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

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.

Markedly prolonged QTc interval in end-stage liver disease and risk of 30-day cardiovascular event after liver transplant.

BACKGROUND AND AIM: The proportional increase of corrected QT interval (QTc) along end-stage liver disease (ESLD) severity may lead to inconsistent outcome reporting if based on conventional threshold of prolonged QTc. We investigated the comprehensive QTc distribution among ESLD patients and assessed the association between QTc > 500 ms, a criterion for diagnosing severe long-QT syndrome, and the 30-day major adverse cardiovascular event (MACE) after liver transplantation (LT) and identified the risk factors for developing QTc > 500 ms. METHODS: Data were collected prospectively from the Asan LT Registry between 2011 and 2018, and outcomes were retrospectively reviewed. Multivariable analysis and propensity score-weighted adjusted odds ratios (ORs) were calculated. Thirty-day MACEs were defined as the composite of cardiovascular mortality, arrhythmias, myocardial infarction, pulmonary thromboembolism, and/or stroke. RESULTS: Of 2579 patients, 194 (7.5%) had QTc > 500 ms (QTc500_Group), and 1105 (42.8%) had prolonged QTc (QTcP_Group), defined as QTc > 470 ms for women and >450 ms for men. The 30-day MACE occurred in 336 (13%) patients. QTc500_Group showed higher 30-day MACE than did those without (20.1% vs 12.5%, P = 0.003), with corresponding adjusted OR of 1.24 (95% CI: 1.06-1.46, P = 0.007). However, QTcP_Group showed comparable 30-day MACE (13.3% vs 12.8% without prolonged QTc, P = 0.764). Significant risk factors for QTc > 500 ms development were advanced liver disease, female sex, hypokalemia, hypocalcemia, high left ventricular end-diastolic volume, and tachycardia. CONCLUSION: Our results revealed that, among ESLD patients, a novel threshold of QTc > 500 ms was associated with post-LT 30-day MACE but not with conventional threshold, indicating that a longer QTc threshold should be considered for this unique patient population.

Appraisal of Cardiac Ejection Fraction With Liver Disease Severity: Implication in Post-Liver Transplantation Mortality.

BACKGROUND AND AIMS: Enhanced sympathetic nervous activation and peripheral vasodilation in end-stage liver disease (ESLD) may limit the importance of left ventricular ejection fraction (LVEF) as an influential prognosticator. We sought to understand the LVEF and cardiac dimensions in ESLD patients in order to define the LVEF threshold to predict all-cause mortality after liver transplantation (LT). APPROACH AND RESULTS: Data were collected prospectively from the Asan LT Registry between 2008 and 2016, and outcomes were retrospectively reviewed. LVEF, end-diastolic volume index (EDVI), and end-diastolic elastance (Eed) were measured by preoperative echocardiography. Of 2,799 patients, 452 (16.2%) had LVEF ≤ 60%, with 29 (1.0%) having LVEF < 55% and 269 (9.6%) had LVEF ≥ 70%. Over a median of 5.4-year follow-up, 329 (11.8%) patients died: 104 (3.7%) died within 90 days. LVEF (range, 30%-81%) was directly proportionate to Model for End-stage Liver Disease (MELD) scores, an index of liver disease severity, in survivors but showed a fixed flat-line pattern in nonsurvivors (interaction P = 0.004 between groups), with lower EDVI (P = 0.013) and higher Eed (P = 0.001) in the MELD ≥ 20 group. Patients with LVEF ≤ 60% had higher 90-day (13% vs. 7.4%; log rank, P = 0.03) and median 5.4-year (26.7% vs. 16.2%; log rank, P = 0.003) mortality rates in the MELD ≥ 20 group, respectively, compared to those with LVEF > 60%. Specifically, in the MELD > 35 group, median 5.4-year mortality rate was 53.3% in patients with LVEF ≤ 60% versus 24% in those with LVEF > 60% (log rank P < 0.001). By contrast, mortality rates of LVEF ≤ 60% and > 60% were similar in the MELD < 20 group (log rank P = 0.817). CONCLUSIONS: LVEF ≤ 60% is strongly associated with higher post-LT mortality rates in the MELD ≥ 20 group, indicating the need to appraise both LVEF and liver disease severity simultaneously. Enhanced diastolic elastance with low EDVI provides insights into pathogenesis of low LVEF in nonsurvivors with MELD ≥ 20.

