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Intraoperative Continuous Veno-Venous Hemofiltration Facilitates Surgery in Liver Transplant Patients With Acute Renal Failure
Intraoperative Continuous Veno-Venous Hemofiltration Facilitates Surgery in Liver Transplant Patients With Acute Renal Failure J.C. LaMattinaa,*, P.J. Kellya, S.I. Hanisha, S.E. Ottmanna, J.M. Powella, W.R. Hutsonb, V. Sivaramanc, O. Udekwuc, and R.N. Bartha a Division of Transplantation, bDepartment of Medicine, and cDepartment of Anesthesia, University of Maryland School of Medicine, Baltimore, Maryland, USA
ABSTRACT Introduction. We have aggressively used continuous veno-venous hemofiltration (CVVH) on high model for end-stage liver disease (MELD) score liver transplant patients with acute kidney injury and hypothesized that the addition of intraoperative CVVH therapy would improve overall outcomes. Methods. We performed a retrospective review of all adult, single organ, liver transplant recipients requiring preoperative renal replacement therapy between January 1, 2011 and June 1, 2013. Intraoperative and perioperative records and laboratory values were collected and used to create a database of these patients. Patients were grouped according to whether or not they underwent CVVH at the time of liver transplantation. Results. Twenty-one patients with new-onset renal failure requiring preoperative renal replacement therapy received a liver transplant alone. Fourteen received intraoperative CVVH and 7 patients did not. The average MELD score was similar between groups (34 for intraoperative CVVH vs 35; P ¼ .8). Preoperative sodium and potassium were higher for the group receiving intraoperative CVVH, but still fell within normal ranges. Preoperative lactate levels were higher in the group that received intraoperative CVVH (4.7 vs 2.0 mmol/L; P ¼ .01). Intraoperative CVVH did not decrease intraoperative transfusion requirements or intensive care unit (ICU) and hospital lengths of stay. Differences in reoperative rates did not reach statistical significance. All patients were weaned off renal replacement therapy. One-year patient survival rate was 86% for intraoperative CVVH versus 71% without. Conclusion. The judicious use of intraoperative CVVH therapy may permit patients with increasing severity of illness to achieve outcomes comparable with less ill patients.
P
ATIENTS with end-stage liver disease and concomitant acute kidney injury are challenging to manage during liver transplantation secondary to significant fluid shifts and electrolyte imbalances. While the increased prevalence of chronic kidney disease and acute kidney injury in patients undergoing liver transplantation in the model for end-stage liver disease (MELD) era is widely reported [1,2], it is likely that the number of liver transplant recipients with acute kidney injury will increase with the introduction of Share 35. Although the intraoperative management of these patients continues to evolve in its complexity, intraoperative strategies remain diverse. We began to aggressively use
intraoperative continuous veno-venous hemofiltration (CVVH) during the study period on high MELD score liver transplant recipients with acute kidney injury and hypothesized that the addition of intraoperative CVVH therapy would facilitate transplantation by assisting in volume, temperature, and electrolyte management, easing the hemodynamic stress associated with reperfusion [3,4] and *Address correspondence to John C. LaMattina, MD, Division of Transplantation, University of Maryland School of Medicine, 29 South Greene Street, Suite 200, Baltimore, MD 21201, USA. E-mail: [email protected]
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.05.005
Transplantation Proceedings, 47, 1901e1904 (2015)
1901
1902
LAMATTINA, KELLY, HANISH ET AL Table 1. Recipient Demographics No Intraoperative Intraoperative CVVH (n ¼ 7) CVVH (n ¼ 14)
Age (y) Male gender (n, %) Ventilator (n, %) Vasopressive agents (n, %) Physiological MELD Total bilirubin INR Platelets Lactate Sodium Potassium Bicarbonate Hemoglobin Indication for transplantation (n) Alcoholic liver disease Fulminant Hepatitis B Hepatitis C NASH/cryptogenic Primary biliary cirrhosis Primary sclerosing cholangitis
52 6 (85) 4 (57) 1 (14) 35 19 14 2.7 1.2 70 46 2.0 0.93 134 2.4 3.6 0.48 26 4.2 9.0 0.92
53 10 (71) 11 (79) 5 (36) 34 16 17 2.5 1.0 70 46 4.7 3.3 141 6.6 4.2 0.64 21 5.5 9.3 1.6
1 0 0 3 2 0 1
1 2 1 6 2 1 1
P
.84 .6 .35 .6 .80 .70 .70 .99 .01 .005 .02 .052 .58
Abbreviations: INR, international normalized ratio; NASH, non-alcoholic steatohepatitis.
decreasing transfusion requirements and complications. The potential ability of CVVH to alleviate elevated intracranial pressures [5] could also be expected to improve outcomes in patients with fulminant failure.
