Acute Kidney Injury After Liver Transplantation: Incidence, Risk Factors, and Outcomes

Öz

Introduction: Although numerous risk factors for acute kidney injury (AKI) have been identified, their cumulative impact remains unclear. This study aimed to identify perioperative risk factors for early post-transplant AKI on patients and outcomes and to predict AKI using clinical variables. Material and Methods: A single-center, retrospective cohort study involving 34 pediatric patients and 31 adults who underwent LT between 2015 and 2017. Results: AKI occurred in 16 (47%) pediatric patients during the first-week post-LT with stage 1, stage 2, and stage 3 AKI frequencies of 43.8, 50, and 6.3%, respectively. Renal replacement therapy (RRT) was initiated in 18.8% of pediatric LT patients. Preoperative liver enzymes and the etiology of liver failure are the most critical factors affecting AKI in pediatric LT patients. AKI occurred in 15 (48%) adult patients during the first-week post-LT with stage 1, stage 2, and stage 3 AKI frequencies of 43%, 21%, and 21%, respectively. The requirement for RRT was seen in 43% of adult LT patients. There were also statistical differences between the two groups regarding the number of patients with preoperative kidney dysfunction (20-80%, p=.047) and mortality rates (6-31 %, p=.047). In adult patients who developed post-LT AKI compared with those who did not develop post-LT AKI, they had significantly higher levels of serum creatinine (sCr) (1.9±1.9 mg/dL vs. 0.7±0.1 mg/dL, p=.013), were given lower amounts of crystalloids (73±32 mL/kg vs. 106±33 mL/kg, p=.018) and had lower urine output (UO) intraoperatively (11±9 mL/kg vs. 20±9 mL/kg, p=.047). There was a higher mortality rate in adult patients with post-LT AKI (89 vs. 11%, p=.003). Conclusion: The results of our study contribute to raising awareness of the potential risk factors associated with preoperative evaluation, intraoperative and postoperative close follow-up, careful anesthesia management, and early onset of post-LT AKI.

Anahtar Kelimeler

• Liver transplantation
• acute kidney injury
• perioperative management
• risk factors
• outcomes

Proje Numarası

KA22/228

Karaciğer Nakli Sonrası Akut Böbrek Hasarı: İnsidans, Risk Faktörleri ve Sonuçlar

Öz

Giriş: Akut böbrek hasarı (ABH) için çok sayıda risk faktörü tanımlanmış olmasına rağmen, bunların kümülatif etkileri belirsizliğini koruyor. Bu çalışmanın amacı, karaciğer transplantasyonu (KT) sonrası hastalarda ABH için perioperatif risk faktörlerini belirlemek ve bu faktörlerin sonuçlar üzerindeki erken klinik değişkenleri kullanarak ABH'yı öngörmektir. Gereç ve Yöntemler: 2015 ve 2017 yılları arasında KT uygulanan 34 pediatrik hasta ve 31 yetişkinin yer aldığı tek merkezli, retrospektif bir kohort çalışmadır. Bulgular: 16 (%47) pediatrik hastada KT sonrası ilk haftada ABH meydana geldi ve sırasıyla evre 1, evre 2 ve evre 3 ABH sıklıkları %43.8, %50 ve %6.3 idi. Pediatrik KT hastalarının %18,8'ine renal replasman tedavisi (RRT) başlandı. Pediatrik KT hastalarında preoperatif karaciğer enzimleri ve karaciğer yetmezliği etiyolojisi ABH'yi etkileyen en önemli faktörlerdir. ABH 15 (%48) yetişkin hastada KT sonrası ilk haftada meydana geldi ve sırasıyla %43, %21 ve %21'lik evre 1, evre 2 ve evre 3 AKI oluştu. Erişkin KT hastalarının %43'ünde RRT gereksinimi görüldü. Ameliyat öncesi böbrek fonksiyon bozukluğu olan hasta sayısı (%20-80, p=.047) ve mortalite oranları (%6-31, p=.047) açısından da iki grup arasında istatistiksel fark vardı. KT sonrası ABH gelişen erişkin hastalar, KT sonrası ABH gelişmeyenlerle karşılaştırıldığında, bu hastalarda anlamlı olarak daha yüksek serum kreatinin (sCr) seviyeleri vardı (1,9±1,9 mg/dL'ye karşı 0,7±0,1 mg /dL, p=.013), daha düşük miktarlarda kristalloid verilmişti (73±32 mL/kg- 106±33 mL/kg, p=.018) ve intraoperatif olarak daha düşük idrar çıkışları (UO) (11±9 mL/ kg'a karşı 20±9 mL/kg, p=.047) olduğu tespit edildi. KT sonrası ABH olan yetişkin hastalarda daha yüksek bir mortalite oranı vardı (%89'a karşı %11, p=.003). Sonuç: Çalışmamızın sonuçları, preoperatif değerlendirme, intraoperatif ve postoperatif yakın takip, dikkatli anestezi yönetimi sağlanmasının önemini vurgulamak ve KT sonrası ABH'nin erken başlaması ile ilişkili potansiyel risk faktörleri konusunda farkındalığın artmasına katkıda bulunmaktadır.

