Fluid balance dynamics and early postoperative outcomes in orthotopic liver transplantation: a prospective cohort study
Dinâmica do balanço hídrico e desfechos pós-operatórios precoces no transplante hepático ortotópico: um estudo de coorte prospectivo
Suzana Margareth Lobo, Pedro Saggioro Paulucci, Lucas Martins Tavares, Graziela Benardin Luckemeyer, Luana Fernandes Machado, Neymar Elias de Oliveira, Silvia Prado Minhoto, Rita Cassia Alves Silva, Renato Ferreira da Silva, Marlon Souza Freitas, Francisco Ricardo Marques Lobo, Joana Berger-Estilita
Abstract
Introduction
This study evaluates the impact of Fluid Balance (FB) patterns on outcomes after Orthotopic Liver Transplantation (OLT). It hypothesizes that deviations from optimal FB increase morbidity.
Methods
In a single-center cohort post hoc analysis of 73 post-OLT patients, FB was categorized into three groups based on cumulative FB at 72 hours: Lowest (negative FB), Intermediate (0-2000 mL), and Highest (> 2000 mL). We analyzed Sequential Organ Failure Assessment (SOFA) scores, mortality rates, and causes of death. Logistic regression identified mortality predictors.
Results
The Highest FB group had the highest SOFA scores and mortality (Group “Lo”: 18.2%, Group “In”: 8.6%, Group “Hi”: 40.5%, p = 0.009). A U-shaped relationship between FB and hospital mortality was observed, with extremes of FB associated with higher mortality. Cumulative FB independently predicted all-cause mortality with a 29.5% increase in the risk of death. FB on day 3 also predicted all-cause mortality, increasing the risk by 83.9%. Furthermore, FB on day 1 was linked to a 134.5% increase in the risk of death due to primary non-function of the liver. SOFALIVER score strongly predicted all-cause mortality, with a one-point increase associated with a 98.8% to 114.7% increase in mortality risk.
Discussion
These findings suggest that both negative and positive extremes of FB are associated with worse outcomes after OLT, reinforcing the U-shaped relationship between FB and mortality. Our results underscore the importance of balanced fluid management, particularly in the early postoperative period. The study highlights the need for individualized FB strategies to optimize organ function and reduce mortality. The use of SOFALIVER scores as a predictor of mortality further emphasizes the importance of liver function monitoring in post-OLT patients. However, the single-centre design and convenience sample limit the generalizability of our findings, necessitating validation through multicenter studies.
Conclusion
Our study provides valuable insights into the relationship between FB patterns and mortality in OLT patients. Both negative and positive extremes of FB are associated with higher mortality, suggesting the need for a balanced and individualized fluid management approach. The strong predictive value of SOFALIVER scores for all-cause mortality highlights the importance of early and continuous monitoring of liver function. Future multicenter randomized controlled trials are needed to validate these findings and develop optimized fluid management protocols for OLT patients.
Keywords
Resumo
Introdução
Este estudo avalia o impacto dos padrões de Balanço Hídrico (FB) nos desfechos após o Transplante Hepático Ortotópico (OLT). Parte da hipótese de que desvios em relação ao FB ideal aumentam a morbidade.
Métodos
Em uma análise post hoc de coorte de centro único com 73 pacientes pós-OLT, o FB foi categorizado em três grupos com base no FB acumulado em 72 horas: Mais Baixo (FB negativo), Intermediário (0–2000 mL) e Mais Alto (> 2000 mL). Foram analisados os escores da Avaliação Sequencial de Falência de Órgãos (SOFA), taxas de mortalidade e causas de óbito. Regressão logística foi utilizada para identificar preditores de mortalidade.
Resultados
O grupo com FB mais alto apresentou os maiores escores de SOFA e mortalidade (Grupo “Lo”: 18,2%, Grupo “In”: 8,6%, Grupo “Hi”: 40,5%, p = 0,009). Observou-se uma relação em forma de U entre o FB e a mortalidade hospitalar, com extremos de FB associados a maior mortalidade. O FB acumulado previu de forma independente a mortalidade por todas as causas, com um aumento de 29,5% no risco de óbito. O FB no terceiro dia também foi preditivo de mortalidade por todas as causas, aumentando o risco em 83,9%. Além disso, o FB no primeiro dia esteve associado a um aumento de 134,5% no risco de óbito por falência primária do fígado. O escore SOFALIVER previu fortemente a mortalidade por todas as causas, com um aumento de 98,8% a 114,7% no risco de óbito a cada ponto adicional.
Discussão
Esses achados sugerem que tanto os extremos negativos quanto os positivos do FB estão associados a piores desfechos após o OLT, reforçando a relação em forma de U entre FB e mortalidade. Nossos resultados destacam a importância de um manejo hídrico equilibrado, especialmente no período pós-operatório inicial. O estudo ressalta a necessidade de estratégias individualizadas de FB para otimizar a função orgânica e reduzir a mortalidade. O uso do escore SOFALIVER como preditor de mortalidade enfatiza ainda mais a importância do monitoramento da função hepática em pacientes pós-OLT. No entanto, o delineamento em centro único e a amostra por conveniência limitam a generalização dos achados, sendo necessária validação por meio de estudos multicêntricos.
Conclusão
Nosso estudo oferece insights valiosos sobre a relação entre os padrões de FB e a mortalidade em pacientes submetidos a OLT. Tanto os extremos negativos quanto positivos de FB estão associados a maior mortalidade, sugerindo a necessidade de uma abordagem equilibrada e individualizada no manejo de fluidos. O forte valor preditivo dos escores SOFALIVER para mortalidade por todas as causas destaca a importância do monitoramento precoce e contínuo da função hepática. Ensaios clínicos randomizados multicêntricos futuros são necessários para validar esses achados e desenvolver protocolos otimizados de manejo hídrico para pacientes submetidos a OLT.
Palavras-chave
Referencias
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Submitted date:
12/11/2024
Accepted date:
22/03/2025
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