Background
Methods
Patient information and data collection
Definitions
SOFA Score | 0 | 1 | 2 | 3 | 4 |
---|---|---|---|---|---|
Respiration | |||||
PaO2/FiO2 | >400 | >300–≤ 400 | >200–≤ 300 | >100–≤ 200 with ventilator | ≤100 with ventilator |
Coagulation | |||||
Platelets, ×103/mm3
| >150 | >100–≤ 150 | >50–≤ 100 | >20–≤ 50 | ≤20 |
Liver | |||||
Bilirubin, mg/dL (μmol/L) | <1.2 (<20) | ≥1.2–< 2.0 (20–32) | ≥2.0–< 6.0 (33–101) | ≥6.0–< 12.0 (102–204) | ≥12.0 (>204) |
Cardiovascular | |||||
Hypotension | MAP ≥ 70 mm Hg | MAP <70 mm Hg | Dopamine ≤5 or dobutamine (any dose)a
| Dopamine >5 or epi ≤0.1 or norepi ≤0.1a
| Dopamine >15 or epi >0.1 or norepi >0.1a
|
CNS | |||||
Glasgow Coma Score | 15 | 13–14 | 10–12 | 6–9 | <6 |
Renal | |||||
Creatinine, mg/dL (μmol/L) or urine output | <1.2 (<110) | ≥1.2–< 2.0 (110–170) | ≥2.0–< 3.5 (171–299) | ≥3.5–< 5.0 (300–440) or <500 mL/day | ≥5.0 (>440) or <200 mL/day |
RIFLE Classification | SCr criteria | UO Criteria | |||
Definition | SCr changes over 1–7 days, sustained for more than 24 h | UO < 0.5 ml/kg/h × 6 h | |||
Risk | Increase in SCr ≥ 1.5 × baseline or decrease in GFR ≥ 25 % | UO < 0.5 ml/kg/h × 6 h | |||
Injury | Increase in SCr ≥ 2.0 × baseline or decrease in GFR ≥ 50 % | UO < 0.5 ml/kg/h × 12 h | |||
Failure | Increase in SCr ≥ 3.0 × baseline or an absolute serum creatinine ≥ 4.0 mg/dl with an acute rise of at least 0.5 mg/dl or decrease in GFR ≥ 75 % | UO < 0.5 ml/kg/h × 24 h or anuria × 12 h | |||
Loss | Complete loss of kidney function > 4 weeks | ||||
ESRD | End-stage renal disease (>3 months) |
Statistical analysis
Results
Patient characteristics
All patients (n = 323) | Survivors (n = 281) | Non-survivors (n = 42) |
P-value | |
---|---|---|---|---|
Age (years) | 50.8 ± 10.4 | 50.9 ± 9.8 | 50.3 ± 13.8 | NS (0.753) |
Gender (M/F) | 231/92 | 199/82 | 32/10 | NS (0.583) |
BMI on admission (kg/m2) | 24.3 ± 4.0 | 24.7 ± 4.0 | 21.1 ± 2.4 |
<0.001
|
History of diabetes mellitus (yes/no) | 55/268 | 46/235 | 9/33 | NS (0.387) |
History of chronic kidney disease (yes/no) | 31/292 | 22/259 | 9/33 |
0.005
|
Proteinuria on admission (yes/no) | 45/278 | 31/250 | 14/28 |
<0.001
|
Hemoglobin on admission (g/dL) | 10.6 ± 2.2 | 10.7 ± 2.2 | 9.8 ± 2.1 |
0.008
|
Leukocytes on admission (× 109/L) | 2.9 ± 3.7 | 2.8 ± 3.5 | 3.3 ± 4.9 | NS (0.569) |
Platelets on admission (× 109/L) [median] | 72.7 [60] | 72.9 ± [60] | 71.1 [59] | NS (0.809) |
Prothrombin time INR on admission | 1.8 ± 0.7 | 1.8 ± 0.7 | 1.9 ± 0.7 | NS (0.050) |
Serum sodium on admission (mmol/L) | 137.8 ± 5.7 | 137.9 ± 5.4 | 137.0 ± 8.0 | NS (0.471) |
AST on admission (U/L) [median] | 88.8 [62] | 87.5 [64] | 98.3 [51] | NS (0.498) |
ALT on admission (U/L) [median] | 67.2 [39] | 67.4 [40] | 65.8 [34] | NS (0.938) |
Total bilirubin on admission (μmol/L) [median] | 145.4 [51] | 130.0 [50] | 244.5 [96] |
0.003
|
A-a gradient on admission (mmHg) [median] | 25.1 [17] | 22.8 [17] | 43.3 [18] |
0.039
|
Serum creatinine on admission (μmol/L) [median] | 97.2 [77] | 92.2 [75] | 114.9 [84] | NS (0.064) |
