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Aims: Hyperbilirubinemia is associated with postoperative acute kidney injury in patients undergoing cardiac surgeries. A high concentration of bilirubin could induce oxidative stress and cell apoptosis. The aim of this study was to investigate whether hyperbilirubinemia aggravated the renal tubule cells injury and the pro-apoptotic potential of bilirubin on renal ischemia reperfusion injury (RIRI). Methods: The human proximal tubular epithelial cell line HK-2 cells were challenged with a gradient concentration of bilirubin for 24 h. Cell injury was assessed by flow cytometry and MTT assay. Bilirubin was injected intraperitoneally into male Sprague-Dawley rats once every 12 h (100 mg/kg), 3 times in total. The same solvent volume without bilirubin powder was used as vehicle in non-bilirubin injection groups. The RIRI surgical procedure was a bilateral renal pedicles clamping (45 min) followed by 30 h reperfusion. The rats were divided into 4 groups: negative control (NC), similar surgical procedures without clamping; Bil, bilirubin injection for 36 h, then rats were sacrificed; RIRI, RIRI surgical procedures; Bil + RIRI, RIRI applied 6 h later than the first bilirubin injection, rats were sacrificed after another 30 h. Results: In vitro, bilirubin induced cell apoptosis and significantly decreased the cell viability of HK-2 cells. Bilirubin induced the active caspase 3 and phosphorylation of p38 in HK-2 cells. In vivo, serum creatinine was higher in Bil + RIRI compared with RIRI (p < 0.01). The tubular injury scores of hematoxylin and eosin and tubular necrosis scores of periodic acid-Schiff were higher in Bil + RIRI than these in RIRI (All p < 0.05). The number of Tunel-positive nuclei was higher in Bil + RIRI compared to RIRI (p < 0.001). The active caspase 3 and phosphorylation of p38 were higher and the Bcl2 was lower in Bil + RIRI compared to RIRI. Moreover, the apoptosis level was higher in Bil compared to NC. Conclusions: Our results reveal that the hyperbilirubinemia induces pro-apoptotic effects and aggravates RIRI.

BackgroundWe compared the effects of thoracic epidural analgesia (TEA) to conventional patient‐controlled analgesia (PCA) on several postoperative parameters of recovery after elective video‐assisted thoracoscopic (VATS) lobectomy.MethodsNinety‐eight patients undergoing elective VATS lobectomy were enrolled. The primary endpoint was pain score. Recovery of bowel function, length of stay in the postanesthesia care unit (PACU), duration of postoperative hospital stay, and complications were assessed. Continuous variables were expressed and compared between groups using either a two‐tailed Student's t or Mann‐Whitney U test. Recovery of bowel function was compared using the log‐rank test.ResultsBaseline characteristics between the groups were similar. Dynamic pain scores on postoperative days (PODs) 0–2 were significantly lower in the TEA group, as were resting pain scores on PODs 1 and 2 (P < 0.05). The mean duration to first flatus (16 ± 0.7 vs. 26 ± 0.7 hours; P < 0.001) and the mean length of stay in the PACU (34 vs. 67 minutes; P = 0.027) were shorter in the TEA compared to the PCA group, respectively. The only difference in postoperative complications was regarding confusion (5 TEA vs. 18 PCA patients; P = 0.002). No difference in overall length of stay was noted.ConclusionsCompared to PCA, TEA provided better postoperative pain control after VATS lobectomy and facilitated postoperative recovery of bowel function without increasing the length of hospital stay. This beneficial effect of TEA might be attributed to the attenuation of sympathetic hyperactivation, improved analgesia, and reduced opioid use.

Background Acute kidney injury (AKI) is a common and critical complication of liver transplantation (LT), which is associated with increased morbidity, mortality and health care cost. We aimed to identify modifiable risk factors of AKI after LT. Methods A literature search of Pubmed, EMBASE and Cochrane Databases was performed to identify studies investigating risk factors of AKI after LT. The Newcastle-Ottawa Scale was used to rate study quality. Effect size and 95% confidence interval were pooled using a random-effect model with inverse-variance method. Results Sixty-seven articles with 28,844 patients were included in the meta-analysis. Seventeen modifiable risk factors were found, including overweight, preoperative use of diuretic, preoperative anemia, donation after cardiac death organ, donor BMI ≥ 30 kg/m2, ABO-incompatible LT, low graft to recipient body weight ratio, intraoperative hypotension, major bleeding, intraoperative use of vasopressor, large RBC transfusion, postreperfusion syndrome, postoperative use of vasopressors, overexposure to calcineurin inhibitor, calcineurin inhibitor without mycophenolate mofetil, graft dysfunction and infection. A total of 38 articles were included in the systematic review, in which 8 modifiable risk factors and 1 protective factor were additionally associated in single studies with the incidence of AKI after LT. Conclusions Effective interventions based on identified modifiable risk factors in the perioperative management and graft allocation and preservation may be promising to reduce the incidence of AKI after LT. Trial registration The protocol for this systematic review is registered with PROSPERO (No. CRD42020166918).

