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BACKGROUND Acute kidney injury (AKI) after liver transplantation is associated with increased morbidity and mortality. It remains controversial whether the choice of vena cava reconstruction technique impacts AKI. METHODS This is a single-center retrospective cohort of 897 liver transplants performed between June 2009 and September 2018 using either the vena cava preserving piggyback technique or caval replacement technique without veno-venous bypass or shunts. The association between vena cava reconstruction technique and stage of postoperative AKI was assessed using multivariable ordinal logistic regression. Causal mediation analysis was used to evaluate warm ischemia time as a potential mediator of this association. RESULTS The incidence of AKI (AKI stage ≥2) within 48 h after transplant was lower in the piggyback group (40.3%) compared to the caval replacement group (51.8%, P < 0.001). Piggyback technique was associated with a reduced risk of developing a higher stage of postoperative AKI (odds ratio, 0.49; 95% confidence interval, 0.37-0.65, P < 0.001). Warm ischemia time was shorter in the piggyback group and identified as potential mediator of this effect. There was no difference in renal function (estimated glomerular filtration rate and the number of patients alive without dialysis) 1 y after transplant. CONCLUSIONS Piggyback technique, compared with caval replacement, was associated with a reduced incidence of AKI after liver transplantation. There was no difference in long-term renal outcomes between the 2 groups.

BACKGROUND: Pulmonary hypertension (PH) is frequently reported in patients with advanced chronic kidney disease (CKD) and is associated with early allograft failure and death. However, the causes of PH are heterogeneous, and patient prognosis may vary by etiologic subtype. METHODS: Data from the UNC Cardiorenal Registry were examined to determine associations between pulmonary hypertension (PH), with or without elevated left atrial pressure (eLAP), and mortality in candidates for kidney transplantation. PH and eLAP were determined by Doppler echocardiography and by tissue Doppler imaging, respectively. RESULTS: From 2006-2013, 778 registry patients were screened preoperatively by echocardiography. Most patients were black (64%) and male (56%); the mean age was 56 years. PH was identified in 97 (12%) patients; of these, eLAP was prevalent in half. During a median follow up of 4.4 years, 179 (23%) received a kidney transplant, and 195 (25%) died. After adjustments for demographics, comorbidities, dialysis vintage and kidney transplantation, PH was associated with twice the 5-year mortality (HR = 2.11; 95% CI: 1.48 – 3.03), with stronger associations in the absence of eLAP (HR = 2.87; 95% CI: 1.83 – 4.49) than with eLAP (HR = 1.11; 95% CI: 0.57 – 2.17); P for interaction = 0.01. CONCLUSION: The mortality risk associated with PH among patients with advanced CKD appears to differ by etiology. Patients with PH in the absence of eLAP are at high risk of death and in need of focused attention. Future research efforts should investigate potential strategies to improve outcomes for these patients.

The pupil undergoes irregular oscillations when exposed to light. These oscillations, known as pupillary unrest in ambient light, originate from oscillatory activity within the Edinger-Westphal nucleus in the midbrain. The midbrain and upper pons also contain nuclei known to be very sensitive to the effects of anesthetics that play a central role in maintaining wakefulness. We hypothesized that anesthetics may display similar effects on wakefulness and pupillary unrest. Repeat measurements of pupillary unrest using infrared pupillometry were performed in 16 patients undergoing general anesthesia and 8 patients undergoing propofol sedation. Pupil scans were analyzed using fast Fourier transformation to quantify the effects of the anesthetics on pupillary unrest. During general anesthesia and deep sedation, observed pupillary unrest values below 0.1 (AU) indicate complete suppression of pupillary oscillations. Pupillary unrest decreased more during general anesthesia [to 24% of baseline (95% CI 17-30%)] than pupil size [51% of baseline (95% CI 45-57%)]. Sedation with propofol was associated with a reduction in pupillary unrest that was correlated to the depth of sedation as assessed by the Richmond Agitation-Sedation Scale and the processed electroencephalogram. Pupillary unrest is caused by oscillatory activity within the midbrain that is affected by the state of wakefulness or by hypnotics directly. Increased sedation and general anesthesia reduce and then abolish pupillary unrest as wakefulness decreases. We speculate that midbrain nuclei responsible for wakefulness and pupillary unrest are either communicating or share a similar sensitivity to the effects of commonly used anesthetics.