Hepatorenal syndrome, n (%) | 29 (9) | 22 (8) | 7 (17) | NS (0.079) |
MAP on admission (mmHg) | 86.1 ± 12.4 | 86.3 ± 12.7 | 84.7 ± 10.3 | NS (0.427) |
Child-Pugh points on admission | 10.1 ± 2.6 | 9.9 ± 2.7 | 11.1 ± 2.0 |
0.010
|
MELD score on admission | 17.6 ± 9.0 | 17.1 ± 8.9 | 21.4 ± 9.7 |
0.025
|
RIFLE on admission (No AKI/Risk/Injury/Failure) | 286/16/9/12 | 250/13/9/9 | 36/3/0/3 | NS (0.449) |
SOFA score on admission | 5.1 ± 2.7 | 4.8 ± 2.5 | 6.7 ± 3.3 |
0.001
|
Anesthesia time during operation (hours) | 12.1 ± 1.8 | 12.1 ± 1.9 | 12.4 ± 1.5 | NS (0.362) |
Donor type (DDLT /LDLT) | 91/232 | 74/207 | 17/25 |
0.018
|
Total operative time (mins) [median] | 687.1 [683] | 685.6 [683] | 697.2 [682] | NS (0.589) |
Cold ischemia time (mins) [median] | 85.0 [15] | 74.8 [15] | 166.4 [17] | NS (0.125) |
Warm ischemia time (mins) [median] | 128.2 [122] | 126.3 [121] | 141.1 [129] | NS (0.115) |
Graft-to-recipient weight ratio (%) | 1.0 ± 0.3 | 1.0 ± 0.3 | 1.1 ± 0.5 | NS (0.125) |
Blood loss volume during operation (ml) [median] | 3034 [2000] | 2672 [1840] | 4430 [2000] |
0.014
|
Length of ICU stay (days) [median] | 21.0 [14] | 19.2 [14] | 33.6 [24] |
0.002
|
Length of hospital stay (days) [median] | 47.8 [38] | 46.7 [38] | 54.7 [44] | NS (0.215) |
All patients | Survivors | Non-survivors |
P-value | |
---|---|---|---|---|
n = 323 |
n = 281 |
n = 42 | ||
Primary liver disease | 323 (100) | 281 (100) | 42 (100) | |
Alcoholic, n (%) | 16 (5) | 12 (4) | 4 (10) | NS (0.254) |
Hepatitis B, n (%) | 111 (34) | 100 (36) | 11 (26) | NS (0.848) |
Hepatitis C, n (%) | 31 (10) | 23 (8) | 8 (19) |
0.003
|
Hepatoma, n (%) | 3 (1) | 3 (1) | 0 (0) | NS (1.000) |
Alcoholic + hepatitis B, n (%) | 21 (6) | 15 (7) | 2 (5) | NS (1.000) |
Alcoholic + hepatitis C, n (%) | 5 (2) | 5 (2) | 0 (0) | NS (1.000) |
Alcoholic + hepatoma, n (%) | 3 (1) | 3 (1) | 0 (0) | NS (1.000) |
Hepatitis B + hepatitis C, n (%) | 17 (5) | 14 (5) | 3 (7) | NS (0.723) |
Hepatitis B + hepatoma, n (%) | 49 (15) | 43 (15) | 6 (14) | NS (0.172) |
Hepatitis C + hepatoma, n (%) | 31 (10) | 29 (10) | 2 (5) | NS (0.134) |
Alcoholic + hepatitis B + hepatoma, n (%) | 2 (1) | 1 (1) | 1 (2) | NS (0.429) |
Other causes, n (%)a
| 34 (10) | 29 (10) | 5 (12) | NS (0.787) |
Presence of AKI after transplantation (Post-OP day1) | 125 (39) | 101 (36) | 24 (57) |
0.011
|
Prerenal type of AKI, n (%) | 2 (1) | 2 (1) | 0 (0) | NS (1.000) |
Infection related AKI, n (%) | 42 (13) | 31 (11) | 11 (26) |
0.006
|
Nephrotoxic agent exposure related AKI, n (%) | 6 (2) | 6 (2) | 0 (0) | NS (0.601) |
Mixed type and other causes of AKI, n (%)b
| 75 (23) | 62 (22) | 13 (31) | NS (0.236) |
Risk factors for adverse outcomes
Patients with no proteinuria on admission | Patients with newly onset proteinuria on post-OP day 1 | Patients with no newly onset proteinuria on post-OP day 1 |
P-value | |
---|---|---|---|---|
LDLT |
n = 208 |
n = 65 (31.2 %) |
n = 143 (68.8 %) | |
