Perioperative management of acute kidney injury after microwave ablation of hepatic hemangioma

Perioperative management of acute kidney injury after microwave ablation of hepatic hemangioma | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perioperative management of acute kidney injury after microwave ablation of hepatic hemangioma Bin Hu, Hong-Bo Huan, Yu-Liang Tu, Jun Gao, Chang-Le Wu, Wei Zhao, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6137226/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Apr, 2025 Read the published version in BMC Cancer → Version 1 posted 9 You are reading this latest preprint version Abstract Objective To improve treatment options for acute kidney injury (AKI) after microwave ablation (MWA) of hepatic hemangioma (HH). Methods From January 1, 2021, to October 28, 2024, 117 patients with HH were treated by MWA at our center, and 2 of them occurred AKI after operation. The preoperative and postoperative data of 2 patients were retrospectively analyzed. Results During the MWA for patients with HH, hemoglobinuria may occur during and after surgery, which may even lead to AKI. A sequential treatment consisting of sodium bicarbonate alkalization, rapid fluid replacement, diuresis and dialysis treatment were given to the patient as early and timely. And their renal function returned to normal. Conclusion Patients with AKI after MWA of HH can fully recover. It suggested that MWA is an effective and safe treatment for HH patients. Hepatic hemangioma microwave ablation acute kidney injury Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Hepatic hemangioma (HH) is a common benign tumor of the liver that is discovered in most patients through physical examination. HH has no tendency to undergo malignant transformation. As the hemangioma progresses, it can cause corresponding symptoms of abdominal discomfort [ 1 , 2 ] . In 2014, the American College of Gastroenterology (ACG) proposed that surgical treatment can be considered for patients with HHs with a diameter of > 10 cm or symptoms of oppression and pain [ 3 ] . Traditional surgeries involve large surgical incisions, high risks, and slow postoperative recovery and are prone to complications such as bleeding [ 4 , 5 ] . Our team has been engaged in tumor ablation therapy for 26 years, and the first ablation surgery was completed in 1999. More than 2,000 ablation surgeries have been performed. In the early stage, we mainly performed thermal ablation surgery for liver cancer, and published several related academic reports [ 6 – 11 ] . Due to the large number of patients with HH in China, in the past 10 years, we have begun to gradually explore the thermal ablation treatment of HH with our previous experience in ablation surgery, and have achieved good results. The principle of MWA is as follows: a microwave electric field is used to make molecules move at high speeds with a microwave frequency, and the molecules rub against each other to generate a high-energy thermal effect, thereby coagulating the target tissue and causing coagulative necrosis [ 12 ] . Because MWA has the advantages of high safety, minimal trauma, and fast postoperative recovery, it is widely used in clinical practice [ 13 – 15 ] . MWA has also been confirmed to be effective in treating HH with favorable clinical outcomes. However, MWA can lead to acute kidney injury (AKI), and current research lacks a systematic evaluation of AKI and clinical therapies for this complication [ 16 , 17 ] . In our center, from January 1, 2021, to October 28, 2024, 117 patients with HH were admitted. All patients underwent laparoscopy combined with ultrasound-guided one-off complete MWA. Two patients developed AKI, and their renal function returned to normal after active symptomatic treatment. The data of 2 patients were retrospectively analyzed, and here the clinical experience is summarized with the aim of providing a reference for the subsequent treatment of HH through MWA. Methods One hundred and seventeen patients diagnosed with HH were admitted to our hospital from January 1, 2021, to October 28, 2024. All patients had HH > 10 cm in diameter and underwent laparoscopy combined with ultrasound-guided one-off complete MWA according to the protocol in the flowchart (Fig. 1 ). In particular, there were two patients among them developed AKI after MWA, and their renal function returned to normal after active symptomatic treatment. Contrast-enhanced computed tomography (CT) scans showed a giant hemangioma with a maximum diameter of 136 mm in the first patient (Fig. 2 A, B) with a history of gallstones combined with cholecystitis, hypertension and diabetes. The second patient had a hepatic hemangioma with a maximum diameter of 104 mm on contrast-enhanced magnetic resonance imaging (MRI), (Fig. 3 A, B) and suffered from hypertension, hyperlipidemia, and myocardial hypertrophy. No obvious positive signs were found in the hospital examination. On the 4th day after admission, with the guidance of digital subtraction angiography (DSA) under local anesthesia, superselective hepatic artery embolization was performed to embolize the branch of the artery feeding the HH. On Day 8 after admission, under general anesthesia, laparoscopy combined with ultrasound-guided MWA treatment of the HH was performed, particularly the first patient also underwent a concurrent cholecystectomy. A urinary catheter was routinely placed in all patients during surgery. During MWA (MWA system produced by Nanjing Kangyou Co., Ltd., model KY-2000; electrode produced by Nanjing Kangyou Co., Ltd., model KY-2450B-T7), with laparoscopic assistance and ultrasound localization, the HH was ablated. The intraoperative ablation power was 60–70 W, the first patient's ablation time was 60 min, the intraoperative rehydration amount was 1,500 ml, the urinary output was 120 ml, and the second patient's ablation time was 26 min, the intraoperative rehydration amount was 1,000 ml, the urinary output was 100 ml. No significant hemoglobinuria was observed in both patients during surgery. Postoperative, 2 patients developed AKI. A sequential treatment consisting of sodium bicarbonate alkalization, rapid fluid replacement, diuresis and dialysis treatment were given to the patient as early and timely. Changes in liver and renal function parameters and hemoglobin (HB) and B-type natriuretic peptide (BNP) and urine output levels before and after surgery were analyzed, and changes in HH according to abdominal imaging data obtained before and after surgery were analyzed. All patients were informed with consent according to protocols approved by the Institutional Review Board of the PLA general Hospital, and this study abide by