الفهرس 
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Abstract
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Summary and Conclusion
Living donor liver transplantation (LDLT) is a widely accepted treatment for end-stage liver diseases. Renal dysfunction is frequent complication after liver transplantation and has an favorable affect on prognosis. It should be essential to determine which patients will experience progressive and severe renal dysfunction after liver transplantation.
The purpose of the present study was to identify the incidence and risk factors of post transplantation, the possible risk factors especially preoperative renal dysfunction as well as postoperative renal dysfunction on patient survival.
The study population consisted of adults and pediatrics who received LDLT from April 2003 to April 2012 in National liver institute (Menofia University). Data were collected from preoperative records, operative records, post operative files (in ICU and ward) and from follow up records of all patients for one month after operation. According to the preoperative results, patients were classified into: patients with preoperative normal renal function and patients with preoperative RD. preoperative renal dysfunction were defined as serum creatinine levels greater than 1.5 mg/dl and GFR <60ml/min (estimated by renal radioisotope scan).
Summary & Conclusion
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The 173 patients (adult and pediatrics) who were followed to one month after LDLT (Hospital stay time) were classified as group I (n = 144) 82.7%, creatinine < 1.5 mg/dl versus group II (n = 29), 17.3%, creatinine > 1.5 mg/dl.Each group was classified as subgroups into gp.I (125) 85.8% and gp.II (18) 14.4%in adults, gp. I (25) 77.3% and gp.II (4) 22.7% in pediatrics. Most of the patients were adult males in both groups, pediatrics (n=29)17.3% and adults (n=144) 82.7% and the mean age was 5.62±5.74 years in ped. and 46.97 ± 7.62 years in adults . Most of the patients were child class C ped.(n=14) 48.3% and adults (n= 93) 64.6%. Class B in ped. (n=11) 37.9%and adults (n=43) 29.9%. Class A in ped. (n= 4)13.8% and adults (n=8)5.6 %. The mean MELD score (within one week before liver transplantation), in adult group was 18.50+7.66 with p-value > 0.05. PELD score was 19.7576+19.8798 in ped. group with p-value > 0.05. Hepatitis C (HCV) was the main underlying etiology of liver cirrhosis and indication for OLT studied patients (n=82)61.6%, while HCC was (n=45)19.2%. Only (n=3)2.1% of the studied patients Suffered from pre LDLT hypertension, (n=35) 24.3% and (n=6) 4.2% in both.
Summary & Conclusion
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The frequency and percentage of postoperative complications in both groups of the patients, primary graft non function (PNF) were occurred in (20) 35.6% with p-value<0.01. Seventeen (17) 53.7% were re operated upon vascular or biliary complication. Biliary complication was in (68) 87%., Vascular comp. was in (n=11) 8.5%, Postoperative infection was detected in (n=6)11.5% of patients who were treated with the proper antibiotics according to culture and sensitivity. Chest comp. in (n=8) 26.9%, neurological comp. in (14) 31.6%, GIT comp. in (15) 10%. Acute cellular rejection, necessitating plus steroid for management was diagnosed in (n=20) 34.7% in both groups of the patients. While cytomegalovirus (CMV) infection was detected in (n=23)36.2%.
Postoperative renal dysfunction (RD) was detected in (n=22) 26.3% of both groups postoperative.
Death was detected in pediatrics (n=15) 51.7%, in adults (n=83) 57.6%. While survival was in ped. (n=14) 48.3% and in adult (n=61)42.4%.
Post-LT ARD occurred in 26.3% of both patients (adults&ped.) who underwent LDLT which are classified into subgroup II in both pediatrics (n=4) 13.8% and adults (n=18) 12.5%.The analyzed pre LDLT variables in the patients groups and subgroups revealed Child class, albumin..serum creatinine,
Summary & Conclusion
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blood group (compatible & identical),MELD & PELD score, co-morbidity (HTN) and underlying HCV etiology of liver cirrhosis and also donor age were found to be significantly associated with post-LDLT ARD in both group &subgroup (p>0.05). Analysis of the type of graft in LDLT showed that which lobe is used, cold & warm ischemia and blood transfusion were not statistically significant risk factors for ARD after liver transplantation. Plasma transfusion and graft recipient weight ratio (GRWR) were revealed statistically significant risk factors for ARD (p>0.05) .It is to be noted that all the studied patients received grafts with GRWR not less than 0.9.
As regards the postoperative complications, primary graft non function and post-LT infection were statistically significant risk factors for ARD (P>0.05, P=0.05) respectively. Post-operative surgical interference, acute cellular rejection (ACR), CMV infection, and type of calcineurin inhibitor (CNI) based immunosuppression (whether cyclosporine |or tacrolimus) were significant factors associated with ARD (p>0.05).
Univariate analysis in pediatrics showed renal dysfunction in the early postoperative period was related to recipient age, Donor age, preoperative total bilirubin, serum creatinine, serum albumin, INR, PELD score, calculated GRWR & Graft weight,
Summary & Conclusion
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actual GRWR & Graft weight, intraoperative plasma transfusion, blood transfusion, intraoperative time, cold and warm ischemia, time of postoperative renal dysfunction. also early hospital stay after LDLT, time of post LDLT surgical intervention and post LDLT survival, (P=0.05).
Univariate analysis in adults showed renal dysfunction in the early postoperative period was related to recipient age, donor age, preoperative total bilirubin serum creatinine, serum albumin, INR, MELD core, calculated GRWR & Graft weight, actual GRWR & Graft weight, intraoperative plasma transfusion, intraoperative time, cold and warm ischemia, time of postoperative renal dysfunction after LDLT. Time of post LDLT surgical intervention (P=0.05) and early hospital stay (p=<0.01) blood transfusion (p=<0.01) post LDLT survival(p=<0.05).
Multivariate analysis in both groups showed that pre-LT s.creatinine, MELD score, Actual graft/wt, operative time/h, and intraoperative plasma transfusion/unit, at time of LDLT were independent predictors of post-OLT ARD (OR=0.075, 0.088, 0.000, 0.011, and 0.004) respectively.
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Among (22)26.3% postoperative RD from 173 patients who underwent LDLT, subgroup II (4) 13.8% in pediatrics group and (18)12.5%, in adults group. 9(11.7%) of both adults &ped. were died, (2) 3.7%cases in ped. While in adult, (7)8.0%, two cases after RRT:
1. VVHDF for pt. with HAT
2. Conventional HD for fungal pt.
(13) 14.6% of both groups, (2)3.7% cases from ped. And (11) 11.9% cases from adult gp.were recovered from early renal dysfunction, one cases after 6 session dialysis (Conventional HD).
Effect of postoperative RD on Mortality, Pre-LT serum creatinine (p<0.01), MELD (p<0.05), GFR (p<0.05, and were not statistically significant risk factors for mortality. Subgroup analysis of patients with actual graft/wt.(SFS),intraoperative plasma transfusion /unit and operative time /h revealed significantly affected the patients’ survival (P>0.05).
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Conclusion
In conclusion, pre-LDLT MELD score, intraoperative blood transfusion and actual graft w.t SFS (GRWR < 0.8) are the most important risk factors for early postoperative renal transplantation in adults groups. In both groups, operative time/min, intraoperative plasma transfusion /unit, actual graft w.t SFS (GRWR < 0.8) are the most important risk factors for early postoperative renal transplantation.
Incidence of postoperative renal dysfunction (RD) was detected in (n=22) 26.3% in both adults & ped. Groups.
Considering the limitation of the uncontrolled retrospective nature of the present analysis, these observations may be useful to establish a treatment strategy for high risk liver transplant patients.
Summary & Conclusion
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