METHODS Between January 1, 2011 and June 1, 2013, our center performed 21 adult, single organ liver transplantations in recipients newly requiring preoperative renal replacement therapy. A retrospective review of these cases was performed after obtaining Institutional Review Board approval. Intraoperative and perioperative records and laboratory values were collected and used to create a database of these patients. Patients were grouped according to whether or not they underwent CVVH at the time of liver transplantation. During the study period, our center began using CVVH in patients with acute kidney injury. In the first year of the study, this was not our standard protocol. The decision to use intraoperative CVVH was made by our multidisciplinary liver transplantation service (liver transplantation surgeons, hepatologists, nephrologists, and intensivists). Typical indications for intraoperative CVVH included new-onset acute kidney injury with oliguria (<500 cc/d urine output, creatinine >3.0 mg/ dL), hyperkalemia, or perceived bleeding risk. CVVH was performed using the Gambro Prismaflex system (Baxter International, Deerfield, Ill, United States) with minimal to no heparin. Dialysis was via a temporary dual-lumen hemodialysis catheter typically placed in the internal jugular vein in the days prior to transplantation. CVVH was initiated in the operating room before commencing surgery. Blood flow rates were adjusted by the attending anesthesiologist, but typically were maintained at 200 cc/min. Dialysate flow rates were adjusted by a specially trained critical care nurse by protocol, but were typically 20 cc/kg/h. Replacement fluid was bicarbonate buffered. A warming circuit was used in all cases. Intraoperative treatment was based on perceived patient need by the attending anesthesiologist and was not standardized.
The primary endpoint of the study was perioperative patient survival. Secondary endpoints included perioperative blood product requirements and rates of reoperation. Statistical analyses were performed using Student t and Fisher exact tests. Data is presented as mean standard deviation.
RESULTS Preoperative Recipient Demographics
Recipient demographics are presented in Table 1. All recipients were initiated on dialysis during this admission and were located in the intensive care unit (ICU) preoperatively. Recipients in both groups had similar ages, MELD scores, platelets, international normalized ratio, and total bilirubin. Recipients who underwent intraoperative CVVH were more likely to be intubated and on pressors (79% vs 57% and 36% vs 14%; P ¼ .35 and .6, respectively). Preoperative lactate, sodium, and potassium were higher in patients who received CVVH intraoperatively, while preoperative bicarbonate was lower. One patient in each group was undergoing a liver retransplantation. Operative Considerations
As shown in Table 2, there was no significant difference in the total operative time, the anhepatic phase time, or the transfusion rate of packed red blood cells (PRBC), fresh frozen plasma (FFP), or platelets between groups. One outlier in the group undergoing intraoperative CVVH received 112 U of PRBC and 110 U of FFP. Censoring this patient from the cohort would have resulted in the mean transfusion rates decreasing to 13 7 U PRBC and 12 7.8 U FFP (P ¼ .40 and .19, respectively). Patient Survival and Perioperative Complications
All patients receiving intraoperative CVVH survived the transplant operation. One patient without CVVH did not survive due to hemodynamic instability following liver reperfusion. As shown in Table 3, 1-year survival rate was 86% and 71% for the group with and without intraoperative CVVH, respectively. No patients underwent retransplantation in either group. Two patients receiving intraoperative CVVH required multiple washouts, 1 of whom also underwent tracheostomy at the time of the second washout. There were no statistically significant differences in blood product transfusion in the first 24 hours postoperatively, ICU length of stay, or postoperative hospitalization. Nonetheless, in the case of patients undergoing
Table 2. Intraoperative Parameters No Intraoperative CVVH (n ¼ 7)
Total operative time (min) Anhepatic time (min) PRBC transfusion (U) FFP transfusion (U) Platelet transfusion (U)
323 77 15 17 8.1
73 36 7.4 7.9 11
Intraoperative CVVH (n ¼ 14)
316 82 20 19 16
75 23 27 27 14
Abbreviations: PRBC, packed red blood cells; FFP, fresh frozen plasma.
