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Bangera A, Basthi PM, Musunuri B, Nagaraju SP, Shetty S, Rao IR. The Kidney and Extracorporeal Therapies in Acute-on-Chronic Liver Failure: What the Nephrologist Needs to Know. Nephrology (Carlton) 2025; 30:e70034. [PMID: 40243165 DOI: 10.1111/nep.70034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2024] [Revised: 01/01/2025] [Accepted: 04/06/2025] [Indexed: 04/18/2025]
Abstract
In this review, we discuss the pathophysiology and management of acute kidney injury (AKI) in the setting of acute-on-chronic liver failure (ACLF). ACLF is characterised by the occurrence of acute hepatic and/or extrahepatic organ failure, induced by immune dysregulation and systemic inflammation in patients with chronic liver disease. Kidney involvement is common, with AKI occurring in 30% to > 95% of ACLF patients, depending on the definition used. Since there is a lack of kidney biopsy data in these patients, the underlying pathophysiological basis of AKI remains incompletely understood, and systemic inflammation is believed to be the primary driver of organ injury. The management of AKI has been largely extrapolated from studies in decompensated cirrhosis, and there is little data specifically in the ACLF setting. However, available evidence suggests that structural kidney injury is more common in ACLF than in decompensated CLD, and therefore, AKI in ACLF is less likely to respond to volume repletion and vasopressors. Treatment options remain limited for those who are non-responsive to intravenous fluids and vasopressors. Liver transplantation (LT), with or without kidney transplantation, is the definitive treatment for these patients. At present, extracorporeal therapies such as therapeutic plasma exchange and kidney replacement therapies play a supportive role in ACLF as a bridge to LT; however, the optimal timing and dosing remain unclear. While theoretically, extracorporeal therapies have the potential to reverse or halt progression of organ damage in ACLF, there is limited evidence currently.
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Affiliation(s)
- Ashika Bangera
- Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Pooja Mohan Basthi
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Balaji Musunuri
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shankar Prasad Nagaraju
- Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shiran Shetty
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Indu Ramachandra Rao
- Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Yenebere P, Kubal CA, Jan MY. Role of continuous renal replacement therapy in management of the preliver transplant patient. Curr Opin Organ Transplant 2025; 30:152-157. [PMID: 39665586 PMCID: PMC11888823 DOI: 10.1097/mot.0000000000001194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2024]
Abstract
PURPOSE OF REVIEW Highlight the importance of acute kidney injury (AKI) among liver transplant candidates, its importance of survival and the vital role of continuous renal replacement therapy (CRRT) as a supportive therapy. RECENT FINDINGS Kidney dysfunction is common in the preliver transplant patient. Early recognition, broad diagnostic work up, and therapeutic interventions are vital in minimizing morbidity and mortality in this critically ill group of patients. Liver dysfunction can impact kidney function in multiple ways, leading to worsening of clinical illness. High mortality and poor prognosis in those with AKI without CRRT and Liver Transplant are highlighted. SUMMARY Etiology of AKI may not be as important as is the potential for liver transplant (LT) listing in offering CRRT. Non eligibility for a LT does not by default imply non eligibility for CRRT. Multidisciplinary approach should be adopted among those with a need for CRRT in the setting of end-stage liver disease. Goals of care conversations are key, in evaluating the role of CRRT in this group of individuals as they have a very high risk of mortality.
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Affiliation(s)
- Priya Yenebere
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine
| | - Chandrashekhar A. Kubal
- Division of Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Muhammad Yahya Jan
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine
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Satapathy SK, Elwir S, Brandman D, Smith C, Jiang Y, Vanatta J, Ha NB, Cheung AC, Bhat M, Patel P, Siddiqui MS, Rinella ME, Watt KD. Risk Stratification for Chronic Kidney Disease After Liver Transplant for Metabolic Dysfunction-associated Steatohepatitis (MASH) Cirrhosis: Results From the NailMASH Consortium. Transplantation 2025; 109:484-495. [PMID: 39434206 DOI: 10.1097/tp.0000000000005236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2024]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a well-recognized complication in patients undergoing liver transplantation (LT), particularly those with metabolic dysfunction-associated steatohepatitis (MASH), a leading cause of cirrhosis in the modern era. This study sought to refine risk stratification for CKD events post-LT in cirrhosis patients with MASH by leveraging baseline renal function at transplant. METHODS A total of 717 MASH cirrhosis patients who had LT (1997-2017) at 7 US centers (NailMASH Consortium) were analyzed. Patients were categorized by estimated glomerular filtration rate (eGFR) at transplant: low (LGFR, eGFR ≤30 mL/min/1.73 m²), medium (MGFR, eGFR >30-≤60 mL/min/1.73 m²), and high (HGFR, eGFR >60 mL/min/1.73 m²). Time-related eGFR intercepts, slopes, and assessments of advanced-stage CKD (aCKD) events, defined as 2 eGFR levels <30 mL/min/1.73 m² separated by ≥90 d, were examined. RESULTS Post-LT, LGFR group showed increased eGFR, whereas the HGFR group experienced a decline. The 3-mo mark was identified as a "reset point," signifying a new reference level, beyond which a different rate of decline was observed. After 3 mo, mean eGFRs of the LGFR group approached MGFRs, whereas the mean eGFR of the HGFR group continued to decrease but remained higher than other groups during a 60-mo follow-up. LGFR patients had significantly higher aCKD probability than MGFR and HGFR groups. Subanalysis at 3 mo post-LT revealed more aCKD events in the LGFR group compared with MGFR and HGFR groups ( P < 0.0001). CONCLUSIONS The study underscores renal impact of LT in MASH cirrhosis, indicating unique eGFR trajectories post-LT tied to baseline eGFR, with a reset point at 3 mo. Monitoring post-LT renal function, especially in those at aCKD risk, is crucial. Renal-sparing immunosuppression may help, regardless of baseline eGFR. Further studies are needed for interventions addressing renal dysfunction of patients with MASH post-LT.
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Affiliation(s)
- Sanjaya K Satapathy
- Northwell Health Center for Liver Diseases and Transplantation, Northshore University Hospital/Northwell Health, Manhasset, NY
| | - Saleh Elwir
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Danielle Brandman
- Center for Liver Disease and Transplantation, New York Presbyterian-Weill Cornell Medicine, New York, NY
| | - Coleman Smith
- MedStar Georgetown Transplant Institute, Washington, DC
| | - Yu Jiang
- University of Tennessee/Methodist University Hospital, Memphis, TN
| | - Jason Vanatta
- University of Tennessee/Methodist University Hospital, Memphis, TN
| | - Nghiem B Ha
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, CA
| | - Amanda C Cheung
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Pratik Patel
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | | | - Mary E Rinella
- Pritzker School of Medicine, University of Chicago, Chicago, IL
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Fallahzadeh MA, Allegretti AS, Nadim MK, Mahmud N, Patidar KR, Cullaro G, Saracino G, Asrani SK. Performance of race-neutral eGFR equations in patients with decompensated cirrhosis. Liver Transpl 2025; 31:170-180. [PMID: 38814160 PMCID: PMC11607170 DOI: 10.1097/lvt.0000000000000410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 05/05/2024] [Indexed: 05/31/2024]
Abstract
The 2021 Chronic Kidney Disease Epidemiology Collaboration equation [CKD-EPI 2021] is a race-neutral equation recently developed and rapidly implemented as a reference standard to estimate glomerular filtration rate(GFR). However, its role in cirrhosis has not been examined especially in low GFR. We analyzed the performance of CKD-EPI 2021 compared to other equations with protocol-measured GFR (mGFR) in cirrhosis. We analyzed 2090 unique adult patients with cirrhosis undergoing protocol GFR measurements using iothalamate clearance from 1985 to 2015 when listed for liver transplantation at Baylor University in Dallas and Fort Worth, Texas. Using mGFR as a reference standard, the CKD-EPI 2021 was compared to CKD-EPI 2012, Modification of Diet in Renal Disease-4, Modification of Diet in Renal Disease-6, Royal Free Hospital, and GFR Assessment in Liver disease overall and in certain subgroups (ascites, mGFR ≤ 30 mL/min/1.73 m 2 , diagnosis, Model for End-Stage Liver Disease and gender). We examined bias (difference between eGFR and mGFR), accuracy (p30: eGFR within ± 30% of mGFR) and agreement between eGFR and mGFR categories. CKD-EPI 2021 had the second lowest bias across the entire range of GFR after GFR Assessment in Liver disease (6.6 vs. 4.6 mL/min/1.73 m 2 , respectively, p < 0.001). The accuracy of CKD-EPI 2021 was similar to CKD-EPI 2012 (p30 = 67.8% vs. 67.9%, respectively) which was higher than the other equations ( p < 0.001). It had a similar performance in patients with ascites, by diagnoses, Model for End-Stage Liver Disease subgroups, by gender, and in non-Black patients. However, it had a relatively higher overestimation in mGFR ≤ 30 mL/min/1.73 m 2 than most equations (18.5 mL/min/1.73m 2 , p < 0.001). Specifically, 64% of patients with mGFR ≤ 30 mL/min/1.73m 2 were incorrectly classified as a less severe CKD stage by CKD-EPI 2021. In Blacks, CKD-EPI 2021 underestimated eGFR by 17.9 mL/min/1.73 m 2 , which was higher than the alternate equations except for Royal Free Hospital ( p < 0.001). The novel race-neutral eGFR equation, CKD-EPI 2021, improves the GFR estimation overall but may not accurately capture true kidney function in cirrhosis, specifically at low GFR. There is an urgent need for a race-neutral equation in liver disease reflecting the complexity of kidney function physiology unique to cirrhosis, given implications for organ allocation and dual organ transplant.
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Affiliation(s)
- Mohammad Amin Fallahzadeh
- Baylor University Medical Center, Baylor Scott and White Health, Dallas, Texas, United States
- Digestive and Liver Diseases Department, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Andrew S. Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Mitra K. Nadim
- Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles, California, United States
| | - Nadim Mahmud
- Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Kavish R. Patidar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Giuseppe Cullaro
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, California, United States
| | - Giovanna Saracino
- Baylor University Medical Center, Baylor Scott and White Health, Dallas, Texas, United States
| | - Sumeet K. Asrani
- Baylor University Medical Center, Baylor Scott and White Health, Dallas, Texas, United States
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Lima C, Santos Ferreira G, Vattimo MDFF, de Paiva Haddad LB, Malbouisson LM, Carneiro D’Albuquerque LA, Maciel AT, Macedo E. Comprehensive biomarker assessment for predicting severe acute kidney injury and need of kidney replacement therapy in liver transplantation patients. Ren Fail 2024; 46:2402076. [PMID: 39287102 PMCID: PMC11409416 DOI: 10.1080/0886022x.2024.2402076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 09/02/2024] [Accepted: 09/03/2024] [Indexed: 09/19/2024] Open
Abstract
BACKGROUND Renal dysfunction is a common complication following liver transplantation (LT). This study aimed to determine whether a comprehensive assessment of kidney function using nineteen serum and urinary biomarkers (BMs) within the first 48 h post-LT could enhance the prediction of severe acute kidney injury (AKI) and the need of kidney replacement therapy (KRT) during the first postoperative week. METHODS Blood and urine (U) samples were collected during the pre- and postoperative periods. Nineteen BMs were evaluated to assess kidney health in the first 48 h after LT. Classification and regression tree (CART) cross-validation identified key predictors to determine the best BM combination for predicting outcomes. RESULTS Among 100 LT patients, 36 developed severe AKI, and 34 required KRT within the first postoperative week. Preoperative assessment of U neutrophil gelatinase-associated lipocalin (NGAL) and liver-type fatty acid-binding protein (L-FABP) predicted the need for KRT with 75% accuracy. The combined assessment of U osmolality (OSM), U kidney injury molecule 1 (KIM-1), and tissue inhibitor of metalloproteinase (TIMP-1) within 48 h post-LT predicted severe AKI with 80% accuracy. U-OSM alone, measured within 48 h post-LT, had an accuracy of 83% for predicting KRT need, outperforming any BM combination. CONCLUSIONS Combined BM analysis can accurately predict severe AKI and KRT needs in the perioperative period of LT. U-OSM alone proved to be an effective tool for monitoring the risk of severe AKI, available in most centers. Further studies are needed to assess its impact on AKI progression postoperatively.Registered at Clinical Trials (clinicaltrials.gov) in March 24th, 2014 by title 'Acute Kidney Injury Biomarkers: Diagnosis and Application in Pre-operative Period of Liver Transplantation (AKIB)' and identifier NCT02095431.
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Affiliation(s)
- Camila Lima
- Medical Surgical Nursing Department, School of Nursing, University of Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Gillene Santos Ferreira
- Medical Surgical Nursing Department, School of Nursing, University of Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | | | | | - Luiz Marcelo Malbouisson
- Department of Anesthesiology, Clinical Surgery Division, University of Sao Paulo, Sao Paulo, Brazil
| | | | - Alexandre Toledo Maciel
- Adult Intensive Care Unit, Research Department, Imed Group, Hospital Sao Camilo Pompeia, Sao Paulo, Brazil
| | - Etienne Macedo
- Nephrology Division, Department of Medicine, University of California San Diego, USA
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Prudhomme T, Mesnard B, Branchereau J, Roumiguié M, Maulat C, Muscari F, Kamar N, Soulié M, Gamé X, Sallusto F, Timsit MO, Drouin S. Simultaneous liver-kidney transplantation: future perspective. World J Urol 2024; 42:489. [PMID: 39162870 PMCID: PMC11335780 DOI: 10.1007/s00345-024-05174-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 07/11/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND The aims of this narrative review were (i) to describe the current indications of SLKT, (ii) to report evolution of SLKT activity, (iii) to report the outcomes of SLKT, (iv) to explain the immune-protective effect of liver transplant on kidney transplant, (v) to explain the interest of delay kidney transplantation, using hypothermic machine perfusion (HMP), (vi) to report kidney after liver transplantation (KALT) indications and (vii) to describe the value of the increase in the use of extended criteria donors (ECD) and particular controlled donation after circulatory death (cDCD) transplant, thanks to the development of new organ preservation strategies. METHOD Electronic databases were screened using the keywords "Simultaneous", "Combined", "kidney transplantation" and "liver transplantation". The methodological and clinical heterogeneity of the included studies meant that meta-analysis was inappropriate. RESULTS A total of 1,917 publications were identified in the literature search. Two reviewers screened all study abstracts independently and 1,107 of these were excluded. Thus, a total of 79 full text articles were assessed for eligibility. Of these, 21 were excluded. In total, 58 studies were included in this systematic review. CONCLUSIONS Simultaneous liver-kidney transplantation has made a significant contribution for patients with dual-organ disease. The optimization of indication and selection of SLKT patients will reduce futile transplantation. Moreover, increasing the use of transplants from extended criteria donors, in particular cDCD, should be encouraged, thanks to the development of new modalities of organ preservation.
