Incidence and Risk Factors of Acute Kidney Injury in Pediatric Liver Transplant Patients: A Retrospective Study.

Background: Acute kidney injury (AKI) significantly contributes to the mortality and morbidity rates among pediatric liver transplant (LT) recipients. Objective: Our study aimed to assess the potential factors contributing to AKI in pediatric LT patients and to analyze the impact of AKI on postoperative mortality and hospitalization duration. Materials and methods: About 235 pediatric LT patients under the age of 18 between the years 2015 and 2021 were evaluated retrospectively. The relationship between preoperative and intraoperative variables of the patients and AKI developed when the early postoperative period was assessed. Results: A correlation was found between the patients' preoperative age, albumin levels, and AKI. AKI was found to be associated with the duration of surgery and intraoperative blood transfusion. Conclusion: Our findings revealed that the severity of AKI in pediatric LT patients is linked to extended surgical durations and increased blood transfusions resulting from hemodynamically compromised blood loss. Furthermore, independent risk factors for AKI were identified as prolonged warm ischemia and the overall duration of the operation. How to cite this article: Demiroz D, Colak YZ, Ozdes OO, Ucar M, Ali Erdogan M, Toprak HI, et al. Incidence and Risk Factors of Acute Kidney Injury in Pediatric Liver Transplant Patients: A Retrospective Study. Indian J Crit Care Med 2024;28(1):75-79.

Ultrasound-guided transversus abdominis plane block for postoperative analgesia in living liver donors: A prospective, randomized, double-blinded clinical trial.

BACKGROUND: Transversus abdominis plane (TAP) block is a peripheral nerve block that reduces postoperative pain, nausea, vomiting and the need for postoperative opioids following various types of abdominal surgery. The primary aim of the present study was to evaluate the effects of TAP block on postoperative analgesia and opioid consumption in living liver donors in whom a right "J" abdominal incision was used. METHODS: This prospective, double-blinded, randomized controlled study was conducted with 50 living liver donors, aged 18-65years, who were scheduled to undergo right hepatectomy. Patients who received ultrasonography-guided subcostal TAP block were allocated into Group 1, and patients who did not receive TAP block were allocated into Group 2. The TAP blocks were performed bilaterally at the conclusion of surgery using 1.5mg∗kg-1 bupivacaine diluted with saline to reach a total volume of 40mL. For each patient, morphine consumption, pain scores at rest and movement, sedation scores, nausea, vomiting and the need for antiemetic medication were assessed at 0, 2, 4, 6, 12 and 24h postoperatively by researchers who were blinded to the study groups. RESULTS: Morphine consumption was significantly lower in Group 1 than in Group 2 at the 2nd, 6th and 24th hours (P<0.05). The mean total morphine consumption values after 24h were 40mg and 65mg in Groups 1 and 2, respectively. The TAP block significantly reduced postoperative visual analog scale pain scores both at rest and during movement at 0, 2, 4, 6, and 24h postoperatively (P<0.05). CONCLUSIONS: The TAP block reduced 24-h postoperative morphine consumption and contributed to analgesia in living liver donors who underwent upper abdominal wall incisions.

Evaluation of pleth variability index as a predictor of fluid responsiveness during orthotopic liver transplantation.

Fluid management is challenging and still remains controversial in orthotopic liver transplantation (OLT). The pleth variability index (PVI) has been shown to be a reliable predictor of fluid responsiveness of perioperative and critically ill patients; however, it has not been evaluated in OLT. This study was designed to examine whether the PVI can reliably predict fluid responsiveness in OLT and to compare PVI with other hemodynamic indexes that are measured using the PiCCO2 monitoring system. Twenty-five patients were enrolled in this study. Each patient was monitored using the noninvasive Masimo and PiCCO2 monitoring system. PVI was obtained with a Masimo pulse oximeter. Cardiac index was obtained using a transpulmonary thermodilution technique (CITPTD). Stroke volume variation (SVV), pulse pressure variation, and systemic vascular resistance index were measured using the PiCCO2 system. Fluid loading (10 mL/kg colloid) was performed at two different phases during the operation, and fluid responsiveness was defined as an increase in CITPTD ≥ 15%. During the dissection phase and the anhepatic phase, respectively, 14 patients (56%) and 18 patients (75%) were classified as responders. There were no differences between the baseline values of the PVI of responders and nonresponders. Area under the curve for PVI was 0.56 (sensitivity 35%, specificity 90%, p = 0.58) at dissection phase, and was 0.55 (sensitivity 55%, specificity 66%, p = 0.58) at anhepatic phase. Of the parameters, a higher area under the curve value was found for SVV. We conclude that PVI was unable to predict fluid responsiveness with sufficient accuracy in patients undergoing OLT, but the SVV parameter was reliable.