P
.82 .80 .57 .72 .19
INTRAOPERATIVE CONTINUOUS VENO-VENOUS HEMOFILTRATION Table 3. Survival and Perioperative Parameters No Intraoperative CVVH (n ¼ 7)
Perioperative survival (n, %) 30-d survival (n, %) 3-mo survival (n, %) 1-y survival (n, %) Return to the OR (30 d) Tracheostomy Exploration/washout Postoperative PRBC transfusion (24 h) Postoperative FFP transfusion (24 h) Postoperative platelet transfusion (24 h) ICU length of stay (d) Postoperative hospital length of stay (d)
6 6 6 5
(86) (86) (86) (71)
Intraoperative CVVH (n ¼ 14)
P
14 (100) 13 (93) 13 (93) 12 (86)
.3 1 1 .57
1 0 1.6 2.9
1* 3* 2.9 4.1
.40
0.71 1.3
2 3.1
.19
0.43 0.78
0.79 1.2
.42
16 11 29 13
22 17 37 16
.38 .29
Abbreviation: OR, operating room. *Two patients required multiple washouts, 1 of whom also underwent tracheostomy at the time of the second washout. Product transfusion is within the first 24 h postoperatively.
CVVH, blood product transfusion and length of stay were numerically higher. Causes of death are presented in Table 4. Safety
There were no line-related complications associated with CVVH use in the peritransplantation period. DISCUSSION
High MELD score patients with dual-organ failure provide clinical and technical challenges to the transplantation community. It was expected that intraoperative CVVH would ameliorate some of the complications classically associated with liver transplantation in recipients with acute kidney injury. In particular, we hypothesized that improved management of the recipient’s volume status, electrolyte balance, acid-base status, and uremia would lead to an improved overall operative course. This proved difficult to demonstrate in our small cohort. Our patient population had high MELD scores (average MELD, 35) with expected 1-year survival rate of approximately 80% based on published series [6e9]. Our data demonstrated a 1-year survival rate of 86% with CVVH versus 71% without CVVH, although not reaching statistical significance. In our cohort of patients, recipients who Table 4. Cause of Death No Intraoperative CVVH (n ¼ 7)
Intraoperative CVVH (n ¼ 14)
1 1 0 0
0 0 1 1
Intraoperative arrest Fibrosing cholestatic hepatitis C HAT Overwhelming sepsis Abbreviation: HAT, hepatic artery thrombosis.
1903
underwent CVVH at the time of transplantation had statistically significantly higher sodium, potassium, and lactate levels, which can be construed as having a greater degree of end-organ dysfunction. Furthermore, a higher number of patients undergoing intraoperative CVVH were intubated and maintained on pressors prior to the transplantation, although this was not statistically significant given our small sample size. One interpretation would suggest that patients undergoing intraoperative CVVH were “sicker” and that intraoperative CVVH facilitated equivalent outcomes to “less sick” patients who did not receive intraoperative CVVH. The 1 patient who experienced an intraoperative death was not on CVVH. Following the introduction of the MELD system, the transplantation community began to more rapidly accrue experience with CVVH and liver transplant recipients. It is widely held that renal dysfunction at the time of liver transplantation has a critical role in long-term liver transplant patient survival [10,11]. A recent large study from University of California, Los Angeles (UCLA) showed that liver transplantation in patients requiring dialysis had comparable post-transplantation survival with our group (75% at 1 year). It has proven difficult to demonstrate a benefit of intraoperative CVVH in a number of studies [12]. Our study draws conclusions similar to the UCLA report, in that patients undergoing intraoperative CVVH seem to represent a much higher acuity cohort. A number of factors that they identified to develop a practical method to determine which patients would be best suited for intraoperative CVVH (preoperative CVVH, donation after cardiac death (DCD) donor, pretransplantation vasopressors, pretransplantation base deficit, cold ischemic time, and bilirubin) were also notable in our study. The judicious use of intraoperative CVVH therapy may permit patients with increasing severity of illness to achieve outcomes comparable with less ill patients. REFERENCES [1] Agopian VG, Petrowsky H, Kaldas FM, Zarrinpar A, Farmer DG, Yersiz H, et al. The evolution of liver transplantation during 3 decades: analysis of 5347 consecutive liver transplants at a single center. Ann Surg 2013;258(3):409e21. [2] Thuluvath PJ, Guidinger MK, Fung JJ, Johnson LB, Rayhill SC, Pelletier SJ. Liver transplantation in the United States, 1999-2008. Am J Transplant 2010;10(4 Pt 2):1003e19. [3] Sedra AH, Strum E. The role of intraoperative hemodialysis in liver transplant patients. Curr Opin Organ Transplant 2011;16(3):323e5. [4] Xia VW, Ghobrial RM, Du B, Chen T, Hu KQ, Hiatt JR, et al. Predictors of hyperkalemia in the prereperfusion, early postreperfusion, and late postreperfusion periods during adult liver transplantation. Anesth Analg 2007;105(3):780e5. [5] Davenport A, Will EJ, Davidson AM. Improved cardiovascular stability during continuous modes of renal replacement therapy in critically ill patients with acute hepatic and renal failure. Crit Care Med 1993;21(3):328e38. [6] Agopian VG, Dhillon A, Baber J, Kaldas FM, Zarrinpar A, Farmer DG, et al. Liver transplantation in recipients receiving renal replacement therapy: outcomes analysis and the role of intraoperative hemodialysis. Am J Transplant 2014;14(7):1638e47.
