Risk factors for renal dysfunction in the postoperative course of liver transplant

Gallardo, Miguel Lebrón; Gutiérrez, Manuel Elías; Pérez, Gemma Seller; Balsera, Emilio Curiel; Ortega, Juan F. Fernández; García, G. Quesada

doi:10.1002/lt.20215

Cited by 116 publications

(64 citation statements)

References 19 publications

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“…Intraoperative blood transfusion is known to affect postoperative renal outcomes in OLT patients [18–20]. A biologically plausible explanation for this association is that kidney hypoperfusion secondary to intraoperative bleeding represents an additional renal insult in patients with pre-OLT AKI.…”

Section: Discussionmentioning

confidence: 99%

Predictors of renal function recovery among patients undergoing renal replacement therapy following orthotopic liver transplantation

et al. 2017

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Renal dysfunction frequently occurs during the periods preceding and following orthotopic liver transplantation (OLT), and in many cases, renal replacement therapy (RRT) is required. Information regarding the duration of RRT and the rate of kidney function recovery after OLT is crucial for transplant program management. We evaluated a sample of 155 stable patients undergoing post-intensive care hemodialysis (HD) from a patient population of 908 adults who underwent OLT. We investigated the average time to renal function recovery (duration of RRT required) and determined the risk factors for remaining on dialysis > 90 days after OLT. Log-rank tests were used for univariate analysis, and Cox proportional hazards models were used to identify factors associated with the risk of remaining on HD. The results of our analysis showed that of the 155 patients, 28% had pre-OLT diabetes mellitus, 21% had pre-OLT hypertension, and 40% had viral hepatitis. Among the patients, the median MELD (Model for End-Stage Liver Disease) score was 27 (interquartile range [IQR] 22-35). When they were listed for liver transplantation, 32% of the patients had serum creatinine (Scr) levels > 1.5 mg/dL or were on HD, and 50% had serum creatinine (Scr) levels > 1.5 mg/dL or were on HD at the time of OLT. Of the transplanted patients, 25% underwent pre-OLT intermittent HD, and 14% and 41% underwent continuous renal replacement therapy (CRRT) pre-OLT and post-OLT, respectively. At 90 days post-OLT, 118 (76%) patients had been taken off dialysis, and 16 (10%) patients had died while undergoing HD. The median recovery time of these post-OLT patients was 33 (IQR 27–39) days. In the multivariate analysis, fulminant hepatic failure as the cause of liver disease (p<0.001), the absence of pre-OLT hypertension (p = 0.016), a lower intraoperative fresh-frozen plasma (FFP) transfusion volume (p = 0.019) and not undergoing pre-OLT intermittent HD (p = 0.032) were associated with performing RRT for less than 90 days. Therefore, a high proportion of OLT patients showed improved renal function after OLT, and those who were diagnosed with fulminant hepatic failure, had no pre-OLT hypertension, received a lower transfused volume of intraoperative FFP and did not undergo pre-OLT intermittent HD had a higher probability of recovery.

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Section: Discussionmentioning

confidence: 99%

Predictors of renal function recovery among patients undergoing renal replacement therapy following orthotopic liver transplantation

et al. 2017

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“…The incidence of post-operative AKI in the setting of LT ranges between 12% and 80%, depending on the definition adopted[17,18], with a 30-d mortality of up to 50% in case of renal dysfunction at transplantation and as high as 90% if renal replacement therapy (RRT) is required[4,19]. …”

Section: Acute Kidney Injury Post-ltmentioning

confidence: 99%

“…Cold ischaemia time (CIT) and graft steatosis have been reported to be associated with PRS in several studies[6,13,17,21,22]. The increased CIT is likely to increase the IRI which is associated with release of increased amounts of pro-inflammatory mediators, generation of free radicals, neutrophil sequestration and activation[50].…”

