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Benken ST, Thomas R, Fraidenburg DR, Benken JJ. Angiotensin II as a Vasopressor for Perioperative Hypotension in Solid Organ Transplant. Biomedicines 2024; 12:1817. [PMID: 39200281 PMCID: PMC11351893 DOI: 10.3390/biomedicines12081817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 07/29/2024] [Accepted: 08/07/2024] [Indexed: 09/02/2024] Open
Abstract
During the perioperative period of transplantation, patients experience hypotension secondary to the side effects of anesthesia, surgical stress, inflammatory triggering, and intraoperative fluid shifts, among others causes. Vasopressor support, in this context, must reverse systemic hypotension, but ideally, the agents used should benefit allograft function and avoid the adverse events commonly seen after transplantation. Traditional therapies to reverse hypotension include catecholamine vasopressors (norepinephrine, epinephrine, dopamine, and phenylephrine), but their utility is limited when considering allograft complications and adverse events such as arrhythmias with agents with beta-adrenergic properties. Synthetic angiotensin II (AT2S-[Giapreza]) is a novel vasopressor indicated for distributive shock with a unique mechanism of action as an angiotensin receptor agonist restoring balance to an often-disrupted renin angiotensin aldosterone system. Additionally, AT2S provides a balanced afferent and efferent arteriole vasoconstriction at the level of the kidney and could avoid the arrhythmic complications of a beta-adrenergic agonist. While the data, to date, are limited, AT2S has demonstrated safety in case reports, pilot studies, and small series in the kidney, liver, heart, and lung transplant populations. There are physiologic and hemodynamic reasons why AT2S could be a more utilized agent in these populations, but further investigation is warranted.
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Affiliation(s)
- Scott T. Benken
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA; (R.T.); (J.J.B.)
| | - Riya Thomas
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA; (R.T.); (J.J.B.)
| | - Dustin R. Fraidenburg
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago College of Medicine, Chicago, IL 60612, USA;
| | - Jamie J. Benken
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA; (R.T.); (J.J.B.)
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Beltran LP, Benken J, Jou J, Benedetti E, Nishioka H, Alamreia E, Belcher RM, Benken ST. Efficacy and Safety of Perioperative Angiotensin II Versus Phenylephrine as a First-Line Continuous Infusion Vasopressor in Kidney Transplant Recipients. Clin Transplant 2024; 38:e15432. [PMID: 39166466 DOI: 10.1111/ctr.15432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 07/18/2024] [Accepted: 08/02/2024] [Indexed: 08/23/2024]
Abstract
INTRODUCTION Angiotensin II (ATII) maintains blood pressure via RAAS with a beneficial adverse effect profile versus catecholamines and phenylephrine. Head-to-head data comparing ATII to phenylephrine are lacking regarding renal allograft function, hemodynamic efficacy, and safety within the perioperative period of kidney transplantation. METHODS This single-center, retrospective study included adult kidney transplant recipients who received continuous infusions of ATII or phenylephrine within a 24-h perioperative period as a first-line vasopressor according to an institutional algorithm. The primary endpoint was allograft function. Secondary endpoints were hemodynamic efficacy and adverse effects. RESULTS Among 105 patients, there was no significant difference in IGF (p = 0.545), SGF (p = 0.557), or DGF (p = 0.878) between patient cohorts. In the 34 patients with cold ischemia time (CIT) > 14-h, IGF was higher (p = 0.013) and DGF (p = 0.045) was lower in the ATII cohort versus phenylephrine. In all patients, ATII was associated with a decreased need for additional vasopressor agents (p < 0.001). Adverse effect profiles were similar between cohorts (p > 0.05). CONCLUSION Among kidney transplant recipients, ATII may be a suitable first-line alternative compared with phenylephrine in the perioperative period for hypotension management with a reduced need for additional vasopressor support. Allograft benefits were observed in patients with prolonged CIT.
