Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Critical Care
Published in: Critical Care 1/2017

Open Access 01-12-2017 | Research

Renal function and oxygenation are impaired early after liver transplantation despite hyperdynamic systemic circulation

Authors: Jenny Skytte Larsson, Gudrun Bragadottir, Bengt Redfors, Sven-Erik Ricksten

Published in: Critical Care | Issue 1/2017

Login to get access

Abstract

Background

Acute kidney injury (AKI) occurs frequently after liver transplantation and is associated with the development of chronic kidney disease and increased mortality. There is a lack of data on renal blood flow (RBF), oxygen consumption, glomerular filtration rate (GFR) and renal oxygenation, i.e. the renal oxygen supply/demand relationship, early after liver transplantation. Increased insight into the renal pathophysiology after liver transplantation is needed to improve the prevention and treatment of postoperative AKI. We have therefore studied renal hemodynamics, function and oxygenation early after liver transplantation in humans.

Methods

Systemic hemodynamic and renal variables were measured during two 30-min periods in liver transplant recipients (n = 12) and post-cardiac surgery patients (controls, n = 73). RBF and GFR were measured by the renal vein retrograde thermodilution technique and by renal extraction of Cr-EDTA (= filtration fraction), respectively. Renal oxygenation was estimated from the renal oxygen extraction.

Results

In the liver transplant group, GFR decreased by 40% (p < 0.05), compared to the preoperative value. Cardiac index and systemic vascular resistance index were 65% higher (p < 0.001) and 36% lower (p < 0.001), respectively, in the liver transplant recipients compared to the control group. GFR was 27% (p < 0.05) and filtration fraction 40% (p < 0.01) lower in the liver transplant group. Renal vascular resistance was 15% lower (p < 0.05) and RBF was 18% higher (p < 0.05) in liver transplant recipients, but the ratio between RBF and cardiac index was 27% lower (p < 0.001) among the liver-transplanted patients compared to the control group. Renal oxygen consumption and extraction were both higher in the liver transplants, 44% (p < 0.01) and 24% (p < 0.05) respectively.

Conclusions

Despite the hyperdynamic systemic circulation and renal vasodilation, there is a severe decline in renal function directly after liver transplantation. This decline is accompanied by an impaired renal oxygenation, as the pronounced elevation of renal oxygen consumption is not met by a proportional increase in renal oxygen delivery. This information may provide new insights into renal pathophysiology as a basis for future strategies to prevent/treat AKI after liver transplantation.

