| Background Over one-fifth of the population in China are affected by liver disease.The incidence and mortality of end-stage liver disease are the highest in the world.Liver transplantation is the ultimate and effective treatment for end-stage liver disease.The incidence of complications is very high after liver transplantation due to various reasons.Acute kidney injury is one of the most common complications after liver transplantation.Lactate metabolism is slow due to liver insufficiency,but a large amount of lactate will be produced during anhepatic phase in patients undergoing liver transplantation.Lactate is one of the evaluation indicators of disease severity and prognosis.Maintaining normal lactate level has certain significance for liver transplantation patients.Sodium bicarbonate Ringer’s solution,as a new type of crystalloid solution,is closer to the components of plasma compared with normal saline and sodium lactate Ringer’s solution.Its remarkable advantage is that bicarbonate is completely independent of liver metabolism,and only 10%is excreted through the kidney,which has little impact on liver and renal function.Whether sodium bicarbonate Ringer’s solution can reduce the lactate levels during liver transplantation,reduce the incidence of acute kidney injury after liver transplantation is unclear.Objective(1)To compare the effects of sodium bicarbonate Ringer’s solution versus normal saline on acute kidney injury after orthotopic liver transplantation.(2)To compare the effects of sodium bicarbonate Ringer’s solution versus sodium lactate Ringer’s solution on the lactate levels during orthotopic liver transplantation.Method(1)Sixty-four participants were randomly assigned to the sodium bicarbonate Ringer’s solution group(BRS)or the normal saline group(NS).The primary outcomes were the incidence and severity of acute kidney injury after liver transplantation.The secondary outcomes included the rate of renal replacement therapy,length of mechanical ventilation,stay in the ICU,stay in the hospital after surgery and 30-day mortality.Other outcomes included the concentration of sodium,chloride,bicarbonate,anion gap,lactate concentration,changes in chloride preoperatively and postoperatively and serum creatinine within 7 days after operation.(2)Thirty participants were randomly assigned to the sodium bicarbonate Ringer’s solution group(BRS)or the sodium lactate Ringer’s solution group(LRS).The primary outcomes were the lactate levels at T0(pre operation);T1(before the beginning of anhepatic phase);T2(before the end of anhepatic phase);T3(new liver stage 5 min)and T4(before the end of surgery).The secondary outcomes included changes in BE and p H during the operation.And serum creatinine,blood urea nitrogen,albumin,total protein,total bilirubin,alanine aminotransferase,aspartate aminotransferase at the end of the operation.Also included the length of mechanical ventilation,stay in the ICU,stay in the hospital after surgery and 30-day mortality.Result(1)Sixty-two patients completed the trial and were analyzed,with 31 patients in each group.There was a significantly lower rate of postoperative acute kidney injury in the BRS group(14/31,45.2%)than in the NS group(24/31,77.4%),with a relative risk of 0.58(95%CI,0.38–0.90;P=0.009).The severity of AKI in the BRS group was lower than that in the NS group(Z=-2.932,P=0.003).The serum creatinine of BRS group was significantly lower than that of NS group at the first and second days after operation(P<0.05).The highest value of serum creatinine in the BRS group was lower than that in the NS group within 7 days after operation(P<0.05).There was no significant difference observed in the secondary outcomes.For other outcomes,the concentration of preoperative sodium was lower than postoperative sodium in the NS group(137.2 vs 140.4,P=0.009).The concentration of preoperative chloride was lower than that of postoperative chloride in the NS group(102.9 vs 106.2,P<0.001).The change in the concentration of chloride in the BRS group was lower than that in the NS group(1.6 vs 4.7,P=0.006).(2)Twenty-seven patients completed the trial and were analyzed,including 13 patients in BRS group and 14 patients in LRS group.There was a significant difference in the lactate levels between the two groups.The lactate levels at T3 and T4 time points in the BRS group was lower than that in the LRS group.Different time points have an impact on the lactate levels.During the operation,the lactate levels of the two groups increased,and reached the highest level after the new liver reperfusion,then decreased.There was no difference in BE and p H between the two groups(P>0.05).At the end of the operation,there were no significant difference in the secondary outcomes(P>0.05).The statistical results of lactate levels during operation are described as follows:(1)The results of repeated measurement analysis of variance show that:The main effect of the group is significant,F=6.382,P=0.018,partialη~2=0.203;The main effect at each time point is significant,F=40.365,P<0.001,partialη~2=0.618;The interaction effect between each time point and group is significant,F=2.949,P=0.036,partialη~2=0.105。(2)The group simple effect test results show that:T0,simple effect of group is not significant,F=0.001,P=0.989,partialη~2=0.001;T1,simple effect of group is not significant,F=3.183,P=0.087,partialη~2=0.113;T2,simple effect of group is not significant,F=2.965,P=0.097,partialη~2=0.106;T3,group simple effect is significant,F=9.176,P=0.006,partialη~2=0.269;T4,group simple effect is significant,F=5.371,P=0.029,partialη~2=0.177。At T0,T1 and T2,there was no significant difference in the lactate levels between BRS group and LRS group(P>0.05).At T3 and T4,the lactate levels in the BRS group was lower than that in the LRS group.(3)The simple effect test results at each time point show that:In the BRS group,the simple effect at each time point was significant,F=6.645,P=0.001,partialη~2=0.547。In the LRS group,the simple effect at each time point was significant,F=20.888,P<0.001,partialη~2=0.792。(4)Multiple comparison found:In BRS group,the lactate levels of T0,T1,T2,T3 were increased,while the lactate levels decreased at T4.The difference between T3 with T0 was significant(P<0.0125),while the difference between T1,T2,T4 with T0 was not significant(P>0.0125).In LRS group,the lactate levels of T0,T1,T2,T3 were increased,while the lactate levels decreased at T4.The difference between T2,T3,T4 with T0 was significant(P<0.0125),while the difference between T1 with T0 was not significant(P>0.0125).Conclusion(1)Sodium bicarbonate Ringer’s solution reduced the incidence and severity of acute kidney injury after orthotopic liver transplantation compared with normal saline.(2)Sodium bicarbonate Ringer’s solution reduced the lactate levels during orthotopic liver transplantation compared with sodium lactate Ringer’s solution. |
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