Autori: Ilaria Umbro (1,2,3), Francesca Tinti (1,2,3), Felicity Evison (4), Marit Kalisvaart (1), Andrea Schlegel (1), Adnan Sharif (5), Bridget Gunson (6), James Ferguson (1), Paolo Muiesan (1), Anna Paola Mitterhofer (2)
Affiliazioni: (1) The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; (2) Department of Clinical Medicine, Nephrology Unit, Sapienza University of Rome, Rome, Italy; (3) Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, Sapienza University of Rome, Rome, Italy; (4) Department of Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom; (5) Department of Nephrology and Transplantation, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; (6) National Institute for Health Research Birmingham Liver Biomedical Research Unit, the Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom.
BACKGROUND:
Acute kidney injury (AKI) is a major cause of mortality after liver transplantation (LT).
Furthermore, liver transplant recipients with post-operative AKI are more likely to develop chronic kidney disease, compared to the transplant recipients without AKI.
Liver transplantation from Donation after Circulatory Death (DCD) is a model with increased occurrence of AKI compared to Donation after Brain Death (DBD).
This is likely to be related to a more severe ischaemic reperfusion injury sustained by the graft.
Aims of the study are:
- to evaluate incidence and classification of AKI in the first 7 days after LT;
- to identify risk factors for AKI after LT;
- to identify a predictive score for AKI in different models of ischaemia of the graft.
METHODS:
This is a retrospective single-centre study of 1150 patients undergone LT at Queen Elizabeth Hospital Birmingham from 2007 to 2014.
Exclusion criteria: urgent transplantation (=66), combined with other organs (=16), living donor liver transplants (=7) and previous renal (=1) grafting.
We considered: renal function pre-transplant and daily within one week post-transplant, characteristics of recipient and donor, graft variables and indicators of initial graft function.
AKI was defined according to the recent KDIGO Guideline (2012) as an increase in sCr by ≥ 0.3 mg/dl within 48 hours or an increase in sCr to ≥ 1.5 times baseline within the first 7 days after LT.
AKI was classified as:
- AKI Stage 1: increase ≥ 0.3 mg/dl or increase of 1.5-1.9 fold from baseline;
- AKI Stage 2: increase of 2-2.9 fold from baseline;
- AKI Stage 3: increase > 3-fold from baseline or increase in serum creatinine to ≥ 4.0 mg/dl or initiation of renal replacement therapy.
RESULTS:
1060 LT patients (247 DCD and 813 DBD) were included in the analysis.
The total incidence of AKI, and AKI stage 3 in particular, were significantly higher in DCD vs. DBD (see Table 1) despite better pre-LT liver and renal functions (see Table 2).
The risk factors for AKI are different in DBD (creatinine, INR, bilirubin, MELD, GFR<60, donor age, HCV) vs. DCD (recipient warm ischaemia time-WIT, donor height, recipient diabetes).
Donor weight, pre-transplant dialysis, recipient BMI, transfusions, duration of liver transplant, post-operative length of hospital stay and peak of AST after transplant are common risk factors for AKI in DBD and DCD recipients (See Table 3).
At the multivariate analysis, recipient BMI, MELD, donor age and plasma transfusions are confirmed as predictive for AKI in DBD recipients, whereas recipient WIT, diabetes, recipient BMI, donor height, plasma transfusions are predictive for AKI in DCD recipients.
Predictive score for AKI: exp(A)/[1+Exp(A)]
DCD patients: donor height, warm ischaemia time, plasma transfusions during transplant, recipient BMI and diabetes
A = [-7.224+(0.1054818* BMI)+(0.646008 if diabetes) +(0.163437*plasma)+ (0.00974447*WIT)+(1.84541953* donor height)]
This model correctly classified the 67.4%-81.7% of patients with sensitivity of 77.9-91.6 % and specificity of 27.6-73.5%.
DBD patients: MELD, plasma transfusions during transplant, donor age and recipient BMI
A = [-2.82403+(0.03887835 *MELD)+(0.05408386*Plasma)+ (0.0090986*age)+(0.0590638*BMI)]
This model correctly classified the 61.1%-69.4% of patients with sensitivity of 69.7-86.6% and specificity of 30.9-58.9%.
CONCLUSIONS:
Incidence of AKI stage 3 in post-liver transplantation DCD > DBD.
Different risk factors for AKI in DCD vs. DBD.
We produced risk prediction equations that may be used to improve our understanding of the risk of AKI after DCD and DBD liver transplantation.
Bibliografia:
Wilkinson A et al. Kidney dysfunction in the recipients of liver transplants. Liver Transpl 2005; (11 Suppl 2): S47-S51
Leithead JA et al. Donation after cardiac death liver transplant recipients have an increased frequency of acute kidney injury.Am J Transpl 2012;12(4):965-975
KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney inter 2013; Suppl 3:1–150