Publications by authors named "Gyu-Sam Hwang"

98 Publications

Association of skeletal muscle index with postoperative acute kidney injury in living donor hepatectomy: A retrospective single-centre cohort study.

Liver Int 2021 Nov 24. Epub 2021 Nov 24.

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Background: Although living donor liver transplantation (LDLT) is the standard treatment option for patients with end-stage liver disease, it always entails ethical concerns about the risk of living donors. Recent studies have reported a correlation between sarcopenia and surgical prognosis in recipients. However, there are few studies of donor sarcopenia and the surgical prognosis of donors. This study investigated the association between sarcopenia and postoperative acute kidney injury in liver donors.

Methods: This retrospective study analysed 2892 donors who underwent donor hepatectomy for LDLT between January 2008 and January 2018. Sarcopenia was classified into pre-sarcopenia and severe sarcopenia, which were determined to be -1 standard deviation (SD), and -2 SD from the mean baseline of the skeletal muscle index, respectively. Multivariate regression analysis was performed to evaluate the association between donor sarcopenia and postoperative AKI. Additionally, we assessed the association between donor sarcopenia and delayed recovery of liver function (DRHF).

Results: In the multivariate analysis, donor sarcopenia was significantly associated a higher incidence of postoperative AKI (adjusted odds ratio [OR]: 2.65, 95% confidence interval [CI]: 1.15-6.11, P = .022 in pre-sarcopenia, OR: 5.59, 95% CI: 1.11-28.15, P = .037 in severe sarcopenia, respectively). Additionally, hypertension and synthetic colloid use were significantly associated with postoperative AKI. In the multivariate analysis, risk factors of DRHF were male gender, indocyanine green retention rate at 15 minutes, and graft type, however, donor sarcopenia was not a risk factor.

Conclusions: Donor sarcopenia is associated with postoperative AKI following donor hepatectomy.
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http://dx.doi.org/10.1111/liv.15109DOI Listing
November 2021

Low Preoperative Antithrombin III Level Is Associated with Postoperative Acute Kidney Injury after Liver Transplantation.

J Pers Med 2021 Jul 26;11(8). Epub 2021 Jul 26.

Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.

We aimed to determine the association between the preoperative antithrombin III (ATIII) level and postoperative acute kidney injury (AKI) after LT (post-LT AKI). We retrospectively evaluated 2395 LT recipients between 2010 and 2018 whose data of perioperative ATIII levels were available. Patients were divided into two groups based on the preoperative level of ATIII (ATIII < 50% vs. ATIII ≥ 50%). Multivariable regression analysis was performed to assess the risk factors for post-LT AKI. The mean preoperative ATIII levels were 30.2 ± 11.8% in the ATIII < 50% group and 67.2 ± 13.2% in the ATIII ≥ 50% group. The incidence of post-LT AKI was significantly lower in the ATIII ≥ 50% group compared to that in the ATIII < 50% group (54.7% vs. 75.5%, < 0.001); odds ratio (OR, per 10% increase in ATIII level) 0.86, 95% confidence interval (CI) 0.81-0.92; < 0.001. After a backward stepwise regression model, female sex, high body mass index, low albumin, deceased donor LT, longer duration of surgery, and high red blood cell transfusion remained significantly associated with post-LT AKI. A low preoperative ATIII level is associated with post-LT AKI, suggesting that preoperative ATIII might be a prognostic factor for predicting post-LT AKI.
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http://dx.doi.org/10.3390/jpm11080716DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8401622PMC
July 2021

Association between Neutrophil-Lymphocyte Ratio and Herpes Zoster Infection in 1688 Living Donor Liver Transplantation Recipients at a Large Single Center.

Biomedicines 2021 Aug 5;9(8). Epub 2021 Aug 5.

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.

Liver transplantation (LT) is closely associated with decreased immune function, a contributor to herpes zoster (HZ). However, risk factors for HZ in living donor LT (LDLT) remain unknown. Neutrophil-lymphocyte ratio (NLR) and immune system function are reportedly correlated. This study investigated the association between NLR and HZ in 1688 patients who underwent LDLT between January 2010 and July 2020 and evaluated risk factors for HZ and postherpetic neuralgia (PHN). The predictive power of NLR was assessed through the concordance index and an integrated discrimination improvement (IDI) analysis. Of the total cohort, 138 (8.2%) had HZ. The incidence of HZ after LT was 11.2 per 1000 person-years and 0.1%, 1.3%, 2.9%, and 13.5% at 1, 3, 5, and 10 years, respectively. In the Cox regression analysis, preoperative NLR was significantly associated with HZ (adjusted hazard ratio [HR], 1.05; 95% confidence interval [CI], 1.02-1.09; = 0.005) and PHN (HR, 1.08; 95% CI, 1.03-1.13; = 0.001). Age, sex, mycophenolate mofetil use, and hepatitis B virus infection were risk factors for HZ versus age and sex for PHN. In the IDI analysis, NLR was discriminative for HZ and PHN ( = 0.020 and = 0.047, respectively). Preoperative NLR might predict HZ and PHN in LDLT recipients.
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http://dx.doi.org/10.3390/biomedicines9080963DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8391531PMC
August 2021

Estimation of Stroke Volume Variance from Arterial Blood Pressure: Using a 1-D Convolutional Neural Network.

Sensors (Basel) 2021 Jul 29;21(15). Epub 2021 Jul 29.

Asan Medical Center, Department of Anesthesiology and Pain Medicine, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Seoul 05505, Korea.

Background: We aimed to create a novel model using a deep learning method to estimate stroke volume variation (SVV), a widely used predictor of fluid responsiveness, from arterial blood pressure waveform (ABPW).

Methods: In total, 557 patients and 8,512,564 SVV datasets were collected and were divided into three groups: training, validation, and test. Data was composed of 10 s of ABPW and corresponding SVV data recorded every 2 s. We built a convolutional neural network (CNN) model to estimate SVV from the ABPW with pre-existing commercialized model (EV1000) as a reference. We applied pre-processing, multichannel, and dimension reduction to improve the CNN model with diversified inputs.

Results: Our CNN model showed an acceptable performance with sample data (r = 0.91, MSE = 6.92). Diversification of inputs, such as normalization, frequency, and slope of ABPW significantly improved the model correlation (r = 0.95), lowered mean squared error (MSE = 2.13), and resulted in a high concordance rate (96.26%) with the SVV from the commercialized model.

