Preoperative high-sensitivity troponin I and B-type natriuretic peptide, alone and in combination, for risk stratification of mortality after liver transplantation / 대한마취과학회지

Background@#Given the severe shortage of donor liver grafts, coupled with growing proportion of cardiovascular death after liver transplantation (LT), precise cardiovascular risk assessment is pivotal for selecting recipients who gain the greatest survival benefit from LT surgery. We aimed to determine the prognostic value of pre-LT combined measurement of B-type natriuretic peptide (BNP) and high-sensitivity troponin I (hsTnI) in predicting early post-LT mortality. @*Methods@#We retrospectively evaluated 2,490 consecutive adult LT patients between 2010 and 2018. Cut-off values of BNP and hsTnI for predicting post-LT 90-day mortality were calculated. According to the derived cut-off values of two cardiac biomarkers, alone and in combination, adjusted hazard ratios (aHR) of post-LT 90-day mortality were determined using multivariate Cox regression analysis. @*Results@#Mortality rate after 90 days was 2.9% (72/2,490). Rounded cut-off values for post-LT 90-day mortality were 400 pg/ml for BNP (aHR 2.02 [1.15, 3.52], P = 0.014) and 60 ng/L for hsTnI (aHR 2.65 [1.48, 4.74], P = 0.001), respectively. Among 273 patients with BNP ≥ 400 pg/ml, 50.9% of patients were further stratified into having hsTnI ≥ 60 ng/L. Combined use of pre-LT cardiac biomarkers predicted post-LT 90-day mortality rate; both non-elevated: 1.0% (21/2,084), either one is elevated: 9.0% (24/267), and both elevated: 19.4% (27/139, log-rank P < 0.001; aHR vs non-elevated 4.23 [1.98, 9.03], P < 0.001). @*Conclusions@#Concomitant elevation of both cardiac biomarkers posed significantly higher risk of 90-day mortality after LT. Pre-LT assessment cardiac strain and myocardial injury, represented by BNP and hsTnI values, would contribute to prioritization of LT candidates and help administer target therapies that could modify early mortality.

Preoperative high-sensitivity troponin I and B-type natriuretic peptide, alone and in combination, for risk stratification of mortality after liver transplantation / 대한마취과학회지

Background@#Given the severe shortage of donor liver grafts, coupled with growing proportion of cardiovascular death after liver transplantation (LT), precise cardiovascular risk assessment is pivotal for selecting recipients who gain the greatest survival benefit from LT surgery. We aimed to determine the prognostic value of pre-LT combined measurement of B-type natriuretic peptide (BNP) and high-sensitivity troponin I (hsTnI) in predicting early post-LT mortality. @*Methods@#We retrospectively evaluated 2,490 consecutive adult LT patients between 2010 and 2018. Cut-off values of BNP and hsTnI for predicting post-LT 90-day mortality were calculated. According to the derived cut-off values of two cardiac biomarkers, alone and in combination, adjusted hazard ratios (aHR) of post-LT 90-day mortality were determined using multivariate Cox regression analysis. @*Results@#Mortality rate after 90 days was 2.9% (72/2,490). Rounded cut-off values for post-LT 90-day mortality were 400 pg/ml for BNP (aHR 2.02 [1.15, 3.52], P = 0.014) and 60 ng/L for hsTnI (aHR 2.65 [1.48, 4.74], P = 0.001), respectively. Among 273 patients with BNP ≥ 400 pg/ml, 50.9% of patients were further stratified into having hsTnI ≥ 60 ng/L. Combined use of pre-LT cardiac biomarkers predicted post-LT 90-day mortality rate; both non-elevated: 1.0% (21/2,084), either one is elevated: 9.0% (24/267), and both elevated: 19.4% (27/139, log-rank P < 0.001; aHR vs non-elevated 4.23 [1.98, 9.03], P < 0.001). @*Conclusions@#Concomitant elevation of both cardiac biomarkers posed significantly higher risk of 90-day mortality after LT. Pre-LT assessment cardiac strain and myocardial injury, represented by BNP and hsTnI values, would contribute to prioritization of LT candidates and help administer target therapies that could modify early mortality.

Preoperative echocardiographic evaluation of cardiac systolic and diastolic function in liver transplant recipients with diabetes mellitus: a propensity-score matched analysis