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Affiliation(s)
- Lyra P Beltran
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Denver, Colorado, USA
| | - Jamie Benken
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Denver, Colorado, USA
| | - Jonathan Jou
- Department of Surgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - Enrico Benedetti
- Department of Surgery, Division of Transplantation, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - Hokuto Nishioka
- Division of Clinical Anesthesiology, Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - Enas Alamreia
- University of Illinois Chicago College of Pharmacy, Denver, Colorado, USA
| | - Rachel M Belcher
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Denver, Colorado, USA
| | - Scott T Benken
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Denver, Colorado, USA
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3
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Ngai J, Keny N, James L, Katz S, Moazami N. Intraoperative Considerations and Management of Simultaneous Heart Kidney Transplantation. J Cardiothorac Vasc Anesth 2023; 37:1862-1869. [PMID: 37210325 DOI: 10.1053/j.jvca.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/21/2023] [Accepted: 05/01/2023] [Indexed: 05/22/2023]
Affiliation(s)
- Jennie Ngai
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Langone Health, New York, New York.
| | - Nikhil Keny
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Langone Health, New York, New York
| | - Les James
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Simon Katz
- NYIT College of Osteopathic Medicine, Glen Head, New York
| | - Nader Moazami
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
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Thomas R, Benken J, Belcher RM, Palmer ME, Benedetti E, Benken ST. Catecholamine Vasopressor Exposure Is Associated With Early Poor Allograft Function and Adverse Events in Living Donor Kidney Transplant Recipients. Transplant Proc 2023; 55:1543-1550. [PMID: 37414695 DOI: 10.1016/j.transproceed.2023.03.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/26/2023] [Accepted: 03/30/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Hypoperfusion leads to allograft injury during kidney transplantation. Catecholamine vasopressors are used to maintain blood pressure in the perioperative period but have demonstrated negative outcomes in the deceased-donor kidney transplant population. Little is known regarding living donor kidney transplants (LDKTs) and vasopressor use. The aim of this study is to describe the incidence of vasopressor use in LDKT and characterize its effects on allograft function and patient outcomes. METHODS This retrospective, observational cohort study included adult patients who underwent an isolated LDKT between August 1, 2017, and September 1, 2018. Patients were divided into those who received perioperative vasopressors and those who did not. The primary objective was to compare allograft function between LDKT recipients that received vasopressors and those who did not. Secondary outcomes included safety endpoints and the identification of clinical variables associated with vasopressor use. RESULTS A total of 67 patients received an LDKT during the study period. Of those, 25 (37%) received perioperative vasopressors, and 42 (62%) did not. Poor graft function, as defined by the development of slow or delayed graft function, occurred more frequently in patients receiving perioperative vasopressors compared with those who did not (6 [24%] vs 1 [2.4%], P = .016). In multivariable regression modeling, only perioperative vasopressors were statistically significantly associated with poor graft function. In addition, patients exposed to vasopressors experienced more postoperative arrhythmias (8 [32%] vs 1 [4.8%], P = .0025). CONCLUSION Using perioperative vasopressors was independently associated with worsened early renal allograft function, including delayed graft function and adverse events in the LDKT population.
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Affiliation(s)
- Riya Thomas
- Department of Surgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Jamie Benken
- Department of Surgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois; Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Rachel M Belcher
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Mary E Palmer
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Enrico Benedetti
- Department of Surgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Scott T Benken
- Department of Surgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois; Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois.
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Patel GP, Smith SA, Romej M, McAdoo B, Wilson EA. Use of Intramuscular Ephedrine Sulfate During Kidney Transplantation. Clin Pharmacol 2023; 15:57-61. [PMID: 37387793 PMCID: PMC10305767 DOI: 10.2147/cpaa.s418124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/21/2023] [Indexed: 07/01/2023] Open
Abstract
Hypotension during kidney transplantation can be common. Vasopressor use during these procedures is often avoided, with a fear of decreasing renal perfusion in the transplanted kidney. However, adequate perfusion for the rest of the body is also necessary, and given that these patients often have underlying hypertension or other comorbid conditions, an appropriate mean arterial pressure (MAP) has to be maintained. Intramuscular injections of ephedrine have been studied in the anesthesiology literature in a variety of case types, and it is seen as a safe and effective method to boost MAP. We present a case series of three patients who underwent renal transplantation and who received an intramuscular injection of ephedrine for hypotension control. The medication worked well for increasing blood pressures without apparent side effects. All three patients were followed for more than one year, and all patients had good graft function at the end of that time period. This series shows that while further research is necessary in this arena, intramuscular ephedrine may have a place in the management of persistent hypotension in the operating room during kidney transplantation.
