Liberal Use of Hemofiltration to Optimize Volume Status in iPAH Patients Does Not Impair Long-Term Kidney Function

Abstract

The post-operative phase after LTx for iPAH can be challenging. A restrictive fluid management facilitates unloading of the untrained left ventricle and reduces the risk for reperfusion edema. In our center, hemofiltration (HF) is pre-emptively started when a patient cannot be balanced negatively despite maximal medicamentous effort. It remains unclear whether such a strategy impairs long-term outcomes. iPAH patients transplanted between 2000 and 2018 were included in this retrospective analysis. Data collected included kidney function, immunosuppressive therapy, use of HF, PGD rates, length of mechanical ventilation and survival RESULTS: Within the study period 99 iPAH patients were transplanted in our institution. Preoperative kidney insufficiency was recorded in 21 patients (21%). Estimated glomerular filtration rate decreased from a median of 83 ml/min at arrival in ICU to a median of 62 ml/min two days after LTx. In thirty patients (30%) HF was started within the first 48 hours with a median length of 21 days (10-27). In these patients serum creatinine (1.1 vs 1.8 mg/dL, p<0.001) and blood urea nitrogen (28 vs 35 mg/dL, p<0.001) was significantly higher in the first three postoperative days. All patients could be successfully weaned from HF. No difference was found between the two groups in terms of serum creatinine at 1, 3 and 5 years: 1.12 vs 1.2 mg/dL, 1.12 vs 1.2 mg/dL and 1.14 vs 1.25 mg/dL, respectively. Patients requiring postoperative HF showed comparable long-term rates of higher CKD stages (18%) to the other patients (23%, p=0.99). Multivariable Cox regression revealed that HF was not a risk factor for long-term survival (p=0.127). Long-term survival was excellent with 5-year survival rates of 79% CONCLUSION: A liberal use of HF in the early postoperative period does not impact long-term kidney function. Our data suggest that an aggressive peri-operative fluid management including early implementation of HF leads to excellent long-term outcomes.