the ethical guidelines of the Helsinki Declaration. Results The size of hepatic hemangiomas significantly decreased in both patients, 76mm and 52mm showing on CT scan respectively on the third and second day after surgery (Fig. 2 C, Fig. 3 C). Postoperative, liver and renal insufficiency occurred, and BNP levels increased (Table 1 , Table 2 ). Hepatoprotective therapy was implemented from the day of surgery. However, the levels of ALT, AST, TBIL, and DBIL reached their highest level on the first postoperative day in both patients, then gradually decreased, and returned to preoperative levels on the 11th postoperative day (Table 1 ; Table 2 ; Fig. 4 A, B; Fig. 5 A, B). Changes in HB were also measured. Unlike previous studies, there was no significant decrease in HB in our patients after surgery (Fig. 4 C; Fig. 5 C). Table 1 Clinical parameters of patient 1 Before surgery 1st day after surgery 2 days after surgery 3 days after surgery Alanine aminotransferase (ALT) (U/L) 39 656.9 409.5 207.4 Aspartate aminotransferase (AST) (U/L) 25 875.9 237.2 83.1 Total bilirubin (TBIL) (µmol/L) 26.5 95.5 28.8 22.3 Direct bilirubin (DBIL) (µmol/L) 8.4 14.5 12.7 11.2 Hemoglobin (HB) (g/L) 167 155 133 138 Creatinine (Cr) (µmol/L) 71 316.1 589.1 614.8 Blood urea nitrogen (BUN) (mmol/L) 4.53 14.1 19.5 16.3 B-type natriuretic peptide (BNP) (pg/ml) 37.92 - - 3997 (Table 1 : Preoperative levels of liver function and renal function parameters were normal, and the postoperative Cr level was increased; postoperatively, liver function was affected, and ALT, AST, and BIL levels rapidly recovered.) Table 2 Clinical parameters of patient 2 Before surgery 1st day after surgery 2 days after surgery 3 days after surgery Alanine aminotransferase (ALT) (U/L) 11 533.9 480.3 299.3 Aspartate aminotransferase (AST) (U/L) 17 932.2 471 258.6 Total bilirubin (TBIL) (µmol/L) 8.3 33.3 13.8 14 Direct bilirubin (DBIL) (µmol/L) 2.4 10.7 5.4 5.2 Hemoglobin (HB) (g/L) 118 127 121 115 Creatinine (Cr) (µmol/L) 58 211.9 391 485.1 Blood urea nitrogen (BUN) (mmol/L) 4.45 8.4 12 13.8 B-type natriuretic peptide (BNP) (pg/ml) 1675 13280 18993 16790 (Table 2 . Preoperative liver and renal function parameters were normal, and the BNP level was high; the postoperative Cr level progressively increased, and the BNP level increased significantly; postoperatively, liver function was obviously affected, but ALT, AST, and BIL levels rapidly recovered.) AKI is defined by rapid deterioration of renal excretory function, diagnosed by the accumulation of end products of nitrogen metabolism (creatinine, 2-fold increase) and/or decreased urine output (UO < 0.5ml/kg/h for 12h) [ 18 ] . The levels of creatinine (CR) showed a progressive increase from the first postoperative day (Table 1 , Table 2 ). Two patients were definitively diagnosed with AKI, and sodium bicarbonate alkalization, rapid fluid replacement, diuresis and dialysis treatment were given to the patient timely. Further analysis found that changes in CR, urine output, and BNP were not exactly the same in the two patients. In the first patient, he had little urine output after surgery. Sodium bicarbonate alkalization, rapid fluid replacement, and diuresis were given timely to him. But the urine output was still low, and there was a soy sauce color and contained sediment in the urine. The urine output on the day of surgery was only 400 ml. CR level progressively increased. With the increase of rapid fluid replacement and the decrease of urine, the patient's BNP level gradually increased. Considering the patient's oliguria, after consultation with his family and the nephrology department, dialysis treatment was initiated on the 3rd day after surgery. After seven dialysis sessions, urine output began to increase on the 13th day after surgery, and Cr and BNP levels gradually decreased to preoperative levels (Fig. 4 D, E, F). The second patient also had little urine output during operation. However, with treatments such as sodium bicarbonate alkalization, rapid fluid replacement, and diuresis, the patient’s urine output increased. The color of the urine initially was light red and then became clear quickly. The urine output on the day of surgery was 1340 ml. Although the postoperative urine output remained normal (Fig. 5 D), the Cr level still progressively increased. The patient had hypertrophic cardiomyopathy, and the BNP level was persistently increased. We believed that the perfusion therapy affected the patient's cardiac function. After consultation with her family and the nephrology department, the patient underwent one round of dialysis on Day 5 after surgery. The patient could not tolerate the fear during the dialysis process, so no additional rounds of dialysis were performed. The Cr and BNP levels gradually decreased to preoperative levels (Fig. 5 E, F). Discussion HH is currently generally considered a vascular malformation caused by excessive development or abnormal differentiation of blood vessels during embryonic development [ 19 ] . As the volume of HH increases, adjacent tissues and organs in the abdominal cavity are affected, which leads to abdominal discomfort, such as abdominal pain, abdominal distension and other related symptoms [ 1 , 2 ] . In some cases, the HH ruptures due to the weak arterial wall or external force, which can be life-threatening in severe cases [ 20 , 21 ] . The clinical treatment of HH is currently controversial, and follow-up observation is often the choice [ 22 ] . In 2014, the ACG proposed that surgical treatment can be considered for patients with HHs with a diameter of > 10 cm or symptoms of oppression and pain [ 3 ] . Surgery is the most effective treatment for HHs. Traditional surgical methods include open or laparoscopic surgical resection [ 23 ] . However, surgical trauma and risk are high, postoperative recovery is slow, and complications such as bleeding are prone to occur [ 4 , 5 ] . With the growth of HH, there would be corresponding abdominal discomfort symptoms, the risk and difficulty of surgery would increase. Previous studies have suggested that HH with a diameter of more than 5cm could be considered for surgical treatment [ 2 , 24 ] . We believe that HH with a diameter of ≥ 5 cm that is consistently increasing can be treated with minimally invasive surgical intervention early to avoid surgical resection. Based on the characteristics of benign lesions of HH, under the premise of strictly controlling the indications for treatment, the principle should be to achieve the best therapeutic effect with the least amount of trauma [ 25 ] . The use of ablation for HHs has been reported in previous studies [ 14 ] . Thermal ablation can cause the destruction of many