1904 [7] Douthitt L, Bezinover D, Uemura T, Kadry Z, Shah RA, Ghahramani N, et al. Perioperative use of continuous renal replacement therapy for orthotopic liver transplantation. Transplant Proc 2012;44(5):1314e7. [8] Townsend DR, Bagshaw SM, Jacka MJ, Bigam D, Cave D, Gibney RT. Intraoperative renal support during liver transplantation. Liver Transpl 2009;15(1):73e8. [9] Gonwa TA, Mai ML, Melton LB, Hays SR, Goldstein RM, Levy MF, et al. Renal replacement therapy and orthotopic liver transplantation: the role of continuous veno-venous hemodialysis. Transplantation 2001;71(10):1424e8.
LAMATTINA, KELLY, HANISH ET AL [10] Nair S, Verma S, Thuluvath PJ. Pretransplant renal function predicts survival in patients undergoing orthotopic liver transplantation. Hepatology 2002;35(5):1179e85. [11] Gonwa TA, McBride MA, Anderson K, Mai ML, Wadei H, Ahsan N. Continued influence of preoperative renal function on outcome of orthotopic liver transplant (OLTX) in the US: where will MELD lead us? Am J Transplant 2006;6(11):2651e9. [12] Parmar A, Bigam D, Meeberg G, Cave D, Townsend DR, Gibney RT, et al. An evaluation of intraoperative renal support during liver transplantation: a matched cohort study. Blood Purif 2011;32(3):238e48.
ABSTRACT Introduction. We have aggressively used continuous veno-venous hemofiltration (CVVH) on high model for end-stage liver disease (MELD) score liver transplant patients with acute kidney injury and hypothesized that the addition of intraoperative CVVH therapy would improve overall outcomes. Methods. We performed a retrospective review of all adult, single organ, liver transplant recipients requiring preoperative renal replacement therapy between January 1, 2011 and June 1, 2013. Intraoperative and perioperative records and laboratory values were collected and used to create a database of these patients. Patients were grouped according to whether or not they underwent CVVH at the time of liver transplantation. Results. Twenty-one patients with new-onset renal failure requiring preoperative renal replacement therapy received a liver transplant alone. Fourteen received intraoperative CVVH and 7 patients did not. The average MELD score was similar between groups (34 for intraoperative CVVH vs 35; P ¼ .8). Preoperative sodium and potassium were higher for the group receiving intraoperative CVVH, but still fell within normal ranges. Preoperative lactate levels were higher in the group that received intraoperative CVVH (4.7 vs 2.0 mmol/L; P ¼ .01). Intraoperative CVVH did not decrease intraoperative transfusion requirements or intensive care unit (ICU) and hospital lengths of stay. Differences in reoperative rates did not reach statistical significance. All patients were weaned off renal replacement therapy. One-year patient survival rate was 86% for intraoperative CVVH versus 71% without. Conclusion. The judicious use of intraoperative CVVH therapy may permit patients with increasing severity of illness to achieve outcomes comparable with less ill patients.
