Acute Kidney Injury After Liver Transplantation: Incidence and Mortality

Introduction

Patients undergoing orthotopic liver transplantation often present with acute kidney injury (AKI) in the postoperative period. It has been associated with a greater number of complications and high mortality rates. The goal of this study was to determine the incidence of AKI during the early posttransplant period and mortality in patients undergoing orthotopic liver transplantation in our hospital.

Patients and Methods

In this retrospective cohort study, we reviewed the medical records of all patients aged >18 years undergoing liver transplantation from April 2008 to April 2011. The exclusion criteria were a glomerular filtration rate (estimated by using the Modification of Diet in Renal Disease formula) <60 mL/min/1.73 m² or AKI at the time of transplantation. AKI was defined as an increase ≥50% from preoperative baseline serum creatinine levels during the hospitalization period.

Results

Of 113 selected patients, 78 (69%) were male. The mean age was 54.03 ± 9.38 years. The mean preoperative baseline creatinine level was 0.94 ± 0.15 mg/dL, and the estimated glomerular filtration rate was 87.09 ± 19.67 mL/min/1.73 m². The mean calculated Model for End-Stage Liver Disease score was 13. Hepatitis C serology was present in 70.8%, hepatitis B in 11.5%, hepatocellular carcinoma in 75.2%, and alcohol abuse in 31.9% of patients. The incidence of AKI was 56.6% (64 of 113 patients). The main risk factors for AKI were Model for End-Stage Liver Disease score and diuretic use at baseline. Renal replacement therapy (RRT) was performed in 19.5% (22 of 113) of patients. The hospital mortality rate in the group with AKI was 25% (16 of 64 patients) and 6.1% (3 of 49 patients) between patients without AKI (odds ratio, 5.11 [confidence interval, 1.39–18.7]; P < .01]. Among patients who underwent RRT, the in-hospital mortality rate was 54.5% (12 of 22 patients) compared with 7.7% (7 of 91 patients) from the other remaining patient cohort (odds ratio, 14.40 [confidence interval, 4.60–45.00]; P < .01).

Conclusions

There was a high incidence of AKI in patients undergoing liver transplantation and an increased risk of mortality among patients who needed RRT.     

Biliary Complications After Pediatric Liver Transplantation

ObjectivesAfter liver transplantation, biliary complications are more prevalent in pediatric patients, with reported rates varying between 15% and 30%.MethodsWe retrospectively analyzed biliary complications observed in 84 pediatric liver transplantation patients between July 2006 and September 2012. Biliary reconstruction was accomplished via a duct-to-duct anastomosis in 5 (83.3%) of the 6 patients receiving whole liver grafts and in 44 (56.4%) of the 78 patients who received a segmental live donor graft. For the remaining 34 patients with living donor and 1 patient with whole liver graft, Roux-en-Y hepaticojejunostomy was the preferred method.ResultsPost-transplantation biliary complications were encountered in 26 patients (30.1%). The biliary complication rate was 38% in 49 duct-to-duct anastomosis, whereas it was 20% in the hepaticojejunostomy group consisting of 35 recipients. Thirteen of the 18 biliary leaks were from duct-to-duct anastomoses and the remaining 5 were from the hepaticojejunostomies and 6 of the 8 biliary strictures were observed in recipients with duct-to-duct anastomosis. In 19 of the 26 patients, the biliary complications were successfully treated with interventional radiologic procedures and 1 was treated with stent placement during endoscopic retrograde cholangiopancreatography.ConclusionsPercutaneous interventional procedures are valuable, effective, and life-saving therapeutic alternatives for the treatment of bile leaks and strictures after pediatric liver transplantations.     

Graft Loss After Pediatric Liver Transplantation

OBJECTIVE: To describe the epidemiology and causes of graft loss after pediatric liver transplantation and to identify risk factors. SUMMARY BACKGROUND DATA: Graft failure after transplantation remains an important problem. It results in patient death or retransplantation, resulting in lower survival rates. METHODS: A series of 157 transplantations in 120 children was analyzed. Graft loss was categorized as early (within 1 month) and late (after 1 month). Risk factors were identified by analyzing recipient, donor, and transplantation variables. RESULTS: Kaplan-Meier 1-month and 1-, 3-, and 5-year patient survival rates were 85%, 82%, 77%, and 71%, respectively. Graft survival rates were 71%, 64%, 59%, and 53%, respectively. Seventy-one of 157 grafts (45%) were lost: 18 (25%) by death of patients with functioning grafts and 53 (75%) by graft-related complications. Forty-five grafts (63%) were lost early after transplantation. Main causes of early loss were vascular complications, primary nonfunction, and patient death. Main cause of late graft loss was fibrosis/cirrhosis, mainly as a result of biliary complications or unknown causes. Child-Pugh score, anhepatic phase, and urgent transplantation were risk factors for early loss. Donor age, donor/recipient weight ratio, blood loss, and technical-variant liver grafts were risk factors for late loss. CONCLUSIONS: To prevent graft loss after pediatric liver transplantation, potential recipients should be referred early so they can be transplanted in an earlier phase of their disease. Technical-variant liver grafts are risk factors for graft survival. The logistics of the operation need to be optimized to minimize the length of the anhepatic phase.     