RBCs, which could cause intravascular hemolysis. After surgery, there is a sudden decrease in HB levels, which can lead to different degrees of hemoglobinuria and even AKI [ 26 ] . Studies have revealed a strong correlation with the size of the hemangioma and the time of ablation, leading researchers to recommend multiple ablations [ 27 – 29 ] . In our center, MWA is used for HH, and significant results have been achieved. After continuous practice, when MWA is used for one-off complete ablation of HH, obvious reduction of the tumor, minimal surgical trauma, and no serious postoperative complications can be achieved. Moreover, we have found that HB levels did not significantly decrease during the first three days. We believe that the thermal ablation destructed RBC in HH. The analysis of the clinical data of patients with renal insufficiency after MWA revealed that renal insufficiency was completely reversible. We believe that the thermal effect causes damage to the blood of the HH and the destruction of blood cells during MWA. In particular, HB is released after the destruction of RBCs. If the number of destroyed RBCs is large and the amount of HB released exceeds the metabolic capacity, hemoglobinuria could develop. In most patients, hemoglobinuria is transient. After adequate fluid replacement, urine alkalinization, and diuretic treatment, the urine output can return to normal without renal function being affected. If RBCs are severely destroyed during surgery, large amounts of free HB accumulate in the body, which may block renal tubules and induce AKI. In this study, Patient 2 did not have significant oliguria after surgery, but there was a progressive increase in Cr level after surgery. We also found that the BNP level increased after surgery. Given that the patient was complicated with hypertrophic cardiomyopathy, she received dialysis treatment only once and was subsequently treated with fluid replacement and urine alkalinization, and the Cr and BNP levels gradually decreased and recovered to the preoperative levels. After surgery, the first patient had soy sauce-colored urine, a significant period of oliguria, and a progressive increase in the Cr level. After 7 cycles of dialysis treatment in the department of nephrology in our hospital, renal function gradually improved, and urine output returned to normal. Through the data analysis and the efficacy evaluation of other patients, to avoid the occurrence of hemoglobinuria and AKI, we took the following measures: a, When performing MWA for large hemangiomas, interventional embolization should be routinely performed prior to the surgery to embolize the blood supplying arterial branches of the HHs individually to block the blood supply to the HHs, thus reducing the number of RBCs destroyed. b, On the day of surgery, adequate fluid replacement therapy should be administered before and during the operation to maintain adequate renal perfusion, and a urinary catheter should be routinely placed during the operation. If low urine output occurs, sodium bicarbonate should be given to alkalinize the urine, and diuretic treatment should be given to eliminate the free HB on the premise of adequate fluid replacement. Therefore, when hemoglobinuria is seen during the operation, it is not a cause for alarm, because only when the free HB is discharged in time, it is possible that AKI will not occur. c, If AKI occurred, as indicated by oliguria and anuria, occurs after surgery, dialysis should be performed as soon as possible. On the basis of these findings, subsequent patients with HH treated with MWA at our center underwent one round of complete ablation. Although transient hemoglobinuria may have occurred during surgery and after surgery, none of the patients had AKI. In summary, during the perioperative period of MWA for HH, with close patient monitoring and management, the occurrence of hemoglobinuria and AKI can be avoided. If hemoglobinuria or even AKI occurs after surgery, renal insufficiency can be completely reversed with timely and correct treatments. Abbreviations Microwave ablation (MWA); Hepatic hemangioma (HH); American College of Gastroenterology (ACG); Red blood cell (RBC); Computed tomography (CT); Magnetic resonance imaging (MRI); Digital subtraction angiography (DSA); Hemoglobin (HB); B-type natriuretic peptide (BNP); Creatinine (CR); Blood urea nitrogen (BUN); Alanine aminotransferase (ALT); Aspartate aminotransferase (AST); Total bilirubin (TBIL); Direct bilirubin (DBIL). Declarations Author Contributions: Study concept and design: Hu, Huan and Jiang; acquisition of data: Hu, Huan, Tu, Gao, Jin, Sun, Wang, Zhu, Zhao, and Wu; analysis and interpretation of data: Hu, Huan, Tu and Jiang; drafting of the manuscript: Hu, Huan, and Gao; critical revision of the manuscript for important intellectual content: Jiang, Hu and Huan; statistical analysis: Hu, Tu and Huan; study supervision: Jiang and Tu. Availability of data and materials: All data generated or analyzed during this study are included in this published article. Ethics approval and consent to participate: All patients were informed with consent according to protocols approved by the Institutional Review Board of the PLA general Hospital, and this study abide by the ethical guidelines of the Helsinki Declaration. Funding: No funding. Consent for publication: Not application. Competing interests: The authors declare that they have no competing interest. References Bajenaru N, Balaban V, Săvulescu F et al. Hepatic hemangioma –review-. J Med Life. 2015; 8 Spec Issue (Spec Issue): 4–11. Hoekstra LT, Bieze M, Erdogan D, et al. Management of giant liver hemangiomas: an update. Expert Rev Gastroenterol Hepatol. 2013;7(3):263–8. Marrero JA, Ahn J, Rajender Reddy K. Americal College of Gastroenterology. ACG clinical guideline: the diagnosis and management of focal liver lesions. Am J Gastroenterol. 2014;109(9):1328–48. Abdel Wahab M, El Nakeeb A, Ali MA, et al. 