Portland Intensive Insulin Therapy During Living Donor Liver Transplantation: Association with Postreperfusion Hyperglycemia and Clinical Outcomes

Abstract

Many liver transplant recipients experience intraoperative hyperglycemia after graft reperfusion. Accordingly, we introduced the Portland intensive insulin therapy (PoIIT) in our practice to better control blood glucose concentration (BGC). We evaluated the effects of PoIIT by comparing with our conventional insulin therapy (CoIT). Of 128 patients who underwent living donor liver transplantation (LDLT) during the phaseout period of CoIT, 89 were treated with the PoIIT and 39 were treated with CoIT. The primary outcome was hyperglycemia (BGC > 180 mg/dL) during the intraoperative postreperfusion phase. The secondary outcomes were postoperative complications such as infection. The incidence of hyperglycemia (22.5% vs. 53.8%, p = 0.001) and prolonged hyperglycemia for >2 hours (7.9% vs. 30.8%, p = 0.002) was significantly lower in PoIIT group than in CoIT group. A mixed linear model further demonstrated that repeatedly measured BGCs were lower in PoIIT group (p < 0.001). The use of PoIIT was significantly associated with decreases in major infections (OR = 0.23 [0.06–0.85], p = 0.028), prolonged mechanical ventilation (OR = 0.29 [0.09–0.89], p = 0.031), and biliary stricture (OR = 0.23 [0.07–0.78], p = 0.018) after adjustments for age, sex, and diabetes mellitus. In conclusion, the PoIIT is effective for maintaining BGC and preventing hyperglycemia during the intraoperative postreperfusion phase of living donor liver transplantation with potential clinical benefits.

Postoperative hyperglycemia may negatively impact cytomegalovirus infection in seropositive liver transplant recipients: a retrospective cohort study

“…Although previous studies have evaluated the association between perioperative hyperglycemia and post‐transplant infectious complications , there have been no studies evaluating the role of postoperative hyperglycemia in modifying the risk of CMV infection in immunosuppressed liver transplant recipients despite the high prevalence and clinical significance of CMV infection . The cutoff BGC of 180 mg/dl is clinically relevant because 180 mg/dl is a feasible target with relatively low risk of severe hypoglycemia when doing intensive insulin therapy . Our findings suggest that maintaining post‐transplant BGC <180 mg/dl complements preemptive CMV therapy and decreases the risk of CMV infection in seropositive liver transplant recipients.…”

“…Because the incidence of CMV infection significantly raised after the surveillance reinforcement and the introduction of immunofluorescence assay at 2008, the presence of interaction between operation period (before versus after 2008) and postoperative hyperglycemia was tested by including the interaction effect term in multivariable analysis to test the risk of bias from the difference in CMV surveillance. The cutoff mean BGC value for categorizing patients as at hyperglycemic group and nonhyperglycemic group was set at 180 mg/dl based on previous researches . The mean BGC was calculated by an average of BGCs firstly measured at fasting state in each postoperative day during the primary admission for a maximum of 1 month.…”

Perioperative intensive glycemic control for liver transplant recipients to prevent surgical site infection: A systematic review and meta‐analysis

“…Two randomized controlled trials 21,22 met the inclusion criteria and are included in a quantitative synthesis. Three retrospective cohort studies [40][41][42] also met the inclusion criteria, however, one of these studies did not present any data regarding SSI, hypoglycemia, allograft rejection or death. 42 The remaining two cohort studies 40,41 Table 1.…”

“…Men were over represented in each of the five studies with 411 out of all 604 study participants being male. Hepatitis C virus, 22,40 Hepatitis B virus, 41 and alcoholrelated cirrhosis, 21 were the main indications for liver transplant. The model of end-stage liver disease (MELD) score for participants in the RCTs ranged from 19 to 28 and was slightly lower in the cohort studies ranging from 13 to 19.…”

“…21,22 Among the cohort studies, blood glucose readings in two studies were performed by analyzing arterial blood samples and managing glucose levels with intravenous insulin. 40,41 In the third cohort study,…”