1
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Spicer AB, Cavalcanti AB, Zampieri FG. Subgroup analyses and heterogeneity of treatment effects in randomized trials: a primer for the clinician. Curr Opin Crit Care 2024; 30:427-438. [PMID: 39150040 DOI: 10.1097/mcc.0000000000001186] [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: 08/17/2024]
Abstract
PURPOSE OF REVIEW To date, most randomized clinical trials in critical care report neutral overall results. However, research as to whether heterogenous responses underlie these results and give opportunity for personalized care is gaining momentum but has yet to inform clinical practice guidance. Thus, we aim to provide an overview of methodological approaches to estimating heterogeneity of treatment effects in randomized trials and conjecture about future paths to application in patient care. RECENT FINDINGS Despite their limitations, traditional subgroup analyses are still the most reported approach. More recent methods based on subphenotyping, risk modeling and effect modeling are still uncommonly embedded in primary reports of clinical trials but have provided useful insights in secondary analyses. However, further simulation studies and subsequent guidelines are needed to ascertain the most efficient and robust manner to validate these results for eventual use in practice. SUMMARY There is an increasing interest in approaches that can identify heterogeneity in treatment effects from randomized clinical trials, extending beyond traditional subgroup analyses. While prospective validation in further studies is still needed, these approaches are promising tools for design, interpretation, and implementation of clinical trial results.
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Affiliation(s)
- Alexandra B Spicer
- Department of Medicine: Allergy, Pulmonary and Critical Care Division; UW School of Medicine and Public Health
| | | | - Fernando G Zampieri
- HCor Research Institute, Sao Paulo, Brazil
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
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2
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Most A, Nordbeck S, Farina N. Iatrogenic hyperchloremia: An overview in hospitalized patients for pharmacists. Am J Health Syst Pharm 2024; 81:e462-e470. [PMID: 38530649 DOI: 10.1093/ajhp/zxae086] [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: 03/23/2024] [Indexed: 03/28/2024] Open
Abstract
PURPOSE The purpose of this therapeutic update is to provide pharmacists with a general overview of the pathophysiology of hyperchloremia and describe strategies to help prevent development of this electrolyte abnormality in hospitalized patients. SUMMARY Hyperchloremia is an electrolyte abnormality associated with an increased incidence of acute kidney injury and metabolic acidosis. Intravenous (IV) fluids utilized for volume resuscitation, medication diluents, and total parental nutrition all may contribute to the development of hyperchloremia. Current evidence suggests that administration of balanced crystalloids for either fluid resuscitation or maintenance fluids may impact serum chloride levels and patient outcomes. In multiple randomized controlled trials, administering balanced crystalloids for fluid resuscitation in critically ill patient populations did not decrease mortality. However, further analyses of subpopulations within these trials have demonstrated that patients with sepsis may benefit from receiving balanced crystalloids for initial fluid resuscitation. Results from several small studies suggest that altering the composition of these IV fluids may help prevent development of hyperchloremia. CONCLUSION Management of hyperchloremia is preventative in nature and can be mitigated through management of resuscitation fluids, medication diluents, and total parenteral nutrition. Inpatient pharmacists should be aware of the potential risk of fluid-associated hyperchloremia and assist with optimal fluid management to prevent and manage hyperchloremia.
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Affiliation(s)
- Amoreena Most
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | - Sarah Nordbeck
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | - Nicholas Farina
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
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3
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Wang L, Dixon C, Nhan J, Kakajiwala A. A balancing act: drifting away from the reflexive use of "ab"normal saline. Pediatr Nephrol 2024; 39:2325-2335. [PMID: 38233719 DOI: 10.1007/s00467-023-06271-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/19/2024]
Abstract
Maintenance intravenous fluids are the most frequently ordered medications for hospitalized children. Since the American Association of Pediatrics published national guidelines, there has been an increased reflexive use of isotonic solutions, especially 0.9% saline, as a prophylaxis against hyponatremia. In this educational review, we discuss the potential deleterious effects of using 0.9% saline, including the development of hyperchloremia, metabolic acidosis, acute kidney injury, hyperkalemia, and a proinflammatory state. Balanced solutions with anion buffers cause relatively minimal harm when used in most children. While the literature supporting one fluid choice over the other is variable, we highlight the benefits of balanced solutions over saline and the importance of prescribing fluid therapy that is individualized for each patient.
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Affiliation(s)
- Linda Wang
- Department of Pediatrics, Division of Nephrology, Children's National Hospital, Washington, DC, USA.