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Affiliation(s)
- Gaurav P Patel
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Susan A Smith
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Michelle Romej
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Billynda McAdoo
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Elizabeth A Wilson
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, 30322, USA
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Halimi JM, Vernier LM, Gueguen J, Goin N, Gatault P, Sautenet B, Barbet C, Longuet H, Roumy J, Buchler M, Blacher J, de Freminville JB. End-diastolic velocity mediates the relationship between renal resistive index and the risk of death. J Hypertens 2023; 41:27-34. [PMID: 36129106 DOI: 10.1097/hjh.0000000000003293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Renal resistive index predicts the risk of death in many populations but the mechanism linking renal resistive index and death remains elusive. Renal resistive index is derived from end-diastolic velocity (EDV) and peak systolic velocity (PSV). However, the predictive value of EDV or PSV considered alone is unknown. METHODS We conducted a retrospective analysis of 2362 consecutive patients who received a kidney transplant from 1985 to 2017. EDV and PSV were measured at 3 months after transplantation, renal resistive index was calculated, and the risk of death was assessed [median follow-up: 6.25 years (0.25-29.15); total observation period: 13 201 patient-years]. RESULTS Doppler indices were available in 1721 of 2362 (78.9%) patients (exclusions: 113 who died or returned to dialysis before, 427 with no Doppler studies, 27 with renal artery stenosis, 74 missing values). Among them, 279 (16.4%) had diabetes before transplantation. Mean age was 51.5 ± 14.7, 1097 (63.7%) were male. During follow-up, 217 of 1721 (12.6%) patients died. Renal resistive index and EDV shared many determinants (notably systolic, diastolic and pulse pressure, recipient age and diabetes) unlike renal resistive index and PSV. EDV used as a binary [lowest tertile vs. higher values: (hazard ratio: 2.57 (1.96-3.36), P < 0.001)] and as a continuous (the lower EDV, the greater the risk of death) variable was significantly associated with the risk of death. This finding was confirmed in multivariable analyses. Prediction of similar magnitude was found for renal resistive index. No association was found between PSV used as a binary or a continuous variable and the risk of death. CONCLUSION Low EDV explains high renal resistive index, and the mechanism-linking renal resistive index to the risk of death is through low EDV.