Conclusions: We developed a new CNN deep-learning model to estimate SVV. Our CNN model seems to be a viable alternative when the necessary medical device is not available, thereby allowing a wider range of application and resulting in optimal patient management.
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http://dx.doi.org/10.3390/s21155130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8347322PMC
July 2021

Clinical impact of mild to moderate pulmonary hypertension in living-donor liver transplantation.

Transpl Int 2021 06 22;34(6):1150-1160. Epub 2021 Apr 22.

Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Severe pulmonary hypertension (PHT) is a contraindication to liver transplantation (LT); however, the prognostic implication of mild to moderate PHT in living-donor LT (LDLT) is unknown. The study cohort retrospectively included 1307 patients with liver cirrhosis who underwent LDLT. PHT was defined as a mean pulmonary artery pressure (PAP) of ≥25 mmHg, measured intraoperatively just before surgery. The primary endpoint was graft failure within 1 year after LDLT, including retransplantation or death from any cause. The secondary endpoints were in-hospital adverse events. In the overall cohort, the median Model for End-stage Liver Disease-Sodium (MELD-Na) score was 19, and 100 patients (7.7%) showed PHT. During 1-year follow-up, graft failure occurred in 94 patients (7.2%). Patients with PHT had lower 1-year graft survival (86% vs. 93.4%, P = 0.005) and survival rates (87% vs. 93.6%, P = 0.011). Mean PAP was associated with a high risk of in-hospital adverse events and 1-year graft failure. Adding the mean PAP to the clinical risk model improved the risk prediction. In conclusion, mild to moderate PHT was associated with higher risks of 1-year graft failure and in-hospital events, including mortality after LDLT in patients with liver cirrhosis. Intraoperative mean PAP can help predict the early clinical outcomes after LDLT.
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http://dx.doi.org/10.1111/tri.13875DOI Listing
June 2021

Rupture Risk of Intracranial Aneurysm and Prediction of Hemorrhagic Stroke after Liver Transplant.

Brain Sci 2021 Mar 31;11(4). Epub 2021 Mar 31.

Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea.

Postoperative hemorrhagic stroke (HS) is a rare yet devastating complication after liver transplantation (LT). Unruptured intracranial aneurysm (UIA) may contribute to HS; however, related data are limited. We investigated UIA prevalence and aneurysmal subarachnoid hemorrhage (SAH) and HS incidence post-LT. We identified risk factors for 1-year HS and constructed a prediction model. This study included 3544 patients who underwent LT from January 2008 to February 2019. Primary outcomes were incidence of SAH, HS, and mortality within 1-year post-LT. Propensity score matching (PSM) analysis and Cox proportional hazard analysis were performed. The prevalence of UIAs was 4.63% ( = 164; 95% confidence interval (CI), 3.95-5.39%). The 1-year SAH incidence was 0.68% (95% CI, 0.02-3.79%) in patients with UIA. SAH and HS incidence and mortality were not different between those with and without UIA before and after PSM. Cirrhosis severity, thrombocytopenia, inflammation, and history of SAH were identified as risk factors for 1-year HS. UIA presence was not a risk factor for SAH, HS, or mortality in cirrhotic patients post-LT. Given the fatal impact of HS, a simple scoring system was constructed to predict 1-year HS risk. These results enable clinical risk stratification of LT recipients with UIA and help assess perioperative HS risk before LT.
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http://dx.doi.org/10.3390/brainsci11040445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8066281PMC
March 2021

REPLY.

Hepatology 2021 Jul 15;74(1):536-537. Epub 2021 Jun 15.

Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

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http://dx.doi.org/10.1002/hep.31722DOI Listing
July 2021

Systolic anterior motion of mitral chordae tendineae: prevalence and clinical implications in liver transplantation.

Anesth Pain Med (Seoul) 2020 Apr 11;15(2):187-192. Epub 2020 Mar 11.

Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Background: Although systolic anterior motion (SAM) of the mitral valve anterior leaflet is well-known to cause hemodynamic perturbation in many anesthetic situations, the prevalence and clinical implication of SAM of mitral chordae tendineae (chordal SAM) in liver transplantation (LT) has not been evaluated. We aimed to assess the impact of chordal SAM on intraoperative postreperfusion syndrome and short and long-term all-cause mortality.

Methods: We retrospectively evaluated 1751 LT recipients from January 2011 to June 2017 who had preoperative echocardiography. Echocardiography-derived parameters and the prevalence of post-reperfusion syndrome between those with chordal SAM and without chordal SAM were compared. The cumulative mortality rate according to the presence of chordal SAM was evaluated by the Kaplan-Meier survival curve.

Results: Of the enrolled recipients, 21 (1.2%) had chordal SAM in preoperative echocardiography. Compared to those without chordal SAM, patients with chordal SAM had a smaller end-systolic volume index (median 18 ml/m vs. 22 ml/m, P = 0.015) and end-diastolic volume index (median 52 ml/m vs. 63 ml/m, P = 0.011). However, there was no difference in systolic and diastolic function in echocardiography. The prevalence of intraoperative post-reperfusion syndrome did not show any difference (42.9% vs. 45.3%, P = 1.000). Over the mean 4.8-year follow-up, cumulative 90-day and overall mortality also did not show a difference (Log rank P > 0.05, both).

Conclusions: Preoperative screening of echocardiography in LT recipients detects 1.2% of chordal SAM. It is found with small left ventricular volume, but is not related with intraoperative post-reperfusion syndrome and short- and long-term postoperative all-cause mortality in LT.
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http://dx.doi.org/10.17085/apm.2020.15.2.187DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7713819PMC
April 2020

Prognostic Value of B-Type Natriuretic Peptide in Liver Transplant Patients: Implication in Posttransplant Mortality.

Hepatology 2021 Jul 15;74(1):336-350. Epub 2021 Jun 15.

Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Republic of Korea.

Background And Aims: Despite frequent cirrhotic cardiomyopathy or subclinical heart failure (HF), the prognostic value of peri-liver transplant (LT) B-type natriuretic peptide (BNP) has been poorly studied in advanced liver disease. We examined the association between BNP and mortality in a large cohort of LT patients and identified risk factors for peri-LT BNP increase.