The Ratio of Plasma Interleukin-18 Is a Sensitive Biomarker for Acute Kidney Injury After Liver Transplantation

Background

Acute kidney injury (AKI) is common after liver transplantation (OLT) and is associated with high morbidity and mortality. Previous studies have shown that interleukin-18 (IL-18) levels are associated with AKI. The purpose of this study was to determine whether plasma IL-18 levels were early predictors for AKI after liver transplantation.

Methods

Plasma samples were obtained from 26 patients who underwent OLT at induction of anesthesia (T1), 1 hour after the surgical incision (T2), the time of reperfusion (T3), as well as 1 (T4), 2 (T5), and 4 hours (T6) after reperfusion. Samples were also obtained at 24 hours after surgery (T7). The AKI criteria were taken according to the Acute Kidney Injury Network criteria.

Results

Twelve patients (46%) developed AKI after OLT. The area under the receiver operating curve of plasma IL-18 concentrations (T4/T1) to predict AKI occurrence was 0.842 at T5, 0.905 at T6, 0.726 at T7, and 0.726 at T5 to T7.

Conclusion

Plasma IL-18 concentrations taken 1 hour after reperfusion were predictive of AKI. Therefore, changing IL-18 ratio may be an early predictor for AKI after OLT.     

Risk Factors for End‐Stage Kidney Disease After Pediatric Liver Transplantation

Adult liver transplant (LT) recipients commonly develop advanced kidney disease. However, burden of end‐stage kidney disease (ESKD) after pediatric LT has not been well‐described. We performed a retrospective cohort study of pediatric LTs in the United States from 1990 to 2010. Multivariable Cox regression models were fit to determine risk factors for ESKD and death. Eight thousand nine hundred seventy six children received LTs. During median follow‐up of 7.8 years, 2005 (22%) subjects died (mortality rate 26.1 cases/1000 person‐years); 167 (2%) developed ESKD (incidence rate 2.2 cases/1000 person‐years). Risk factors for ESKD included older age at LT (highest risk age >15 vs. < 5 years, HR = 4.94, p < 0.001), hepatitis C (HR 2.79, p = 0.004), liver re‐transplant (HR 2.67, p < 0.001), eGFR pre‐LT < 60 versus ≥ 60 (HR 2.37, p < 0.001), hepatitis B (HR 2.25, p = 0.027), black race (HR 1.46, p = 0.046), and male sex (HR 1.44, p = 0.022). LT recipients with ESKD had increased risk of mortality (HR 2.37, p < 0.001). Among pediatric LT recipients, rate of ESKD was lower than among adults and far exceeded by rate of death, however follow‐up time in this study may underestimate lifetime burden of ESKD. Although uncommon, ESKD was highly associated with mortality. Pediatric LT recipients should be routinely monitored for kidney disease, particularly those at highest risk of ESKD.     

Progressive Chronic Kidney Disease After Pediatric Lung Transplantation

The development of chronic kidney disease (CKD) was evaluated in a large cohort of pediatric lung transplant recipients. Retrospective chart review identified 125 patients undergoing first lung transplant at St. Louis Children's Hospital and surviving 1 year. Mean age at transplant was 10.3 +/- 0.55 years, while mean time after transplant was 4.9 years. Serum creatinine nearly doubled from baseline 0.48 mg/dL +/- 0.02 (n = 125) to 0.87 mg/dL +/- 0.04 (n = 120) at 1 year, and tripled to 1.39 mg/dL +/- 0.15 (n = 23) by 7 years after transplant. The glomerular filtration rate (GFR), as estimated by the Schwartz formula, decreased from baseline 163 +/- 5.9 mL/min/1.73 m(2) (n = 109) to 88 +/- 2.5 (n = 104), reaching 69 +/- 9.0 (n = 6) by 10 years (p < 0.01). Seven patients developed end-stage kidney disease, and by 5 years after transplant, 38% of patients reached GFR < 60 mL/min. Older age at transplant and primary diagnosis of cystic fibrosis (CF) were both associated with decreased renal survival by Kaplan-Meier (KM) analysis. In summary, pediatric lung transplant recipients experience significant loss of renal function over time, as observed in other solid organ transplant recipients, and is most dramatic in adolescents.     

