Incidence and Perioperative Risk Factors of Acute Kidney Injury Among Lung Transplant Recipients

BackgroundAcute kidney injury (AKI) is a significant burden in an early postoperative period after lung transplantation (LT). The development of severe AKI, including a need for continuous renal replacement therapy (CRRT), is associated with increased mortality among lung transplant recipients. Evaluation of AKI incidence and predictive factors related to the development of severe AKI and with the use of CRRT in the early postoperative period after LT.MethodsRetrospective study of 73 consecutive patients after LT operated between 2015 and 2018 in our center. We noted the stage of AKI according to KDIGO guidelines in the 7 postoperative days.ResultsWe noted AKI among 62 lung transplant recipients (84.9%). We recognized the first and second stages of AKI in 21 patients (28.8%) and 19 patients 26%, respectively (group A). We identified severe AKI (group C) in 22 recipients (30.1%), 9 of whom needed CRRT postoperatively. There was a nonsignificant difference between groups in baseline serum creatinine (0.69 ± 0.22 mg/dL vs 0.84 ± 0.34; P = .073). Group C subjects statistically more often suffered from pulmonary hypertension (P < .001) and diabetes (P < .001). In both groups, the duration of the procedure was comparable, but, among patients with severe AKI, procedures were performed more often with the use of extracorporeal circulation (50% vs 68%; P = .194)ConclusionsPulmonary hypertension and diabetes could be significant risk factors of high-grade AKI development after LT. Identification of factors modifying renal insufficiency development in lung transplant recipients needs further investigations.     

Basiliximab With Delayed Tacrolimus Improves Short-Term Renal Outcomes Post-Liver Transplantation—a Real-World Experience

BackgroundAcute kidney injury (AKI) is common after liver transplantation (LT). Induction with interleukin-2 receptor antagonists is often used as a “renal-sparing” strategy. The aim of this study was to assess this approach in a real-world setting in an LT center.MethodsA retrospective cohort analysis of LTs between 2011 and 2018 was performed to assess the impact of a renal-sparing strategy using basiliximab in conjunction with mycophenolate mofetil and corticosteroids from day 0 post-LT along with delayed introduction of tacrolimus. This was compared with a group receiving tacrolimus, mycophenolate mofetil, and corticosteroids from the outset.ResultsThe renal-sparing regimen was associated with significantly lower incidence of all-stage AKI at day 7 post-LT (36% vs 55%, P = .006) and less decline in renal function at 3 months (39% vs 57%, P = .01). No further significant differences in renal outcomes were observed at other time points on follow-up to 1 year post-LT. There was no significant difference in the incidence of acute cellular rejection, inpatient length of stay or graft survival. The decision to adopt a renal-sparing regimen was predominantly made on a clinically reactive basis within the first 24 hours post-LT in 77%, and was preordained in 23%. Cost-effectiveness analysis did not find evidence of a significant cost saving when using a renal-sparing strategy.ConclusionThis study provides real-world analysis of the use of a renal-sparing immunosuppression regimen in LT. Although improvements in incidence of AKI in the short term were demonstrated, this did not translate to cost savings or improved renal outcomes after 3 months.     

Acute Kidney Injury After Pediatric Liver Transplantation

BackgroundThe aim of the present study is to assess acute kidney injury (AKI) incidence according to the pRIFLE and AKIN criteria and to evaluate the risk factors for early developing AKI in postoperative intensive care unit after pediatric liver transplantation (LT).MaterialsAfter exclusion of retransplantations, 7 cadaveric and 44 living donors, totaling 51 pediatric LT patients that were performed between 2005 and 2017, were reviewed retrospectively. AKI was defined according to both pediatric RIFLE (Risk for renal dysfunction, Injury to the kidney, Failure of kidney function, Loss of kidney function, and End-stage renal disease) and Acute Kidney Injury Network (AKIN) criteria. Documented data were compared between AKI and non-AKI patients.ResultsAKI incidences were 17.6% by AKIN and 37.8% by pRIFLE criteria. AKIN-defined AKI group had statistically lower serum albumin level, higher serum sodium level, higher furosemide dose, and higher rate of red blood cell (RBC) transfusion than the non-AKI group (P = .02, P = .02, P = .01 and P = .04, respectively). AKI patients had significantly prolonged mechanical ventilation (P = .01) and hospital LOS (P = .02). The pRIFLE-defined AKI group had significantly lower serum albumin level, higher blood urea nitrogen (BUN) level, and higher ascites drained and also showed higher requirement for RBC and 20% human albumin transfusions than the non-AKI group (P = .02, P = .04, P: =.007, P = .02 and P = .05, respectively).ConclusionWe evaluated that hypoalbuminemia, high requirement for RBC and 20% human albumin transfusions, high serum sodium, high furosemide use, and high flow of ascites are risk factors for AKI and high BUN levels can be predictive for AKI in pediatric LT patients. The effect of AKI on outcome variables were prolonged mechanical ventilation and hospital LOS.     

