Risk factors for acute kidney injury and 30-day mortality after liver transplantation

Introduction. The aim of this study is to evaluate the risk factors for acute kidney injury (AKI) and 30-day mortality after liver transplantation.Material and methods. This is a retrospective cohort of consecutive adults undergoing orthotopic liver transplantation (OLT) at a referral hospital in Brazil, from January 2013 to January 2014. Risk factors for AKI and death were investigated.Results. A total 134 patients were included, with median age of 56 years. AKI was found in 46.7% of patients in the first 72 h after OLT. Risk factors for AKI were: viral hepatitis (OR 2.9, 95% CI = 1.2-7), warm ischemia time (OR 1.1, 95% CI = 1.01-1.2) and serum lactate (OR 1.3, 95%CI = 1.02-1.89). The length of intensive care unit (ICU) stay was longer in AKI group: 4 (3-7) days vs. 3 (2-4) days (p = 0.001), as well as overall hospitalization stay: 16 (9-26) days vs. 10 (8-14) days (p = 0.001). The 30-day mortality was 15%. AKI was an independent risk factor for mortality (OR 4.3, 95% CI = 1.3-14.6). MELD-Na ≥ 22 was a predictor for hemodialysis need (OR 8.4, 95%CI = 1.5-46.5). Chronic kidney disease (CKD) was found in 36 patients (56.2% of AKI patients).Conclusions. Viral hepatitis, longer warm ischemia time and high levels of serum lactate are risk factors for AKI after OLT. AKI is a risk factor for death and can lead to CKD in a high percentage of patients after OLT. A high MELD-Na score is a predictor for hemodialysis need.     

The prognosis and risk factors for acute kidney injury in high-risk patients after surgery for type A aortic dissection in the ICU

BackgroundAcute kidney injury (AKI) is a major complication of cardiac surgery, with high rates of morbidity and mortality. The aim of this study was to identify risk factors for the incidence and prognosis of AKI in high-risk patients before and after surgery for acute type A aortic dissection (TAAD) in the intensive care unit (ICU).MethodsWe performed a retrospective cohort study from April 2018 to April 2019. The primary end points of this study were morbidity due to AKI and risk factors for incidence, and the secondary end points were mortality at 28 days and risk factors for death.ResultsWe enrolled 60 patients, 52 (86.67%) patients developed postoperative AKI, 28 (53.84%) patients died. Preoperative lactic acid level (P=0.022) and cardiopulmonary bypass (CPB) duration (P=0.009) were identified as independent risk factors for postoperative AKI. The 28-day mortality for postoperative patients with TAAD was 46.67%, 53.84% for those with TAAD and AKI, 67.5% for those who required continue renal replacement therapy (CRRT). The risk factors for 28-day mortality due to postoperative AKI for patients requiring CRRT were CPB duration (P=0.019) and norepinephrine dose upon diagnosis of AKI (P=0.037).ConclusionsMorbidity due to AKI in postoperative patients with TAAD was 86.67%, and preoperative lactic acid level and CPB duration were independent risk factors. The 28-day mortality of postoperative patients with TAAD was 46.67%, 53.84% for those with TAAD and AKI, and 67.5% for those requiring CRRT. CPB duration and norepinephrine dose upon diagnosis of AKI may influence patients’ short-term prognosis.     

The AKI Prediction Score: a new prediction model for acute kidney injury after liver transplantation

BackgroundAcute kidney injury (AKI) is a frequent complication after liver transplantation. Although numerous risk factors for AKI have been identified, their cumulative impact remains unclear. Our aim was therefore to design a new model to predict post-transplant AKI.MethodsRisk analysis was performed in patients undergoing liver transplantation in two centres (n = 1230). A model to predict severe AKI was calculated, based on weight of donor and recipient risk factors in a multivariable regression analysis according to the Framingham risk-scheme.ResultsOverall, 34% developed severe AKI, including 18% requiring postoperative renal replacement therapy (RRT). Five factors were identified as strongest predictors: donor and recipient BMI, DCD grafts, FFP requirements, and recipient warm ischemia time, leading to a range of 0–25 score points with an AUC of 0.70. Three risk classes were identified: low, intermediate and high-risk. Severe AKI was less frequently observed if recipients with an intermediate or high-risk were treated with a renal-sparing immunosuppression regimen (29 vs. 45%; p = 0.007).ConclusionThe AKI Prediction Score is a new instrument to identify recipients at risk for severe post-transplant AKI. This score is readily available at end of the transplant procedure, as a tool to timely decide on the use of kidney-sparing immunosuppression and early RRT.     