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Affiliation(s)
- Thomas Prudhomme
- Department of Urology, Kidney Transplantation and Andrology, TSA 50032 Rangueil Hospital, Toulouse Cedex 9, 31059, France.
- Center for Research in Transplantation and Translational Immunology, Nantes Université, INSERM, UMR 1064, Nantes, 44000, France.
| | - Benoit Mesnard
- Center for Research in Transplantation and Translational Immunology, Nantes Université, INSERM, UMR 1064, Nantes, 44000, France
- Department of Urology, University Hospital of Nantes, Nantes, France
| | - Julien Branchereau
- Center for Research in Transplantation and Translational Immunology, Nantes Université, INSERM, UMR 1064, Nantes, 44000, France
- Department of Urology, University Hospital of Nantes, Nantes, France
| | - Mathieu Roumiguié
- Department of Urology, Kidney Transplantation and Andrology, TSA 50032 Rangueil Hospital, Toulouse Cedex 9, 31059, France
| | - Charlotte Maulat
- Department of Digestive Surgery, University Hospital of Rangueil, Toulouse, France
| | - Fabrice Muscari
- Department of Digestive Surgery, University Hospital of Rangueil, Toulouse, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, University Hospital of Rangueil, Toulouse, France
| | - Michel Soulié
- Department of Urology, Kidney Transplantation and Andrology, TSA 50032 Rangueil Hospital, Toulouse Cedex 9, 31059, France
| | - Xavier Gamé
- Department of Urology, Kidney Transplantation and Andrology, TSA 50032 Rangueil Hospital, Toulouse Cedex 9, 31059, France
| | - Federico Sallusto
- Department of Urology, Kidney Transplantation and Andrology, TSA 50032 Rangueil Hospital, Toulouse Cedex 9, 31059, France
| | - Marc Olivier Timsit
- Department of Urology, Hôpital Européen Georges Pompidou, APHP-Centre, Paris, France
| | - Sarah Drouin
- Service Médico-Chirurgical de Transplantation Rénale, APHP Sorbonne-Université, Hôpital Pitié-Salpêtrière, Paris, Île-de-France, France
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Tajima T, Shin JH, Kunisawa S, Sasaki N, Hata K, Fushimi K, Hatano E, Imanaka Y. Cost-effectiveness analysis of adult living-donor liver transplantation in Japan. Hepatol Res 2024; 54:465-478. [PMID: 37985222 DOI: 10.1111/hepr.13992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 10/05/2023] [Accepted: 11/12/2023] [Indexed: 11/22/2023]
Abstract
AIM Living-donor liver transplantation (LDLT) is a highly effective life-saving procedure; however, it requires substantial medical resources, and the cost-effectiveness of LDLT versus conservative management (CM) for adult patients with end-stage liver disease (ESLD) remains unclear in Japan. METHODS We performed a cost-effectiveness analysis using the Diagnostic Procedure Combination (DPC) data from the nationwide database of the DPC research group. We selected adult patients (18 years or older) who were admitted or discharged between 2010 and 2021 with a diagnosis of ESLD with Child-Pugh class C or B. A decision tree and Markov model were constructed, and all event probabilities were computed in 3-month cycles over a 10-year period. The willingness-to-pay per quality-adjusted life-year (QALY) was set at 5 million Japanese yen (JPY) (49,801 US dollars [USD]) from the perspective of the public health-care payer. RESULTS After propensity score matching, we identified 1297 and 111,849 patients in the LDLT and CM groups, respectively. The incremental cost-effectiveness ratio for LDLT versus CM for Child-Pugh classes C and B was 2.08 million JPY/QALY (20,708 USD/QALY) and 5.24 million JPY/QALY (52,153 USD/QALY), respectively. The cost-effectiveness acceptability curves showed the probabilities of being below the willingness-to-pay of 49,801 USD/QALY as 95.4% in class C and 48.5% in class B. Tornado diagrams revealed all variables in class C were below 49,801 USD/QALY while their ranges included or exceeded 49,801 USD/QALY in class B. CONCLUSIONS Living-donor liver transplantation for adult patients with Child-Pugh class C was cost-effective compared with CM, whereas LDLT versus CM for class B patients was not cost-effective in Japan.
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Affiliation(s)
- Tetsuya Tajima
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Jung-Ho Shin
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Susumu Kunisawa
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Noriko Sasaki
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koichiro Hata
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, Tokyo, Japan
| | - Etsuro Hatano
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Ali H, Moond V, Lawson C, Budh D, Ohri R, Patel P, Jun WY, Rodriguez‐Zarate E, Mohan BP. Renal replacement therapy prior to liver transplant and inpatient mortality in patients without advanced kidney disease: A nationwide study. JGH Open 2024; 8:e13028. [PMID: 38268962 PMCID: PMC10805480 DOI: 10.1002/jgh3.13028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 11/10/2023] [Accepted: 12/16/2023] [Indexed: 01/26/2024]
Abstract
Background and Aim The utility of renal replacement therapy (RRT) before liver transplant (LT) in patients without end-stage renal disease (ESRD) or advanced chronic kidney disease (CKD-IV/V) is debatable and lacks data support. We aimed to evaluate the impact of RRT on patients undergoing LT. Methods We used the National Readmission Database (2016-2019) to identify all index hospitalizations undergoing RRT before LT (cases). A matched comparison cohort of similar hospitalizations without RRT before LT was identified (controls) after 1:1 propensity score matching for age, gender, and available comorbidities. Results We matched 364 cases (RRT before LT) to 364 controls (LT without prior RRT). There was no statistical difference in all-cause inpatient mortality (4.9% vs 3.6% P = 0.4). A significantly greater proportion of cases were associated with ICU admission (40.7% vs 17.0%, P < 0.001) and RRT requirement post LT (100% vs 17%, P < 0.001). There was no difference in 30- (hazard ratio [HR] 1.1, 0.4-2.6), 60- (HR 0.9, 0.4-1.8), or 90-day (HR 0.8, 0.4-1.6) inpatient mortality between the groups. Also, 180-day survival estimates were comparable (P = 0.5). The results were similar in patients with no chronic kidney disease (CKD) and CKD-III. Conclusion RRT prior to LT, in patients without advanced CKD or ESRD, was associated with greater instances of ICU stay and need for future RRT. Also, 30-, 60-, and 90-day inpatient mortality rates were similar, and 180-day survival estimates were comparable.
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Affiliation(s)
- Hassam Ali
- Department of Medicine and GastroenterologyEast Carolina University/Brody School of MedicineGreenvilleNorth CarolinaUSA
| | - Vishali Moond
- Department of Internal MedicineSaint Peter's University Hospital/Robert Wood Johnson Medical SchoolNew BrunswickNew JerseyUSA
| | - Cameron Lawson
- Department of Medicine and GastroenterologyEast Carolina University/Brody School of MedicineGreenvilleNorth CarolinaUSA
| | - Deepa Budh
- Department of Internal MedicineSt. Barnabas Hospital/Albert Einstein College of MedicineNew YorkNew YorkUSA
| | - Ritika Ohri
- Department of NephrologyUniversity of Utah Health School of MedicineSalt Lake CityUtahUSA
| | - Pratik Patel
- Department of GastroenterologyMather Hospital/Hofstra University Zucker School of MedicinePort JeffersonNew YorkUSA
| | - Wong Yu Jun
- Department of Gastroenterology & HepatologyChangi General Hospital, SingHealthSingapore
- Duke‐NUS Medical SchoolSingapore
| | - Eduardo Rodriguez‐Zarate
- Department of Gastroenterology & HepatologyUniversity of Utah School of MedicineSalt Lake CityUtahUSA
| | - Babu P. Mohan
- Department of Gastroenterology & HepatologyUniversity of Utah School of MedicineSalt Lake CityUtahUSA
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Huang X, Bindra J, Chopra I, Niewoehner J, Wan GJ. Treatment-Related Cost Analysis of Terlipressin for Adults with Hepatorenal Syndrome with Rapid Reduction in Kidney Function. Adv Ther 2023; 40:5432-5446. [PMID: 37812332 PMCID: PMC10611877 DOI: 10.1007/s12325-023-02674-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 08/31/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Hepatorenal syndrome (HRS), a special form of acute kidney failure, is a rare, acute, life-threatening complication of cirrhosis and has a very poor prognosis. Terlipressin (TERLIVAZ®) is the first and only pharmacological treatment approved by Food and Drug Administration (September 2022) to improve kidney function for adults with HRS with rapid reduction in kidney function. We constructed a decision analytic economic model to estimate the cost per complete response/HRS reversal of terlipressin + albumin from a United States hospital perspective. METHODS A decision analytic model was developed to estimate the HRS treatment-related cost per response over an HRS hospitalization (assuming 14 days). Patients can experience either HRS reversal (complete response) or no HRS reversal (partial/no response) upon receipt of treatment. The efficacy, safety, and treatment duration data were from published head-to-head randomized international trials. Total treatment cost comprised drug acquisition and treatment-related costs (intensive care unit [ICU], dialysis [intermittent or continuous], pulse oximetry monitoring for terlipressin, and adverse events) sourced from the published literature. Cost per response, defined as the total treatment cost per HRS reversal was estimated for each treatment. The number needed to treat (NNT), defined as the number of patients treated to achieve HRS reversal in 1 additional patient, was estimated. RESULTS Cost per response of terlipressin + albumin was lower than midodrine and octreotide + albumin (M&O) (US$85,315 vs. $467,794) and norepinephrine + albumin ($81,614 vs. $139,324). NNT for HRS reversal was 2 patients with terlipressin + albumin vs. M&O + albumin and 4 patients with terlipressin + albumin vs. norepinephrine + albumin, respectively. CONCLUSIONS The analysis shows that terlipressin is a cost-effective treatment due to its higher efficacy and administration in the non-ICU setting. Terlipressin is a value-based treatment option for appropriate adults with HRS with rapid reduction in kidney function.
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Affiliation(s)
- Xingyue Huang
- Mallinckrodt Pharmaceuticals, 440 Route 22 East, Bridgewater, NJ, USA.
| | - Jas Bindra
- Falcon Research Group, North Potomac, MD, USA
| | | | - John Niewoehner
- Mallinckrodt Pharmaceuticals, 440 Route 22 East, Bridgewater, NJ, USA
| | - George J Wan
- Mallinckrodt Pharmaceuticals, 440 Route 22 East, Bridgewater, NJ, USA
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Azpilicueta-Idarreta M, Prieto-Torre M, Montijano-Herrero L, Fernández-Ruiz L, Antón-Gamero M. Kidney injury associated with liver transplantation. An Pediatr (Barc) 2023; 99:232-239. [PMID: 37598081 DOI: 10.1016/j.anpede.2023.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/04/2023] [Indexed: 08/21/2023] Open
Abstract
INTRODUCTION Kidney injury associated with paediatric liver transplantation (LT) is common, but its evaluation is challenging. Our aim was to analyse the presence of perioperative acute kidney injury (AKI) and study the prevalence of chronic kidney disease (CKD) using different glomerular filtration rate (GFR) estimation formulas. METHODS We conducted a cross-sectional study in a cohort of children aged less than 18 years with a history of LT followed up for 5.42 years. We estimated the GFR using the creatinine-based Schwartz bedside formula (2009), the cystatin C-based Caucasian Asian Pediatric and Adult cohort (CAPA) equation and the combined Full-Age Spectrum (FAS) formula as modified by Pottel. We analysed the agreement between them using the Bland-Altman method and the kappa statistic. We measured the albumin level in urine, the urine volume adjusted to 100 mL of GFR and blood pressure. We performed univariate and multivariate analyses of the risk factors associated with CKD. RESULTS The sample included 52 patients with a median age of 9.21 years. Fifteen (28.8%) had AKI. Five (10%) had CKD and the only associated risk factor was acute liver failure at the time of LT (odds ratio, 8.57; P = 0.04). There was poor agreement between the different estimation formulas. One patient was classified as having CKD with the Schwartz formula compared to four patients with the CAPA and the Pottel combined FAS formulas. Up to 42% of children without CKD had some positive marker of kidney injury. CONCLUSIONS The exclusive use of the 2009 Schwartz bedside formula to estimate GFR may lead to underdiagnosis of CKD in children post LT. Other markers of kidney injury are common, and their detection may help prevent the progression of CKD.
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Affiliation(s)
| | - María Prieto-Torre
- Servicio de Gastroenterología, Hospital Universitario Reina Sofía, Córdoba, Spain
| | | | | | - Montserrat Antón-Gamero
- Unit de Nefrología Pediátrica, Hospital Universitario Reina Sofía, Córdoba, Spain; Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain.
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11
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Mujtaba MA, Gamilla-Crudo AK, Merwat SN, Hussain SA, Kueht M, Karim A, Khattak MW, Rooney PJ, Jamil K. Terlipressin in combination with albumin as a therapy for hepatorenal syndrome in patients aged 65 years or older. Ann Hepatol 2023; 28:101126. [PMID: 37302573 DOI: 10.1016/j.aohep.2023.101126] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/28/2023] [Accepted: 05/19/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION AND OBJECTIVES Clinical data for older patients with advanced liver disease are limited. This post hoc analysis evaluated the efficacy and safety of terlipressin in patients aged ≥65 years with hepatorenal syndrome using data from 3 Phase III, randomized, placebo-controlled studies (OT-0401, REVERSE, CONFIRM). PATIENTS AND METHODS The pooled population of patients aged ≥65 years (terlipressin, n = 54; placebo, n = 36) was evaluated for hepatorenal syndrome reversal-defined as a serum creatinine level ≤1.5 mg/dL (≤132.6 μmol/L) while receiving terlipressin or placebo, without renal replacement therapy, liver transplantation, or death-and the incidence of renal replacement therapy (RRT). Safety analyses included an assessment of adverse events. RESULTS Hepatorenal syndrome reversal was almost 2-times higher in terlipressin-treated patients compared with patients who received placebo (31.5% vs 16.7%; P = 0.143). Among surviving patients, the need for RRT was significantly reduced in the terlipressin group, with an almost 3-times lower incidence of RRT versus the placebo group (Day 90: 25.0% vs 70.6%; P = 0.005). Among 23 liver-transplant-listed patients, significantly fewer patients in the terlipressin versus placebo group needed RRT by Days 30 and 60 (P = 0.027 each). Fewer patients in the terlipressin group needed RRT post-transplant (P = 0.011). More terlipressin-treated patients who were listed for and received a liver transplant were alive and RRT-free by Day 90. No new safety signals were revealed in the older subpopulation compared with previously published data. CONCLUSIONS Terlipressin therapy may lead to clinical improvements in highly vulnerable patients aged ≥65 years with hepatorenal syndrome. CLINICAL TRIAL NUMBERS OT-0401, NCT00089570; REVERSE, NCT01143246; CONFIRM, NCT02770716.