The impact of long-term exposure to tacrolimus on chronic kidney disease after lung transplantation: A retrospective analysis from a single transplantation center

BackgroundChronic kidney disease (CKD) is a progressive and irreversible complication in lung transplant patients who have received long-term treatment with tacrolimus. This study aimed to verify long-term tacrolimus exposure values in CKD progression.MethodsWe retrospectively analyzed the clinical data of adult lung transplant recipients performed at our center between 2012 and October 2015. Patients who completed the 5-year follow-up period were enrolled in this study. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m².ResultsEighty patients were analyzed. Compared with baseline (109 ± 38.1 mL/min/1.73 m2), the average eGFR values of our patients gradually decreased during the fifth-year post transplantation (46.5%, 58.3 ± 28.3 mL/min/1.73 m2), and the decline in eGFR values was particularly pronounced in the first year (31.2%, 74.6 ± 28.91 mL/min/1.73 m2). Moreover, 10 (12.7%), 21 (26.9%), 24 (31.2%), 28 (41.2%), and 48 (60%) patients had eGFR <60 mL/min/1.73 m² at 3, 6, 1, 3, and 5 years after lung transplantation (LT), respectively. A significant negative correlation was found between tacrolimus dose and eGFR 6 months after LT (P = 0.0414). We found no correlation between the serum tacrolimus concentration and CKD progression.ConclusioneGFR constantly decreased and the incidence of CKD increased during the 5-year follow-up period after LT. The tacrolimus dose had a significant negative correlation with eGFR at 6 months after LT. Meanwhile, whole-blood tacrolimus trough concentrations were not correlated with eGFR decline. When possible, lower dosing within 1 year after LT can reduce potential nephrotoxic side effects.     

Early Detection of Hepatocellular Carcinoma Recurrence in the Posttransplant Population: A Comparison of RETREAT and Cleveland Clinic Florida Scoring System

BackgroundLiver transplantation (LT) for hepatocellular carcinoma (HCC) is curative in most cases; however, recurrence is observed in some patients. The Risk Estimation of Tumor Recurrence After Transplant (RETREAT) score is an externally validated scoring system for prediction of post-LT HCC recurrence. The Cleveland Clinic Florida Scoring System (CCFSS) is a potential new scoring system for prediction of HCC recurrence. Our study aimed to compare the RETREAT and CCFSS.MethodsWe conducted a retrospective cohort study of 52 adult patients with HCC who underwent LT at a tertiary care center. Mantel-Haenszel chi-square analyses were conducted to compare the RETREAT and CCFSS classifications for detecting HCC recurrence.ResultsA total of 52 patients underwent LT. The median follow-up period was 37 months. Four patients had post-LT HCC recurrence, with all recurrences occurring within 2 years of LT. The RETREAT score was better able to detect low, moderate, and high levels of risk (P < .001), compared to the CCFSS score (P = 0.480). Both risk scores had a sensitivity of 75%; the specificity of the RETREAT score was 95.8%, whereas the specificity of the CCFSS was 60.4%. Alpha-fetoprotein level at the time of LT was associated with HCC recurrence (P = .014).ConclusionsThis is the first study to evaluate the CCFSS as a potential new scoring system to predict HCC recurrence after LT. The RETREAT score is more specific than the CCFSS. The incorporation of alpha-fetoprotein level at the time of LT improves the estimation of HCC recurrence in the post-LT period.     

