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Xing J, Loh SKN. Perioperative acute kidney injury: Current knowledge and the role of anaesthesiologists. PROCEEDINGS OF SINGAPORE HEALTHCARE 2023. [DOI: 10.1177/20101058231163406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
Background Among the different types of perioperative organ injury, acute kidney injury (AKI) occurs frequently and is consistently associated with increased rates of mortality and mortality. Despite development of many clinical trials to assess perioperative interventions, reliable means to prevent or reverse AKI are still lacking. Objectives This narrative review discusses recent literature on modifiable risk factors, current approaches to prevention and potential directions for future research. Methods A Pubmed search with the relevant keywords was done for articles published in the last 10 years. Results New insights into preoperative identification and optimisation, intraoperative strategies, including the choice of anaesthetic, haemodynamic and fluid management, have been made, with the aim of preventing perioperative AKI. Conclusion A patient-centric multidisciplinary approach is essential to protect kidney function of patients going for surgery. Much can be done by anaesthesiologists perioperatively, to reduce the risk of development of AKI, especially in susceptible patients. There is a need for further multicentred trials to enhance the currently generic perioperative recommendations.
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Affiliation(s)
- Jieyin Xing
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Samuel Kent Neng Loh
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
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2
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Taylor B, Scott TE, Shaw J, Chockalingam N. Renal safety of critical care sedation with sevoflurane: a systematic review and meta-analysis. J Anesth 2023; 37:794-805. [PMID: 37498387 DOI: 10.1007/s00540-023-03227-y] [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: 01/24/2023] [Accepted: 07/11/2023] [Indexed: 07/28/2023]
Abstract
Volatile anesthetic agents are increasingly widely used for critical care sedation. There are concerns that sevoflurane presents a risk of renal injury when used in this role. RCTs comparing the use of critical care sevoflurane sedation with any control in humans were systematically identified using MEDLINE, Cochrane CENTRAL, web of Science, and CINAHL (until May 2022), if they presented comparative data on renal function or serum inorganic fluoride levels. Pooled SMDs (95% CI) were calculated where possible after assessment of quality with GRADE and risk of bias with ROB-2. Eight studies analyzing 793 patients were included. The median duration of use of critical care sevoflurane sedation was 4.8 [IQR 3.5-9.2] hours; however, most trials also included a period of prior intraoperative use. No significant difference was found in serum creatinine at 1 day (SMD 0.05, 95% CI - 0.12 to 0.21), 48 h (SMD = - 0.04; 95% Cl - 0.25 to 0.17), 72 h (SMD = - 0.15; 95% CI - 0.45 to 0.15), and at discharge (SMD = - 0.1; 95% CI - 0.3 to 0.13) between the sevoflurane group and the control groups. Creatinine clearance was measured in two studies at 48 h with no significant difference (SMD = - 0.13; 95% Cl - 0.38 to 0.11). Levels of serum inorganic fluoride were significantly elevated in patients where sevoflurane was used. Sevoflurane was not associated with renal failure when used for critical care sedation of fewer than 72-h duration, despite the elevation of serum fluoride. Longer-term studies are currently inadequate, including in patients with compromised renal function, to further evaluate the role of sevoflurane in this setting.Trial registration PROSPERO (CRD42022333099).
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Affiliation(s)
- Ben Taylor
- Department of Anaesthesia and Critical Care, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK.
- Academic Department of Military Anaesthesia and Critical Care, Birmingham, UK.
- Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University, Stoke-on-Trent, UK.
| | - Timothy E Scott
- Department of Anaesthesia and Critical Care, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
- Academic Department of Military Anaesthesia and Critical Care, Birmingham, UK
- Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University, Stoke-on-Trent, UK
| | - James Shaw
- Academic Department of Military Anaesthesia and Critical Care, Birmingham, UK
- Emergency Medical Retrieval and Transport Service Cymru, Llanelli, UK
| | - Nachiappan Chockalingam
- Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University, Stoke-on-Trent, UK
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3
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Zeng B, Liu Y, Xu J, Niu L, Wu Y, Zhang D, Tang X, Zhu Z, Chen Y, Hu L, Yu S, Yu P, Zhang J, Wang W. Future Directions in Optimizing Anesthesia to Reduce Perioperative Acute Kidney Injury. Am J Nephrol 2023; 54:434-450. [PMID: 37742618 DOI: 10.1159/000533534] [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: 05/05/2023] [Accepted: 08/01/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Perioperative acute kidney injury (AKI) is common in surgical patients and is associated with high morbidity and mortality. There are currently few options for AKI prevention and treatment. Due to its complex pathophysiology, there is no efficient medication therapy to stop the onset of the injury or repair the damage already done. Certain anesthetics, however, have been demonstrated to affect the risk of perioperative AKI in some studies. The impact of anesthetics on renal function is particularly important as it is closely related to the prognosis of patients. Some anesthetics can induce anti-inflammatory, anti-necrotic, and anti-apoptotic effects. Propofol, sevoflurane, and dexmedetomidine are a few examples of anesthetics that have protective association with AKI in the perioperative period. SUMMARY In this study, we reviewed the clinical characteristics, risk factors, and pathogenesis of AKI. Subsequently, the protective effects of various anesthetic agents against perioperative AKI and the latest research are introduced. KEY MESSAGE This work demonstrates that a thorough understanding of the reciprocal effects of anesthetic drugs and AKI is crucial for safe perioperative care and prognosis of patients. However, more complete mechanisms and pathophysiological processes still need to be further studied.
