Department of Medicine, Hepatology Unit, University School of Medicine, Padova, Italy.
Department of Anesthesiology, Penn State Hershey Medical Center, Hershey, PA, USA.
Minerva Anestesiol. 2017 Jan;83(1):88-101. doi: 10.23736/S0375-9393.16.11661-X. Epub 2016 Oct 19.
Acute kidney injury is associated with high mortality in the perioperative period of liver transplantation. The aim of this position paper was to provide an up-to-date overview with special emphases on diagnosis, risk factors, and treatment.
The Liver Intensive Care Group of Europe nominated a panel of recognized international experts who reviewed the available literature published from 1990 to January 2016 and produced clinical recommendations. The level of evidence and strength of recommendation were judged according to the Grading of Recommendations Assessment Development and Evaluation system.
Diagnosis of AKI should be based on the KDIGO criteria. The preoperative risk factors are more related to the patient's predisposing factors and post-operative risk factors tend to be difficult to control. Therefore, focusing on intra-operative risk factors it would be important to maintain an adequate hemodynamics and to keep inferior vena cava clamping as short as possible. Biomarkers to identify AKI at an early stage are available; however, there is a lack of robust data that indicates their true beneficial effect. Intraoperative renal replacement therapy may be beneficial in some selective cases whereas its postoperative timing is still under debate.
Perioperative liver transplant risk factors for acute kidney injury are difficult to control. Therefore, the focus should be on intra-operative hemodynamics and nephrotoxic drugs avoidance. Prospective randomized trials are needed to show the beneficial effect of early replacement therapy. In this context, the new biomarkers would be helpful in identifying kidney injury earlier.
急性肾损伤与肝移植围手术期高死亡率相关。本立场文件旨在提供最新的概述，重点关注诊断、危险因素和治疗。
欧洲肝脏重症监护组指定了一个由国际公认的专家组成的小组，对 1990 年至 2016 年 1 月发表的现有文献进行了回顾，并提出了临床建议。根据推荐评估、制定与评估系统（Grading of Recommendations Assessment Development and Evaluation system）对证据水平和推荐强度进行了判断。
AKI 的诊断应基于 KDIGO 标准。术前危险因素更多地与患者的易患因素有关，而术后危险因素往往难以控制。因此，关注术中危险因素，保持适当的血液动力学和尽量缩短下腔静脉夹闭时间非常重要。目前已有用于早期识别 AKI 的生物标志物，但缺乏表明其真正有益效果的可靠数据。术中肾脏替代治疗在某些选择性病例中可能有益，但其术后时机仍存在争议。
围手术期肝移植急性肾损伤的危险因素难以控制。因此，重点应放在术中血液动力学和避免肾毒性药物上。需要前瞻性随机试验来证明早期替代治疗的有益效果。在这种情况下，新的生物标志物将有助于更早地识别肾损伤。