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Affiliation(s)
- Jean-Michel Halimi
- Service de Néphrologie-Hypertension, Dialyses, Transplantation rénale, Hôpital Bretonneau, Centre Hospitalier Universitaire de Tours
- EA4245, University of Tours, Tours
- INI-CRCT, Nancy
| | - Louis-Marie Vernier
- Service de Néphrologie-Hypertension, Dialyses, Transplantation rénale, Hôpital Bretonneau, Centre Hospitalier Universitaire de Tours
| | - Juliette Gueguen
- Service de Néphrologie-Hypertension, Dialyses, Transplantation rénale, Hôpital Bretonneau, Centre Hospitalier Universitaire de Tours
| | - Nicolas Goin
- Service de Néphrologie-Hypertension, Dialyses, Transplantation rénale, Hôpital Bretonneau, Centre Hospitalier Universitaire de Tours
| | - Philippe Gatault
- Service de Néphrologie-Hypertension, Dialyses, Transplantation rénale, Hôpital Bretonneau, Centre Hospitalier Universitaire de Tours
- EA4245, University of Tours, Tours
| | - Bénédicte Sautenet
- Service de Néphrologie-Hypertension, Dialyses, Transplantation rénale, Hôpital Bretonneau, Centre Hospitalier Universitaire de Tours
- INI-CRCT, Nancy
- INSERM U1246 SPHERE, Université de Tours-Université de Nantes
| | - Christelle Barbet
- Service de Néphrologie-Hypertension, Dialyses, Transplantation rénale, Hôpital Bretonneau, Centre Hospitalier Universitaire de Tours
| | - Hélène Longuet
- Service de Néphrologie-Hypertension, Dialyses, Transplantation rénale, Hôpital Bretonneau, Centre Hospitalier Universitaire de Tours
| | - Jérôme Roumy
- Service d'Imagerie Médicale, Hôpital Bretonneau, CHU Tours, Tours
| | - Matthias Buchler
- Service de Néphrologie-Hypertension, Dialyses, Transplantation rénale, Hôpital Bretonneau, Centre Hospitalier Universitaire de Tours
- EA4245, University of Tours, Tours
| | - Jacques Blacher
- Centre de Diagnostic et de Thérapeutique, Hôtel-Dieu
- Université Paris, Paris, France
| | - Jean-Baptiste de Freminville
- Service de Néphrologie-Hypertension, Dialyses, Transplantation rénale, Hôpital Bretonneau, Centre Hospitalier Universitaire de Tours
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Andrews L, Benken J, Benedetti E, Nishioka H, Pierce D, Dalton K, Han J, Shin B, Benken S. Effects of angiotensin II in the management of perioperative hypotension in kidney transplant recipients. Clin Transplant 2022; 36:e14754. [PMID: 35771088 PMCID: PMC9787019 DOI: 10.1111/ctr.14754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/31/2022] [Accepted: 06/12/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Due to the mechanisms of action of conventional catecholamine vasopressors, there is increased risk of renal allograft injury and adverse events in transplant recipients with fluid-refractory distributive shock during the perioperative period. As such, mechanistically alternative vasopressors like angiotensin II (ATII) may avoid these complications, but there is an absence of data supporting use in this population. METHODS This was a single-center, single-arm, open-label, phase 4 study conducted as a 1-year pilot of 20 adult renal transplant recipients receiving ATII as their first continuous infusion vasopressor in the perioperative period. The study aim was to systematically assess the safety and hemodynamic effects of ATII. Safety was assessed based on the incidence of adverse events. Hemodynamic effect was assessed by the achievement of per protocol hemodynamic goals (i.e., SBP ≥120 mmHg) and the need for adjunct vasopressors. RESULTS Most cases involved deceased donors (70%), with a corresponding mean (SD) cold ischemia time of 14.7 (8.6) h. Over a surgery duration of 5.3 (1.2) h, subjects received 3.2 (2.0) L of total volume resuscitation prior to ATII initiation. No adverse events were directly related to ATII administration. Throughout this period, ATII was utilized for a median of 1.0 (IQR, 1.5) h intraoperatively (N = 7), 26.5 (IQR, 84.8) h postoperatively (N = 4), and 63.8 (IQR, 57.8) h in subjects who required ATII both intra- and postoperatively (N = 9). Only one of the 20 patients needed adjunct continuous infusion vasopressors in addition to ATII. CONCLUSIONS Based on the observations of this pilot study, ATII is a safe and effective vasopressor option for renal transplant recipients requiring perioperative hypotension reversal.