Approach And Results: Using prospectively collected data from the Asan LT Registry between 2008 and 2019, 3,811 patients who measured serial pretransplant BNP (preBNP) and peak BNP levels within the first 3 posttransplant days (postBNP ) were analyzed. Thirty-day all-cause mortality predicted by adding preBNP and/or postBNP to the traditional Revised Cardiac Risk Index (RCRI) was evaluated. PreBNP > 400 pg/mL (known cutoff of acute HF) was found in 298 (7.8%); however, postBNP  > 400 pg/mL was identified in 961 (25.2%) patients, specifically in 40.4% (531/1,315) of those with a Model for End-Liver Disease score (MELDs) > 20. Strong predictors of postBNP  > 400 pg/mL were preBNP, hyponatremia, and MELDs, whereas those of preBNP > 400 pg/mL were MELDs, kidney failure, and respiratory failure. Among 100 (2.6%) post-LT patients who died within 30 days, patients with postBNP  ≤ 150 pg/mL (43.1%, reference group), 150-400 pg/mL (31.7%), 400-1,000 pg/mL (18.5%), 1,000-2,000 pg/mL (4.7%), and >2,000 pg/mL (2.0%) had 30-day mortalities of 0.9%, 2.2%, 4.0%, 7.7%, and 22.4%, respectively. Adding preBNP, postBNP , and both BNP to RCRI improved net reclassification index to 22.5%, 29.5%, and 33.1% of 30-day mortality, respectively.

Conclusions: PostBNP  > 400 pg/mL after LT was markedly prevalent in advanced liver disease and mainly linked to elevated preBNP. Routine monitoring of peri-LT BNP provides incremental prognostic information; therefore, it could help risk stratification for mortality as a practical and useful biomarker in LT.
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http://dx.doi.org/10.1002/hep.31661DOI Listing
July 2021

Response to Comment on "Effect of Remote Ischemic Preconditioning Conducted in Living Liver Donors on Postoperative Liver Function in Donors and Recipients Following Liver Transplantation: A Randomized Clinical Trial".

Ann Surg 2021 Dec;274(6):e821

Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.

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http://dx.doi.org/10.1097/SLA.0000000000004513DOI Listing
December 2021

von Willebrand factor to protein C ratio-related thrombogenicity with systemic inflammation is predictive of graft dysfunction after liver transplantation: Retrospective cohort study.

Int J Surg 2020 Dec 1;84:109-116. Epub 2020 Nov 1.

Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea. Electronic address:

Introduction: Early allograft dysfunction (EAD) is known to be a prototype of graft failure and ultimately influences long-term graft failure or death. We hypothesized that pretransplant thrombogenicity evaluated by procoagulant and anticoagulant, von Willebrand factor (vWF), factor Ⅷ (FⅧ), protein C (PC) and their imbalance ratio of vWF-to-PC (vWFPCR) and FVIII-to-PC (FⅧPCR), is associated with EAD and 90-day graft failure after living-related liver transplantation (LDLT) and contributes to further exacerbation of graft dysfunction when coexists with systemic inflammation.

Material And Methods: Of 1199 prospectively registered LDLT patients, 698 with measurements of each thrombogenicity parameters were analyzed. Risk factors for EAD development were searched and subsequent best cut-offs was calculated according to the receiver operator characteristic curve analysis. When comparing the outcome, multivariable regression analysis and inverse probability of treatment weighting (IPTW) of the propensity score were performed.

Results: The prevalence of EAD was 10.7% (n = 75/698) after LDLT. Of parameters, vWFPCR had highest predictivity potential of EAD with the best cut-off of 8.06. The relationship between vWFPCR≥8.06 showed significant association with EAD development (OR [95%CI], 2.55[1.28-5.09], P = 0.008) and 90-day graft failure (HR [95%CI], 2.24 [1-4.98], P = 0.043) after IPTW-adjustment. Furthermore, risk of EAD increased proportionally with increasing C-reactive protein as a continuous metric of systemic inflammation, and more steeply in those with higher thrombogenicity (i.e., higher vWFPCR). Adding vWFPCR to MELD score improved EAD risk prediction by 21.9%.

Conclusions: Pretransplant thrombogenicity assessed by imbalance of pro- and anticoagulant, was significantly associated with EAD and 90-day graft failure after LDLT and this association was worsened by systemic inflammation.
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http://dx.doi.org/10.1016/j.ijsu.2020.10.030DOI Listing
December 2020

Over 500 Liver Transplants Including More Than 400 Living-Donor Liver Transplants in 2019 at Asan Medical Center.

Transplant Proc 2021 Jan-Feb;53(1):83-91. Epub 2020 Oct 1.

Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Background: More than 400 liver transplants were performed at Asan Medical Center (AMC) in 2011, and over 500 liver transplants including 420 living-donor liver transplants (LDLTs) were performed in 2019. Herein, we report the methodology of these procedures.

Methods: Since the first adult LDLTs at AMC using the left and right lobes were successfully performed, various innovative techniques and approaches have been developed: modified right lobe, dual graft, donor exchange for ABO incompatibility, expansion of indications and no-touch techniques for hepatocellular carcinoma, intraoperative cine-portogram and additional intervention for large collaterals, management of portal vein thrombosis (PVT) and stenosis, salvage LDLT after major hepatectomy, and timely LDLT for patients with acute-on-chronic liver failure.

Results: Four hundred twenty LDLTs in 403 adult and 17 pediatric patients and 85 deceased-donor liver transplants in 74 adult and 11 pediatric patients were performed. The number of deceased-donor liver transplants remained constant since 2011, but the number of LDLTs increased steadily. One hundred thirty patients (25.7%) required urgent liver transplantations and 24 patients with acute-on-chronic liver failure underwent LDLT. PVT including grade 1,2,3, and 4 was reported in 91 patients (18.0%), and Yerdel's grade 2, 3, and 4 PVT was reported in 47 patients (51.6%); all patients with PVT were successfully treated. Adult LDLTs for hepatocellular carcinoma and ABO incompatibility accounted for 52.6% and 24.3% of the cases, respectively. In-hospital mortality in 2019 was 2.97%.

Conclusion: Continual efforts to overcome challenging problems in LDLT with various innovations and dedication of the team members during the perioperative period to improve patient outcomes were crucial in increasing the number of liver transplantations at Asan Medical Center.
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http://dx.doi.org/10.1016/j.transproceed.2020.08.027DOI Listing
April 2021

Preoperative high-sensitivity troponin I and B-type natriuretic peptide, alone and in combination, for risk stratification of mortality after liver transplantation.