| | - Celeste Dixon
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Jennifer Nhan
- Department of Pediatrics, Division of Nephrology, Children's National Hospital, Washington, DC, USA
| | - Aadil Kakajiwala
- Department of Pediatrics, Division of Nephrology, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
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4
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Carvalho Pereira L, Carvalho Pereira I, Dias Delfino Cabral T, Viana P, Mendonça Ribeiro A, Amaral S. Balanced Crystalloids Versus Normal Saline in Kidney Transplant Patients: An Updated Systematic Review, Meta-analysis, and Trial Sequential Analysis. Anesth Analg 2024; 139:58-67. [PMID: 38578867 DOI: 10.1213/ane.0000000000006932] [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: 04/07/2024]
Abstract
BACKGROUND The use of balanced crystalloids over normal saline for perioperative fluid management during kidney transplantation and its benefits on acid-base and electrolyte balance along with its influence on postoperative clinical outcomes remains a topic of controversy. Therefore, we conducted this review to assess the impact of balanced solutions compared to normal saline on outcomes for kidney transplant patients. METHODS We searched MEDLINE, EMBASE, and Cochrane databases for randomized controlled trials (RCTs) comparing balanced lower-chloride solutions to normal saline in renal transplant patients. Our main outcome of interest was delayed graft function (DGF). Additionally, we examined acid-base and electrolyte measurements, along with postoperative renal function. We computed relative risk (RR) using the Mantel-Haenszel test for binary outcomes, and mean difference (MD) for continuous data, and applied DerSimonian and Laird random-effects models to address heterogeneity. Furthermore, we performed a trial sequential analysis (TSA) for all outcomes. RESULTS Twelve RCTs comprising a total of 1668 patients were included; 832 (49.9%) were assigned to receive balanced solutions. Balanced crystalloids reduced the occurrence of DGF compared to normal saline, with RR of 0.82 (95% confidence interval [CI], 0.71-0.94), P = .005; I² = 0%. The occurrence was 25% (194 of 787) in the balanced crystalloids group and 34% (240 of 701) in the normal saline group. Moreover, our TSA supported the primary outcome result and suggests that the sample size was sufficient for our conclusion. End-of-surgery chloride (MD, -8.80 mEq·L -1 ; 95% CI, -13.98 to -3.63 mEq.L -1 ; P < .001), bicarbonate (MD, 2.12 mEq·L -1 ; 95% CI, 1.02-3.21 mEq·L -1 ; P < .001), pH (MD, 0.06; 95% CI, 0.04-0.07; P < .001), and base excess (BE) (MD, 2.41 mEq·L -1 ; 95% CI, 0.88-3.95 mEq·L -1 ; P = .002) significantly favored the balanced crystalloids groups and the end of surgery potassium (MD, -0.17 mEq·L -1 ; 95% CI, -0.36 to 0.02 mEq·L -1 ; P = .07) did not differ between groups. However, creatinine did not differ in the first (MD, -0.06 mg·dL -1 ; 95% CI, -0.38 to 0.26 mg·dL -1 ; P = .71) and seventh (MD, -0.06 mg·dL -1 ; 95% CI, -0.18 to 0.06 mg·dL -1 ; P = .30) postoperative days nor urine output in the first (MD, -1.12 L; 95% CI, -3.67 to 1.43 L; P = .39) and seventh (MD, -0.01 L; 95% CI, -0.45 to 0.42 L; P = .95) postoperative days. CONCLUSIONS Balanced lower-chloride solutions significantly reduce the occurrence of DGF and provide an improved acid-base and electrolyte control in patients undergoing kidney transplantation.
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Affiliation(s)
- Lucas Carvalho Pereira
- From the Department of Medicine, Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
| | - Igor Carvalho Pereira
- From the Department of Medicine, Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
| | | | - Patricia Viana
- Department of Medicine, University of Extreme South of Santa Catarina, Criciuma, Santa Catarina, Brazil
| | - Arthur Mendonça Ribeiro
- Departament of Anesthesiology, Universidade Federal of Rio Grande do Sul, Rio Grande do Sul, Brazil
| | - Sara Amaral
- Department of Anesthesiology, Universidade Nova de Lisboa, Lisboa, Portugal
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5
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Imran M, Khlidj Y, Naeem A, Tanveer A, Fakih N, Kamran A, Abuelazm M. Perioperative balanced crystalloids versus normal saline during kidney transplantation: a systematic review and meta-analysis of randomized controlled trials. Int Urol Nephrol 2024; 56:2195-2213. [PMID: 38349600 DOI: 10.1007/s11255-023-03936-z] [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: 11/29/2023] [Accepted: 12/27/2023] [Indexed: 06/21/2024]
Abstract
BACKGROUND In kidney transplant (KT) surgery, the perioperative administration of intravenous (IV) fluids plays a crucial role, with potential effects on graft function. Our meta-analysis aims to assess the post-KT outcomes of perioperative balanced crystalloids (BC) versus normal saline (NS). METHODS We conducted a comprehensive search across five databases to identify relevant randomized controlled trials (RCTs). The search results were imported into Covidence for article eligibility screening, and all relevant outcome data were synthesized using risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CIs) in meta-analysis models within RevMan 5.4. PROSPERO ID CRD42023448457. RESULTS Pooled data from 15 RCTs with 2,008 participants showed that the rate of delayed graft function (DGF) was significantly lower with BC (RR: 0.78, 95% CI [0.68, 0.91], P = 0.0009). Also, BC was associated with significantly higher post-op blood pH (MD: 0.05, 95% CI [0.03, 0.07], P < 0.01), lower serum chloride (MD: - 7.31, 95% CI [- 10.58, - 3.77], P < 0.01), and sodium (MD: - 1.94, 95% CI [- 3.32, - 0.55], P = 0.006) as compared to NS. However, serum potassium, serum creatinine, and urine output at POD 1 to 7 did not differ between the two groups. CONCLUSION BC significantly reduced the incidence of DGF, resulting in more stable post-operative acid-base parameters, and lower chloride levels compared to NS. Hence, substituting NS with BC offers a strategy to protect grafts from acidotic and hyperchloremic insults, optimizing KT outcomes.