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Affiliation(s)
- Muhammad A Mujtaba
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, USA.
| | | | - Shehzad N Merwat
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, USA
| | - Syed A Hussain
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, USA
| | - Michael Kueht
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, USA
| | - Aftab Karim
- Texas Health Presbyterian Hospital, 8200 Walnut Hill Ln, Dallas, TX, USA
| | - Muhammad W Khattak
- University of Illinois College of Medicine, 1 Illini Dr, Peoria, IL, USA
| | - Peggy J Rooney
- Mallinckrodt Pharmaceuticals, 53 I-78 Frontage Rd, Hampton, NJ, USA
| | - Khurram Jamil
- Mallinckrodt Pharmaceuticals, 53 I-78 Frontage Rd, Hampton, NJ, USA
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12
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Fukumitsu K, Kaido T, Matsumura Y, Ito T, Ogiso S, Ishii T, Seo S, Hata K, Masui T, Taura K, Nagao M, Okajima H, Uemoto S, Hatano E. Pretransplant Renal Dysfunction Negatively Affects Prognosis After Living Donor Liver Transplantation: A Single-Center Retrospective Study. Transplant Proc 2023; 55:1623-1630. [PMID: 37414696 DOI: 10.1016/j.transproceed.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 05/16/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND To evaluate the influence of preoperative renal function on prognosis after living donor liver transplantation (LDLT). METHODS Living donor liver transplantation cases were categorized into 3 groups as follows: renal failure with hemodialysis (HD; n = 42), renal dysfunction (RD; n = 94) (glomerular filtration rate <60 mL/min/1.73 m2), and normal renal function (NF; n = 421). The study used no prisoners, and participants were neither coerced nor paid. The manuscript complies with the Helsinki Congress and the Declaration of Istanbul. RESULTS Five-year overall survival (OS) rates were 59.0%, 69.3%, and 80.0% in the HD, RD, and NF groups, respectively (P < .01). The frequency of bacteremia within 90 days after LDLT was 76.2%, 37.2%, and 34.7%, respectively (P < .01 in HD vs RD and HD vs NF). Patients with bacteremia showed a worse outcome than those without (1-year OS, 65.6% vs 93.3%), thus corroborating the poor prognosis in the HD group. The high frequency of bacteremia in the HD group was mainly attributable to health care-associated bacterium, such as coagulase-negative Staphylococci, Enterococcus spp., and Pseudomonas aeruginosa. In the HD group, HD was started within 50 days before LDLT for acute renal failure in 35 patients, of which 29 (82.9%) successfully withdrew from HD after LDLT and demonstrated better prognosis (1-year OS, 69.0% vs 16.7%) than those who continued HD. CONCLUSIONS Preoperative renal dysfunction is associated with poor prognosis after LDLT, possibly due to a high incidence of health care-associated bacteremia.
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Affiliation(s)
- Ken Fukumitsu
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Toshimi Kaido
- Department of Gastroenterological and General Surgery, St. Luke's International Hospital, Tokyo, Japan
| | - Yasufumi Matsumura
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takashi Ito
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Satoshi Ogiso
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takamichi Ishii
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Satoru Seo
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koichiro Hata
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshihiko Masui
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kojiro Taura
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Miki Nagao
- Department of Clinical Laboratory Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hideaki Okajima
- Department of Pediatric Surgery, Kanazawa Medical University, Ishikawa, Japan
| | | | - Etsuro Hatano
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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13
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Yoo BM, Hong SY, Hong SK, Ahn YH, Kang HG, Lee S, Suh S, Han ES, Lee JM, Choi Y, Lee KW, Suh KS, Yi NJ. Posttransplant renal replacement therapy is an alarm signal for survival outcomes in pediatric liver transplantation. Pediatr Transplant 2023; 27:e14422. [PMID: 36325595 DOI: 10.1111/petr.14422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 08/28/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The impact of renal replacement therapy (RRT) on the long-term survival outcomes of pediatric liver recipients remains controversial. METHODS A total of 224 patients aged <18 years, who underwent liver transplantation (LT), were divided into two groups: patients who underwent renal replacement therapy (RRT) (group R, n = 25, 11.2%) and those who did not (group N, n = 199, 88.8%). The posttransplant patient survival outcomes according to RRT use constituted the primary end-point. RRT was initiated preoperatively in 12 patients (48.0%) and postoperatively in 13 [early: <6 months after LT (n = 5, 20.0%) and late: ≥6 months after LT (n = 8, 32.0%)]. The indications for RRT included liver disease involving the kidney (44.0%) and hepatorenal syndrome (56.0%). RESULTS The age at the time of LT (71.6 vs. 19.1 months) was higher, the pediatric end-stage liver disease score was lower (9.9 vs. 21.2), and the duration of hospitalization posttransplantation (41.0 vs. 27.0 days) was longer, while the rates of hepatic artery thrombosis (8.0% vs. 3.5%) were higher in group R (p < .05). The number of patients (60.0% vs. 93.0%; p < .001) and graft survival rates (68.0% vs. 93.0%; p < .001) were significantly lower in group R. Multivariate analysis revealed that posttransplant RRT and hepatic artery complications were risk factors for patient survival outcomes. Renal function was recovered in 7 patients (28.0%) in group R, and 9 (36.0%) eventually underwent kidney transplantation. CONCLUSION The survival outcomes of children requiring posttransplant RRT were significantly worse than those of children, who did not undergo RRT. Physicians should pay meticulous attention to patients requiring post-LT RRT.
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Affiliation(s)
- Byung Min Yoo
- Seoul National University College of Medicine, Seoul, South Korea
| | - Su Young Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Yo Han Ahn
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Sola Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Sanggyun Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Eui Soo Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Jeong-Moo Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
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14
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Fernández-Carrillo C, Li Y, Ventura-Cots M, Argemi J, Dai D, Clemente-Sánchez A, Duarte-Rojo A, Behari J, Ganesh S, Jonassaint NL, Tevar AD, Hughes CB, Humar A, Molinari M, Landsittel DP, Bataller R. Poor Outcomes of Patients With NAFLD and Moderate Renal Dysfunction or Short-Term Dialysis Receiving a Liver Transplant Alone. Transpl Int 2022; 35:10443. [PMID: 36568138 PMCID: PMC9784907 DOI: 10.3389/ti.2022.10443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 10/27/2022] [Indexed: 12/13/2022]
Abstract
The outcomes of patients with moderate renal impairment and the impact of liver disease etiology on renal function recovery after liver transplant alone (LTA) are largely unknown. We explored whether NAFLD patients with pre-LTA moderate renal dysfunction (GFR 25-45 ml/min/1.73 m2) may be more susceptible to develop post-LTA severe renal dysfunction (GFR<15 ml/min/1.73 m2) than ALD patients, as well as other overall outcomes. Using the UNOS/OPTN database, we selected patients undergoing liver transplant for NAFLD or ALD (2006-2016), 15,103 of whom received LTA. NAFLD patients with moderate renal dysfunction were more likely to develop subsequent GFR<15 ml/min/1.73 m2 than ALD patients (11.1% vs. 7.38%, p < 0.001). Patients on short-term dialysis pre-LTA (≤12 weeks) were more likely to develop severe renal dysfunction (31.7% vs. 18.1%), especially in NAFLD patients, and were more likely to receive a further kidney transplant (15.3% vs. 3.7%) and had lower survival (48.6% vs. 50.4%) after LTA (p < 0.001 for all). NAFLD was an independent risk factor for post-LTA severe renal dysfunction (HR = 1.2, p = 0.02). NAFLD patients with moderate renal dysfunction and those receiving short-term dialysis prior to LTA are at a higher risk of developing subsequent severe renal dysfunction. Underlying etiology of liver disease may play a role in predicting development and progression of renal failure in patients receiving LTA.
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Affiliation(s)
- Carlos Fernández-Carrillo
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,CIBERehd. Instituto de Salud Carlos III, Madrid, Spain,Gastroenterología y Hepatología, IDIPHISA, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Yaming Li
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Meritxell Ventura-Cots
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,CIBERehd. Instituto de Salud Carlos III, Madrid, Spain
| | - Josepmaria Argemi
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,CIBERehd. Instituto de Salud Carlos III, Madrid, Spain
| | - Dongling Dai
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Ana Clemente-Sánchez
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,CIBERehd. Instituto de Salud Carlos III, Madrid, Spain
| | - Andres Duarte-Rojo
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Jaideep Behari
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Swaytha Ganesh
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Naudia L. Jonassaint
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Amit D. Tevar
- Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Christopher B. Hughes
- Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Abhinav Humar
- Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Michele Molinari
- Thomas E. Starzl Transplant Institute, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Douglas P. Landsittel
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Ramon Bataller
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, United States,*Correspondence: Ramon Bataller,
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15
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Salman AA, Salman MA, Said M, Elkassar H, El Sherbiny M, Youssef A, Elbaz M, Elmeligui AM, Hassan MB, Omar MG, Samir H, Abdelkader Morad M, Shaaban HED, Youssef M, Moustafa A, Tourky MS, Elewa A, Khalid S, Monazea K, Shawkat M. Albuminuria as a predictor of mortality in type II diabetic patients after living-donor liver transplantation. Ann Med 2022; 54:2598-2605. [PMID: 36164711 PMCID: PMC9521493 DOI: 10.1080/07853890.2022.2124446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 09/02/2022] [Accepted: 09/08/2022] [Indexed: 11/01/2022] Open
Abstract
PURPOSE Diabetes mellitus (DM) increases the risk of morbidity and mortality after liver resection. Albuminuria is associated with a higher risk for all-cause and cardiovascular mortality. This study evaluated albuminuria as a predictor of the outcome of living donor liver transplantation (LDLT) in patients with pre-existing DM. METHODS This retrospective study involved 103 type II diabetic patients with end-stage liver disease who received LDLT. Preoperative spot urine albumin: creatinine ratio was used to determine the degree of albuminuria. The primary outcome measure was the impact of urinary albumin excretion on the 3-year mortality rate after LDLT in this diabetic cohort. RESULTS Hepatitis C virus infection was the main cause of cirrhosis. Albuminuria was detected in 41 patients (39.8%); 15 had macroalbuminuria, while 26 had microalbuminuria. Patients with microalbuminuria were significantly older than those with macroalbuminuria and normal albumin in urine. After 3 years, twenty-four patients (23.3%) died within 3 years after LT. Myocardial infarction was the leading cause of death (25%). Albuminuria was an independent factor affecting 3-year mortality with an odds ratio of 5.17 (95% CI: 1.86-14.35). CONCLUSION Preoperative albuminuria is an independent factor affecting mortality within 3 years after LDLT in type II diabetic patients. Myocardial infarction was the leading cause of death in 25% of cases, followed by hepatocellular carcinoma recurrence, sepsis, and graft failure.KEY MESSAGESDiabetes mellitus (DM) increases the risk of morbidity and mortality after liver resection.Albuminuria is associated with a higher risk for all-cause and cardiovascular mortality.Preoperative albuminuria is a significant predictor of mortality within 3 years after LDLT in diabetic patients.
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Affiliation(s)
| | | | - Mostafa Said
- Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hesham Elkassar
- Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohammad El Sherbiny
- Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Youssef
- Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohammed Elbaz
- Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed M. Elmeligui
- Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Badr Hassan
- Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mahmoud Gouda Omar
- Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hussien Samir
- Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Hossam El-Din Shaaban
- Gastroenterology Department, National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Mohamed Youssef
- Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Moustafa
- Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Sabry Tourky
- Department of Surgery, Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - Ahmed Elewa
- General Surgery Department, National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Sadaf Khalid
- General Surgery Department, Royal Free Hospital, London, UK
| | - Khaled Monazea
- General Surgery Department, Assiut Faculty of Medicine for Boys, Al-Azhar University, Cairo, Egypt
| | - Mohamed Shawkat
- Internal Medicine Department, Faculty of Medicine, Minia University, Minia, Egypt
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16
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Campion D, Rizzi F, Bonetto S, Giovo I, Roma M, Saracco GM, Alessandria C. Assessment of glomerular filtration rate in patients with cirrhosis: Available tools and perspectives. Liver Int 2022; 42:2360-2376. [PMID: 35182100 DOI: 10.1111/liv.15198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 11/08/2021] [Accepted: 12/09/2021] [Indexed: 12/07/2022]
Abstract
Renal dysfunction often complicates the course of liver disease, resulting in higher morbidity and mortality. The accurate assessment of kidney function in these patients is essential to early identify, stage and treat renal impairment as well as to better predict the prognosis, prioritize the patients for liver transplantation and decide whether to opt for simultaneous liver-kidney transplants. This review analyses the available tools for direct or indirect assessment of glomerular filtration rate, focusing on the flaws and strengths of each method in the specific setting of cirrhosis. The aim is to deliver a clear-cut view on this complex issue, trying to point out which strategies to prefer in this context, especially in the peculiar setting of liver transplantation. Moreover, a glance is given at future promising tools for glomerular filtration rate assessment, including new biomarkers and new equations specifically modelled for the cirrhotic population.
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Affiliation(s)
- Daniela Campion
- Department of Gastroenterology and Hepatology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Felice Rizzi
- Department of Gastroenterology and Hepatology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Silvia Bonetto
- Department of Gastroenterology and Hepatology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Ilaria Giovo
- Department of Gastroenterology and Hepatology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Michele Roma
- Department of Gastroenterology and Hepatology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Giorgio M Saracco
- Department of Gastroenterology and Hepatology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Carlo Alessandria
- Department of Gastroenterology and Hepatology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
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17
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Allegretti AS, Subramanian RM, Francoz C, Olson JC, Cárdenas A. Respiratory events with terlipressin and albumin in hepatorenal syndrome: A review and clinical guidance. Liver Int 2022; 42:2124-2130. [PMID: 35838488 PMCID: PMC9762017 DOI: 10.1111/liv.15367] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 07/06/2022] [Accepted: 07/12/2022] [Indexed: 12/13/2022]
Abstract
Hepatorenal syndrome-acute kidney injury (HRS-AKI) is a serious complication of severe liver disease with a clinically poor prognosis. Supportive care using vasoconstrictors and intravenous albumin are the current mainstays of therapy. Terlipressin is an efficacious vasoconstrictor that has been used for 2 decades as the first-line treatment for HRS-AKI in Europe and has demonstrated greater efficacy in improving renal function compared to placebo and other vasoconstrictors. One of the challenges associated with terlipressin use is monitoring and mitigating serious adverse events, specifically adverse respiratory events, which were noted in a subset of patients in the recently published CONFIRM trial, the largest randomized trial examining terlipressin use for HRS-AKI. In this article, we review terlipressin's pharmacology, hypothesize how its mechanism contributes to the risk of respiratory compromise and propose strategies that will decrease the frequency of these events by rationally selecting patients at lower risk for these events.
