Intraoperative hypotension during liver transplantation and postoperative outcomes: Retrospective cohort study

Jacek B Cywinski; Yufei Li; Xiaodan Liu; Sandeep Khanna; Samuel Irefin; Ahmad Mousa; Kamal Maheshwari

doi:10.1016/j.jclinane.2024.111486

Intraoperative hypotension during liver transplantation and postoperative outcomes: Retrospective cohort study

J Clin Anesth. 2024 May 8:96:111486. doi: 10.1016/j.jclinane.2024.111486. Online ahead of print.

Authors

Jacek B Cywinski¹, Yufei Li², Xiaodan Liu³, Sandeep Khanna⁴, Samuel Irefin⁵, Ahmad Mousa⁵, Kamal Maheshwari³

Affiliations

¹ Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address: cywinsj@ccf.org.
² Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
³ Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
⁴ Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
⁵ Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.

PMID: 38728933
DOI: 10.1016/j.jclinane.2024.111486

Abstract

Study objectives: Evaluation of the association between intraoperative hypotension (IOH) and important postoperative outcomes after liver transplant such as incidence and severity of acute kidney injury (AKI), MACE and early allograft dysfunction (EAD).

Design: Retrospective, single institution study.

Settings: Operating room.

Patients: 1576 patients who underwent liver transplant in our institution between January 2005 and February 2022.

Measurements: IOH was measured as the time, area under the threshold (AUT), or time-weighted average (TWA) of mean arterial pressure (MAP) less than certain thresholds (55,60 and 65 mmHg). Associations between IOH exposures and AKI severity were assessed via proportional odds models. The odds ratio from the proportional odds model estimated the relative odds of having higher stage of AKI for higher exposure to IOH. Associations between exposures and MACE and EAD were assessed through logistic regression models. Potential confounding variables including patient baseline and surgical characteristics were adjusted for all models.

Main results: The primary analysis included 1576 surgeries that met the inclusion and exclusion criteria. Of those, 1160 patients (74%) experienced AKI after liver transplant surgery, with 780 (49%), 248(16%), and 132 (8.4%) experiencing mild, moderate, and severe injury, respectively. No significant association between hypotension exposure and postoperative AKI (yes or no) nor severity of AKI was observed. The odds ratios (95% CI) of having more severe AKI were 1.02 (0.997, 1.04) for a 50-mmHg·min increase in AUT of MAP <55 mmHg (P = 0.092); 1.03 (0.98, 1.07) for a 15-min increase in time spent under MAP <55 mmHg (P = 0.27); and 1.24 (0.98, 1.57) for a 1 mmHg increase in TWA of MAP <55 mmHg (P = 0.068). The associations between IOH and the incidence of MACE or EAD were not significant.

Conclusion: Our results did not show the association between IOH and investigated outcomes.

Keywords: Acute kidney injury; Intraoperative hypotension; Liver transplantation; Major cardiovascular events; Primary graft dysfunction.