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Affiliation(s)
- Muhammad Imran
- University College of Medicine and Dentistry, The University of Lahore, Lahore, Pakistan
| | - Yehya Khlidj
- Faculty of Medicine, University of Algiers, Algiers 16000, Algeria
| | | | - Aiman Tanveer
- University College of Medicine and Dentistry, The University of Lahore, Lahore, Pakistan
| | - Nour Fakih
- Department of Natural Sciences, Lebanese American University, Beirut, Lebanon.
| | - Ateeba Kamran
- Karachi Medical and Dental College, Karachi, Pakistan
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6
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Yamani F, Cianfarini C, Batlle D. Delayed Graft Function and the Renin-angiotensin System. Transplantation 2024; 108:1308-1318. [PMID: 38361243 PMCID: PMC11136607 DOI: 10.1097/tp.0000000000004934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Delayed graft function (DGF) is a form of acute kidney injury (AKI) and a common complication following kidney transplantation. It adversely influences patient outcomes increases the financial burden of transplantation, and currently, no specific treatments are available. In developing this form of AKI, activation of the renin-angiotensin system (RAS) has been proposed to play an important role. In this review, we discuss the role of RAS activation and its contribution to the pathophysiology of DGF following the different stages of the transplantation process, from procurement and ischemia to transplantation into the recipient and including data from experimental animal models. Deceased kidney donors, whether during cardiac or brain death, may experience activation of the RAS. That may be continued or further potentiated during procurement and organ preservation. Additional evidence suggests that during implantation of the kidney graft and reperfusion in the recipient, the RAS is activated and may likely remain activated, extrapolating from other forms of AKI where RAS overactivity is well documented. Of particular interest in this setting is the status of angiotensin-converting enzyme 2, a key RAS enzyme essential for the metabolism of angiotensin II and abundantly present in the apical border of the proximal tubules, which is the site of predominant injury in AKI and DGF. Interventions aimed at safely downregulating the RAS using suitable shorter forms of angiotensin-converting enzyme 2 could be a way to offer protection against DGF.
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Affiliation(s)
- Fatmah Yamani
- Division of Nephrology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Cosimo Cianfarini
- Division of Nephrology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Daniel Batlle
- Division of Nephrology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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7
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Arabi YM, Belley-Cote E, Carsetti A, De Backer D, Donadello K, Juffermans NP, Hammond N, Laake JH, Liu D, Maitland K, Messina A, Møller MH, Poole D, Mac Sweeney R, Vincent JL, Zampieri FG, AlShamsi F. European Society of Intensive Care Medicine clinical practice guideline on fluid therapy in adult critically ill patients. Part 1: the choice of resuscitation fluids. Intensive Care Med 2024; 50:813-831. [PMID: 38771364 DOI: 10.1007/s00134-024-07369-9] [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: 11/13/2023] [Accepted: 02/20/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE This is the first of three parts of the clinical practice guideline from the European Society of Intensive Care Medicine (ESICM) on resuscitation fluids in adult critically ill patients. This part addresses fluid choice and the other two will separately address fluid amount and fluid removal. METHODS This guideline was formulated by an international panel of clinical experts and methodologists. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was applied to evaluate the certainty of evidence and to move from evidence to decision. RESULTS For volume expansion, the guideline provides conditional recommendations for using crystalloids rather than albumin in critically ill patients in general (moderate certainty of evidence), in patients with sepsis (moderate certainty of evidence), in patients with acute respiratory failure (very low certainty of evidence) and in patients in the perioperative period and patients at risk for bleeding (very low certainty of evidence). There is a conditional recommendation for using isotonic saline rather than albumin in patients with traumatic brain injury (very low certainty of evidence). There is a conditional recommendation for using albumin rather than crystalloids in patients with cirrhosis (very low certainty of evidence). The guideline provides conditional recommendations for using balanced crystalloids rather than isotonic saline in critically ill patients in general (low certainty of evidence), in patients with sepsis (low certainty of evidence) and in patients with kidney injury (very low certainty of evidence). There is a conditional recommendation for using isotonic saline rather than balanced crystalloids in patients with traumatic brain injury (very low certainty of evidence). There is a conditional recommendation for using isotonic crystalloids rather than small-volume hypertonic crystalloids in critically ill patients in general (very low certainty of evidence). CONCLUSIONS This guideline provides eleven recommendations to inform clinicians on resuscitation fluid choice in critically ill patients.
