ABSTRACT
PURPOSE: We present a retrospective study describing the perioperative use of continuous renal replacement therapy (CRRT) for orthotopic liver transplantation (OLT). MATERIALS AND METHODS: We retrospectively reviewed the clinical course of patients who underwent OLT with the perioperative use of CRRT. The following variables were recorded: Gender, age, indication for transplantation, time when CRRT was initiated, postoperative need for CRRT, and the patient and organ (liver, kidneys) outcome up to 1 year after transplantation. RESULTS: Among 105 patients who underwent OLT from 2006 to 2010; we used CRRT in 12 cases (11.4%) perioperatively, including 9 (8.3%) patients intraoperatively. Perioperative CRRT was employed for volume, electrolyte, and/or pH management. All patients who underwent CRRT perioperatively were alive at 1 month, 10 (83.3%), at 3 and 6 months and 9 (75%) at 1 year after OLT. Only 1 surviving patient (8.3%) required renal replacement therapy at 1 month after surgery. Renal replacement therapy was not required in any surviving patient up to 12 months posttransplantation. CONCLUSION: Perioperative and especially intraoperative use of CRRT therapy can potentially improve the outcomes of patients undergoing OLT.
Subject(s)
Acute Kidney Injury/therapy , End Stage Liver Disease/surgery , Liver Transplantation , Renal Replacement Therapy , Acute Kidney Injury/mortality , Acute Kidney Injury/physiopathology , Adult , Aged , End Stage Liver Disease/complications , End Stage Liver Disease/mortality , Female , Humans , Kidney/physiopathology , Liver Transplantation/adverse effects , Liver Transplantation/mortality , Male , Middle Aged , Pennsylvania , Perioperative Care , Recovery of Function , Renal Replacement Therapy/adverse effects , Renal Replacement Therapy/mortality , Retrospective Studies , Time Factors , Treatment Outcome , Young AdultABSTRACT
We present a case of severe hyperammonemia with subsequent brain herniation in an adult man after renal transplantation. After successful surgery and an initially uneventful postoperative course, the patient developed significant mental status changes associated with seizure activity. His condition rapidly deteriorated, requiring mechanical ventilation and cardiovascular support. Laboratory studies at that time demonstrated an increased serum ammonia level without evidence of liver or kidney dysfunction. Further investigation revealed an increased orotic acid level in the urine, suggesting a urea cycle disorder (UCD). Despite aggressive therapy, the patient's condition continued to deteriorate. Magnetic resonance imaging demonstrated severe brain edema with no cerebral perfusion; after consultation with the family, care was withdrawn. The combination of hyperammonemia and elevated urine orotic acid with normal liver and kidney function suggested a UCD. It is important to note that patients with a UCD may be free of symptoms for many years. Several factors are able to trigger the disease in adulthood, leading to encephalopathy and death. In this case, the patient's seizures were initially assumed to be a side effect of immunosuppressive therapy. Further diagnostic measures were only performed late in the course of the disease, which delayed the diagnosis of UCD.