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Affiliation(s)
- Lauren Andrews
- Department of Pharmacy PracticeUniversity of Illinois at Chicago College of PharmacyChicagoIllinoisUSA,University of Illinois Hospital & Health Sciences SystemChicagoIllinoisUSA
| | - Jamie Benken
- Department of Pharmacy PracticeUniversity of Illinois at Chicago College of PharmacyChicagoIllinoisUSA,University of Illinois Hospital & Health Sciences SystemChicagoIllinoisUSA
| | - Enrico Benedetti
- University of Illinois Hospital & Health Sciences SystemChicagoIllinoisUSA,Department of Transplant SurgeryUniversity of Illinois at Chicago College of MedicineChicagoIllinoisUSA
| | - Hokuto Nishioka
- University of Illinois Hospital & Health Sciences SystemChicagoIllinoisUSA,Department of Critical Care MedicineUniversity of Illinois at Chicago College of MedicineChicagoIllinoisUSA
| | - Dana Pierce
- Department of Pharmacy PracticeUniversity of Illinois at Chicago College of PharmacyChicagoIllinoisUSA,University of Illinois Hospital & Health Sciences SystemChicagoIllinoisUSA
| | - Kaitlyn Dalton
- Department of PharmacySt. David’s Health CareAustinTexasUSA
| | - Justin Han
- Department of Pharmacy PracticeUniversity of Illinois at Chicago College of PharmacyChicagoIllinoisUSA
| | - Bona Shin
- Department of Pharmacy PracticeUniversity of Illinois at Chicago College of PharmacyChicagoIllinoisUSA
| | - Scott Benken
- Department of Pharmacy PracticeUniversity of Illinois at Chicago College of PharmacyChicagoIllinoisUSA,University of Illinois Hospital & Health Sciences SystemChicagoIllinoisUSA
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Jan MY, Moe SM, Adebiyi O, Chen J, Powelson J, Burney HN, Yaqub MS, Mishler DP, Moorthi RN, Taber TE, Anderson MD, Li Y, Li X, Fridell JA, Goggins WC, Sharfuddin AA. Vasopressin for Post-kidney Transplant Hypotension. Kidney Int Rep 2022; 7:1364-1376. [PMID: 35694563 PMCID: PMC9174042 DOI: 10.1016/j.ekir.2022.03.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 03/24/2022] [Accepted: 03/29/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction Hypotension after deceased donor kidney transplant (DDKT) is a risk factor for delayed graft function (DGF) and poor graft survival (GS). We hypothesize that vasopressin use in hypotensive DDKT recipients (DDKTRs) to increase blood pressure (BP) reduces DGF rates and is safe without increasing mortality. Methods Group with vasopressin "study group" (n = 45) was defined as DDKTRs between 2012 and 2017 who required vasopressin for hypotension systolic BP (SBP) <120 mm Hg or diastolic BP (DBP) <60 mm Hg. DDKTRs with no-vasopressin "comparison group" (n = 90) were propensity score-matched DDKTRs between 2012 and 2017 without vasopressin use. Primary outcomes were GS, creatinine and allograft biopsy rate at 1 year, DGF rate, and death during transplant hospitalization. Results Vasopressin group had lower mean maximum and minimum SBP and DBP in the operating room (OR). Median vasopressin start time post-DDKT was 2 hours (interquartile range [IQR] 1-6), and duration of use was 42 hours (IQR 24-63). DGF, creatinine at 1 year, and allograft biopsy rates were comparable. No deaths occurred during transplant hospitalization. Multivariable analysis did not find an effect of vasopressin use on GS. Conclusion Treatment of hypotensive DDKTRs with vasopressin is safe and facilitated similar graft function and survival with that of nonhypotensive patients. In the absence of a randomized control trial, our study supports the safety of vasopressin therapy to prevent the adverse effects of hypotension.