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Affiliation(s)
- Yaseen M Arabi
- Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, King Abdullah International Medical Research Center, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Emilie Belley-Cote
- Divisions of Cardiology and Critical Care, McMaster University, Riyadh, Saudi Arabia
| | - Andrea Carsetti
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Katia Donadello
- Department of Surgery, Dentistry, Gynaecology and Paediatrics, University of Verona, Verona, Italy
- Anaesthesia and Intensive Care B Unit, AOUI-University Hospital Integrated Trust of Verona, Verona, Italy
| | - Nicole P Juffermans
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Naomi Hammond
- Critical Care Program, The George Institute for Global Health and UNSW, Sydney, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
| | - Jon Henrik Laake
- Department of Anaesthesiology and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Dawei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Kathryn Maitland
- Institute of Global Health and Innovation, Division of Medicine, Imperial College, London, UK
| | - Antonio Messina
- IRCCS Humanitas Research Hospital, Department of Anesthesia and Intensive Care Medicine, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, København, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniele Poole
- Operative Unit of Anesthesia and Intensive Care, S. Martino Hospital, Belluno, Italy
| | - Rob Mac Sweeney
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Fernando G Zampieri
- Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
| | - Fayez AlShamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
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8
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Krause M, Tzeng E, Kertai MD, Abrams BA. A Year of Changes: The End of the Pandemic Marks the Beginning of New Priorities. Semin Cardiothorac Vasc Anesth 2024; 28:61-65. [PMID: 38730539 DOI: 10.1177/10892532241255427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Affiliation(s)
- Martin Krause
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Eric Tzeng
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Benjamin A Abrams
- Department of Anesthesiology, University of Colorado, Aurora, CO, USA
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9
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Collins MG, Chadban SJ. Dealing With Delayed Graft Function. Transplantation 2024; 108:1273-1274. [PMID: 38809428 DOI: 10.1097/tp.0000000000004764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Affiliation(s)
- Michael G Collins
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Steven J Chadban
- Department of Renal Medicine, Kidney Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Kidney Node, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
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10
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Katayama A, Maffucci P, Domanski A, Wang R, Sakai T. Abdominal Organ Transplantation: Noteworthy Literature in 2023. Semin Cardiothorac Vasc Anesth 2024; 28:113-126. [PMID: 38598365 DOI: 10.1177/10892532241247122] [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] [Indexed: 04/12/2024]
Abstract
This review highlights noteworthy literature published in 2023 and pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. We feature 9 studies from 593 peer-reviewed papers on pancreatic transplantation, 3 from 194 on intestinal transplantation, and 28 from over 4513 on kidney transplantation. The liver transplantation section includes a special focus on 20 studies from 5666 clinical trial publications. We explore a broad range of topics, including donor management, perioperative recipient management, and innovative pharmacologic and mechanical interventions tested for the improvement of patient and graft outcomes and survival.
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Affiliation(s)
- Akira Katayama
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan
| | - Patrick Maffucci
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alex Domanski
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ryan Wang
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA, USA
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11
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Klonarakis MP, Dhillon M, Sevinc E, Elliott MJ, James MT, Lam NN, McLaughlin KJ, Ronksley PE, Ruzycki SM, Harrison TG. The effect of goal-directed fluid therapy on delayed graft function in kidney transplant recipients: A systematic review and meta-analysis. Transplant Rev (Orlando) 2024; 38:100834. [PMID: 38335896 DOI: 10.1016/j.trre.2024.100834] [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: 12/19/2023] [Revised: 01/22/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024]
Abstract
Delayed graft function (DGF) is a common post-operative complication with potential long-term sequelae for many kidney transplant recipients, and hemodynamic factors and fluid status play a role. Fixed perioperative fluid infusions are the standard of care, but more recent evidence in the non-transplant population has suggested benefit with goal-directed fluid strategies based on hemodynamic targets. We searched MEDLINE, EMBASE, Cochrane Controlled Trials Registry and Google Scholar through December 2022 for randomized controlled trials comparing risk of DGF between goal-directed and conventional fluid therapy in adults receiving a living or deceased donor kidney transplant. Effect estimates were reported with odds ratios (OR) and pooled using random effects meta-analysis. We identified 4 studies (205 participants) that met the inclusion criteria. The use of goal-directed fluid therapy had no significant effect on DGF (OR 1.37 95% CI, 0.34-5.6; p = 0.52; I2 = 0.11). Subgroup analysis examining effects among deceased and living kidney donation did not reveal significant differences in the effects of fluid strategy on DGF between subgroups. Overall, the strength of the evidence for goal-directed versus conventional fluid therapy to reduce DGF was of low certainty. Our findings highlight the need for larger trials to determine the effect of goal-directed fluid therapy on this patient-centered outcome.
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Affiliation(s)
| | - Mannat Dhillon
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Emir Sevinc
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Meghan J Elliott
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew T James
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ngan N Lam
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kevin J McLaughlin
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shannon M Ruzycki
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tyrone G Harrison
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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12
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Collins MG, Fahim MA, Hawley CM, Johnson DW, Chadban SJ. Questions about the BEST-Fluids trial - Authors' reply. Lancet 2024; 403:911-912. [PMID: 38460988 DOI: 10.1016/s0140-6736(23)02680-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/24/2023] [Indexed: 03/11/2024]
Affiliation(s)
- Michael G Collins
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia; Australasian Kidney Trials Network, Centre for Health Services Research, The University of Queensland, Brisbane, QLD, Australia.
| | - Magid A Fahim
- Australasian Kidney Trials Network, Centre for Health Services Research, The University of Queensland, Brisbane, QLD, Australia; Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Carmel M Hawley
- Australasian Kidney Trials Network, Centre for Health Services Research, The University of Queensland, Brisbane, QLD, Australia; Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, QLD, Australia; Translational Research Institute, Brisbane, QLD, Australia
| | - David W Johnson
- Australasian Kidney Trials Network, Centre for Health Services Research, The University of Queensland, Brisbane, QLD, Australia; Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, QLD, Australia; Translational Research Institute, Brisbane, QLD, Australia
| | - Steven J Chadban
- Department of Renal Medicine, Kidney Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Kidney Node, Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
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13
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Verney C, Dreyfuss D, Gaudry S. Questions about the BEST-Fluids trial. Lancet 2024; 403:911. [PMID: 38460987 DOI: 10.1016/s0140-6736(23)02684-3] [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: 07/11/2023] [Accepted: 11/24/2023] [Indexed: 03/11/2024]
Affiliation(s)
- Charles Verney
- CHRU Tours, Médecine Intensive Réanimation, Tours, France
| | - Didier Dreyfuss
- French National Institute of Health and Medical Research (INSERM), UMR_S1155, Remodeling and Repair of Renal Tissue, Hôpital Tenon, Paris, France; Université de Paris, AP-HP, Hôpital Louis, Mourier, DMU ESPRIT, Médecine Intensive-Réanimation, Colombes, France
| | - Stéphane Gaudry
- French National Institute of Health and Medical Research (INSERM), UMR_S1155, Remodeling and Repair of Renal Tissue, Hôpital Tenon, Paris, France; AP-HP, Hôpital Avicenne, Service de Réanimation Médico-Chirurgicale, Bobigny 93000, France.