Trial registration

ClinicalTrials.gov, NCT02455115. Registered on 23 April 2015.
Literature
1.
Hilmi IA, Damian D, Al-Khafaji A, Planinsic R, Boucek C, Sakai T, Chang CC, Kellum JA. Acute kidney injury following orthotopic liver transplantation: incidence, risk factors, and effects on patient and graft outcomes. Br J Anaesth. 2015;114(6):919–26.CrossRefPubMed
2.
Junge G, Schewior LV, Kohler S, Neuhaus R, Langrehr JM, Tullius S, Kahl A, Frei U, Neuhaus P. Acute renal failure after liver transplantation: incidence, etiology, therapy, and outcome. Transplant Proc. 2006;38(3):723–4.CrossRefPubMed
3.
Biagioni E, Cavazzuti I, Busani S, Trevisan D, Zavatti L, Ferrari E, Girardis M. Acute renal failure and renal replacement therapy in the postoperative period of orthotopic liver transplant patients versus nonelective abdominal surgery patients. Transplant Proc. 2011;43(4):1145–7.CrossRefPubMed
4.
Klaus F, Keitel da Silva C, Meinerz G, Carvalho LM, Goldani JC, Cantisani G, Zanotelli ML, Duro Garcia V, Keitel E. Acute kidney injury after liver transplantation: incidence and mortality. Transplant Proc. 2014;46(6):1819–21.CrossRefPubMed
5.
Barri YM, Sanchez EQ, Jennings LW, Melton LB, Hays S, Levy MF, Klintmalm GB. Acute kidney injury following liver transplantation: definition and outcome. Liver Transpl. 2009;15(5):475–83.CrossRefPubMed
6.
Chertow GM, Burdick E, Honour M, Bonventre JV, Bates DW. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol. 2005;16(11):3365–70.CrossRefPubMed
7.
Arroyo V, Guevara M, Gines P. Hepatorenal syndrome in cirrhosis: pathogenesis and treatment. Gastroenterology. 2002;122(6):1658–76.CrossRefPubMed
8.
Ruiz-del-Arbol L, Monescillo A, Arocena C, Valer P, Gines P, Moreira V, Milicua JM, Jimenez W, Arroyo V. Circulatory function and hepatorenal syndrome in cirrhosis. Hepatology. 2005;42(2):439–47.CrossRefPubMed
9.
Pan HC, Chien YS, Jenq CC, Tsai MH, Fan PC, Chang CH, Chang MY, Tian YC, Fang JT, Yang CW, et al. Acute kidney injury classification for critically ill cirrhotic patients: a comparison of the KDIGO, AKIN, and RIFLE classifications. Sci Rep. 2016;6:23022.CrossRefPubMedPubMedCentral
10.
11.
Caregaro L, Menon F, Angeli P, Amodio P, Merkel C, Bortoluzzi A, Alberino F, Gatta A. Limitations of serum creatinine level and creatinine clearance as filtration markers in cirrhosis. Arch Intern Med. 1994;154(2):201–5.CrossRefPubMed
12.
Sherman DS, Fish DN, Teitelbaum I. Assessing renal function in cirrhotic patients: problems and pitfalls. Am J Kidney Dis. 2003;41(2):269–78.CrossRefPubMed
13.
Levitsky J, O’Leary JG, Asrani S, Sharma P, Fung J, Wiseman A, Niemann CU. Protecting the kidney in liver transplant recipients. Am J Transplant. 2016;16(9):2532–44.CrossRefPubMed
14.
Bragadottir G, Redfors B, Nygren A, Sellgren J, Ricksten SE. Low-dose vasopressin increases glomerular filtration rate, but impairs renal oxygenation in post-cardiac surgery patients. Acta Anaesthesiol Scand. 2009;53(8):1052–9.CrossRefPubMed
15.
Bragadottir G, Redfors B, Ricksten SE. Effects of levosimendan on glomerular filtration rate, renal blood flow, and renal oxygenation after cardiac surgery with cardiopulmonary bypass: a randomized placebo-controlled study. Crit Care Med. 2013;41(10):2328–35.CrossRefPubMed
16.
Redfors B, Bragadottir G, Sellgren J, Sward K, Ricksten SE. Dopamine increases renal oxygenation: a clinical study in post-cardiac surgery patients. Acta Anaesthesiol Scand. 2010;54(2):183–90.CrossRefPubMed
17.
Skytte Larsson J, Bragadottir G, Krumbholz V, Redfors B, Sellgren J, Ricksten SE. Effects of acute plasma volume expansion on renal perfusion, filtration, and oxygenation after cardiac surgery: a randomized study on crystalloid vs colloid. Br J Anaesth. 2015;115(5):736–42.CrossRefPubMed
18.
Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, Levin A. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11(2):R31.CrossRefPubMedPubMedCentral
19.
Redfors B, Sward K, Sellgren J, Ricksten SE. Effects of mannitol alone and mannitol plus furosemide on renal oxygen consumption, blood flow and glomerular filtration after cardiac surgery. Intensive Care Med. 2009;35(1):115–22.CrossRefPubMed
20.
Sward K, Valsson F, Sellgren J, Ricksten SE. Bedside estimation of absolute renal blood flow and glomerular filtration rate in the intensive care unit. A validation of two independent methods. Intensive Care Med. 2004;30(9):1776–82.CrossRefPubMed
21.
