen und anästhesiologischen Techniken und Möglichkeiten geändert, sondern auch die Indikationen und das Patientengut. Hinzu kommt, dass die Empfänger ein zunehmendes Lebensalter und damit einhergehend mehr Begleiterkrankungen aufweisen.

Die Zahl an Lebertransplantationen ist weltweit weiter ansteigend. Es benötigen aber mehr Menschen eine Lebertransplantation, als Organe zur Verfügung stehen. Dies liegt am zunehmenden Bedarf an Spenderorganen bei gleichzeitig weiter rückläufiger Zahl postmortaler Organspenden.

Diese Diskrepanz zwischen Spenderorganen und Empfängern kann nur zu einem kleinen Teil durch Split-Lebertransplantationen oder die Leberlebendspende kompensiert werden.

Um den Spenderpool zu erweitern, werden zunehmend auch marginale Organe, die nur die erweiterten Spenderkriterien („extended donor criteria [EDC]“) erfüllen, allokiert. In manchen Ländern zählen hierzu auch die sogenannten DCD-Organe (DCD: „donation after cardiac death“), d. h. Organe, die erst nach dem kardiozirkulatorischen Tod des Spenders entnommen werden.

Es ist bekannt, dass marginale Spenderorgane mit einem erhöhten Risiko für ein schlechteres Transplantat- und Patientenüberleben nach Lebertransplantation einhergehen.

Um die Qualität marginaler Spenderorgane zu verbessern, hat sich eine rasante Entwicklung der Techniken der Organkonservierung über die letzten Jahre gezeigt. Mit der maschinellen Organperfusion besteht beispielsweise die Möglichkeit, die Organqualität deutlich zu verbessern. Insgesamt haben sich die Risikokonstellationen von Spenderorgan und Transplantatempfänger deutlich geändert.

Aus diesem Grunde ist es von großer Bedeutung, spezifische Prädiktoren für eine erfolgreiche Lebertransplantation sowie die entsprechenden Risikofaktoren für einen schlechten postoperativen Verlauf zu kennen, um das bestmögliche Transplantat- und Patientenüberleben nach Lebertransplantation zu ermöglichen.

Diese Einflussfaktoren, inklusive möglicher Risiko-Scores, sollen hier ebenso wie die neuen technischen Möglichkeiten in der Lebertransplantation beleuchtet werden.

Continuous Renal Replacement Therapy after Liver Transplantation: Peri-Operative Associated Factors and Impact on Survival

Continuous renal replacement therapy (CRRT) following orthotopic liver transplantation (OLT) is usually started for multifactorial reasons, with variable incidence among series. This paper presents a single-center retrospective observational study on the early use (within one week) of CRRT after consecutive cadaveric OLT from January 2008 to December 2016. Preoperative patient characteristics and intraoperative data were collected, and patients were divided into two groups (CRRT and no CRRT) to explore the factors associated with the use of CRRT. Repeated measurements of postoperative creatinine were analyzed with generalized estimating equation (GEE) models. Among 528 OLT patients, 75 (14.2%) were treated with CRRT at least once in the first week. Patients treated with CRRT showed lower survival in a Kaplan−Meier curve (log-rank p value < 0.01). Patients treated with CRRT had a more severe preoperative profile, with a significantly higher age, MELD, BUN, creatinine, and total bilirubin, as well as a longer surgery time and a higher number of transfusions of red blood cells, plasma, and platelets (all p values < 0.05). In a stepwise multiple analysis, the following characteristics remained independently associated with the use of CRRT: the MELD score OR 1.12 (95% CL: 1.07−1.16), p value < 0.001, and the preoperative value for blood urea nitrogen OR 1.016 (95% CL: 1.010−1.023), p value < 0.001. The early use of CRRT after OLT occurred at a low rate in this large cohort; however, it was associated with worse outcomes. Apart from the preoperative severity, repeated intraoperative hypotension episodes, which were likely modifiable or preventable, were associated with the increased use of CRRT and higher postoperative creatinine.

Abdominal Organ Transplantation: Noteworthy Literature in 2021

This review highlights noteworthy literature pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. In 2021, we identified noteworthy papers from over 1,200 peer-reviewed publications on pancreatic transplantation, over 1,400 on intestinal transplantation, and over 9,000 on kidney transplantation. The liver transplantation section focuses on clinical trials and systematic reviews and meta-analyses published in 2021 and features 20 selected papers. COVID-19 and abdominal organ transplantation are featured in an independent section.

Perioperative management of adult living donor liver transplantation: Part 1 - recipients

Living donor liver transplantation was first developed to mitigate the limited access to deceased donor organs in Asia in the 1990s. This alternative liver transplantation option has become an established and widely practiced transplantation method for adult patients suffering from end-stage liver disease. It has successfully addressed the shortage of deceased donors. The Society for the Advancement of Transplant Anesthesia and the Korean Society of Transplant Anesthesia jointly reviewed published studies on the perioperative management of live donor liver transplant recipients. The review aims to offer transplant anesthesiologists and critical care physicians a comprehensive overview of the perioperative management of adult live liver transplantation recipients. We feature the status, outcomes, surgical procedure, portal venous decompression, anesthetic management, prevention of acute kidney injury, avoidance of blood transfusion, monitoring and therapeutic strategies of hemodynamic derangements, and Enhanced Recovery After Surgery protocols for liver transplant recipients. This article is protected by copyright. All rights reserved.

