Intraoperative Hyperglycemia during Liver Resection: Predictors and Association with the Extent of Hepatocytes Injury

<div><p>Background</p><p>Patients undergoing liver resection are at risk for intraoperative hyperglycemia and acute hyperglycemia is known to induce hepatocytes injury. Thus, we aimed to evaluate whether intraoperative hyperglycemia during liver resection is associated with the extent of hepatic injury.</p><p>Methods</p><p>This 1 year retrospective observation consecutively enrolled 85 patients undergoing liver resection for hepatocellular carcinoma. Blood glucose concentrations were measured at predetermined time points including every start/end of intermittent hepatic inflow occlusion (IHIO) <i>via</i> arterial blood analysis. Postoperative transaminase concentrations were used as surrogate parameters indicating the extent of surgery-related acute hepatocytes injury.</p><p>Results</p><p>Thirty (35.5%) patients developed hyperglycemia (blood glucose > 180 mg/dl) during surgery. Prolonged (≥ 3 rounds) IHIO (odds ratio [OR] 7.34, <i>P</i> = 0.004) was determined as a risk factors for hyperglycemia as well as cirrhosis (OR 4.07, <i>P</i> = 0.022), lower prothrombin time (OR 0.01, <i>P</i> = 0.025), and greater total cholesterol level (OR 1.04, <i>P</i> = 0.003). Hyperglycemia was independently associated with perioperative increase in transaminase concentrations (aspartate transaminase, β 105.1, standard error 41.7, <i>P</i> = 0.014; alanine transaminase, β 81.6, standard error 38.1, <i>P</i> = 0.035). Of note, blood glucose > 160 or 140 mg/dl was not associated with postoperative transaminase concentrations.</p><p>Conclusions</p><p>Hyperglycemia during liver resection might be associated with the extent of hepatocytes injury. It would be rational to maintain blood glucose concentration < 180 mg/dl throughout the surgery in consideration of parenchymal disease, coagulation status, lipid profile, and the cumulative hepatic ischemia in patients undergoing liver resection for hepatocellular carcinoma.</p></div

Significant difference in perioperative increase of AST (‘x’ mark) and ALT (‘o’ mark) according to the occurrence of intraoperative hyperglycemia (HG).

<p>Significant difference in perioperative increase of AST (‘x’ mark) and ALT (‘o’ mark) according to the occurrence of intraoperative hyperglycemia (HG).</p

Up-and-down blood glucose fluctuation in response to clamping (C) and unclamping (U) of intermittent hepatic inflow occlusion (IHIO). I, anesthetic induction.

<p>Up-and-down blood glucose fluctuation in response to clamping (C) and unclamping (U) of intermittent hepatic inflow occlusion (IHIO). I, anesthetic induction.</p

Probability of intraoperative hyperglycemia in relation to the increase in prothrombin time internationalized ratio and serum total cholesterol concentration.

<p>Probability of intraoperative hyperglycemia in relation to the increase in prothrombin time internationalized ratio and serum total cholesterol concentration.</p

Multivariate analysis for intraoperative hyperglycemia during liver resection.

<p>Due to concern of multicollinearity prothrombin time and total cholesterol level were separately enrolled into the multivariate model. Odds ratio and P values of other variables were described based on the model with prothrombin time internationalized ratio (INR).</p><p>Multivariate analysis for intraoperative hyperglycemia during liver resection.</p

Oral Valganciclovir as a Preemptive Treatment for Cytomegalovirus (CMV) Infection in CMV-Seropositive Liver Transplant Recipients

<div><p>Objectives</p><p>Cytomegalovirus (CMV) infections in liver transplant recipients are common and result in significant morbidity and mortality. Intravenous ganciclovir or oral valganciclovir are the standard treatment for CMV infection. The present study investigates the efficacy of oral valganciclovir in CMV infection as a preemptive treatment after liver transplantation.</p><p>Methods</p><p>Between 2012 and 2013, 161 patients underwent liver transplantation at Samsung Medical Center. All patients received tacrolimus, steroids, and mycophenolate mofetil. Patients with CMV infection were administered oral valganciclovir (VGCV) 900mg/day daily or intravenous ganciclovir (GCV) 5mg/kg twice daily as preemptive treatment. Stable liver transplant recipients received VGCV.</p><p>Results</p><p>Eighty-three patients (51.6%) received antiviral therapy as a preemptive treatment because of CMV infection. The model for end-stage liver disease (MELD) score and the proportions of Child-Pugh class C, hepatorenal syndrome, and deceased donor liver transplantation in the CMV infection group were higher than in the no CMV infection group. Sixty-one patients received GCV and 22 patients received VGCV. The MELD scores in the GCV group were higher than in the VGCV group, but there were no statistical differences in the pretransplant variables between the two groups. AST, ALT, and total bilirubin levels in the GCV group were higher than in the VGCV group when CMV infection occurred. The incidences of recurrent CMV infection in the GCV and VGCV groups were 14.8% and 4.5%, respectively (P=0.277).</p><p>Conclusion</p><p>Oral valganciclovir is feasible as a preemptive treatment for CMV infection in liver transplant recipients with stable graft function.</p></div

Baseline characteristics of patients with and without CMV infection.

<p>CMV, cytomegalovirus; BMI, body mass index; MELD, model for end-stage liver disease; DDLT, deceased donor liver transplantation; ICU, intensive care unit</p><p>Baseline characteristics of patients with and without CMV infection.</p

(A) Graft survival and (B) patient survival stratified according to antiviral agent use.

<p>The 1-year and 2-year survival rates of patients with CMV infection and patients without CMV infection were 86.7%% vs. 92.3% and 84.2% vs. 92.3%, respectively (<i>P</i> = 0.218). With respect to antiviral agents, the 1-year and 2-year survival rates of the intravenous GCV and the oral VGCV groups were 95.5% vs. 83.6% and 86.8% vs. 83.6%, respectively (<i>P</i> = 0.365)</p

Clinical characteristics of patients who received intravenous GCV and oral VGCV.

<p>GCV, ganciclovir; VGCV, valganciclovir; BMI, body mass index; MELD, model for end-stage liver disease; DDLT, deceased donor liver transplantation; ICU, intensive care unit</p><p>Clinical characteristics of patients who received intravenous GCV and oral VGCV.</p

Clinical characteristics between intravenous GCV and oral VGCV.

<p>GCV, ganciclovir; VGCV, valganciclovir; AST, aspartate transaminase; ALT, alanine transaminase; ALP, alkaline phosphatase; LT, liver transplantation; CMV, cytomegalovirus</p><p>Clinical characteristics between intravenous GCV and oral VGCV.</p