Paolo Angeli1, Dimitri Bezinover2, Gianni Biancofiore3, Anja Bienholz4, James Findlay5, Catherine Paugam Burtz6,7, Koen Reyntjens8, Tetsuro Sakai9, Fuat H Saner10, Dana Tomescu11, Gebhard Wagener12, Emmanuel Weiss6,7. 1. Department of Medicine, Hepatology Unit, University School of Medicine, Padova, Italy. 2. Department of Anesthesiology, Penn State Hershey Medical Center, Hershey, PA, USA. 3. Department of Transplant Anesthesia and Critical Care, Azienda Ospedaliera Universitaria, Pisa, Italy. 4. Department of Nephrology, University Duisburg-Essen, Essen, Germany. 5. Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA. 6. Department of Anesthesia and Critical Care, APHP Hopital Beaujon, Clichy, France. 7. University Paris Diderot-Paris 7, Paris, France. 8. Department of Anesthesia, University Medical Center, University of Groningen, Groningen, The Netherlands. 9. Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. 10. Department of General, Visceral, and Transplant Surgery, University Duisburg-Essen, Essen, Germany - fuat.saner@uni-due.de. 11. Department of Anesthesiology and Critical Care, Fundeni Clinical Institute, Bucharest, Romania. 12. Department of Anesthesiology, University of Columbia, New York, NY, USA.
Abstract
INTRODUCTION: Acute kidney injury is associated with high mortality in the perioperative period of liver transplantation. The aim of this position paper was to provide an up-to-date overview with special emphases on diagnosis, risk factors, and treatment. EVIDENCE ACQUISITION: The Liver Intensive Care Group of Europe nominated a panel of recognized international experts who reviewed the available literature published from 1990 to January 2016 and produced clinical recommendations. The level of evidence and strength of recommendation were judged according to the Grading of Recommendations Assessment Development and Evaluation system. EVIDENCE SYNTHESIS: Diagnosis of AKI should be based on the KDIGO criteria. The preoperative risk factors are more related to the patient's predisposing factors and post-operative risk factors tend to be difficult to control. Therefore, focusing on intra-operative risk factors it would be important to maintain an adequate hemodynamics and to keep inferior vena cava clamping as short as possible. Biomarkers to identify AKI at an early stage are available; however, there is a lack of robust data that indicates their true beneficial effect. Intraoperative renal replacement therapy may be beneficial in some selective cases whereas its postoperative timing is still under debate. CONCLUSIONS: Perioperative liver transplant risk factors for acute kidney injury are difficult to control. Therefore, the focus should be on intra-operative hemodynamics and nephrotoxic drugs avoidance. Prospective randomized trials are needed to show the beneficial effect of early replacement therapy. In this context, the new biomarkers would be helpful in identifying kidney injury earlier.
INTRODUCTION:Acute kidney injury is associated with high mortality in the perioperative period of liver transplantation. The aim of this position paper was to provide an up-to-date overview with special emphases on diagnosis, risk factors, and treatment. EVIDENCE ACQUISITION: The Liver Intensive Care Group of Europe nominated a panel of recognized international experts who reviewed the available literature published from 1990 to January 2016 and produced clinical recommendations. The level of evidence and strength of recommendation were judged according to the Grading of Recommendations Assessment Development and Evaluation system. EVIDENCE SYNTHESIS: Diagnosis of AKI should be based on the KDIGO criteria. The preoperative risk factors are more related to the patient's predisposing factors and post-operative risk factors tend to be difficult to control. Therefore, focusing on intra-operative risk factors it would be important to maintain an adequate hemodynamics and to keep inferior vena cava clamping as short as possible. Biomarkers to identify AKI at an early stage are available; however, there is a lack of robust data that indicates their true beneficial effect. Intraoperative renal replacement therapy may be beneficial in some selective cases whereas its postoperative timing is still under debate. CONCLUSIONS: Perioperative liver transplant risk factors for acute kidney injury are difficult to control. Therefore, the focus should be on intra-operative hemodynamics and nephrotoxic drugs avoidance. Prospective randomized trials are needed to show the beneficial effect of early replacement therapy. In this context, the new biomarkers would be helpful in identifying kidney injury earlier.