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14
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Gueret G, Laffon M. Questions about the BEST-Fluids trial. Lancet 2024; 403:910. [PMID: 38460986 DOI: 10.1016/s0140-6736(23)02683-1] [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: 07/24/2023] [Accepted: 11/24/2023] [Indexed: 03/11/2024]
Affiliation(s)
- Gildas Gueret
- Service d'Anesthésie, Centre Hospitalier de Cornouaille, Quimper 29000, France.
| | - Marc Laffon
- Département d'Anesthésie Réanimation, CHU de Tours, Tours, France
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15
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Canet E, Zafrani L. Questions about the BEST-Fluids trial. Lancet 2024; 403:908-909. [PMID: 38460984 DOI: 10.1016/s0140-6736(23)02681-8] [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: 06/22/2023] [Accepted: 11/24/2023] [Indexed: 03/11/2024]
Affiliation(s)
- Emmanuel Canet
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, France; Université de Nantes, Nantes 44093, France.
| | - Lara Zafrani
- Department of Medical Intensive Care Unit, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris Cité, Paris, France; INSERM U944, Saint-Louis Research Institute, University of Paris Cité, Paris, France
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16
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Masset C, Chapelet A, Dumont R, Ville S, Garandeau C, Houzet A, Kervella D, Dantal J, Blancho G, Cantarovich D, Giral M, Figueres L. Questions about the BEST-Fluids trial. Lancet 2024; 403:909-910. [PMID: 38460985 DOI: 10.1016/s0140-6736(23)02682-x] [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: 07/17/2023] [Accepted: 11/24/2023] [Indexed: 03/11/2024]
Affiliation(s)
- Christophe Masset
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU de Nantes, Nantes, France; Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, Nantes 44093, France.
| | - Agnès Chapelet
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU de Nantes, Nantes, France
| | - Romain Dumont
- Department of Anesthesia and Critical Care, CHU de Nantes, Nantes, France
| | - Simon Ville
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU de Nantes, Nantes, France; Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, Nantes 44093, France
| | - Claire Garandeau
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU de Nantes, Nantes, France
| | - Aurélie Houzet
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU de Nantes, Nantes, France; Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, Nantes 44093, France
| | - Delphine Kervella
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU de Nantes, Nantes, France; Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, Nantes 44093, France
| | - Jacques Dantal
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU de Nantes, Nantes, France; Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, Nantes 44093, France
| | - Gilles Blancho
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU de Nantes, Nantes, France; Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, Nantes 44093, France
| | - Diego Cantarovich
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU de Nantes, Nantes, France
| | - Magali Giral
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU de Nantes, Nantes, France; Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, Nantes 44093, France
| | - Lucile Figueres
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU de Nantes, Nantes, France; Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, Nantes 44093, France
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17
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Voet M, Lemson J, Cornelissen M, Malagon I. Anesthesia and intensive care unit care in pediatric kidney transplantation: An international survey. Paediatr Anaesth 2024; 34:235-242. [PMID: 38062930 DOI: 10.1111/pan.14810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 11/10/2023] [Accepted: 11/15/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Despite the high perioperative risk profile, international guidelines for anesthesia and intensive care unit (ICU) care in pediatric kidney transplantation do not exist. Optimizing hemodynamics can be challenging in these patients, while scientific data to guide decisions in hemodynamic monitoring, hemodynamic targets, and perioperative fluid management are lacking. The limited annual number of pediatric kidney transplantations, even in reference centers, necessitates the urge for international collaboration to share knowledge and develop research and guidelines. The aim of this study was to collect data on current perioperative anesthesia and ICU care practices in pediatric kidney transplantation. METHODS An international survey with an anonymized link was sent from a validated electronic data capture system (Castor). Inclusion criteria were: medical doctor in anesthesia, (ICU), or pediatric nephrology working in a pediatric kidney transplantation specialized center; and signed informed consent. Data were analyzed using descriptive statistics. RESULTS Thirty-three records were analyzed. Responders were anesthesiologists (58%), pediatric nephrologists (30%), and pediatric intensivists (12%), representing 13 countries worldwide. About half of the centers (48%) performed more than 10 pediatric kidney transplantations a year. Perioperative hemodynamic support was guided by intra-arterial blood pressure (88%), central venous pressure (CVP; 88%), and cardiac output (CO; 39%). The most variation was seen in the hemodynamic targets CVP and CO, fluid administration, and inotrope/vasopressor use. The protocolized use of furosemide (46%) and mannitol (61%) also varied between centers. Postoperative care for the youngest recipients occurred in the pediatric intensive care unit at all centers. CONCLUSION The results of this survey reveal a large variation in anesthesia and ICU care in pediatric kidney transplantation centers worldwide, particularly in CVP and CO targets, hemodynamic therapy, and the use of furosemide and mannitol. These data identify areas for further research and can be a starting point for international research collaboration and guideline development.