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Affiliation(s)
- Muhammad Y. Jan
- Division of Nephrology and Hypertension, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sharon M. Moe
- Division of Nephrology and Hypertension, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana Clinical and Translational Sciences Institute, Indianapolis, Indiana, USA
| | - Oluwafisayo Adebiyi
- Division of Nephrology and Hypertension, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jeannie Chen
- Department of Pharmacy, Indiana University Health, Indianapolis, Indiana, USA
| | - John Powelson
- Division Transplant Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Heather N. Burney
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Muhammad S. Yaqub
- Division of Nephrology and Hypertension, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dennis P. Mishler
- Division of Nephrology and Hypertension, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ranjani N. Moorthi
- Division of Nephrology and Hypertension, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Tim E. Taber
- Division of Nephrology and Hypertension, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Melissa D. Anderson
- Division of Nephrology and Hypertension, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Yang Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Xiaochun Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jonathan A. Fridell
- Division Transplant Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - William C. Goggins
- Division Transplant Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Asif A. Sharfuddin
- Division of Nephrology and Hypertension, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Mohamed RMSM, Ahmad EA, Omran BHF, Sakr AT, Ibrahim IAAEH, Mahmoud MF, El-Naggar ME. Mitigation of dexamethasone-induced nephrotoxicity by modulating the activity of adrenergic receptors: Implication of Wnt/β-arrestin2/β-catenin pathway. Life Sci 2022; 293:120304. [PMID: 35016879 DOI: 10.1016/j.lfs.2022.120304] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/24/2021] [Accepted: 01/04/2022] [Indexed: 12/19/2022]
Abstract
The present study aimed to investigate the role of α and β-adrenergic receptors (βARs) in mediation or modulation of the dexamethasone-induced nephrotoxicity by using different pharmacological interventions. Nephrotoxicity was induced by subcutaneous injection of dexamethasone (10 mg/kg) for 7 days in Wistar albino rats. Eight groups were used: control; dexamethasone; carvedilol; phenylephrine; carvedilol and phenylephrine; propranolol; doxazosin; propranolol and doxazosin. At the end of experiment, rats were euthanized and blood, urine and kidney samples were collected. Serum and urinary creatinine and urinary total protein levels were measured. Also, the renal tissue levels of diacylglycerol (DAG); Akt kinase activity, malondialdehyde (MDA), NADPH oxidase 2 (NOX2), transforming growth factor-β (TGF-β), Wnt3A and β-catenin were recorded. Furthermore, histopathological and β-arrestin2-immunohistochemical examinations of renal tissues were performed. Results: Dexamethasone induced glomerular damage, proteinuria, renal oxidative stress and upregulated the renal Wnt/β-arrestin2/β-catenin pathway and the profibrotic signals. Blocking the α1 and βARs by carvedilol reduced the dexamethasone-induced nephrotoxicity. Pre-injection of phenylephrine did not reduce the reno-protective action of carvedilol. Blocking the βARs only by propranolol reduced the dexamethasone-induced nephrotoxicity to the same extent of carvedilol group. Blocking the α1ARs only by doxazosin reduced dexamethasone-induced nephrotoxicity to a higher extent than other treatments. However, combined use of propranolol and doxazosin did not synergize the reno-protective effects of doxazosin. Conclusion: Dexamethasone induces nephrotoxicity, possibly, by upregulating the Wnt/β-arrestin2/β-catenin pathway. Blocking either α1ARs or βARs can effectively protect against the dexamethasone-induced nephrotoxicity. However, combined blocking of α1ARs and βARs does not synergize the reno-protective effects.
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Affiliation(s)
- Rasha M S M Mohamed
- Department of Clinical Pharmacology, Faculty of Medicine, Zagazig University, Zagazig 44519, Egypt
| | - Enssaf Ahmad Ahmad
- Department of Human Anatomy and Embryology, Faculty of Medicine, Zagazig University, Zagazig 44519, Egypt
| | - Bothina H F Omran
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Zagazig University, Zagazig 44519, Egypt
| | - Amr T Sakr
- Department of Biochemistry, Faculty of Pharmacy, El-Sadat University, University of Sadat City, Menoufia 32897, Egypt
| | - Islam A A E-H Ibrahim
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Zagazig University, Zagazig 44519, Egypt.
