Intraoperative renal support during liver transplantation

Abstract

Acute kidney injury (AKI) is common in liver failure prior to orthotopic liver transplantation (OLT) and may complicate the intraoperative course. We describe the logistics of intraoperative continuous renal replacement therapy (CRRT) during OLT and the associated clinical outcomes. We performed a retrospective review of adult patients (age Ͼ 18 years) receiving intraoperative CRRT during OLT at the University of Alberta Hospital between January 1, 1996 and December 31, 2005. Demographic, detailed clinical, and perioperative data, physiologic and laboratory measures, details of renal replacement therapy (RRT) provided, and data on renal recovery and survival were ascertained. Of 636 OLTs, 41 (6.4%) received intraoperative CRRT. The most common indications for OLT in these patients were hepatitis C (34.2%) and alcoholic (29.3%) cirrhosis. The median [interquartile range (IQR)] Model for End-Stage Liver Disease score was 38 (31-43), and 90.2% were classified as Child-Pugh class C. Preoperatively, 70% were in the intensive care unit, 58.5% were mechanically ventilated, and 48.7% required vasopressor support. The median (IQR) duration of intraoperative CRRT was 258 (189-390) minutes, representing 57% of the total operative time. Filter circuit clotting occurred in 40% but was not associated with a shorter CRRT duration (P ϭ 0.41). No other complications were described. CRRT allowed an even or negative intraoperative fluid balance in 92.7%. CRRT was continued in 78% after OLT for a median (IQR) of 5 (3-11) days. Of these, 24 (75%) were transitioned to intermittent hemodialysis for a median (IQR) of 15 (4-39) days. Survival was 97.6% at 1 month and 75.6% at 1 year. Renal recovery to RRT independence occurred in 100% of survivors by 1 year; however, the mean (standard deviation) estimated glomerular filtration rate (eGFR) was 54.7 (19.1) mL/minute/m 2 , with 62.1% having an eGFR Ͻ 60 mL/minute/m 2 . In conclusion, our data suggest that intraoperative CRRT during OLT is achievable and safe. Intraoperative CRRT may be a valuable adjuvant therapy for those with preoperative AKI. Additional investigations are warranted. Liver Transpl 15:73-78, 2009.

The Challenges of Providing Renal Replacement Therapy in Decompensated Liver Cirrhosis

“…This study demonstrates that intraoperative CRRT is feasible and is useful in providing negative or even fluid balance despite a large number of blood transfusions in this cohort [27]. Although it is not clear from the study findings, presumptively intra-operative CRRT was also beneficial in managing hyperkalemia and metabolic acidosis, both of which are common during liver transplantation surgery.…”

“…Townsend et al [27] described their experience with intraoperative CRRT. Overall, intraoperative CRRT was used in 41 patients (6.4%) at their center.…”

An Evaluation of Intraoperative Renal Support during Liver Transplantation: A Matched Cohort Study

“…We recently described the feasibility and safety of intraoperative CRRT in a series of 41 patients undergoing LT; however, this study was limited by lack of a control group for comparison [19]. Accordingly, we performed a follow-up matched cohort study of intraoperative CRRT during LT. Our objectives were to: (1) describe the factors associated with the use of intraoperative CRRT; (2) describe the impact of intraoperative CRRT on metabolic and acid-base homeostasis; (3) describe the impact of intraoperative CRRT on occurrence of postoperative complications, and (4) evaluate for differences in postoperative treatment intensity, resource use, morbidity and mortality between those receiving intraoperative CRRT and controls.…”

Renal Dysfunction and Liver Transplantation

“…Indications included either typical, life threatening symptoms of AKI, such as overhydration or hyperkalemia, or disorders typical for this group of patients: lactic acidosis, hyponatremia, risk of brain oedema or necessity of transfusion of large volumes of blood preparations. In 78% of cases, CVVHD procedures were continued after OLT for 3-11 days (Townsend et al, 2009). …”