Risk factors of the post-reperfusion syndrome during orthotopic liver transplantation: a clinical observational study

Background

Post reperfusion syndrome (PRS) is a relatively common and life-threatening complication during orthotopic liver transplantation (OLT). It is associated with poor patient and transplanted liver outcomes.

Objective

This study aimed to compare the risk factors of PRS during OLT.

Design

Clinical-epidemiological observational retrospective study.

Setting

We gathered the records of patients who underwent OLT in 3 years, from May 22, 2016, to May 22, 2019, in Namazi and Bu-Ali Sina organ transplantation hospitals.

Patients

In this study, we assessed 1182 patients who underwent OLT. Patients were divided into two groups based on the presence or absence of PRS.

Main outcome measures

Diagnosing the predictors of PRS was the primary outcome of this study.

Results

Results showed that age > 60 years, Child-Pugh scores C, higher Model End Stage liver disease score, and preoperative sodium < 130 mmol/l (parameters of the liver recipient), increase in cold ischemic time (the donors’ parameters), and the classical technique (the surgical parameters) were the strong predictors of PRS.

Conclusions

The results indicated that underlying liver disease was not the predictor of PRS in the presence of other risk factors; therefore, clinicians have to consider these risk factors in patients undergoing OLT.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01635-3.

Perioperative acute kidney injury: impact and recent update

PURPOSE OF REVIEW

Acute kidney injury (AKI) is common in hospitalized patients and is a major risk factor for increased length of stay, morbidity, and mortality in postoperative patients. There are multiple barriers to reducing perioperative AKI - the etiology is multi-factorial and the diagnosis is fraught with issues. We review the recent literature on perioperative AKI and some considerations for anesthesiologists that examine the far-reaching effects of AKI on multiple organ systems.

RECENT FINDINGS

This review will discuss recent literature that addresses the epidemiology, use of novel biomarkers in risk stratification, and therapeutic modalities for AKI in burn, pediatrics, sepsis, trauma, cardiac, and liver disease, contrast-induced AKI, as well as the evidence assessing goal-directed fluid therapy.

SUMMARY

Recent studies address the use of risk stratification models and biomarkers, more sensitive than creatinine, in the preoperative identification of patients at risk for AKI. Although exciting, these scores and models need validation. There is a need for research assessing whether early AKI detection improves outcomes. Enhanced recovery after surgery utilizing goal-directed fluid therapy has not been shown to make an appreciable difference in the incidence of AKI. Reducing perioperative AKI requires a multi-pronged and possibly disease-specific approach.

Risk factors and prediction of acute kidney injury after liver transplantation: Logistic regression and artificial neural network approaches

BACKGROUND

Acute kidney injury (AKI) has serious consequences on the prognosis of patients undergoing liver transplantation. Recently, artificial neural network (ANN) was reported to have better predictive ability than the classical logistic regression (LR) for this postoperative outcome.

AIM

To identify the risk factors of AKI after deceased-donor liver transplantation (DDLT) and compare the prediction performance of ANN with that of LR for this complication.

METHODS

Adult patients with no evidence of end-stage kidney dysfunction (KD) who underwent the first DDLT according to model for end-stage liver disease (MELD) score allocation system was evaluated. AKI was defined according to the International Club of Ascites criteria, and potential predictors of postoperative AKI were identified by LR. The prediction performance of both ANN and LR was tested.

RESULTS

The incidence of AKI was 60.6% (n = 88/145) and the following predictors were identified by LR: MELD score > 25 (odds ratio [OR] = 1.999), preoperative kidney dysfunction (OR = 1.279), extended criteria donors (OR = 1.191), intraoperative arterial hypotension (OR = 1.935), intraoperative massive blood transfusion (MBT) (OR = 1.830), and postoperative serum lactate (SL) (OR = 2.001). The area under the receiver-operating characteristic curve was best for ANN (0.81, 95% confidence interval [CI]: 0.75-0.83) than for LR (0.71, 95%CI: 0.67-0.76). The root-mean-square error and mean absolute error in the ANN model were 0.47 and 0.38, respectively.

CONCLUSION

The severity of liver disease, pre-existing kidney dysfunction, marginal grafts, hemodynamic instability, MBT, and SL are predictors of postoperative AKI, and ANN has better prediction performance than LR in this scenario.

Predictive Role of the D-Dimer Level in Acute Kidney Injury in Living Donor Liver Transplantation: A Retrospective Observational Cohort Study

This study aimed to determine the association between serum D-dimer levels and the risk of acute kidney injury (AKI) in patients undergoing living donor liver transplantation (LDLT). Clinical data of 675 patients undergoing LDLT were retrospectively analyzed. The exclusion criteria included a history of kidney dysfunction, emergency cases, and missing data. The final study population of 617 patients was divided into the normal and high D-dimer groups (cutoff: 0.5 mg/L). After LDLT, 145 patients (23.5%) developed AKI. A high D-dimer level (>0.5 mg/L) was an independent predictor of postoperative development of AKI in the multivariate analysis when combined with diabetes mellitus [DM], platelet count, and hourly urine output. AKI was significantly higher in the high D-dimer group than in the normal D-dimer group (odds ratio [OR], 2.792; 95% confidence interval [CI], 1.227-6.353). Patients with a high D-dimer exhibited a higher incidence of early allograft dysfunction, longer intensive care unit stay, and a higher mortality rate. These results could improve the risk stratification of postoperative AKI development by encouraging the determination of preoperative D-dimer levels in patients undergoing LDLT.

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

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