| | - Mona F Mahmoud
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Zagazig University, Zagazig 44519, Egypt
| | - Mostafa E El-Naggar
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, University of Sadat City, Menoufia 32897, Egypt
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Mendez NV, Raveh Y, Livingstone JJ, Ciancio G, Guerra G, Burke III GW, Shatz VB, Souki FG, Chen LJ, Morsi M, Figueiro JM, Ibrahim TM, DeFaria WL, Nicolau-Raducu R. Perioperative risk factors associated with delayed graft function following deceased donor kidney transplantation: A retrospective, single center study. World J Transplant 2021; 11:114-128. [PMID: 33954089 PMCID: PMC8058644 DOI: 10.5500/wjt.v11.i4.114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/05/2021] [Accepted: 03/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There is an abundant need to increase the availability of deceased donor kidney transplantation (DDKT) to address the high incidence of kidney failure. Challenges exist in the utilization of higher risk donor organs into what appears to be increasingly complex recipients; thus the identification of modifiable risk factors associated with poor outcomes is paramount.
AIM To identify risk factors associated with delayed graft function (DGF).
METHODS Consecutive adults undergoing DDKT between January 2016 and July 2017 were identified with a study population of 294 patients. The primary outcome was the occurrence of DGF.
RESULTS The incidence of DGF was 27%. Under logistic regression, eight independent risk factors for DGF were identified including recipient body mass index ≥ 30 kg/m2, baseline mean arterial pressure < 110 mmHg, intraoperative phenylephrine administration, cold storage time ≥ 16 h, donation after cardiac death, donor history of coronary artery disease, donor terminal creatinine ≥ 1.9 mg/dL, and a hypothermic machine perfusion (HMP) pump resistance ≥ 0.23 mmHg/mL/min.
CONCLUSION We delineate the association between DGF and recipient characteristics of pre-induction mean arterial pressure below 110 mmHg, metabolic syndrome, donor-specific risk factors, HMP pump parameters, and intraoperative use of phenylephrine.
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Affiliation(s)
- Nicholas V Mendez
- Department of Anesthesiology, University of Miami/Jackson Memorial Hospital, Miami, FL 33136, United States
| | - Yehuda Raveh
- Department of Anesthesiology, University of Miami/Jackson Memorial Hospital, Miami, FL 33136, United States
| | - Joshua J Livingstone
- Department of Anesthesiology, University of Miami/Jackson Memorial Hospital, Miami, FL 33136, United States
| | - Gaetano Ciancio
- Department of Surgery, Miami Transplant Institute/University of Miami/Jackson Memorial Hospital, Miami, FL 33136, United States
| | - Giselle Guerra
- Division of Nephrology of the Department of Medicine, University of Miami/Jackson Memorial Hospital, Miami, FL 33136, United States
| | - George W Burke III
- Department of Surgery, Miami Transplant Institute/University of Miami/Jackson Memorial Hospital, Miami, FL 33136, United States
| | - Vadim B Shatz
- Department of Anesthesiology, University of Miami/Jackson Memorial Hospital, Miami, FL 33136, United States
| | - Fouad G Souki
- Department of Anesthesiology, University of Miami/Jackson Memorial Hospital, Miami, FL 33136, United States
| | - Linda J Chen
- Department of Surgery, Miami Transplant Institute/University of Miami/Jackson Memorial Hospital, Miami, FL 33136, United States
| | - Mahmoud Morsi
- Department of Surgery, Miami Transplant Institute/University of Miami/Jackson Memorial Hospital, Miami, FL 33136, United States
| | - Jose M Figueiro
- Department of Surgery, Miami Transplant Institute/University of Miami/Jackson Memorial Hospital, Miami, FL 33136, United States
| | - Tony M Ibrahim
- Department of Surgery, Miami Transplant Institute/University of Miami/Jackson Memorial Hospital, Miami, FL 33136, United States
| | - Werviston L DeFaria
- Department of Surgery, Miami Transplant Institute/University of Miami/Jackson Memorial Hospital, Miami, FL 33136, United States
| | - Ramona Nicolau-Raducu
- Department of Anesthesiology, University of Miami/Jackson Memorial Hospital, Miami, FL 33136, United States
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11