The impact of crystalloid versus colloid fluids on postoperative nausea and vomiting: A systematic review and meta-analysis of randomized controlled trials

Study objectiveEvidence suggests that administering appropriate volumes of perioperative fluid replacement therapies can decrease the incidence of postoperative nausea and vomiting (PONV). However, the relative effects of colloids and crystalloids on PONV are still unclear. The objective of this systematic review was to determine whether administering colloids to adults undergoing noncardiac surgery significantly reduces PONV incidence and rescue antiemetic use, compared with administering crystalloids.DesignThis study has been registered in PROSPERO (ID: CRD42016036174). We performed a meta-analysis of randomized controlled trials that compared the incidence of PONV and rescue antiemetic use in surgical patients randomized to receive colloid or crystalloid fluids. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using a random-effects model. Heterogeneity was explored through I² statistics.PatientsNine randomized trials that included a total of 843 surgical patients met the inclusion criteria.MeasurementsThe primary outcome of interest was the incidence of overall PONV. Secondary outcomes included the incidence of postoperative nausea (PON), postoperative vomiting (POV), and rescue antiemetic use.Main resultsCompared with crystalloid fluids, perioperative colloid administration did not reduce the incidence of overall PONV (RR 0.802; 95% CI: 0.561, 1.145; I² = 57.168%). However, the colloid infusion group (RR 0.625; 95% CI: 0.440, 0.888) had reduced PONV compared with the crystalloid infusion group (RR 1.244; 95% CI: 0.742, 2.085), in the subgroup with anesthesia duration >3 h and who underwent major surgery. Meta-regression analysis also showed that the slope was significant (p = 0.04215) for duration of anesthesia.ConclusionsColloid administration reduced the incidence of PONV in adults undergoing elective, noncardiac, major surgery under general anesthesia for >3 h. However, clinical studies performed in larger cohorts are required to determine the impact of colloids on PONV.     

Is There a Relationship Between Intraoperative Hemodynamic Instability and Calcineurin Inhibitor-Related Toxicity,Early After Liver Transplantation? A Single-Center Observational Study

This study evaluated the relationship between intraoperative hemodynamic instability (IOHI) and the development of calcineurin inhibitor (CNI) toxicity in the early postoperative period after liver transplantation (LT). Eighty-two patients were enrolled during a 1-year period and a 3-month follow-up. IOHI, requiring continuous infusion of vasopressors, was observed in 31 patients (38%, group 1; control group 2, n = 51). Acute kidney injury (AKI) developed in 28 patients (52% in group 1 vs 24% in group 2, P = .02), and CNI-related neurotoxicity (CNI-NT) in 26 (48% in group 1 vs 22% in group 2, P = .03). Group 1 patients received mainly deceased donor grafts (87% vs 57% in group 2, P < .001). An independent association between IOHI and CNI-NT (P = .029) and AKI (P = .016) was observed. The receiver-operator characteristic curve revealed an area under the curve of 0.63 for IHI (sensitivity 56%; specificity 75%) and 0.65 for AKI (sensitivity 56%; specificity 70.2%). In conclusion, patients undergoing LT with IOHI may be more prone to developing CNI-NT and AKI in the early postoperative period.     

Scoring Systems and Postoperative Outcomes in Pediatric Liver Transplantation

PurposeThe aim of this study is to investigate the effects of risk scores (Pediatric End-stage Liver Disease [PELD], Child-Turcotte-Pugh [CTP], and Pediatric Risk of Mortality [PRISM-III]) of pediatric liver transplant patients on the postoperative period.MethodSeven cadaveric and 45 living donors, totaling 52 pediatric liver transplantation (LT) patients, were reviewed retrospectively. PELD and CTP scores were calculated based on data at hospital admission. PRISM-III score was calculated from data during the first 24 hours of intensive care unit (ICU) admission. Hospital length of stay (LOS), ICU LOS, patients who developed acute kidney injury (AKI), requirement for inotropic-vasopressor therapy, hospital mortality, long-term mortality, duration of mechanical ventilation, metabolic disease, and demographic features were documented.For CTP score, class C was defined as high, and A and B as low. Cutoff values of PELD and PRISM-III scores were detected by using receiver operating characteristic curves. According to these cutoff values, patients were divided into 2 groups as high and low for each score. Documented data was analyzed and compared in groups for each score.ResultsHospital LOS was significantly longer in the high-PELD (P = .01) and high-CTP (P = .01) groups. ICU LOS was significantly longer in the high-PRISM-III group (P = .01). Requirement for inotropic-vasopressor therapy was significantly higher in the high-PELD (P = .04) and high-CTP (P = .04) groups.ConclusionHemodynamic instability and long hospital LOS can be expected in pediatric post-LT patients with high PELD or CTP scores; there is also the risk that AKI maybe higher for high-PELD score patients. Unexpectedly, the PRISM-III score did not have any correlation with the severity of physiological condition and mortality.     

