Effect of dexmedetomidine on the incidence of postoperative acute kidney injury in living donor liver transplantation recipients: A randomized controlled trial.

BACKGROUND: Acute kidney injury (AKI) is one of the most common complications after living-donor liver transplantation (LDLT) that has great impact on recipient and graft outcomes. Dexmedetomidine is reported to decrease the incidence of AKI. In the current study, we investigated whether intraoperative dexmedetomidine infusion would reduce the AKI following LDLT. MATERIAL AND METHODS: In total, 205 adult patients undergoing elective LDLT were randomly assigned to the dexmedetomidine group (n=103) or the control group (n=102). Dexmedetomidine group received continuous dexmedetomidine infusion at a rate of 0.4 mcgÖ¼/kg/hr after the anesthesia induction until 2 hours after graft reperfusion. The primary outcome was to compare the incidence of AKI. Secondary outcomes included serial lactate levels during surgery, chronic kidney disease, major adverse cardiovascular events, early allograft dysfunction, graft failure, overall mortality, duration of mechanical ventilation, ICU and hospital length of stay. Intraoperative hemodynamic parameters were also collected. RESULTS: Of 205 recipients, 42.4% (n=87) developed AKI. The incidence of AKI was lower in the dexmedetomidine group (35.0%, n=36/103) compared with the control (50.0%, n=51/102) ( P =0.042). There were significantly lower lactate levels in the dexmedetomidine group after reperfusion (4.39 [3.99-4.8] vs 5.02 [4.62-5.42], P =0.031) until the end of surgery (4.23 [3.73-4.73] vs 5.35 [4.84-5.85], P =0.002). There were no significant differences in the other secondary outcomes besides lactate. Also, intraoperative mean blood pressure, cardiac output, and systemic vascular resistance did not show any difference. CONCLUSION: Our study suggests that intraoperative dexmedetomidine administration was associated with significantly decreased AKI incidence and lower intraoperative serum lactate levels in LDLT recipients, without untoward hemodynamic effects.

Transient decrease in B-type natriuretic peptide level after liver transplantation does not ensure favorable post-transplant 30-day outcomes.

BACKGROUND: High B-type natriuretic peptide (BNP) levels within the first 3 postoperative days (postBNPPOD3) after liver transplantation (LT) are greatly predictive of the 30-day mortality. We evaluated clinical impact of transient decrease in postBNPPOD3 compared to pretransplant BNP (preBNP) level on mortality and major adverse cardiac event (MACE) within 30 days after LT. METHODS: We retrospectively evaluated 3,811 LT patients who measured delta BNP (deltaBNP), defined by serial postBNPPOD3 minus preBNP. Thirty-day all-cause mortality and MACE were estimated in patients with deltaBNP < 0 (n = 594, 15.6%) and > 0 (n = 3,217, 84.4%), respectively. Kaplan-Meier survival and multivariable Cox regression analysis were used. RESULTS: Within 30 days, 100 (2.6%) of all patients died. Unexpectedly, 30-day mortality rate (6.1% [95% CI: 4.2-8.4%] vs. 2.0% [95% CI: 1.5-2.5%], P < 0.001) and MACE (24.2% [95% CI: 20.4-28.5%] vs. 15.3% [95% CI: 14.0-16.7%], P < 0.001) were higher in patients with deltaBNP < 0 compared to those with deltaBNP > 0, respectively. Patients with deltaBNP < 0 had higher preBNP level (median [interquartile range], 251 [118, 586] vs. 43 [21, 92] pg/ml, P < 0.001) and model for end-stage liver disease score (26 [14, 37] vs. 14 [9, 23], P < 0.001) and more transfused intraoperatively. DeltaBNP < 0 remained significant after adjustments for potential confounders in multivariable analysis of 30-day mortality and MACE. CONCLUSIONS: DeltaBNP < 0 within the first 3 postoperative days is mainly attributed to pre-LT severe liver and cardiac disease status, therefore, transient decrease in BNP level after LT does not ensure favorable post-LT 30-day outcomes.

The Association between Prognostic Nutritional Index (PNI) and Intraoperative Transfusion in Patients Undergoing Hepatectomy for Hepatocellular Carcinoma: A Retrospective Cohort Study.

