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.

These findings confirmed clinical significance of PTE during adult LT and suggested the possibility of predicting this devastating complication.

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.

CLD patients have a high incidence of AKI. Compared with creatinine criteria alone, incorporating UO into the diagnostic criteria increased the measured incidence of AKI. Stage 2-3 AKI-UO has a high negative impact on hospital mortality. (Hepatology 2017;66:1592-1600).

Liver transplantation (LT) is one of the highest risk noncardiac surgeries. We reviewed the incidence, etiologies, and outcomes of intraoperative cardiac arrest (ICA) during LT. Adult cadaveric LT recipients from January 1, 2001 through December 31, 2009 were reviewed. ICA was defined as an event requiring either closed chest compression or open cardiac massage. Cardiac arrest patients who recovered with only pharmacological interventions were excluded. Data included etiologies and outcomes of ICA, intraoperative deaths (IDs) and hospital deaths (HDs), and potential ICA risk factors. ICA occurred in 68 of 1238 LT recipients (5.5%). It occurred most frequently during the neohepatic phase (60 cases or 90%), and 39 of these cases (65.0%) experienced ICA within 5 minutes after graft reperfusion. The causes of ICA included postreperfusion syndrome (PRS; 26 cases or 38.2%) and pulmonary thromboembolism (PTE; 24 cases or 35.3%). A higher Model for End-Stage Liver Disease (MELD) score was found to be the most significant risk factor for ICA. The ID rate after ICA was 29.4% (20 cases), and the HD rate was 50.0% (34 cases). The 30-day patient survival rate after ICA was 55.9%, and the 1-year survival rate was 45.6%: these rates were significantly lower (P < 0.001) than those for non-ICA patients (97.4% and 85.1%, respectively). In conclusion, the incidence of ICA in adult cadaveric LT was 5.5% with an intraoperative mortality rate of 29.4%. ICA most frequently occurred within 5 minutes after reperfusion and resulted mainly from PRS and PTE. A higher MELD score was identified as a risk factor.

Summary Use of piggyback technique (PB) and elimination of venovenous bypass (VVB) have been advocated in adult liver transplantation (LT). However, individual contribution of these two modifications on clinical outcomes has not been fully investigated. We performed a retrospective review of 426 LTs within a 3‐year period, when three different surgical techniques were employed per the surgeons’ preference: retrohepatic caval resection with VVB (RCR + VVB) in 104 patients, PB with VVB (PB + VVB) in 148, and PB without VVB (PB‐Only) in 174. The primary outcomes were intraoperative blood transfusion and the patient and graft survivals. Demographic profiles were similar, except younger recipient age in RCR + VVB and fewer number of grafts with cold ischemic time over 16 h in PB‐Only. PB‐Only required lesser intraoperative red blood cells (P = 0.006), fresh frozen plasma (P = 0.005), and cell saver return (P = 0.007); had less incidence of acute renal failure (P = 0.001), better patient survival (P = 0.039), and graft survival (P = 0.003). The benefits of PB + VVB were only found in shortened total surgical time (P = 0.0001) and warm ischemic time (P = 0.0001), and less incidence of acute renal failure (P = 0.001) than RCR + VVB. PB‐Only method seemed to provide the best clinical outcome. The benefit of PB was not fully achieved when it was used with VVB.

IV NAC was not effective in reducing renal or hepatic injury in the setting of liver transplantation. The dose and duration of NAC used, though higher than most renal protection studies, may have been ineffective for raising GSH levels in some patients.