Risk factors for acute kidney injury after pancreatoduodenectomy,and association with postoperative complications and death

BackgroundAcute kidney injury (AKI) is associated with increased morbidity and mortality after general surgery, although little is known among patients undergoing pancreatoduodenectomy. The objective was to investigate the association between AKI and postoperative complications and death after pancreatoduodenectomy.MethodsAll patients ≥18 years who underwent a pancreatoduodenectomy 2008–2019 at the Karolinska University Hospital, Stockholm, Sweden, were included. Standardized criteria for AKI, including estimated glomerular filtration rate (eGFR) and urine volume measurements, were used to grade postoperative AKI.ResultsIn total, 970 patients were included with a median age of 68 years (IQR 61–74) of whom 517 (53.3%) were men. There were 137 (14.1%) patients who developed postoperative AKI. Risk factors for AKI included lower preoperative eGFR, cardiovascular disease and treatment with renin-angiotensin system inhibitors or diuretics. Those who developed AKI had a higher risk of severe postoperative complications, including Clavien-Dindo score ≥ IIIa (adjusted OR 3.35, 95% CI 2.24–5.01) and ICU admission (adjusted OR 7.83, 95% CI 4.39–13.99). In time-to-event analysis, AKI was associated with an increased risk for both 30-day mortality (adjusted HR 4.51, 95% CI 1.54–13.27) and 90-day mortality (adjusted HR 4.93, 95% CI 2.37–10.26). Patients with benign histology and AKI also had an increased 1-year mortality (HR 4.89, 95% CI 1.88–12.71).ConclusionsPostoperative AKI was associated with major postoperative complications and an increased risk of postoperative mortality. Monitoring changes in serum creatinine levels and urine volume output could be important in the immediate perioperative period to improve outcomes after pancreatoduodenectomy.     

原位肝移植术后肺部感染及危险因素分析

目的探讨原位肝移植术后肺部感染的特点及其危险因素，以提高肝移植术后肺部感染的诊治水平。方法对250例原位肝移植术后肺部感染患者的资料进行了回顾性分析，以术前、术中及术后主要的临床表现和实验室指标作为研究对象，分析肺部感染组和对照组间的差别。结果250例原位肝移植患者中，57例术后共发生肺部感染72次，肺部感染率为22．8％（57／250）。最常见为细菌感染，单一细菌感染36例次，两种细菌感染5例次，多种细菌同时感染6例次。其次为真菌感染13例次，占18．1％（13／72），其中7例次合并细菌感染。病毒感染12例次，占16．7％（12／72），均为巨细胞病毒感染，其中3例次合并细菌感染。肺部感染组术后1、2、3年生存率分别为71．9％、61．4%、53．4%，对照组分别为93．1％、75．8％、67．2％（P〈0．05）。Logistic回归分析表明肝移植患者有术前感染、机械通气时间大于12h、手术时间、术中输血总量〉1000 ml、术后再次手术史、术后胸水、重症监护室住院天数这7个因素是术后肺部感染的独立危险因素。结论肺部感染以细菌感染为主，但多种病原菌的混合感染以及多重耐药菌日益增多。在临床工作中应重视对相关危险因素的控制，早期诊断、早期治疗是治疗成功的关键。     

Impact of acute kidney injury after extended liver resections

BackgroundComplex liver resection is a risk factor for the development of AKI, which is associated with increased morbidity and mortality. Aim of this study was to assess risk factors for acute kidney injury (AKI) and its impact on outcome for patients undergoing complex liver surgery.MethodsAKI was defined according to the KDIGO criteria. Primary endpoint was the occurrence of AKI after liver resection. Secondary endpoints were complications and mortality.ResultsOverall, 146 patients undergoing extended liver resection were included in the study. The incidence of AKI was 21%. The incidence of chronic kidney disease (CKD) and hepatocellular carcinoma were significantly higher in patients with AKI. In the AKI group, the proportion of extended right hepatectomies was the highest (53%), followed by ALPPS (43%). Increased intraoperative blood loss, increased postoperative complications and perioperative mortality was associated with AKI. Besides age and CKD, ALPPS was an independent risk factor for postoperative AKI. A small future liver remnant seemed to increase the risk of AKI in patients undergoing ALPPS.ConclusionFollowing extended liver resection, AKI is associated with an increased morbidity and mortality. ALPPS is a major independent risk factor for the development of AKI and a sufficient future liver remnant could avoid postoperative AKI.     