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Affiliation(s)
- Andrew S. Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ram M. Subramanian
- Divisions of Gastroenterology and Hepatology and Pulmonary and Critical Care Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Claire Francoz
- Hepatology and Liver intensive Care Unit, Hospital Beaujon, Clichy, France
| | - Jody C. Olson
- Divisions of Gastroenterology, Hepatology, Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Andrés Cárdenas
- GI and Liver Unit, Institut de Malalties Digestives, Hospital Clinic, Barcelona, Spain. Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Barcelona and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
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18
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Park CS, Yoon YI, Kim N, Hwang S, Ha TY, Jung DH, Song GW, Moon DB, Ahn CS, Park GC, Kim KH, Cho YP, Lee SG. Analysis of outcomes and renal recovery after adult living-donor liver transplantation among recipients with hepatorenal syndrome. Am J Transplant 2022; 22:2381-2391. [PMID: 35615988 DOI: 10.1111/ajt.17105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/22/2022] [Accepted: 05/23/2022] [Indexed: 01/25/2023]
Abstract
When timely access to deceased-donor livers is not feasible, living-donor liver transplantation (LDLT) is an attractive option for patients with hepatorenal syndrome (HRS). This study's primary objective was to describe outcomes after LDLT among HRS recipients, and the secondary objective was to determine predictors of poor renal recovery after LDLT. This single-center, retrospective study included 2185 LDLT recipients divided into HRS (n = 126, 5.8%) and non-HRS (n = 2059, 94.2%) groups. The study outcomes were survival and post-LT renal recovery. The HRS group had a higher death rate than the non-HRS group (17.5% vs. 8.6%, p < 0.001). In the HRS group, post-LT renal recovery occurred in 69.0%, and the death rate was significantly lower in association with HRS recovery compared with non-recovery (5.7% vs. 43.6%, p < 0.001). Multivariable analysis indicated that post-LT sepsis (p < 0.001) and non-recovery of HRS (p < 0.001) were independent negative prognostic factors for survival. Diabetes mellitus (p = 0.01), pre-LT peak serum creatinine ≥3.2 mg/dl (p = 0.002), time interval from HRS diagnosis to LDLT ≥38 days (p = 0.01), and post-LT sepsis (p = 0.03) were important negative prognostic factors for renal recovery after LDLT. In conclusion, post-LT renal recovery was important for survival, and the interval from HRS to LDLT was significantly associated with post-LT renal recovery.
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Affiliation(s)
- Cheon-Soo Park
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.,Department of Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young-In Yoon
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Nayoung Kim
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Shin Hwang
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Tae-Yong Ha
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Dong-Hwan Jung
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Gi-Won Song
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Deok-Bog Moon
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Chul-Soo Ahn
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Gil-Chun Park
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Ki-Hun Kim
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Yong-Pil Cho
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Sung-Gyu Lee
- Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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Jiang D, Ji T, Liu W, Bednarsch J, Selzner M, Pratschke J, Lurje G, Cao T, Brüggenwirth IMA, Martins PN, Arke Lang S, Peter Neumann U, Czigany Z. Four Decades of Clinical Liver Transplantation Research: Results of a Comprehensive Bibliometric Analysis. Transplantation 2022; 106:1897-1908. [PMID: 35831925 DOI: 10.1097/tp.0000000000004224] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Nearly 40 y have passed since the 1983 National Institutes of Health Consensus-Development-Conference, which has turned liver transplantation (LT) from a clinical experiment into a routine therapeutic modality. Since' clinical LT has changed substantially. We aimed to comprehensively analyze the publication trends in the most-cited top-notch literature in LT science over a 4-decade period. METHODS A total of 106 523 items were identified between January 1981 and May 2021 from the Web of Science Core Collection. The top 100 articles published were selected using 2 distinct citation-based strategies to minimize bias. Various bibliometric tools were used for data synthesis and visualization. RESULTS The citation count for the final dataset of the top 100 articles ranged from 251 to 4721. Most articles were published by US authors (n = 61). The most prolific institution was the University of Pittsburgh (n = 15). The highest number of articles was published in Annals of Surgery, Hepatology, and Transplantation ; however, Hepatology publications resulted in the highest cumulative citation of 9668. Only 10% of the articles were classified as evidence level 1. Over 90% of first/last authors were male. Our data depict the evolution of research focus over 40 y. In part, a disproportional flow of citations was observed toward already well-cited articles. This might also project a slowed canonical progress, which was described in other fields of science. CONCLUSIONS This study highlights key trends based on a large dataset of the most-cited articles over a 4-decade period. The present analysis not only provides an important cross-sectional and forward-looking guidance to clinicians, funding bodies, and researchers but also draws attention to important socio-academic or demographic aspects in LT.
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Affiliation(s)
- Decan Jiang
- Department of Surgery and Transplantation, Faculty of Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Tengfei Ji
- Department of Hepatobiliary Surgery, Affiliated Huadu Hospital of Southern Medical University (People's Hospital of Huadu District), Guangzhou, P.R. China
| | - Wenjia Liu
- Department of Surgery and Transplantation, Faculty of Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Jan Bednarsch
- Department of Surgery and Transplantation, Faculty of Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Markus Selzner
- Multi Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Georg Lurje
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Tiansheng Cao
- Department of Hepatobiliary Surgery, Affiliated Huadu Hospital of Southern Medical University (People's Hospital of Huadu District), Guangzhou, P.R. China
| | - Isabel M A Brüggenwirth
- Department of Surgery, Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
| | - Paulo N Martins
- Transplant Division, Department of Surgery, UMass Memorial Hospital, University of Massachusetts, Worcester, MA
| | - Sven Arke Lang
- Department of Surgery and Transplantation, Faculty of Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, Faculty of Medicine, University Hospital RWTH Aachen, Aachen, Germany
- Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Zoltan Czigany
- Department of Surgery and Transplantation, Faculty of Medicine, University Hospital RWTH Aachen, Aachen, Germany
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
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20
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Abstract
End-stage kidney disease (ESKD) after liver transplantation is associated with high morbidity and mortality. This increase in mortality can be offset by performing a kidney transplant at the time of the liver transplant in select cases. Accordingly, Margreiter and colleague; s performed the first simultaneous liver-kidney (SLK) transplant in 1983. The number of SLK transplants has increased by more than 300% since then. In 1990%, 1.7% of all liver transplants in the United States were SLK transplants which increased to 9.9% by 2016. This steep increase was likely due to the implementation of the model of end-stage liver disease (MELD) scoring system in 2002, which is heavily weighted by serum creatinine.
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Affiliation(s)
- Gayatri Nair
- Division of Kidney Disease and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, 400 Community Drive, Manhasset, NY 11030, USA
| | - Vinay Nair
- Division of Kidney Disease and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, 400 Community Drive, Manhasset, NY 11030, USA.
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21
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Chang A, Schaubel DE, Chen M, Abt PL, Bittermann T. Trends and Outcomes of Hypothermic Machine Perfusion Preservation of Kidney Allografts in Simultaneous Liver and Kidney Transplantation in the United States. Transpl Int 2022; 35:10345. [PMID: 35356400 PMCID: PMC8958417 DOI: 10.3389/ti.2022.10345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 01/18/2022] [Indexed: 11/18/2022]
Abstract
Optimal kidney graft outcomes after simultaneous liver-kidney (SLK) transplant may be threatened by the increased cold ischemia time and hemodynamic perturbations of dual organ transplantation. Hypothermic machine perfusion (MP) of kidney allografts may mitigate these effects. We analyzed U.S. trends and renal outcomes of hypothermic non-oxygenated MP vs. static cold storage (CS) of kidney grafts from 6,689 SLK transplants performed between 2005 and 2020 using the United Network for Organ Sharing database. Outcomes included delayed graft function (DGF), primary non-function (PNF), and kidney graft survival (GS). Overall, 17.2% of kidney allografts were placed on MP. Kidney cold ischemia time was longer in the MP group (median 12.8 vs. 10.0 h; p < 0.001). Nationally, MP utilization in SLK increased from <3% in 2005 to >25% by 2019. Center preference was the primary determinant of whether a graft underwent MP vs. CS (intraclass correlation coefficient 65.0%). MP reduced DGF (adjusted OR 0.74; p = 0.008), but not PNF (p = 0.637). Improved GS with MP was only observed with Kidney Donor Profile Index <20% (HR 0.71; p = 0.030). Kidney MP has increased significantly in SLK in the U.S. in a heterogeneous manner and with variable short-term benefits. Additional studies are needed to determine the ideal utilization for MP in SLK.
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Affiliation(s)
- Alex Chang
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Douglas E Schaubel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Melissa Chen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Peter L Abt
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Therese Bittermann
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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22
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Analysis of Prognostic Factors for Patients Undergoing Renal Replacement Therapy With Acute Kidney Injury Prior to Living Donor Liver Transplantation. Transplant Proc 2022; 54:380-385. [PMID: 35042598 DOI: 10.1016/j.transproceed.2021.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 10/28/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication in patients undergoing liver transplantation (LT) for end-stage liver disease (ESLD), and renal replacement therapy (RRT) is required in many cases. This study was performed to identify the prognostic factors for patients undergoing RRT owing to AKI before living donor liver transplantation (LDLT). MATERIALS AND METHODS From January 2010 to December 2018, LDLT was performed in 464 adult patients in our center. We reviewed 33 patients who underwent RRT before LDLT among 464 consecutive cases. Patients who continued to RRT after LDLT or who underwent subsequent kidney transplantation were considered to have not recovered from renal impairment. RESULTS Among 33 patients, there were 23 patients in the recovery group and 10 patients in the nonrecovery group. The preoperative duration of RRT was shorter in the recovery group, but it was not statistically significant. In the nonrecovery group, diabetes mellitus was found to have a higher prevalence and ischemic time was longer. Other perioperative factors were not significantly different between the 2 groups. After LDLT, the peak total bilirubin level was higher, and the intensive care unit stay was longer in the nonrecovery group. The overall survival rate was higher in the recovery group. CONCLUSIONS Liver transplant recipients who maintain RRT after LDLT have poor outcome. It is necessary to know the risk factors and manage them well, perioperatively.
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23
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Protopapas AA, Papagiouvanni I, Fragkou N, Alevroudis E, Sinakos E, Goulis I. Estimation of glomerular filtration rate in patients with cirrhosis: evaluation of equations currently used in clinical practice and validation of Royal Free Hospital cirrhosis glomerular filtration rate. Eur J Gastroenterol Hepatol 2022; 34:84-91. [PMID: 32956187 DOI: 10.1097/meg.0000000000001935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Conventional creatinine-based glomerular filtration rate (GFR) equations have been reported to overestimate renal function in patients with cirrhosis. The Royal Free Hospital (RFH) cirrhosis GFR equation was developed to accurately estimate GFR in this population. The aim of this study was to evaluate the ability of widely available equations [Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI), Modification of Diet in Renal Disease equations (MDRD-4, MDRD-6)] and the RFH equation to correctly estimate the GFR of patients with cirrhosis. METHODS We retrospectively analyzed data from patients with cirrhosis who underwent measurement of GFR with the use of 51Cr-EDTA (GFR-M). The CKD-EPI, MDRD-4, MDRD-6 and RFH equations were calculated, while bias, precision and accuracy were estimated for each one of them and then compared with paired t-tests. Bias was defined as the mean difference between the GFR-M and the result of each equation; precision was defined as the SD of the differences and accuracy was defined as the square root of the mean squared error (mean of the squared differences). Higher values are associated with worse bias and better precision/accuracy. RESULTS One-hundred and thirty-four cirrhotic patients were included. Bias was estimated for CKD-EPI, MDRD-4, MDRD-6 and RFH at -5.91, -3.13, 0.92 and 18.24, respectively. Significant differences were observed between all equations (P < 0.001). Regarding precision, only the comparison between MDRD-4 (20.81) and RFH (16.6) yielded a statistically significant result (P = 0.037). Finally, CKD-EPI (19.32) and MDRD-6 (18.81) exhibited better accuracy than GFR-RFH (24.61) (P = 0.006 and 0.001). CONCLUSION RFH demonstrates inferior accuracy in predicting renal function in patients with cirrhosis, in comparison to conventional equations.
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Affiliation(s)
- Adonis A Protopapas
- First Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA Hospital
| | - Ioanna Papagiouvanni
- Fourth Department of Internal Medicine, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki
| | - Nikolaos Fragkou
- Fourth Department of Internal Medicine, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki
| | - Emmanouil Alevroudis
- Second Department of Radiology, Nuclear Medicine Unit, National and Kapodistrian University of Athens, General University Hospital 'Attikon', Athens, Greece
| | - Emmanouil Sinakos
- Fourth Department of Internal Medicine, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki
| | - Ioannis Goulis
- Fourth Department of Internal Medicine, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki
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24
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Xiang Z, Li Y, Zhu C, Hong T, He X, Zhu H, Jiang D. Gastrointestinal Cancers and Liver Cirrhosis: Implications on Treatments and Prognosis. Front Oncol 2021; 11:766069. [PMID: 34746008 PMCID: PMC8567751 DOI: 10.3389/fonc.2021.766069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 10/04/2021] [Indexed: 12/12/2022] Open
Abstract
Liver cirrhosis tends to increase the risk in the management of gastrointestinal tumors. Patients with gastrointestinal cancers and liver cirrhosis often have serious postoperative complications and poor prognosis after surgery. Multiple studies have shown that the stage of gastrointestinal cancers and the grade of cirrhosis can influence surgical options and postoperative complications. The higher the stage of cancer and the poorer the degree of cirrhosis, the less the surgical options and the higher the risk of postoperative complications. Therefore, in the treatment of patients with gastrointestinal cancer and liver cirrhosis, clinicians should comprehensively consider the cancer stage, cirrhosis grade, and possible postoperative complications. This review summarizes the treatment methods of patients with different gastrointestinal cancer complicated with liver cirrhosis.
