Propofol intravenous anaesthesia with desflurane compared with desflurane alone on postoperative liver function after living-donor liver transplantation: A randomised controlled trial

A Review of the Risk Factors and Approaches to Prevention of Post-Reperfusion Syndrome During Liver Transplantation

Post-reperfusion syndrome (PRS) is a severe and highly lethal syndrome that occurs after declamping the portal vein forceps during liver transplantation. It is marked by severe hemodynamic disturbances manifested by decreased mean arterial pressure, increased heart rate and elevated pulmonary artery pressure. The complex pathogenesis of PRS remains understudied. It is generally believed to be related to the large amount of acidic, cold blood that enters the circulation after release of the portal clamp. This blood is rich in oxygen-free radicals and metabolic toxins, which not only aggravate the ischemia-reperfusion injury of the liver but also further attack the systemic organs indiscriminately. Considering the range of possible adverse prognoses including acute kidney injury, delirium and graft nonfunction, it is imperative that clinicians increase their awareness and prevention of PRS. The aim of this article is to review the current risk factors, pathophysiological mechanisms and prevention strategies for PRS.

The Effects of Volatile Anesthetics on Early Clinical Outcomes in Liver Transplantation: A Systematic Review and Meta-Analysis

BACKGROUND

The aim of this systematic review and meta-analysis was to evaluate the effects of volatile anesthesia (VA) on early clinical outcomes in liver transplantation.

METHODS

We searched electronic databases to identify relevant studies comparing VA to non-VA in liver transplant recipients. The primary outcome assessed was early allograft dysfunction (EAD), and secondary outcomes were postoperative peak liver function tests (LFT) including aspartate transaminase (AST) and alanine transaminase (ALT) levels, and hospitalization time.

RESULTS

Six relevant studies involving 919 patients were analyzed. In meta-analysis of prospective studies, VA was associated with fewer incidence of EAD than non-VA (RR: 0.45; 95% CI: 0.25, 0.84; P = .012; I2 = 0%; Ph = 0.334) but this association was not significant in meta-analysis of retrospective studies (OR: 0.83; 95% CI: 0.58, 1.19; P = .310; I2 = 0%; Ph = 0.624). No significant difference in peak AST (SMD: -0.14 U/L; 95% CI: -0.65, 0.37 U/L; P = .594; I2 = 69.9%; Ph = 0.036) and ALT (SMD: -0.16 U/L; 95% CI: -0.65, 0.33 U/L; P = .529; I2 = 67.0%; Ph = 0.048) were found between VA and non-VA. The hospitalization time also did not differ between the two groups (SMD: -0.09 days; 95% CI: -0.29, 0.10 days; P = .350; I2 = 0%; Ph = 0.864).

CONCLUSIONS

While there is potential protective effect of VA against EAD in liver transplant recipients, certainty remains low, whereas VA was not associated with postoperative LFT or hospitalization time.

Impact of propofol versus desflurane anesthesia on postoperative hepatic and renal functions in infants with living-related liver transplantation: a randomized controlled trial

BACKGROUND

The effects of anesthetics on liver and kidney functions after infantile living-related liver transplantation (LRLT) are unclear. This study aimed to investigate the effects of propofol-based total intravenous anesthesia (TIVA) or desflurane-based inhalation anesthesia on postoperative liver and kidney functions in infant recipients after LRLT and to evaluate hepatic ischemia-reperfusion injury (HIRI).

METHODS

Seventy-six infants with congenital biliary atresia scheduled for LRLT were randomly divided into two anesthesia maintenance groups: group D with continuous inhalation of desflurane and group P with an infusion of propofol. The primary focus was to assess alterations of liver transaminase and serum creatinine (Scr) levels within the first 7 days after surgery. And the peak aminotransferase level within 72 h post-surgery was used as a surrogate marker for HIRI.

