title: Intraoperative hemodialysis during liver transplantation: a decade of experience.
abstract: Liver transplantation (LT) for patients with renal dysfunction is frequently complicated by major fluid shifts, acidosis, and electrolyte and coagulation abnormalities. Continuous renal replacement therapy (CRRT) has been previously shown to ameliorate these problems. We describe the safety and clinical outcomes of intraoperative hemodialysis (IOHD) during LT for a group of patients with high Model for End-Stage Liver Disease (MELD) scores. We performed a retrospective study at our institution of patients who underwent IOHD from 2002 to 2012. Seven hundred thirty-seven patients underwent transplantation, and 32% received IOHD. The mean calculated MELD score was 37, with 38% having a MELD score ≥ 40. Preoperatively, 61% were in the intensive care unit, 19% were mechanically ventilated, 43% required vasopressor support, and 80% were on some form of renal replacement therapy at the time of transplantation, the majority being on CRRT. Patients on average received 35 U of blood products and 4.8 L of crystalloids without significant changes in hemodynamics or electrolytes. The average urine output was 450 ml, and the average amount of fluid removal with dialysis was 1.8 L. The 90-day patient and dialysis-free survival rates were 90% and 99%, respectively. One-year patient survival rates based on the pretransplant renal replacement status and the MELD status were not statistically different. This is the first large study to demonstrate the safety and feasibility of IOHD in a cohort of critically ill patients with high MELD scores undergoing LT with good patient and renal outcomes.
authors.affiliation: Departments of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA.
authors.forename: Mitra K
authors.initials: MK
authors.lastname: Nadim
authors.forename: Wanwarat
authors.initials: W
authors.lastname: Annanthapanyasut
authors.forename: Lea
authors.initials: L
authors.lastname: Matsuoka
authors.forename: Kari
authors.initials: K
authors.lastname: Appachu
authors.forename: Mark
authors.initials: M
authors.lastname: Boyajian
authors.forename: Lingyun
authors.initials: L
authors.lastname: Ji
authors.forename: Ashraf
authors.initials: A
authors.lastname: Sedra
authors.forename: Yuri S
authors.initials: YS
authors.lastname: Genyk
mesh_terms: D000368:Aged; D003422:Critical Care; D004573:Electrolytes; D058625:End Stage Liver Disease / Q000401:mortality / Q000601:surgery*; D005260:Female; D006439:Hemodynamics; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007432:Intraoperative Period; D053208:Kaplan-Meier Estimate; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D009173:Mycophenolic Acid / Q000031:analogs & derivatives / Q000627:therapeutic use; D011241:Prednisone / Q000627:therapeutic use; D006435:Renal Dialysis / Q000379:methods*; D017582:Renal Replacement Therapy; D012121:Respiration, Artificial; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D004573:Electrolytes; D007166:Immunosuppressive Agents; D009173:Mycophenolic Acid; D011241:Prednisone