肝移植术后急性肾损伤标志物的研究进展

急性肾损伤作为肝移植术后严重的并发症，严重影响患者生存率。但关于其定义尚无统一标准．多以血清肌酐浓度或尿量作为指标。本文就目前常见诊断标准．发生机制及早期生物学指标作一综述。     

Atypical Acute Leukemia Early After Liver Transplantation

Acute myeloid leukemia (AML) has been rarely reported after transplantation, namely seven cases described so far. The putative mechanism of action is long-standing immunosuppression, even though no clear correlation with the type of drug has ever been demonstrated. We report the case of a 28-year-old male patient who presented with a early onset of AML after liver transplantation for hepatitis B virus-related acute liver failure. The AML was characterized by aggressive clinical features with extrahematologic sites of involvement and an atypical immunophenotype; the laboratory findings were consistent with the diagnosis of monocytic acute leukemia.     

Chronic Kidney Disease After Liver Transplantation for Acute Liver Failure Is Not Associated With Perioperative Renal Dysfunction

Renal dysfunction of acute liver failure (ALF) may have distinct pathophysiological mechanisms to hepatorenal syndrome of cirrhosis. Yet, the impact of perioperative renal function on posttransplant renal outcomes in ALF patients specifically has not been established. The aims of this study were ( 1 ) to describe the incidence and risk factors for chronic renal dysfunction following liver transplantation for ALF and ( 2 ) to compare renal outcomes with age–sex‐matched patients transplanted for chronic liver disease. This was a single‐center study of 101 patients transplanted for ALF. Fifty‐three‐and‐a‐half percent had pretransplant acute kidney injury and 64.9% required perioperative renal replacement therapy. After transplantation the 5‐year cumulative incidence of chronic kidney disease (eGFR <60 mL/min/1.73 m²) was 41.5%. There was no association between perioperative acute kidney injury (p = 0.288) or renal replacement therapy (p = 0.134) and chronic kidney disease. Instead, the independent predictors of chronic kidney disease were older age (p = 0.019), female gender (p = 0.049), hypertension (p = 0.031), cyclosporine (p = 0.027) and nonacetaminophen‐induced ALF (p = 0.039). Despite marked differences in the perioperative clinical condition and survival of patients transplanted for ALF and chronic liver disease, renal outcomes were the same. In conclusion, in patients transplanted for ALF the severity of perioperative renal injury does not predict posttransplant chronic renal dysfunction.     

Clinical Outcomes in Kidney Transplantation from Deceased Donors with Acute Kidney Injury Based on Acute Kidney Injury Network Criteria

Introduction

Kidneys from acute kidney injury (AKI) donors are used for kidney transplantation. However, different Acute Kidney Injury Network (AKIN) criteria may show varying results after transplantation. We investigated the clinical outcomes in kidney transplantation from deceased donors with AKI as defined by the AKIN criteria at a single center.

Delivery Method in Patients After Liver or Kidney Transplantation

Pregnancy following renal or liver transplant is safe for the mother, fetus, and allograft if standard practice guidelines are strictly followed. Cesarean delivery is often required for the safety of the mother and child. The aim of this paper was the evaluation of delivery method in patients after liver (G1) and kidney transplantation (G2) in comparison with the population of healthy pregnant women (G0).

Risk Factors of Cytomegalovirus Infection After Pediatric Liver Transplantation

PurposeCytomegalovirus (CMV) infection is known to be the most frequently viral infection among patients after liver transplantation. This is especially true in pediatric living-donor liver transplantation because the recipients have often not been infected with CMV and postoperative primary infection with CMV frequently occurs.Patients and MethodsOf 93 patients who underwent pediatric liver transplantation at our department, 33 patients (36.3%) were diagnosed with CMV infection using the antigenemia method (C7-HRP). Retrospective review and statistical analysis were conducted to confirm risk factors of post-transplantation CMV infection.ResultPositive lymphocytes were diagnosed between postoperative days 8 and 111 after transplantation. Ganciclovir or foscavir were administrated to 21 patients. The other 10 patients who had one positive lymphocyte were observed and the cell disappeared on follow-up examination. We did not observe any cases of positive lymphocytes with C7-HRP in patients who received a graft from a CMV antibody?negative donor. Independent predictors associated with CMV infection in the multivariable analysis were administration of OKT3 and grafts from CMV antibody?positive donors.ConclusionIn CMV infection after pediatric liver transplantation, cases with CMV antibody?positive donors and with OKT3 administration for acute rejection are considered high risk, and cases with CMV antibody?negative donors are considered low risk.