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Affiliation(s)
- Ze Xiang
- Department of Gastroenterology, Yancheng Third People’s Hospital, Yancheng, China
- School of Medicine, Zhejiang University, Hangzhou, China
- Chu Kochen Honors College, Zhejiang University, Hangzhou, China
| | - Yiqi Li
- School of Medicine, Zhejiang University, Hangzhou, China
- Chu Kochen Honors College, Zhejiang University, Hangzhou, China
| | - Chaojie Zhu
- School of Medicine, Zhejiang University, Hangzhou, China
- Chu Kochen Honors College, Zhejiang University, Hangzhou, China
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Tu Hong
- School of Medicine, Zhejiang University, Hangzhou, China
- Chu Kochen Honors College, Zhejiang University, Hangzhou, China
| | - Xianglin He
- Chu Kochen Honors College, Zhejiang University, Hangzhou, China
| | - Hua Zhu
- Department of Gastroenterology, Yancheng Third People’s Hospital, Yancheng, China
| | - Danbin Jiang
- Department of Gastroenterology, Yancheng Third People’s Hospital, Yancheng, China
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25
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Pozo-Laderas J, Guler I, Rodríguez-Perálvarez M, Robles J, Mula A, López-Cillero P, de la Fuente C. Early postoperative mortality in liver transplant recipients involving indications other than hepatocellular carcinoma. A retrospective cohort study. Med Intensiva 2021; 45:395-410. [DOI: 10.1016/j.medin.2020.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
PURPOSE OF REVIEW Transplantation is the life-saving therapy for patients suffering from end-organ failure, and as such, equitable access to transplantation (ATT) is of paramount importance. Unfortunately, gender/sex-based disparities exist, and despite the transplant community's awareness of this injustice, gender/sex-based disparities have persisted for more than two decades. Importantly, no legislation or allocation policy has addressed inequity in ATT that women disproportionately face. In fact, introduction of the model for end-stage liver disease-based liver allocation system in 2002 widened the gender disparity gap and it continues to be in effect today. Moreover, women suffering from kidney disease are consistently less likely to be referred for transplant evaluation and subsequently less likely to achieve a kidney transplant, yet they comprise the majority of living kidney donors. RECENT FINDINGS Acknowledging gender/sex-based disparities in ATT is the first step toward interventions aimed at mitigating this long-standing injustice in healthcare. SUMMARY This article provides a background of end-stage liver and kidney disease in women, summarizes the existing literature describing the issue of gender disparity in ATT, and identifies potential areas of intervention and future investigation.
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Affiliation(s)
- Saulat S Sheikh
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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27
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Pozo-Laderas JC, Guler I, Rodríguez-Perálvarez M, Robles JC, Mula A, López-Cillero P, de la Fuente C. Early postoperative mortality in liver transplant recipients involving indications other than hepatocellular carcinoma. A retrospective cohort study. Med Intensiva 2021; 45:395-410. [PMID: 34563340 DOI: 10.1016/j.medine.2020.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 02/11/2020] [Indexed: 11/28/2022]
Abstract
AIMS To analyze the perioperative differences in a consecutive cohort of liver transplant recipients (LTRs) classified according to the indication of transplantation, and assess their impact upon early mortality 90 days after transplantation. DESIGN A retrospective cohort study was carried out. SCOPE A single university hospital. PATIENTS A total of 892 consecutive adult LTRs were included from January 1995 to December 2017. Recipients with acute liver failure, retransplantation or with grafts from non-brain death donors were excluded. Two cohorts were analyzed according to transplant indication: hepatocellular carcinoma (HCC-LTR) versus non-carcinoma (non-HCC-LTR). MAIN VARIABLES OF INTEREST Recipient early mortality was the primary endpoint. The pretransplant recipient and donor characteristics, surgical time data and postoperative complications were analyzed as independent predictors. RESULTS The crude early postoperative mortality rate related to transplant indication was 13.3% in non-HCC-LTR and 6.6% in HCC-LTR (non-adjusted HR=2.12, 95%CI=1.25-3.60; p=0.005). Comparison of the perioperative features between the cohorts revealed multiple differences. Multivariate analysis showed postoperative shock (HR=2.02, 95%CI=1.26-3.24; p=0.003), early graft vascular complications (HR=4.01, 95%CI=2.45-6.56; p<0.001) and multiorgan dysfunction syndrome (HR=18.09, 95%CI=10.70-30.58; p<0.001) to be independent predictors of mortality. There were no differences in early mortality related to transplant indication (adjusted HR=1.60, 95%CI=0.93-2.76; p=0.086). CONCLUSIONS The crude early postoperative mortality rate in non-HCC-LTR was higher than in HCC-LTR, due to a greater incidence of postoperative complications with an impact upon mortality (shock at admission to intensive care and the development of multiorgan dysfunction syndrome).
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Affiliation(s)
- J C Pozo-Laderas
- Intensive Care Medicine, Reina Sofia University Hospital and Maimonides Biomedical Research Institute (IMIBIC), Cordoba, Spain.
| | - I Guler
- Methodology and Biostatistics, IMIBIC, Cordoba, Spain
| | | | - J C Robles
- Intensive Care Medicine, Reina Sofia University Hospital and Maimonides Biomedical Research Institute (IMIBIC), Cordoba, Spain
| | - A Mula
- Intensive Care Medicine, Reina Sofia University Hospital and Maimonides Biomedical Research Institute (IMIBIC), Cordoba, Spain
| | - P López-Cillero
- Surgery and Liver Transplantation, Reina Sofia University Hospital and IMIBIC, Cordoba, Spain
| | - C de la Fuente
- Intensive Care Medicine, Reina Sofia University Hospital and Maimonides Biomedical Research Institute (IMIBIC), Cordoba, Spain
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28
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Lee HA, Seo YS. Current knowledge about biomarkers of acute kidney injury in liver cirrhosis. Clin Mol Hepatol 2021; 28:31-46. [PMID: 34333958 PMCID: PMC8755473 DOI: 10.3350/cmh.2021.0148] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 07/28/2021] [Indexed: 11/05/2022] Open
Abstract
Acute kidney injury (AKI) is common in advanced cirrhosis. Prerenal azotemia, hepatorenal syndrome, and acute tubular necrosis are the main causes of AKI in patients with cirrhosis. Evaluation of renal function and differentiation between functional and structural kidney injury are important issues in the management of cirrhosis. However, AKI in cirrhosis exists as a complex clinical spectrum rather than concrete clinical entity. Based on current evidence, changes in serum creatinine (Cr) levels remain the most appropriate standard for defining AKI in cirrhosis. However, serum Cr has a limited role in assessing renal function in this population. This review examines previous studies that investigated the ability of recent biomarkers for AKI in cirrhosis from the perspective of earlier and accurate diagnosis, classification of AKI phenotype, and prediction of clinical outcomes. Serum cystatin C and urine neutrophil gelatinase-associated lipocalin have been extensively studied in cirrhosis, and have facilitated improved diagnosis and prognosis prediction in patients with AKI. In addition, urine N-acetyl-β-D-glucosaminidase, interleukin 18, and kidney injury molecule 1 are other promising biomarkers for advanced cirrhosis. However, the clinical significance of these markers remains unclear because there are no cut-off values defining the normal range and differentiating phenotypes of AKI. In addition, AKI has been defined in terms of serum Cr, and renal biopsy-the gold standard-has not been carried out in most studies. Further discovery of innovate biomarkers and incorporation of various markers could improve the diagnosis and prognosis prediction of AKI, and will translate into meaningful improvements in patient outcomes.
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Affiliation(s)
- Han Ah Lee
- Departments of Internal Medicine, Korea University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Yeon Seok Seo
- Departments of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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29
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Liu PMF, de Carvalho ST, Fradico PF, Cazumbá MLB, Campos RGB, Simões E Silva AC. Hepatorenal syndrome in children: a review. Pediatr Nephrol 2021; 36:2203-2215. [PMID: 33001296 PMCID: PMC7527294 DOI: 10.1007/s00467-020-04762-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/01/2020] [Accepted: 09/05/2020] [Indexed: 02/07/2023]
Abstract
Hepatorenal syndrome (HRS) occurs in patients with cirrhosis or fulminant hepatic failure and is a kind of pre-renal failure due to intense reduction of kidney perfusion induced by severe hepatic injury. While other causes of pre-renal acute kidney injury (AKI) respond to fluid infusion, HRS does not. HRS incidence is 5% in children with chronic liver conditions before liver transplantation. Type 1 HRS is an acute and rapidly progressive form that often develops after a precipitating factor, including gastrointestinal bleeding or spontaneous bacterial peritonitis, while type 2 is considered a slowly progressive form of kidney failure that often occurs spontaneously in chronic ascites settings. HRS pathogenesis is multifactorial. Cirrhosis causes portal hypertension; therefore, stasis and release of vasodilator substances occur in the hepatic vascular bed, leading to vasodilatation of splanchnic arteries and systemic hypotension. Many mechanisms seem to work together to cause this imbalance: splanchnic vasodilatation; vasoactive mediators; hyperdynamic circulation states and subsequent cardiac dysfunction; neuro-hormonal mechanisms; changes in sympathetic nervous system, renin-angiotensin system, and vasopressin. In patients with AKI and cirrhosis, fluid expansion therapy needs to be initiated as soon as possible and nephrotoxic drugs discontinued. Once HRS is diagnosed, pharmacological treatment with vasoconstrictors, mainly terlipressin plus albumin, should be initiated. If there is no response, other options can include surgical venous shunts and kidney replacement therapy. In this regard, extracorporeal liver support can be a bridge for liver transplantation, which remains as the ideal treatment. Further studies are necessary to investigate early biomarkers and alternative treatments for HRS.
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Affiliation(s)
- Priscila Menezes Ferri Liu
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais, UFMG, Avenida Alfredo Balena, 190, 2nd floor, #281 room, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Sarah Tayná de Carvalho
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais, UFMG, Avenida Alfredo Balena, 190, 2nd floor, #281 room, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Pollyanna Faria Fradico
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais, UFMG, Avenida Alfredo Balena, 190, 2nd floor, #281 room, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Maria Luiza Barreto Cazumbá
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais, UFMG, Avenida Alfredo Balena, 190, 2nd floor, #281 room, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Ramon Gustavo Bernardino Campos
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais, UFMG, Avenida Alfredo Balena, 190, 2nd floor, #281 room, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Ana Cristina Simões E Silva
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais, UFMG, Avenida Alfredo Balena, 190, 2nd floor, #281 room, Belo Horizonte, Minas Gerais, 30130-100, Brazil.
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Nilles KM, Levitsky J. Current and Evolving Indications for Simultaneous Liver Kidney Transplantation. Semin Liver Dis 2021; 41:308-320. [PMID: 34130337 DOI: 10.1055/s-0041-1729969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
This review will discuss the etiologies of kidney disease in liver transplant candidates, provide a historical background of the prior evolution of simultaneous liver-kidney (SLK) transplant indications, discuss the current indications for SLK including Organ Procurement and Transplantation Network policies and Model for End Stage Liver Disease exception points, as well as provide an overview of the safety net kidney transplant policy. Finally, the authors explore unanswered questions and future research needed in SLK transplantation.
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Affiliation(s)
- Kathy M Nilles
- Division of Gastroenterology and Hepatology, Department of Medicine, MedStar Georgetown Transplant Institute, Georgetown University School of Medicine, Washington, District of Columbia
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Department of Medicine, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Thuluvath AJ, Savva Y, Chen PH. Poor Graft and Patient Survival After Liver Transplantation in Sarcoidosis. J Clin Gastroenterol 2021; 54:884-890. [PMID: 33027134 DOI: 10.1097/mcg.0000000000001289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
GOALS AND BACKGROUND There are limited data on post-liver transplantation (LT) outcomes of patients with sarcoidosis. STUDY We examined the clinical characteristics and post-LT outcomes of patients with sarcoidosis using the United Network for Organ Sharing database from 1985 to 2016 and compared them to patients (entire cohort as well as age, gender, and year of LT-matched counterparts) with primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC). For the matched design, a conditional logistic regression was used for categorical variables and marginal generalized estimating equation regression models for continuous variables. Survival functions were constructed using the Kaplan-Meier estimator. RESULTS A total of 206 patients with sarcoidosis, transplanted during the study period, were compared with 3933 patients with PBC and 5323 with PSC. In total, 197 patients with sarcoidosis were compared with 576 with PBC and 576 with PSC in the 1:3 matched analysis. The sarcoidosis group had a higher proportion of blacks (53.3%) and a higher prevalence of obesity and type II diabetes mellitus. The graft and patient survival for sarcoidosis patients were lower when compared with unmatched PBC and PSC patients. The results remained unchanged in the matched analysis. At 5-year, patient survival was ~15% lower for the sarcoidosis group when compared with PBC and PSC. In multivariate analysis using matched data, hazard ratios (HRs) for graft (HR=1.68, 95% confidence interval=1.03-2.75, P=0.04), and patient (HR=2.01, confidence interval=1.22-3.34, P<0.01) survival were higher for sarcoidosis. CONCLUSIONS Patients who underwent LT for sarcoidosis had a lower graft and patient survival when compared with those with PBC or PSC. That being said, 66% of patients survived 5 years after transplantation, suggesting that LT is an acceptable option in this population.
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Affiliation(s)
| | - Yulia Savva
- The Institute of Digestive Health and Liver Disease, Mercy Medical Center, Baltimore, MD
| | - Po-Hung Chen
- Department of Medicine
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine
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Morelli MC, Rendina M, La Manna G, Alessandria C, Pasulo L, Lenci I, Bhoori S, Messa P, Biancone L, Gesualdo L, Russo FP, Petta S, Burra P. Position paper on liver and kidney diseases from the Italian Association for the Study of Liver (AISF), in collaboration with the Italian Society of Nephrology (SIN). Dig Liver Dis 2021; 53 Suppl 2:S49-S86. [PMID: 34074490 DOI: 10.1016/j.dld.2021.03.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/31/2021] [Accepted: 03/31/2021] [Indexed: 02/07/2023]
Abstract
Liver and kidney are strictly connected in a reciprocal manner, in both the physiological and pathological condition. The Italian Association for the Study of Liver, in collaboration with the Italian Society of Nephrology, with this position paper aims to provide an up-to-date overview on the principal relationships between these two important organs. A panel of well-recognized international expert hepatologists and nephrologists identified five relevant topics: 1) The diagnosis of kidney damage in patients with chronic liver disease; 2) Acute kidney injury in liver cirrhosis; 3) Association between chronic liver disease and chronic kidney disease; 4) Kidney damage according to different etiology of liver disease; 5) Polycystic kidney and liver disease. The discussion process started with a review of the literature relating to each of the five major topics and clinical questions and related statements were subsequently formulated. The quality of evidence and strength of recommendations were graded according to the GRADE system. The statements presented here highlight the importance of strong collaboration between hepatologists and nephrologists for the management of critically ill patients, such as those with combined liver and kidney impairment.
