Analysis of Predictors for Lactate Elimination After Reperfusion in Recipients of Living-Donor Liver Transplantation J.H. Jun, G.S. Kim, Y.R. Na, M.S. Gwak, J.S. Ko, and S.K. Lee ABSTRACT Background. Graft-recipient weight ratio (GRWR) is the only documented predictor that influences the lactate elimination after reperfusion in living-donor liver transplantation (LDLT). This study was performed to investigate the predictors of lactate elimination after reperfusion in recipients of adult LDLT. Methods. The medical records of 159 patients who underwent LDLT were analyzed. Lactate level (mmol/L) was measured from just before the initiation of surgery (P0) and 5, 60, and 120 minutes after reperfusion of graft (R0, R1, and R2, respectively). The change of lactate level after reperfusion was defined as difference between lactate level measured at R0 and R2. Patients were divided into accumulation and elimination groups. Donor and recipient factors were compared between the 2 groups. Results. Lactate accumulation occurred in 80 of 159 recipients (50.3%), and elimination occurred in 79 (49.7%). GRWR and Model for End-Stage Liver Disease (MELD) score were higher in the elimination group. Lactate at R0 was lower in the elimination group. Conclusions. Higher GRWR and MELD score and lower lactate level immediate after reperfusion of graft were predictors of lactate elimination after reperfusion during adult LDLT.
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N DECREASED-DONOR liver transplantation (DDLT), blood lactate levels usually continue to increase until reperfusion, and they decrease after reperfusion [1,2]. Orii et al reported that the lactate profiles of living-donor liver transplantation (LDLT) were similar to those of DDLT and that graft size relative to body size was the only documented predictor that influenced lactate elimination after reperfusion [3]. But, the subjects of that study were mostly pediatric recipients (67%) with large grafts relative to body size [3]. We have experienced lactate elimination after reperfusion varying considerably during adult LDLT. Therefore, the present study was performed to determine which clinical factors showed influences on lactate elimination after reperfusion during adult LDLT. PATIENTS AND METHODS With Institutional Review Board approval, we performed a retrospective analysis of 320 adult patients who underwent LDLT in our hospital from December 2009 to May 2012. Of these, retransplantations (n ¼ 5), incomplete data (n ¼ 25), cases with continuous renal replacement therapy before surgery (n ¼ 14), and cases received lactated Ringer solution before reperfusion (n ¼ 32) were ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 46, 709e711 (2014)
excluded from the study. Cases with change of lactate level (mmol/L) after reperfusion of 0.5 to 0.5 (n ¼ 85) were excluded to avoid considering laboratory errors. The remaining 159 patients were analyzed in the present study. Anesthesia was standardized with isoflurane and remifentanil for maintenance. Mechanical ventilation was controlled to maintain normocapnia. Grafts were flushed with histidine-tryptophanketoglutarate solution, and actual graft weights were measured after flushing. Blood was sampled from a radial artery at just before the initiation of surgery (P0) and 5, 60, and 120 minutes after reperfusion (R0, R1, and R2, respectively). The change of lactate level after
From the Department of Anesthesiology and Pain Medicine (J.H.J., G.S.K., Y.R.N., M.S.G., J.S.K.) and Department of Surgery (S.K.L.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. Address reprint requests to Gaab Soo Kim, MD, PhD, Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Korea. E-mail: [email protected] 0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.11.090 709
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reperfusion was defined as the difference between lactate levels measured at R0 and R2. Positive value was considered to show elimination and negative number accumulation, and accordingly, the recipients were divided into accumulation group and elimination group. Donor and recipient factors were compared between the 2 groups. Continuous variables were tested for normal distribution. Unpaired t test was used for analyzing the difference in lactate level according to the group. The donor and recipient factors of the groups were compared by Fisher exact test or Mann-Whitney test. Binary logistic regression analysis was performed, including lactate level at R0 and donor and recipient factors for multiple comparisons. The SPSS software version 21.0 (IBM, Armonk, New York) was used for all of the statistical analyses. P values of
I
N DECREASED-DONOR liver transplantation (DDLT), blood lactate levels usually continue to increase until reperfusion, and they decrease after reperfusion [1,2]. Orii et al reported that the lactate profiles of living-donor liver transplantation (LDLT) were similar to those of DDLT and that graft size relative to body size was the only documented predictor that influenced lactate elimination after reperfusion [3]. But, the subjects of that study were mostly pediatric recipients (67%) with large grafts relative to body size [3]. We have experienced lactate elimination after reperfusion varying considerably during adult LDLT. Therefore, the present study was performed to determine which clinical factors showed influences on lactate elimination after reperfusion during adult LDLT. PATIENTS AND METHODS With Institutional Review Board approval, we performed a retrospective analysis of 320 adult patients who underwent LDLT in our hospital from December 2009 to May 2012. Of these, retransplantations (n ¼ 5), incomplete data (n ¼ 25), cases with continuous renal replacement therapy before surgery (n ¼ 14), and cases received lactated Ringer solution before reperfusion (n ¼ 32) were ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 46, 709e711 (2014)
excluded from the study. Cases with change of lactate level (mmol/L) after reperfusion of 0.5 to 0.5 (n ¼ 85) were excluded to avoid considering laboratory errors. The remaining 159 patients were analyzed in the present study. Anesthesia was standardized with isoflurane and remifentanil for maintenance. Mechanical ventilation was controlled to maintain normocapnia. Grafts were flushed with histidine-tryptophanketoglutarate solution, and actual graft weights were measured after flushing. Blood was sampled from a radial artery at just before the initiation of surgery (P0) and 5, 60, and 120 minutes after reperfusion (R0, R1, and R2, respectively). The change of lactate level after
From the Department of Anesthesiology and Pain Medicine (J.H.J., G.S.K., Y.R.N., M.S.G., J.S.K.) and Department of Surgery (S.K.L.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. Address reprint requests to Gaab Soo Kim, MD, PhD, Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Korea. E-mail: [email protected] 0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.11.090 709
710
JUN, KIM, NA ET AL
reperfusion was defined as the difference between lactate levels measured at R0 and R2. Positive value was considered to show elimination and negative number accumulation, and accordingly, the recipients were divided into accumulation group and elimination group. Donor and recipient factors were compared between the 2 groups. Continuous variables were tested for normal distribution. Unpaired t test was used for analyzing the difference in lactate level according to the group. The donor and recipient factors of the groups were compared by Fisher exact test or Mann-Whitney test. Binary logistic regression analysis was performed, including lactate level at R0 and donor and recipient factors for multiple comparisons. The SPSS software version 21.0 (IBM, Armonk, New York) was used for all of the statistical analyses. P values of