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Affiliation(s)
- Marieke Voet
- Department of Pediatric Anesthesia, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joris Lemson
- Department of Pediatric Intensive Care, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marlies Cornelissen
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ignacio Malagon
- Department of Pediatric Anesthesia, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
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18
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Corr M, Orr A, Courtney AE. The Minimisation of Cardiovascular Disease Screening for Kidney Transplant Candidates. J Clin Med 2024; 13:953. [PMID: 38398266 PMCID: PMC10889488 DOI: 10.3390/jcm13040953] [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: 01/03/2024] [Revised: 01/29/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Background: There is increasing evidence that cardiac screening prior to kidney transplantation does not improve its outcomes. However, risk aversion to perioperative events means that, in practice, testing remains common, limiting the availability of 'real-world' data to support any change. Our objective was to assess perioperative and 1-year post-transplant cardiovascular events in a kidney transplant candidate cohort who received minimal cardiovascular screening. Methods: The retrospective cohort study included all adult kidney-only transplant recipients in a single UK region between January 2015 and December 2021. Kidney transplant recipients asymptomatic of cardiac disease, even those with established risk factors, did not receive cardiac stress testing. The perioperative and 1-year post-transplant cardiovascular event incidences were examined. Logistic regression was used to identify variables of statistical significance that predicted cardiovascular or cerebrovascular events. Results: A total of 895 recipients fulfilled the inclusion criteria. Prior to transplantation, 209 (23%) recipients had an established cardiac diagnosis, and 193 (22%) individuals had a diagnosis of diabetes. A total of 18 (2%) patients had a perioperative event, and there was a 5.7% incidence of cardiovascular events 1 year post-transplantation. The cardiovascular mortality rate was 0.0% perioperatively, 0.2% at 3 months post-transplant, and 0.2% at 1 year post-transplant. Conclusions: This study demonstrates comparable rates of cardiovascular events despite reduced screening in asymptomatic recipients. It included higher risk individuals who may, on the basis of screening results, have been excluded from transplantation in other programmes. It provides further evidence that extensive cardiac screening prior to kidney transplantation is unlikely to be offset by reduced rates of cardiovascular events.
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Affiliation(s)
- Michael Corr
- Centre for Public Health, Institute of Clinical Sciences B, Royal Victoria Hospital, Queen’s University Belfast, Belfast BT12 6BA, UK
| | - Amber Orr
- Barnsley Hospital NHS Foundation Trust, Barnsley S75 2EP, UK
| | - Aisling E. Courtney
- Regional Nephrology & Transplant Unit, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, UK
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19
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Chapman J, Silva HT, Bromberg J. Lessons From a Rare Randomized Controlled Trial of Immunosuppressant Management After Kidney Transplantation. Transplantation 2024; 108:323-324. [PMID: 37749787 DOI: 10.1097/tp.0000000000004819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Affiliation(s)
| | - Helio Tedesco Silva
- Nephrology Division, Hospital do Rim, Fundação Oswaldo Ramos, Escola Paulista de Medicina, Universiade Federal de São Paulo, Brazil
| | - Jonathan Bromberg
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
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20
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Venkataraman K, McTaggart SJ, Collins MG. Choosing fluids to reduce the risks of acute electrolyte disturbances in children after a kidney transplant. Kidney Int 2024; 105:247-250. [PMID: 38245215 DOI: 10.1016/j.kint.2023.11.015] [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: 10/27/2023] [Accepted: 11/10/2023] [Indexed: 01/22/2024]
Abstract
Intravenous (i.v.) fluid therapy is critically important in pediatric kidney transplantation. Because of the high volumes given perioperatively, transplant recipients can develop significant electrolyte abnormalities depending on the types of fluids used. Current practices in pediatric transplantation aim to balance risks of hyponatremia from traditionally used hypotonic fluids, such as 0.45% sodium chloride, against hyperchloremia and acidosis associated with isotonic 0.9% sodium chloride. Using the balanced solution Plasma-Lyte 148 as an alternative might mitigate these risks.
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Affiliation(s)
- Karthik Venkataraman
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Steven J McTaggart
- Child and Adolescent Renal Service, Queensland Children's Hospital, Brisbane, Queensland, Australia; Children's Health Queensland Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Michael G Collins
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.
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21
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Abstract
Perioperative oliguria is an alarm signal. The initial assessment includes closer patient monitoring, evaluation of volemic status, risk-benefit of fluid challenge or furosemide stress test, and investigation of possible perioperative complications.