Early prediction of acute kidney injury after liver transplantation by scoring system and decision tree

Background and aimsEarly detection of acute kidney injury (AKI) is crucial for the prognosis of patients after liver transplantation (LT). This passage aims to analyze the perioperative clinical markers of AKI after LT and establish predictive models based on clinical variables for early detection of AKI after LT.MethodsWe prospectively collected 109 patients with LT, and compared the differences of perioperative clinical markers between the AKI group and non-AKI group. The scoring system and decision tree model were established through the risk factors. Another 163 patients who underwent LT in the same center from 2017 to 2018 were retrospectively collected to verify the models.ResultsIn multiple comparisons of risk factors of post-LT AKI, pre-operative factors were excluded automatically, intraoperative and post-operative factors including operating time, intraoperative hypotension time, post-operative infection, the peak of post-operative AST, and post-operative shock were the independent risk factors for post-LT AKI. The scoring system established with the risk factors has good predictive power (AUC = 0.755) in the validation cohort. The decision tree also shows that post-operative shock was the most important marker, followed by post-operative infection.ConclusionFive intraoperative and post-operative factors are independently associated with post-LT AKI rather than pre-operative factors, which indicates that operation technique and post-operative management may more important for the prevention of post-LT AKI. The scoring system and decision tree model could complement each other, and provide quantitative and intuitive prediction tools for clinical practice of early detection of post-LT AKI.     

Retrospective analysis on incidence and risk factors for early acute renal injury after lung transplantation

BackgroundAcute renal injury (AKI) is a common complication of lung transplantation. However, there has been no related research on whether the relationship between fluid balance and input and output influences the occurrence of early AKI. This study aimed to explore the relationship between early fluid balance and input and output on the incidence of early AKI after lung transplantation.MethodsData from 31 patients who underwent lung transplantation in the Department of Intensive Care Medicine of the Sichuan Academy of Medical Sciences, Sichuan People's Hospital, from August 2018 to July 2021 were collected. To summarize the occurrence of early AKI after lung transplantation, The main indicators of lung transplantation patients were collected. The risk factors for early AKI after lung transplantation were analyzed.ResultsAmong the 31 patients who underwent lung transplantation, 21 had early postoperative AKI, with an incidence rate of 67.7%. Compared with the non-AKI group, the hospitalization and ICU hospitalization times of the AKI group were longer (P < 0.05). Multivariate regression analysis showed that intraoperative input volume, BMI, and fluid balance on the first day after lung transplantation were independent risk factors for AKI.ConclusionIntraoperative input volume, BMI, and fluid balance on the first day after lung transplantation were independent risk factors for AKI.     

Risk of Hepatic Artery Complications After Liver Transplantation in Patients Who Received Pretransplant Transarterial Chemoembolization Therapy: A Single-Center Experience

