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Acute kidney injury after liver transplantation is associated with viral hepatitis, prolonged warm ischemia, serum lactate and higher mortality
Geraldo B. Silva Junior
,
Corresponding author
geraldobezerrajr@yahoo.com.br

Correspondence and reprint request:
, Elizabeth F. Daher**, Adller G.C. Barreto**, Eanes D.B. Pereira**
* School of Medicine, Post-Graduation Program in Collective Health, Health Sciences Center, University of Fortaleza. Fortaleza, Ceara, Brazil
** Post-Graduation Program in Medical Sciences, Department of Internal Medicine, School of Medicine, Federal University of Ceara. Fortaleza, Ceara, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="s0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0005">Dear Editor&#44;</span><p id="p0005" class="elsevierStylePara elsevierViewall">We thank for the interest in our recent published article<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and the letter from Prof&#46; Xue&#44; <span class="elsevierStyleItalic">et al&#46;</span> Our findings evidenced that viral hepatitis&#44; warm ischemia time and serum lactate are associated with acute kidney injury &#40;AKI&#41; development after liver transplantation &#40;LT&#41;&#46; Another important finding is that AKI was associated with death and chronic kidney disease &#40;CKD&#41; after LT&#46;</p><p id="p0010" class="elsevierStylePara elsevierViewall">The first concern raised by Prof&#46; Xue was the lack of information about albumin levels&#44; body mass index &#40;BMI&#41; and race&#46; As it is a retrospective study&#44; we do not have some data&#46; Albumin levels were not determined in some patients&#44; so we have not included in the analysis&#46; We agree that hypoalbuminemia can be associated with death in different clinical settings&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> including liver transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Unfortunately&#44; we did not include this data&#46; However&#44; we have used serum albumin to calculate CHILD score&#44; which did not show any significant association with renal function and was not different when comparing patients with and without AKI&#46; BMI was also not included in our analysis&#46; The effect of BMI in the outcomes of LT is not well defined&#44; as studies show discrepant results&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> so we believe the lack of this parameter do not invalidate our results&#46; Furthermore almost all patients in our study had ascites and it leads to a bias in the BMI calculation&#44; so we have decided not to use this parameter in our study&#46; Regarding race&#44; it is important to clarify that in Brazil&#44; due to historic facts&#44; we do not have well defined races&#46; Almost all Brazilians are a mixture of races &#40;white&#44; African descendents and American indians&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> so that race could not be considered as a variable in our studies&#46;</p><p id="p0015" class="elsevierStylePara elsevierViewall">Another point raised by Prof&#46; Xue was the information about intraoperative bleeding&#44; blood transfusion and the use of hydroxyethyl starch&#46; The incidence of intraoperative bleeding was similar in both groups &#40;AKI <span class="elsevierStyleItalic">vs&#46;</span> non-AKI&#58; 51 <span class="elsevierStyleItalic">vs&#46;</span> 40&#37;&#44; p &#61; 0&#46;2&#41;&#44; as well as volume of blood products &#40;AKI <span class="elsevierStyleItalic">vs&#46;</span> non-AKI&#58; 60&#37; <span class="elsevierStyleItalic">vs&#46;</span> 47&#37;&#44; p &#61; 0&#46;1&#41;&#46; Hemodynamic instability was not evaluated&#46; We agree that this is an important complication that is associated with AKI in the setting of LT&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> but we do not have information about this&#46; As the incidence of bleeding and transfusion was similar in both groups&#44; we had considered that hemodynamic instability was also similar&#46; Intravascular volume resuscitation was routinely done in all patients&#44; according to individualized needs&#44; and it was not done with hydroxyethyl starch&#44; so this product was not cited in our study&#46; Postoperative complications were not included in the analysis&#46; In fact&#44; there were few postoperative complications in our patients&#46; There are many factors contributing for the low incidence of complications after LT in our center&#44; including surgeons&#8217; large experience in transplantations&#44; critical care support and pre-transplant patients&#8217; preparation&#46; As the focus of the study was AKI&#44; we did not collected detailed information about other postoperative complications&#44; and&#44; as few patients had other complications&#44; we considered that it did not worth mentioning in this paper&#46;</p><p id="p0020" class="elsevierStylePara elsevierViewall">The AKI definition used was the AKIN<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> based on serum creatinine&#46; We considered the highest creatinine registered during the first 72 h after surgery&#46; As stated in our paper&#44; we do not have urine output registration in many patients&#44; so we could not use this parameter to classify patients AKI stage&#46; There were very few patients in the AKIN 1 stage&#44; so we have excluded then from the analysis&#46; We considered only AKIN 2 and 3 because it represents a more severe kidney injury&#44; which has impact on patients&#8217; outcomes&#46;</p><p id="p0025" class="elsevierStylePara elsevierViewall">In summary&#44; we have evidenced in our study the occurrence of important risk factors for AKI after LT &#40;viral hepatitis&#44; warm ischemia time and serum lactate&#41; and highlight the association of AKI with mortality and CKD in this group of patients&#46; We agree that this study has some limitations&#44; the main being the retrospective design&#44; but the lack of some data do not invalidate the results presented and the main message of the paper&#46;</p></span></span>"
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Article information
ISSN: 16652681
Original language: English
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es en pt

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