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Influence of surgical technique on diuresis during liver transplantation
Influence of Surgical Technique on Diuresis During Liver Transplantation F. Acosta, M.A. Rodriguez, T. Sansano, C.G. Palenciano, M. Reche, V. Roques, R. Beltran, R. Robles, F.S. Bueno, P. Ramirez, and P. Parrilla
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IRRHOTIC patients may have varying degrees of renal dysfunction, including hepatorenal syndrome, and many of them need diuretic therapy.1 During orthotopic liver transplantation (OLT) the marked changes in volemia and the clamping of the inferior vena cava may aggravate oliguria. Our aim was to see whether diuresis varied during OLT depending on the surgical technique chosen.
Table 1. Diuresis During OLT Phases
Preanhepatic Anhepatic Neohepatic
BP Group
NBP Group
PGB Group
3.0 ⫾ 1.0 2.6 ⫾ 1.3 5.5 ⫾ 1.3**#
3.4 ⫾ 3.7 2.0 ⫾ 1.7** 5.8 ⫾ 3.7
2.8 ⫾ 1.3 4.7 ⫾ 1.7*a 8.0 ⫾ 4.9***##
Values (mL/kg/h) are mean ⫾ SD. *P ⬍ .05; **P ⬍ .01; and ***P ⬍ .001 vs preanhepatic. # P ⬍ .05; ##P ⬍ .01; and P ⬍ .001 vs anhepatic. a P ⬍ .05 vs BP and NBP groups.
PATIENTS AND METHODS We studied 71 cirrhotic patients undergoing OLT. The patients were divided into three groups: patients receiving the standard surgical technique with venovenous bypass (VVBP) (BP group, n ⫽ 8), patients with the same technique but without VVBP (NBP group, n ⫽ 43), and patients receiving the technique for preserving the inferior vena cava (IVC), or piggy-back technique (PGB group, n ⫽ 20). From the start of the operation we established a diuretic therapy consisting of infusion of mannitol (0.25 g/kg). When diuresis was ⬍1 mL/kg we added a bolus of furosemide (1 mg/kg) followed by infusion (0.25 to 1 mg/kg/h). Hourly diuresis was measured at each of the OLT phases.
patients without VVBP. However, although VVBP is useful in reducing renal impairment during the anhepatic phase, no clear advantage in kidney function could be demonstrated with the routine use of VVBP.3 As for diuretic treatment, we did not need to use furosemide in the PGB group, although we obtained diuresis similar to other authors who indicate it routinely.4,5 We conclude that as well as diuretic therapy the IVC preservation technique seems fundamental for achieving a steady increase in diuresis during OLT.
Statistics ANOVA and chi-square tests were used. Significance was set at P ⬍ .05.
REFERENCES 1. Laffi G, La Villa G, Gentilini P: Semin Liver Dis 14:71, 1994 2. Veroli P, el Hage C, Ecoffey C: Anesth Analg 75:489, 1992
RESULTS
We found no differences between groups for Child-Pugh grade. It is worth noting that four patients in the BP group (50%) and 23 patients in the NBP Group (53%) needed furosemide at some stage of the procedure, whereas it was not administered to any of the PGB group patients. Diuresis only decreased during the anhepatic phase in the NBP group and is significantly greater in the PGB group. Finally, diuresis increased in the neohepatic phase in all three groups (Table 1). DISCUSSION 2
Like Veroli et al., we see that despite the use of furosemide, diuresis decreases during the anhepatic phase in
© 2000 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 32, 2657 (2000)
3. Grande L, Rimola A, Cugat E, et al: Hepatology 23:1418, 1996 4. Fleitas M, Casanova D, Martino E, et al: Arch Surg 129:842, 1994 5. Cherqui D, Lauzet JY, Rotman N, et al: Transplantation 58:793, 1994
From the Liver Transplant Unit, University Hospital “V.Arrixaca,” Murcia, Spain. Address reprint requests to Dr Francisco Acosta, San Cristo´bal, 4 (3B), 30001-Murcia, Spain.
