Continuous Renal Replacement Therapy During Liver Transplant: The Anesthesiologist-Nephrologist Collaboration at a...

Acute kidney injury frequently complicates the end stages of liver diseases, worsening the condition of patients waiting for liver transplants. Continuous renal replacement therapy during liver transplant is still a limited experience, with large variability in the indication criteria. The recent KDIGO guidelines on acute kidney injury may help identify patients who could potentially benefit from the procedure. Therefore, close collaboration between intensivists and nephrologists is essential for shared criteria and treatment management. This study aimed to assess the feasibility and safety in clinical practice of a joint intraoperative continuous renal replacement therapy (IO-CRRT) program. Some aspects of clinical impact were analyzed as a secondary outcome.

A collaborative organization between nephrologists and anesthesiologists was implemented at St. Orsola Hospital of Bologna (Italy) to manage liver transplant candidates with acute kidney injury. Feasibility, the main outcome, was assessed through adherence to clinical indications and operative details. We also compared a group receiving IO-CRRT (n = 20) and a historical control group (n = 13) without replacement therapy.

No substantial operative deviations from the program were found, excluding 4 patients mistakenly enrolled. The IO-CRRT group had better control of lactates, serum bicarbonate gain, and smoother acute sodium changes compared to controls.

The overall organization proved to be feasible and safe, provided a high level of collaboration is guaranteed. The trend of some metabolic parameters appeared to benefit from IO-CRRT, which may reasonably help in balancing metabolism during liver transplant surgery. This strategy could increase the opportunity for transplant for some patients who otherwise would be excluded.