Korean J Anesthesiol 2021 06 26;74(3):242-253. Epub 2020 Aug 26.

Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Background: Given the severe shortage of donor liver grafts, coupled with growing proportion of cardiovascular death after liver transplantation (LT), precise cardiovascular risk assessment is pivotal for selecting recipients who gain the greatest survival benefit from LT surgery. We aimed to determine the prognostic value of pre-LT combined measurement of B-type natriuretic peptide (BNP) and high-sensitivity troponin I (hsTnI) in predicting early post-LT mortality.

Methods: We retrospectively evaluated 2,490 consecutive adult LT patients between 2010 and 2018. Cut-off values of BNP and hsTnI for predicting post-LT 90-day mortality were calculated. According to the derived cut-off values of two cardiac biomarkers, alone and in combination, adjusted hazard ratios (aHR) of post-LT 90-day mortality were determined using multivariate Cox regression analysis.

Results: Mortality rate after 90 days was 2.9% (72/2,490). Rounded cut-off values for post-LT 90-day mortality were 400 pg/ml for BNP (aHR 2.02 [1.15, 3.52], P = 0.014) and 60 ng/L for hsTnI (aHR 2.65 [1.48, 4.74], P = 0.001), respectively. Among 273 patients with BNP ≥ 400 pg/ml, 50.9% of patients were further stratified into having hsTnI ≥ 60 ng/L. Combined use of pre-LT cardiac biomarkers predicted post-LT 90-day mortality rate; both non-elevated: 1.0% (21/2,084), either one is elevated: 9.0% (24/267), and both elevated: 19.4% (27/139, log-rank P < 0.001; aHR vs non-elevated 4.23 [1.98, 9.03], P < 0.001).

Conclusions: Concomitant elevation of both cardiac biomarkers posed significantly higher risk of 90-day mortality after LT. Pre-LT assessment cardiac strain and myocardial injury, represented by BNP and hsTnI values, would contribute to prioritization of LT candidates and help administer target therapies that could modify early mortality.
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http://dx.doi.org/10.4097/kja.20296DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8175877PMC
June 2021

Markedly prolonged QTc interval in end-stage liver disease and risk of 30-day cardiovascular event after liver transplant.

J Gastroenterol Hepatol 2021 Mar 30;36(3):758-766. Epub 2020 Jul 30.

Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Background And Aim: The proportional increase of corrected QT interval (QTc) along end-stage liver disease (ESLD) severity may lead to inconsistent outcome reporting if based on conventional threshold of prolonged QTc. We investigated the comprehensive QTc distribution among ESLD patients and assessed the association between QTc > 500 ms, a criterion for diagnosing severe long-QT syndrome, and the 30-day major adverse cardiovascular event (MACE) after liver transplantation (LT) and identified the risk factors for developing QTc > 500 ms.

Methods: Data were collected prospectively from the Asan LT Registry between 2011 and 2018, and outcomes were retrospectively reviewed. Multivariable analysis and propensity score-weighted adjusted odds ratios (ORs) were calculated. Thirty-day MACEs were defined as the composite of cardiovascular mortality, arrhythmias, myocardial infarction, pulmonary thromboembolism, and/or stroke.

Results: Of 2579 patients, 194 (7.5%) had QTc > 500 ms (QTc500_Group), and 1105 (42.8%) had prolonged QTc (QTcP_Group), defined as QTc > 470 ms for women and >450 ms for men. The 30-day MACE occurred in 336 (13%) patients. QTc500_Group showed higher 30-day MACE than did those without (20.1% vs 12.5%, P = 0.003), with corresponding adjusted OR of 1.24 (95% CI: 1.06-1.46, P = 0.007). However, QTcP_Group showed comparable 30-day MACE (13.3% vs 12.8% without prolonged QTc, P = 0.764). Significant risk factors for QTc > 500 ms development were advanced liver disease, female sex, hypokalemia, hypocalcemia, high left ventricular end-diastolic volume, and tachycardia.

Conclusion: Our results revealed that, among ESLD patients, a novel threshold of QTc > 500 ms was associated with post-LT 30-day MACE but not with conventional threshold, indicating that a longer QTc threshold should be considered for this unique patient population.
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http://dx.doi.org/10.1111/jgh.15179DOI Listing
March 2021

Real-Time Monitoring of Blood Pressure Using Digitalized Pulse Arrival Time Calculation Technology for Prompt Detection of Sudden Hypertensive Episodes During Laryngeal Microsurgery: Retrospective Observational Study.

J Med Internet Res 2020 05 15;22(5):e13156. Epub 2020 May 15.

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Background: Laryngeal microsurgery (LMS) is often accompanied by a sudden increase in blood pressure (BP) during surgery because of stimulation around the larynx. This sudden change in the hemodynamic status is not immediately reflected in a casual cuff-type measurement that takes intermittent readings every 3 to 5 min.

Objective: This study aimed to investigate the potential of pulse arrival time (PAT) as a marker for a BP surge, which usually occurs in patients undergoing LMS.

Methods: Intermittent measurements of BP and electrocardiogram (ECG) and photoplethysmogram (PPG) signals were recorded during LMS. PAT was defined as the interval between the R-peak on the ECG and the maximum slope on the PPG. Mean PAT values before and after BP increase were compared. PPG-related parameters and the correlations between changes in these variables were calculated.

Results: BP surged because of laryngoscopic manipulation (mean systolic BP [SBP] from 115.3, SD 21.4 mmHg, to 159.9, SD 25.2 mmHg; P<.001), whereas PAT decreased significantly (from mean 460.6, SD 51.9 ms, to 405.8, SD 50.1 ms; P<.001) in most of the cases. The change in SBP showed a significant correlation with the inverse of the PAT (r=0.582; P<.001). Receiver-operating characteristic curve analysis indicated that an increase of 11.5% in the inverse of the PAT could detect a 40% increase in SBP, and the area under the curve was 0.814.

Conclusions: During LMS, where invasive arterial catheterization is not always possible, PAT shows good correlation with SBP and may, therefore, have the potential to identify abrupt BP surges during laryngoscopic manipulations in a noninvasive manner.
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http://dx.doi.org/10.2196/13156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7260662PMC
May 2020

Response to the Comment on "Effect of Remote Ischemic Preconditioning Conducted in Living Liver Donors on Postoperative Liver Function in Donors and Recipients Following Liver Transplantation: A Randomized Clinical Trial".