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Affiliation(s)
- Bin Zeng
- Department of Gastroenterology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Yinuo Liu
- Department of Metabolism and Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China,
- The Second Clinical Medical College of Nanchang University, Nanchang, China,
| | - Jiawei Xu
- Department of Metabolism and Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Liyan Niu
- Department of Metabolism and Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Second Clinical Medical College of Nanchang University, Nanchang, China
- Huan Kui College, Nanchang University, Nanchang, China
| | - Yuting Wu
- Huan Kui College, Nanchang University, Nanchang, China
- Department of Metabolism and Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Deju Zhang
- Huan Kui College, Nanchang University, Nanchang, China
- Food and Nutritional Sciences, School of Biological Sciences, The University of Hong Kong, Hong Kong, Hong Kong, China
| | - Xiaoyi Tang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zicheng Zhu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yixuan Chen
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Leilei Hu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shuchun Yu
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Peng Yu
- Department of Metabolism and Endocrinology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jing Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wenting Wang
- Department of Anesthesiology, The Second Affiliated Hospital of Hainan Medical University, Haikou, China
- Department of Cardiopulmonary Bypass, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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4
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Kroneisl M, Spraakman NA, Koomen JV, Hijazi Z, Hoogstra-Berends FH, Leuvenink HGD, Struys MMRF, Henning RH, Nieuwenhuijs-Moeke GJ. Peri-Operative Kinetics of Plasma Mitochondrial DNA Levels during Living Donor Kidney Transplantation. Int J Mol Sci 2023; 24:13579. [PMID: 37686384 PMCID: PMC10487554 DOI: 10.3390/ijms241713579] [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: 08/02/2023] [Revised: 08/27/2023] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
During ischemia and reperfusion injury (IRI), mitochondria may release mitochondrial DNA (mtDNA). mtDNA can serve as a propagator of further injury but in specific settings has anti-inflammatory capacities as well. Therefore, the aim of this study was to study the perioperative dynamics of plasma mtDNA during living donor kidney transplantation (LDKT) and its potential as a marker of graft outcome. Fifty-six donor-recipient couples from the Volatile Anesthetic Protection of Renal Transplants-1 (VAPOR-1) trial were included. Systemic venous, systemic arterial, and renal venous samples were taken at multiple timepoints during and after LDKT. Levels of mtDNA genes changed over time and between vascular compartments. Several donor, recipient, and transplantation-related variables significantly explained the course of mtDNA genes over time. mtDNA genes predicted 1-month and 24-month estimated glomerular filtration rate (eGFR) and acute rejection episodes in the two-year follow-up period. To conclude, mtDNA is released in plasma during the process of LDKT, either from the kidney or from the whole body in response to transplantation. While circulating mtDNA levels positively and negatively predict post-transplantation outcomes, the exact mechanisms and difference between mtDNA genes are not yet understood and need further exploration.
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Affiliation(s)
- Marie Kroneisl
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Nora A. Spraakman
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Jeroen V. Koomen
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Zeinab Hijazi
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Femke H. Hoogstra-Berends
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Henri G. D. Leuvenink
- Department of Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Michel M. R. F. Struys
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- Department of Basic and Applied Medical Sciences, Ghent University, 9000 Ghent, Belgium
| | - Rob H. Henning
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Gertrude J. Nieuwenhuijs-Moeke
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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Schnider TW, Nieuwenhuijs-Moeke GJ, Beck-Schimmer B, Hemmerling TM. Pro-Con Debate: Should All General Anesthesia Be Done Using Target-Controlled Propofol Infusion Guided by Objective Monitoring of Depth of Anesthesia? Anesth Analg 2023; 137:565-575. [PMID: 37590801 DOI: 10.1213/ane.0000000000006293] [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: 08/19/2023]
Abstract
In this Pro-Con commentary article, we discuss whether all general anesthesia should be done using target-controlled propofol anesthesia guided by monitoring of depth of anesthesia. This is an ongoing debate since more than 25 years, representing a scientific, cultural as well as geographical divide in the anesthesia community. The Pro side argues that total intravenous anesthesia causes less postoperative nausea and higher patient satisfaction than anesthesia using volatile anesthetics. Target-controlled infusion (TCI) of anesthetic agents allows for better titration of intravenous anesthesia using pharmacokinetic models. Processed EEG monitors, such as bispectral index monitoring, allows for better assessing the effect of TCI anesthesia than solely assessment of clinical parameters, such as ECG or blood pressure. The combination of TCI propofol and objective depth of anesthesia monitoring allows creating a pharmacokinetic-pharmacodynamic profile for each patient. Finally, anesthesia using volatile anesthetics poses health risks for healthcare professionals and contributes to greenhouse effect. The Con side argues that for procedures accompanied with ischemia and reperfusion injury of an organ or tissue and for patients suffering from a severe inflammation' the use of volatile anesthetics might well have its advantages above propofol. In times of sudden shortage of drugs, volatile anesthetics can overcome the restriction in the operating theater or even on the intensive care unit, which is another advantage. Volatile anesthetics can be used for induction of anesthesia when IV access is impossible, end-tidal measurements of volatile anesthetic concentration allows confirmation that patients receive anesthetics. Taking environmental considerations into account, both propofol and volatile anesthetics bear certain harm to the environment, be it as waste product or as greenhouse gases. The authors therefore suggest to carefully considering advantages and disadvantages for each patient in its according environment. A well-balanced choice based on the available literature is recommended. The authors recommend careful consideration of advantages and disadvantages of each technique when tailoring an anesthetic to meet patient needs. Where appropriate, anesthesia providers are encouraged to account for unique features of anesthetic drug behavior, patient-reported and observed postoperative outcomes, and economic and environmental considerations when choosing any of the 2 described techniques.
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Affiliation(s)
- Thomas W Schnider
- From the Department for Anesthesiology, Intensive, Rescue and Pain medicine, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Gertrude J Nieuwenhuijs-Moeke
- Department of Anesthesiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
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Klucniks A, Kerner V. Anaesthesia for intestinal transplantation. BJA Educ 2023; 23:312-319. [PMID: 37465232 PMCID: PMC10350554 DOI: 10.1016/j.bjae.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 07/20/2023] Open
Affiliation(s)
| | - V. Kerner
- Anuradhapura Teaching Hospital, Anuradhapura, Sri Lanka
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7
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Franzén S, Frithiof R, Hultström M. Postoperative acute kidney injury after volatile or intravenous anesthesia: a meta-analysis. Am J Physiol Renal Physiol 2023; 324:F329-F334. [PMID: 36794753 DOI: 10.1152/ajprenal.00316.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
Postoperative acute kidney injury (AKI) is a common complication after surgery. The pathophysiology of postoperative AKI is complex. One potentially important factor is anesthetic modality. We, therefore, conducted a meta-analysis of the available literature regarding anesthetic modality and incidence of postoperative AKI. Records were retrieved until January 17, 2023, with the search terms ("propofol" OR "intravenous") AND ("sevoflurane" OR "desflurane" OR "isoflurane" OR "volatile" OR "inhalational") AND ("acute kidney injury" OR "AKI"). A meta-analysis for common effects and random effects was performed after exclusion assessment. Eight records were included in the meta-analysis with a total of 15,140 patients (n = 7,542 propofol and n = 7,598 volatile). The common and random effects model revealed that propofol was associated with a lower incidence of postoperative AKI compared with volatile anesthesia [odds ratio: 0.63 (95% confidence interval: 0.56-0.72) and 0.49 (95% confidence interval: 0.33-0.73), respectively]. In conclusion, the meta-analysis revealed that propofol anesthesia is associated with a lower incidence of postoperative AKI compared with volatile anesthesia. This may motivate choosing propofol-based anesthesia in patients with increased risk of postoperative AKI due to preexisting renal impairment or surgery with a high risk of renal ischemia.NEW & NOTEWORTHY This study analyzed the available literature on anesthetic modality and incidence of postoperative AKI. The meta-analysis revealed that propofol is associated with lower incidence of AKI compared with volatile anesthesia. It might therefore be considerable to use propofol anesthesia in surgeries with increased susceptibility for developing renal injuries such as cardiopulmonary bypass and major abdominal surgery.