Liver Transplant in Patients with Viral Hepatitis and Human Immunodeficiency Virus Coinfection: The First 2 Cases in Turkey.

OBJECTIVES: The outcomes of liver transplant in human immunodeficiency virus-infected patients are improving with advances in antiretroviral treatment. Data about such cases are rare in Turkey. We present the first 2 living-donor liver transplants performed in Turkey in patients with viral hepatitis/human immunodeficiency virus coinfection. CASE 1: A 47-year-old man infected with human immunodeficiency virus with chronic hepatitis B and D and hepatocellular carcinoma within the Milan criteria had been taking antiretroviral medication before his liver transplant. An unrelated right lobe liver transplant was performed uneventfully in this patient, who was human immunodeficiency virus RNA-negative and had a CD4 T-cell count of 500/µL. Antiretroviral treatment continued in the early postoperative period, and a triple immunosuppressive regimen consisting of cyclosporine, mycophenolate mofetil, and steroids was initiated. Burkholderia cepacia pneumonia developed postoperatively, and was treated successfully. The patient was discharged on postoperative day 18, and is still alive 58 months after the operation. CASE 2: A 62-year-old man with human immunodeficiency virus and chronic hepatitis C virus infection was taking antiretroviral treatment before the liver transplant. The patient was hepatitis C virus RNA-positive, human immunodeficiency virus RNA-negative, and had a CD4 T-cell count of 620/µL. His son was the donor, and a right lobe liver transplant was performed uneventfully in antiretroviral treatment continued in the early postoperative period and a triple immunosuppressive regimen consisting tacrolimus, mycophenolate mofetil, and steroids was initiated. Broad-spectrum ß-lactamase-positive Escherichia coli bacteremia and hospital-acquired pneumonia developed postoperatively and were treated successfully. The patient was discharged on postoperative day 19, and remains alive 13 months after the operation. CONCLUSIONS: Living-donor liver transplant is a promising treatment choice for end-stage liver disease in human immunodeficiency virus-infected patients.

Postoperative cognitive dysfunction in living liver transplant donors.

OBJECTIVES: Postoperative cognitive dysfunction is a serious complication that may be associated with increased mortality. Living-donor liver transplant includes major surgery for the donor. The purpose of this study was to evaluate preoperative and postoperative cognitive function of liver donors in living-donor liver transplant. MATERIALS AND METHODS: In 102 patients who had hepatectomy for liver transplant donation, preoperative and postoperative (1 week) neuropsychologic tests were performed including the Trail Making Test, the Stroop effect, score on the Beck Depression Inventory, and the mini-mental state examination. RESULTS: Liver transplant donors had significantly lower mean Trail Making A Test duration and greater mean Trail Making B Test error number after than before surgery. The mean Stroop effect reading durations (black and white reading; reading colored words) were significantly greater after than before surgery; the mean time difference between naming the colors of colored words minus reading colored words, and the error number, were smaller after than before surgery. The mean score on the Beck Depression Inventory and mini-mental state examination score were similar before and after surgery. CONCLUSIONS: Mild frontal lobe dysfunction may be present in liver donors at 1 week after surgery, and postoperative attention problems may be experienced by these patients.

Effect of autotransfusion system on tumor recurrence and survival in hepatocellular carcinoma patients.

AIM: To investigate the therapeutic efficacy and safety of continuous autotransfusion system (CATS) during liver transplantation of hepatocellular carcinoma patients. METHODS: Eighty-three hepatocellular carcinoma (HCC) patients who underwent liver transplantation with intraoperative CATS (n = 24, CATS group) and without (n = 59, non-CATS group) between April 2006 and November 2011 at the Liver Transplant Institute of Inonu University were analyzed retrospectively. Postoperative HCC recurrence was monitored by measuring alpha-fetoprotein (AFP) levels at 3-mo intervals and performing imaging analysis by thoracoabdominal multidetector computed tomography at 6-month intervals. Inter-group differences in recurrence and correlations between demographic, clinical, and pathological data were assessed by ANOVA and χ(2) tests. Overall and disease-free survivals were calculated by the univariate Kaplan-Meier method. RESULTS: Of the 83 liver transplanted HCC patients, 89.2% were male and the overall mean age was 51.3 ± 8.9 years (range: 18-69 years). The CATS and non-CATS groups showed no statistically significant differences in age, sex ratio, body mass index, underlying disease, donor type, graft-to-recipient weight ratio, Child-Pugh and Model for End-Stage Liver Disease scores, number of tumors, tumor size, AFP level, Milan and University of California San Francisco selection criteria, tumor differentiation, macrovascular invasion, median hospital stay, recurrence rate, recurrence site, or mortality rate. The mean follow-up time of the non-CATS group was 17.9 ± 12.8 mo, during which systemic metastasis and/or locoregional recurrence developed in 25.4% of the patients. The mean follow-up time for the CATS group was 25.8 ± 15.1 mo, during which systemic metastasis and/or locoregional recurrence was detected in 29.2% of the patients. There was no significant difference between the CATS and non-CATS groups in recurrence rate or site. Additionally, no significant differences existed between the groups in overall or disease-free survival. CONCLUSION: CATS is a safe procedure and may decrease the risk of tumor recurrence in HCC patients.