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Affiliation(s)
- Maria Cristina Morelli
- Internal Medicine Unit for the treatment of Severe Organ Failure, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di S.Orsola, Bologna, Italy, Via Albertoni 15, 40138, Bologna, Italy
| | - Maria Rendina
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Policlinic Hospital, Piazza G. Cesare 11, 70124, Bari, Italy
| | - Gaetano La Manna
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, St. Orsola Hospital, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Torino, Corso Bramante 88, 10126, Torino, Italy
| | - Luisa Pasulo
- Gastroenterology and Transplant Hepatology, "Papa Giovanni XXIII" Hospital, Piazza OMS 1, 24127, Bergamo, Italy
| | - Ilaria Lenci
- Department of Internal Medicine, Hepatology Unit, Tor Vergata University, Rome Viale Oxford 81, 00133, Rome, Italy
| | - Sherrie Bhoori
- Hepatology and Hepato-Pancreatic-Biliary Surgery and Liver Transplantation, Fondazione IRCCS, Istituto Nazionale Tumori, Via Giacomo Venezian, 1, 20133, Milan, Italy
| | - Piergiorgio Messa
- Unit of Nephrology, Università degli Studi di Milano, Via Commenda 15, 20122, Milano, Italy; Nephrology, Dialysis and Renal Transplant Unit-Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Via Commenda 15, 20122 Milano, Italy
| | - Luigi Biancone
- Division of Nephrology Dialysis and Transplantation, Department of Medical Sciences, Città Della Salute e della Scienza Hospital, University of Turin, Corso Bramante, 88-10126, Turin, Italy
| | - Loreto Gesualdo
- Nephrology Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, Università degli Studi di Bari "Aldo Moro", Piazza G. Cesare 11, 70124, Bari, Italy
| | - Francesco Paolo Russo
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Salvatore Petta
- Section of Gastroenterology and Hepatology, PROMISE, University of Palermo, Piazza delle Cliniche, 2 90127, Palermo, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Via Giustiniani 2, 35128, Padua, Italy.
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Goldberg D, Mantero A, Newcomb C, Delgado C, Forde K, Kaplan D, John B, Nuchovich N, Dominguez B, Emanuel E, Reese PP. Development and Validation of a Model to Predict Long-Term Survival After Liver Transplantation. Liver Transpl 2021; 27:797-807. [PMID: 33540489 PMCID: PMC8742146 DOI: 10.1002/lt.26002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 12/14/2020] [Accepted: 01/14/2021] [Indexed: 12/12/2022]
Abstract
Patients are prioritized for liver transplantation (LT) under an "urgency-based" system using the Model for End-Stage Liver Disease score. This system focuses solely on waitlist mortality, without considerations of posttransplant morbidity, mortality, and health care use. We sought to develop and internally validate a continuous posttransplant risk score during 5-year and 10-year time horizons. This retrospective cohort study used national registry data of adult deceased donor LT (DDLT) recipients with ≥90 days of pretransplant waiting time from February 27, 2002 to December 31, 2018. We fit Cox regression models at 5 and 10 years to estimate beta coefficients for a risk score using manual variable selection and calculated the absolute predicted survival time. Among 21,103 adult DDLT recipients, 11 variables were selected for the final model. The area under the curves at 5 and 10 years were 0.63 (95% confidence interval [CI], 0.60-0.66) and 0.67 (95% CI, 0.64-0.70), respectively. The group with the highest ("best") scores had 5-year and 10-year survivals of 89.4% and 85.4%, respectively, compared with 45.9% and 22.2% for those with the lowest ("worst") scores. Our score was significantly better at predicting long-term survival compared with the existing scores. We developed and validated a risk score using nearly 17 years of data to prioritize patients with end-stage liver disease based on projected posttransplant survival. This score can serve as the building block by which the transplant field can change the entire approach to prioritizing patients to an approach that is based on considerations of maximizing benefits (ie, survival benefit-based allocation) rather than simply waitlist mortality.
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Affiliation(s)
- David Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Alejandro Mantero
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL
| | - Craig Newcomb
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Cindy Delgado
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Kimberly Forde
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - David Kaplan
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Binu John
- Bruce Carter VA Medica Center, Miami, FL
| | - Nadine Nuchovich
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Barbara Dominguez
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Ezekiel Emanuel
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Peter P. Reese
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Renal-Electrolye and Hypertension Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Xin X, Tang J, Jia HM, Zhang TE, Zheng Y, Huang LF, Ding Q, Li JC, Guo SY, Li WX. Development of a Multivariable Prediction Model for Citrate Accumulation in Liver Transplant Patients Undergoing Continuous Renal Replacement Therapy with Regional Citrate Anticoagulation. Blood Purif 2021; 51:111-121. [PMID: 33951630 DOI: 10.1159/000513947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 12/16/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Patients with impaired citrate metabolism may experience citrate accumulation (CA), which causes life-threatening metabolic acidosis and hypocalcemia. CA poses a challenge for clinicians when deciding on the use of regional citrate anticoagulation (RCA) for patients with liver dysfunction. This study aimed to develop a prediction model integrating multiple clinical variables to assess the risk of CA in liver transplant patients. METHODS This single-center prospective cohort study included postoperative liver transplant patients who underwent continuous renal replacement therapy (CRRT) with RCA. The study end point was CA. A prediction model was developed using a generalized linear mixed-effect model based on the Akaike information criterion. The predictive values were assessed using the receiver operating characteristic curve and bootstrap resampling (times = 500) to estimate the area under the curve (AUC) and the corresponding 95% confidence interval (CI). A nomogram was used to visualize the model. RESULTS This study included 32 patients who underwent 133 CRRT sessions with RCA. CA occurred in 46 CRRT sessions. The model included lactate, norepinephrine >0.1 μg/kg/min, alanine aminotransferase, total bilirubin, and standard bicarbonate, which were tested before starting each CRRT session and body mass index, diabetes mellitus, and chronic kidney disease as predictors. The AUC of the model was 0.867 (95% CI 0.786-0.921), which was significantly higher than that of the single predictor (p < 0.05). A nomogram visualized the prediction model. CONCLUSIONS The prediction model integrating multiple clinical variables showed a good predictive value for CA. A nomogram visualized the model for easy application in clinical practice.
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Affiliation(s)
- Xin Xin
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jing Tang
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Hui-Miao Jia
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Tian-En Zhang
- Department of Health Science, Gettysburg College, Gettysburg, Pennsylvania, USA
| | - Yue Zheng
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Li-Feng Huang
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Qi Ding
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jun-Cong Li
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Shu-Yan Guo
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Wen-Xiong Li
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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Cullaro G, Verna EC, Emond JC, Orandi BJ, Mohan S, Lai JC. Early Kidney Allograft Failure After Simultaneous Liver-kidney Transplantation: Evidence for Utilization of the Safety Net? Transplantation 2021; 105:816-823. [PMID: 32413016 PMCID: PMC7971118 DOI: 10.1097/tp.0000000000003310] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND With the implementation of the "Safety Net," we aimed to determine the impact of simultaneous liver-kidney transplantation (SLKT), as compared to kidney transplant after liver transplant (KALT), on kidney allograft failure (KF). METHODS An analysis of the UNOS database for all adult patients who received either an SLKT or KALT from 2002 to 2017. The outcomes were 90-day KF and 1-year KF (as reported to UNOS, at 90- and 365-day postkidney transplant, respectively). We compared the following groups of patients: SLKT <25 (SLKT with final model for end-stage liver disease [MELD] <25), SLKT25/35 (MELD ≥25/<35), and SLKT35 (MELD ≥35) to KALT. RESULTS Of the 6276 patients, there were 1481 KALT, 1579 SLKT <25, 1832 SLKT25/35, and 1384 SLKT ≥35. The proportion of patients with 90-day and 1-year KF increased significantly among the KALT, SLKT <25, SLKT25/35, and SLKT ≥35 groups (P < 0.001; test for trend): 90-day KF: 3.3% versus 5.5% versus 7.3% versus 9.3% and 1-year KF: 5.1% versus 9.4% versus 12.3% versus 14.7%. After adjustment and compared with KALT, beginning at an MELD ≥25 those undergoing SLKT had significantly higher risk of 90-day and 1-year KF: 90-day KF: SLKT25/35: hazard ratio, 1.6(1.0-2.3); SLKT ≥35: 2.1(1.3-3.3); 1-year KF: SLKT25/35: hazard ratio, 1.7(1.2-2.4); SLKT ≥35: 2.1(1.5-3.0). CONCLUSIONS As compared to KALT recipients, SLKT recipients with an MELD ≥25 had significantly higher risk of early KF. Given the now well-established "Safety Net," KALT may serve as an opportunity to improve kidney outcomes in patients with an MELD ≥25.
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Affiliation(s)
- Giuseppe Cullaro
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, CA, USA
| | - Elizabeth C. Verna
- Center for Liver Disease and Transplantation, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Jean C. Emond
- Department of Surgery, Division of Transplantation, Vagelos College of Physicians & Surgeons, New York, New York
| | - Babak J. Orandi
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, CA, USA
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36
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Kumar R, Priyadarshi RN, Anand U. Chronic renal dysfunction in cirrhosis: A new frontier in hepatology. World J Gastroenterol 2021; 27:990-1005. [PMID: 33776368 PMCID: PMC7985728 DOI: 10.3748/wjg.v27.i11.990] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/17/2021] [Accepted: 03/08/2021] [Indexed: 02/06/2023] Open
Abstract
Chronic kidney disease (CKD) in patients with liver cirrhosis has become a new frontier in hepatology. In recent years, a sharp increase in the diagnosis of CKD has been observed among patients with cirrhosis. The rising prevalence of risk factors, such as diabetes, hypertension and nonalcoholic fatty liver disease, appears to have contributed significantly to the high prevalence of CKD. Moreover, the diagnosis of CKD in cirrhosis is now based on a reduction in the estimated glomerular filtration rate of < 60 mL/min over more than 3 mo. This definition has resulted in a better differentiation of CKD from acute kidney injury (AKI), leading to its greater recognition. It has also been noted that a significant proportion of AKI transforms into CKD in patients with decompensated cirrhosis. CKD in cirrhosis can be structural CKD due to kidney injury or functional CKD secondary to circulatory and neurohormonal imbalances. The available literature on combined cirrhosis-CKD is extremely limited, as most attempts to assess renal dysfunction in cirrhosis have so far concentrated on AKI. Due to problems related to glomerular filtration rate estimation in cirrhosis, the absence of reliable biomarkers of CKD and technical difficulties in performing renal biopsy in advanced cirrhosis, CKD in cirrhosis can present many challenges for clinicians. With combined hepatorenal dysfunctions, fluid mobilization becomes problematic, and there may be difficulties with drug tolerance, hemodialysis and decision-making regarding the need for liver vs simultaneous liver and kidney transplantation. This paper offers a thorough overview of the increasingly known CKD in patients with cirrhosis, with clinical consequences and difficulties occurring in the diagnosis and treatment of such patients.
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Affiliation(s)
- Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Rajeev Nayan Priyadarshi
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
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Dick AAS, Winstanley E, Ohara M, Blondet NM, Healey PJ, Perkins JD, Reyes JD. Do funding sources influence long-term patient survival in pediatric liver transplantation? Pediatr Transplant 2021; 25:e13887. [PMID: 33112037 DOI: 10.1111/petr.13887] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/10/2020] [Accepted: 09/21/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Socioeconomic status has been associated with inferior outcomes after multiple surgical procedures, but has not been well studied with respect to pediatric liver transplantation. This study evaluated the impact of insurance status (as a proxy for socioeconomic status) on patient and allograft survival in pediatric first-time liver transplant recipients. METHODS Our retrospective analysis of the UNOS data base from January 2002 through September 2017 revealed 6997 pediatric patients undergoing first-time isolated liver transplantation. A mixed Cox proportional hazards model adjusted for donor, recipient, and program characteristics determined the RR of insurance status on allograft and patient survival. All results were considered significant at P < .05. All statistical results were obtained using R version 3.5.1 and coxme version 2.2-10. RESULTS Medicaid status had a significant negative impact on long-term survival after controlling for multiple covariates. Pediatric patients undergoing first-time isolated liver transplantation with Medicaid insurance had a RR of 1.42 [confidence interval: 1.18-1.60] of post-transplant death. CONCLUSION Pediatric patients undergoing first-time isolated liver transplantation have multiple risk factors that may impact long-term survival. Having Medicaid insurance almost doubles the chances of dying post-liver transplant. This patient population may require more global support post-transplant to improve long-term survival.
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Affiliation(s)
- André A S Dick
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, WA, USA.,Section of Pediatric Transplantation, Seattle Children's Hospital, Seattle, WA, USA
| | | | - Michael Ohara
- Department of Social Work, Seattle Children's Hospital, Seattle, WA, USA
| | - Niviann M Blondet
- Division of Gastroenterology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Patrick J Healey
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, WA, USA.,Section of Pediatric Transplantation, Seattle Children's Hospital, Seattle, WA, USA
| | - James D Perkins
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, WA, USA
| | - Jorge D Reyes
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, WA, USA.,Section of Pediatric Transplantation, Seattle Children's Hospital, Seattle, WA, USA
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Niewiński G, Smyk W, Graczyńska A, Kostrzewa K, Raszeja-Wyszomirska J, Ołdakowska-Jedynak U, Małyszko J, Wójcicki M, Zieniewicz K. Kidney Function After Liver Transplantation in a Single Center. Ann Transplant 2021; 26:e926928. [PMID: 33619240 PMCID: PMC7911851 DOI: 10.12659/aot.926928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Renal dysfunction in the peri-transplant period appears to complicate both short- and long-term outcome of liver transplantation (LT). The aim of this study was to analyze the impact of selected clinical features in the peri-liver transplant period, as well calcineurin inhibitor, particularly tacrolimus given after LT, on kidney function in a single liver transplant center’s experience. Material/Methods A total 125 consecutive liver-grafted individuals (82 M, 43 F), mean age 50±13 y (with alcohol-related liver disease in 48 (38%) patients) were included into the study. Their clinical data were collected in the database until 46 months of follow-up, and the Python packages Pandas (version 0.22.0) and scikit-learn (version 0.21.3) were used for data analysis. Results More advanced liver disease as judged by Child-Pugh class and MELD score differed significantly patients with preserved (serum creatinine SCr <1.5 mg/dL) and impaired (SCr ≥1.5 mg/dL) kidney function before LT. Older age and higher SCr pre-LT were associated with higher levels of SCr after LT in 2 time-points. SCr before LT was correlated with delta SCr for the highest and last recorded value (P<0.0001). Higher amounts of transfused colloids during surgery were associated with increased delta SCr for the highest value (P=0.019) after grafting in logistic regression analysis. There were no associations between SCr after LT and duration of anhepatic phase, urine output ≤100 mL/h, or post-reperfusion syndrome during transplantation (all P>0.05). There were no associations between SCr after LT and tacrolimus trough levels in analyses of correlations and linear regression analyses (all P>0.05). Conclusions We found that pretransplant serum creatinine was the only factor affecting kidney function after LT in our liver transplant center. The restricted fluid policy was safe and effective in terms of long-term renal function. The role of kidney-saving immunosuppressive protocols in preserving renal function long-term after LT was also confirmed.