Postoperative acute kidney injury and early and long-term mortality in acute aortic dissection patients: A meta-analysis

Objective:To evaluate the impact of postoperative acute kidney injury (AKI) on early and long-term mortality in patients with acute aortic dissection by conducting a meta-analysis.Methods:An extensive literature search was performed in PubMed and Embase databases until February 15, 2020. Observational studies that reported the associations between postoperative AKI and early (in-hospital and within 30 days) or long-term mortality in patients with acute aortic dissection were included.Results:Seven studies comprising 1525 acute aortic dissection patients were identified. A random effect meta-analysis showed that postoperative AKI was significantly associated with higher risk of long-term mortality (risk ratio [RR] 2.32; 95% confidence interval [CI] 1.50–3.59). Subgroup analysis revealed that the pooled RR of long-term mortality was 1.42 (95% CI 0.90–2.22) for stage 1 AKI, 1.72 (95% CI 0.95–3.12) for stage 2 AKI, and 4.46 (95% CI 2.72–7.32) for stage 3 AKI, respectively. Furthermore, postoperative stage 3 AKI was associated with an increased risk of early mortality (RR 11.3; 95% CI 4.2–30.5).Conclusions:This meta-analysis provided clinical evidence that postoperative stage 3 AKI is associated with higher risk of early and long-term mortality, even after adjusting important confounding factors. However, the current findings should be interpreted with caution due to the retrospective nature and limited number of studies analyzed.     

D-dopachrome tautomerase predicts outcome but not the development of acute kidney injury after orthotopic liver transplantation

Background

Elevated concentrations of D-dopachrome tautomerase (D-DT) were associated with adverse outcome in various clinical settings. However, no study assessed D-DT concentrations in patients requiring orthotopic liver transplantation (OLT). The aim of this observational study was to measure serum D-DT concentrations in patients undergoing OLT and associate D-DT with survival and acute kidney injury (AKI).

Bone disease after orthotopic liver transplantation

After orthotopic liver transplantation (OLT), not infrequently a deterioration of bone disease leading to compression fractures of vertebrae is seen. In a consecutive series of 36 adult OLT patients, we studied, clinically and radiologically, the incidence and degree of bone disease before and after OLT; we also studied whether clinical, radiological and laboratory findings were related to the event of postoperative vertebral collapse. Before OLT, radiological signs of mostly slight osteoporosis were seen in a minority of patients. After OLT, 38% of patients developed vertebral collapse, mainly in the second trimester. Collapse occurred in both previously normal and abnormal vertebrae. Of the preoperative parameters sex, age, menopause, intake of prednisolone, duration and diagnosis of liver disease, duration and degree of cholestasis, bone radiology and urinary calcium, only a low urinary calcium was related to postoperative collapse. Of the postoperative parameters duration of cholestasis, urinary calcium, duration of hospital stay, prednisolone dose and outcome in terms of life and death, none was related to collapse. We conclude that vertebral collapse after OLT occurs frequently and is not easily predicted. Early prevention of bone disease in patients with chronic liver disease before OLT and a low steroid-containing immunosuppressive regimen after OLT are advocated.     

Predictors and in-hospital outcomes of preoperative acute kidney injury in patients with type A acute aortic dissection

Background Acute kidney injury (AKI) is common after surgery for acute aortic dissection (AAD) and increases in-hospital and long-term mortality. However, few data exist on the clinical and prognostic relevance of early preoperative AKI in patients with type A AAD. We aimed to determine the incidence and predictors of preoperative AKI and the impact of AKI on in-hospital outcomes in patients with type A AAD. Methods From May 2009 to June 2014, we retrospectively enrolled 178 patients admitted to our hospital within 48 h from symptom onset and receiving open surgery for type A AAD. The patients were divided into no AKI and AKI groups and staged with AKI severity according to the KDIGO criteria before surgery. Results AKI occurred in 41 patients (23.0%). The incidence of in-hospital complications was significantly higher in patients with preoperative AKI compared to no AKI (41.5% vs. 9.5%, P < 0.001), including renal infarction (7.3% vs. 0, P = 0.012), and it increased with AKI severity (P_trend < 0.001). Patients with AKI had higher in-hospital mortality compared with patients without AKI, although no significant difference was found (14.6% vs. 5.1%, P = 0.079). Multivariate analysis indicated that male gender, diastolic blood pressure on admission and bilateral renal artery involvement were independent predictors of preoperative AKI in patients with type A AAD. Conclusions Early AKI before surgery was common in patients with type A AAD, and was associated with increased in-hospital complications. Male gender, diastolic blood pressure on admission and bilateral renal artery involvement were major predictors for preoperative AKI.     