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Affiliation(s)
- Roberta T. Tallarico
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California San Francisco
| | - Ian E. McCoy
- Department of Medicine, Division of Nephrology, University of California San Francisco
| | - Francois Dépret
- Department of Anesthesiology and Critical Care Medicine, St-Louis Hospital, Assistance-Publique Hopitaux de Paris, France
| | - Matthieu Legrand
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California San Francisco
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22
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Hayes WN, Laing E, Brown R, Silsby L, Smith L, Thomas H, Kaloyirou F, Sharma R, Griffiths J, Hume-Smith H, Marks SD, Kessaris N, Christian M, Dudley J, Shenoy M, Malina M, Muorah M, Ware N, Yadav P, Reynolds B, Bryant W, Spiridou A, Wray J, Peters MJ. A pragmatic, open-label, randomized controlled trial of Plasma-Lyte-148 versus standard intravenous fluids in children receiving kidney transplants (PLUTO). Kidney Int 2024; 105:364-375. [PMID: 37914088 PMCID: PMC10804931 DOI: 10.1016/j.kint.2023.09.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/07/2023] [Accepted: 09/24/2023] [Indexed: 11/03/2023]
Abstract
Acute electrolyte and acid-base imbalance is experienced by many children following kidney transplant. This is partly because doctors give very large volumes of artificial fluids to keep the new kidney working. When severe, fluid imbalance can lead to seizures, cerebral edema and death. In this pragmatic, open-label, randomized controlled trial, we randomly assigned (1:1) pediatric kidney transplant recipients to Plasma-Lyte-148 or standard of care perioperative intravenous fluids (predominantly 0.45% sodium chloride and 0.9% sodium chloride solutions). We then compared clinically significant electrolyte and acid-base abnormalities in the first 72 hours post-transplant. The primary outcome, acute hyponatremia, was experienced by 53% of 68 participants in the Plasma-Lyte-148 group and 58% of 69 participants in the standard fluids group (odds ratio 0·77 (0·34 - 1·75)). Five of 16 secondary outcomes differed with Plasma-Lyte-148: hypernatremia was significantly more frequent (odds ratio 3·5 (1·1 - 10·8)), significantly fewer changes to fluid prescriptions were made (rate ratio 0·52 (0·40-0·67)), and significantly fewer participants experienced hyperchloremia (odds ratio 0·17 (0·07 - 0·40)), acidosis (odds ratio 0·09 (0·04 - 0·22)) and hypomagnesemia (odds ratio 0·21 (0·08 - 0·50)). No other secondary outcomes differed between groups. Serious adverse events were reported in 9% of participants randomized to Plasma-Lyte-148 and 7% of participants randomized to standard fluids. Thus, perioperative Plasma-Lyte-148 did not change the proportion of children who experienced acute hyponatremia compared to standard fluids. However fewer fluid prescription changes were made with Plasma-Lyte-148, while hyperchloremia and acidosis were less common.
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Affiliation(s)
- Wesley N Hayes
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; University College London Great Ormond Street Institute of Child Health, London, UK.
| | - Emma Laing
- National Health Service Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Rosemary Brown
- National Health Service Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Laura Silsby
- National Health Service Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Laura Smith
- National Health Service Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Helen Thomas
- National Health Service Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Fotini Kaloyirou
- National Health Service Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Rupa Sharma
- National Health Service Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - James Griffiths
- National Health Service Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Helen Hume-Smith
- Department of Anesthetics, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Stephen D Marks
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; University College London Great Ormond Street Institute of Child Health, London, UK
| | - Nicos Kessaris
- Department of Transplant Surgery, Guys and St Thomas NHS Foundation Trust, London, UK
| | - Martin Christian
- Department of Pediatric Nephrology, Nottingham Children's Hospital, Nottingham, UK
| | - Jan Dudley
- Department of Pediatric Nephrology, Bristol Children's Hospital, Bristol, UK
| | - Mohan Shenoy
- Department of Pediatric Nephrology, Manchester Children's Hospital, Manchester, UK
| | - Michal Malina
- Department of Pediatric Nephrology, Great North Children's Hospital, Newcastle, UK
| | - Mordi Muorah
- Department of Pediatric Nephrology, Birmingham Children's Hospital, Birmingham, UK
| | - Nicholas Ware
- Department of Pediatric Nephrology, Evelina Childrens Hospital, London, UK
| | - Pallavi Yadav
- Department of Pediatric Nephrology, Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
| | - Ben Reynolds
- Department of Pediatric Nephrology, Glasgow Hospital for Sick Children, Glasgow, UK
| | - William Bryant
- Department of Data Research Innovation and Virtual Environments, Great Ormond Street Hospital for Children, London, UK
| | - Anastassia Spiridou
- Department of Data Research Innovation and Virtual Environments, Great Ormond Street Hospital for Children, London, UK
| | - Jo Wray
- Department of Psychology, Great Ormond Street Hospital for Children, London, UK
| | - Mark J Peters
- University College London Great Ormond Street Institute of Child Health, London, UK; Pediatric Intensive Care Unit, Great Ormond Street Hospital for Children, London, UK
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23
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Chadban S, Gill JS. How hard are the hard outcomes reported in national transplant registries? Am J Transplant 2024; 24:158-159. [PMID: 37918483 DOI: 10.1016/j.ajt.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 10/26/2023] [Accepted: 10/26/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Steven Chadban
- Department of Renal Medicine, Kidney Node, CPC, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - John S Gill
- Division of Nephrology, St. Paul's Hospital, University of British Columbia, Vancouver, Canada.
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24
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Mistry AM, Naidugari J, Craven J, Williams L, Beall J, Khatri P, Broderick JP, Rice TW, Kamel H, Mack W. Usage of mineralocorticoids and isotonic crystalloids in subarachnoid hemorrhage patients in the United States. J Stroke Cerebrovasc Dis 2024; 33:107449. [PMID: 37995500 PMCID: PMC10841607 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/23/2023] [Accepted: 10/26/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND The usage rates of mineralocorticoids (fludrocortisone) to treat hyponatremia and isotonic crystalloids (saline and balanced crystalloids) to maintain intravascular volume in patients with aneurysmal subarachnoid hemorrhage (aSAH) patients across the United States are unknown. METHODS We surveyed National Institute of Neurologic Disorders and Stroke (NINDS) StrokeNet sites in 2023, which are mostly large, tertiary, academic centers, and analyzed subarachnoid hemorrhage encounters from 2010 to 2020 in the Premier Healthcare Database that is representative of all types of hospitals and captures about 20 % of all acute inpatient care in the United States. RESULTS Although mineralocorticoids are used by 70 % of the NINDS StrokeNet sites, it is used in less than 20 % of the aSAH encounters in the Premier Database. Although saline is ubiquitously used, balanced crystalloids are increasingly used for fluid therapy in aSAH patients. Its use in the NINDS StrokeNet sites and the Premier Healthcare Database is 41 and 45 %, respectively. CONCLUSIONS The use of mineralocorticoids remains low, and balanced crystalloids are increasingly used as fluid therapy in aSAH patients. The effectiveness of mineralocorticoids and balanced crystalloids in improving outcomes for aSAH patients must be rigorously tested in randomized clinical trials.