0041-1345/00/$–see front matter PII S0041-1345(00)01827-3 2657
C
IRRHOTIC patients may have varying degrees of renal dysfunction, including hepatorenal syndrome, and many of them need diuretic therapy.1 During orthotopic liver transplantation (OLT) the marked changes in volemia and the clamping of the inferior vena cava may aggravate oliguria. Our aim was to see whether diuresis varied during OLT depending on the surgical technique chosen.
Table 1. Diuresis During OLT Phases
Preanhepatic Anhepatic Neohepatic
BP Group
NBP Group
PGB Group
3.0 ⫾ 1.0 2.6 ⫾ 1.3 5.5 ⫾ 1.3**#
3.4 ⫾ 3.7 2.0 ⫾ 1.7** 5.8 ⫾ 3.7
2.8 ⫾ 1.3 4.7 ⫾ 1.7*a 8.0 ⫾ 4.9***##
Values (mL/kg/h) are mean ⫾ SD. *P ⬍ .05; **P ⬍ .01; and ***P ⬍ .001 vs preanhepatic. # P ⬍ .05; ##P ⬍ .01; and P ⬍ .001 vs anhepatic. a P ⬍ .05 vs BP and NBP groups.
PATIENTS AND METHODS We studied 71 cirrhotic patients undergoing OLT. The patients were divided into three groups: patients receiving the standard surgical technique with venovenous bypass (VVBP) (BP group, n ⫽ 8), patients with the same technique but without VVBP (NBP group, n ⫽ 43), and patients receiving the technique for preserving the inferior vena cava (IVC), or piggy-back technique (PGB group, n ⫽ 20). From the start of the operation we established a diuretic therapy consisting of infusion of mannitol (0.25 g/kg). When diuresis was ⬍1 mL/kg we added a bolus of furosemide (1 mg/kg) followed by infusion (0.25 to 1 mg/kg/h). Hourly diuresis was measured at each of the OLT phases.
patients without VVBP. However, although VVBP is useful in reducing renal impairment during the anhepatic phase, no clear advantage in kidney function could be demonstrated with the routine use of VVBP.3 As for diuretic treatment, we did not need to use furosemide in the PGB group, although we obtained diuresis similar to other authors who indicate it routinely.4,5 We conclude that as well as diuretic therapy the IVC preservation technique seems fundamental for achieving a steady increase in diuresis during OLT.
Statistics ANOVA and chi-square tests were used. Significance was set at P ⬍ .05.
REFERENCES 1. Laffi G, La Villa G, Gentilini P: Semin Liver Dis 14:71, 1994 2. Veroli P, el Hage C, Ecoffey C: Anesth Analg 75:489, 1992
RESULTS
We found no differences between groups for Child-Pugh grade. It is worth noting that four patients in the BP group (50%) and 23 patients in the NBP Group (53%) needed furosemide at some stage of the procedure, whereas it was not administered to any of the PGB group patients. Diuresis only decreased during the anhepatic phase in the NBP group and is significantly greater in the PGB group. Finally, diuresis increased in the neohepatic phase in all three groups (Table 1). DISCUSSION 2
Like Veroli et al., we see that despite the use of furosemide, diuresis decreases during the anhepatic phase in
© 2000 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010 Transplantation Proceedings, 32, 2657 (2000)
3. Grande L, Rimola A, Cugat E, et al: Hepatology 23:1418, 1996 4. Fleitas M, Casanova D, Martino E, et al: Arch Surg 129:842, 1994 5. Cherqui D, Lauzet JY, Rotman N, et al: Transplantation 58:793, 1994
From the Liver Transplant Unit, University Hospital “V.Arrixaca,” Murcia, Spain. Address reprint requests to Dr Francisco Acosta, San Cristo´bal, 4 (3B), 30001-Murcia, Spain.
0041-1345/00/$–see front matter PII S0041-1345(00)01827-3 2657