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Efune GE, Zerillo J, Zhou G, Mazzeffi MA, Demaria S, Wang C. Intravenous Fluid Management Practices in Kidney Transplant Patients: A Multicenter Observational Cohort Pilot Study. Semin Cardiothorac Vasc Anesth 2020; 24:256-264. [PMID: 31994444 DOI: 10.1177/1089253220901665] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Limited evidence exists with regard to best practices in fluid management during kidney transplantation, which may directly affect the incidence of DGF. The authors of this study embarked on a collaborative observational multicenter pilot study to evaluate fluid administration practices in different transplant centers, with a focus on the relationship between total administered crystalloid volume and its association with DGF. METHODS Twenty consecutive kidney transplant patients were included from 9 academic medical centers in the United States. One hundred eighty patients were included in the final cohort and variables were compared between patients with and without DGF. Administered crystalloid volume was the primary variable of interest; however, additional patient and surgical variables were compared between patients with and without DGF. Variation in crystalloid administration was explored between centers by comparing median administered crystalloid volumes per kilogram of body weight. Also, unadjusted and adjusted logistic regression analyses were performed to determine which variables were independently associated with DGF. RESULTS Multivariable regression modeling demonstrated that cold ischemic time and ephedrine use during surgery were independently associated with DGF. There was no independent association between administered crystalloid volume and DGF. CONCLUSION In this study of patients having kidney transplantation, we did not find an independent association between administered crystalloid volume and DGF, although there was significant variability in crystalloid administration between centers. Our data suggest that DGF was driven mainly by surgical factors such as cold ischemic time. Ephedrine was also independently associated with DGF, which should be explored in future studies.
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Affiliation(s)
- Guy E Efune
- UT Southwestern Medical Center, Dallas, TX, USA
| | - Jeron Zerillo
- Icahn School of Medicine at Mt Sinai, New York, NY, USA
| | - George Zhou
- Icahn School of Medicine at Mt Sinai, New York, NY, USA
| | | | | | - Cynthia Wang
- UT Southwestern Medical Center, Dallas, TX, USA.,VA North Texas Healthcare System, Dallas, TX, USA
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12
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Perioperative Assessment and Intraoperative Core Concepts in the Complex Kidney Patient. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0204-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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13
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Ross J. Kidney Transplantation. Anesthesiology 2017. [DOI: 10.1007/978-3-319-50141-3_34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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14
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Anesthetic considerations in organ procurement surgery: a narrative review. Can J Anaesth 2015; 62:529-39. [PMID: 25715847 DOI: 10.1007/s12630-015-0345-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 02/13/2015] [Indexed: 12/28/2022] Open
Abstract
PURPOSE While a few publications specify the anesthetic implications of either brain or cardiac death, they lack detail on how to provide anesthesia during organ donation surgery. We provide a thorough description of important anesthetic considerations during organ donation surgery in patients with either brain or cardiac death. SOURCE A thorough literature review was undertaken to locate all relevant articles that describe systemic effects of brain and cardiac death and their anesthetic implications. We searched PubMed, Pubget, and EMBASE™ for relevant articles using the following search terms: anesthesia, management, donation cardiac death, donation brain death. In addition, we reviewed the relevant protocols at our own institution. PRINCIPAL FINDINGS Highly specific intraoperative management by an anesthesiologist is required during organ procurement after brain death. To manage the heart-beating brain-dead donor, the anesthesiologist must incorporate knowledge of the effects of brain death on each organ system as well as the effects of the preoperative measures that the donor required in the intensive care unit. It is also important to know which organs are going to be procured in order to establish specific goals and implement strategies (e.g., lung-protective ventilation or intraoperative glycemic control) to optimize donor outcome. During organ procurement after cardiac death, an anesthesiologist's direct involvement is particularly important for lung donors. CONCLUSION Anesthesiologist-guided physiological optimization of the brain-dead donor may be a factor in determining the outcome of the organ recipient. Additionally, anesthesiologists have an important role in helping to ensure that the highest quality and most appropriate care are rendered to non-heart-beating donors. This is achieved through establishing protocols in their hospitals for donation after cardiac death that maximize the number of available organs with the best chance for long-term graft viability.
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