Prospective Randomized Trial Comparing Hepatic Venous Outflow and Renal Function after Conventional versus Piggyback Liver Transplantation

Abstract

BackgroundThis randomized prospective clinical trial compared the hepatic venous outflow drainage and renal function after conventional with venovenous bypass (n = 15) or piggyback (n = 17) liver transplantation.MethodsFree hepatic vein pressure (FHVP) and central venous pressure (CVP) measurements were performed after graft reperfusion. Postoperative serum creatinine (Cr) was measured daily on the first week and on the 14th, 21st and 28th postoperative days (PO). The prevalence of acute renal failure (ARF) up to the 28th PO was analyzed by RIFLE-AKIN criteria. A Generalized Estimating Equation (GEE) approach was used for comparison of longitudinal measurements of renal function.ResultsFHVP-CVP gradient > 3 mm Hg was observed in 26.7% (4/15) of the patients in the conventional group and in 17.6% (3/17) in the piggyback group (p = 0.68). Median FHVP-CVP gradient was 2 mm Hg (0–8 mmHg) vs. 3 mm Hg (0–7 mm Hg) in conventional and piggyback groups, respectively (p = 0.73). There is no statistically significant difference between the conventional (1/15) and the piggyback (2/17) groups regarding massive ascites development (p = 1.00). GEE estimated marginal mean for Cr was significantly higher in conventional than in piggyback group (2.14 ± 0.26 vs. 1.47 ± 0.15 mg/dL; p = 0.02). The conventional method presented a higher prevalence of severe ARF during the first 28 PO days (OR = 3.207; 95% CI, 1.010 to 10.179; p = 0.048).ConclusionPatients submitted to liver transplantation using conventional or piggyback methods present similar results regarding venous outflow drainage of the graft. Conventional with venovenous bypass technique significantly increases the harm of postoperative renal dysfunction.Trial RegistrationClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT01707810

Piggyback or Cava Replacement: Which Implantation Technique Protects Liver Recipients From Acute Kidney Injury and Complications?

“…The implementation of the PB technique was always related to the idea to prevent IVC clamping, to maintain venous backflow, and to reduce the necessity of VVB, which is also known to induce a certain hemodynamic recipient instability . Total cava clamping and the consecutive interruption of blood outflow from the inferior body including the kidneys has been discussed as a crucial intraoperative risk factor of AKI development after LT . However, general data are scarce, and our results did not support such historical ideas.…”

Intraoperative Hepatic Blood Inflow Can Predict Early Acute Kidney Injury following DCD Liver Transplantation: A Retrospective Observational Study

“…Systemic hemodynamic changes after LT are the cause of postoperative AKI [27]. Longer anhepatic phase, longer operation time, and larger pRBC transfusion all influence systemic hemodynamics and then influence renal blood perfusion.…”

Trial design and endpoints in clinical transplant research

“…If the block sizes are known to the investigators, it may become possible to predict the allocation of the next patient within a centre at the end of each block. An example of this is seen in a recent trial of conventional versus piggy‐back venous drainage in liver transplantation . Patients were stratified by Child–Pugh score and randomized in blocks of size 2.…”