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Affiliation(s)
- Grzegorz Niewiński
- II Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Wiktor Smyk
- Liver and Internal Medicine Unit, Medical University of Warsaw, Warsaw, Poland
| | - Agata Graczyńska
- II Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | | | | | | | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Maciej Wójcicki
- Liver and Internal Medicine Unit, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Zieniewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
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Rajakumar A, Appuswamy E, Kaliamoorthy I, Rela M. Renal Dysfunction in Cirrhosis: Critical Care Management. Indian J Crit Care Med 2021; 25:207-214. [PMID: 33707901 PMCID: PMC7922436 DOI: 10.5005/jp-journals-10071-23721] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Cirrhotic patients with manifestations of the end-stage liver disease have a high risk for developing renal dysfunction even with minor insults. The development of renal dysfunction increases the morbidity and mortality of these patients. Causes of renal dysfunction in cirrhotics can be due to hepatorenal syndrome (HRS) or acute kidney injury (AKI) resulting from prerenal, renal, and postrenal causes. Development of pretransplant renal dysfunction has been shown to affect post-liver transplantation outcomes. Early detection and aggressive strategies for the prevention of further progression of renal dysfunction seem to decrease the morbidity and improve survival in this group of patients. This article aims to outline the pathogenesis of renal dysfunction in cirrhosis, etiological factors, and evaluation of renal dysfunction, strategies for aggressive therapy for renal dysfunction, the indications of renal replacement therapy (RRT) in this group of patients, and the various modalities of RRT with their merits and demerits. A thorough understanding of the pathogenesis, early detection, and aggressive corrective measures for AKI can prevent further progression. In conclusion, a good knowledge of treatment modalities available for renal dysfunction in cirrhosis and institution of timely interventions can significantly improve survival in this group of patients.
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Affiliation(s)
- Akila Rajakumar
- Department of Liver Anaesthesia and Intensive Care, Dr. Rela Institute and Medical Centre, Chennai, Tamil Nadu, India
| | - Ellango Appuswamy
- Department of Liver Anaesthesia and Intensive Care, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - Ilankumaran Kaliamoorthy
- Department of Liver Anaesthesia and Intensive Care, Dr. Rela Institute and Medical Centre, Chennai, Tamil Nadu, India
| | - Mohamed Rela
- Department of Liver Transplantation and HPB Surgery, Dr. Rela Institute and Medical Centre, Chennai, Tamil Nadu, India
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New OPTN Simultaneous Liver-Kidney Transplant (SLKT) Policy Improves Racial and Ethnic Disparities. J Clin Med 2020; 9:jcm9123901. [PMID: 33271833 PMCID: PMC7760665 DOI: 10.3390/jcm9123901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 12/19/2022] Open
Abstract
(1) Background: On 10 August 2017, the Organ Procurement and Transplantation Network (OPTN) adopted standardized eligibility criteria to properly determine which transplant candidates should undergo Simultaneous Liver-Kidney Transplant (SLKT). Racial and ethnic disparities have not been examined after 2017. Therefore, using the United Network for Organ Sharing (UNOS), we aim to evaluate post-graft survival outcomes among Caucasians, African Americans, and Hispanics. (2) Methods: Kaplan-Meier curves and Cox regression models are used to compare post-transplant graft survival for Caucasians, African Americans (AAs), and Hispanics. Competing risk analysis is used to evaluate the cumulative incidence of death or re-transplantation with re-transplantation and death as competing risks. (3) Results: On multivariate Cox regression analysis, no differences in graft survival are found in AA (hazard ratio (HR): 1.30; 95% CI: 0.74-2.29 p = 0.354) or Hispanics (HR: 1.18; 95% CI: 0.70-2 p = 0.520) compared to Caucasians after 2017. On competing risk analysis of the risk of death with re-transplantation as a competing risk, no difference is found between ethnic minorities after 2017. There is a similar finding from competing risk analysis of the risk of re-transplantation with death as a competing risk. (4) Conclusion: After introducing standardized eligibility criteria for SLKT allocation, the post-graft survival outcomes remain similar between the different racial and ethnic groups, displaying the benefits of adopting such policy in 2017.
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Velayudham B, Thomas RG, Vasudevan C, Senthilkumar RP, Thirumalvalavan, Murugesan. Serum cystatin C unmasks renal dysfunction in cirrhosis and performs better in estimation of glomerular filtration rate. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2020; 31:1320-1330. [PMID: 33565444 DOI: 10.4103/1319-2442.308341] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
In this study, we aimed to measure glomerular filtration rate (mGFR) using 99Tc DTPA in patients with Child-Pugh C cirrhosis and normal serum creatinine levels; and to compare the performance of creatinine and cystatin C-based equations [estimated GFRs (eGFRs)] to 99TcDTPA GFR in the same group. We selected a group of 65 consecutive patients with advanced liver cirrhosis and apparently normal renal function by serum creatinine alone. Patients with confounding and reversible factors were excluded. Demographic data, blood, urine, and imaging tests along with simultaneous measurement of serum creatinine and cystatin C were analyzed. The GFR was measured by 99Tc DTPAscintigraphy (mGFR) in 41 patients. We compared the performance of chronic kidney disease epidemiology collaboration (CKD-EPI-creatinine, CKD-EPI-cystatinC, CKD-EPI-creatinine-cystatinC) and Modification of Diet in Renal Disease equation equations for bias (mean difference), precision (root mean square error), and accuracy (P10 and P30). Bland-Altman plots were used to show the agreement of eGFR and mGFR. Twenty-five out of 41 patients (61%) had significant renal dysfunction (GFR ≤60 mL/min/ 1.73m2) by 99TcDTPA in our study and three patients were already in Stage 4 CKD. Unlike serum creatinine, serum cystatin C values were deranged in these patients. Among all GFR estimating formulae, CKD-EPI-creatinine-cystatinC combined equation had the least bias (-2.3), superior precision (7.1), highest P30 accuracy (78%), good sensitivity (87.5%), and best specificity (96%) in our study. Two-thirds of patients with cirrhosis had significant renal impairment despite having normal serum creatinine. Isolated serum creatinine values are misleading in cirrhosis. Cystatin C unmasks renal dysfunction in these patients. CKD-EPI-creatinine-cystatinC equation showed the best correlation and accuracy with 99TcDTPA GFR in our study. Creatinine based GFR estimation is fallacious in cirrhosis. Cystatin C and equations based on it may be worthwhile in liver disease.
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Affiliation(s)
- Balaraman Velayudham
- Department of Nephrology, Government Kilpauk Medical College, Chennai, Tamil Nadu, India
| | - Remi George Thomas
- Department of Nephrology, Government Kilpauk Medical College, Chennai, Tamil Nadu, India
| | - C Vasudevan
- Department of Nephrology, Government Kilpauk Medical College, Chennai, Tamil Nadu, India
| | - R P Senthilkumar
- Department of Nephrology, Government Kilpauk Medical College, Chennai, Tamil Nadu, India
| | - Thirumalvalavan
- Department of Nephrology, Government Kilpauk Medical College, Chennai, Tamil Nadu, India
| | - Murugesan
- Department of Nephrology, Government Kilpauk Medical College, Chennai, Tamil Nadu, India
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Changing epidemiology and outcomes of acute kidney injury in hospitalized patients with cirrhosis - a US population-based study. J Hepatol 2020; 73:1092-1099. [PMID: 32387698 PMCID: PMC7994029 DOI: 10.1016/j.jhep.2020.04.043] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/09/2020] [Accepted: 04/27/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Acute kidney injury (AKI) is a significant clinical event in cirrhosis yet contemporary population-based studies on the impact of AKI on hospitalized cirrhotics are lacking. We aimed to characterize longitudinal trends in incidence, healthcare burden and outcomes of hospitalized cirrhotics with and without AKI using a nationally representative dataset. METHODS Using the 2004-2016 National Inpatient Sample (NIS), admissions for cirrhosis with and without AKI were identified using ICD-9 and ICD-10 codes. Regression analysis was used to analyze the trends in hospitalizations, costs, length of stay and inpatient mortality. Descriptive statistics, simple and multivariable logistic regression were used to assess associations between individual characteristics, comorbidities, and cirrhosis complications with AKI and death. RESULTS In over 3.6 million admissions for cirrhosis, 22% had AKI. AKI admissions were more costly (median $13,127 [IQR $7,367-$24,891] vs. $8,079 [IQR $4,956-$13,693]) and longer (median 6 [IQR 3-11] days vs. 4 [IQR 2-7] days). Over time, AKI prevalence doubled from 15% in 2004 to 30% in 2016. CKD was independently and strongly associated with AKI (adjusted odds ratio 3.75; 95% CI 3.72-3.77). Importantly, AKI admissions were 3.75 times more likely to result in death (adjusted odds ratio 3.75; 95% CI 3.71-3.79) and presence of AKI increased risk of mortality in key subgroups of cirrhosis, such as those with infections and portal hypertension-related complications. CONCLUSIONS The prevalence of AKI is significantly increased among hospitalized cirrhotics. AKI substantially increases the healthcare burden associated with cirrhosis. Despite advances in cirrhosis care, a significant gap remains in outcomes between cirrhotics with and without AKI, suggesting that AKI continues to represent a major clinical challenge. LAY SUMMARY Sudden damage to the kidneys is becoming more common in people who are hospitalized and have cirrhosis. Despite advances in cirrhosis care, those with damage to the kidneys remain at higher risk of dying.
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Renal disease in the allograft recipient. Best Pract Res Clin Gastroenterol 2020; 46-47:101690. [PMID: 33158468 DOI: 10.1016/j.bpg.2020.101690] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 01/31/2023]
Abstract
Chronic renal failure after liver transplantation (LT) is significantly more frequent than after lung or heart transplantation and it results in an increased short and long-term mortality. Renal impairment may occur before LT (functional or due to preexisting parenchymal kidney disease), in the peri-operative period or later after LT. The number of patients with renal failure after LT has increased due to the liver allocation based on MELD and to the more liberal use of higher risk grafts. Calcineurin inhibitor (CNI) nephrotoxicity is the most important cause of renal dysfunction but is a modifiable factor. Strategy to prevent CNI-associated nephrotoxicity is post-op CNI minimization by induction therapy and reduced dose and/or delayed introduction of CNI in combination with mycophenolate mofetil (MMF) or everolimus with no penalty in term of rejection. With everolimus, usually started one month after LT, a drastic minimization of CNI is possible and this results in superior kidney function until at least 3 years follow up. At the moment of renal impairment a drastic reduction of CNI dose together with the introduction of MMF results in an improvement in GFR at 6 to 2 years with a low rate of acute rejection. However, secondary prevention fails to normalize renal function in most of the patients once e GFR <60 ml/min/1.73m2ml.
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Lunsford KE, Agopian VG, Yi SG, Nguyen DTM, Graviss EA, Harlander-Locke MP, Saharia A, Kaldas FM, Mobley CM, Zarrinpar A, Hobeika MJ, Veale JL, Podder H, Farmer DG, Knight RJ, Danovitch GM, Gritsch HA, Li XC, Ghobrial RM, Busuttil RW, Gaber AO. Delayed Implantation of Pumped Kidneys Decreases Renal Allograft Futility in Combined Liver-Kidney Transplantation. Transplantation 2020; 104:1591-1603. [PMID: 32732836 DOI: 10.1097/tp.0000000000003040] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Combined liver-kidney transplantation (CLKT) improves survival for liver transplant recipients with renal dysfunction; however, the tenuous perioperative hemodynamic and metabolic milieu in high-acuity CLKT recipients increases delayed graft function and kidney allograft failure. We sought to analyze whether delayed KT through pumping would improve kidney outcomes following CLKT. METHODS A retrospective analysis (University of California Los Angeles [n = 145], Houston Methodist Hospital [n = 79]) was performed in all adults receiving CLKT at 2 high-volume transplant centers from February 2004 to January 2017, and recipients were analyzed for patient and allograft survival as well as renal outcomes following CLKT. RESULTS A total of 63 patients (28.1%) underwent delayed implantation of pumped kidneys during CLKT (dCLKT) and 161 patients (71.9%) received early implantation of nonpumped kidneys during CLKT (eCLKT). Most recipients were high-acuity with median biologic model of end-stage liver disease (MELD) score of, 35 for dCLKT and 34 for eCLKT (P = ns). Pretransplant, dCLKT had longer intensive care unit stay, were more often intubated, and had greater vasopressor use. Despite this, dCLKT exhibited improved 1-, 3-, and 5-year patient and kidney survival (P = 0.02) and decreased length of stay (P = 0.001), kidney allograft failure (P = 0.012), and dialysis duration (P = 0.031). This reduced kidney allograft futility (death or continued need for hemodialysis within 3 mo posttransplant) for dCLKT (6.3%) compared with eCLKT (19.9%) (P = 0.013). CONCLUSIONS Delayed implantation of pumped kidneys is associated with improved patient and renal allograft survival and decreased hospital length of stay despite longer kidney cold ischemia. These data should inform the ethical debate as to the futility of performing CLKT in high-acuity recipients.