P
ATIENTS with end-stage liver disease and concomitant acute kidney injury are challenging to manage during liver transplantation secondary to significant fluid shifts and electrolyte imbalances. While the increased prevalence of chronic kidney disease and acute kidney injury in patients undergoing liver transplantation in the model for end-stage liver disease (MELD) era is widely reported [1,2], it is likely that the number of liver transplant recipients with acute kidney injury will increase with the introduction of Share 35. Although the intraoperative management of these patients continues to evolve in its complexity, intraoperative strategies remain diverse. We began to aggressively use
intraoperative continuous veno-venous hemofiltration (CVVH) during the study period on high MELD score liver transplant recipients with acute kidney injury and hypothesized that the addition of intraoperative CVVH therapy would facilitate transplantation by assisting in volume, temperature, and electrolyte management, easing the hemodynamic stress associated with reperfusion [3,4] and *Address correspondence to John C. LaMattina, MD, Division of Transplantation, University of Maryland School of Medicine, 29 South Greene Street, Suite 200, Baltimore, MD 21201, USA. E-mail: [email protected]
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.05.005
Transplantation Proceedings, 47, 1901e1904 (2015)
1901
1902
LAMATTINA, KELLY, HANISH ET AL Table 1. Recipient Demographics No Intraoperative Intraoperative CVVH (n ¼ 7) CVVH (n ¼ 14)
Age (y) Male gender (n, %) Ventilator (n, %) Vasopressive agents (n, %) Physiological MELD Total bilirubin INR Platelets Lactate Sodium Potassium Bicarbonate Hemoglobin Indication for transplantation (n) Alcoholic liver disease Fulminant Hepatitis B Hepatitis C NASH/cryptogenic Primary biliary cirrhosis Primary sclerosing cholangitis
52 6 (85) 4 (57) 1 (14) 35 19 14 2.7 1.2 70 46 2.0 0.93 134 2.4 3.6 0.48 26 4.2 9.0 0.92
53 10 (71) 11 (79) 5 (36) 34 16 17 2.5 1.0 70 46 4.7 3.3 141 6.6 4.2 0.64 21 5.5 9.3 1.6
1 0 0 3 2 0 1
1 2 1 6 2 1 1
P
.84 .6 .35 .6 .80 .70 .70 .99 .01 .005 .02 .052 .58
Abbreviations: INR, international normalized ratio; NASH, non-alcoholic steatohepatitis.
decreasing transfusion requirements and complications. The potential ability of CVVH to alleviate elevated intracranial pressures [5] could also be expected to improve outcomes in patients with fulminant failure.
METHODS Between January 1, 2011 and June 1, 2013, our center performed 21 adult, single organ liver transplantations in recipients newly requiring preoperative renal replacement therapy. A retrospective review of these cases was performed after obtaining Institutional Review Board approval. Intraoperative and perioperative records and laboratory values were collected and used to create a database of these patients. Patients were grouped according to whether or not they underwent CVVH at the time of liver transplantation. During the study period, our center began using CVVH in patients with acute kidney injury. In the first year of the study, this was not our standard protocol. The decision to use intraoperative CVVH was made by our multidisciplinary liver transplantation service (liver transplantation surgeons, hepatologists, nephrologists, and intensivists). Typical indications for intraoperative CVVH included new-onset acute kidney injury with oliguria (<500 cc/d urine output, creatinine >3.0 mg/ dL), hyperkalemia, or perceived bleeding risk. CVVH was performed using the Gambro Prismaflex system (Baxter International, Deerfield, Ill, United States) with minimal to no heparin. Dialysis was via a temporary dual-lumen hemodialysis catheter typically placed in the internal jugular vein in the days prior to transplantation. CVVH was initiated in the operating room before commencing surgery. Blood flow rates were adjusted by the attending anesthesiologist, but typically were maintained at 200 cc/min. Dialysate flow rates were adjusted by a specially trained critical care nurse by protocol, but were typically 20 cc/kg/h. Replacement fluid was bicarbonate buffered. A warming circuit was used in all cases. Intraoperative treatment was based on perceived patient need by the attending anesthesiologist and was not standardized.
The primary endpoint of the study was perioperative patient survival. Secondary endpoints included perioperative blood product requirements and rates of reoperation. Statistical analyses were performed using Student t and Fisher exact tests. Data is presented as mean standard deviation.