Ann Surg 2021 Dec;274(6):e710-e711

Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

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http://dx.doi.org/10.1097/SLA.0000000000003865DOI Listing
December 2021

Reply.

Hepatology 2020 08;72(2):784

Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

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http://dx.doi.org/10.1002/hep.31162DOI Listing
August 2020

Early postoperative weight gain is associated with increased risk of graft failure in living donor liver transplant recipients.

Sci Rep 2019 12 27;9(1):20096. Epub 2019 Dec 27.

Department of Anaesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Korea.

Fluid overload (FO) has been shown to adversely affect multiple organs and survival in critically ill patients. Liver transplantation (LT) carries the risk of massive transfusion, which frequently results in FO. We investigated the association of postoperative weight gain with graft failure, early allograft dysfunction (EAD), and overall mortality in LT. 1833 living donor LT (LDLT) recipients were retrospectively analysed. Patients were divided into 2 groups according to postoperative weight gain (<3% group [n = 1391] and ≥3% group [n = 442]) by using maximally selected log-rank statistics for graft failure. Multivariate Cox and logistic regression analyses were performed. The ≥3% group was associated with graft failure (adjusted HR [aHR], 1.763; 95% CI, 1.248-2.490; P = 0.001). When postoperative weight change was used as a continuous variable, the aHR for each 1% increase in postoperative weight was 1.045 (95% CI, 1.009-1.082; P = 0.015). In addition, the ≥3% group was associated with EAD (adjusted OR [aOR], 1.553; 95% CI, 1.024-2.356; P = 0.038) and overall mortality (aHR, 1.731; 95% CI, 1.182-2.535; P = 0.005). In conclusion, postoperative weight gain may be independently associated with increased risk of graft failure, EAD, and mortality in LDLT recipients.
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http://dx.doi.org/10.1038/s41598-019-56543-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6934543PMC
December 2019

Remote Ischemic Preconditioning and Diazoxide Protect from Hepatic Ischemic Reperfusion Injury by Inhibiting HMGB1-Induced TLR4/MyD88/NF-κB Signaling.

Int J Mol Sci 2019 Nov 24;20(23). Epub 2019 Nov 24.

Department of Anesthesiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.

Remote ischemic preconditioning (RIPC) is known to have a protective effect against hepatic ischemia-reperfusion (IR) injury in animal models. However, the underlying mechanism of action is not clearly understood. This study examined the effectiveness of RIPC in a mouse model of hepatic IR and aimed to clarify the mechanism and relationship of the ATP-sensitive potassium channel (K) and HMGB1-induced TLR4/MyD88/NF-κB signaling. C57BL/6 male mice were separated into six groups: (i) sham-operated control, (ii) IR, (iii) RIPC+IR, (iv) RIPC+IR+glyburide (K blocker), (v) RIPC+IR+diazoxide (K opener), and (vi) RIPC+IR+diazoxide+glyburide groups. Histological changes, including hepatic ischemia injury, were assessed. The levels of circulating liver enzymes and inflammatory cytokines were measured. Levels of apoptotic proteins, proinflammatory factors (TLR4, HMGB1, MyD88, and NF-κB), and IκBα were measured by Western blot and mRNA levels of proinflammatory cytokine factors were determined by RT-PCR. RIPC significantly decreased hepatic ischemic injury, inflammatory cytokine levels, and liver enzymes compared to the corresponding values observed in the IR mouse model. The K opener diazoxide + RIPC significantly reduced hepatic IR injury demonstrating an additive effect on protection against hepatic IR injury. The protective effect appeared to be related to the opening of K, which inhibited HMGB1-induced TRL4/MyD88/NF-kB signaling.
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http://dx.doi.org/10.3390/ijms20235899DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6929132PMC
November 2019

Preoperative echocardiographic evaluation of cardiac systolic and diastolic function in liver transplant recipients with diabetes mellitus: a propensity-score matched analysis.

Anesth Pain Med (Seoul) 2019 Oct;14(4):465-473

Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Background: Diabetes mellitus (DM) increases risk of heart failure. It has been shown that diabetes leads to DM-cardiomyopathy, characterized by systolic and diastolic dysfunction. Pre-transplant diastolic dysfunction, has been associated with poor graft outcome and mortality. We assessed the hypothesis that end-stage liver disease (ESLD) patients with diabetes (DM-ESLD), have more advanced cardiac systolic and diastolic dysfunction, compared to ESLD patients without diabetes (Non DM-ESLD).

Methods: We retrospectively evaluated preoperative echocardiography of 1,319 consecutive liver transplant recipients (1,007 Non DM-ESLD vs. 312 DM-ESLD [23.7%]) January 2012-May 2016. Systolic and diastolic indices, such as left ventricular ejection fraction, transmital E/A ratio, tissue doppler s', e' velocity, and E/e' ratio (index of left ventricular end-diastolic pressure), were compared using 1:2 propensity-score matching.

Results: DM-ESLD patients showed no differences in systolic indices of left ventricular ejection fraction and s' velocity, whereas diastolic indices of E/A ratio ≤ 1 (49.0% vs. 40.2% P = 0.014), e' velocity (median = 7.0 vs. 7.4 cm/s, P < 0.001) and E/e' ratio (10.9 ± 3.2 vs. 10.1 ± 3.0, P < 0.001), showed worse diastolic function compare with Non DM-ESLD patients, respectively.

Conclusions: DM-ESLD patients suffer higher degree of diastolic dysfunction compared with Non DM-ESLD patients. Based on this, careful preoperative screening for diastolic dysfunction in DM-ESLD patients is encouraged, because poor transplant outcomes have been noted in patients with preoperative diastolic dysfunction.
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http://dx.doi.org/10.17085/apm.2019.14.4.465DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7713801PMC
October 2019

Deep Learning-Based Stroke Volume Estimation Outperforms Conventional Arterial Contour Method in Patients with Hemodynamic Instability.

J Clin Med 2019 Sep 9;8(9). Epub 2019 Sep 9.

Department of Biomedical Engineering, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.