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Affiliation(s)
- Stephanie Franzén
- Department of Surgical Sciences, Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Robert Frithiof
- Department of Surgical Sciences, Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Michael Hultström
- Department of Surgical Sciences, Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
- Department of Medical Cell Biology, Integrative Physiology, Uppsala University, Uppsala, Sweden
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8
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Urinary Biomarkers in a Living Donor Kidney Transplantation Cohort—Predictive Value on Graft Function. Int J Mol Sci 2023; 24:ijms24065649. [PMID: 36982720 PMCID: PMC10054503 DOI: 10.3390/ijms24065649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023] Open
Abstract
Early non-invasive detection and prediction of graft function after kidney transplantation is essential since interventions might prevent further deterioration. The aim of this study was to analyze the dynamics and predictive value of four urinary biomarkers: kidney injury molecule-1 (KIM-1), heart-type fatty acid binding protein (H-FABP), N-acetyl-β-D-glucosaminidase (NAG), and neutrophil gelatinase-associated lipocalin (NGAL) in a living donor kidney transplantation (LDKT) cohort. Biomarkers were measured up to 9 days after the transplantation of 57 recipients participating in the VAPOR-1 trial. Dynamics of KIM-1, NAG, NGAL, and H-FABP significantly changed over the course of 9 days after transplantation. KIM-1 at day 1 and NAG at day 2 after transplantation were significant predictors for the estimated glomerular filtration rate (eGFR) at various timepoints after transplantation with a positive estimate (p < 0.05), whereas NGAL and NAG at day 1 after transplantation were negative significant predictors (p < 0.05). Multivariable analysis models for eGFR outcome improved after the addition of these biomarker levels. Several donor, recipient and transplantation factors significantly affected the baseline of urinary biomarkers. In conclusion, urinary biomarkers are of added value for the prediction of graft outcome, but influencing factors such as the timing of measurement and transplantation factors need to be considered.
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9
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Protective Effect of Oxygen and Isoflurane in Rodent Model of Intestinal Ischemia-Reperfusion Injury. Int J Mol Sci 2023; 24:ijms24032587. [PMID: 36768910 PMCID: PMC9917127 DOI: 10.3390/ijms24032587] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 01/22/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023] Open
Abstract
Animal research in intestinal ischemia-reperfusion injury (IRI) is mainly performed in rodent models. Previously, intraperitoneal (I.P.) injections with ketamine-xylazine mixtures were used. Nowadays, volatile anesthetics (isoflurane) are more common. However, the impact of the anesthetic method on intestinal IRI has not been investigated. We aim to analyze the different anesthetic methods and their influence on the extent of intestinal IRI in a rat model. Male Sprague-Dawley rats were used to investigate the effect of I.P. anesthesia on 60 min of intestinal ischemia and 60 min of reperfusion in comparison to hyperoxygenation (100% O2) and volatile isoflurane anesthesia. In comparison to I.P. anesthesia with room air (21% O2), supplying 100% O2 improved 7-day survival by cardiovascular stabilization, reducing lactic acidosis and preventing vascular leakage. However, this had no effect on the intestinal epithelial damage, permeability, and inflammatory response observed after intestinal IRI. In contrast to I.P. + 100% O2, isoflurane anesthesia reduced intestinal IRI by preventing ongoing low-flow reperfusion hypotension, limiting intestinal epithelial damage and permeability, and by having anti-inflammatory effects. When translating the aforementioned results of this study to clinical situations, such as intestinal ischemia or transplantation, the potential protective effects of hyperoxygenation and volatile anesthetics require further research.
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Experimental and Clinical Aspects of Sevoflurane Preconditioning and Postconditioning to Alleviate Hepatic Ischemia-Reperfusion Injury: A Scoping Review. Int J Mol Sci 2023; 24:ijms24032340. [PMID: 36768670 PMCID: PMC9916998 DOI: 10.3390/ijms24032340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/21/2022] [Accepted: 01/22/2023] [Indexed: 01/27/2023] Open
Abstract
Ischemia-reperfusion injury (IRI) is an inflammatory process inherent in organ transplantation procedures. It is associated with tissue damage and, depending on its intensity, can impact early graft function. In liver transplantation (LT), strategies to alleviate IRI are essential in order to increase the use of extended criteria donor (ECD) grafts, which are more susceptible to IRI, as well as to improve postoperative graft and patient outcomes. Sevoflurane, a commonly used volatile anesthetic, has been shown to reduce IRI. This scoping review aims to give a comprehensive overview of the existing experimental and clinical data regarding the potential benefits of sevoflurane for hepatic IRI (HIRI) and to identify any gaps in knowledge to guide further research. We searched Medline and Embase for relevant articles. A total of 380 articles were identified, 45 of which were included in this review. In most experimental studies, the use of sevoflurane was associated with a significant decrease in biomarkers of acute liver damage and oxidative stress. Administration of sevoflurane before hepatic ischemia (preconditioning) or after reperfusion (postconditioning) appears to be protective. However, in the clinical setting, results are conflicting. While some studies showed a reduction of postoperative markers of liver injury, the benefit of sevoflurane on clinical outcomes and graft survival remains unclear. Further prospective clinical trials remain necessary to assess the clinical relevance of the use of sevoflurane as a protective factor against HIRI.