Effect of Remote Ischemic Preconditioning Conducted in Living Liver Donors on Postoperative Liver Function in Donors and Recipients Following Liver Transplantation: A Randomized Clinical Trial.

OBJECTIVE: This study aimed to assess the effects of remote ischemic preconditioning (RIPC) on liver function in donors and recipients after living donor liver transplantation (LDLT). BACKGROUND: Ischemia reperfusion injury (IRI) is known to be associated with graft dysfunction after liver transplantation. RIPC is used to lessen the harmful effects of IRI. METHODS: A total of 148 donors were randomly assigned to RIPC (n = 75) and control (n = 73) groups. RIPC involves 3 cycles of 5-minute inflation of a blood pressure cuff to 200 mm Hg to the upper arm, followed by 5-minute reperfusion with cuff deflation. The primary aim was to assess postoperative liver function in donors and recipients and the incidence of early allograft dysfunction and graft failure in recipients. RESULTS: RIPC was not associated with any differences in postoperative aspartate aminotransferase (AST) and alanine aminotransferase levels after living donor hepatectomy, and it did not decrease the incidence of delayed graft hepatic function (6.7% vs 0.0%, P = 0.074) in donors. AST level on postoperative day 1 [217.0 (158.0, 288.0) vs 259.5 (182.0, 340.0), P = 0.033] and maximal AST level within 7 postoperative days [244.0 (167.0, 334.0) vs 296.0 (206.0, 395.5), P = 0.029) were significantly lower in recipients who received a preconditioned graft. No differences were found in the incidence of early allograft dysfunction (4.1% vs 5.6%, P = 0.955) or graft failure (1.4% vs 5.6%, P = 0.346) among recipients. CONCLUSIONS: RIPC did not improve liver function in living donor hepatectomy. However, RIPC performed in liver donors may be beneficial for postoperative liver function in recipients after living donor liver transplantation.

Early postoperative weight gain is associated with increased risk of graft failure in living donor liver transplant recipients.

Fluid overload (FO) has been shown to adversely affect multiple organs and survival in critically ill patients. Liver transplantation (LT) carries the risk of massive transfusion, which frequently results in FO. We investigated the association of postoperative weight gain with graft failure, early allograft dysfunction (EAD), and overall mortality in LT. 1833 living donor LT (LDLT) recipients were retrospectively analysed. Patients were divided into 2 groups according to postoperative weight gain (<3% group [n = 1391] and ≥3% group [n = 442]) by using maximally selected log-rank statistics for graft failure. Multivariate Cox and logistic regression analyses were performed. The ≥3% group was associated with graft failure (adjusted HR [aHR], 1.763; 95% CI, 1.248-2.490; P = 0.001). When postoperative weight change was used as a continuous variable, the aHR for each 1% increase in postoperative weight was 1.045 (95% CI, 1.009-1.082; P = 0.015). In addition, the ≥3% group was associated with EAD (adjusted OR [aOR], 1.553; 95% CI, 1.024-2.356; P = 0.038) and overall mortality (aHR, 1.731; 95% CI, 1.182-2.535; P = 0.005). In conclusion, postoperative weight gain may be independently associated with increased risk of graft failure, EAD, and mortality in LDLT recipients.

Preoperative Myocardial Ischemia Detected With Electrocardiography Is Associated With Reduced 1-Year Survival Rate in Patients Undergoing Liver Transplant.

BACKGROUND: Although electrocardiography (ECG) is routinely used as a preoperative cardiac assessment tool, impact of ECG-detected myocardial ischemia on postoperative outcomes remains unclear. We aimed to assess use of ECG as a predictor of postoperative mortality in patients undergoing liver transplant (LT). METHODS: Electronic medical records of patients who underwent LT were retrospectively analyzed. The primary end point was postoperative 1-year all-cause mortality. Electrocardiographic myocardial ischemia was diagnosed based on automated ECG interpretation suggesting ischemia or infarction. Cox proportional hazard analysis was performed to identify independent risk factors including Model for End-Stage Liver Disease score, revised cardiac risk index, echocardiographic wall motion abnormalities, and myocardial perfusion scan (MPS) abnormalities. RESULTS: Of the 1430 patients, 78 (5.5%) showed ischemic change on ECG. The 1-year mortality of patients with ischemic change on ECG was significantly higher than that of those without (11.5% vs 4.0%; P = .004). In the Cox proportional hazard model, ischemic change on ECG (hazard ratio [HR], 2.91; 95% CI, 1.43-5.92; P = .003), Model for End-Stage Liver Disease score (HR 1.06; 95% CI 1.04-1.09; P < .001), and revised cardiac risk index (HR, 2.84; 95% CI, 1.86-4.35; P < .001) were independent variables predicting 1-year mortality; however, MPS abnormalities and echocardiographic wall motion abnormalities were not. CONCLUSION: In patients undergoing LT, preoperative ischemic ECG findings should not be overlooked, as they are associated with increased mortality, while abnormalities on MPS and resting ECG are not. Thorough evaluations to detect underlying modifiable coronary artery disease are needed in patients with these findings.