分子吸附再循环系统对肝移植术早期成功率的影响

目的 探讨影响肝移植术早期成功率的危险因素,总结在肝移植术前应用分子吸附再循环系统(MARS)治疗对术后患者早期生存率的影响。 方法 回顾性分析50例肝移植患者术前80次MARS治疗的临床资料,对有关临床指标进行排序分析;术后生存30d的28例为生存组,死亡6例为死亡组,对部分术前危险因素进行回归分析。 结果 50例患者中免除移植出院8例,移植前死亡8例,34例过渡到移植,移植后死亡6例。单次6 h MARS治疗较大幅度降低患者血清总胆红素、肌酐、尿酸、血氨、肿瘤坏死因子α(TNF α)和白细胞介素-10(IL-10)水平,同时显著改善系列器官功能衰竭评分(SOFA)(P<0.05);移植术后早期死亡与术前SOFA、肌酐、国际标准化比率(INR)、TNF α和IL-10等存在明显相关性。 结论 术前SOFA、肌酐、INR、TNF α和IL-10水平是移植后早期死亡的主要术前危险因素,术前MARS支持可以显著改善这些危险因素,有效提高移植成功率,甚至避免移植手术。     

Acute kidney injury after liver surgery: does postoperative urine output correlate with postoperative serum creatinine?

BackgroundAcute kidney injury (AKI) after hepatectomy occurs in around 10% of cases. AKI is often defined based only on postoperative serum creatinine increase. This study aimed to assess if postoperative urine output (UO) correlated with serum creatinine after hepatectomy.MethodsAll consecutive hepatectomy patients (2010–2016) were assessed. AKI was defined according to KDIGO criteria: serum creatinine increase ≥26.5 μmol/l, creatinine increase ≥1.5x baseline creatinine, or postoperative oliguria. Oliguria was defined as daily mean UO <0.5 mL/kg/h. AKI was subdivided into creatinine-based or oliguria-based AKI according to the defining criterion.ResultsOut of 285 patients, AKI was observed in 79 cases (28%). Creatinine-based AKI occurred in 25 patients (9%) and oliguria-based only AKI in 54 patients (19%). Ten patients fulfilled both criteria (4%). Postoperative UO correlated poorly with postoperative serum creatinine level in both whole cohort (rho = −0.34, p <0.001) and AKI subgroup (rho = −0.189, p = 0.124). No association was found between postoperative oliguria and postoperative serum creatinine increase (HR = 0.5, 95%CI: 0.2–1.9, p = 0.341). On multivariable analysis, operation duration >360 minutes was the only predictor of creatinine increase (HR = 3.6, 95%CI: 1.1–11.4, p = 0.032).ConclusionPostoperative UO showed poor correlation with postoperative serum creatinine both in all patients and AKI patients. Surgery duration >360 minutes appeared as the only independent predictor of postoperative serum creatinine increase.     

Infection within 2 weeks before liver transplantation closely related to prognosis of posttransplant infection: A single-center retrospective observational study in China

