Development of AKI within the first 72 h after transplant impacted short-term and long-term graft survival.

The greatest part of liver allograft injury occurs during reperfusion, not during the cold ischemia phase. The aim of this study, therefore, was to investigate how the severity of postreperfusion syndrome (PRS) influences short-term outcome for the patient and for the liver allograft. Over a 2-year period, 338 consecutive patients who presented for orthotopic liver transplantation (OLT) were included in this retrospective study. They were divided into 2 groups according to the severity of the PRS they experienced. The first group comprised 152 patients with mild or no PRS; the second group comprised 186 patients with significant PRS. Perioperative hemodynamic parameters, coagulation profiles, blood product requirements, incidence of infection, incidence of rejection and outcome data for both groups were collected and analyzed. There was no demographic difference between the groups except for age; group 2 had older patients than group 1 (54.94 Ϯ 9.07 versus 51.52 Ϯ 9.91, P ϭ 0.001). Compared to group 1, group 2 patients required more red blood cell transfusions (11.31 Ϯ 10.90 versus 8.08 Ϯ 7.89 units, P ϭ 0.002), more fresh frozen plasma transfusions (10.25 Ϯ 10.96 versus 7.03 Ϯ 7.64 units, P ϭ 0.002), more cryoprecipitate (1.88 Ϯ 4.72 units versus 0.61 Ϯ 1.80 units, P ϭ 0.001), and were more likely to suffer from fibrinolysis (52.7% versus 41.4%, P ϭ 0.041). Interestingly, group 2 had a shorter average warm ischemia time than group 1 (33.19 Ϯ 8.55 versus 36.21 Ϯ 11.83 minutes, P ϭ 0.01). Group 2 also required longer, on average, mechanical ventilation (14.95 Ϯ 29.79 versus 8.55 Ϯ 17.79 days, P ϭ 0.015), remained in the intensive care unit longer (17.65 Ϯ 31.00 versus 11.49 Ϯ 18.67 days, P ϭ 0.025), and had a longer hospital stay (27.29 Ϯ 32.35 versus 20.85 Ϯ 21.08 days, P ϭ 0.029). Group 2 was more likely to require retransplantation (8.6% versus 3.3%, P ϭ 0.044). In conclusion, the severity of PRS during OLT appears to be related to the outcome of patient and liver allograft.

Introduction Dexmedetomidine is a highly selective α2-adrenoceptor agonist with sedative, anxiolytic and analgesic properties that has minimal effects on respiratory drive. Its sedative and hypotensive effects are mediated via central α2A and imidazoline type 1 receptors while activation of peripheral α2B–adrenoceptors result in an increase in arterial blood pressure and systemic vascular resistance (SVR). In this randomized, prospective, clinical study we attempted to quantify the short-term hemodynamic effects resulting from a rapid IV bolus administration of dexmedetomidine in pediatric cardiac transplant patients. Methods Twelve patients, aged ≤10 years of age, weighing ≤40kg, presenting for routine surveillance of right and left heart cardiac catheterization after cardiac transplantation were enrolled. After an inhaled or IV induction, the tracheas were intubated and anesthesia was maintained with 1 minimum alveolar concentration of isoflurane in room air, fentanyl (1mcg/kg) and rocuronium (1mg/kg). At the completion of the planned cardiac catheterization, 100% oxygen was administered. After recording a set of baseline values that included heart rate (HR), systolic blood pressure, diastolic blood pressure, central venous pressure, systolic pulmonary artery pressure, diastolic pulmonary artery pressure, pulmonary artery wedge pressure and thermodilution-based cardiac output, a rapid IV dexmedetomidine bolus of either 0.25mcg/kg or 0.5mcg/kg was administered over 5 seconds. The hemodynamic measurements were repeated at 1 min and 5 mins. Results There were 6 patients in each group. Investigation suggested that systolic blood pressure, diastolic blood pressure, systolic pulmonary artery pressure, diastolic pulmonary artery pressure, pulmonary artery wedge pressure and systemic vascular resistance all increased at 1 minute after rapid IV bolus for both doses, and decreased significantly to near baseline for both doses by 5 minutes. The transient increase in pressures was more pronounced in the systemic system than in the pulmonary system. In the systemic system there was a larger percent increase in the diastolic pressures than the systolic pressures. Cardiac output, CVP and pulmonary vascular resistance did not change significantly. HR decreased at 1 min for both doses and was, within the 0.5 mcg/kg group, the only hemodynamic variable still changed from baseline at the 5 min time point Conclusion Rapid IV bolus administration of dexmedetomidine in this small sample of children having undergone heart transplants was clinically well tolerated, although it resulted in a transient but significant increase in systemic and pulmonary pressure and a decrease in HR. In the systemic system there is a larger percent increase in the diastolic pressures than the systolic pressures, and furthermore these transient increases in pressures were more pronounced in the systemic system than in the pulmonary system.

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Introduction Acute kidney injury (AKI) is a common complication after liver transplantation (LT). Few studies investigating the incidence and risk factors for AKI after live donor LT (LDLT) have been published. Hypothesis LDLT recipients have a lower risk for post-LT AKI than cadaveric donor LT (CDLT) recipients due to higher quality liver grafts. Methods We retrospectively reviewed LDLTs and CDLTs performed at the University of Pittsburgh Medical Center between Jan. 2006 and Dec. 2011. AKI was defined as a 50% increase in serum creatinine (SCr) from baseline (preoperative) values within 48 hours (1). One hundred LDLT and 424 CDLT recipients were included in the propensity score matching logistic model based on age, gender, MELD score, Child score, pre-transplant SCr, and pre-existing diabetes mellitus. Eighty-six pairs were created after one-to-one propensity-matching. The binary outcome of AKI was analyzed using mixed effects logistic regression, incorporating the main exposure of interest (LDLT versus CDLT) with the aforementioned matching criteria and post-reperfusion syndrome, number of units of packed red cells, and donor age as fixed effects. Results In the corresponding matched dataset, the incidence of AKI at 72 hours was 23.3% in the LDLT group, significantly lower than 44.2% in the CDLT group (p=0.004). Multivariable mixed effects logistic regression showed that live donor liver allografts were significantly associated with reduced odds of AKI at 72 hours post-LT (p=0.047, OR=0.307; 95% CI 0.096–0.984). The matched patients had lower body weights, better-preserved liver functions, and more stable intraoperative hemodynamic parameters. The donors were also younger for the matched patients than for the un-matched patients. Conclusion Receiving a graft from live donor has a protective effect against early post-LT AKI.