To the Editor:
The article by Salem and Tray1 relating early posthepatectomy hypophosphatemia to transient postoperative hyperphosphaturia reports on a very interesting and stimulating study, which strongly suggests the need for additional research on the topic.
We think that an important point to address in greater detail is the relationship between the occurrence of these early posthepatectomy events (hypophosphatemia and hyperphosphaturia) and the subsequent manifestation of complications. This was described by George and Shiu several years ago,2 later independently, to varying degrees, by other authors including some of us,3–5 and questioned by others.6 More recently, we have become used to seeing this association reconfirmed in clinical practice, in a volume of 40 to 50 hepatectomies per year. Impaired renal handling of phosphate in acute phase response has been addressed repeatedly in the last 2 decades, and Salem and Tray have demonstrated elegantly that it is an important event after hepatectomy.1
Hypophosphatemia, explained in full or in part by this event, is known to impair the immune response and other functions but receives inconsistent consideration in the management of many postoperative patients, and the relationship with unfavorable outcomes still remains in several cases speculative or unknown. Furthermore, it is not yet totally clear to what extent phosphorus replenishment may be protective. A key point would be to understand more concretely the underlying mechanism(s) binding all of this together (ie, a common cause for a more severe early hyperphosphaturia and hypophosphatemia and the greater likelihood of subsequent complications), the exceptions (some patients exhibit severe hypophosphatemia within totally uneventful clinical courses), and, obviously, the practical implications for patient care.
Ivo Giovannini, MD
Carlo Chiarla, MD
Felice Giuliante, MD
Francesco Ardito, MD
Maria Vellone, MD
Gennaro Nuzzo, MD
Catholic University School of Medicine and CNR-IASI Center for Pathophysiology of Shock
Rome, Italy
ivo.giovannini@rm.unicatt.it
REFERENCES
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