Neutrophil-to-lymphocyte ratio is a predictor of early graft dysfunction following living donor liver transplantation.

BACKGROUND & AIMS: Early allograft dysfunction (EAD) is predictive of poor graft and patient survival following living donor liver transplantation (LDLT). Considering the impact of the inflammatory response on graft injury extent following LDLT, we investigated the association between neutrophil-to-lymphocyte ratio (NLR) and EAD, 1-year graft failure, and mortality following LDLT, and compared it to C-reactive protein (CRP), procalcitonin, platelet-to-lymphocyte ratio and the Glasgow prognostic score. METHODS: A total of 1960 consecutive adult LDLT recipients (1531/429 as development/validation cohort) were retrospectively evaluated. Cut-offs were derived using the area under the receiver operating characteristic curve (AUROC), and multivariable regression and Cox proportional hazard analyses were performed. RESULTS: The risk of EAD increased proportionally with increasing NLR, and the NLR AUROC was 0.73, similar to CRP and procalcitonin and higher than the rest. NLR ≥ 2.85 (best cut-off) showed a significantly higher EAD occurrence (20.5% vs 5.8%, P < 0.001), higher 1-year graft failure (8.2% vs 4.9%, log-rank P = 0.009) and higher 1-year mortality (7% vs 4.5%, log-rank P = 0.039). NLR ≥ 2.85 was an independent predictor of EAD (odds ratio, 1.89 [1.26-2.84], P = 0.002) after multivariable adjustment, whereas CRP and procalcitonin were not. Increasing NLR was independently associated with higher 1-year graft failure and mortality (both P < 0.001). Consistent results in the validation cohort strengthened the prognostic value of NLR. CONCLUSIONS: Preoperative NLR ≥ 2.85 predicted higher risk of EAD, 1-year graft failure and 1-year mortality following LDLT, and NLR was superior to other parameters, suggesting that preoperative NLR may be a practical index for predicting graft function following LDLT.

Early postoperative hypoalbuminaemia is associated with pleural effusion after donor hepatectomy: A propensity score analysis of 2316 donors.

Pleural effusion and hypoalbuminaemia frequently occur after hepatectomy. Despite the emphasis on the safety of donors, little is known about the impact of postoperative albumin level on pleural effusion in liver donors. We retrospectively assessed 2316 consecutive liver donors from 2004 to 2014. The analysis of donors from 2004 to 2012 showed that postoperative pleural effusion occurred in 47.4% (970/2046), and serum albumin levels decreased until postoperative day 2 (POD2) and increased thereafter. In multivariable analysis, the lowest albumin level within POD2 (POD2ALB) was inversely associated with pleural effusion (OR 0.28, 95% CI 0.20-0.38; P < 0.001). POD2ALB ≤3.0 g/dL, the cutoff value at the 75th percentile, was associated with increased incidence of pleural effusion after propensity score (PS) matching (431 pairs; OR 1.69, 95% CI 1.30-2.21; P < 0.001). When we further analysed data from 2010 to 2014, intraoperative albumin infusion was associated with higher POD2ALB (P < 0.001) and lower incidence of pleural effusion (P = 0.024), compared with synthetic colloid infusion after PS matching (193 pairs). In conclusion, our data showed that POD2ALB is inversely associated with pleural effusion, and that intraoperative albumin infusion is associated with a lower incidence of pleural effusion when compared to synthetic colloid infusion in liver donors.

Risk stratification of myocardial injury after liver transplantation in patients with computed tomographic coronary angiography-diagnosed coronary artery disease.