Although the stroke volume (SV) estimation by arterial blood pressure has been widely used in clinical practice, its accuracy is questionable, especially during periods of hemodynamic instability. We aimed to create novel SV estimating model based on deep-learning (DL) method. A convolutional neural network was applied to estimate SV from arterial blood pressure waveform data recorded from liver transplantation (LT) surgeries. The model was trained using a gold standard referential SV measured via pulmonary artery thermodilution method. Merging a gold standard SV and corresponding 10.24 seconds of arterial blood pressure waveform as an input/output data set with 2-senconds of sliding overlap, 484,384 data sets from 34 LT surgeries were used for training and validation of DL model. The performance of DL model was evaluated by correlation and concordance analyses in another 491,353 data sets from 31 LT surgeries. We also evaluated the performance of pre-existing commercialized model (EV1000), and the performance results of DL model and EV1000 were compared. The DL model provided an acceptable performance throughout the surgery ( = 0.813, concordance rate = 74.15%). During the reperfusion phase, where the most severe hemodynamic instability occurred, DL model showed superior correlation (0.861; 95% Confidence Interval, (CI), 0.855-0.866 vs. 0.570; 95% CI, 0.556-0.584, < 0.001) and higher concordance rate (90.6% vs. 75.8%) over EV1000. In conclusion, the DL-based model was superior for estimating intraoperative SV and thus might guide physicians to precise intraoperative hemodynamic management. Moreover, the DL model seems to be particularly promising because it outperformed EV1000 in circumstance of rapid hemodynamic changes where physicians need most help.
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http://dx.doi.org/10.3390/jcm8091419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6780281PMC
September 2019

Appraisal of Cardiac Ejection Fraction With Liver Disease Severity: Implication in Post-Liver Transplantation Mortality.

Hepatology 2020 04 6;71(4):1364-1380. Epub 2020 Mar 6.

Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Background And Aims: Enhanced sympathetic nervous activation and peripheral vasodilation in end-stage liver disease (ESLD) may limit the importance of left ventricular ejection fraction (LVEF) as an influential prognosticator. We sought to understand the LVEF and cardiac dimensions in ESLD patients in order to define the LVEF threshold to predict all-cause mortality after liver transplantation (LT).

Approach And Results: Data were collected prospectively from the Asan LT Registry between 2008 and 2016, and outcomes were retrospectively reviewed. LVEF, end-diastolic volume index (EDVI), and end-diastolic elastance (Eed) were measured by preoperative echocardiography. Of 2,799 patients, 452 (16.2%) had LVEF ≤ 60%, with 29 (1.0%) having LVEF < 55% and 269 (9.6%) had LVEF ≥ 70%. Over a median of 5.4-year follow-up, 329 (11.8%) patients died: 104 (3.7%) died within 90 days. LVEF (range, 30%-81%) was directly proportionate to Model for End-stage Liver Disease (MELD) scores, an index of liver disease severity, in survivors but showed a fixed flat-line pattern in nonsurvivors (interaction P = 0.004 between groups), with lower EDVI (P = 0.013) and higher Eed (P = 0.001) in the MELD ≥ 20 group. Patients with LVEF ≤ 60% had higher 90-day (13% vs. 7.4%; log rank, P = 0.03) and median 5.4-year (26.7% vs. 16.2%; log rank, P = 0.003) mortality rates in the MELD ≥ 20 group, respectively, compared to those with LVEF > 60%. Specifically, in the MELD > 35 group, median 5.4-year mortality rate was 53.3% in patients with LVEF ≤ 60% versus 24% in those with LVEF > 60% (log rank P < 0.001). By contrast, mortality rates of LVEF ≤ 60% and > 60% were similar in the MELD < 20 group (log rank P = 0.817).

Conclusions: LVEF ≤ 60% is strongly associated with higher post-LT mortality rates in the MELD ≥ 20 group, indicating the need to appraise both LVEF and liver disease severity simultaneously. Enhanced diastolic elastance with low EDVI provides insights into pathogenesis of low LVEF in nonsurvivors with MELD ≥ 20.
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http://dx.doi.org/10.1002/hep.30913DOI Listing
April 2020

Effect of Remote Ischemic Preconditioning Conducted in Living Liver Donors on Postoperative Liver Function in Donors and Recipients Following Liver Transplantation: A Randomized Clinical Trial.

Ann Surg 2020 04;271(4):646-653

Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Objective: This study aimed to assess the effects of remote ischemic preconditioning (RIPC) on liver function in donors and recipients after living donor liver transplantation (LDLT).

Background: Ischemia reperfusion injury (IRI) is known to be associated with graft dysfunction after liver transplantation. RIPC is used to lessen the harmful effects of IRI.

Methods: A total of 148 donors were randomly assigned to RIPC (n = 75) and control (n = 73) groups. RIPC involves 3 cycles of 5-minute inflation of a blood pressure cuff to 200 mm Hg to the upper arm, followed by 5-minute reperfusion with cuff deflation. The primary aim was to assess postoperative liver function in donors and recipients and the incidence of early allograft dysfunction and graft failure in recipients.

Results: RIPC was not associated with any differences in postoperative aspartate aminotransferase (AST) and alanine aminotransferase levels after living donor hepatectomy, and it did not decrease the incidence of delayed graft hepatic function (6.7% vs 0.0%, P = 0.074) in donors. AST level on postoperative day 1 [217.0 (158.0, 288.0) vs 259.5 (182.0, 340.0), P = 0.033] and maximal AST level within 7 postoperative days [244.0 (167.0, 334.0) vs 296.0 (206.0, 395.5), P = 0.029) were significantly lower in recipients who received a preconditioned graft. No differences were found in the incidence of early allograft dysfunction (4.1% vs 5.6%, P = 0.955) or graft failure (1.4% vs 5.6%, P = 0.346) among recipients.

Conclusions: RIPC did not improve liver function in living donor hepatectomy. However, RIPC performed in liver donors may be beneficial for postoperative liver function in recipients after living donor liver transplantation.
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http://dx.doi.org/10.1097/SLA.0000000000003498DOI Listing
April 2020

Preoperative Myocardial Ischemia Detected With Electrocardiography Is Associated With Reduced 1-Year Survival Rate in Patients Undergoing Liver Transplant.

Transplant Proc 2019 Oct 22;51(8):2755-2760. Epub 2019 Jul 22.

Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Background: Although electrocardiography (ECG) is routinely used as a preoperative cardiac assessment tool, impact of ECG-detected myocardial ischemia on postoperative outcomes remains unclear. We aimed to assess use of ECG as a predictor of postoperative mortality in patients undergoing liver transplant (LT).