BackgroundInfections still represent the main factors influencing morbidity and mortality following liver transplantation. This study aimed to evaluate the incidence and risk factors for infection and survival after liver transplantation.MethodsWe retrospectively examined medical records in 210 liver recipients who underwent liver transplantation between April 2015 and October 2017 in our hospital. Clinical manifestations and results of pathogen detection test were used to define infection. We analyzed the prevalence, risk factors and prognosis of patients with infection.ResultsThe median follow-up was 214 days; the incidence of infection after liver transplantation was 46.7% (n = 98) which included pneumonia (43.4%), biliary tract infection (21.9%), peritonitis (21.4%) and bloodstream infection (7.6%). Among the pathogens in pneumonia, the most frequently isolated was Acinetobacter baumanii (23.5%) and Klebsiella pneumoniae (21.2%). Model for end-stage liver disease (MELD) score (OR = 1.083, 95% CI: 1.045–1.123; P < 0.001), biliary complication (OR = 4.725, 95% CI: 1.119–19.947; P = 0.035) and duration of drainage tube (OR = 1.040, 95% CI: 1.007–1.074; P = 0.017) were independent risk factors for posttransplant infection. All-cause mortality was 11.0% (n = 23). The prognostic factors for postoperative infection in liver recipients were prior-transplant infection, especially pneumonia within 2 weeks before transplantation. Kaplan-Meier curves of survival showed that recipients within 2 weeks prior infection had a significantly lower cumulative survival rate compared with those without infection (65.2% vs. 90.0%; hazard ratio: 4.480; P < 0.001).ConclusionsInfection, especially pneumonia within 2 weeks before transplantation, complication with impaired renal function and MELD score after 7 days of transplantation was an independent prognostic factor for postoperative infection in liver transplant recipients.     

Inflammatory bowel disease after liver transplantation: A role for cytomegalovirus infection

Objective. Despite the use of immunosuppressive drugs, recurrent and de novo inflammatory bowel disease (IBD) can develop after orthotopic liver transplantation (OLT). Cytomegalovirus (CMV) infection has been suggested to play a role in the pathogenesis of IBD. The aim of this study was to investigate the role of CMV infection in the development of IBD after OLT. Material and methods. All 84 patients who underwent transplantation for primary sclerosing cholangitis (PSC) or autoimmune hepatitis (AIH) in our center between May 1987 and June 2002 and who survived the first year after transplantation were included in the study. Diagnosis of active CMV infection was made using the pp65–antigenemia assay. Results. Thirty-one of the 84 patients (37%) had IBD prior to OLT. Eighteen patients (21%) experienced IBD after OLT, either as flare-up (n=12) or de novo (n=6), at a median of 1.4 years (range 0.3 to 6.3) after OLT. Forty-eight percent of all patients experienced CMV infection after OLT, at a median of 27 days (range 8 to 193). CMV infection was primary in half the patients. At 1, 3, and 5 years after OLT, active IBD-free survival without CMV infection was 91, 88, and 88%, respectively. With CMV infection these figures were 93, 82, and 67%. De novo IBD was seen only in those who had experienced a CMV infection (p=0.02). Conclusions. In patients transplanted for end-stage PSC or AIH, active IBD, especially de novo IBD, occurred more often in patients who experienced CMV infection in the postoperative period. This finding supports a pathogenic role for CMV in the development of IBD.     

Application of machine learning models for predicting acute kidney injury following donation after cardiac death liver transplantation

Background: Acute kidney injury(AKI) is a common complication after liver transplantation(LT) and is an indicator of poor prognosis. The establishment of a more accurate preoperative prediction model of AKI could help to improve the prognosis of LT. Machine learning algorithms provide a potentially effective approach. Methods: A total of 493 patients with donation after cardiac death LT(DCDLT) were enrolled. AKI was defined according to the clinical practice guidelines of kidney disease: improving global outcomes(KDIGO). The clinical data of patients with AKI(AKI group) and without AKI(non-AKI group) were compared. With logistic regression analysis as a conventional model, four predictive machine learning models were developed using the following algorithms: random forest, support vector machine, classical decision tree, and conditional inference tree. The predictive power of these models was then evaluated using the area under the receiver operating characteristic curve(AUC). Results: The incidence of AKI was 35.7%(176/493) during the follow-up period. Compared with the nonAKI group, the AKI group showed a remarkably lower survival rate( P 0.001). The random forest model demonstrated the highest prediction accuracy of 0.79 with AUC of 0.850 [95% confidence interval(CI): 0.794–0.905], which was significantly higher than the AUCs of the other machine learning algorithms and logistic regression models( P 0.001). Conclusions: The random forest model based on machine learning algorithms for predicting AKI occurring after DCDLT demonstrated stronger predictive power than other models in our study. This suggests that machine learning methods may provide feasible tools for forecasting AKI after DCDLT.     