Total operative time (mins) [median] | 703.9 [695] | 789.3 [811] | 707.6 [691] | NS (0.087) |
Cold ischemia time (mins) [median] | 85.4 [14] | 27.9 [15] | 21.9 [13] | NS (0.659) |
Warm ischemia time (mins) [median] | 128.2 [130] | 194.0 [182] | 127.6 [133] |
0.004
|
DDLT |
n = 70 |
n = 47 (67.1 %) |
n = 23 (32.9 %) | |
Total operative time (mins) [median] | 640.0 [633] | 646.2 [653] | 625.8 [632] | NS (0.876) |
Cold ischemia time (mins) [median] | 651.3 [583] | 756.5 [634] | 552.0 [541] |
0.039
|
Warm ischemia time (mins) [median] | 113.5 [91] | 114.0 [90] | 101.4 [90] | NS (0.737) |
Parameters | Beta Coefficient | Standard error | Odds ratios (95 % CI) |
P-value |
---|---|---|---|---|
Univariate logistic regression | ||||
BMI on admission (kg/m2) | −0.247 | 0.050 | 0.781 (0.708–0.861) |
<0.001
|
History of chronic kidney disease | 1.167 | 0.437 | 3.211 (1.364–7.557) |
0.008
|
Proteinuria on admission | 1.480 | 0.398 | 4.391 (2.011–9.587) |
<0.001
|
Hemoglobin on admission (g/dL) | −0.218 | 0.083 | 0.804 (0.683–0.947) |
0.009
|
Total bilirubin on admission (mg/dL) | 0.037 | 0.011 | 1.038 (1.015–1.061) |
0.001
|
Donor type (DDLT /LDLT) | −0.41 | 0.169 | 0.664 (0.477–0.925) |
0.015
|
A-a gradient on admission | 0.009 | 0.003 | 1.009 (1.002–1.016) |
0.007
|
Child-Pugh points on admission | 0.176 | 0.070 | 1.193 (1.040–1.368) |
0.012
|
MELD score on admission | 0.046 | 0.056 | 1.047 (0.999–1.098) | NS (0.056) |
SOFA score on admission | 0.219 | 0.057 | 1.245 (1.114–1.391) |
<0.001
|
Blood loss volume during operation (ml) | <0.001 | <0.001 | 1.000 (1.000–1.000) |
0.003
|
Length of ICU stay (days) | 0.018 | 0.006 | 1.018 (1.007–1.029) |
0.002
|
Multivariate logistic regression | ||||
Proteinuria on admission | 1.320 | 0.478 | 3.745 (1.468–9.554) |
0.006
|
SOFA on admission | 0.157 | 0.067 | 1.170 (1.027–1.333) |
0.019
|
Constant | −2.471 | 0.245 | 0.085 |
<0.001
|
Calibration and discrimination of the scoring systems
Calibration | Discrimination | |||||
---|---|---|---|---|---|---|
Goodness-of-fit (x2) | df |
p
| AUROC ± SE | 95 % CI |
P
| |
On admission | ||||||
Proteinuria | - | - | - | 0.582 ± 0.053 | 0.479–0.685 | NS (0.100) |
Child-Pugh points | 10.157 | 7 | 0.180 | 0.580 ± 0.041 | 0.499–0.662 | NS (0.087) |
MELD score | 5.845 | 8 | 0.665 | 0.609 ± 0.067 | 0.418–0.680 | NS (0.067) |
RIFLE | ─ | ─ | ─ | 0.577 ± 0.067 | 0.355–0.618 | NS (0.845) |
SOFA | 1.618 | 5 | 0.899 | 0.648 ± 0.049 | 0.552–0.745 |
0.002
|
Proteinuria plus SOFA | 1.047 | 5 | 0.959 | 0.659 ± 0.052 | 0.557–0.761 |
0.002
|
Proteinuria plus nonrenal SOFA | 6.347 | 6 | 0.385 | 0.658 ± 0.055 | 0.550–0.765 |
0.002
|
Postoperative day 1 | ||||||
Proteinuria | - | - | - | 0.609 ± 0.090 | 0.432–0.786 | NS (0.240) |
Child-Pugh points | 2.438 | 5 | 0.786 | 0.639 ± 0.062 | 0.479–0.721 | NS (0.142) |
MELD score | 5.947 | 8 | 0.653 | 0.705 ± 0.044 | 0.620–0.791 |
<0.001
|
RIFLE | 2.684 | 2 | 0.261 | 0.626 ± 0.048 | 0.531–0.720 |
0.007
|
SOFA | 3.063 | 8 | 0.930 | 0.761 ± 0.043 | 0.676–0.845 |
<0.001
|