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Affiliation(s)
- Keri E Lunsford
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, J.C. Walter Jr Transplant Center, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX
| | - Vatche G Agopian
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Stephanie G Yi
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, J.C. Walter Jr Transplant Center, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX
| | - Duc T M Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital and Research Institute, Houston, TX
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital and Research Institute, Houston, TX
| | - Michael P Harlander-Locke
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Ashish Saharia
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, J.C. Walter Jr Transplant Center, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX
| | - Fady M Kaldas
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Constance M Mobley
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, J.C. Walter Jr Transplant Center, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX
| | - Ali Zarrinpar
- Division of Transplant and Hepatobiliary Surgery, Department of Surgery, University of Florida, Gainesville, FL
| | - Mark J Hobeika
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, J.C. Walter Jr Transplant Center, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX
| | - Jeffrey L Veale
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Hemangshu Podder
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, J.C. Walter Jr Transplant Center, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX
| | - Douglas G Farmer
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Richard J Knight
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, J.C. Walter Jr Transplant Center, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX
| | - Gabriel M Danovitch
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - H Albin Gritsch
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Xian C Li
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, J.C. Walter Jr Transplant Center, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX
| | - R Mark Ghobrial
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, J.C. Walter Jr Transplant Center, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX
| | - Ronald W Busuttil
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - A Osama Gaber
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, J.C. Walter Jr Transplant Center, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX
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Huang HB, Xu Y, Zhou H, Zhu Y, Qin JP. Intraoperative Continuous Renal Replacement Therapy During Liver Transplantation: A Meta-Analysis. Liver Transpl 2020; 26:1010-1018. [PMID: 32275802 DOI: 10.1002/lt.25773] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/28/2020] [Accepted: 03/29/2020] [Indexed: 01/01/2023]
Abstract
Continuous renal replacement therapy (CRRT) is frequently used to treat recipients with renal failure before or after liver transplantation (LT), though evidence supporting its use during surgery remains unclear. Therefore, we conducted a quantitative meta-analysis to evaluate the effect of intraoperative continuous renal replacement therapy (IORRT) in recipients with pretransplant severe renal dysfunction. We searched PubMed, Embase, and the Cochrane database for trials focusing on LT recipients supported with or without IORRT. Outcomes assessed were mortality, preoperative characteristics, intraoperative data, and predefined postoperative outcomes. Seven trials with 1051 recipients were eligible. Preoperatively, the IORRT group recipients had higher Model for End-Stage Liver Disease scores (weighted mean difference [WMD], 6.19; 95% confidence interval [CI], 2.51-9.87), Charlson scores (WMD, 0.45; 95% CI, 0.09-0.80), acute liver failure (odds ratio [OR], 1.82; 95% CI, 1.27-2.61), serum creatinine (WMD, 71.33 μmol/L; 95% CI, 1.98-140.69 μmol/L), total bilirubin level (WMD, 5.05 μmol/L; 95% CI, 1.75-8.35 μmol/L), intensive care unit admission (OR, 3.53; 95% CI, 1.23-10.13), vasoactive therapy (OR, 3.80; 95% CI, 2.64-5.46), ventilator care (OR, 2.52; 95% CI, 1.18-5.35), and renal replacement therapy (RRT) (OR, 29.37; 95% CI, 7.66-112.54) compared with control patients. IORRT patients also required more intraoperative blood product transfusion and had more post-LT RRT (OR, 25.67; 95% CI, 4.92-133.85). However, there were no significant differences in short-term mortality (OR, 2.12; 95% CI, 0.82-5.44) between the groups. In addition, worse longterm mortality was seen in the IORRT group. In conclusion, IORRT is feasible and safe and may help sicker recipients tolerate the LT procedure to achieve short-term clinical outcomes comparable with less ill patients without IORRT. More high-quality evidence is needed to verify our conclusion in the future.
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Affiliation(s)
- Hui-Bin Huang
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yuan Xu
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Hua Zhou
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yan Zhu
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jun-Ping Qin
- Department of Critical Care Medicine, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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Jiang DD, Roayaie K, Woodland D, Orloff S, Scott D. Survival and renal function after liver transplantation alone in patients meeting the new United Network for Organ Sharing simultaneous liver‐kidney criteria. Clin Transplant 2020; 34:e14020. [DOI: 10.1111/ctr.14020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/12/2020] [Accepted: 06/12/2020] [Indexed: 01/03/2023]
Affiliation(s)
- Da David Jiang
- Division of Abdominal Organ Transplantation Oregon Health & Science University Portland OR USA
| | - Kayvan Roayaie
- Division of Abdominal Organ Transplantation Oregon Health & Science University Portland OR USA
| | - David Woodland
- Division of Abdominal Organ Transplantation Oregon Health & Science University Portland OR USA
| | - Susan Orloff
- Division of Abdominal Organ Transplantation Oregon Health & Science University Portland OR USA
| | - David Scott
- Division of Abdominal Organ Transplantation Oregon Health & Science University Portland OR USA
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Racial/Ethnic Disparities in Access and Outcomes of Simultaneous Liver-Kidney Transplant Among Liver Transplant Candidates With Renal Dysfunction in the United States. Transplantation 2020; 103:1663-1674. [PMID: 30720678 DOI: 10.1097/tp.0000000000002574] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Since the Model for End-stage Liver Disease (MELD) allocation system was implemented, the proportion of simultaneous liver-kidney transplantation (SLKT) has increased significantly. However, whether racial/ethnic disparities exist in access to SLKT and post-SLKT survival remains understudied. METHODS A retrospective cohort of patients aged ≥18 years with renal dysfunction on the liver transplant (LT) waiting list was obtained from Organ Procurement and Transplantation Network. Renal dysfunction was defined as estimated glomerular filtration rate <60 mL/min/1.73 m at listing for LT. Multilevel time-to-competing-events regression adjusting for center effect was used to examine the likelihood of receiving SLKT. Inverse probability of treatment weighted survival analyses were used to analyze posttransplant mortality outcomes. RESULTS For patients with renal dysfunction at listing for LT, not listed for simultaneous kidney transplant, non-Hispanic black (NHB) and Hispanic patients were more likely to receive SLKT than non-Hispanic white (NHW) patients (NHB: multivariable-adjusted hazard ratio [aHR] 2.57; 95% confidence interval [CI], 1.42-4.65; Hispanic: aHR, 2.03; 95% CI, 1.14-3.60). For post-SLKT outcomes, compared to NHW patients, NHB patients had a lower mortality risk before 24 months (aHR, 0.80; 95% CI, 0.65-0.97) but had a higher mortality risk (aHR, 2.00; 95% CI, 1.59-2.55) afterward; in contrast, Hispanic patients had a lower overall mortality risk than NHW patients (aHR, 0.61; 95% CI, 0.51-0.74). CONCLUSIONS In the MELD era, racial/ethnic differences exist in access and survival of SLKT for patients with renal dysfunction at listing for LT. Future studies are warranted to examine whether these differences remain in the post-SLK allocation policy era.
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Allaire M, Walter A, Sutter O, Nahon P, Ganne-Carrié N, Amathieu R, Nault JC. TIPS for management of portal-hypertension-related complications in patients with cirrhosis. Clin Res Hepatol Gastroenterol 2020; 44:249-263. [PMID: 31662286 DOI: 10.1016/j.clinre.2019.09.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 08/25/2019] [Accepted: 09/13/2019] [Indexed: 02/04/2023]
Abstract
Portal hypertension is primarily due to liver cirrhosis, and is responsible for complications that include variceal bleeding, ascites and hepatorenal syndrome. The transjugular intrahepatic portosystemic shunt (TIPS) is a low-resistance channel between the portal vein and the hepatic vein, created by interventional radiology, that aims to reduce portal pressure. TIPS is a potential treatment for severe portal-hypertension-related complications, including esophageal and gastric variceal bleeding. TIPS is currently indicated as salvage therapy in this setting when patients fail to respond to standard endoscopic and medical treatment. More recently, early TIPS has been shown to be effective in decreasing risk of rebleeding after variceal hemorrhage and mortality in Child-Pugh B patients with active hemorrhage at endoscopy, and in Child-Pugh C patients. TIPS is also an efficient treatment for refractory ascites and hepatic hydrothorax. In contrast, the role of TIPS in the hepatorenal syndrome has not been precisely defined. The aim of this review was to specifically describe the current role of TIPS in management of portal hypertension in patients with cirrhosis.
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Affiliation(s)
- Manon Allaire
- Service d'hépato-gastroentérologie, CHU Côte-de-Nacre, Caen, France
| | - Aurélie Walter
- Service d'hépato-gastroentérologie, CHU Côte-de-Nacre, Caen, France
| | - Olivier Sutter
- Service de radiologie, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique Hôpitaux de Paris, Bondy, France
| | - Pierre Nahon
- Service d'hépatologie, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique des Hôpitaux de Paris, 93143 Bondy, France; Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris 13, Laboratoire génomique fonctionnelle des tumeurs solides, 75006 Paris, France; Unité de formation et de recherche santé médecine et biologie humaine, université Paris 13, communauté d'universités et établissements Sorbonne Paris Cité, Paris, France
| | - Nathalie Ganne-Carrié
- Service d'hépatologie, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique des Hôpitaux de Paris, 93143 Bondy, France; Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris 13, Laboratoire génomique fonctionnelle des tumeurs solides, 75006 Paris, France; Unité de formation et de recherche santé médecine et biologie humaine, université Paris 13, communauté d'universités et établissements Sorbonne Paris Cité, Paris, France
| | - Roland Amathieu
- Unité de formation et de recherche santé médecine et biologie humaine, université Paris 13, communauté d'universités et établissements Sorbonne Paris Cité, Paris, France; Réanimation polyvalente, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique des Hôpitaux de Paris, Bondy, France
| | - Jean-Charles Nault
- Service d'hépatologie, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique des Hôpitaux de Paris, 93143 Bondy, France; Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris 13, Laboratoire génomique fonctionnelle des tumeurs solides, 75006 Paris, France; Unité de formation et de recherche santé médecine et biologie humaine, université Paris 13, communauté d'universités et établissements Sorbonne Paris Cité, Paris, France.
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Kościelska M, Matuszkiewicz-Rowińska J, Zieniewicz K, Krawczyk M, Giercuszkiewicz D, Sierdziński J, Żebrowski P, Małyszko J. Intraoperative Dialysis During Liver Transplantation. Transplant Proc 2020; 52:2454-2458. [PMID: 32448654 DOI: 10.1016/j.transproceed.2020.01.129] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/26/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Orthotopic liver transplantation (LT) is a technically complex surgical procedure associated with a major risk of hemodynamic instability and metabolic derangement, especially in patients with coexisting renal dysfunction. Some centers have applied intraoperative renal replacement therapy (ioRRT) to support patients with preoperative renal failure and prevent critical complications. Although there is a strong theoretical rationale for this treatment, there remains a paucity of definite data demonstrating its benefits. METHODS This was a retrospective observational study of all adult patients undergoing intraoperative dialysis in our center from January 2010 till December 2016. RESULTS The study group consisted of 88 patients with a mean MELD score of 31.4. Six patients underwent simultaneous liver and kidney transplantation. Forty-four (50%) recipients were admitted to the intensive care unit before transplantation, and 19 (21.6%) needed mechanical ventilation. Twenty-eight (31.8%) of the procedures were retransplantations, and 40 (45.4%) patients had been undergoing renal replacement therapy before LT. The mean preoperative serum creatinine was 2.82 ± 1.13 mg/dL. The majority of patients (54.5%) was operated on using the veno-venous bypass technique. The mean arterial blood pH and potassium levels after reperfusion were 7.2 ± 0.12 and 4.04 ± 0.95 mmol/L, respectively. Postreperfusion syndrome (PRS) occurred in 11 (13.9%) patients in whom dialysis started at least 15 minutes before reperfusion. Dialysis circuit clotting occurred in 9.1% of cases. There were no other adverse events of ioRRT. CONCLUSION Our data suggests that intraoperative dialysis in severely ill patients with a high MELD score is safe and effective. Lower than expected PRS occurrence needs to be confirmed in a study with a control group.
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Affiliation(s)
- Małgorzata Kościelska
- Department of Nephrology, Dialysis, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland.
| | | | - Krzysztof Zieniewicz
- Department of General, Liver, and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Marek Krawczyk
- Department of General, Liver, and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Dorota Giercuszkiewicz
- Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Janusz Sierdziński
- Department of Medical Informatics and Telemedicine, Medical University of Warsaw, Warsaw, Poland
| | - Paweł Żebrowski
- Department of Nephrology, Dialysis, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
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Wang L, Long Y, Li KX, Xu GS. Pharmacological treatment of hepatorenal syndrome: a network meta-analysis. Gastroenterol Rep (Oxf) 2020; 8:111-118. [PMID: 32280470 PMCID: PMC7136720 DOI: 10.1093/gastro/goz043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 08/06/2019] [Accepted: 08/09/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Observational studies suggest that hepatorenal syndrome (HRS) patients who receive pharmacological therapy before orthotopic liver transplantation display a post-transplant outcome similar to those without HRS. The aim of this study was to comprehensively compare and rank the pharmacological therapies for HRS. METHODS We reviewed PubMed, Elsevier, Medline, and the Cochrane Central Register of Controlled Trials (CENTRAL) for studies that were published between 1 January 1999 and 24 February 2018. The primary endpoint was reversal of HRS. The secondary endpoints were the changes in serum creatinine (Scr) and serum sodium. We evaluated the different therapeutic strategies using network meta-analysis on the basis of Bayesian methodology. RESULTS The study included 24 articles with 1,419 participants evaluating seven different therapeutic strategies for HRS. The most effective treatments to induce reversal of HRS were terlipressin plus albumin, noradrenaline plus albumin, and terlipressin, which had a surface under the cumulative ranking curve (SUCRA) of 0.086, 0.151, and 0.451, respectively. The top two treatments for decreasing Scr were dopamine plus furosemide plus albumin (rank probability: 0.620) and terlipressin plus albumin (rank probability: 0.570). For increasing serum sodium, the optimal treatment was octreotide plus midodrine plus albumin (rank probability: 0.800), followed by terlipressin plus albumin (rank probability: 0.544). CONCLUSIONS Terlipressin plus albumin and dopamine plus furosemide plus albumin should be prioritized for decreasing Scr in HRS, and octreotide plus midodrine plus albumin was the most effective at increasing serum sodium. Terlipressin plus albumin showed a comprehensive effect in both decreasing Scr and increasing serum sodium.
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Affiliation(s)
- Li Wang
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P. R. China
| | - Yin Long
- Grade 2013, the Second Clinical Medical College of Nanchang University, Nanchang, Jiangxi, P. R. China
| | - Ke-Xin Li
- Grade 2015, the Queen Mary College of Nanchang University, Nanchang, Jiangxi, P. R. China
| | - Gao-Si Xu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P. R. China
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