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11
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Sharma S, Saner FH, Bezinover D. A brief history of liver transplantation and transplant anesthesia. BMC Anesthesiol 2022; 22:363. [PMID: 36435747 PMCID: PMC9701388 DOI: 10.1186/s12871-022-01904-1] [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: 09/06/2022] [Accepted: 11/13/2022] [Indexed: 11/28/2022] Open
Abstract
In this review, we describe the major milestones in the development of organ transplantation with a specific focus on hepatic transplantation. For many years, the barriers preventing successful organ transplantation in humans seemed insurmountable. Although advances in surgical technique provided the technical ability to perform organ transplantation, limited understanding of immunology prevented successful organ transplantation. The breakthrough to success was the result of several significant discoveries between 1950 and 1980 involving improved surgical techniques, the development of effective preservative solutions, and the suppression of cellular immunity to prevent graft rejection. After that, technical innovations and laboratory and clinical research developed rapidly. However, these advances alone could not have led to improved transplant outcomes without parallel advances in anesthesia and critical care. With increasing organ demand, it proved necessary to expand the donor pool, which has been achieved with the use of living donors, split grafts, extended criteria organs, and organs obtained through donation after cardiac death. Given this increased access to organs and organ resources, the number of transplantations performed every year has increased dramatically. New regulatory organizations and transplant societies provide critical oversight to ensure equitable organ distribution and a high standard of care and also perform outcome analyses. Establishing dedicated transplant anesthesia teams results in improved organ transplantation outcomes and provides a foundation for developing new standards for other subspecialties in anesthesiology, critical care, and medicine overall. Through a century of discovery, the success we enjoy at the present time is the result of the work of well-organized multidisciplinary teams following standardized protocols and thereby saving thousands of lives worldwide each year. With continuing innovation, the future is bright.
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Affiliation(s)
- Sonal Sharma
- Department of Anesthesiology and Perioperative Medicine, Pennsylvania State University, Milton S. Hershey Medical Center, 500 University Dr, Hershey, PA, 17033, USA
| | - Fuat H Saner
- Department of General, Visceral, and Transplant Surgery, Medical Center University Essen, Hufeland 55, 45147, Essen, Germany
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.
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12
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Spraakman NA, Coester AM, Bourgonje AR, Nieuwenhuijs VB, Sanders JSF, Leuvenink HGD, van Goor H, Nieuwenhuijs-Moeke GJ. Systemic and Renal Dynamics of Free Sulfhydryl Groups during Living Donor Kidney Transplantation. Int J Mol Sci 2022; 23:ijms23179789. [PMID: 36077183 PMCID: PMC9455962 DOI: 10.3390/ijms23179789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/12/2022] [Accepted: 08/17/2022] [Indexed: 11/16/2022] Open
Abstract
During ischemia−reperfusion injury (IRI), reactive oxygen species are produced that can be scavenged by free sulfhydryl groups (R-SH, free thiols). In this study, we hypothesized that R-SH levels decrease as a consequence of renal IRI and that R-SH levels reflect post-transplant graft function. Systemic venous, arterial, renal venous, and urinary samples were collected in donors and recipients before, during, and after transplantation. R-SH was measured colorimetrically. Systemic arterial R-SH levels in recipients increased significantly up to 30 sec after reperfusion (p < 0.001). In contrast, renal venous R-SH levels significantly decreased at 5 and 10 min compared to 30 sec after reperfusion (both p < 0.001). This resulted in a significant decrease in delta R-SH (defined as the difference between renal venous and systemic arterial R-SH levels) till 30 sec after reperfusion (p < 0.001), indicating a net decrease in R-SH levels across the transplanted kidney. Overall, these results suggest trans-renal oxidative stress as a consequence of IRI during kidney transplantation, reflected by systemic and renal changes in R-SH levels in transplant recipients.
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Affiliation(s)
- Nora A. Spraakman
- Department of Anesthesiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- Correspondence:
| | - Annemieke M. Coester
- Department of Surgery, Amphia Hospital, Molengracht 21, 4818 CK Breda, The Netherlands
| | - Arno R. Bourgonje
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | | | - Jan-Stephan F. Sanders
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Henri G. D. Leuvenink
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Harry van Goor
- Department of Pathology and Medical Biology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Gertrude J. Nieuwenhuijs-Moeke
- Department of Anesthesiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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Analysis of Volatile Anesthetic-Induced Organ Protection in Simultaneous Pancreas-Kidney Transplantation. J Clin Med 2022; 11:jcm11123385. [PMID: 35743457 PMCID: PMC9225086 DOI: 10.3390/jcm11123385] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/26/2022] [Accepted: 06/09/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Despite recent advances in surgical procedures and immunosuppressive regimes, early pancreatic graft dysfunction, mainly specified as ischemia-reperfusion injury (IRI)-Remains a common cause of pancreas graft failure with potentially worse outcomes in simultaneous pancreas-kidney transplantation (SPKT). Anesthetic conditioning is a widely described strategy to attenuate IRI and facilitate graft protection. Here, we investigate the effects of different volatile anesthetics (VAs) on early IRI-associated posttransplant clinical outcomes as well as graft function and outcome in SPKT recipients. METHODS Medical data of 105 patients undergoing SPKT between 1998-2018 were retrospectively analyzed and stratified according to the used VAs. The primary study endpoint was the association and effect of VAs on pancreas allograft failure following SPKT; secondary endpoint analyses included "IRI- associated posttransplant clinical outcome" as well as long-term graft function and outcome. Additionally, peak serum levels of C-reactive protein (CRP) and lipase during the first 72 h after SPKT were determined and used as further markers for "pancreatic IRI" and graft injury. Typical clinicopathological characteristics and postoperative outcomes such as early graft outcome and long-term function were analyzed. RESULTS Of the 105 included patients in this study three VAs were used: isoflurane (n = 58 patients; 55%), sevoflurane (n = 22 patients; 21%), and desflurane (n = 25 patients, 24%). Donor and recipient characteristics were comparable between both groups. Early graft loss within 3 months (24% versus 5% versus 8%, p = 0.04) as well as IRI-associated postoperative clinical complications (pancreatitis: 21% versus 5% versus 5%, p = 0.04; vascular thrombosis: 13% versus 0% versus 5%; p = 0.09) occurred more frequently in the Isoflurane group compared with the sevoflurane and desflurane groups. Anesthesia with sevoflurane resulted in the lowest serum peak levels of lipase and CRP during the first 3 days after transplantation, followed by desflurane and isoflurane (p = 0.039 and p = 0.001, respectively). There was no difference with regard to 10-year pancreas graft survival as well as endocrine/metabolic function among all three VA groups. Multivariate analysis revealed the choice of VAs as an independent prognostic factor for graft failure three months after SPKT (HR 0.38, 95%CI: 0.17-0.84; p = 0.029). CONCLUSIONS In our study, sevoflurane and desflurane were associated with significantly increased early graft survival as well as decreased IRI-associated post-transplant clinical outcomes when compared with the isoflurane group and should be the focus of future clinical studies evaluating the positive effects of different VA agents in patients receiving SPKT.