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Cite Share Download PDF Status: Published Journal Publication published 30 Apr, 2025 Read the published version in BMC Cancer → Version 1 posted Editorial decision: Accepted 23 Apr, 2025 Reviews received at journal 18 Apr, 2025 Reviews received at journal 17 Apr, 2025 Reviewers agreed at journal 17 Apr, 2025 Reviewers agreed at journal 17 Apr, 2025 Reviewers agreed at journal 17 Apr, 2025 Reviewers invited by journal 17 Apr, 2025 Submission checks completed at journal 17 Apr, 2025 First submitted to journal 16 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6137226","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":444600447,"identity":"15bd8ad4-c2fe-42c7-93e7-b84507bf5ca6","order_by":0,"name":"Bin Hu","email":"","orcid":"","institution":"Chinese PLA General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bin","middleName":"","lastName":"Hu","suffix":""},{"id":444600448,"identity":"9e67daef-dc9b-41d3-970e-10a88c3b98e5","order_by":1,"name":"Hong-Bo Huan","email":"","orcid":"","institution":"Chinese PLA General 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Jiang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzklEQVRIiWNgGAWjYBACxmYQeaCGh429sfHBBxK0HJPj4zncbDiDeLsOMBvLSaS3SXMQo5i5nfnZwy9n2BLbJB82SDMw2MnpNhB0GJu5scwNmcQ26cQG4wKGZGOzAwS1MJhJS3xgA2tJnsFwIHEbYS3s34BamIEOO9hwmIc4LTxmkh9uMBuzSTA2NhOrpUya4cwxOTaexGbGGQZE+MWw//g2yR/Hanjk248///Ghwk6OsJYGYEDzwLkGBJSDgDzIcT+IUDgKRsEoGAUjGAAAvwpB/cJRlRsAAAAASUVORK5CYII=","orcid":"","institution":"Chinese PLA General Hospital","correspondingAuthor":true,"prefix":"","firstName":"Kai","middleName":"","lastName":"Jiang","suffix":""}],"badges":[],"createdAt":"2025-03-02 03:38:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6137226/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6137226/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12885-025-14214-9","type":"published","date":"2025-04-30T15:56:53+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":81010674,"identity":"c6ee7bca-27a4-4c46-bbe7-d49337868351","added_by":"auto","created_at":"2025-04-21 08:19:27","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":206189,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA flowchart summarizing patient selection and treatment.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6137226/v1/500bd6e0cb6ddcc347136eb2.jpg"},{"id":81012139,"identity":"5136f7ea-eb76-4985-b298-a5ee599782a6","added_by":"auto","created_at":"2025-04-21 08:27:25","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":657240,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe imaging data changes of the first patient. \u003c/strong\u003eA and B are preoperative contrast-enhanced computed tomography (CT) scans of the abdomen, and the maximum diameter of the hemangioma is 136 mm; C is a CT scan of the abdomen 3 days after surgery, and the diameter of the hemangioma is 76 mm.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6137226/v1/e30717119410a1d3419dfc5e.jpg"},{"id":81010662,"identity":"c6050c55-41d1-472e-82d5-1954c492fe5a","added_by":"auto","created_at":"2025-04-21 08:19:23","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":466799,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe imaging data changes of the second patient.\u003c/strong\u003e A and B are preoperative contrast-enhanced magnetic resonance imaging (MRI) images of the abdomen, and the maximum diameter of the hemangioma is 104 mm; C is a computed tomography (CT) scan of the abdomen 2 days after surgery, and the diameter of the hemangioma is 52 mm.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6137226/v1/e5434767e5495ff721ced855.jpg"},{"id":81010648,"identity":"8c8563a1-d477-4fc4-a51f-694ee8b1aace","added_by":"auto","created_at":"2025-04-21 08:19:22","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1081639,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChanges in observation indicators before and after surgery for the first patient\u003c/strong\u003e. A and B show the trends in ALT and AST levels; postoperatively, liver function was affected, and the recovery was fast. C shows the change trend of HB levels. The HB level decreased slightly after surgery. D shows the urine output on the day of surgery and after surgery. After surgery, a period of oliguria occurred. The urine output gradually returned to normal after dialysis treatment. E and F show the changes in CR and BNP levels, respectively. After dialysis treatment, CR and BNP gradually returned to their preoperative levels.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6137226/v1/4adb504d5fadf90aa8fa4ec1.jpg"},{"id":81010649,"identity":"c5acab5c-0e80-4477-9dd9-4e7d9b5670cb","added_by":"auto","created_at":"2025-04-21 08:19:22","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1141395,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChanges in observation indicators before and after surgery for the second patient. \u003c/strong\u003eA and B show the trends in AST and ALT levels; postoperatively, liver function was affected, but liver function parameters rapidly recovered; C shows the trend of HB levels. The HB level decreased after surgery, but the postoperative decrease was not significant. D is the urine output on the day of surgery and after surgery, and there was no significant period of oliguria after surgery. E and F show the changes in CR and BNP levels, respectively. After symptomatic and supportive treatment, CR and BNP levels gradually recovered to their preoperative levels.\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6137226/v1/66a02da65a419bcea44429b2.jpg"},{"id":81987410,"identity":"22969137-377e-4fb3-8562-987635a5031b","added_by":"auto","created_at":"2025-05-05 16:02:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4252530,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6137226/v1/2b72ad6d-6983-42ef-89d8-5b9f7bd9ce0c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perioperative management of acute kidney injury after microwave ablation of hepatic hemangioma","fulltext":[{"header":"Background","content":"\u003cp\u003eHepatic hemangioma (HH) is a common benign tumor of the liver that is discovered in most patients through physical examination. HH has no tendency to undergo malignant transformation. As the hemangioma progresses, it can cause corresponding symptoms of abdominal discomfort \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. In 2014, the American College of Gastroenterology (ACG) proposed that surgical treatment can be considered for patients with HHs with a diameter of \u0026gt;\u0026thinsp;10 cm or symptoms of oppression and pain \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Traditional surgeries involve large surgical incisions, high risks, and slow postoperative recovery and are prone to complications such as bleeding \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Our team has been engaged in tumor ablation therapy for 26 years, and the first ablation surgery was completed in 1999. More than 2,000 ablation surgeries have been performed. In the early stage, we mainly performed thermal ablation surgery for liver cancer, and published several related academic reports \u003csup\u003e[\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Due to the large number of patients with HH in China, in the past 10 years, we have begun to gradually explore the thermal ablation treatment of HH with our previous experience in ablation surgery, and have achieved good results.