Applied nutritional investigationPre- and perioperative factors affecting infection after living donor liver transplantation
Introduction
Infections after liver transplantation (LT) are the most frequent causes of morbidity and in-hospital death [1]. Patients who undergo LT are regarded as at unusually high risk for perioperative infection. For example, protein–energy malnutrition, which is common in patients with end-stage liver disease requiring LT, is considered to confer a vulnerability to preoperative infection, including spontaneous bacterial peritonitis and pneumonia from a deteriorated immune function [2], [3]. LT is a massive invasion of the host. The number of intraoperatively transfused cellular blood products is also a risk factor for infections [4]. Furthermore, immunosuppression and multiple catheter insertions increase the risk of post-transplantation infection. Consequently, infectious complications, including sepsis and bacteremia, often occur after LT and are the most frequent causes of in-hospital death. Therefore, the prevention of post-transplantation infection plays a crucial role in improving short-term outcomes after LT.
Malnutrition is a risk factor for postoperative complications and mortality rates in patients with a cirrhotic liver who undergo surgery [5], [6]. However, the impact of preoperative nutritional status and of nutritional interventions on postoperative infectious complications in LT remains controversial [7], [8], [9], [10], especially in patients undergoing living donor LT (LDLT). Patients with advanced cirrhosis characteristically show a decrease in plasma concentrations of branched-chain amino acids (BCAAs). These BCAAs not only serve as an essential substrate in the synthesis of body proteins, but also act as an important regulator of protein turnover. Moreover, BCAAs have beneficial effects on hepatic encephalopathy through the promotion of ammonia detoxification and the correction of the plasma amino acid imbalance, liver regeneration, and hepatic cachexia in patients with liver diseases [11]. Improving systemic conditions, including nutritional status, to the greatest extent possible before LT facilitates early postoperative recovery. Supplementation with a BCAA-enriched nutrient mixture is reportedly beneficial not only for patients with liver cirrhosis but also for patients undergoing hepatectomy [12], [13], [14], [15]. However, the value of pretransplantation BCAA supplementation remains unclear. The aim of the present study therefore was to examine pre- and perioperative predictors, including nutritional factors such as BCAA supplementation, for post-transplantation infectious complications so that a strategy could be established to improve short-term outcomes after LDLT.
Section snippets
Materials and methods
The present study retrospectively analyzed data from 100 consecutive adult patients (46 men and 54 women, ≥18 y old, age range 18–69 y, median age 56 y) who underwent LDLT at the Kyoto University Hospital from February 2008 through February 2010 after introducing the nutritional assessment described below. The Model for End-stage Liver Disease score was 19 (range 7–46). Thirty-two patients were ABO incompatible and 68 were identical or compatible. The indications for LT were hepatocellular
Post-transplantation sepsis
Univariate analysis showed that an age younger than 60 y, a Model for End-stage Liver Disease score of at least 20, a low pretransplantation BCM, and the absence of preoperative supplementation with the BCAA-enriched nutrient mixture were of prognostic significance for post-transplantation sepsis (Table 1). Multivariate analysis showed that a low pretransplantation BCM (P = 0.032) and no preoperative BCAA-enriched nutrient supplementation (P = 0.020) were of independent prognostic significance
Discussion
The present study examined the risk factors affecting three types of infectious complications after LDLT. We identified the independent risk factors as a Child–Pugh C classification, massive perioperative blood loss, a low pretransplantation BCM, and the absence of preoperative supplementation with a BCAA-enriched nutrient mixture. Decompensated liver cirrhosis, indicated by a Child–Pugh C classification, is usually accompanied by deteriorated immune function and nutritional status at the time
Conclusion
Preoperative nutritional status, supplementation with a nutrient mixture enriched with BCAAs, and massive operative blood loss were closely associated with the occurrence of post-transplantation infectious complications. Perioperative management, including nutritional therapy, is needed to improve short-term outcomes after LT.
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