Intraoperative Continuous Veno-Venous Hemofiltration Facilitates Surgery in Liver Transplant Patients With Acute Renal Failure.

Abstract

We have aggressively utilized continuous veno-venous hemofiltration (CVVH) on high MELD liver transplant patients with acute kidney injury in an effort to decrease transfusion requirements and complications, and improve overall outcomes. Methods: We performed a retrospective review of all adult, single organ, liver transplant recipients requiring pre-operative renal replacement therapy between 2011 and 2013. Intra- and peri-operative records were collected to create a database of these patients. Patients were grouped according to whether or not they underwent CVVH at the time of liver transplant. Results: Twenty-one 21 patients requiring CVVH received a liver transplant alone. Of these 21 patients, 14 received intraoperative CVVH and 7 patients did not. The average MELD score was similar between groups (34 for CVVH vs. 35, p=0.8). Pre-operative sodium and potassium were higher for the group receiving CVVH (p<0.01, p=0.02) but still fell within normal ranges. Pre-operative lactate levels were higher in the group that received intraoperative CVVH (4.7 vs. 2.0 mmol/L (p=0.01)). Intraoperative CVVH did not decrease intraoperative transfusion requirements (16 vs. 20 units PRBC, p=0.6; 17 vs. 19 units FFP, p=0.7; 8 vs. 16 units platelets, p=0.2), post-operative acidosis (7.40 vs. 7.35, p=0.8), or ICU and hospital lengths of stay. Furthermore, post-operative day 1 transfusion requirements were not decreased by intraoperative CVVH, (3 vs. 2 units PRBC, p=0.4; 2 vs. 1 unit FFP, p=0.2; 0.8 vs. 0.4 units platelets, p=0.4). Differences in reoperative rates did not reach statistical significance (29% with CVVH vs. 50%, p=0.6.) All patients were weaned off renal replacement therapy. Rolling one-year patient and graft survival was 100% for intraoperative CVVH versus 71% without, but this was not statistically significant (p=0.2). Conclusions: Patients undergoing intraoperative CVVH achieved statistically equivalent survival and transfusion outcomes despite higher pre-operative sodium, potassium, and lactate values, with trends of higher survival and decreased re-operative rates. The judicious use of intraoperative CVVH therapy may permit patients with increasing severity of illness to achieve outcomes comparable to less ill patients; however, aggressive pre- and post-operative CVVH may diminish the effect of intraoperative CVVH in cases with relatively short operative times.