Teresa Sacco

Background: Acute kidney injury (AKI) is a frequent and severe complication after liver transplantation (LT), occurring in 30–60% of cases. It increases mortality, prolongs hospital stay, and increases the risk of chronic kidney disease. Intraoperative, modifiable anesthetic factors play a key preventive role. This systematic review synthesizes the overall prevalence of AKI and examines the evidence linking intraoperative anesthetic management to AKI after LT, emphasizing modifiable factors that may inform future perioperative strategies. Methods: We conducted a systematic, computerized search on PubMed, EMBASE, Cochrane Library, and Scopus from January 2004 to November 16, 2025, following a registered protocol on PROSPERO (ID: CRD420250580749). Randomized controlled trials (RCTs) and cohort studies assessing intraoperative predictors of AKI were considered eligible for inclusion. The primary outcome was the incidence of post-LT AKI. Intraoperative factors associated with post-LT AKI, including intraoperative hypotension, fluid therapy, transfusion strategies, and the use of vasopressors and/or inotropic agents, were also assessed. Results: A total of 50 studies (8 RCTs and 42 cohort studies) involving 22,434 patients were included. The pooled incidence of post-LT AKI from observational studies was 41% (95% CI 36–46%). Across the included studies, intraoperative hemodynamic instability, excessive or unbalanced fluid administration, liberal transfusion practices, and suboptimal use of vasopressors were consistently associated with an increased risk of post-transplant AKI. Conclusions: AKI after LT is mainly influenced by modifiable perioperative factors. Prevention relies on maintaining stable hemodynamics, careful fluid and transfusion management, and avoiding intraoperative hypotension. Prompt and adequate vasopressor support appeared protective. A multimodal, personalized, kidney-protective approach is essential for improving post-transplant outcomes.

Background: Intraoperative fluid management based on pulse pressure variation has shown potential to reduce postoperative pulmonary complications (PPCs) and improve clinical outcomes in various surgical settings. However, its efficacy and safety have not been assessed in patients undergoing thoracic surgery with one-lung ventilation. Methods: Patients scheduled for pulmonary lobectomy using uniportal video-assisted thoracic surgery approach were randomly assigned to two groups. In the PPV group, fluid administration was guided by the pulse pressure variation parameter, while in the near-zero group, it was guided by conventional hemodynamic parameters. The primary outcome was the partial pressure of oxygen (PaO₂)/ fraction of inspired oxygen (FiO₂) ratio 15 min after extubation. The secondary outcomes included extubation time, the incidence of postoperative pulmonary complications in the first three postoperative days, and the length of hospital stay. Results: The PaO₂/FiO₂ ratio did not differ between the two groups (364.48 ± 38.06 vs. 359.21 ± 36.95; p = 0.51), although patients in the PPV group (n = 44) received a larger amount of both crystalloids (1145 ± 470.21 vs. 890 ± 459.31, p = 0.01) and colloids (162.5 ± 278.31 vs 18.18 ± 94.68, p = 0.002) compared to the near-zero group (n = 44). No differences were found in extubation time, type and number of PPCs, and length of hospital stay. Conclusions: PPV-guided fluid management in thoracic surgery requiring one-lung ventilation does not improve pulmonary gas exchange as measured by the PaO₂/FiO₂ ratio and does not seem to offer clinical benefits. Additionally, it results in increased fluid administration compared to fluid management based on conventional hemodynamic parameters.

Background: Laparoscopic bariatric surgery provides many benefits including lower postoperative pain scores, reduced opioid consumption, shorter hospital stays, and improved quality of recovery. However, the anaesthetic management of obese patients requires caution in determining postoperative risk and in planning adequate postoperative pathways. Currently, there are no specific indications for intensive care unit (ICU) admission in this surgical population and most decisions are made on a case-by-case basis. The aim of this study is to investigate whether Obesity Surgery Mortality Risk Score (OS-MRS) is able to predict ICU admission in patients undergoing laparoscopic bariatric surgery (LBS). Methods: We retrospectively reviewed data of patients who underwent LBS during a 2-year period (2017–2019). The collected data included demographics, comorbidities and surgery-related variables. Postoperative ICU admission was decided via bariatric anaesthesiologists’ evaluations, based on the high risk of postoperative cardiac or respiratory complications. Anaesthesia protocol was standardized. Logistic regression was used for statistical analysis. Results: ICU admission was required in 2% (n = 15) of the 763 patients. The intermediate risk group of the OS-MRS was detected in 84% of patients, while the American Society of Anaesthesiologists class III was reported in 80% of patients. A greater OS-MRS (p = 0.01), advanced age (p = 0.04), male gender (p = 0.001), longer duration of surgery (p = 0.0001), increased number of patient comorbidities (p = 0.002), and previous abdominal surgeries (p = 0.003) were predictive factors for ICU admission. Conclusions: ICU admission in obese patients undergoing LBS is predicted by OS-MRS together with age, male gender, number of comorbidities, previous abdominal surgeries, and duration of surgery.