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Franzén S, Semenas E, Taavo M, Mårtensson J, Larsson A, Frithiof R. Renal function during sevoflurane or total intravenous propofol anaesthesia a single-centre parallel randomised controlled study. Br J Anaesth 2022; 128:838-848. [DOI: 10.1016/j.bja.2022.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 11/02/2022] Open
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Xu Y, Niu Y, Li H, Pan G. Downregulation of lncRNA TUG1 attenuates inflammation and apoptosis of renal tubular epithelial cell induced by ischemia-reperfusion by sponging miR-449b-5p via targeting HMGB1 and MMP2. Inflammation 2021; 43:1362-1374. [PMID: 32206944 DOI: 10.1007/s10753-020-01214-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
We aimed to evaluate the functions of long non-coding RNA taurine upregulated gene 1 (lncRNA TUG1) in renal ischemia-reperfusion (I/R) injury and identify the potential mechanisms. Pathological changes of renal tissues were examined using H&E staining after mimic renal I/R injury in vivo. The contents of serum renal functional parameters and inflammatory factors were measured. The expression of TUG1 and miR-449b-5p in renal tissues and HK-2 cells stimulated by I/R were detected. Then, the effects of TUG1 silencing on inflammation and apoptosis of cells were evaluated. Dual luciferase reporter assays were executed for determining the correlation between miR-449b-5p and TUG1, high mobility group box 1 (HMGB1), or matrix metalloproteinase 2 (MMP2). Subsequently, cells were co-transfected with miR-449b-5p mimic and pcDNA3.1 TUG1. The levels of inflammation, apoptosis, and the expression of HMGB1 and MMP2 were detected. The results revealed that renal tissues were obviously damaged after I/R accompanied by changes in renal functional markers and inflammatory factors. TUG1 was highly expressed whereas miR-449b-5p was lowly expressed. TUG1 silencing reduced the inflammation and apoptosis. Dual luciferase reporter assays confirmed that miR-449b-5p was a target of TUG1 as well as HMGB1 and MMP2 were direct targets of miR-449b-5p. Meanwhile, miR-449b-5p mimic presented the same results with TUG1 silencing, which were reversed after TUG1 overexpression. Moreover, MMP2 and HMGB1 expression was decreased after miR-449b-5p overexpression while that of was increased after TUG1 overexpression. These findings demonstrated that TUG1 silencing attenuates I/R-induced inflammation and apoptosis via targeting miR-449b-5p and regulating HMGB1 and MMP2 expression.
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Affiliation(s)
- Yuan Xu
- Department of organ transplantation, Affiliated Hospital of Guizhou Medical University, Guiyang City, 550004, Guizhou Province, China
| | - Yulin Niu
- Department of organ transplantation, Affiliated Hospital of Guizhou Medical University, Guiyang City, 550004, Guizhou Province, China
| | - Haiyang Li
- Department of hepatobiliary surgery, Affiliated Hospital of Guizhou Medical University, Guiyang City, 550004, Guizhou Province, China.
| | - Guanghui Pan
- Department of organ transplantation, Affiliated Hospital of Guizhou Medical University, Guiyang City, 550004, Guizhou Province, China.
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Gaya da Costa M, Kalmar AF, Struys MMRF. Inhaled Anesthetics: Environmental Role, Occupational Risk, and Clinical Use. J Clin Med 2021; 10:1306. [PMID: 33810063 PMCID: PMC8004846 DOI: 10.3390/jcm10061306] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/14/2021] [Accepted: 03/18/2021] [Indexed: 12/17/2022] Open
Abstract
Inhaled anesthetics have been in clinical use for over 150 years and are still commonly used in daily practice. The initial view of inhaled anesthetics as indispensable for general anesthesia has evolved during the years and, currently, its general use has even been questioned. Beyond the traditional risks inherent to any drug in use, inhaled anesthetics are exceptionally strong greenhouse gases (GHG) and may pose considerable occupational risks. This emphasizes the importance of evaluating and considering its use in clinical practices. Despite the overwhelming scientific evidence of worsening climate changes, control measures are very slowly implemented. Therefore, it is the responsibility of all society sectors, including the health sector to maximally decrease GHG emissions where possible. Within the field of anesthesia, the potential to reduce GHG emissions can be briefly summarized as follows: Stop or avoid the use of nitrous oxide (N2O) and desflurane, consider the use of total intravenous or local-regional anesthesia, invest in the development of new technologies to minimize volatile anesthetics consumption, scavenging systems, and destruction of waste gas. The improved and sustained awareness of the medical community regarding the climate impact of inhaled anesthetics is mandatory to bring change in the current practice.
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Affiliation(s)
- Mariana Gaya da Costa
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, 9713GZ Groningen, The Netherlands;
| | - Alain F. Kalmar
- Department of Anesthesia and Intensive Care Medicine, Maria Middelares Hospital, 9000 Ghent, Belgium;
- Department of Basic and Applied Medical Sciences, Ghent University, 9000 Ghent, Belgium
| | - Michel M. R. F. Struys
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, 9713GZ Groningen, The Netherlands;
- Department of Basic and Applied Medical Sciences, Ghent University, 9000 Ghent, Belgium
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Nieuwenhuijs-Moeke GJ, Bosch DJ, Leuvenink HG. Molecular Aspects of Volatile Anesthetic-Induced Organ Protection and Its Potential in Kidney Transplantation. Int J Mol Sci 2021; 22:ijms22052727. [PMID: 33800423 PMCID: PMC7962839 DOI: 10.3390/ijms22052727] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/25/2021] [Accepted: 03/03/2021] [Indexed: 12/16/2022] Open
Abstract
Ischemia reperfusion injury (IRI) is inevitable in kidney transplantation and negatively impacts graft and patient outcome. Reperfusion takes place in the recipient and most of the injury following ischemia and reperfusion occurs during this reperfusion phase; therefore, the intra-operative period seems an attractive window of opportunity to modulate IRI and improve short- and potentially long-term graft outcome. Commonly used volatile anesthetics such as sevoflurane and isoflurane have been shown to interfere with many of the pathophysiological processes involved in the injurious cascade of IRI. Therefore, volatile anesthetic (VA) agents might be the preferred anesthetics used during the transplantation procedure. This review highlights the molecular and cellular protective points of engagement of VA shown in in vitro studies and in vivo animal experiments, and the potential translation of these results to the clinical setting of kidney transplantation.