Prevalence and clinical characteristics of alpha-1 antitrypsin deficiency in liver explants in a Mexican cohort

IntroductionAlpha-1 antitrypsin deficiency (AATD) is a risk factor for liver disease. PASD-positive inclusions have been found unexpectedly in approximately 10% of liver explants in patients with no previous diagnosis of AATD, particularly, in patients with non-alcoholic steatohepatitis (NASH), supporting a synergistic mechanism of liver injury between AATD and environmental factors. We aimed to determine the clinical characteristics of mestizo patients in which AATD was diagnosed before or after liver transplantation.MethodsLiver explants of patients with cryptogenic, alcoholic, and NAFLD/NASH cirrhosis undergoing orthotopic liver transplantation (OLT) were included. Liver histopathology was assessed by two expert pathologists. Hematoxylin and eosin staining, PASD staining, and confirmatory AAT immunohistochemistry were performed. In explants with positive histopathology, genotyping for SERPINA1 was performed.ResultsA total of 180 liver transplants were performed during the study period. Of these, 44 patients with cryptogenic cirrhosis, NASH, and alcoholic cirrhosis were included. Of these patients, two liver explants (4.5%) had PASD-positive inclusions stain and confirmatory immunochemistry. During the period evaluated, another two patients with a diagnosis of AATD before the OLT were also included. The four patients had overweight or obesity, three had type 2 diabetes mellitus, and two developed liver steatosis after the OLT.ConclusionAATD was found to be an infrequent finding in patients with cryptogenic, NASH/NAFLD, and alcoholic cirrhosis in our population. However, it is important to consider this entity as it may represent an additional factor in the appearance and progression of liver fibrosis in patients with metabolic syndrome.     

Surgical dilemma: liver resection or liver transplantation for hepatocellular carcinoma and cirrhosis. Intention-to-treat analysis in patients within and outwith Milan criteria

Background:

The optimal role of surgery in the management of hepatocellular carcinoma (HCC) is in continuous evolution.

Objective:

The objective of this study was to analyse survival rates after liver resection (LR) and orthotopic liver transplantation (OLT) for HCC within and outwith Milan criteria in an intention-to-treat analysis.

Methods:

During 1997–2007, 179 patients with cirrhosis and HCC either underwent LR (n= 60) or were listed for OLT (n= 119). Patients with incidental HCC after OLT, preoperative macrovascular invasion before LR, non-cirrhosis and Child–Pugh class C cirrhosis prior to OLT were eliminated, leaving 51 patients primarily treated with LR and 106 patients listed for primary OLT (84 of whom were transplanted) to be included in this analysis. A total of 66 patients fell outwith Milan criteria (26 LR, 40 OLT) and 91 continued to meet Milan criteria (25 LR, 66 OLT).

Results:

The median length of follow-up was 26 months. The mean waiting time for OLT was 7 months. During that time, 21 patients were removed from the waiting list as a result of tumour progression. Probabilities of dropout were 2% and 13% at 6 and 12 months, respectively, for patients within Milan criteria, and 34% and 57% at 6 and 12 months, respectively, for patients outwith Milan criteria (P < 0.01). Tumour size >3 cm was found to be the independent factor associated with dropout (hazard ratio [HR] 6.0). Postoperative survival was slightly higher after OLT, but this was not statistically significant (64% for OLT vs. 57% for LR). Overall survival from time of listing for OLT or LR did not differ between the two groups (P= 0.9); for patients within Milan criteria, 1- and 4-year survival rates after LR were 88% and 61%, respectively, compared with 92% and 62%, respectively, after OLT (P= 0.54). For patients outwith Milan criteria, 1- and 4-year survival rates after LR were 69% and 54%, respectively, compared with 65% and 40%, respectively, after OLT (P= 0.42). Tumour size >3 cm was again found to be an independent factor for poor outcome (HR 2.4) in the intention-to-treat analysis.

Conclusions:

Survival rates for patients with HCC are similar in LR and OLT. Liver resection can potentially decrease the dropout rate and serve as a bridge for future salvage LT, particularly in patients with tumours >3 cm.     

