January 11, 2021Open Access

Intraoperative hypotension during liver transplant surgery is associated with postoperative acute kidney injury: a historical cohort study

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Liver transplant surgery (n=205). Intervention: Intraoperative hypotension (MAP < 65 mmHg) vs. Shorter duration or absence of intraoperative hypotension. Primary outcome: Postoperative acute kidney injury (AKI) stages 1-3 based on modified KDIGO criteria (OR 1.05, 95% CI 1.02-1.09, p=<0.001).

AJAlexandre JoostenGeneral Cardiology VLValério LucidiUniversité Libre de Bruxelles BIBrigitte IckxUniversité Libre de Bruxelles

Key Result

Intraoperative hypotension during liver transplant surgery was independently associated with an increased risk of postoperative acute kidney injury, with each 1% increase in case time spent with a MAP < 65 mmHg increasing the risk by 5% (OR 1.05).

Study Design

Type

Cohort (n=205)

Multicenter

Structured PICO

Does intraoperative hypotension increase the risk of postoperative acute kidney injury in patients undergoing liver transplant surgery?

Population

205 patients undergoing liver transplant surgery, excluding those with preoperative creatinine > 1.5 mg/dl or combined transplantation, evaluated for the association between intraoperative hypotension and postoperative acute kidney injury.

Exposure

Intraoperative hypotension (IOH), defined as mean arterial pressure (MAP) < 65 mmHg, categorized by duration of case time (intermediate: 8.6-39.5%, long: > 39.5%).

Comparator

Short duration of IOH (< 8.6% of case time).

Outcome

Postoperative acute kidney injury (AKI) classified according to modified KDIGO criteria.hard clinical

Intraoperative hypotension during liver transplant surgery is strongly and independently associated with the development of postoperative acute kidney injury in a duration-dependent manner.

Main Result

Odds Ratio: 1.05 (95% CI 1.02–1.09)

p-value: p=<0.001

Limitations

Observational, historical, single-centre design with a relatively small sample size
Potential bias from unmeasured confounding parameters at patient and hospital levels
Urine output was not used for AKI classification, potentially underestimating incidence
Exclusion of patients with pre-existing renal impairment
Postoperative hypotension was not considered
Lack of data on mixed venous oxygen saturation, stroke volume index, and systemic vascular resistance
No data on post-reperfusion syndrome
Odds ratio may overestimate risk for a frequent outcome like AKI

Abstract

BACKGROUND: Acute kidney injury (AKI) occurs frequently after liver transplant surgery and is associated with significant morbidity and mortality. While the impact of intraoperative hypotension (IOH) on postoperative AKI has been well demonstrated in patients undergoing a wide variety of non-cardiac surgeries, it remains poorly studied in liver transplant surgery. We tested the hypothesis that IOH is associated with AKI following liver transplant surgery. METHODS: This historical cohort study included all patients who underwent liver transplant surgery between 2014 and 2019 except those with a preoperative creatinine > 1.5 mg/dl and/or who had combined transplantation surgery. IOH was defined as any mean arterial pressure (MAP) 39.5%) duration. AKI stages were classified according to a "modified" "Kidney Disease: Improving Global Outcomes" (KDIGO) criteria. Logistic regression modelling was conducted to assess the association between IOH and postoperative AKI. The model was run both as a univariate and with multiple perioperative covariates to test for robustness to confounders. RESULTS: Of the 205 patients who met our inclusion criteria, 117 (57.1%) developed AKI. Fifty-two (25%), 102 (50%) and 51 (25%) patients had short, intermediate and long duration of IOH respectively. In multivariate analysis, IOH was independently associated with an increased risk of AKI (adjusted odds ratio OR 1.05; 95%CI 1.02-1.09; P < 0.001). Compared to "short duration" of IOH, "intermediate duration" was associated with a 10-fold increased risk of developing AKI (OR 9.7; 95%CI 4.1-22.7; P < 0.001). "Long duration" was associated with an even greater risk of AKI compared to "short duration" (OR 34.6; 95%CI 11.5-108.6; P < 0.001). CONCLUSIONS: Intraoperative hypotension is independently associated with the development of AKI after liver transplant surgery. The longer the MAP is < 65 mmHg, the higher the risk the patient will develop AKI in the immediate postoperative period, and the greater the likely severity. Anesthesiologists and surgeons must therefore make every effort to avoid IOH during surgery.

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Cite This Study

Joosten et al. (Mon,) conducted a cohort in Liver transplant surgery (n=205). Intraoperative hypotension (MAP < 65 mmHg) vs. Shorter duration or absence of intraoperative hypotension was evaluated on Postoperative acute kidney injury (AKI) stages 1-3 based on modified KDIGO criteria (OR 1.05, 95% CI 1.02-1.09, p=<0.001). Intraoperative hypotension during liver transplant surgery was independently associated with an increased risk of postoperative acute kidney injury, with each 1% increase in case time spent with a MAP < 65 mmHg increasing the risk by 5% (OR 1.05).

synapsesocial.com/papers/6a5e4ce59403c3eaf3e2883a https://doi.org/https://doi.org/10.1186/s12871-020-01228-y

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