Renal Dysfunction Is an Independent Risk Factor for Mortality after Liver Resection and the Main Determinant of Outcome in Posthepatectomy Liver Failure
Introduction. The aim of this study was to assess the interaction of liver and renal dysfunction as risk factors for mortality after liver resection. Materials and Methods. A retrospective analysis of 501 patients undergoing liver resection in a single unit was undertaken. Posthepatectomy liver failure (PHLF) was defined according to the International Study Group of Liver Surgery (ISGLS) definition (assessed on day 5) and renal dysfunction according to RIFLE criteria. 90-day mortality was recorded. Results. Twenty-three patients died within 90 days of surgery (4.6%). The lowest mortality occurred in patients without evidence of PHLF or renal dysfunction (2.7%). The mortality rate in patients with isolated PHLF or renal dysfunction was 20% compared to 45% in patients with both. Diabetes ( ), renal dysfunction ( ), and PHLF on day 5 ( ) were independent predictors of 90-day mortality. Discussion. PHLF and postoperative renal dysfunction are independent predictors of 90-day mortality following liver resection but the predictive value for mortality is significantly higher when failure of both organ systems occurs simultaneously. 1. Introduction Despite advances in both operative technique and perioperative care liver resection is associated with mortality rates of 0 to 22% (median 3.7%) and morbidity rates of 12.5% to 66% (median 36%) [1] including liver [2, 3] and renal dysfunction [4]. Liver dysfunction is a major contributor to both morbidity and mortality with an incidence between 1.2% and 32% in published series [5–12]. Renal dysfunction has also been shown to be associated with mortality following liver resection [13], with a reported incidence between 5 and 15% [4, 14]. Posthepatectomy renal failure may occur in conjunction with liver failure when maldistributive circulatory changes occur causing intravascular hypovolaemia [4, 15] but is also related to operative stress and blood loss [16, 17]. Postoperative liver dysfunction has been defined by the “50-50 criteria” as a prothrombin index of less than 50% (mean normal prothrombin time (PT) divided by patient’s observed PT) and a serum bilirubin of >50？μmol/L on the fifth postoperative day, which has been shown to predict liver failure and death after hepatectomy [2]. More recently posthepatectomy liver failure (PHLF) has been defined by the International Study Group of Liver Surgery (ISGLS) as a postoperatively acquired deterioration in the ability of the liver to maintain its synthetic, excretory, and detoxifying functions, characterized by an increased INR (or need of clotting factors to maintain
References
[1]
C. D. Mann, T. Palser, C. D. Briggs et al., “A review of factors predicting perioperative death and early outcome in hepatopancreaticobiliary cancer surgery,” HPB, vol. 12, no. 6, pp. 380–388, 2010.
[2]
S. Balzan, J. Belghiti, O. Farges et al., “The “50-50 criteria” on postoperative day 5: an accurate predictor of liver failure and death after hepatectomy,” Annals of Surgery, vol. 242, no. 6, pp. 824–829, 2005.
[3]
T. Schreckenbach, J. Liese, W. O. Bechstein, and C. Moench, “Posthepatectomy liver failure,” Digestive Surgery, vol. 29, no. 1, pp. 79–85, 2012.
[4]
F. Saner, “Kidney failure following liver resection,” Transplantation Proceedings, vol. 40, no. 4, pp. 1221–1224, 2008.
[5]
M. A. J. van den Broek, S. W. M. O. Damink, C. H. C. Dejong et al., “Liver failure after partial hepatic resection: definition, pathophysiology, risk factors and treatment,” Liver International, vol. 28, no. 6, pp. 767–780, 2008.
[6]
O. Farges, B. Malassagne, J. F. Flejou, S. Balzan, A. Sauvanet, and J. Belghiti, “Risk of major liver resection in patients with underlying chronic liver disease: a reappraisal,” Annals of Surgery, vol. 229, no. 2, pp. 210–215, 1999.
[7]
J. Belghiti, K. Hiramatsu, S. Benoist, P. P. Massault, A. Sauvanet, and O. Farges, “Seven hundred forty-seven hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection,” Journal of the American College of Surgeons, vol. 191, no. 1, pp. 38–46, 2000.
[8]
A. Cucchetti, G. Ercolani, M. Vivarelli et al., “Impact of model for end-stage liver disease (MELD) score on prognosis after hepatectomy for hepatocellular carcinoma on cirrhosis,” Liver Transplantation, vol. 12, no. 6, pp. 966–971, 2006.
[9]
S. Dinant, W. de Graaf, B. J. Verwer et al., “Risk assessment of posthepatectomy liver failure using hepatobiliary scintigraphy and CT volumetry,” Journal of Nuclear Medicine, vol. 48, no. 5, pp. 685–692, 2007.
[10]
M. Karoui, C. Penna, M. Amin-Hashem et al., “Influence of preoperative chemotherapy on the risk of major hepatectomy for colorectal liver metastases,” Annals of Surgery, vol. 243, no. 1, pp. 1–7, 2006.
[11]
L. McCormack, H. Petrowsky, W. Jochum, K. Furrer, and P. A. Clavien, “Hepatic steatosis is a risk factor for postoperative complications after major hepatectomy: a matched case-control study,” Annals of Surgery, vol. 245, no. 6, pp. 923–930, 2007.