\u003c/p\u003e \u003cp\u003eThe principle of MWA is as follows: a microwave electric field is used to make molecules move at high speeds with a microwave frequency, and the molecules rub against each other to generate a high-energy thermal effect, thereby coagulating the target tissue and causing coagulative necrosis \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Because MWA has the advantages of high safety, minimal trauma, and fast postoperative recovery, it is widely used in clinical practice \u003csup\u003e[\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. MWA has also been confirmed to be effective in treating HH with favorable clinical outcomes. However, MWA can lead to acute kidney injury (AKI), and current research lacks a systematic evaluation of AKI and clinical therapies for this complication \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. In our center, from January 1, 2021, to October 28, 2024, 117 patients with HH were admitted. All patients underwent laparoscopy combined with ultrasound-guided one-off complete MWA. Two patients developed AKI, and their renal function returned to normal after active symptomatic treatment. The data of 2 patients were retrospectively analyzed, and here the clinical experience is summarized with the aim of providing a reference for the subsequent treatment of HH through MWA.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eOne hundred and seventeen patients diagnosed with HH were admitted to our hospital from January 1, 2021, to October 28, 2024. All patients had HH\u0026thinsp;\u0026gt;\u0026thinsp;10 cm in diameter and underwent laparoscopy combined with ultrasound-guided one-off complete MWA according to the protocol in the flowchart (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In particular, there were two patients among them developed AKI after MWA, and their renal function returned to normal after active symptomatic treatment. Contrast-enhanced computed tomography (CT) scans showed a giant hemangioma with a maximum diameter of 136 mm in the first patient (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA, B) with a history of gallstones combined with cholecystitis, hypertension and diabetes. The second patient had a hepatic hemangioma with a maximum diameter of 104 mm on contrast-enhanced magnetic resonance imaging (MRI), (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA, B) and suffered from hypertension, hyperlipidemia, and myocardial hypertrophy. No obvious positive signs were found in the hospital examination.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOn the 4th day after admission, with the guidance of digital subtraction angiography (DSA) under local anesthesia, superselective hepatic artery embolization was performed to embolize the branch of the artery feeding the HH. On Day 8 after admission, under general anesthesia, laparoscopy combined with ultrasound-guided MWA treatment of the HH was performed, particularly the first patient also underwent a concurrent cholecystectomy. A urinary catheter was routinely placed in all patients during surgery. During MWA (MWA system produced by Nanjing Kangyou Co., Ltd., model KY-2000; electrode produced by Nanjing Kangyou Co., Ltd., model KY-2450B-T7), with laparoscopic assistance and ultrasound localization, the HH was ablated. The intraoperative ablation power was 60\u0026ndash;70 W, the first patient's ablation time was 60 min, the intraoperative rehydration amount was 1,500 ml, the urinary output was 120 ml, and the second patient's ablation time was 26 min, the intraoperative rehydration amount was 1,000 ml, the urinary output was 100 ml. No significant hemoglobinuria was observed in both patients during surgery. Postoperative, 2 patients developed AKI. A sequential treatment consisting of sodium bicarbonate alkalization, rapid fluid replacement, diuresis and dialysis treatment were given to the patient as early and timely. Changes in liver and renal function parameters and hemoglobin (HB) and B-type natriuretic peptide (BNP) and urine output levels before and after surgery were analyzed, and changes in HH according to abdominal imaging data obtained before and after surgery were analyzed. All patients were informed with consent according to protocols approved by the Institutional Review Board of the PLA general Hospital, and this study abide by the ethical guidelines of the Helsinki Declaration.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe size of hepatic hemangiomas significantly decreased in both patients, 76mm and 52mm showing on CT scan respectively on the third and second day after surgery (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC). Postoperative, liver and renal insufficiency occurred, and BNP levels increased (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Hepatoprotective therapy was implemented from the day of surgery. However, the levels of ALT, AST, TBIL, and DBIL reached their highest level on the first postoperative day in both patients, then gradually decreased, and returned to preoperative levels on the 11th postoperative day (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e; Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA, B; Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eA, B). Changes in HB were also measured. Unlike previous studies, there was no significant decrease in HB in our patients after surgery (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eC; Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eC).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical parameters of patient 1\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore surgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1st day after surgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 days after surgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 days after surgery\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlanine aminotransferase (ALT) (U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e656.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e409.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e207.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAspartate aminotransferase (AST) (U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e875.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e237.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e83.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal bilirubin (TBIL) (\u0026micro;mol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirect bilirubin (DBIL) (\u0026micro;mol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin (HB) (g/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e138\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine (Cr) (\u0026micro;mol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e316.