Anahtar Kelimeler

• Karaciğer transplantasyonu
• akut böbrek hasarı
• perioperatif yönetim
• risk faktörleri
• sonuçlar

Destekleyen Kurum

Yok

Proje Numarası

KA22/228

Teşekkür

Değerlendirme için dergi editör ekibine teşekkür ediyoruz.

Kaynakça

1. 1. Arani RH, Abbasi MR, Mansournia MA, et al. Acute Kidney Injury After Liver Transplant: In-cidence, Risk Factors, and Impact on Patient Out¬comes. Exp Clin Transplant. 2021 19(12):1277-85. https://doi.org/10.6002/ect.2021.0300
2. 2. Barri YM, Sanchez EQ, Jennings LW, et al. (2009) Acute kidney injury following liver trans-plantation: definition and outcome. Liver Transpl. 15(5):475-83. https://doi.org/10.1002/lt.21682
3. 3. Bilbao I, Charco R, Balsells J, et al. Risk factors for acute renal failure requiring dialysis after liver transplantation. Clin Transplant. 1998: 12(2):123-9.
4. 4. Caragata R, Wyssusek KH, Kruger P. Acute kid-ney injury following liver transplantation: A sys-tematic review of published predictive models. Anaesth Intensive Care. 2016 :44(2);251–61. https://doi.org/10.1177/0310057X1604400212
5. 5. Cuenca AG, Kim HB, Vakili K. Pediatric liver transplantation. Semin Pediatr Surg. 2017:26(4):217-23. https://doi.org/10.1053/j.semped-surg.2017.07.014
6. 6. Durand F, Graupera I, Gines P, et al. Pathogene-sis of Hepatorenal Syndrome: Implications for Therapy. Am J Kidney Dis. 2016;67(2):318-28. https://doi.org/10.1053/j.ajkd.2015.09.013
7. 7. Feldcamp T, Bienholz A, Paul A, et al. Renal damage after liver transplantation. Biosci Rep. 2020;40(1):BSR20191187. https://doi.org/10.1042/BSR20191187
8. 8. Haan JE, Hoorn EJ, Geus HRH. Acute kidney in¬jury after liver transplantation: recent insights and future perspectives. Best Pract Res Clin Gas¬troenterol. 2017;31(2):161-9. https://doi.org/10.1016/j.bpg.2017.03.004

