Perioperative Clinical Trials in AKI

Nonsteroidal anti-inflammatory drugs in the perioperative period: current controversies and concerns

Nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase (COX)-2-specific inhibitors provide significant analgesic and opioid-sparing benefits. However, these analgesics are commonly avoided owing to concerns of potential adverse effects. The evidence for NSAID-related adverse effects is conflicting and of poor quality, and these analgesics are safer than what has been implied. Thus, it is imperative that NSAIDs or COX-2-specific inhibitors are administered routinely unless there are well-founded contraindications.

Retrospective evaluation of plasma transfusions in dogs undergoing general anaesthesia: 85 cases (2017-2021)

OBJECTIVE

To describe the use of plasma transfusion in anaesthetized dogs, specifically the triggers for use, the population administered plasma, reported adverse events and human errors associated with transfusion.

STUDY DESIGN

Retrospective observational study.

ANIMALS

A total of 85 client-owned dogs.

METHODS

A search of electronic transfusion and anaesthetic records at a university teaching hospital was performed to identify dogs administered plasma during the study period (January 2017 to June 2021). Data collected included signalment, surgical procedure, intraoperative triggers for transfusion, the type of plasma, rate of transfusion and the presence of transfusion reactions, human errors or deviation from transfusion guidelines.

RESULTS

During this period, 85 dogs were administered plasma. Sepsis was diagnosed in 49/85 (58%) dogs, with 42/85 (49%) animals undergoing surgery for septic peritonitis. Perianaesthetic hypotension contributed to the decision to administer plasma in 67/85 (79%) dogs. In 33/85 (39%) dogs, hypotension was the only reason for transfusion, while 31/85 (36%) had other influencing factors, most commonly hypoproteinaemia. Fresh frozen plasma was administered in 95% of cases. Only 31% of transfusions were started at a slower 'test dose' rate and 79% of dogs administered boluses of plasma. No definite, probable or possible transfusion reactions were identified using current veterinary guidelines.

CONCLUSIONS AND CLINICAL RELEVANCE

Plasma transfusions were commonly administered to dogs presenting with sepsis for haemodynamic optimization. Clinicians often chose to bolus plasma instead of initiating transfusions at the recommended initial slow starting rate. No transfusion reactions were identified; however, some reactions may have been masked by the effects of general anaesthesia and/or have been difficult to recognize in this critically ill canine population.

Implications of Renal Disease in Patients Undergoing Structural Interventions

Percutaneous structural interventions have a major impact on the morbidity, mortality, and quality of life of patients by providing a lower-risk alternative to cardiac surgery. However, renal disease has a significant impact on outcomes of these interventions. This review explores the incidence, outcomes, pathophysiology, and preventative measures of acute kidney injury and chronic kidney disease on transcatheter aortic valve replacement, transcatheter mitral valve repair, and percutaneous balloon mitral valvuloplasty. Given the expanding indications for percutaneous structural interventions, further research is needed to identify ideal patients with chronic kidney disease or end-stage renal disease who would benefit from intervention.

Protective mechanisms of Leontopodium leontopodioides extracts on lipopolysaccharide-induced acute kidney injury viathe NF-κB/NLRP3 pathway

Sepsis-induced uncontrolled systemic inflammatory response syndrome (SIRS) is a critical cause of multiple organ failure. Acute kidney injury (AKI) is one of the most serious complications associated with an extremely high mortality rate in SIRS, and it lacked simple, safe, and effective treatment strategies. Leontopodium leontopodioides (Willd.) Beauv (LLB) is commonly used in traditional Chinese medicine for the treatment of acute and chronic nephritis. However, it remains unclear whether lipopolysaccharide (LPS) affects LPS-induced AKI. To identify the molecular mechanisms of LLB in LPS-induced HK-2 cells and mice, LLB was prepared by extraction with 70% methanol, while a lipopolysaccharide (LPS)-induced HK-2 cell model and an AKI model were established in this study. Renal histopathology staining was performed to observe the morphology changes. The cell supernatant and kidney tissues were collected for determining the levels of inflammatory factors and protein expression by ELISA, immunofluorescence, and Western blot. The results indicated that LLB significantly reduced the expression of IL-6 and TNF-α in LPS-induced HK-2 cells, as well as the secretion of IL-6, TNF-α, and IL-1β in the supernatant. The same results were observed in LPS-induced AKI serum. Further studies revealed that LLB remarkably improved oxidative stress and apoptosis based on the content of MDA, SOD, and CAT in serum and TUNEL staining results. Notably, LLB significantly reduced the mortality due to LPS infection. Renal histopathology staining results supported these results. Furthermore, immunofluorescence and Western blot results confirmed that LLB significantly reduced the expression of the protein related to the NF-κB signaling pathway and NLRP3, ASC, and Caspase-1 which were significantly increased through LPS stimulation. These findings clearly demonstrated the potential use of LLB in the treatment of AKI and the crucial role of the NF-κB/NLRP3 pathway in the process through which LLB attenuates AKI induced by LPS.

Intraoperative venous congestion and acute kidney injury in cardiac surgery: an observational cohort study

BACKGROUND

Increased intravascular volume has been associated with protection from acute kidney injury (AKI), but in patients with congestive heart failure, venous congestion is associated with increased AKI. We tested the hypothesis that intraoperative venous congestion is associated with AKI after cardiac surgery.

METHODS

In patients enrolled in the Statin AKI Cardiac Surgery trial, venous congestion was quantified as the area under the curve (AUC) of central venous pressure (CVP) >12, 16, or 20 mm Hg during surgery (mm Hg min). AKI was defined using Kidney Disease Improving Global Outcomes (KDIGO) criteria and urine concentrations of tissue inhibitor of metalloproteinase-2 and insulin-like growth factor binding protein 7 ([TIMP-2]⋅[IGFBP7]), a marker of renal stress. We measured associations between venous congestion, AKI and [TIMP-2]⋅[IGFBP7], adjusted for potential confounders. Values are reported as median (25th-75th percentile).

RESULTS

Based on KDIGO criteria, 104 of 425 (24.5%) patients developed AKI. The venous congestion AUCs were 273 mm Hg min (81-567) for CVP >12 mm Hg, 66 mm Hg min (12-221) for CVP >16 mm Hg, and 11 mm Hg min (1-54) for CVP >20 mm Hg. A 60 mm Hg min increase above the median venous congestion AUC above each threshold was independently associated with increased AKI (odds ratio=1.06; 95% confidence interval [CI], 1.02-1.10; P=0.008; odds ratio=1.12; 95% CI, 1.02-1.23; P=0.013; and odds ratio=1.30; 95% CI, 1.06-1.59; P=0.012 for CVP>12, >16, and >20 mm Hg, respectively). Venous congestion before cardiopulmonary bypass was also associated with increased [TIMP-2]⋅[IGFBP7] measured during cardiopulmonary bypass and after surgery, but neither venous congestion after cardiopulmonary bypass nor venous congestion throughout surgery was associated with postoperative [TIMP-2]⋅[IGFBP7].

CONCLUSION

Intraoperative venous congestion was independently associated with increased AKI after cardiac surgery.