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e589.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e614.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood urea nitrogen (BUN) (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB-type natriuretic peptide (BNP) (pg/ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3997\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e(Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: Preoperative levels of liver function and renal function parameters were normal, and the postoperative Cr level was increased; postoperatively, liver function was affected, and ALT, AST, and BIL levels rapidly recovered.)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical parameters of patient 2\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore surgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1st day after surgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 days after surgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 days after surgery\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlanine aminotransferase (ALT) (U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e533.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e480.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e299.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAspartate aminotransferase (AST) (U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e932.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e471\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e258.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal bilirubin (TBIL) (\u0026micro;mol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirect bilirubin (DBIL) (\u0026micro;mol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin (HB) (g/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine (Cr) (\u0026micro;mol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e211.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e391\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e485.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood urea nitrogen (BUN) (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB-type natriuretic peptide (BNP) (pg/ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1675\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18993\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16790\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Preoperative liver and renal function parameters were normal, and the BNP level was high; the postoperative Cr level progressively increased, and the BNP level increased significantly; postoperatively, liver function was obviously affected, but ALT, AST, and BIL levels rapidly recovered.)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAKI is defined by rapid deterioration of renal excretory function, diagnosed by the accumulation of end products of nitrogen metabolism (creatinine, 2-fold increase) and/or decreased urine output (UO\u0026thinsp;\u0026lt;\u0026thinsp;0.5ml/kg/h for 12h) \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. The levels of creatinine (CR) showed a progressive increase from the first postoperative day (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Two patients were definitively diagnosed with AKI, and sodium bicarbonate alkalization, rapid fluid replacement, diuresis and dialysis treatment were given to the patient timely. Further analysis found that changes in CR, urine output, and BNP were not exactly the same in the two patients. In the first patient, he had little urine output after surgery. Sodium bicarbonate alkalization, rapid fluid replacement, and diuresis were given timely to him. But the urine output was still low, and there was a soy sauce color and contained sediment in the urine. The urine output on the day of surgery was only 400 ml. CR level progressively increased. With the increase of rapid fluid replacement and the decrease of urine, the patient's BNP level gradually increased. Considering the patient's oliguria, after consultation with his family and the nephrology department, dialysis treatment was initiated on the 3rd day after surgery. After seven dialysis sessions, urine output began to increase on the 13th day after surgery, and Cr and BNP levels gradually decreased to preoperative levels (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eD, E, F). The second patient also had little urine output during operation. However, with treatments such as sodium bicarbonate alkalization, rapid fluid replacement, and diuresis, the patient\u0026rsquo;s urine output increased. The color of the urine initially was light red and then became clear quickly. The urine output on the day of surgery was 1340 ml. Although the postoperative urine output remained normal (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eD), the Cr level still progressively increased. The patient had hypertrophic cardiomyopathy, and the BNP level was persistently increased. We believed that the perfusion therapy affected the patient's cardiac function. After consultation with her family and the nephrology department, the patient underwent one round of dialysis on Day 5 after surgery. The patient could not tolerate the fear during the dialysis process, so no additional rounds of dialysis were performed. The Cr and BNP levels gradually decreased to preoperative levels (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eE, F).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eHH is currently generally considered a vascular malformation caused by excessive development or abnormal differentiation of blood vessels during embryonic development \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. As the volume of HH increases, adjacent tissues and organs in the abdominal cavity are affected, which leads to abdominal discomfort, such as abdominal pain, abdominal distension and other related symptoms \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. In some cases, the HH ruptures due to the weak arterial wall or external force, which can be life-threatening in severe cases \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. The clinical treatment of HH is currently controversial, and follow-up observation is often the choice \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. In 2014, the ACG proposed that surgical treatment can be considered for patients with HHs with a diameter of \u0026gt;\u0026thinsp;10 cm or symptoms of oppression and pain \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Surgery