Dopamine “Renal Dose” Versus Fenoldopam Mesylate to Prevent Ischemia-Reperfusion Injury in Renal Transplantation

Effect of glycopyrrolate on the postoperative urine output of patients following kidney transplantation: a retrospective observational study

OBJECTIVES

To compare the urine output and estimated glomerular filtration rate (eGFR) of patients postoperatively administered sugammadex or glycopyrrolate 7 days following kidney transplantation (KT).

METHODS

We retrospectively enrolled 134 consecutive patients who underwent KT under general anesthesia. Their urine output and eGFR were recorded every 24 hours between postoperative day (POD) 1 and 7. We used regression analysis to evaluate the relationship between the reversal agent administered and the outcomes of the participants.

RESULTS

The urine output and eGFR of the participants did not differ between the two groups. Multivariate analysis showed that body mass index (BMI) (odds ratio (OR) 1.21; 95% confidence interval (CI) 1.05-1.40), diabetes mellitus (OR 3.14; 95% CI 1.07-9.16), neurovascular disease (OR 7.00; 95% CI 1.61-30.42), and the duration of surgery (OR 1.01; 95% CI 1.00-1.01) were associated with lower urine output on POD 7. In addition, only BMI (OR 1.25; 95% CI 1.09-1.42) was associated with low eGFR on POD 7.

CONCLUSIONS

The urine output and eGFR of patients administered sugammadex or glycopyrrolate following KT did not differ 7 days later. Moreover, glycopyrrolate does not affect urine output or eGFR on POD 7, according to multivariate regression analysis.

The impact of hepatitis C virus direct acting agents in liver transplant using very old donor grafts: a real-world single-center analysis

The correct timing of use of direct acting agents (DAAs) among transplanted patients remains unknown. The aim of this paperwork is to evaluate the impact of DAAs treatment in pre- or peri-operative period in liver transplantation when grafts ≥ 70 years are used. This is a retrospective analysis comparing adult liver transplant performed for HCV-related cirrhosis and/or hepatocarcinoma using a graft ≥ 70 in the period 2015-2018 (Group DAA-HCV-OLD, study group) to three different groups: (a) anti-HCV-Ab-negative patients receiving graft ≥ 70 (no-HCV-OLD), (b) anti-HCV-Ab-negative patients receiving a graft aged 18-69 years (no-HCV-YOUNG), and (c) anti-HCV-Ab-positive patients receiving a donor graft ≥ 70 in the period 2007-2011 (no-DAA-HCV-OLD). Totally, 528 liver transplants were considered: 164 in DAA-HCV-OLD, 143 in no-HCV-OLD, 120 in no-HCV-YOUNG and 101 in no-DAA-HCV-OLD Group. Graft survival rates at 1 and 3 years were 88% and 81% in DAA-HCV-OLD Group, 82% and 68% in no-DAA-HCV-OLD (p = 0.007), 89% and 84% in no-HCV-OLD (p = 0.76), and 94% and 92% in no-HCV-YOUNG (p = 0.02). No differences were observed among groups in the incidence of primary non-function, primary dysfunction, vascular or biliary complications. DAAs were able to zero HCV-related graft loss, with a 3-year graft survival > 80%. The outcomes of older graft recipients became equal irrespectively of their HCV serological status.

Anesthetic Management and 30-Day Outcomes After Renal Autotransplantation

Background: Renal autotransplantation is a complex procedure performed for various indications such as treatment of renal vascular and urologic lesions and loin pain hematuria syndrome (LPHS). Because of the rarity of the procedure, few reports have been published, and little is known about anesthetic management and postoperative outcomes of patients with LPHS. The goal of this study was to review and describe all cases of renal autotransplantation performed at Cleveland Clinic during a specified period, focusing on anesthetic management and postoperative 30-day outcomes.

Methods: We performed a retrospective review of the records of all patients who underwent renal autotransplantation from 2005 to 2014 at the Cleveland Clinic and collected demographic, anesthetic, surgical, and postoperative data.