Proteinuria plus SOFA | 7.406 | 6 | 0.285 | 0.828 ± 0.062 | 0.707–0.949 |
<0.001
|
Proteinuria plus nonrenal SOFA | 11.595 | 5 | 0.041 | 0.823 ± 0.078 | 0.670–0.977 |
0.001
|
Postoperative day 7 | ||||||
Proteinuria | - | - | - | 0.757 ± 0.056 | 0.647–0.866 |
<0.001
|
Child-Pugh points | 6.365 | 4 | 0.173 | 0.750 ± 0.065 | 0.593–0.847 |
0.001
|
MELD score | 26.161 | 8 | 0.001 | 0.856 ± 0.038 | 0.782–0.930 |
<0.001
|
RIFLE | 9.602 | 2 | 0.008 | 0.825 ± 0.042 | 0.742–0.908 |
<0.001
|
SOFA | 6.073 | 6 | 0.415 | 0.899 ± 0.031 | 0.838–0.961 |
<0.001
|
Proteinuria plus SOFA | 8.625 | 6 | 0.196 | 0.907 ± 0.041 | 0.825–0.988 |
<0.001
|
Proteinuria plus nonrenal SOFA | 7.856 | 6 | 0.249 | 0.903 ± 0.038 | 0.828–0.978 |
<0.001
|
Postoperative day 14 | ||||||
Proteinuria | - | - | - | 0.773 ± 0.067 | 0.642–0.904 |
0.005
|
Child-Pugh points | 3.469 | 3 | 0.325 | 0.783 ± 0.052 | 0.682–0.885 |
<0.001
|
MELD score | 134.84 | 8 | <0.001 | 0.850 ± 0.056 | 0.740–0.960 |
<0.001
|
RIFLE | 1.658 | 2 | 0.436 | 0.780 ± 0.050 | 0.681–0.879 |
<0.001
|
SOFA | 24.495 | 7 | 0.001 | 0.892 ± 0.044 | 0.806–0.978 |
<0.001
|
Proteinuria plus SOFA | 3.987 | 7 | 0.781 | 0.900 ± 0.042 | 0.819–0.982 |
<0.001
|
Proteinuria plus nonrenal SOFA | 5.009 | 7 | 0.659 | 0.894 ± 0.038 | 0.819–0.969 |
<0.001
|
Indices for predicting short-term prognosis
Predictive factors | Cutoff point | Youden index | Sensitivity (%) | Specificity (%) | Overall correctness (%) |
---|---|---|---|---|---|
Proteinuria | |||||
On admission | positive | 0.16 | 28 | 88 | 58 |
Postoperative day 1 | positive | 0.22 | 64 | 58 | 61 |
Postoperative day 7 | positive | 0.51 | 85 | 66 | 76 |
Postoperative day 14 | positive | 0.55 | 90 | 65 | 77 |
Child-Pugh points | |||||
On admission | 12 | 0.17 | 95 | 22 | 59 |
Postoperative day 1 | 10 | 0.26 | 90 | 37 | 64 |
Postoperative day 7 | 9 | 0.42 | 60 | 82 | 71 |
Postoperative day 14 | 8 | 0.42 | 50 | 92 | 71 |
MELD score | |||||
On admission | 15 | 0.19 | 65 | 56 | 61 |
Postoperative day 1 | 22 | 0.27 | 60 | 71 | 66 |
Postoperative day 7 | 20 | 0.58 | 69 | 87 | 78 |
Postoperative day 14 | 23 | 0.62 | 75 | 87 | 81 |
RIFLE | |||||
On admission | I category | 0.04 | 7 | 97 | 52 |
Postoperative day 1 | I category | 0.20 | 57 | 64 | 61 |
Postoperative day 7 | I category | 0.56 | 72 | 82 | 77 |
Postoperative day 14 | R category | 0.60 | 74 | 82 | 78 |
SOFA | |||||
On admission | 5 | 0.23 | 52 | 71 | 62 |
Postoperative day 1 | 11 | 0.41 | 77 | 64 | 71 |
Postoperative day 7 | 7 | 0.70 | 83 | 87 | 84 |
Postoperative day 14 | 7 | 0.69 | 85 | 84 | 84 |
Proteinuria plus SOFA | |||||
On admission | 5 | 0.26 | 57 | 70 | 63 |
Postoperative day 1 | 12 | 0.54 | 79 | 75 | 77 |
Postoperative day 7 | 8 | 0.72 | 85 | 85 | 85 |
Postoperative day 14 | 8 | 0.72 | 89 | 83 | 86 |
Proteinuria plus nonrenal SOFA | |||||
On admission | 5 | 0.26 | 54 | 76 | 63 |
Postoperative day 1 | 12 | 0.54 | 54 | 100 | 77 |
Postoperative day 7 | 8 | 0.68 | 86 | 82 | 84 |
Postoperative day 14 | 7 | 0.67 | 100 | 67 | 84 |