BACKGROUND: Diabetes mellitus (DM) increases risk of heart failure. It has been shown that diabetes leads to DM-cardiomyopathy, characterized by systolic and diastolic dysfunction. Pre-transplant diastolic dysfunction, has been associated with poor graft outcome and mortality. We assessed the hypothesis that end-stage liver disease (ESLD) patients with diabetes (DM-ESLD), have more advanced cardiac systolic and diastolic dysfunction, compared to ESLD patients without diabetes (Non DM-ESLD).METHODS: We retrospectively evaluated preoperative echocardiography of 1,319 consecutive liver transplant recipients (1,007 Non DM-ESLD vs. 312 DM-ESLD [23.7%]) January 2012–May 2016. Systolic and diastolic indices, such as left ventricular ejection fraction, transmital E/A ratio, tissue doppler s′, e′ velocity, and E/e′ ratio (index of left ventricular end-diastolic pressure), were compared using 1:2 propensity-score matching.RESULTS: DM-ESLD patients showed no differences in systolic indices of left ventricular ejection fraction and s′ velocity, whereas diastolic indices of E/A ratio ≤ 1 (49.0% vs. 40.2% P = 0.014), e′ velocity (median = 7.0 vs. 7.4 cm/s, P < 0.001) and E/e′ ratio (10.9 ± 3.2 vs. 10.1 ± 3.0, P < 0.001), showed worse diastolic function compare with Non DM-ESLD patients, respectively.CONCLUSIONS: DM-ESLD patients suffer higher degree of diastolic dysfunction compared with Non DM-ESLD patients. Based on this, careful preoperative screening for diastolic dysfunction in DM-ESLD patients is encouraged, because poor transplant outcomes have been noted in patients with preoperative diastolic dysfunction.

The predictive performance of infusion strategy nomogram based on a fluid kinetic model / 대한마취과학회지

BACKGROUND: In a previous study, fluid kinetic models were applied to describe the volume expansion of the fluid space by administration of crystalloid and colloid solutions. However, validation of the models were not performed, it is necessary to evaluate the predictive performance of these models in another population. METHODS: Ninety five consenting patients undergoing elective spinal surgery under general anesthesia were enrolled in this study. These patients were randomly assigned to three fluid groups i.e. Hartmann's solution (H group, n = 28), Voluven(R) (V group, n = 34), and Hextend(R) (X group, n = 33). After completion of their preparation for surgery, the patients received a loading and maintenance volume of each fluid predetermined by nomograms based on fluid pharmacokinetic models during the 60-minute use of an infusion pump. Arterial samples were obtained at preset intervals of 0, 10, 20, and 30 min after fluid administration. The predictive performances of the fluid kinetic modes were evaluated using the fractional change of arterial hemoglobin. The relationship between blood-volume dilution and target dilution of body fluid space was also evaluated using regression analysis. RESULTS: A total of 194 hemoglobin measurements were used. The bias and inaccuracy of these models were -2.69 and 35.62 for the H group, -1.53 and 43.21 for the V group, and 9.05 and 41.82 for the X group, respectively. The blood-volume dilution and target dilution of body-fluid space showed a significant linear relationship in each group (P < 0.05). CONCLUSIONS: Based on the inaccuracy of predictive performance, the fluid-kinetic model for Hartmann's solution showed better performance than the other models.

The comparison of predictive performance in bispectral index prediction during target effect-site controlled infusion of propofol using different blood effect-site equilibration rate constants in the same pharmacokinetic model / 대한마취과학회지

BACKGROUND: Blood-brain equilibration rate constant (k(e0)) is derived from either pharmacokinetic and pharmacodynamic modeling (k(e0_model)) or a model-independent observed time to peak effect (k(e0_tpeak)). Performance in bispectral index (BIS) prediction was compared between k(e0_model) and k(e0_tpeak) for microemulsion or long chain triglyceride (LCT) propofol. METHODS: Time to peak effect (t(peak), time to a maximally reduced BIS value) of microemulsion propofol after an intravenous bolus (1 mg/kg) was measured in 100 patients (group A(micro)). An observed t(peak) of 1.6 min for LCT propofol was obtained from an earlier study. Another 40 patients received a target controlled infusions of microemulsion propofol (k(e0_model) = 0.187/min, group B(micro) = 20) or LCT propofol (k(e0_model) = 0.26/min, group B(LCT) = 20) and remifentanil. The k(e0_tpeak)'s in group B(micro) and B(LCT) were calculated using the observed t(peak) value obtained from group A(micro) and 1.6 min, respectively. Effect-site concentrations of propofol were recalculated using the amounts of propofol infused over time and k(e0_tpeak)'s. Predicted BIS values calculated by sigmoid Emax equations with k(e0_model) and k(e0_tpeak) were compared with observed BIS values during induction and emergence for both formulations of propofol. RESULTS: Observed t(peak) of microemulsion propofol was 1.68 min. The median performance errors of BIS in group B(micro) were -1.83% (-24.8 to 18.9, k(e0_model)) and -2.42% (-26.1 to 36.2, k(e0_tpeak)), while 8.01% (-20.5 to 30.1, k(e0_model)) and 7.37% (-27.0 to 49.1, k(e0_tpeak)) in group B(LCT). The median absolute performance errors of BIS in group B(micro) were 11.87% (2.2-31.1k(e0_model)) and 14.38% (-0.6 to 44.6, k(e0_tpeak)), while 17.31% (5.54-36.0, k(e0_model)) and 18.28% (-0.1 to 56.0, k(e0_tpeak)) in group B(LCT). CONCLUSIONS: The k(e0_model) showed better performance in BIS prediction than the k(e0_tpeak).