RESULTS Preoperative Recipient Demographics
Recipient demographics are presented in Table 1. All recipients were initiated on dialysis during this admission and were located in the intensive care unit (ICU) preoperatively. Recipients in both groups had similar ages, MELD scores, platelets, international normalized ratio, and total bilirubin. Recipients who underwent intraoperative CVVH were more likely to be intubated and on pressors (79% vs 57% and 36% vs 14%; P ¼ .35 and .6, respectively). Preoperative lactate, sodium, and potassium were higher in patients who received CVVH intraoperatively, while preoperative bicarbonate was lower. One patient in each group was undergoing a liver retransplantation. Operative Considerations
As shown in Table 2, there was no significant difference in the total operative time, the anhepatic phase time, or the transfusion rate of packed red blood cells (PRBC), fresh frozen plasma (FFP), or platelets between groups. One outlier in the group undergoing intraoperative CVVH received 112 U of PRBC and 110 U of FFP. Censoring this patient from the cohort would have resulted in the mean transfusion rates decreasing to 13 7 U PRBC and 12 7.8 U FFP (P ¼ .40 and .19, respectively). Patient Survival and Perioperative Complications
All patients receiving intraoperative CVVH survived the transplant operation. One patient without CVVH did not survive due to hemodynamic instability following liver reperfusion. As shown in Table 3, 1-year survival rate was 86% and 71% for the group with and without intraoperative CVVH, respectively. No patients underwent retransplantation in either group. Two patients receiving intraoperative CVVH required multiple washouts, 1 of whom also underwent tracheostomy at the time of the second washout. There were no statistically significant differences in blood product transfusion in the first 24 hours postoperatively, ICU length of stay, or postoperative hospitalization. Nonetheless, in the case of patients undergoing
Table 2. Intraoperative Parameters No Intraoperative CVVH (n ¼ 7)
Total operative time (min) Anhepatic time (min) PRBC transfusion (U) FFP transfusion (U) Platelet transfusion (U)
323 77 15 17 8.1
73 36 7.4 7.9 11
Intraoperative CVVH (n ¼ 14)
316 82 20 19 16
75 23 27 27 14
Abbreviations: PRBC, packed red blood cells; FFP, fresh frozen plasma.
P
.82 .80 .57 .72 .19
INTRAOPERATIVE CONTINUOUS VENO-VENOUS HEMOFILTRATION Table 3. Survival and Perioperative Parameters No Intraoperative CVVH (n ¼ 7)
Perioperative survival (n, %) 30-d survival (n, %) 3-mo survival (n, %) 1-y survival (n, %) Return to the OR (30 d) Tracheostomy Exploration/washout Postoperative PRBC transfusion (24 h) Postoperative FFP transfusion (24 h) Postoperative platelet transfusion (24 h) ICU length of stay (d) Postoperative hospital length of stay (d)
6 6 6 5
(86) (86) (86) (71)
Intraoperative CVVH (n ¼ 14)
P
14 (100) 13 (93) 13 (93) 12 (86)
.3 1 1 .57
1 0 1.6 2.9
1* 3* 2.9 4.1
.40
0.71 1.3
2 3.1
.19
0.43 0.78
0.79 1.2
.42
16 11 29 13
22 17 37 16
.38 .29
Abbreviation: OR, operating room. *Two patients required multiple washouts, 1 of whom also underwent tracheostomy at the time of the second washout. Product transfusion is within the first 24 h postoperatively.
CVVH, blood product transfusion and length of stay were numerically higher. Causes of death are presented in Table 4. Safety
There were no line-related complications associated with CVVH use in the peritransplantation period. DISCUSSION
High MELD score patients with dual-organ failure provide clinical and technical challenges to the transplantation community. It was expected that intraoperative CVVH would ameliorate some of the complications classically associated with liver transplantation in recipients with acute kidney injury. In particular, we hypothesized that improved management of the recipient’s volume status, electrolyte balance, acid-base status, and uremia would lead to an improved overall operative course. This proved difficult to demonstrate in our small cohort. Our patient population had high MELD scores (average MELD, 35) with expected 1-year survival rate of approximately 80% based on published series [6e9]. Our data demonstrated a 1-year survival rate of 86% with CVVH versus 71% without CVVH, although not reaching statistical significance. In our cohort of patients, recipients who Table 4. Cause of Death No Intraoperative CVVH (n ¼ 7)
Intraoperative CVVH (n ¼ 14)
1 1 0 0
0 0 1 1
Intraoperative arrest Fibrosing cholestatic hepatitis C HAT Overwhelming sepsis Abbreviation: HAT, hepatic artery thrombosis.