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Affiliation(s)
- Gertrude J. Nieuwenhuijs-Moeke
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands;
- Correspondence: ; Tel.: +31-631623075
| | - Dirk J. Bosch
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands;
| | - Henri G.D. Leuvenink
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands;
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The impact of sevoflurane anesthesia on postoperative renal function: a systematic review and meta-analysis of randomized-controlled trials. Can J Anaesth 2020; 67:1595-1623. [DOI: 10.1007/s12630-020-01791-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 05/05/2020] [Accepted: 05/11/2020] [Indexed: 12/29/2022] Open
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19
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Prevention of Ischemia-Reperfusion Injury in Human Kidney Transplantation: A Meta-Analysis of Randomized Controlled Trials. Nephrourol Mon 2020. [DOI: 10.5812/numonthly.101590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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20
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Ostermann M, Cennamo A, Meersch M, Kunst G. A narrative review of the impact of surgery and anaesthesia on acute kidney injury. Anaesthesia 2020; 75 Suppl 1:e121-e133. [PMID: 31903567 DOI: 10.1111/anae.14932] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The epidemiology of peri-operative acute kidney injury varies depending on the definition, type of surgery and acute and chronic comorbidities. Haemodynamic instability, disturbance of the microcirculation, endothelial dysfunction, inflammation and tubular cell injury are the main factors contributing to the pathogenesis. There are no specific therapies. The most effective strategies to protect renal function during the peri-operative period are: the avoidance of nephrotoxic insults; optimisation of haemodynamics; prevention of hypotension; and meticulous fluid management, including avoidance of both hypovolaemia and hypervolaemia. Peri-operative acute kidney injury is associated with an increased risk of short- and long-term postoperative complications, including a longer stay in hospital, development of premature chronic kidney disease and increased mortality. Resource utilisation and healthcare costs are also higher. In future, the development of advanced clinical prediction scores, new imaging and monitoring techniques and the application of new biomarkers for acute kidney injury have the prospect of identifying acute kidney injury earlier and allowing a more personalised management approach with the aim of reducing the global burden of acute kidney injury.
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Affiliation(s)
- M Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, London, UK
| | - A Cennamo
- Department of Critical Care, Guy's and St Thomas' Hospital, London, UK
| | - M Meersch
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany
| | - G Kunst
- Department of Anaesthesia, King's College London, King's College Hospital, London, UK.,School of Cardiovascular Medicine and Sciences, King's College London, British Heart Foundation Centre of Excellence, London, UK
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21
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Perioperative considerations for kidney and pancreas-kidney transplantation. Best Pract Res Clin Anaesthesiol 2020; 34:3-14. [PMID: 32334785 DOI: 10.1016/j.bpa.2020.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 12/16/2019] [Accepted: 01/06/2020] [Indexed: 01/28/2023]
Abstract
Kidney transplantation is the treatment of choice in patients with end-stage renal disease, as it improves survival and quality of life. Living donor kidney transplant prior to pancreas transplantation, or simultaneous pancreas and kidney transplantation are discussed. Patients usually present comorbidities and extensive preoperative workups are recommended, especially cardiac assessment, though type and frequency of surveillance is not established. Nephroprotective strategies include adequate fluid status and goal-directed therapy. The conventional use of diuretics has not demonstrated a real nephroprotective effect at follow-up. Thromboprophylaxis regimes, especially for the pancreatic graft outcome, are of importance. Notably, transplantation in the obese population has increased in recent decades. Strict preoperative evaluation and pulmonary considerations must be kept in mind. Finally, robotic kidney transplant is a recent approach that presents anesthetic challenges, mainly related to steep Trendelenburg position and fluid restriction.
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22
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Irwin MG, Chung CKE, Ip KY, Wiles MD. Influence of propofol-based total intravenous anaesthesia on peri-operative outcome measures: a narrative review. Anaesthesia 2020; 75 Suppl 1:e90-e100. [PMID: 31903578 DOI: 10.1111/anae.14905] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2019] [Indexed: 12/12/2022]
Abstract
Propofol-based total intravenous anaesthesia is well known for its smooth, clear-headed recovery and anti-emetic properties, but there are also many lesser known beneficial properties that can potentially influence surgical outcome. We will discuss the anti-oxidant, anti-inflammatory and immunomodulatory effects of propofol and their roles in pain, organ protection and immunity. We will also discuss the use of propofol in cancer surgery, neurosurgery and older patients.
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Affiliation(s)
- M G Irwin
- Department of Anaesthesiology, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - C K E Chung
- Department of Anaesthesiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - K Y Ip
- Department of Anaesthesiology, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - M D Wiles
- Department of Anaesthesia, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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23
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Comparison of the Effects of Target-Controlled Infusion of Propofol and Sevoflurane as Maintenance of Anesthesia on Hemodynamic Profile in Kidney Transplantation. Anesthesiol Res Pract 2019; 2019:5629371. [PMID: 31885551 PMCID: PMC6925739 DOI: 10.1155/2019/5629371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 08/23/2019] [Accepted: 10/03/2019] [Indexed: 11/17/2022] Open
Abstract
Background Target-controlled infusion (TCI) propofol and sevoflurane are common agents for general anesthesia, including for kidney transplantation procedure. This study compared the effect of TCI propofol and sevoflurane on intraoperative hemodynamic profile in kidney transplant patients. Methods A single-blinded prospective study was performed in 46 kidney transplant recipients who were randomized into receiving TCI propofol or sevoflurane as anesthetics maintenance. Hemodynamic parameters such as mean arterial pressure (MAP), cardiac index (CI), stroke volume index (SVI), and systemic vascular resistance index (SVRI) were measured at baseline before induction, postintubation, first surgical incision, every 15 minutes after the first incision, reperfusion, and 15 minutes after reperfusion. Data were analyzed using unpaired t-test, paired t-test, and general linear model. Results Intraoperative MAP, CI, SVI, and SVRI changes were similar in both groups (p = 0.480, 0.216, 0.086, and 0.054). In comparison to the baseline value, TCI propofol and sevoflurane groups showed significant reductions of MAP at postintubation (p=0.010; p < 0.001) and during the first surgical incision (p=0.009; p < 0.001); significant reduction of CI at postintubation (p=0.003; p < 0.001) and during the first surgical incision (p < 0.001; p < 0.001); significant reduction of SVI at postintubation (p=0.013; p=0.008), during the first surgical incision (p=0.008; p=0.003), and 15 minutes after reperfusion (p=0.010; p=0.005); and significant increasing of SVRI during the first surgical incision (p=0.007; p=0.005). The TCI propofol group showed significantly lower SVRI compared to the sevoflurane group postintubation (p=0.029) and during the first surgical incision (p=0.026). Conclusion Intraoperative hemodynamic profile was similar between the TCI propofol and sevoflurane group during kidney transplant surgery. The TCI propofol group had higher CI and SVI but showed significantly lower SVRI as compared to the sevoflurane group. The incidence of postanesthesia agitation, postoperative outcome, and complication were not significantly different between the two groups.