Methods: Electronic medical records of patients who underwent LT were retrospectively analyzed. The primary end point was postoperative 1-year all-cause mortality. Electrocardiographic myocardial ischemia was diagnosed based on automated ECG interpretation suggesting ischemia or infarction. Cox proportional hazard analysis was performed to identify independent risk factors including Model for End-Stage Liver Disease score, revised cardiac risk index, echocardiographic wall motion abnormalities, and myocardial perfusion scan (MPS) abnormalities.

Results: Of the 1430 patients, 78 (5.5%) showed ischemic change on ECG. The 1-year mortality of patients with ischemic change on ECG was significantly higher than that of those without (11.5% vs 4.0%; P = .004). In the Cox proportional hazard model, ischemic change on ECG (hazard ratio [HR], 2.91; 95% CI, 1.43-5.92; P = .003), Model for End-Stage Liver Disease score (HR 1.06; 95% CI 1.04-1.09; P < .001), and revised cardiac risk index (HR, 2.84; 95% CI, 1.86-4.35; P < .001) were independent variables predicting 1-year mortality; however, MPS abnormalities and echocardiographic wall motion abnormalities were not.

Conclusion: In patients undergoing LT, preoperative ischemic ECG findings should not be overlooked, as they are associated with increased mortality, while abnormalities on MPS and resting ECG are not. Thorough evaluations to detect underlying modifiable coronary artery disease are needed in patients with these findings.
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http://dx.doi.org/10.1016/j.transproceed.2019.02.063DOI Listing
October 2019

Respiratory Variations in Electrocardiographic R-Wave Amplitude during Acute Hypovolemia Induced by Inferior Vena Cava Clamping in Patients Undergoing Liver Transplantation.

J Clin Med 2019 May 20;8(5). Epub 2019 May 20.

Department of Anesthesiology and Pain Medicine, University of Ulsan College of Medicine, Asan Medical Center, 05505 Seoul, Korea.

The aim of this study was to analyze whether the respiratory variation in electrocardiogram (ECG) standard lead II R-wave amplitude (ΔRDII) could be used to assess intravascular volume status following inferior vena cava (IVC) clamping. This clamping causes an acute decrease in cardiac output during liver transplantation (LT). We retrospectively compared ΔRDII and related variables before and after IVC clamping in 34 recipients. Receiver operating characteristic (ROC) curve and area under the curve (AUC) analyses were used to derive a cutoff value of ΔRDII for predicting pulse pressure variation (PPV). After IVC clamping, cardiac output significantly decreased while ΔRDII significantly increased ( = 0.002). The cutoff value of ΔRDII for predicting a PPV >13% was 16.9% (AUC: 0.685) with a sensitivity of 57.9% and specificity of 77.6% (95% confidence interval 0.561 - 0.793, = 0.015). Frequency analysis of ECG also significantly increased in the respiratory frequency band ( = 0.016). Although significant changes in ΔRDII during vena cava clamping were found at norepinephrine doses <0.1 µg/kg/min ( = 0.032), such changes were not significant at norepinephrine doses >0.1 µg/kg/min ( = 0.093). ΔRDII could be a noninvasive dynamic parameter in LT recipients presenting with hemodynamic fluctuation. Based on our data, we recommended cautious interpretation of ΔRDII may be requisite according to vasopressor administration status.
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http://dx.doi.org/10.3390/jcm8050717DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6572700PMC
May 2019

Quantitative Analysis of an Intraoperative Digitalized Esophageal Heart Sound Signal to Speculate on Perturbed Cardiovascular Function.

J Clin Med 2019 May 20;8(5). Epub 2019 May 20.

Biosignal Analysis and Perioperative Outcome Research Laboratory, Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.

Although visualization of heart sounds, known as phonocardiography, provides valuable information on cardiovascular hemodynamics, its use has not been widely encouraged due to the scarcity of information on its interpretation. In the present study, using the intraoperative phonocardiogram recorded by an esophageal stethoscope, we quantitatively evaluated the time and frequency domains of modulation of the heart sounds components and their association with left ventricular contractility and systemic vascular resistance under the effects of various cardiovascular drugs. We analyzed 29 pairs of intraoperative digitalized phonocardiographic signals and their corresponding hemodynamic data before and after cardiovascular drug administration (ephedrine, esmolol, phenylephrine, and/or nicardipine) in 17 patients who underwent liver transplantation. The S1 and S2 components of the heart sounds (the first and second heart sounds, respectively) were identified and their modulation in time and frequency domains was analyzed. As an index of cardiovascular function, systolic tissue Doppler wave velocity (TDI S'), maximal dP/dt from the arterial waveform, and systemic vascular resistance were simultaneously evaluated. Ephedrine/esmolol and phenylephrine/nicardipine primarily affected the S1 and S2 components of the heart sounds, respectively. This result implies that the intraoperative phonocardiogram may have the potential to be useful in detecting the changes in contractility and afterload that commonly occur in patients receiving anesthesia. In an era of constant need for noninvasive hemodynamic assessment, phonocardiography has the potential for use as a novel and informative tool for monitoring of hemodynamic function.
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http://dx.doi.org/10.3390/jcm8050715DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6572513PMC
May 2019

Impact of Remote Ischemic Preconditioning Conducted in Living Kidney Donors on Renal Function in Donors and Recipients Following Living Donor Kidney Transplantation: A Randomized Clinical Trial.

J Clin Med 2019 May 20;8(5). Epub 2019 May 20.

Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.

Although remote ischemic preconditioning (RIPC) has been shown to have renoprotective effects, few studies have assessed the effects of RIPC on renal function in living kidney donors. This study investigated whether RIPC performed in living kidney donors could improve residual renal function in donors and outcomes in recipients following kidney transplantation. The donors were randomized into a control group ( = 85) and a RIPC group ( = 85). The recipients were included according to the matched donors. Serum creatinine (sCr) concentrations and estimated glomerular filtration rate (eGFR) were compared between control and RIPC groups in donors and recipients. Delayed graft function, acute rejection, and graft failure within one year after transplantation were evaluated in recipients. sCr was significantly increased in the control group (mean, 1.13; 95% confidence interval (CI), 1.07-1.18) than the RIPC group (1.01; 95% CI, 0.95-1.07) ( = 0.003) at discharge. Donors with serum creatinine >1.4 mg/dL at discharge had higher prevalence of chronic kidney disease ( = 6, 26.1%) than donors with a normal serum creatinine level ( = 8, 5.4%) ( = 0.003) after one year. sCr concentrations and eGFR were similar in the RIPC and control groups of recipients over the one-year follow-up period. Among recipients, no outcome variables differed significantly in the RIPC and control groups. RIPC was effective in improving early renal function in kidney donors but did not improve renal function in recipients.
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http://dx.doi.org/10.3390/jcm8050713DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6572316PMC
May 2019

Beat-to-Beat Tracking of Pulse Pressure and Its Respiratory Variation Using Heart Sound Signal in Patients Undergoing Liver Transplantation.