BACKGROUND: PNI is significantly associated with surgical outcomes; however, the association between PNI and intraoperative transfusions is unknown. METHODS: This study retrospectively analyzed 1065 patients who underwent hepatectomy. We divided patients into two groups according to the PNI (<44 and >44) and compared their transfusion rates and surgical outcomes. We performed multivariate logistic and Cox regression analysis to determine risk factors for transfusion and the 5-year survival. Additionally, we found the net reclassification index (NRI) to validate the discriminatory power of PNI. RESULTS: The PNI <44 group had higher transfusion rates (adjusted odds ratio [OR]: 2.20, 95%CI: 1.06-4.60, p = 0.035) and poor surgical outcomes, such as post hepatectomy liver failure (adjusted [OR]: 3.02, 95%CI: 1.87-4.87, p < 0.001), and low 5-year survival (adjusted OR: 1.68, 95%CI: 1.17-2.24, p < 0.001). On multivariate analysis, PNI <44, age, hemoglobin, operation time, synthetic colloid use, and laparoscopic surgery were risk factors for intraoperative transfusion. On Cox regression analysis, PNI <44, MELD score, TNM staging, synthetic colloid use, and transfusion were associated with poorer 5-year survival. NRI analysis showed significant improvement in the predictive power of PNI for transfusion (p = 0.002) and 5-year survival (p = 0.004). CONCLUSIONS: Preoperative PNI <44 was significantly associated with higher transfusion rates and surgical outcomes.

Association of Preoperative Prognostic Nutritional Index and Postoperative Acute Kidney Injury in Patients with Colorectal Cancer Surgery.

The prognostic nutritional index (PNI) has been reported to be associated with postoperative complications and prognosis in cancer surgery. However, few studies have evaluated the association between preoperative PNI and postoperative acute kidney injury (AKI) in colorectal cancer patients. This study evaluated association of preoperative PNI and postoperative AKI in patients who underwent colorectal cancer surgery. This study retrospectively analyzed 3543 patients who underwent colorectal cancer surgery between June 2008 and February 2012. The patients were classified into four groups by the quartile of PNI: Q1 (≤43.79), Q2 (43.79-47.79), Q3 (47.79-51.62), and Q4 (≥51.62). Multivariate regression analysis was performed to assess the risk factors for AKI and 1-year mortality. AKI was defined according to Kidney Disease Improving Global Outcomes classification (KDIGO) criteria. Additionally, we assessed surgical outcomes such as hospital stay, ICU admission, and postoperative complications. The incidence of postoperative AKI tended to increase in the Q1 group (13.4%, 9.2%, 9.4%, 8.8%). In the multivariate analysis, high preoperative PNI was significantly associated with low risk of postoperative AKI (adjusted odds ratio [OR]: 0.96, 95% confidence interval [CI]: 0.93-0.99, p = 0.003) and low 1-year mortality (OR: 0.92, 95% CI: 0.86-0.98, p = 0.011). Male sex, body mass index, diabetes mellitus, and hypertension were risk factors for AKI. The Q1 (≤43.79) group had poor surgical outcomes, such as postoperative AKI (OR: 1.52, 95% CI: 1.18-1.95, p = 0.001), higher rates of ICU admission (OR: 3.13, 95% CI: 1.82-5.39, p < 0.001) and higher overall mortality (OR: 3.81, 95% CI: 1.86-7.79, p < 0.001). In conclusion, low preoperative PNI levels, especially in the Q1 (≤43.79), were significantly associated with postoperative AKI and surgical outcomes, such as hospital stay, postoperative ICU admission, and mortality.

Comparison of the Effects of Laparoscopic and Open Surgery on Postoperative Acute Kidney Injury in Patients with Colorectal Cancer: Propensity Score Analysis.

Postoperative acute kidney injury (AKI) is a serious complication that increases patient morbidity and mortality. However, few studies have evaluated the effect of laparoscopic surgery on postoperative AKI. This study compared the incidence of postoperative AKI between laparoscopic and open surgery in patients with colorectal cancer. This study retrospectively analyzed 3637 patients who underwent colorectal cancer surgery between June 2008 and February 2012. The patients were classified into laparoscopic (n = 987) and open (n = 2650) surgery groups. We performed multivariable regression analysis to assess the risk factors for AKI and propensity score matching analysis to compare the incidence of AKI between the two groups. We also assessed postoperative intensive care unit (ICU) admission, complications, hospital stay, and 1-year mortality. We observed no significant differences in the incidence of postoperative AKI between the two groups before (8.8% vs. 9.1%, p = 0.406) and after (8.8% vs. 7.7%, p = 0.406) matching. Laparoscopic surgery was not associated with AKI even after adjusting for intraoperative variables (adjusted odds ratio (OR): 1.17, 95% confidence interval (CI): 0.84-1.62, p = 0.355). Body mass index, diabetes mellitus, hypertension, and albumin were risk factors for AKI. ICU admission (0.6% vs. 2.5%, p = 0.001), complications (0.2% vs. 1.5%, p = 0.002), hospital stay (6.89 days vs. 8.61 days, p < 0.001), and 1-year mortality (0.1% vs. 0.9%, p = 0.021) were significantly better in the laparoscopic than in the open group. The incidence of postoperative AKI did not differ significantly between laparoscopic and open surgery. However, considering its better surgical outcomes, laparoscopic surgery may be recommended for patients with colorectal cancer.