We aimed to determine if the severity of computed tomographic coronary angiography (CTCA)-diagnosed coronary artery disease (CAD) is associated with postliver transplantation (LT) myocardial infarction (MI) within 30 days and early mortality. We retrospectively evaluated 2118 consecutive patients who underwent CAD screening using CTCA. Post-LT type-2 MI, elicited by oxygen supply-and-demand mismatch within a month after LT, was assessed according to the severity of CTCA-diagnosed CAD. Obstructive CAD (>50% narrowing, 9.2% prevalence) was identified in 21.7% of patients with 3 or more known CAD risk factors of the American Heart Association. Post-LT MI occurred in 60 (2.8%) of total patients in whom 90-day mortality rate was 16.7%. Rates of post-LT MI were 2.1%, 3.1%, 3.4%, 4.3%, and 21.4% for normal, nonobstructive CAD, and 1-, 2-, and 3-vessel obstructive CAD, respectively. Two-vessel or 3-vessel obstructive CAD showed a 4.9-fold higher post-LT MI risk compared to normal coronary vessels. The sensitivity and negative predictive value of obstructive CAD in detecting post-LT MI were, respectively, 20% and 97.5%. In conclusion, negative CTCA finding in suspected patients can successfully exclude post-LT MI, whereas proceeding with invasive angiography is needed to further risk-stratify in patients with significant CTCA-diagnosed CAD. Prognostic role of CTCA in predicting post-LT MI needs further research.

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.

Effect of Total Intravenous Anesthesia vs Volatile Induction With Maintenance Anesthesia on Emergence Agitation After Nasal Surgery: A Randomized Clinical Trial.

Importance: Emergence agitation is common after nasal surgery under general anesthesia and may lead to serious consequences for the patient, including an increased risk of injury, pain, hemorrhage, and self-extubation. Despite decades of research, studies on the incidence, risk factors, and prevention of emergence agitation in adult patients are ongoing, and opinions differ on the different effects of inhalation and intravenous anesthesia. Objective: To investigate the effect of anesthetic method on the occurrence of emergence agitation after nasal surgery. Design, Setting, and Participants: This prospective, randomized, single-blind, clinical trial included 80 patients undergoing open rhinoplasty, septoplasty, turbinoplasty, endoscopic sinus surgery, and functional endoscopic sinus surgery under general anesthesia who were randomized to receive total intravenous anesthesia (TIVA) with remifentanil hydrochloride and propofol (n = 40) or volatile induction and maintenance of anesthesia (VIMA) with sevoflurane and nitrous oxide (n = 40) in Asan Medical Center, a tertiary referral center in Seoul, Republic of Korea. Data were collected from August 24 through October 14, 2016, and analyzed from October 26, 2016, through September 14, 2017. Main Outcomes and Measures: The occurrence of emergence agitation defined by the following 2 individual criteria: a Richmond Agitation-Sedation Scale score of at least 1 and a Riker Sedation-Agitation Scale score of at least 5 immediately after extubation. Results: Among the 80 patients included in the analysis (68.8% men [n = 55]; mean [SD] age, 41.6 [17.9] years), emergence agitation measured by the Richmond Agitation Sedation Scale occurred in 8 of 40 patients (20.0%) in the VIMA group and 1 of 40 (2.5%) in the TIVA group. The risk difference was 17.5 (95% CI, 3.6-31.4). Emergence agitation measured by the Riker Sedation-Agitation Scale score occurred in 10 of 40 patients (25.0%) in the VIMA group and 1 of 40 (2.5%) in the TIVA group. The risk difference was 22.5 (95% CI, 7.3-37.7). Conclusions and Relevance: The occurrence of emergence agitation after nasal surgery under general anesthesia can be significantly reduced by using TIVA rather than VIMA. Trial Registration: CRIS identifier: KCT0002145.

Prevalent metabolic derangement and severe thrombocytopenia in ABO-incompatible liver recipients with pre-transplant plasma exchange.