Schnermann J. The expanding role of aldosterone in the regulation of body Na content. Pflugers Arch. 2003;446(4):410–1.CrossRefPubMed
22.
23.
Sward K, Valsson F, Sellgren J, Ricksten SE. Differential effects of human atrial natriuretic peptide and furosemide on glomerular filtration rate and renal oxygen consumption in humans. Intensive Care Med. 2005;31(1):79–85.CrossRefPubMed
24.
Redfors B, Bragadottir G, Sellgren J, Sward K, Ricksten SE. Acute renal failure is NOT an “acute renal success”--a clinical study on the renal oxygen supply/demand relationship in acute kidney injury. Crit Care Med. 2010;38(8):1695–701.CrossRefPubMed
25.
Siniscalchi A, Gamberini L, Laici C, Bardi T, Ercolani G, Lorenzini L, Faenza S. Post reperfusion syndrome during liver transplantation: from pathophysiology to therapy and preventive strategies. World J Gastroenterol. 2016;22(4):1551–69.CrossRefPubMedPubMedCentral
26.
27.
Brezis M, Rosen S. Hypoxia of the renal medulla--its implications for disease. N Engl J Med. 1995;332(10):647–55.CrossRefPubMed
28.
Niemann CU, Walia A, Waldman J, Davio M, Roberts JP, Hirose R, Feiner J. Acute kidney injury during liver transplantation as determined by neutrophil gelatinase-associated lipocalin. Liver Transpl. 2009;15(12):1852–60.CrossRefPubMed
29.
Portal AJ, McPhail MJ, Bruce M, Coltart I, Slack A, Sherwood R, Heaton ND, Shawcross D, Wendon JA, Heneghan MA. Neutrophil gelatinase--associated lipocalin predicts acute kidney injury in patients undergoing liver transplantation. Liver Transpl. 2010;16(11):1257–66.CrossRefPubMed
30.
Wagener G, Minhaz M, Mattis FA, Kim M, Emond JC, Lee HT. Urinary neutrophil gelatinase-associated lipocalin as a marker of acute kidney injury after orthotopic liver transplantation. Nephrol Dial Transplant. 2011;26(5):1717–23.CrossRefPubMedPubMedCentral
31.
Moller S, Henriksen JH, Bendtsen F. Extrahepatic complications to cirrhosis and portal hypertension: haemodynamic and homeostatic aspects. World J Gastroenterol. 2014;20(42):15499–517.CrossRefPubMedPubMedCentral
32.
Ferguson JW, Dover AR, Chia S, Cruden NL, Hayes PC, Newby DE. Inducible nitric oxide synthase activity contributes to the regulation of peripheral vascular tone in patients with cirrhosis and ascites. Gut. 2006;55(4):542–6.CrossRefPubMedPubMedCentral
33.
Richer M, Robert S, Lebel M. Renal hemodynamics during norepinephrine and low-dose dopamine infusions in man. Crit Care Med. 1996;24(7):1150–6.CrossRefPubMed
34.
Hoogenberg K, Smit AJ, Girbes AR. Effects of low-dose dopamine on renal and systemic hemodynamics during incremental norepinephrine infusion in healthy volunteers. Crit Care Med. 1998;26(2):260–5.CrossRefPubMed
35.
Redfors B, Bragadottir G, Sellgren J, Sward K, Ricksten SE. Effects of norepinephrine on renal perfusion, filtration and oxygenation in vasodilatory shock and acute kidney injury. Intensive Care Med. 2011;37(1):60–7.CrossRefPubMed
36.
Mukhtar A, Salah M, Aboulfetouh F, Obayah G, Samy M, Hassanien A, Bahaa M, Abdelaal A, Fathy M, Saeed H. The use of terlipressin during living donor liver transplantation: effects on systemic and splanchnic hemodynamics and renal function*. Crit Care Med. 2011;39(6):1329–34.CrossRefPubMed
Metadata
Title
Renal function and oxygenation are impaired early after liver transplantation despite hyperdynamic systemic circulation
Authors
Jenny Skytte Larsson
Gudrun Bragadottir
Bengt Redfors
Sven-Erik Ricksten
Publication date
01-12-2017
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2017
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-017-1675-4

Other articles of this Issue 1/2017

Critical Care 1/2017 Go to the issue

Letter

Variability of response to the fluid bolus is again demonstrated

Review

Respiratory support in patients with acute respiratory distress syndrome: an expert opinion

Research

Long-term continuous renal replacement therapy and anticoagulation with citrate in critically ill patients with severe liver dysfunction

Research

Selepressin, a novel selective vasopressin V1A agonist, is an effective substitute for norepinephrine in a phase IIa randomized, placebo-controlled trial in septic shock patients

Letter

Accounting for single center effects in systematic reviews cannot be overlooked

Research

Role of vasopressin and terlipressin in refractory shock compared to conventional therapy in the neonatal and pediatric population: a systematic review, meta-analysis, and trial sequential analysis