Anesth Pain Med.  2022 Apr;17(2):213-220. 10.17085/apm.21056.

Intraoperative lactic acid concentration during liver transplantation and cutoff values to predict early mortality: a retrospective analysis of 3,338 cases

• Kim KS
• Lee SH
• Sang BH
• Hwang GS

• KMID: 2531698
• DOI: http://doi.org/10.17085/apm.21056

Abstract

Background
We aimed to explore the distribution of intraoperative lactic acid (LA) level during liver transplantation (LT) and determine the optimal cutoff values to predict post-LT 30-day and 90-day mortality. Methods: Intraoperative LA data from 3,338 patients were collected between 2008 to 2019 and all-cause mortalities within 30 and 90 days were retrospectively reviewed. Of the three LA levels measured during preanhepatic, anhepatic, and neohepatic phase of LT, the peak LA level was selected to explore the distribution and predict early post-LT mortality. To determine the best cutoff values of LA, we used a classification and regression tree algorithm and maximally selected rank statistics with the smallest P value. Results: The median intraoperative LA level was 4.4 mmol/L (range: 0.5–34.7, interquartile range: 3.0–6.2 mmol/L). Of the 3,338 patients, 1,884 (56.4%) had LA levels > 4.0 mmol/L and 188 (5.6%) had LA levels > 10 mmol/L. Patients with LA levels > 16.7 mmol/L and 13.5–16.7 mmol/L showed significantly higher 30-day mortality rates of 58.3% and 21.2%, respectively. For the prediction of the 90-day mortality, 8.4 mmol/L of intraoperative LA was the best cutoff value. Conclusions: Approximately 6% of the LT recipients showed intraoperative hyperlactatemia of > 10 mmol/L during LT, and those with LA > 8.4 mmol/L were associated with significantly higher early post-LT mortality.

Keyword

Early post-LT mortality; Intraoperative hyperlactatemia; Lactic acid; Liver transplantation; 30-day mortality

Figure

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  Fig. 1. Distribution of preoperative and intraoperative lactic acid. Vertical line indicate median lactic acid level. LA: lactic acid.

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  Fig. 2. Distribution of (A) preoperative and (B) intraoperative lactic acid levels according to liver disease severity. Vertical lines indicate median lactic acid. MELDs: model for end-liver disease score.

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  Fig. 3. Decision tree diagram for 30-day mortality, showing intraoperative lactic acid cutoffs of 13.5 mmol/L and 16.7 mmol/L as optimal cutoffs in predicting 30-day all-cause mortality. LA: lactic acid, LA_op_MAX: lactic acid_intraoperative_maximal value.

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  Fig. 4. Kaplan–Meier survival plot shows 30-day mortality according to intraoperative lactic acid > 16.7 mmol/L, 13.5–16.7 mmol/L and < 13.5 mmol/L (A) 90-day mortality according to intraoperative lactic acid > 8.4 mmol/L and 8.4 ≤ mmol/L (B). LA: lactic acid.

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