Desensitisation with therapeutic plasma exchange (TPE) is essential for ABO-incompatible (ABO-I) liver transplants (LTs). However, excessive citrate load and coagulation disturbances after TPE have been poorly studied, in particular in cirrhotic patients with hypocapnic alkalosis, metabolic compensation and electrolyte imbalances. We retrospectively evaluated 1123 consecutive LT recipients (923 ABO-compatible [ABO-C], 200 ABO-I) from November 2008 to May 2015. TPE was generally performed a day before LT and blood sampling was performed before anaesthesia induction. We performed propensity score matching (PSM) and inverse probability treatment weighting (IPTW) analyses. In 199 PSM pairs, metabolic alkalosis was prevalent in ABO-I LT recipients (expectedly due to citrate conversion) with higher pH ≥ 7.50 (IPTW-adjusted odds ratio [aOR] = 2.23) than in ABO-C LT recipients. With increasing cirrhosis severity, the arterial pH and bicarbonate levels showed dose-dependent relationships, whereas mild hypoxaemia was more prevalent in ABO-I LT recipients. ABO-I LT recipients exhibited worsened hypokalaemia ≤3.0 mmol/l (17.6%, aOR = 1.44), hypomagnesaemia ≤1.7 mg/dl (27.6%, aOR = 3.43) and thrombocytopenia <30,000/µl (19.1%, aOR = 2.26) confirmed by lower maximal clot firmness (P = 0.001) in rotational thromboelastometry (EXTEM), which necessitated platelet transfusions. Preoperative identification of these change may prevent worsening of severe electrolyte disturbances and thrombocytopenia for optimal LT anaesthesia.

Low Mean Arterial Blood Pressure is Independently Associated with Postoperative Acute Kidney Injury After Living Donor Liver Transplantation: A Propensity Score Weighing Analysis.

BACKGROUND As end-stage liver disease progresses, renal blood flow linearly correlates with mean arterial blood pressure (MBP) due to impaired autoregulation. We investigated whether the lower degree of postoperative MBP would predict the occurrence of postoperative acute kidney injury (AKI) after liver transplantation. MATERIAL AND METHODS This retrospective study enrolled 1,136 recipients with normal preoperative kidney function. Patients were categorized into two groups according to the averaged postoperative MBP: <90 mmHg (MBPbelow90) and ≥90 mmHg (MBPover90). The primary endpoint was occurrence of postoperative AKI, defined by the creatinine criteria of the Kidney Disease Improving Global Outcomes. The logistic regression model with inverse probability treatment weighting (IPTW) of propensity score was used to compare the risk of postoperative AKI between two groups. RESULTS MBPbelow90 group (83.0±5.1 mmHg) showed higher prevalence and risk of postoperative AKI (74.2% versus 62.6%, p<0.001; IPTW-OR 1.34 [1.12-1.61], p=0.001) compared with MBPover90 group (97.3±5.2 mmHg). When stratified by quartiles of baseline cystatin C glomerular filtration ratio (GFR), the association between MBPbelow90 and postoperative AKI remained significant only with the lowest quartile (cystatin C GFR ≤85 mL/min/1.73 m²; IPTW-OR 2.24 [1.53-3.28], p<0.001), but not with 2nd-4th quartiles. CONCLUSIONS Our results suggest that maintaining supranormal MBP over 90 mmHg may be beneficial to reduce the risk of post-LT AKI, especially for liver transplant recipients with cystatin C GFR ≤85 mL/min/1.73 m².

The Impact of Postreperfusion Syndrome on Acute Kidney Injury in Living Donor Liver Transplantation: A Propensity Score Analysis.

BACKGROUND: Postreperfusion syndrome (PRS) has been shown to be related to postoperative morbidity and graft failure in orthotopic liver transplantation. To date, little is known about the impact of PRS on the prevalence of postoperative acute kidney injury (AKI) and the postoperative outcomes after living donor liver transplantation (LDLT). The purpose of our study was to determine the impact of PRS on AKI and postoperative outcomes after LDLT surgery. METHODS: Between January 2008 and October 2015, we retrospectively collected and evaluated the records of 1865 patients who underwent LDLT surgery. We divided the patients into 2 groups according to the development of PRS: PRS group (n = 715) versus no PRS group (n = 1150). Risk factors for AKI and mortality were investigated by multivariable logistic and Cox proportional hazards regression model analysis. Propensity score (PS) analysis (PS matching and inverse probability of treatment weighting analysis) was designed to compare the outcomes between the 2 groups. RESULTS: The prevalence of PRS and the mortality rate were 38% and 7%, respectively. In unadjusted analyses, the PRS group showed more frequent development of AKI (P < .001), longer hospital stay (P = .010), and higher incidence of intensive care unit stay over 7 days (P < .001) than the no PRS group. After PS matching and inverse probability of treatment weighting analysis, the PRS group showed a higher prevalence of postoperative AKI (P = .023 and P = .017, respectively) and renal dysfunction 3 months after LDLT (P = .036 and P = .006, respectively), and a higher incidence of intensive care unit stay over 7 days (P = .014 and P = .032, respectively). CONCLUSIONS: We demonstrated that the magnitude and duration of hypotension caused by PRS is a factor contributing to the development of AKI and residual renal dysfunction 3 months after LDLT.