BackgroundPretransplant transarterial chemoembolization (TACE) for patients with hepatocellular carcinoma (HCC) has been associated with an increased risk of hepatic artery thrombosis (HAT) after liver transplantation (LT). Innovative surgical LT and interventional vascular radiology TACE techniques may mitigate the risk of HAT. We sought to investigate the incidence of HAT after LT in patients who received pre-transplant TACE at our center.MethodsWe performed a single-center retrospective review of all LT patients, >18 years of age, from October 1, 2012, to May 31, 2018. Outcomes were compared between patients who received pre-LT TACE and those who did not. Median follow-up was 26 months.ResultsAmong the 162 LT recipients, 110 (67%) patients did not receive pre-LT TACE (Group I), while 52 (32%) received pre-LT TACE (Group II). The <30-day incidence rates of post-LT HAT were as follows: Group I = 1.8% and Group II = 1.9% (P = .9). Most hepatic arterial complications occurred >30 days after LT. Based on competing risks regression analysis, TACE was not associated with an increased risk of HAT. Patient or graft survivals were comparable between the 2 groups (P = .1 and .2, respectively).ConclusionsOur study shows a similar incidence of hepatic artery complications post-LT in patients who received TACE before LT compared with those who did not. In addition, we suggest that the surgical technique of early vascular control of the common hepatic artery during LT, in combination with a super-selective vascular intervention radiology approach, has clinical utility in reducing the risk of HAT in patients requiring pre-transplant TACE.     

Extracorporeal membrane oxygenation in patients with hepatopulmonary syndrome undergoing liver transplantation: A systematic review of the literature

BackgroundIsolated cases of extracorporeal membrane oxygenation (ECMO) in patients with hepatopulmonary syndrome (HPS) undergoing liver transplantation (LT) have been reported with increasing frequency. We aimed to systemically review and synthesize the available literature on ECMO use in this population.MethodsA systematic literature review of the PubMed, Web of Science, Cochrane Library, and Embase databases (end-of-search date: November 14, 2021) was conducted in accordance with the PRISMA statement. Eligible studies presented clinical parameters and outcomes of adult or pediatric patients with HPS receiving ECMO support at the time of, or following, LT.ResultsSixteen studies from 4 continents reporting on 17 patients who were initiated on ECMO prior to (n = 2), during (n = 1) or after LT (n = 14) were included. Nine of the 16 studies were published between 2019 and 2021. The median pre-LT PaO₂ was 38.0 mmHg (IQR 35.0–52.0). The median time from LT to ECMO initiation was 7 days (IQR, 3–12). Six patients (50%, n = 6 of 12) were extubated post-LT, before deterioration, development of refractory hypoxemia, and initiation of ECMO. Most patients were cannulated with a venovenous configuration (75%, n = 12 of 16). Most patients cannulated with a venoarterial or veno-arterial-venous strategy (75%, n = 3 of 4) had concurrent hemodynamic instability. The median total time on ECMO was 13 days (IQR 10–29). Using linear regression, for patients cannulated postoperatively, each day between LT and ECMO initiation was associated with a 3.5-day increase in total ECMO duration (95%CI: 2.23–4.73, p < 0.001, R² = 73.7%). The median postoperative intensive care unit length of stay was 40 days (IQR, 37–61) and hospital length of stay was 59.5 days (IQR 42–77). 82.4% of patients (14 of 17) survived to discharge.ConclusionsECMO is feasible in patients with HPS undergoing LT and appears to be associated with better outcomes compared to other causes of cardiopulmonary failure in LT patients. As the volume of experience grows, ECMO may become a central part of perioperative support in LT patients with severe HPS.     

Acute Kidney Injury After Ex Vivo Lung Perfusion (EVLP)

BackgroundEx vivo lung perfusion (EVLP) identifies viability for marginal organs but complicates and lengthens lung transplantation surgery. Preliminary evidence supports equivalency for EVLP-assisted versus traditional (non-EVLP) procedures regarding graft function, postoperative course, mortality, and survival. However, acute kidney injury (AKI), a common serious complication of lung transplantation, has not been assessed. We tested the hypothesis that EVLP-assisted and non-EVLP lung transplantations are associated with different AKI rates.MethodsDemographic, procedural, and renal data were gathered for 13 EVLP-viable lung transplantations and a non-EVLP group matched 4:1 for single versus double, pulmonary disease, and age. AKI was defined by AKI Network (AKIN) criteria and peak creatinine rise relative to baseline (Δ%Cr) during the 1st 10 postoperative days. Chi-square was performed for AKIN and 2-tailed t test for %ΔCr.ResultsPatient and procedural characteristics were similar between the groups. One non-EVLP patient required postoperative dialysis. AKI rates were also similar, as assessed by both AKIN (EVLP 7/13 (54%) vs non-EVLP 32/52 (62%); P = .61) and %ΔCr (EVLP 91 ± 81% vs non-EVLP 72 ± 62%; P = .63).ConclusionsWe did not observe different AKI rates between EVLP-assisted and traditional lung transplant procedures. Although 1 non-EVLP patient required dialysis, AKI rates were otherwise similar. These findings further support EVLP as a strategy to expand the organ pool and reduce concerns for high–renal risk recipients. The small sample size and retrospective design are limitations. However, our sample size is similar to other reports, and it is the first to analyze AKI after EVLP-assisted lung transplantation. Larger multicenter prospective studies are needed.     