J Clin Med 2019 04 30;8(5). Epub 2019 Apr 30.

Department of Anesthesiology and Pain Medicine, Biosignal Analysis and Perioperative Outcome Research Laboratory, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea.

Purpose: To investigate the possibility of esophageal phonocardiography as a monitor for invasively measured pulse pressure (PP) and its respiratory variation (PPV) in patients undergoing liver transplantation.

Methods: In 24 liver transplantation recipients, all hemodynamic parameters, including PP and PPV, were measured during five predetermined surgical phases. Simultaneously, signals of esophageal heart sounds (S1, S2) were identified, and S1-S2 interval (phonocardiographic systolic time, PST) and its respiratory variation (PSV) within a 20-s window were calculated. Beat-to-beat correlation between PP and its corresponding PST was assessed during each time window, according to the surgical phases. To compare PPV and PSV along with 5 phases (a total of 120 data pairs), Pearson correlation was conducted.

Results: Beat-to-beat PST values were closely correlated with their corresponding 3360 pairs of PP values (median = 0.568 [IQR 0.246-0.803]). Compared with the initial phase of surgery, correlation coefficients were significantly lower during the reperfusion period (median = 0.717 [IQR 0.532-0.886] vs. median = 0.346 [IQR 0.037-0.677]; = 0.002). The correlation between PSV and PPV showed similar variation according to the surgical phases ( = 0.576 to 0.689, < 0.05, for pre-reperfusion; 0.290 to 0.429 for the post-reperfusion period).

Conclusions: Continuous monitoring of intraoperative PST with an esophageal stethoscope has the potential to act as an indirect estimator of beat-to-beat arterial PP. Moreover, PSV appears to exhibit a trend similar to that of PPV with moderate accuracy. However, variation according to the surgical phase limits the merit of the current results, thereby necessitating cautious interpretation.
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http://dx.doi.org/10.3390/jcm8050593DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6572412PMC
April 2019

Neutrophil-to-lymphocyte ratio is a predictor of early graft dysfunction following living donor liver transplantation.

Liver Int 2019 08 8;39(8):1545-1556. Epub 2019 Apr 8.

Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Republic of Korea.

Background & Aims: Early allograft dysfunction (EAD) is predictive of poor graft and patient survival following living donor liver transplantation (LDLT). Considering the impact of the inflammatory response on graft injury extent following LDLT, we investigated the association between neutrophil-to-lymphocyte ratio (NLR) and EAD, 1-year graft failure, and mortality following LDLT, and compared it to C-reactive protein (CRP), procalcitonin, platelet-to-lymphocyte ratio and the Glasgow prognostic score.

Methods: A total of 1960 consecutive adult LDLT recipients (1531/429 as development/validation cohort) were retrospectively evaluated. Cut-offs were derived using the area under the receiver operating characteristic curve (AUROC), and multivariable regression and Cox proportional hazard analyses were performed.

Results: The risk of EAD increased proportionally with increasing NLR, and the NLR AUROC was 0.73, similar to CRP and procalcitonin and higher than the rest. NLR ≥ 2.85 (best cut-off) showed a significantly higher EAD occurrence (20.5% vs 5.8%, P < 0.001), higher 1-year graft failure (8.2% vs 4.9%, log-rank P = 0.009) and higher 1-year mortality (7% vs 4.5%, log-rank P = 0.039). NLR ≥ 2.85 was an independent predictor of EAD (odds ratio, 1.89 [1.26-2.84], P = 0.002) after multivariable adjustment, whereas CRP and procalcitonin were not. Increasing NLR was independently associated with higher 1-year graft failure and mortality (both P < 0.001). Consistent results in the validation cohort strengthened the prognostic value of NLR.

Conclusions: Preoperative NLR ≥ 2.85 predicted higher risk of EAD, 1-year graft failure and 1-year mortality following LDLT, and NLR was superior to other parameters, suggesting that preoperative NLR may be a practical index for predicting graft function following LDLT.
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http://dx.doi.org/10.1111/liv.14103DOI Listing
August 2019

Early postoperative hypoalbuminaemia is associated with pleural effusion after donor hepatectomy: A propensity score analysis of 2316 donors.

Sci Rep 2019 02 26;9(1):2790. Epub 2019 Feb 26.

Department of Anaesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Pleural effusion and hypoalbuminaemia frequently occur after hepatectomy. Despite the emphasis on the safety of donors, little is known about the impact of postoperative albumin level on pleural effusion in liver donors. We retrospectively assessed 2316 consecutive liver donors from 2004 to 2014. The analysis of donors from 2004 to 2012 showed that postoperative pleural effusion occurred in 47.4% (970/2046), and serum albumin levels decreased until postoperative day 2 (POD2) and increased thereafter. In multivariable analysis, the lowest albumin level within POD2 (POD2ALB) was inversely associated with pleural effusion (OR 0.28, 95% CI 0.20-0.38; P < 0.001). POD2ALB ≤3.0 g/dL, the cutoff value at the 75th percentile, was associated with increased incidence of pleural effusion after propensity score (PS) matching (431 pairs; OR 1.69, 95% CI 1.30-2.21; P < 0.001). When we further analysed data from 2010 to 2014, intraoperative albumin infusion was associated with higher POD2ALB (P < 0.001) and lower incidence of pleural effusion (P = 0.024), compared with synthetic colloid infusion after PS matching (193 pairs). In conclusion, our data showed that POD2ALB is inversely associated with pleural effusion, and that intraoperative albumin infusion is associated with a lower incidence of pleural effusion when compared to synthetic colloid infusion in liver donors.
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http://dx.doi.org/10.1038/s41598-019-39126-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6391412PMC
February 2019
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