Results: A total of 64 patients underwent renal autotransplantation from 2005 to 2014. The most frequent indications were nephrolithiasis and LPHS. General endotracheal anesthesia with epidural for pain control was used in 47% of cases. Median duration of anesthesia was 528 minutes. Most patients were sent to a regular nursing floor postoperatively, but 28% of patients required intensive care unit admission. Two patients developed graft ischemia, and 1 patient developed graft failure requiring nephrectomy. No anesthetic-related complications and no mortality were associated with this procedure during the study.

Conclusion: Renal autotransplantation is a safe option for patients with LPHS. Additional studies are needed to assess the effect of intraoperative anesthetic management on outcomes in this patient population.

Challenges in early clinical drug development for ischemia-reperfusion injury in kidney transplantation

INTRODUCTION

In an effort to expand the donor pool, kidneys from donation after cardiac death (DCD) donors are increasingly utilised in renal transplantation. These kidneys suffer greater ischemia-reperfusion injury (IRI) and have a higher incidence of delayed graft function. In the last 25 years, relatively few pharmacological therapies to reduce IRI have been tested in randomised controlled trials in renal transplantation and currently no pharmacological agents are routinely utilised for this purpose.

AREAS COVERED

The authors look at why promising treatments in pre-clinical studies have not translated to significant clinical benefit in human trials. This may reflect a translational disconnect between the pre-clinical models used and clinical problems that are encountered in the transplant population. They also discuss the issues in conducting clinical trials and its implication on drug development.

EXPERT OPINION

Translating pharmacological strategies for reducing IRI is highly challenging at every stage of development from pre-clinical studies to clinical trials. Scientific knowledge of the complexity of IRI is rapidly evolving and new treatments are expected to emerge. There are ethical barriers that prevent donor treatments, particularly in the DCD setting. However, new clinical techniques such as normothermic regional and ex-vivo perfusion represent exciting opportunities to utilise pharmacological agents earlier in the process of transplantation.

Summary of FDA workshop on ischemia reperfusion injury in kidney transplantation

The Food and Drug Administration (FDA) held an open public workshop in September 2011 to discuss the current state of science related to the effects of ischemia reperfusion injury (IRI) on outcomes in kidney transplantation. Topics included the development of IRI and delayed graft function (DGF), histology and biomarkers, donor factors, recipient factors, organ quality and organ preservation by means of cold storage solutions or machine perfusion. Various mechanisms of injury and maladaptive response to IRI were discussed as potential targets of intervention. Animal models evaluating specific pathophysiological pathways were presented, as were the limitations of extrapolating animal results to humans. Clinical trials of various drug products administered in the peri-transplant period were summarized; a few demonstrated early improvements in DGF, but none demonstrated an improvement in late graft function. Clinical trial design for IRI and DGF were also discussed.

Novel pharmacological approaches to the treatment of renal ischemia-reperfusion injury: a comprehensive review

Renal ischemia-reperfusion (I-R) contributes to the development of ischemic acute renal failure (ARF). Multi-factorial processes are involved in the development and progression of renal I-R injury with the generation of reactive oxygen species, nitric oxide and peroxynitrite, and the decline of antioxidant protection playing major roles, leading to dysfunction, injury, and death of the cells of the kidney. Renal inflammation, involving cytokine/adhesion molecule cascades with recruitment, activation, and diapedesis of circulating leukocytes is also implicated. Clinically, renal I-R occurs in a variety of medical and surgical settings and is responsible for the development of acute tubular necrosis (a characteristic feature of ischemic ARF), e.g., in renal transplantation where I-R of the kidney directly influences graft and patient survival. The cellular mechanisms involved in the development of renal I-R injury have been targeted by several pharmacological interventions. However, although showing promise in experimental models of renal I-R injury and ischemic ARF, they have not proved successful in the clinical setting (e.g., atrial natriuretic peptide, low-dose dopamine). This review highlights recent pharmacological developments, which have shown particular promise against experimental renal I-R injury and ischemic ARF, including novel antioxidants and antioxidant enzyme mimetics, nitric oxide and nitric oxide synthase inhibitors, erythropoietin, peroxisome-proliferator-activated receptor agonists, inhibitors of poly(ADP-ribose) polymerase, carbon monoxide-releasing molecules, statins, and adenosine. Novel approaches such as recent research involving combination therapies and the potential of non-pharmacological strategies are also considered.