The Impact of Tenofovir Disoproxil Fumarate on Reduced Bone Mineral Density and Fractures in Liver Transplant Recipients

BackgroundTenofovir disoproxil fumarate (TDF) is associated with reduced bone density in patients with human immunodeficiency virus, but the effect of TDF on bone density in liver transplant (LT) recipients is unknown.MethodsWe performed a single-center, retrospective study of LT recipients with hepatitis B taking TDF compared to a control group with non-hepatitis B virus viral hepatitis. The primary outcome was reduced bone density, defined as femoral neck or lumbar T-score less than ?1. Other outcomes included mean T-score and fractures.ResultsThree hundred ninety-three patients were studied: 52 patients in the TDF group and 341 patients in the control group; 64.3% patients in the TDF group had reduced bone density vs 71.4% in the control group (P = .58) before LT, compared to 75% and 81.5% (P = .57), respectively, after LT. Mean posttransplant lumbar T-scores were lower in the TDF group (?1.74 vs ?0.75, P = .04). There was no difference between the 2 groups for the other outcomes. In a multivariate Cox proportional hazards model, TDF use did not affect the risk of post-LT reduced bone density (hazard ratio = 0.99; 95% confidence interval, 0.56-1.76; P = .97).ConclusionTDF use was not associated with reduced bone mineral density or increased rates of fractures in LT recipients compared to controls in this study.     

Intravenous amino acid therapy for kidney protection in cardiac surgery patients: A pilot randomized controlled trial

ObjectiveTo determine whether a continuous intravenous infusion of standard amino acids could preserve kidney function after on-pump cardiac surgery.MethodsAdult patients scheduled to receive cardiac surgery lasting longer than 1 hour on-pump were randomized to standard care (n = 36) or an infusion of amino acids initiated immediately after induction of anesthesia (n = 33). The study's primary outcome measurements assessed renal function. These assessments included duration of renal dysfunction, duration and severity of acute kidney injury (AKI), estimated glomerular filtration rate (eGFR) over time, urine output, and use of renal-replacement therapy. Complications and other measures of morbidity were also assessed.ResultsSixty-nine patients (mean age 71.5 [standard deviation 9.2] years; 19 of 69 women) were enrolled and randomized. Patients received coronary artery bypass graft surgery (37/69), valve surgery (24/69), coronary artery bypass graft and valve surgery (6/69), or other procedures (2/69). Mean on-pump time was 268 [standard deviation 136] minutes. Duration of renal dysfunction did not differ between the groups (relative risk, 0.86; 95% confidence interval [CI], 0.19-3.79, P = .84). However, patients who received the amino acid infusion had a reduced duration of AKI (relative risk, 0.02; 95% CI, 0.005-0.11, P < .0001) and greater eGFR (+10.8%; 95% CI, 1.0%-20.8%, P = .033). Daily mean urine output was also significantly greater in patients who received the amino acid infusion (1.4 ± 0.5 vs 1.7 ± 0.9 L/d; P = .046).ConclusionsCommencing an infusion of standard amino acids immediately after the induction of anesthesia did not alter duration of renal dysfunction; however, other key measures of renal function (duration of AKI, eGFR and urine output) were significantly improved. These results warrant replication in multicenter clinical trials.     

