Elección de fluidos en el periodo perioperatorio del trasplante renal

Determination of inorganic ions and carbohydrates in cardioplegia and nephroplegia solutions by ion chromatography

In this study, methods for analyzing inorganic ions and carbohydrates in cardioplegia and nephroplegia solutions were developed and validated using ion chromatography with both conductivity and pulsed amperometric detection. The inorganic ions such as sodium, potassium, and calcium were separated by a cation-exchange column with 27 mM methanesulfonic acid as mobile phase at 0.5 mL/min. The anion (chloride) and carbohydrates (mannitol and glucose) were analyzed by an anion-exchange column using a mobile phase of 20 mM sodium hydroxide at 1.0 mL/min. The methods showed a high sensitivity for all analytes, with quantification limits from 0.0002 to 0.06 mg/L. Good linearities between the peak areas and concentrations were found for all analytes within the selected concentration range (R2  > 0.999). Relative standard deviation values for repeatability and interday precision were 0.1%-1.0% and 0.7%-1.6%, respectively. The accuracy was validated by determining the percentage recovery, which was between 98.0% and 101.3% for all analytes, indicating good accuracy of the methods. The robustness was verified by using an experimental design. Finally, real samples were analyzed to determine the content of the analytes. All assay values were between 96.8% and 102.5%.

A Comparison Between Saline and Balanced Solutions in Kidney Transplants: A Randomized Clinical Trial

Objective This study aimed to investigate the impact of different types of intravenous fluids - normal saline (NS), lactated Ringer's solution (LR), and PlasmaLyte (PL) - on the acid-base balance and electrolyte concentration following kidney transplant, a common procedure for patients with end-stage renal disease (ESRD). Methodology A randomized controlled trial design was employed, wherein the primary parameters analyzed were postoperative pH and serum potassium levels. Postoperative concentrations of serum bicarbonate, sodium, chloride, and creatinine, as well as graft functionality, were assessed as secondary outcomes. These measurements were performed at the start and end of surgery, as well as 24 and 72 hours postoperatively. Results A total of 53 patients were included in the study and randomized into three cohorts: NS, LR, and PL, each of which showed comparability in terms of demographic and transplantation specifics. Notably, patients in the NS group exhibited a more significant decrease in pH (NS group: 7.285 ±0.098, LR group: 7.324 ±0.075, PL group: 7.7338 ±0.059) and bicarbonate levels (17.0 ±4.2, 20.9 ±2.8, 20.0 ±4.5) post 24 hours after the operation and displayed a similar pattern immediately after the surgery. However, there were no discernible differences in potassium (p=0.460), sodium (p=0.681), and chloride (p=0.321) levels across the groups. Furthermore, the study did not observe any significant differences in postoperative graft functionality. Conclusion The use of NS as the intraoperative fluid of choice led to lower pH and bicarbonate levels following kidney transplant, as compared to LR and PL. However, these results did not correlate with improvements in graft functionality.

Tacrolimus Concentration Is Effectively Predicted Using Combined Clinical and Genetic Factors in the Perioperative Period of Kidney Transplantation and Associated with Acute Rejection

Background

Tacrolimus has unpredictable pharmacokinetic (PK) characteristics, which are partially attributed to CYP3A5 polymorphism. The potential effects of clinical factors in the postoperative period of transplantation on tacrolimus PK and those of early tacrolimus PK variability on clinical outcomes are yet to be clarified.

Methods

We examined the genetic and clinical factors affecting early tacrolimus PK variability in 256 kidney transplant recipients. The relationships among tacrolimus exposure, graft function delay (DGF), and acute rejection (AR) were further explored. Findings. The CYP3A5 genotype were strongly associated with tacrolimus concentration/dose ratio (C₀/D). Additionally, ABCB1 (rs1045642 and rs2032582) and ABCC2 (rs3740066) were found to have potential independent effects on early tacrolimus C₀/D in multivariate analysis. Red blood counts and albumin level were the most significant clinical factors associated with tacrolimus C₀/D. Wuzhi capsule also exerted an effect on tacrolimus PK. A model combined with pharmacogenetic and clinical factors explained 43.4% tacrolimus PK variability compared with 16.3% on the basis of CYP3A5 genotype only. Notably, increasing tacrolimus concentrations in the early postoperative stage were associated with AR, but not DGF.

Conclusions

Combined analysis of genotype and specific clinical factors is important for the formulation of precise tacrolimus dose regimens in the early stage after kidney transplantation.

Fluid Management During Kidney Transplantation: A Consensus Statement of the Committee on Transplant Anesthesia of the American Society of Anesthesiologists

BACKGROUND

Intraoperative fluid management may affect the outcome after kidney transplantation. However, the amount and type of fluid administered, and monitoring techniques vary greatly between institutions and there are limited prospective randomized trials and meta-analyses to guide fluid management in kidney transplant recipients.

METHODS

Members of the American Society of Anesthesiologists (ASA) committee on transplantation reviewed the current literature on the amount and type of fluids (albumin, starches, 0.9% saline, and balanced crystalloid solutions) administered and the different monitors used to assess fluid status, resulting in this consensus statement with recommendations based on the best available evidence.

RESULTS

Review of the current literature suggests that starch solutions are associated with increased risk of renal injury in randomized trials and should be avoided in kidney donors and recipients. There is no evidence supporting the routine use of albumin solutions in kidney transplants. Balanced crystalloid solutions such as Lactated Ringer are associated with less acidosis and may lead to less hyperkalemia than 0.9% saline solutions. Central venous pressure is only weakly supported as a tool to assess fluid status.

CONCLUSIONS

These recommendations may be useful to anesthesiologists making fluid management decisions during kidney transplantation and facilitate future research on this topic.