The aims of this study were to evaluate the incidence, risk factors, and outcomes of hyperbilirubinemia in cardiac patients with veno-arterial (VA) ECMO. Data on 89 adult patients with cardiac diseases who received VA ECMO implantation in our hospital were retrospectively reviewed. All patients were divided into the following three groups: 24 in normal group (N, total bilirubin [TBIL] ≤3 mg/dL), 30 in high bilirubin group (HB, 6 mg/dL ≥ TBIL > 3 mg/dL), and 35 in severe high bilirubin group (SHB, TBIL > 6 mg/dL). lg(variables + 1) was performed for nonnormally distributed variables. The incidence of hyperbilirubinemia (>3 mg/dL) was 73%. In a multiple linear regression analysis, lg(peak TBIL + 1) was significantly associated with lg(peak AST + 1) (b-coefficient 0.188, P = 0.001), lg(peak pFHb + 1) (b-coefficient 0.201, P = 0.003), and basic TBIL (b-coefficient 0.006, P = 0.009). Repeated measurement analysis of variance revealed that the main effect for three groups in pFHb and lg(AST + 1) was significant at first 3 days during ECMO. The patients in SHB had low platelets during ECMO and low in-hospital survival rate. Hyperbilirubinemia remains common in patients with VA ECMO and is associated with low platelets and high in-hospital mortality. Hemolysis and liver dysfunction during ECMO and basic high bilirubin levels are risk factors of hyperbilirubinemia.

Background: Acute kidney injury (AKI) is a common postoperative complication of orthotopic liver transplantation (OLT). So far, little attention has been paid on the association between overweight and AKI after OLT, and animal models or clinical studies have drawn conflicting conclusions. The objective of our study was to determine whether overweight (BMI [Body Mass Index] ≥ 25 kg/m 2) is associated with an increased risk of AKI after OLT. Methods: This retrospective cohort study included 244 patients receiving OLT in the Affiliated Hospital of Qingdao University between January 1, 2017, and August 29, 2019. Preoperative, intraoperative, and postoperative data were collected retrospectively. The primary outcome was the development of AKI as defined by Kidney Disease, Improving Global Outcome (KIDGO) staging system. Logistic regression analysis was used to determine the relationship between overweight and the occurrence of postoperative AKI. Data analysis was conducted from September to October 2019, revision in April 2020. Results: Among 244 patients receiving OLT (mean [standard deviation] age, 54.1 [9.6] years; 84.0% male) identified, 163 patients (66.8%) developed postoperative AKI. Overweight (BMI ≥ 25 kg/m 2) was associated with a higher rate of postoperative severe AKI (stage 2/3) compared with normal weight (18.5 ≤ BMI < 25 kg/m 2) (41 [47.7%] vs 39 [28.7%]; adjusted odds ratio [OR], 2.539; 95% confidence interval [CI], 1.389-4.642; P = 0.002). Furthermore, patients with obese were at even higher risk of postoperative severe AKI after controlling for confounding factors (adjusted OR: 3.705; 95% CI: 1.108-12.388; P = 0.033). Conclusions: Overweight is independently associated with an increased risk of postoperative severe AKI among patients receiving OLT. The association of BMI with severe AKI after OLT is J-shaped.

Background Acute kidney injury (AKI) is a major complication following liver resection. The aim of this study was to determine the risk factors for AKI after hepatic resection and whether intraoperative hypotension (IOH) was related to AKI. Methods Adult patients (≥ 18 years) undergoing liver resection between November 2017 and November 2019 at our hospital were retrospectively reviewed. AKI was defined as ≥50% increase in serum creatinine from baseline value within 48 h after surgery. IOH was defined as the lowest absolute mean arterial pressure (MAP) < 65 mmHg for more than 10 cumulative minutes during the surgery. Patients were divided into AKI group and non-AKI group, and were stratified by age ≥ 65 years. Results 796 patients who met our inclusion and exclusion criteria were analyzed. After multivariable regression analysis, the IOH (OR, 2.565; P = 0.009) and age ≥ 65 years (OR, 2.463; P = 0.008) were risk factors for AKI. The IOH (OR, 3.547; P = 0.012) and received red blood cell (OR, 3.032; P = 0.036) were risk factors of AKI in age ≥ 65 years patients. Conclusions The IOH and age ≥ 65 years were risk factors for postoperative AKI, and IOH was associated with AKI in age ≥ 65 years patients following liver resection.

Background Hyperbilirubinemia (HB) is a serious complication in aortic arch surgery, which is associated with acute kidney injury (AKI). The association between HB and chronic kidney disease (CKD) is unknown. The aim of this study was to investigate the impact of HB associated AKI on CKD after aortic arch surgery. Methods We reviewed 284 patients who underwent aortic arch surgery from 2016 to 2020 in our hospital. AKI was defined as a 50% increase in sCr from baseline value within the first 7 postoperative days. HB was defined as total bilirubin > 51.3 μmol/L. Patients were divided into 3 groups based on AKI and HB: HB associated AKI (HB-AKI) group (AKI patients suffered HB within the first 7 postoperative days); AKI without HB group and Non-AKI group. Results Follow-up for 204 patients ranged from 3 to 12 months. Kaplan–Meier analysis showed that the 1-year cumulative incidence of CKD was highest in HB-AKI (32.6%) than AKI without HB (17.8%) and Non-AKI (7.4%, log-rank test, p < 0.001), and the incidence of CKD was higher in HB group than that in Non-HB group (26.7% vs. 13.9%, log-rank test, p = 0.015). Preoperative sCr (HR 1.010, 95% CI 1.004–1.016, p = 0.001), AKI without HB (HR 2.887, 95% CI 1.133–7.354, p = 0.026) and HB-AKI (HR 4.490, 95% CI 1.59–12.933, p = 0.005) were associated with CKD during 1-year follow-up. Conclusions Patients suffering HB associated AKI were at more increased odds of CKD than patients suffering AKI without HB after aortic arch surgery.