RESULTS

There were no differences in preoperative hepatic and renal functions between the two groups. Upon the intensive care unit (ICU) arrival, the levels of aspartate aminotransferase (AST, P = 0.001) and alanine aminotransferase (ALT, P = 0.005) in group P were significantly lower than those in group D. These changes persisted until the fourth and sixth days after surgery. The peak AST and ALT levels within 72 h after surgery were also lower in group P than in group D (856 (552, 1221) vs. 1468 (732, 1969) U/L, P = 0.001 (95% CI: 161-777) and 517 (428, 704) vs. 730 (541, 1100) U/L, P = 0.006, (95% CI: 58-366), respectively). Patients in group P had lower levels of Scr upon the ICU arrival and on the first day after surgery, compared to group D (17.8 (15.2, 22.0) vs. 23.0 (20.8, 30.8) μmol/L, P < 0.001 (95% CI: 3.0-8.7) and 17.1 (14.9, 21.0) vs. 20.5 (16.5, 25.3) μmol/L, P = 0.02 (95% CI: 0.0-5.0) respectively). Moreover, the incidence of severe acute kidney injury was significantly lower in group P compared to that in group D (15.8% vs. 39.5%, P = 0.038).

CONCLUSIONS

Propofol-based TIVA might improve liver and kidney functions after LRLT in infants and reduce the incidence of serious complications, which may be related to the reduction of HIRI. However, further biomarkers will be necessary to prove these associations.

Myocardial Protection by Desflurane: From Basic Mechanisms to Clinical Applications

ABSTRACT

Coronary heart disease is an affliction that is common and has an adverse effect on patients' quality of life and survival while also raising the risk of intraoperative anesthesia. Mitochondria are the organelles most closely associated with the pathogenesis, development, and prognosis of coronary heart disease. Ion abnormalities, an acidic environment, the production of reactive oxygen species, and other changes during abnormal myocardial metabolism cause the opening of mitochondrial permeability transition pores, which disrupts electron transport, impairs mitochondrial function, and even causes cell death. Differences in reliability and cost-effectiveness between desflurane and other volatile anesthetics are minor, but desflurane has shown better myocardial protective benefits in the surgical management of patients with coronary artery disease. The results of myocardial protection by desflurane are briefly summarized in this review, and biological functions of the mitochondrial permeability transition pore, mitochondrial electron transport chain, reactive oxygen species, adenosine triphosphate-dependent potassium channels, G protein-coupled receptors, and protein kinase C are discussed in relation to the protective mechanism of desflurane. This article also discusses the effects of desflurane on patient hemodynamics, myocardial function, and postoperative parameters during coronary artery bypass grafting. Although there are limited and insufficient clinical investigations, they do highlight the possible advantages of desflurane and offer additional suggestions for patients.

Postoperative acute kidney injury after volatile or intravenous anesthesia: a meta-analysis

Postoperative acute kidney injury (AKI) is a common complication after surgery. The pathophysiology of postoperative AKI is complex. One potentially important factor is anesthetic modality. We, therefore, conducted a meta-analysis of the available literature regarding anesthetic modality and incidence of postoperative AKI. Records were retrieved until January 17, 2023, with the search terms ("propofol" OR "intravenous") AND ("sevoflurane" OR "desflurane" OR "isoflurane" OR "volatile" OR "inhalational") AND ("acute kidney injury" OR "AKI"). A meta-analysis for common effects and random effects was performed after exclusion assessment. Eight records were included in the meta-analysis with a total of 15,140 patients (n = 7,542 propofol and n = 7,598 volatile). The common and random effects model revealed that propofol was associated with a lower incidence of postoperative AKI compared with volatile anesthesia [odds ratio: 0.63 (95% confidence interval: 0.56-0.72) and 0.49 (95% confidence interval: 0.33-0.73), respectively]. In conclusion, the meta-analysis revealed that propofol anesthesia is associated with a lower incidence of postoperative AKI compared with volatile anesthesia. This may motivate choosing propofol-based anesthesia in patients with increased risk of postoperative AKI due to preexisting renal impairment or surgery with a high risk of renal ischemia.NEW & NOTEWORTHY This study analyzed the available literature on anesthetic modality and incidence of postoperative AKI. The meta-analysis revealed that propofol is associated with lower incidence of AKI compared with volatile anesthesia. It might therefore be considerable to use propofol anesthesia in surgeries with increased susceptibility for developing renal injuries such as cardiopulmonary bypass and major abdominal surgery.