[12]
J. T. Mullen, D. Ribero, S. K. Reddy et al., “Hepatic insufficiency and mortality in 1,059 noncirrhotic patients undergoing major hepatectomy,” Journal of the American College of Surgeons, vol. 204, no. 5, pp. 854–862, 2007.
[13]
K. Slankamenac, S. Breitenstein, U. Held, B. Beck-Schimmer, M. A. Puhan, and P. Clavien, “Development and validation of a prediction score for postoperative acute renal failure following liver resection,” Annals of Surgery, vol. 250, no. 5, pp. 720–727, 2009.
[14]
T. Armstrong, F. K. S. Welsh, J. Wells, K. Chandrakumaran, T. G. John, and M. Rees, “The impact of pre-operative serum creatinine on short-term outcomes after liver resection,” HPB, vol. 11, no. 8, pp. 622–628, 2009.
[15]
J. G. Abuelo, “Normotensive ischemic acute renal failure,” The New England Journal of Medicine, vol. 357, no. 8, pp. 797–805, 2007.
[16]
W. R. Jarnagin, M. Gonen, Y. Fong et al., “Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade,” Annals of Surgery, vol. 236, no. 4, pp. 397–407, 2002.
[17]
H. Imamura, Y. Seyama, N. Kokudo et al., “One thousand fifty-six hepatectomies without mortality in 8 years,” Archives of Surgery, vol. 138, no. 11, pp. 1198–1206, 2003.
[18]
N. N. Rahbari, O. J. Garden, R. Padbury et al., “Posthepatectomy liver failure: a definition and grading by the international study group of liver surgery (ISGLS),” Surgery, vol. 149, no. 5, pp. 713–724, 2011.
[19]
J. Belghiti, P. A. Clavien, E. Gadzijev et al., “The Brisbane 2000 terminology of liver anatomy and resections,” HPB, vol. 2, no. 3, pp. 333–339, 2000.
[20]
G. P. Copeland, D. Jones, and M. Walters, “POSSUM: a scoring system for surgical audit,” The British Journal of Surgery, vol. 78, no. 3, pp. 355–360, 1991.
[21]
R. Bellomo, C. Ronco, J. A. Kellum, R. L. Mehta, and P. Palevsky, “Acute renal failure—definition, outcome measures, animal models, fluid therapy and information technology needs: the second international consensus conference of the acute dialysis quality initiative (ADQI) group,” Critical Care, vol. 8, no. 4, pp. R204–R212, 2004.
[22]
A. Agresti, An Introduction to Categorical Data Analysis, John Wiley & Sons, Hoboken, NJ, USA, 2nd edition, 2002.
[23]
“‘R’—project for statistical computing,” 2011, http://www.r-project.org/.
[24]
N. N. Rahbari, C. Reissfelder, M. Koch et al., “The predictive value of postoperative clinical risk scores for outcome after hepatic resection: a validation analysis in 807 patients,” Annals of Surgical Oncology, vol. 18, no. 13, pp. 3640–3649, 2011.
[25]
R. M. Jones, C. E. Moulton, and K. J. Hardy, “Central venous pressure and its effect on blood loss during liver resection,” The British Journal of Surgery, vol. 85, no. 8, pp. 1058–1060, 1998.
[26]
R. A. Schroeder, B. H. Collins, E. Tuttle-Newhall et al., “Intraoperative fluid management during orthotopic liver transplantation,” Journal of Cardiothoracic and Vascular Anesthesia, vol. 18, no. 4, pp. 438–441, 2004.
[27]
T. Kawai, Y. Yokoyama, M. Nagino, T. Kitagawa, and Y. Nimura, “Is there any effect of renal failure on the hepatic regeneration capacity following partial hepatectomy in rats?” Biochemical and Biophysical Research Communications, vol. 352, no. 2, pp. 311–316, 2007.
[28]
S. A. Little, W. R. Jarnagin, R. P. DeMatteo, L. H. Blumgart, and Y. Fong, “Diabetes is associated with increased perioperative mortality but equivalent long-term outcome after hepatic resection for colorectal cancer,” Journal of Gastrointestinal Surgery, vol. 6, no. 1, pp. 88–94, 2002.
[29]
G. K. Michalopoulos, “Liver regeneration,” Journal of Cellular Physiology, vol. 213, no. 2, pp. 286–300, 2007.
[30]
I. R. Wanless and J. S. Lentz, “Fatty liver hepatitis (steatohepatitis) and obesity: an autopsy study with analysis of risk factors,” Hepatology, vol. 12, no. 5, pp. 1106–1110, 1990.
[31]
K. E. Behrns, G. G. Tsiotos, N. F. DeSouza, M. K. Krishna, J. Ludwig, and D. M. Nagorney, “Hepatic steatosis as a potential risk factor for major hepatic resection,” Journal of Gastrointestinal Surgery, vol. 2, no. 3, pp. 292–298, 1998.
[32]
Y. M. Sun, Y. Su, J. Li, and L. F. Wang, “Recent advances in understanding the biochemical and molecular mechanism of diabetic nephropathy,” Biochemical and Biophysical Research Communications, vol. 433, no. 4, pp. 359–361, 2013.