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Affiliation(s)
- Akshitkumar M Mistry
- Department of Neurosurgery, University of Louisville, 220 Abraham Flexner Way, 15th Floor, Louisville, KY 40202, USA.
| | - Janki Naidugari
- School of Medicine, University of Louisville, Louisville, KY, USA
| | - Jocelyn Craven
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Logan Williams
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Jonathan Beall
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Pooja Khatri
- Departments of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH, USA
| | - Joseph P Broderick
- Departments of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH, USA
| | - Todd W Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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25
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Lobo DN. The 2023 Sir David Cuthbertson Lecture. A fluid journey: Experiments that influenced clinical practice. Clin Nutr 2023; 42:2270-2281. [PMID: 37820519 DOI: 10.1016/j.clnu.2023.09.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 10/13/2023]
Abstract
This review summarises some of my work on fluid and electrolyte balance over the past 25 years and shows how the studies have influenced clinical practice. Missing pieces in the jigsaw are filled in by summarising the work of others. The main theme is the biochemical, physiological and clinical problems caused by inappropriate use of saline solutions including the hyperchloraemic acidosis caused by 0.9% saline. The importance of accurate and near-zero fluid balance in clinical practice is also emphasised. Perioperative fluid and electrolyte therapy has important effects on clinical outcome in a U-shaped dose response fashion, in which excess or deficit progressively increases complications and worsens outcome. Salt and water overload, with weight gain in excess of 2.5 kg worsens surgical outcome, impairs gastrointestinal function and increases the risk of anastomotic dehiscence. Hyperchloraemic acidosis caused by overenthusiastic infusion of 0.9% saline leads to adverse outcomes and dysfunction of many organ systems, especially the kidney. Salt and water deficit causes similar adverse effects as fluid overload at the cellular level and also leads to worse outcomes. Serum albumin is shown to be affected mainly by dilution and inflammation and is not a good nutritional marker. These findings have been incorporated in the British consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP) and National Institute for Health and Care Excellence (NICE) guidelines on intravenous fluid therapy in adults in hospital and are helping change clinical practice and improve outcomes.
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Affiliation(s)
- Dileep N Lobo
- Nottingham Digestive Diseases Centre, Division of Translational Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; David Greenfield Metabolic Physiology Unit, MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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26
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Mistry AM, Naidugari J, Craven J, Williams L, Beall J, Khatri P, Broderick JP, Rice TW, Kamel H, Mack W. Usage of Mineralocorticoids and Isotonic Crystalloids in Subarachnoid Hemorrhage Patients in the United States. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.28.23296245. [PMID: 37808838 PMCID: PMC10557832 DOI: 10.1101/2023.09.28.23296245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Background The usage rates of mineralocorticoids (fludrocortisone) to treat hyponatremia and isotonic crystalloids (saline and balanced crystalloids) to maintain intravascular volume in patients with aneurysmal subarachnoid hemorrhage (aSAH) patients across the United States are unknown. Methods We surveyed National Institute of Neurologic Disorders and Stroke (NINDS) StrokeNet sites, which are mostly large, tertiary, academic centers, and analyzed subarachnoid hemorrhage encounters in the Premier Healthcare Database that is representative of all types of hospitals and captures about 20% of all acute inpatient care in the United States. Results Although mineralocorticoids are used by 70% of the NINDS StrokeNet sites in aSAH patients, it is used in less than 25% of the aSAH encounters in the Premier Database. Although saline is ubiquitously used, balanced crystalloids are increasingly used for fluid therapy in aSAH patients. Its use in the NINDS StrokeNet sites and the Premier Healthcare Database is 41% and 45%, respectively. Conclusions The use of mineralocorticoids remains low, and balanced crystalloids are increasingly used as fluid therapy in aSAH patients. The effectiveness of mineralocorticoids and balanced crystalloids in improving outcomes for aSAH patients must be rigorously tested in randomized clinical trials.
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Affiliation(s)
| | - Janki Naidugari
- School of Medicine, University of Louisville, Louisville, KY, USA
| | - Jocelyn Craven
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Logan Williams
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Jonathan Beall
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Pooja Khatri
- Departments of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH, USA
| | - Joseph P. Broderick
- Departments of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH, USA
| | - Todd W. Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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27
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Masone MC. Choice of fluid affects DGF in transplant recipients. Nat Rev Urol 2023; 20:456. [PMID: 37430168 DOI: 10.1038/s41585-023-00797-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
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Sharif A. Choosing fluids to reduce the risk of delayed graft function after deceased donor kidney transplantation. Lancet 2023; 402:80-81. [PMID: 37343575 DOI: 10.1016/s0140-6736(23)00770-5] [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: 03/30/2023] [Accepted: 04/04/2023] [Indexed: 06/23/2023]
Affiliation(s)
- Adnan Sharif
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham B15 2GW, UK; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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