Effect of Propofol versus Sevoflurane Anesthesia on Acute Kidney Injury after Lung Transplantation Surgery: A Prospective Randomized Controlled Trial

This prospective randomized controlled trial aimed to compare the effects of sevoflurane and propofol anesthesia on the occurrence of acute kidney injury (AKI) following lung transplantation (LTx) surgery. Sixty adult patients undergoing bilateral LTx were randomized to receive either inhalation of sevoflurane or continuous infusion of propofol for general anesthesia. The primary outcomes were AKI incidence according to the Acute Kidney Injury Network (AKIN) criteria and blood biomarker of kidney injury, including neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C levels within 48 h of surgery. Serum interleukin (IL)-1β, IL-6, tumor necrosis factor-α, and superoxide dismutase were measured before and after surgery. The post-operative 30-day morbidity and long-term mortality were also assessed. Significantly fewer patients in the propofol group developed AKI compared with the sevoflurane group (13% vs. 38%, p = 0.030). NGAL levels were significantly lower in the propofol group at immediately after, 24 h, and 48 h post-operation. IL-6 levels were significantly lower in the propofol group immediately after surgery. AKI occurrence was significantly associated with a lower 5-year survival rate. Total intravenous anesthesia with propofol reduced the AKI incidence in LTx compared with sevoflurane, which is understood to be mediated by the attenuation of inflammatory responses.

Anesthesia and the renal sympathetic nervous system in perioperative AKI

Approximately 7% of patients undergoing non-cardiac surgery with general anesthesia develop postoperative acute kidney injury (AKI). It is well-known that general anesthesia may have an impact on renal function and water balance regulation, but the mechanisms and potential differences between anesthetics are not yet completely clear. Recently published large animal studies have demonstrated that volatile (gas) anesthesia stimulates the renal sympathetic nervous system more than intravenous propofol anesthesia, resulting in decreased water and sodium excretion and reduced renal perfusion and oxygenation. Whether this is the case also in humans remains to be clarified. Increased renal sympathetic nerve activity may impair renal excretory function and oxygenation and induce structural injury in ischemic AKI models and could therefore be a contributing factor to AKI in the perioperative setting. This review summarizes anesthetic agents' effects on the renal sympathetic nervous system that may be important in the pathogenesis of perioperative AKI.

Perioperative management of adult living donor liver transplantation: Part 1 - recipients

Living donor liver transplantation was first developed to mitigate the limited access to deceased donor organs in Asia in the 1990s. This alternative liver transplantation option has become an established and widely practiced transplantation method for adult patients suffering from end-stage liver disease. It has successfully addressed the shortage of deceased donors. The Society for the Advancement of Transplant Anesthesia and the Korean Society of Transplant Anesthesia jointly reviewed published studies on the perioperative management of live donor liver transplant recipients. The review aims to offer transplant anesthesiologists and critical care physicians a comprehensive overview of the perioperative management of adult live liver transplantation recipients. We feature the status, outcomes, surgical procedure, portal venous decompression, anesthetic management, prevention of acute kidney injury, avoidance of blood transfusion, monitoring and therapeutic strategies of hemodynamic derangements, and Enhanced Recovery After Surgery protocols for liver transplant recipients. This article is protected by copyright. All rights reserved.

Propofol attenuates inflammatory response and apoptosis to protect d-galactosamine/lipopolysaccharide induced acute liver injury via regulating TLR4/NF-κB/NLRP3 pathway

OBJECTIVE

Propofol has been reported to be protective against liver injury due to its anti-inflammatory, anti-oxidative and anti-apoptotic activities. The purpose of this study was to examine the protective effects of propofol on d-galactosamine/lipopolysaccharide (d-GalN/LPS) induced acute liver injury.

METHODS

Mice were given an intraperitoneal injection of propofol before d-GalN/LPS treatment. Liver injury was confirmed by serum biochemical analysis and liver histopathological analysis. Relevant molecular events were determined by ELISA, western blot, and test kits. Cell apoptosis were evaluated by TUNEL assay.

RESULTS

The results showed that propofol significantly prevented d-GalN/LPS-induced liver damage by preventing associated increases of serum alanine transaminase (ALT) and aspartate transaminase (AST) and restoring liver histopathological changes. Propofol markedly inhibited the production of inflammatory cytokines and oxidative stress-related factors. Propofol markedly reduced hepatocyte apoptosis, decreased Bax, Bad, cleaved caspase-3 and increased Bcl-2 expression. Besides, NLRP3 inflammasome and TLR4/NF-κB pathway were inactivated under the treatment of propofol according to the expression of pathways-related proteins.

CONCLUSION

Taken together, propofol contributed to liver protection against d-GalN/LPS-induced liver injury in mice by inhibiting inflammation, oxidative stress and hepatocyte apoptosis through regulating TLR4/NF-κB/NLRP3 pathway.