BACKGROUND:Pupillary unrest under ambient light (PUAL) is the fluctuation in pupil diameter in time around a mean value. PUAL is augmented by light and diminished by administration of opioids. We hypothesized that, because pupillary unrest is a marker of opioid effect, low levels of PUAL may be asso

Patients with end-stage liver disease are often hyponatremic due to multiple physiological processes associated with hepatic failure. For severely hyponatremic patients undergoing liver transplantation, intraoperative management of serum sodium concentration ([Na]s) is challenging. [Na]s tends to increase during transplantation by the administration of fluids with higher sodium concentration than the patient's [Na]s. An overly rapid increase in [Na]s (>1 mEq·L·hour) is difficult to avoid and increases the risk of serious perioperative complications. We report the successful use of intravenous desmopressin to reverse an overly rapid rise in [Na]s during living donor liver transplantation.

The proper diagnosis of hyponatremia is a vital component of the perioperative care of liver transplant patients, as hyponatremia is common among patients with end-stage liver disease. The general recommendation for the treatment of chronic hyponatremia is to limit the speed of correction. Unfortunately, the peri-transplantation period is often punctuated by large fluctuations in serum sodium concentration, which increases the risk of neurologic complications and osmotic demyelination syndrome. Consequently, the therapeutic goals and management strategies for hyponatremia vary greatly between the pre-transplantation, intraoperative, and post-transplantation periods. In this chapter, the definition, prognosis, pathophysiology, and treatment of hyponatremia in patients with cirrhosis are reviewed.

Hypertension is the major risk factor for premature cardiovascular disease, morbidity and mortality. It is the leading cause of death and disability globally, contributing to cardiovascular and renal diseases, including stroke, heart failure, coronary heart disease, and chronic kidney disease. We sought to determine the transcriptional changes that occur in cardiac endothelial cells secondary to hypertension, using ribosomal profiling of mice expressing the ribosomal protein Rpl22 tagged with the hemagglutinin (HA) epitope under control of Tie2-Cre (Tie2-Cre:RiboTag mice). Immunoprecipitation of HA-Rpl22 from heart tissue isolated from Tie2-Cre:RiboTag mice resulted in an approximate 10-fold enrichment of endothelial genes (Pecam-1, VE-cadherin) relative to genes highly expressed in cardiomyocytes (Tnnt2, Fabp3) as assessed by RT-PCR. Subsequently, Tie2-Cre:RiboTag mice were implanted with osmotic pumps delivering saline or angiotensin II (1000ng/kg/min) for 4 weeks. Angiotensin II infusion significantly increased blood pressure (p1.5, p

Lucas G.H.W. Can Anaesth Soc J 1960; 7: 237-56. To review the history of the early development of cyclopropane Cyclopropane was initially investigated because it was thought to be the toxic element in ethylene. Instead, it turned out to be an excellent anesthetic with very rapid onset and recovery while maintaining stable hemodynamics. Its use was ultimately limited because it was highly explosive. Development required collaboration among laboratory scientists and clinicians in Toronto, Canada, clinicians in Madison, USA, and industry in both countries. The phenomenal success of cyclopropane in over 40 years of clinical use resulted from a lucky, but incorrect, hypothesis that it was a toxic contaminant.

As part of the Journal’s 60 anniversary Diamond Jubilee Celebration, a number of seminal articles from the Journal archives are highlighted in the Journal’s 61 printed volume and online at: www.springer.com/12630. The following article was selected on the basis of its novelty at the time of publication, its scientific merit, and its overall importance to clinical practice: Lucas GHW. The discovery and pharmacology of cyclopropane. Can Anaesth Soc J 1960; 7: 237-56. Drs. Michael P. Bokoch and Adrian W. Gelb provide expert commentary on the discovery and use of a remarkable hemodynamically stable, rapid onset of action, anesthetic gas, the widespread use of which ultimately ended due to its proclivity for explosion.