Intraoperative management of liver transplant recipients having severe renal dysfunction: results of 42 cases

Abstract

PurposeWhereas continuous renal replacement therapy (CRRT) has been utilized during liver transplantation (LT), there was a lack of evidence to support this practice. We investigated the adverse events at the perioperative periods in recipients of LT who received preoperative CRRT without intraoperative CRRT.MethodsWe retrospectively reviewed medical records of adult patients (age ≥ 18 years) who received LT between December 2009 and May 2015. Perioperative data were collected from the recipients, who received preoperative CRRT until immediately before LT, because of refractory renal dysfunction.ResultsOf 706 recipients, 42 recipients received preoperative CRRT. The mean (standard deviation) Model for end-stage liver disease score were 49.6 (13.4). Twenty-six point two percent (26.2%) of recipients experienced the serum potassium > 4.5 mEq/L before reperfusion and treated with regular insulin. Thirty-eight point one percent (38.1%) of recipients were managed with sodium bicarbonate because of acidosis (base excess < −10 mEq/L throughout LT). All patients finished their operations without medically uncontrolled complications such as severe hyperkalemia (serum potassium > 5.5 mEq/L), refractory acidosis, or critical arrhythmias. Mortality was 19% at 30 day and 33.3% at 1 year.ConclusionAlthough intraoperative CRRT was not used in recipients with severe preoperative renal dysfunction, LT was safely performed. Our experience raises a question about the need for intraoperative CRRT.

Changes in the allocation policy for deceased donor livers in Korea: perspectives from anesthesiologists

“…Any CRRT performed immediately before LT would partially adjust the acid-base balance and electrolytes. Also, in line with another report from our institution, serum potassium level and metabolic acidosis can be well controlled medically in recipients managed with preoperative CRRT [ 11 ]. However, the presence of HRS prior to transplantation is a strong predictor of mortality after LT [ 12 ].…”

Intraoperative renal replacement therapy during liver transplantation in children: Safety, efficacy and impact on survival

“…27 All of this emphasizes a need for careful selection of candidates who will benefit from iCRRT the most, yet, there are no such guidelines currently in pediatric LT. Our findings agree with the adult data showing no difference in postoperative complications, mechanical ventilation days, reoperations, graft failures or mortality among patients who receive iCRRT versus those who do not. [14][15][16][17] However, iCRRT continues to be used in approximately 30% of all adult liver transplants centers. 15,16 In adults, most patients supported with iCRRT have higher severity of illness and MELD scores, longer CRRT days, higher inotropic requirements, and longer mechanical ventilation days prior to liver transplant.…”

“…Intraoperative bleeding, with the need for massive transfusion and subsequent metabolic abnormalities during resuscitation, including acidosis, and electrolyte derangements pose an additional challenge during surgery in a child with pre-existing AKI. [10][11][12] Even though intraoperative CRRT (iCRRT) has been proposed to mitigate critical intraoperative complications and facilitate fluid and electrolyte management in adults with preoperative renal dysfunction, there remains an ongoing debate about its usefulness and impact on short and long-term outcomes after LT. [13][14][15][16][17] Data in adult studies cannot be extrapolated to pediatric liver failure. The underlying diseases leading to ALF and ACLF are unique in children, and the delivery of CRRT in children is highly nuanced requiring multidisciplinary experience and expertise.…”

Perioperative risk factors of progressive chronic kidney disease following liver transplantation: analyses of a 10-year follow-up single-center cohort

“…In addition, posttransplantation CKD is independently associated with high mortality and morbidity, which has elicited concerns in posttransplantation management. Prevention of renal injury has emerged as a priority for transplant physicians [ 2 3 4 ].…”