Section: Specific Intra-operative Risk Factors For Post-lt Prs-inducementioning

confidence: 99%

Acute kidney injury and post-reperfusion syndrome in liver transplantation

Umbro¹,

Tinti²,

Scalera³

et al. 2016

WJG

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In the past decades liver transplantation (LT) has become the treatment of choice for patients with end stage liver disease (ESLD). The chronic shortage of cadaveric organs for transplantation led to the utilization of a greater number of marginal donors such as older donors or donors after circulatory death (DCD). The improved survival of transplanted patients has increased the frequency of long-term complications, in particular chronic kidney disease (CKD). Acute kidney injury (AKI) post-LT has been recently recognized as an important risk factor for the occurrence of de novo CKD in the long-term outcome. The onset of AKI post-LT is multifactorial, with pre-LT risk factors involved, including higher Model for End-stage Liver Disease score, more sever ESLD and pre-existing renal dysfunction, either with intra-operative conditions, in particular ischaemia reperfusion injury responsible for post-reperfusion syndrome (PRS) that can influence recipient’s morbidity and mortality. Post-reperfusion syndrome-induced AKI is an important complication post-LT that characterizes kidney involvement caused by PRS with mechanisms not clearly understood and implication on graft and patient survival. Since pre-LT risk factors may influence intra-operative events responsible for PRS-induced AKI, we aim to consider all the relevant aspects involved in PRS-induced AKI in the setting of LT and to identify all studies that better clarified the specific mechanisms linking PRS and AKI. A PubMed search was conducted using the terms liver transplantation AND acute kidney injury; liver transplantation AND post-reperfusion syndrome; acute kidney injury AND post-reperfusion syndrome; acute kidney injury AND DCD AND liver transplantation. Five hundred seventy four articles were retrieved on PubMed search. Results were limited to title/abstract of English-language articles published between 2000 and 2015. Twenty-three studies were identified that specifically evaluated incidence, risk factors and outcome for patients developing PRS-induced AKI in liver transplantation. In order to identify intra-operative risk factors/mechanisms specifically involved in PRS-induced AKI, avoiding confounding factors, we have limited our study to “acute kidney injury AND DCD AND liver transplantation”. Accordingly, three out of five studies were selected for our purpose.

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“…It affects between 25% and 60% of recipients[2-4], the variation being largely related to the definition of AKI utilised[5,6]. The incidence of AKI following OLT is much higher than with other non-cardiac major surgery, in patients with previously normal renal function[7].…”

Section: Introductionmentioning

confidence: 99%

Early acute kidney injury after liver transplantation: Predisposing factors and clinical implications

Rahman

Davidson

Mallett

2017

WJH

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AIMTo investigate the additional clinical impact of hepatic ischaemia reperfusion injury (HIRI) on patients sustaining acute kidney injury (AKI) following liver transplantation.METHODSThis was a single-centre retrospective study of consecutive adult patients undergoing orthotopic liver transplantation (OLT) between January 2013 and June 2014. Early AKI was identified by measuring serum creatinine at 24 h post OLT (> 1.5 × baseline) or by the use of continuous veno-venous haemofiltration (CVVHF) during the early post-operative period. Patients with and without AKI were compared to identify risk factors associated with this complication. Peak serum aspartate aminotransferase (AST) within 24 h post-OLT was used as a surrogate marker for HIRI and severity was classified as minor (< 1000 IU/L), moderate (1000-5000 IU/L) or severe (> 5000 IU/L). The impact on time to extubation, intensive care length of stay, incidence of chronic renal failure and 90-d mortality were examined firstly for each of the two complications (AKI and HIRI) alone and then as a combined outcome.RESULTSOut of the 116 patients included in the study, 50% developed AKI, 24% required CVVHF and 70% sustained moderate or severe HIRI. Median peak AST levels were 1248 IU/L and 2059 IU/L in the No AKI and AKI groups respectively (P = 0.0003). Furthermore, peak serum AST was the only consistent predictor of AKI on multivariate analysis P = 0.02. AKI and HIRI were individually associated with a longer time to extubation, increased length of intensive care unit stay and reduced survival. However, the patients who sustained both AKI and moderate or severe HIRI had a longer median time to extubation (P < 0.001) and intensive care length of stay (P = 0.001) than those with either complication alone. Ninety-day survival in the group sustaining both AKI and moderate or severe HIRI was 89%, compared to 100% in the groups with either or neither complication (P = 0.049).CONCLUSIONHIRI has an important role in the development of AKI post-OLT and has a negative impact on patient outcomes, especially when occurring alongside AKI.

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Risk factors for renal dysfunction in the postoperative course of liver transplant

Cited by 116 publications

References 19 publications

Predictors of renal function recovery among patients undergoing renal replacement therapy following orthotopic liver transplantation

Predictors of renal function recovery among patients undergoing renal replacement therapy following orthotopic liver transplantation

Acute kidney injury and post-reperfusion syndrome in liver transplantation

Early acute kidney injury after liver transplantation: Predisposing factors and clinical implications

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