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Echavarría R, Garcia D, Figueroa F, Franco-Acevedo A, Palomino J, Portilla-Debuen E, Goldaraz-Monraz MDLP, Moreno-Carranza B, Melo Z. Anesthetic preconditioning increases sirtuin 2 gene expression in a renal ischemia reperfusion injury model. MINERVA UROL NEFROL 2019; 72:243-249. [PMID: 31726818 DOI: 10.23736/s0393-2249.19.03361-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Renal transplant surgical proceedings are known to elicit periods of hypoxia and consequent blood flow reestablishment triggering ischemia-reperfusion (I-R) injury. Kidney damage induced by I-R injury associates with a higher risk of graft dysfunction and rejection. Anesthetic preconditioning exerts a beneficial effect on I-R injury by reducing oxidative stress, inflammation and apoptosis. However, the degree of renoprotection stimulated by commonly used anesthetics, as well as their mechanisms of action, are largely unknown. Sirtuins are class III histone deacetylases that reduce cellular stress, promote genome stability and regulate senescence. So far, the relationship between sirtuins and anesthetic preconditioning in the context of renal I-R has not been studied. The main objective of the present work was to determine the renal expression of sirtuins after I-R damage in rats under different anesthetic preconditioning treatments. METHODS Unilateral ischemia was performed via occlusion of the left renal hilum for 45 min and followed by 24 hours of reperfusion. Anesthetic preconditioning schemes (morphine 0.5 mg/kg, fentanyl 10 µg/kg, propofol 7.5 mg/kg, or dexmedetomidine 25 µg/kg) were administered 1 hour before ischemia. Creatinine levels were determined in serum, and expression of kidney injury molecule 1 and sirtuin 1, 2, 3 and 7 in kidney tissue was quantified by RT-PCR. RESULTS Anesthetic preconditioning with morphine, fentanyl, propofol and dexmedetomidine reduced kidney injury markers after I-R and modulated sirtuin gene expression. Opioids or dexmedetomidine administration before ischemia increased sirtuin 2 expression and correlated with improved renal function. CONCLUSIONS Anesthetic preconditioning is a promising strategy to prevent I-R injury associated with transplantation. Our results suggest that sirtuin 2 is involved in the protective mechanisms of some commonly used anesthetics against I-R damage.
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Affiliation(s)
- Raquel Echavarría
- Western Biomedical Research Center, National Council of Science and Technology (CONACyT), Mexical Institute of Social Security (IMSS), Guadalajara, Mexico
| | - David Garcia
- Western Biomedical Research Center, National Council of Science and Technology (CONACyT), Mexical Institute of Social Security (IMSS), Guadalajara, Mexico
| | - Francisco Figueroa
- High Specialty Medical Unit, Western Biomedical Research Center, Mexical Institute of Social Security (IMSS), Guadalajara, Mexico
| | - Adriana Franco-Acevedo
- Western Biomedical Research Center, National Council of Science and Technology (CONACyT), Mexical Institute of Social Security (IMSS), Guadalajara, Mexico.,University of Guadalajara, Guadalajara, Mexico
| | - Julio Palomino
- Western Biomedical Research Center, National Council of Science and Technology (CONACyT), Mexical Institute of Social Security (IMSS), Guadalajara, Mexico.,Durango-Santander University, Hermosillo, Mexico
| | - Eliseo Portilla-Debuen
- Western Biomedical Research Center, National Council of Science and Technology (CONACyT), Mexical Institute of Social Security (IMSS), Guadalajara, Mexico
| | - María de la Paz Goldaraz-Monraz
- High Specialty Medical Unit, Western Biomedical Research Center, Mexical Institute of Social Security (IMSS), Guadalajara, Mexico
| | - Bibiana Moreno-Carranza
- Institute of Neurobiology, National Autonomous University of Mexico (UNAM), Querétaro, Mexico.,School of Medicine, Anáhuac Querétaro University, El Marqués, Mexico
| | - Zesergio Melo
- Western Biomedical Research Center, National Council of Science and Technology (CONACyT), Mexical Institute of Social Security (IMSS), Guadalajara, Mexico -
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General Anesthetic Agents and Renal Function after Nephrectomy. J Clin Med 2019; 8:jcm8101530. [PMID: 31554223 PMCID: PMC6832234 DOI: 10.3390/jcm8101530] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 02/06/2023] Open
Abstract
The association between the choice of general anesthetic agents and the risk of acute kidney injury (AKI) and long-term renal dysfunction after nephrectomy has not yet been evaluated. We reviewed 1087 cases of partial or radical nephrectomy. The incidence of postoperative AKI, new-onset chronic kidney disease (CKD) and CKD upstaging were compared between general anesthetic agent groups (propofol, sevoflurane, and desflurane). Four different propensity score analyses were performed to minimize confounding for each pair of comparison (propofol vs. sevoflurane; propofol vs. desflurane; sevoflurane vs. desflurane; propofol vs. volatile agents). Study outcomes were compared before and after matching. Kaplan-Meier survival curve analysis was performed to compare renal survival determined by the development of new-onset CKD between groups up to 36 months after nephrectomy. Propofol was associated with a lower incidence of AKI (propofol 23.2% vs. sevoflurane 39.5%, p = 0.004; vs. propofol 21.0% vs. desflurane 34.3%, p = 0.031), a lower incidence of CKD upstaging (propofol 27.2% vs. sevoflurane 58.4%, p < 0.001; propofol 32.4% vs. desflurane 48.6%, p = 0.017) and better three-year renal survival after nephrectomy compared to sevoflurane or desflurane group (Log-rank test propofol vs. sevoflurane p < 0.001; vs. desflurane p = 0.015) after matching. Propofol was also associated with a lower incidence of new-onset CKD after nephrectomy compared to sevoflurane after matching (p < 0.001). There were no significant differences between sevoflurane and desflurane. However, subgroup analysis of partial nephrectomy showed a significant difference only in CKD upstaging. In conclusion, propofol, compared to volatile agents, could be a better general anesthetic agent for nephrectomy to attenuate postoperative renal dysfunction. However, limitations of the retrospective study design and inconsistent results of the subgroup analysis preclude firm conclusions.
