Intraoperative Oliguria with Decreased SvO2 Predicts Acute Kidney Injury after Living Donor Liver Transplantation

Abstract

Acute kidney injury (AKI) is a frequent complication after living donor liver transplantation (LDLT), and is associated with increased mortality. However, the association between intraoperative oliguria and the risk of AKI remains uncertain for LDLT. We sought to determine the association between intraoperative oliguria alone and oliguria coupled with hemodynamic derangement and the risk of AKI after LDLT. We evaluated the hemodynamic variables, including mean arterial pressure, cardiac index, and mixed venous oxygen saturation (SvO2). We reviewed 583 adult patients without baseline renal dysfunction and who did not receive hydroxyethyl starch during surgery. AKI was defined using the Kidney Disease Improving Global Outcomes criteria according to the serum creatinine criteria. Multivariable logistic regression analysis was performed with and without oliguria and oliguria coupled with a decrease in SvO2. The performance was compared with respect to the area under the receiver operating characteristic curve (AUC). Intraoperative oliguria <0.5 and <0.3 mL/kg/h were significantly associated with the risk of AKI; however, their performance in predicting AKI was poor. The AUC of single predictors increased significantly when oliguria was combined with decreased SvO2 (AUC 0.72; 95% confidence interval (CI) 0.68–0.75 vs. AUC of oliguria alone 0.61; 95% CI 0.56–0.61; p < 0.0001; vs. AUC of SvO2 alone 0.66; 95% CI 0.61–0.70; p < 0.0001). Addition of oliguria coupled with SvO2 reduction also increased the AUC of multivariable prediction (AUC 0.87; 95% CI 0.84–0.90 vs. AUC with oliguria 0.73; 95% CI 0.69–0.77; p < 0.0001; vs. AUC with neither oliguria nor SvO2 reduction 0.68; 95% CI 0.64–0.72; p < 0.0001). Intraoperative oliguria coupled with a decrease in SvO2 may suggest the risk of AKI after LDLT more reliably than oliguria alone or decrease in SvO2 alone. Intraoperative oliguria should be interpreted in conjunction with SvO2 to predict AKI in patients with normal preoperative renal function and who did not receive hydroxyethyl starch during surgery.

Intraoperative oliguria does not predict postoperative acute kidney injury in major abdominal surgery: a cohort analysis

“…A post hoc analysis study of the RELIEF trial reported that oliguria, defined as urine output of less than 0.5 mL/kg/h, had a low predictive ability for postoperative AKI. Indeed, it was the absence of oliguria that demonstrated a good predictive ability of not developing postoperative AKI (34) . To enhance the predictive ability of oliguria, a study by Kim and colleagues suggests that intraoperative oliguria in combination with a decrease in SvO 2 can predict postoperative AKI more reliably than each of these factors alone, in a retrospective cohort of patients undergoing living donor liver transplantation (34) .…”

Intraoperative Oxygen Delivery and Acute Kidney Injury after Liver Transplantation

“…Baseline graft parameters, including the incidence of a living/deceased donor and cold ischemic time, were significantly different between those with high and low mean DO 2 I groups. A deceased donor and cold ischemic time are reported to be associated with an increased risk of AKI [9,12,14,23]. A warm ischemic time of graft from donation after circulatory death is also associated with the severity of postoperative AKI [22].…”

“…Intraoperative hemodynamic variables have been investigated as modifiable risk factors in patients undergoing liver transplantation. Intraoperative arterial blood pressure, baseline central venous pressure, baseline right ventricular end-diastolic pressure and mixed venous oxygen saturation (SvO 2 ) during the anhepatic phase were reported to be associated with the development of posttransplant AKI [13,14]. Preoperative anemia and intraoperative transfusion amounts have also been reported as risk factors of AKI [9,13].…”

“…However, the etiology of AKI after liver transplantation is known to be multifactorial [21], and the baseline graft qualities, including the type of donor graft (deceased vs. living donor; circulatory vs. brain death) [12] and warm and cold graft ischemic time [9,14,22,23], are associated with AKI. Therefore, we sought to adjust perioperative variables by performing propensity score matching analysis.…”

Impact of Early versus Late Initiation of Renal Replacement Therapy in Patients with acute kidney injury after liver transplantation: a retrospective study.

“…Liver transplantation is the most effective treatment for end-stage liver disease. AKI is a common complication following liver transplantation, which was found in 26.3%-75.6% patients, this disparity is large dependent on the definition of AKI [12,13,14]. [15,16].…”