is the most effective treatment for HHs. Traditional surgical methods include open or laparoscopic surgical resection \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. However, surgical trauma and risk are high, postoperative recovery is slow, and complications such as bleeding are prone to occur \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. With the growth of HH, there would be corresponding abdominal discomfort symptoms, the risk and difficulty of surgery would increase. Previous studies have suggested that HH with a diameter of more than 5cm could be considered for surgical treatment \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. We believe that HH with a diameter of \u0026ge;\u0026thinsp;5 cm that is consistently increasing can be treated with minimally invasive surgical intervention early to avoid surgical resection. Based on the characteristics of benign lesions of HH, under the premise of strictly controlling the indications for treatment, the principle should be to achieve the best therapeutic effect with the least amount of trauma \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe use of ablation for HHs has been reported in previous studies \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Thermal ablation can cause the destruction of many RBCs, which could cause intravascular hemolysis. After surgery, there is a sudden decrease in HB levels, which can lead to different degrees of hemoglobinuria and even AKI \u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. Studies have revealed a strong correlation with the size of the hemangioma and the time of ablation, leading researchers to recommend multiple ablations \u003csup\u003e[\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. In our center, MWA is used for HH, and significant results have been achieved. After continuous practice, when MWA is used for one-off complete ablation of HH, obvious reduction of the tumor, minimal surgical trauma, and no serious postoperative complications can be achieved. Moreover, we have found that HB levels did not significantly decrease during the first three days. We believe that the thermal ablation destructed RBC in HH.\u003c/p\u003e \u003cp\u003eThe analysis of the clinical data of patients with renal insufficiency after MWA revealed that renal insufficiency was completely reversible. We believe that the thermal effect causes damage to the blood of the HH and the destruction of blood cells during MWA. In particular, HB is released after the destruction of RBCs. If the number of destroyed RBCs is large and the amount of HB released exceeds the metabolic capacity, hemoglobinuria could develop. In most patients, hemoglobinuria is transient. After adequate fluid replacement, urine alkalinization, and diuretic treatment, the urine output can return to normal without renal function being affected. If RBCs are severely destroyed during surgery, large amounts of free HB accumulate in the body, which may block renal tubules and induce AKI. In this study, Patient 2 did not have significant oliguria after surgery, but there was a progressive increase in Cr level after surgery. We also found that the BNP level increased after surgery. Given that the patient was complicated with hypertrophic cardiomyopathy, she received dialysis treatment only once and was subsequently treated with fluid replacement and urine alkalinization, and the Cr and BNP levels gradually decreased and recovered to the preoperative levels. After surgery, the first patient had soy sauce-colored urine, a significant period of oliguria, and a progressive increase in the Cr level. After 7 cycles of dialysis treatment in the department of nephrology in our hospital, renal function gradually improved, and urine output returned to normal.\u003c/p\u003e \u003cp\u003eThrough the data analysis and the efficacy evaluation of other patients, to avoid the occurrence of hemoglobinuria and AKI, we took the following measures: a, When performing MWA for large hemangiomas, interventional embolization should be routinely performed prior to the surgery to embolize the blood supplying arterial branches of the HHs individually to block the blood supply to the HHs, thus reducing the number of RBCs destroyed. b, On the day of surgery, adequate fluid replacement therapy should be administered before and during the operation to maintain adequate renal perfusion, and a urinary catheter should be routinely placed during the operation. If low urine output occurs, sodium bicarbonate should be given to alkalinize the urine, and diuretic treatment should be given to eliminate the free HB on the premise of adequate fluid replacement. Therefore, when hemoglobinuria is seen during the operation, it is not a cause for alarm, because only when the free HB is discharged in time, it is possible that AKI will not occur. c, If AKI occurred, as indicated by oliguria and anuria, occurs after surgery, dialysis should be performed as soon as possible. On the basis of these findings, subsequent patients with HH treated with MWA at our center underwent one round of complete ablation. Although transient hemoglobinuria may have occurred during surgery and after surgery, none of the patients had AKI.\u003c/p\u003e \u003cp\u003eIn summary, during the perioperative period of MWA for HH, with close patient monitoring and management, the occurrence of hemoglobinuria and AKI can be avoided. If hemoglobinuria or even AKI occurs after surgery, renal insufficiency can be completely reversed with timely and correct treatments.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMicrowave ablation (MWA); Hepatic hemangioma (HH); American College of Gastroenterology (ACG); Red blood cell (RBC); Computed tomography (CT); Magnetic resonance imaging (MRI); Digital subtraction angiography (DSA); Hemoglobin (HB); B-type natriuretic peptide (BNP); Creatinine (CR); Blood urea nitrogen (BUN); Alanine aminotransferase (ALT); Aspartate aminotransferase (AST); Total bilirubin (TBIL); Direct bilirubin (DBIL).\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy concept and design: Hu, Huan and Jiang; acquisition of data: Hu, Huan, Tu, Gao, Jin, Sun, Wang, Zhu, Zhao, and Wu; analysis and interpretation of data: Hu, Huan, Tu and Jiang; drafting of the manuscript: Hu, Huan, and Gao; critical revision of the manuscript for important intellectual content: Jiang, Hu and Huan; statistical analysis: Hu, Tu and Huan; study supervision: Jiang and Tu.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and\u0026nbsp;consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients were informed with consent\u0026nbsp;according to protocols approved by the Institutional Review Board of the PLA general Hospital, and this study abide by the ethical guidelines of the Helsinki Declaration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot application.