Single-center analysis of the first 304 living-donor liver transplantations in 3 years.

BACKGROUND/AIMS: Living donor liver transplantations (LDLT) is a definitive treatment for patients with end-stage liver disease (ESLD), especially in the countries with donation problem. Between April 2007 and April 2010, we performed LDLT in 289 patients. Fifteen of the cases required re-transplantations. This study evaluates these 304 consecutive LDLTs donor and recipient outcomes. METHODOLOGY: Complication rates and survival data of the recipients and donors of 304 LDLT cases were analyzed. RESULTS: All donors are alive and well. Overall complication rate was 27%. Early postoperative recipient complication rate was 51%. Most frequent complication was infection. In the long-term there were 57 biliary stricture and 5 chronic bile fistula cases. Chronic and acute rejection attacks developed in 7 and 103 patients, respectively. Hepatic artery thrombosis rate was 8%. One, two and three year survival rates were 82%, 79% and 75%, respectively. Recipient mortality was 25%, mostly due to vascular complications, septic complications, liver dysfunction and chronic rejection. CONCLUSIONS: More than 150 liver tranplantations per year in a single center is a challenge in Turkey, where there is a shortage of deceased donor grafts. LDLT is a safe procedure for donors and effective for ESLD. Improvement in surgical technique would provide better outcomes.

Instillation of skin, nephrostomy tract, and renal puncture site with ropivacaine decreases pain and improves ventilatory function after percutaneous nephrolithotomy.

BACKGROUND AND PURPOSE: Pain after percutaneous nephrolithotomy (PCNL) is well investigated, but no optimal management strategy has yet been defined. Ventilatory changes after uncomplicated PCNL remain obscure. We investigated whether pain can be managed with a combination of a parenteral non-narcotic drug and instillation of a local anesthetic into the operative field. We also measured ventilatory changes early after PCNL to determine whether this analgesic modality improves ventilatory status. PATIENTS AND METHODS: In a randomized blinded study, 34 well-matched patients underwent PCNL with single subcostal access. At the end of the operation, 30 mL of either 0.02% ropivacaine or saline was instilled into the renal puncture site, nephrostomy tract, and skin. Postoperatively, patients received parenteral metamizol (dipyrone) (500 mg/dose) on demand. Pain visual analog score (VAS), peak expiratory flow rate (PEF), and blood-gas analysis were performed at 2, 6, and 24 hours postoperatively. The number of analgesic doses required was recorded. RESULTS: The VAS at 6 hours, time to first analgesic demand, and total analgesic need were significantly lower (P=0.001, 0.008, and 0.001, respectively) in the ropivacaine group, whereas the PEF at 2 and 6 hours was significantly higher (P=0.001 for each). Analgesic use in the first 12 and 24 hours was lower in this group. Blood-gas analysis was within the normal range in both groups. Time of surgery and hemoglobin decrease were not significantly different. CONCLUSIONS: A decrease in PEF indicating restricted ventilation appears early after PCNL. Because these patients were chosen carefully to have normal function preoperatively, this decrease was attributed to nociception. A combination of ropivacaine instillation with metamizol decreases pain and analgesic use and improves PEF more than use of metamizol alone. Such a multimodal pain-management strategy is effective in minimizing postoperative opioid use with proper pain management, resulting in better ventilation.

Arterial myocardial revascularization using bilateral radial artery 17 years after right pneumonectomy.

We report the case of a 51-year-old man who underwent arterial myocardial revascularization with the use of bilateral radial arteries, 17 years after undergoing a right pneumonectomy. We used a fast-track anesthesia protocol for the procedure. There was no perioperative complication, and postoperative recovery was uneventful. The patient was discharged from the hospital 5 days after the operation.