Preoperative risk factor analysis in orthotopic liver transplantation with pretransplant artificial liver support therapy

AIM: To assess the value of pre-transplant artificial liver support in reducing the pre-operative risk factors relating to early mortality after orthotopic liver transplantation (OLT). METHODS: Fifty adult patients with various stages and various etiologies undergoing OLT procedures were treated with molecular adsorbent recycling system (MARS) as preoperative liver support therapy. The study included two parts, the first one is to evaluate the medical effectiveness of single MARS treatment with some clinical and laboratory parameters, which were supposed to be the therapeutical pre-transplant risk factors, the second part is to study the patients undergoing OLT using the regression analysis on preoperative risk factors relating to early mortality (30 d) after OLT. RESULTS: In the 50 patients, the statistically significant improvement in the biochemical parameters was observed (pre-treatment and post-treatment). Eight patients avoided the scheduled Ltx due to significant relief of clinical condition or recovery of failing liver function, 8 patients died, 34 patients were successfully bridged to Ltx, the immediate outcome of this 34 patients within 30d observation was: 28 kept alive and 6 patients died. CONCLUSION: Pre-operative SOFA, level of creatinine, INR, TNF-α, IL-10 are the main preoperative risk factors that cause early death after operation, MARS treatment before transplantion can relieve these factors significantly.     

Low immediate postoperative platelet count is associated with hepatic insufficiency after hepatectomy

AIM: To investigate the relationship between low immediate postoperative platelet count and perioperative outcome after liver resection in patients with hepatocellular carcinoma (HCC).METHODS: In a cohort of 565 consecutive hepatitis B-related HCC patients who underwent major liver resection, the characteristics and clinical outcomes after liver resection were compared between patients with immediate postoperative platelet count < 100 × 10⁹/L and patients with platelet count ≥ 100 × 10⁹/L. Risk factors for postoperative hepatic insufficiency were evaluated by multivariate analysis.RESULTS: Patients with a low immediate postoperative platelet count (< 100 × 10⁹/L) had more grade III-V complications (20.5% vs 12.4%, P = 0.016), and higher rates of postoperative liver failure (6.8% vs 2.6%, P = 0.02), hepatic insufficiency (31.5% vs 21.2%, P < 0.001) and mortality (6.8% vs 0.5%, P < 0.001), compared to patients with a platelet count ≥ 100 × 10⁹/L. The alanine aminotransferase levels on postoperative days 3 and 5, and bilirubin on postoperative days 1, 3 and 5 were higher in patients with immediate postoperative low platelet count. Multivariate analysis revealed that immediate postoperative low platelet count, rather than preoperative low platelet count, was a significant independent risk factor for hepatic insufficiency.CONCLUSION: A low immediate postoperative platelet count is an independent risk factor for hepatic insufficiency. Platelets can mediate liver regeneration in the cirrhotic liver.     

Factors determining achievement of early postoperative cardiac rehabilitation goal in patients with or without preoperative kidney dysfunction undergoing isolated cardiac surgery

BackgroundThe aim of this multicenter study was to evaluate the relationship between preoperative kidney function, postoperative acute kidney injury (AKI), and postoperative fluid balance (POFB) with the progress of early postoperative cardiac rehabilitation (CR) in patients undergoing isolated cardiac surgery.MethodsFour hundred twenty three consecutive patients (137 females, 286 males, aged 66 ± 13 years) who underwent various elective cardiac surgeries in the participating institutes were selected and divided into 5 groups depending on chronic kidney disease (CKD) stage. We evaluated the effects of CKD stage on the progress of early postoperative CR, and analyzed the factors determining the achievement of Japanese Circulation Society (JCS) early postoperative CR guidelines goal.ResultsInitiation of sitting (F = 7.59, p < 0.01) and standing (F = 4.83, p < 0.01), walking (F = 4.40, p < 0.01), and 100-m unassisted walk (F = 13.09, p < 0.01) were related with severity of preoperative CKD stage. The proportion of patients who could not achieve JCS early postoperative CR guideline goal was 15.0% in patients with CKD and 12.9% in patients without CKD. Multivariable analyses identified Risk, Injury, Failure, Loss, and End-stage Kidney (RIFLE) classification (of postoperative AKI) and blood urea nitrogen as factors determining achievement of early postoperative CR goal in patients with CKD; and POFB/preoperative body weight (PBW), RIFLE classification as determinants in patients without CKD. Using the receiver-operating characteristics curve analysis to predict achievement of the early postoperative CR goal, POFB/PBW 4.9% was identified as the cut-off value for achievement of the JCS early postoperative CR guideline goal.ConclusionPreoperative CKD stage correlated significantly with the progress of early postoperative CR after cardiac surgery. Independent determinants of achieving JCS early postoperative CR guideline goal were postoperative AKI in patients with or without CKD, and POFB/PBW only in patients without CKD.