9. 9. Hamada M, Matsukawa S, Shimizu S, et al Acute kidney injury after pediatric liver transplantation: incidence, risk factors, and association with out¬come. J Anesth. 2017:31(5),758-63. https://doi.org/10.1007/s00540-017-2395-2
10. 10. Hilmi IA, Damian D, Al-Khafaji A, et al. Acute kidney injury following orthotopic liver trans-plantation: incidence, risk factors, and effects on patient and graft outcomes. Br J Anesth. 2015:114(6):919-26. https://doi.org/10.1093/bja/aeu556
11. 11. Hoste EAJ, Kellum JA, Selby NM, Zarbock A, Palevsky PM, Bagshaw SM, et al. (2018) Global epidemiology and outcomes of acute kidney in-jury. Nat Rev Nephrol. 14(10):607-25. https://doi.org/10.1038/s41581-018-0052-0
12. 12. Kalisvaart M, Schlegel A, Umbro I, et al. The AKI Prediction Score: a new prediction model for acute kidney injury after liver transplantation. HPB(Oxford). 2019;21(12):1707-17. https://doi.org/10.1016/j.hpb.2019.04.008
13. 13. Karapanagiotou A, Kydona C, Dimitriadis C, et al. Acute kidney injury after orthotopic liver transplantation. Transplant. Proc. 2012; 44(9):2727-9. https://doi.org/j.transproceed.2012.09.096
14. 14. Larsson JS, Bragadottir G, Redfors B, et al. Re-nal function and oxygenation are impaired early after liver transplantation despite hyperdynamic systemic circulation. Crit Care. 2017;21(1):87. https://doi.org/10.1186/s13054-017-1675-4
15. 15. Mehta RL, Burdmann EA, Cerd J, et al. Recog-nition and management of acute kidney injury in the International Society of Nephrology oby25 Global Snapshot: A multinational cross-sectional study. Lancet. 2016;387(10032):2017–25. https://doi.org/10.1016/S0140-6736(16)30240-9
16. 16. Mizota T, Hamada M, Matsukawa S, et al. Rela¬tionship Between Intraoperative Hypotension and Acute Kidney Injury After Living Donor Liver Transplantation: A Retrospective Analysis. J Cardiothorac Vasc Anesth. 2017;31(2):582-9. https://doi.org/10.1053/j.jvca.2016.12.002
17. 17. Mrzljak A, Franusic L, Pavicic-Saric J, et al. Pre- and intraoperative predictors of acute kidney in¬jury after liver Transplantation. World J Clin Cases. 2020;8(18): 4034-42. https://doi.org/10.12998/wjcc.v8.i18.4034
18. 18. Nadim MK, Genyk YS, Tokin C, et al. Impact of the etiology of acute kidney injury on outcomes following liver transplantation: acute tubular ne¬crosis versus hepatorenal syndrome. Liver Transpl. 2012;18(5): 539-48. https://doi.org/10.1002/lt.23384
19. 19. O’Riordan A, Wong V, McQuillan R, et al. Acute renal disease, as defined by the RIFLE cri¬teria, post-liver transplantation. Am J Transplant. 2007;7(1):168-76. https://doi.org/10.1111/j.1600-6143.2006.01602.x
20. 20. Redfors B, Bragadottir G, Sellgren J, et al. Ef-fects of norepinephrine on renal perfusion, filtra¬tion and oxygenation in vasodilatory shock and acute kidney injury. Intensive Care Med. 201137(1);60-7. https://doi.org/s00134-010-2057-4
21. 21. Romano TG, Schmidtbauer I, Silva FMQ, et al. Role of MELD score and serum creatinine as prognostic tools for the development of acute kidney injury after liver transplantation. PLoS One. 2013;8(5):e64089. https://doi.org/10.1371/journal.pone.0064089
22. 22. Rueggeberg A, Boehm S, Napieralski F, et al. Development of a risk stratification model for predicting acute renal failure in orthotopic liver transplantation recipients. Anesthesia. 2008;63(11):1174-80. https://doi.org/10.1111/j.1365-2044.2008.05604.x
23. 23. Saner FH, Cicinnati VR, Sotiropoulos G, et al. Strategies to prevent or reduce acute and chronic kidney injury in liver transplantation. Liver Int. 2011;32(2): 179-88. https://doi.org/10.1111/j.1478-3231.2011.02563.x
24. 24. Silver LJ, Pan S, Bucuvalas JC, et al. Acute Kid-ney Injury Following Pediatric Liver Transplant. J Intensive Care Med. 2022;37(1):107-13. https://doi.org/10.1177/0885066620978729
25. 25. Rahman S, Davidson BR, Mallett SV. Early acute kidney injury after liver transplantation: Predisposing factors and clinical implica-tions. World J Hepatol. 2017;9(18):823-32. https://doi.org/10.4254/wjh.v9.i18.823
26. 26. Thongprayoon C, Kaewput W, Thamcharoen N, et al. Incidence and Impact of Acute Kidney In¬jury after Liver Transplantation: A Meta-Analy¬sis. J Clin Med. 2019;178(3):372. https://doi.org/10.3390/jcm8030372
27. 27. Wang Y, Li Q, Ma T, et al. Transfusion of older red blood cells increases the risk of acute kidney injury after orthotopic liver transplantation: a propensity score analysis. Anesth Analg. 2018;127(1):202-9 https://doi.org/10.1213/ANE.0000000000002437
28. 28. Wiesen P, Massion PB, Joris J, et al. Incidence and risk factors for early renal dysfunction after liver transplantation. World J Transplant. 2016;6(1):220-32. https://doi.org/10.5500/wjt.v6.i1.220
29. 29. Zongyi Y, Baifeng L, Funian Z, et al. Risk factors of acute kidney injury after orthotopic liver trans¬plantation in China. Sci Rep. 2017;7:41555. https://doi.org/10.1038/srep41555