Impact of Inhalational Anesthetics on Liver Regeneration After Living Donor Hepatectomy: A Propensity Score-Matched Analysis.

BACKGROUND: Although desflurane and sevoflurane, the most commonly used inhalational anesthetics, have been linked to postoperative liver injury, their impact on liver regeneration remains unclear. We compared the influence of these anesthetics on the postoperative liver regeneration index (LRI) after living donor hepatectomy (LDH). METHODS: We conducted a retrospective chart review of 1629 living donors who underwent right hepatectomy for LDH between January 2008 and August 2016. The patients were divided into sevoflurane (n = 1206) and desflurane (n = 423) groups. Factors associated with LRI were investigated using multivariable logistic regression analysis. Propensity score matching analysis compared early (1 postoperative week) and late (within 1-2 months) LRIs and delayed recovery of hepatic function between the 2 groups. RESULTS: The mean early and late LRIs in the 1629 patients were 63.3% ± 41.5% and 93.7% ± 48.1%, respectively. After propensity score matching (n = 403 pairs), there were no significant differences in early and late LRIs between the sevoflurane and desflurane groups (early LRI: 61.2% ± 41.5% vs 58.9% ± 42.4%, P = .438; late LRI: 88.3% ± 44.3% vs 94.6% ± 52.4%, P = .168). Male sex (regression coefficient [ß], 4.6; confidence interval, 1.6-7.6; P = .003) and remnant liver volume (ß, -4.92; confidence interval, -5.2 to -4.7; P < .001) were associated with LRI. The incidence of delayed recovery of hepatic function was 3.6% (n = 29) with no significant difference between the 2 groups (3.0% vs 4.2%, P = .375) after LDH. CONCLUSIONS: Both sevoflurane and desflurane can be safely used without affecting liver regeneration and delaying liver function recovery after LDH.

Comparison of the analgesic effect of patient-controlled oxycodone and fentanyl for pain management in patients undergoing colorectal surgery.

Oxycodone is a µ-opioid receptor agonist and is generally indicated for the relief of moderate to severe pain. The aim of this study was to compare the analgesic efficacy of patient-controlled oxycodone and fentanyl for postoperative pain in patients undergoing colorectal surgery. Patients scheduled to undergo elective colorectal surgery (n=82) were allocated to receive oxycodone (n=41, concentration of 1 mg/mL) or fentanyl (n=41, concentration of 15 µg/mL) for postoperative pain management. After the operation, pain using a numerical rating scale (NRS), delivery to demand ratio, infused dose of patient-controlled analgesia (PCA), side effects, and sedation levels were evaluated. Median (25%-75%) cumulative PCA dose of oxycodone group at 48 hours (66.9, 58.4-83.7 mL) was significantly less than that of fentanyl group (80.0, 63.4-103.3 mL, P=.037). Six hours after surgery, the mean (SD) NRS scores of the oxycodone and fentanyl groups were 6.2 (2.4) and 6.8 (1.9), respectively (P=.216). The mean equianalgesic potency ratio of oxycodone to fentanyl was 55:1. The groups did not differ in postoperative nausea, vomiting, and level of sedation. Patient-controlled oxycodone provides similar effects for pain relief compared to patient-controlled fentanyl in spite of less cumulative PCA dose. Based on these results, oxycodone can be a useful alternative to fentanyl for PCA in patients after colorectal surgery.

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

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® (V group, n = 34), and Hextend® (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.

BACKGROUND: Blood-brain equilibration rate constant (ke0 ) 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 (tpeak, time to a maximally reduced BIS value) of microemulsion propofol after an intravenous bolus (1 mg/kg) was measured in 100 patients (group Amicro). An observed tpeak 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 Bmicro = 20) or LCT propofol (k e0_model = 0.26/min, group BLCT = 20) and remifentanil. The k e0_tpeak's in group Bmicro and BLCT were calculated using the observed tpeak value obtained from group Amicro 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 tpeak of microemulsion propofol was 1.68 min. The median performance errors of BIS in group Bmicro 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 BLCT. The median absolute performance errors of BIS in group Bmicro 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 BLCT. CONCLUSIONS: The k e0_model showed better performance in BIS prediction than the k e0_tpeak.