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBajenaru N, Balaban V, Săvulescu F et al. Hepatic hemangioma \u0026ndash;review-. J Med Life. 2015; 8 Spec Issue (Spec Issue): 4\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoekstra LT, Bieze M, Erdogan D, et al. Management of giant liver hemangiomas: an update. Expert Rev Gastroenterol Hepatol. 2013;7(3):263\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarrero JA, Ahn J, Rajender Reddy K. Americal College of Gastroenterology. ACG clinical guideline: the diagnosis and management of focal liver lesions. Am J Gastroenterol. 2014;109(9):1328\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbdel Wahab M, El Nakeeb A, Ali MA, et al. Surgical Management of Giant Hepatic Hemangioma: Single Center's Experience with 144 Patients. J Gastrointest Surg. 2018;22(5):849\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJu M, Xu F, Zhao W, et al. Efficacy and factors affecting the choice of enucleation and liver resection for giant hemangioma: a retrospective propensity score-matched study. BMC Surg. 2020;20(1):271.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJiang K, Su M, Zhao X, et al. One-off complete radiofrequency ablation of hepatocellular carcinoma adjacent to the gallbladder by a novel laparoscopic technique without gallbladder isolation. Cell Biochem Biophys. 2014;68(3):547\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJiang K, Chen J, Liu Y, et al. Heat-Irrigate Effect' of Radiofrequency Ablation on Relevant Regional Hepatocyte in Living Swine Liver-Initial Study on Pathology. Cell Biochem Biophys. 2015;72(1):37\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKai J, Ming S, Yang L, et al. Complete radio frequency ablation of hepatocellular carcinoma adjacent to the main bile duct and blood vessels between the first and the second hepatic portal. Cell Biochem Biophys. 2013;66(2):397\u0026ndash;402.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJiang K, Su M, Zhang W, et al. Complete radiofrequency ablation of hepatolithiasis-associated cholangiocarcinoma and successful management of post-ablation bronchobiliary fistula. Cell Biochem Biophys. 2014;68(3):555\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJiang K, Su M, Liu Y, et al. Optimal conditions for heat-conduct effect in liver tissue during radiofrequency ablation. Panminerva Med. 2013;55(3):297\u0026ndash;302.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJiang K, Zhang W, Su M, et al. Laparoscopic radiofrequency ablation of solitary small hepatocellular carcinoma in the caudate lobe. Eur J Surg Oncol. 2013;39(11):1236\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIzzo F, Granata V, Grassi R, et al. Radiofrequency Ablation and Microwave Ablation in Liver Tumors: An Update. Oncologist. 2019;24(10):e990\u0026ndash;1005.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMusick JR, Philips P, Scoggins CR, et al. Laparoscopic microwave ablation versus percutaneous microwave ablation of hepatic malignancies: Efficacy and recurrence-free survival outcomes in patients. Surgery. 2023;173(3):598\u0026ndash;602.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCai Q, Qian TG, Zhao QY, et al. Percutaneous microwave ablation versus sclerotherapy for large hepatic hemangioma: a multi-center cohort study. Int J Hyperth. 2024;41(1):2285705.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Z, Liu M, Zhang DZ, et al. 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BMC Cancer. 2019;19(1):550.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hepatic hemangioma, microwave ablation, acute kidney injury","lastPublishedDoi":"10.21203/rs.3.rs-6137226/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6137226/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo improve treatment options for acute kidney injury (AKI) after microwave ablation (MWA) of hepatic hemangioma (HH).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFrom January 1, 2021, to October 28, 2024, 117 patients with HH were treated by MWA at our center, and 2 of them occurred AKI after operation. The preoperative and postoperative data of 2 patients were retrospectively analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eDuring the MWA for patients with HH, hemoglobinuria may occur during and after surgery, which may even lead to AKI. A sequential treatment consisting of sodium bicarbonate alkalization, rapid fluid replacement, diuresis and dialysis treatment were given to the patient as early and timely. And their renal function returned to normal.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePatients with AKI after MWA of HH can fully recover. It suggested that MWA is an effective and safe treatment for HH patients.\u003c/p\u003e","manuscriptTitle":"Perioperative management of acute kidney injury after microwave ablation of hepatic hemangioma","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-21 08:19:15","doi":"10.21203/rs.3.rs-6137226/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2025-04-23T18:31:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-18T15:35:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-17T22:22:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211164971211644926628585080915066664736","date":"2025-04-17T22:17:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"321560518213310392100839653884328888588","date":"2025-04-17T13:56:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"89258872972857606386198418099525546560","date":"2025-04-17T13:54:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-17T13:43:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-17T05:28:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2025-04-16T15:05:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ad43c981-6703-4368-bc33-b96aba951e39","owner":[],"postedDate":"April 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-05T15:58:20+00:00","versionOfRecord":{"articleIdentity":"rs-6137226","link":"https://doi.org/10.1186/s12885-025-14214-9","journal":{"identity":"bmc-cancer","isVorOnly":false,"title":"BMC Cancer"},"publishedOn":"2025-04-30 15:56:53","publishedOnDateReadable":"April 30th, 2025"},"versionCreatedAt":"2025-04-21 08:19:15","video":"","vorDoi":"10.1186/s12885-025-14214-9","vorDoiUrl":"https://doi.org/10.1186/s12885-025-14214-9","workflowStages":[]},"version":"v1","identity":"rs-6137226","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6137226","identity":"rs-6137226","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}