Retrospective analysis on incidence and risk factors of early onset acute kidney injury after lung transplantation and its association with mortality

ObjectivesAcute kidney injury (AKI) is a common complication after lung transplantation (LTx) which is closely related to the poor prognosis of patients. We aimed to explore potential risk factors and outcomes associated with early post-operative AKI after LTx.MethodsA retrospective study was conducted in 136 patients who underwent LTx at our institution from 2017 to 2019. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guideline. Univariate and multivariate analyses were conducted to identify risk factors related to AKI. The primary outcome was the incidence of AKI after LTx. Secondary outcomes were associations between AKI and short-term clinical outcomes and mortality.ResultsOf the 136 patients analyzed, 110 developed AKI (80.9%). AKI was associated with higher baseline eGFR (odds ratio (OR) 1.01 (95% confidence interval (CI): 1.00–1.03)) and median tacrolimus (TAC) concentration (OR 1.15 (95% CI: 1.02–1.30)). Patients with AKI suffered longer mechanical ventilation days (p = .015) and ICU stay days (p = .011). AKI stage 2–3 patients had higher risk of 1-year mortality (HR 16.98 (95% CI: 2.25–128.45)) compared with no-AKI and stage 1 patients.ConclusionsOur results suggested early post-operative AKI may be associated with higher baseline eGFR and TAC concentrations. AKI stage 1 may have no influence on survival rate, whereas AKI stage 2–3 may be associated with increased mortality at 1-year.     

Predicting Early Graft Dysfunction and Mortality After Liver Transplant Using the De Ritis Ratio

BackgroundPredicting complications after liver transplantation (LT) remains challenging. We propose incorporating the De Ritis ratio (DRR), a widely known parameter of liver dysfunction, into current or future scoring models to predict early allograft dysfunction (EAD) and mortality after LT.MethodsA retrospective chart review was conducted on 132 adults receiving a deceased donor LT from April 2015 to March 2020 and their matching donors. Donor variables, postoperative liver function, and DRR were correlated with the occurrence of EAD, post-transplant complications expressed by the Clavien-Dindo score, and 30-day mortality as outcome variables.ResultsEarly allograft dysfunction was observed in 26.5% of patients and 7.6% of patients who died within 30 days after transplant. Recipients were more likely to experience EAD when receiving grafts from donation after circulatory death (P = .04), donor risk index (DRI) >2 (P = .006), ischemic injury at time-zero biopsy (P = .02), longer secondary warm ischemia time (P < .05), or higher Clavien-Dindo scores (IIIb-V; P < .001). The DRI, total bilirubin, and DRR on postoperative day 5 yielded significant associations with the primary outcomes and were used to develop the Gala-Lopez score using a weighted scoring model. This accurately predicted EAD, high Clavien-Dindo, and 30-day mortality in 75%, 81%, and 64% of patients.ConclusionIncluding recipient and donor variables in predictive models, and for the first time DRR, as a constituent, should be regarded to predict EAD, severe complications, and 30-day mortality post-LT. Further studies will be required to validate the present findings and their applicability when using normothermic regional and machine perfusion technologies.     

TT Genotype of Transforming Growth Factor Beta1 +869C/T Is Associated With the Development of Chronic Kidney Disease After Liver Transplantation

BackgroundChronic kidney disease (CKD) is a frequent complication in patients with liver transplantation (LT), and calcineurin inhibitor chronic nephrotoxicity, mediated by transforming growth factor beta1 (TGF-β1) is an important contributing factor. The aim of this study was to assess the influence of genetic polymorphisms of TGF-β1 in the development of CKD at 6 months after transplantation.MethodsOne hundred sixty-four LT patients (63.4% male; overall mean age, 48.7 ± 11.6 years) were included in the analysis. CKD was considered at the 6th month after LT and was defined as an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m² as calculated on the basis of Modification of Diet in Renal Disease 4-variable equation. TGF-β1 +869 C/T and +915 G/C polymorphisms were analyzed with the use of hybridization with fluorescent probes and analysis by means of flow cytometry with the Luminex system. The association between the presence of CKD at 6 months and these polymorphisms, as well as with other known risk factors for CKD after LT, was considered.ResultsIn the univariate analysis, the TT genotype of TGF-β1 +869 (P = .036; odds ratio, 2.1; 95% confidence interval, 1.1–4.2), age at LT (P < .001), pre-transplantation serum creatinine levels (P = .03), eGFR (P < .001), CKD (P = .027), and immunosuppression with cyclosporine (P = .017) were associated with CKD at 6 months after transplantation. In the multivariate analysis, TGF-β1 +869TT genotype (P = .017), immunosuppression with cyclosporine (P = .002), age at LT (P = .024), and pre-transplantation CKD (P < .001) remained as independent variables associated with the development of CKD at 6 months after transplantation.ConclusionsThe genetic polymorphism TGF-β1 +869 C/T may be an independent risk factor for CKD after liver transplantation.     

