Postoperative renal impairment is associated with increased length of stay for incisional hernia repair after liver transplantation

Abstract

Background: Incisional hernia repair is the most common procedure after orthotopic liver transplantation. Although enhanced recovery protocols are increasingly employed, the post-orthotopic liver transplantation patient may not benefit from all aspects of these models. The aim of the present study is to assess which perioperative interventions and patient factors affect hospital length of stay in a cohort of post-orthotopic liver transplantation patients undergoing incisional hernia repair.

Methods: We conducted a retrospective review of a series of adult patients undergoing incisional hernia repair after orthotopic liver transplantation. The primary endpoint was length of stay. Results were stratified by demographic, intraoperative, and postoperative variables.

Results: Eleven percent (172/1523) of patients who received orthotopic liver transplantation during the study period underwent subsequent incisional hernia repair. Median length of stay was 5 days (range 2-50). The strongest predictor of length of stay was postoperative renal function. Despite liberal intraoperative administration of volume (median 642 mL/h) and brisk intraoperative urine output (median 72 mL/h), postoperative acute kidney injury occurred in 48% of patients. Those that developed acute kidney injury received less intraoperative volume (6 vs 8.5 mL/kg/h; P = .031) and the severity of postoperative renal injury was inversely related to the amount intraoperative volume given.

Conclusions: In patients undergoing incisional hernia repair after orthotopic liver transplantation, postoperative renal function is frequently impaired. Although many aspects of current ERAS protocols may be applied to post-transplant patients, restrictive intraoperative fluid administration strategies should be employed with caution given a high propensity for the development of post-operative acute kidney injury in this complex population.

Fig 1

Postoperative renal function predicts length of hospital stay for incisional hernia repair after orthotopic liver transplantation. Despite a universally liberal intraoperative fluid strategy, postoperative AKI occurred in 48% of patients. Those that developed AKI received less intraoperative volume (6 vs 8.5 mL/kg/min; P = .031) and the severity of postoperative renal injury was inversely related to intraoperative volume (A). Intraoperative urine output was not effective at predicting postoperative AKI (B). The degree of renal injury was directly related to length of stay (C); patients who developed AKI had a median stay of 8 days compared to 4 days in patients who did not (D).