1903
underwent CVVH at the time of transplantation had statistically significantly higher sodium, potassium, and lactate levels, which can be construed as having a greater degree of end-organ dysfunction. Furthermore, a higher number of patients undergoing intraoperative CVVH were intubated and maintained on pressors prior to the transplantation, although this was not statistically significant given our small sample size. One interpretation would suggest that patients undergoing intraoperative CVVH were “sicker” and that intraoperative CVVH facilitated equivalent outcomes to “less sick” patients who did not receive intraoperative CVVH. The 1 patient who experienced an intraoperative death was not on CVVH. Following the introduction of the MELD system, the transplantation community began to more rapidly accrue experience with CVVH and liver transplant recipients. It is widely held that renal dysfunction at the time of liver transplantation has a critical role in long-term liver transplant patient survival [10,11]. A recent large study from University of California, Los Angeles (UCLA) showed that liver transplantation in patients requiring dialysis had comparable post-transplantation survival with our group (75% at 1 year). It has proven difficult to demonstrate a benefit of intraoperative CVVH in a number of studies [12]. Our study draws conclusions similar to the UCLA report, in that patients undergoing intraoperative CVVH seem to represent a much higher acuity cohort. A number of factors that they identified to develop a practical method to determine which patients would be best suited for intraoperative CVVH (preoperative CVVH, donation after cardiac death (DCD) donor, pretransplantation vasopressors, pretransplantation base deficit, cold ischemic time, and bilirubin) were also notable in our study. The judicious use of intraoperative CVVH therapy may permit patients with increasing severity of illness to achieve outcomes comparable with less ill patients. REFERENCES [1] Agopian VG, Petrowsky H, Kaldas FM, Zarrinpar A, Farmer DG, Yersiz H, et al. The evolution of liver transplantation during 3 decades: analysis of 5347 consecutive liver transplants at a single center. Ann Surg 2013;258(3):409e21. [2] Thuluvath PJ, Guidinger MK, Fung JJ, Johnson LB, Rayhill SC, Pelletier SJ. Liver transplantation in the United States, 1999-2008. Am J Transplant 2010;10(4 Pt 2):1003e19. [3] Sedra AH, Strum E. The role of intraoperative hemodialysis in liver transplant patients. Curr Opin Organ Transplant 2011;16(3):323e5. [4] Xia VW, Ghobrial RM, Du B, Chen T, Hu KQ, Hiatt JR, et al. Predictors of hyperkalemia in the prereperfusion, early postreperfusion, and late postreperfusion periods during adult liver transplantation. Anesth Analg 2007;105(3):780e5. [5] Davenport A, Will EJ, Davidson AM. Improved cardiovascular stability during continuous modes of renal replacement therapy in critically ill patients with acute hepatic and renal failure. Crit Care Med 1993;21(3):328e38. [6] Agopian VG, Dhillon A, Baber J, Kaldas FM, Zarrinpar A, Farmer DG, et al. Liver transplantation in recipients receiving renal replacement therapy: outcomes analysis and the role of intraoperative hemodialysis. Am J Transplant 2014;14(7):1638e47.
1904 [7] Douthitt L, Bezinover D, Uemura T, Kadry Z, Shah RA, Ghahramani N, et al. Perioperative use of continuous renal replacement therapy for orthotopic liver transplantation. Transplant Proc 2012;44(5):1314e7. [8] Townsend DR, Bagshaw SM, Jacka MJ, Bigam D, Cave D, Gibney RT. Intraoperative renal support during liver transplantation. Liver Transpl 2009;15(1):73e8. [9] Gonwa TA, Mai ML, Melton LB, Hays SR, Goldstein RM, Levy MF, et al. Renal replacement therapy and orthotopic liver transplantation: the role of continuous veno-venous hemodialysis. Transplantation 2001;71(10):1424e8.
LAMATTINA, KELLY, HANISH ET AL [10] Nair S, Verma S, Thuluvath PJ. Pretransplant renal function predicts survival in patients undergoing orthotopic liver transplantation. Hepatology 2002;35(5):1179e85. [11] Gonwa TA, McBride MA, Anderson K, Mai ML, Wadei H, Ahsan N. Continued influence of preoperative renal function on outcome of orthotopic liver transplant (OLTX) in the US: where will MELD lead us? Am J Transplant 2006;6(11):2651e9. [12] Parmar A, Bigam D, Meeberg G, Cave D, Townsend DR, Gibney RT, et al. An evaluation of intraoperative renal support during liver transplantation: a matched cohort study. Blood Purif 2011;32(3):238e48.