Association of Inflammatory Biomarkers with Immunosuppression Management and Outcomes in Kidney Transplant Recipients with COVID-19

BackgroundKidney transplant recipients with coronavirus disease 2019 (COVID-19) are at increased risk for adverse outcomes, such as acute kidney injury (AKI), intensive care unit (ICU) admission, and death. The association of inflammatory biomarkers with outcomes and the impact of changes in immunosuppression on biomarker levels are unknown.MethodsWe investigated factors associated with a composite of AKI, ICU admission, or death, and whether immunosuppression changes correlated with changes in inflammatory biomarkers and outcomes in kidney transplant recipients with a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction.ResultsOf 59 patients, 50% had estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m². Patients who discontinued calcineurin inhibitors (CNIs) had higher peak high-sensitivity C-reactive protein (hs-CRP) than those who maintained the same dose (median, 344; interquartile range [IQR], 145-374 vs median, 41; IQR, 22-116 mg/L, P = .03). Of the patients, 73% were hospitalized, 22% had admissions to the ICU, and 20% died. Of the 56% with AKI, 35% required dialysis. All patients with AKI but without pulmonary manifestations recovered to 10% of baseline creatinine levels. Factors associated with the composite outcome were eGFR <60 mL/min/1.73 m² (odds ratio [OR], 5.833; 95% confidence interval [CI], 1.880-18.099; P = .002), hs-CRP (OR, 1.011/unit increase; 95% CI, 1.002-1.021; P = .019), white blood cell count (OR, 1.173/unit increase; 95% CI, 1.006-1.368; P = .041), and decreased or discontinued CNI (OR, 4.286; 95% CI, 1.353-13.572; P = .013). eGFR<60 mL/min/1.73 m² (OR, 11.176; 95% CI, 1.581-79.001; P = .016), and peak hs-CRP (OR, 1.010/unit increase; 95% CI, 1.000-1.020; P = .049) remained associated with the composite in the multivariable model.ConclusionsKidney transplant recipients with COVID-19 have high rates of ICU admissions, AKI, and death. Those with eGFR<60 mL/min/1.73 m² are at highest risk. CNI reduction is associated with higher inflammatory biomarkers, correlating with worse outcomes. More studies are needed to determine if this association should drive clinical management.     

A Single Center Experience of the Prognosis After Liver Transplantation From Discarded Graft Due to Poor Graft Conditions in Prioritized Centers

BackgroundLiver transplantation (LT) has the limitation of graft shortage. Therefore, to increase the donor pool, even marginal grafts are being transplanted depending on the recipient's condition. This study was conducted to analyze the post-LT prognosis using discarded liver grafts.Methods and MaterialsFrom January 2010 to September 2020, deceased-donor LT was performed in 160 patients in our center. Among them, 121 patients (allocated group) were preferentially allocated to our center, and the remaining 39 patients (24.4%, discarded group) received liver grafts that were discarded by prioritized centers.ResultsThe preoperative model for end-stage liver disease score were 27.0 ± 10.41 and 27.0 ±11.79 for each group (P = .99). There were no differences between the 2 groups in operation time (P = .06) and intraoperative packed red cell transfusion (P = .90). There were no differences between the 2 groups in early allograft dysfunction (P = .48) and hospital stay (P = .26) after deceased-donor LT. In-hospital mortality occurred in 10 patients (8.3%) in the allocated group and 4 patients (10.3%) in the discarded group. Only the length of intensive care unit stay was significantly longer in the discarded group (P = 0.04). The 5-year survival rate was 73.8% in the allocated group and 72.2% in the discarded group.ConclusionsThe outcome of the discarded group is never worse than that of the allocated group. deceased-donor LT from the discarded graft can be acceptable. As a result, the number of discarded grafts can be reduced.