Acute kidney injury following orthotopic liver transplantation: incidence, risk factors, and effects on patient and graft outcomes.

BACKGROUND: Liver transplant recipients frequently develop acute kidney injury (AKI), but the predisposing factors and long-term consequences of AKI are not well understood. The aims of this study were to identify predisposing factors for early post-transplant AKI and the impact of AKI on patient and graft survival and to construct a model to predict AKI using clinical variables. METHODS: In this 5-year retrospective study, we analysed clinical and laboratory data from 424 liver transplant recipients from our centre. RESULTS: By 72 h post-transplant, 221 patients (52%) had developed AKI [according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria]. Predisposing factors for development of AKI were female sex, weight (>100 kg), severity of liver disease (Child-Pugh score), pre-existing diabetes mellitus, number of units of blood or fresh frozen plasma transfused during surgery, and non-alcoholic steatohepatitis as the aetiology of end-stage liver disease (P≤0.05). Notably, preoperative serum creatinine (SCr) was not a significant predisposing factor. After fitting a forward stepwise regression model, female sex, weight >100 kg, high Child-Pugh score, and diabetes remained significantly associated with the development of AKI within 72 h (P≤0.05). The area under the receiver operator characteristic curve for the final model was 0.71. The incidence of new chronic kidney disease and requirement for dialysis at 3 months and 1 yr post-transplant were significantly higher among patients who developed AKI. CONCLUSIONS: Development of AKI within the first 72 h after transplant impacted short-term and long-term graft survival.

Succinylcholine-induced hyperkalemia in a patient with mucositis secondary to chemotherapy.

OBJECTIVE: To report a case of fatal hyperkalemia owing to succinylcholine administration in a patient with mucositis secondary to chemotherapy. DESIGN: Case report. SETTING: Adult intensive care unit (ICU) at Dartmouth-Hitchcock Medical Center. PATIENTS: One patient with mucositis secondary to chemotherapy. MEASUREMENTS AND MAIN RESULTS: A 37-yr-old female with recently diagnosed acute myelogenous leukemia was admitted to the ICU with mental status changes and progressive dyspnea requiring intubation and mechanical ventilation. Before ICU admission, the patient had suffered from painful mucositis causing severe dysphagia and bleeding, which was thought to be the result of chemotherapy. By the 10th ICU day, the patient's respiratory and mental status improved and the patient was successfully extubated. However, 8 hrs after extubation, she gradually developed severe respiratory distress, requiring reintubation and mechanical ventilation. The patient was given 14 mg of etomidate and 100 mg of succinylcholine intravenously. Immediately after the intubation, she suffered cardiac arrest. Her serum potassium level was 13.1 mEq/L and HCO3- was 16 mEq/L. The resuscitation attempt was unsuccessful, and the patient was pronounced dead. CONCLUSION: Oral mucositis is a frequent and potentially severe complication of cancer chemotherapy. We believe that mucositis was a contributing factor to this case of fatal hyperkalemia after administration of succinylcholine, with a mechanism similar to that reported with thermal injury. Only nondepolarizing muscle relaxants should be used in patients who are at risk for mucositis. Mucositis should be added to the list of conditions in which succinylcholine is contraindicated.

Acute renal failure and dialysis in the chronically critically ill patient.

Acute renal failure is a common clinical problem in the intensive care unit (ICU) and is associated with significant morbidity and mortality. There is no "magic bullet" to prevent acute renal failure or to modify the clinical course of established renal failure. The approach to therapy is directed to the early initiation of dialysis therapy. Continuous dialysis therapy is becoming the preferred form of dialysis in the ICU.