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Abstract
The care of patients with acute kidney injury (AKI) has been limited due to the lack of effective therapeutics that can either prevent AKI during high-risk situations or treat AKI once established. A revolution in the scientific understanding of the pathogenesis of AKI has led to the identification of potential therapeutic targets. These targets include pathways involved in inflammation, cellular repair and fibrosis, cellular metabolism and mitochondrial function, oxidative stress, apoptosis, and hemodynamics and oxygen delivery. Many compounds are entering early-phase clinical trials. In addition, efforts to better describe sub-categories of AKI (through endo-phenotyping) hold promise to target therapies more effectively based upon pathways that are operative in the pathogenesis. These advances bring optimism that the care of patients with AKI will be transformed with the hope of better outcomes.
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Affiliation(s)
- Matthew Hulse
- Divison of Critical Care, Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA, 22908, USA
| | - Mitchell H Rosner
- Division of Nephrology, Department of Medicine, University of Virginia Health System, 135 Hospital Drive, Suite 1031, Charlottesville, VA, 22908, USA.
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27
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Jung H, Choi EK, Baek SI, Cho C, Jin Y, Kwak KH, Jeon Y, Park SS, Kim S, Lim DG. The Effect of Nitric Oxide on Remote Ischemic Preconditioning in Renal Ischemia Reperfusion Injury in Rats. Dose Response 2019; 17:1559325819853651. [PMID: 31191188 PMCID: PMC6542129 DOI: 10.1177/1559325819853651] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 04/29/2019] [Accepted: 04/30/2019] [Indexed: 12/12/2022] Open
Abstract
Although remote ischemic preconditioning (RIPC) is an organ-protective maneuver from subsequent ischemia reperfusion injury (IRI) by application of brief ischemia and reperfusion to other organs, its mechanism remains unclear. However, it is known that RIPC reduces the heart, brain, and liver IRI, and that nitric oxide (NO) is involved in the mechanism of this effect. To identify the role of NO in the protective effect of RIPC in renal IRI, this study examined renal function, oxidative status, and histopathological changes using N-nitro-L-arginine methyl ester (L-NAME), an NO synthase inhibitor. Remote ischemic preconditioning was produced by 3 cycles of 5 minutes ischemia and 5 minutes reperfusion. Blood urea nitrogen, creatinine (Cr), and renal tissue malondialdehyde levels were lower, histopathological damage was less severe, and superoxide dismutase level was higher in the RIPC + IRI group than in the IRI group. The renoprotective effect was reversed by L-NAME. Obtained results suggest that RIPC before renal IRI contributes to improvement of renal function, increases antioxidative marker levels, and decreases oxidative stress marker levels and histopathological damage. Moreover, NO is likely to play an important role in this protective effect of RIPC on renal IRI.
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Affiliation(s)
- Hoon Jung
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Eun Kyung Choi
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Seung Ik Baek
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Changhee Cho
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Yehun Jin
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Kyung Hwa Kwak
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Younghoon Jeon
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Sung-Sik Park
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Sioh Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Dong Gun Lim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
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Nieuwenhuijs-Moeke GJ, van den Berg TAJ, Bakker SJL, van den Heuvel MC, Struys MMRF, Lisman T, Pol RA. Preemptively and non-preemptively transplanted patients show a comparable hypercoagulable state prior to kidney transplantation compared to living kidney donors. PLoS One 2018; 13:e0200537. [PMID: 30011293 PMCID: PMC6047796 DOI: 10.1371/journal.pone.0200537] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 06/26/2018] [Indexed: 12/14/2022] Open
Abstract
To prevent renal graft thrombosis in kidney transplantation, centres use different perioperative anticoagulant strategies, based on various risk factors. In our centre, patients transplanted preemptively are considered at increased risk of renal graft thrombosis compared to patients who are dialysis-dependent at time of transplantation. Therefore these patients are given a single dose of 5000 IU unfractionated heparin intraoperatively before clamping of the vessels. We questioned whether there is a difference in haemostatic state between preemptively and non-preemptively transplanted patients and whether the distinction in intraoperative heparin administration used in our center is justified. For this analysis, citrate samples of patients participating in the VAPOR-1 trial were used and several haemostatic and fibrinolytic parameters were measured in 29 preemptively and 28 non-preemptively transplanted patients and compared to 37 living kidney donors. Sample points were: induction anaesthesia (T1), 5 minutes after reperfusion (T2) and 2 hours postoperative (T3). At T1, recipient groups showed comparable elevated levels of platelet factor 4 (PF4, indicating platelet activation), prothrombin fragment F1+2 and D-dimer (indicating coagulation activation) and Von Willebrand Factor (indicating endothelial activation) compared to the donors. The Clot Lysis Time (CLT, a measure of fibrinolytic potential) was prolonged in both recipient groups compared to the donors. At T3, F1+2, PF4 and CLT were higher in non-preemptively transplanted recipients compared to preemptively transplanted recipients. Compared to donors, non-preemptive recipients showed a prolonged CLT, but comparable levels of PF4 and D-dimer. In conclusion pre-transplantation, preemptively and non-preemptively transplanted patients show a comparable enhanced haemostatic state. A distinction in intraoperative heparin administration between preemptive and non-preemptive transplantation does not seem justified.
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Affiliation(s)
- Gertrude J. Nieuwenhuijs-Moeke
- Department of Anaesthesiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
- * E-mail:
| | - Tamar A. J. van den Berg
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Stephan J. L. Bakker
- Department of Nephrology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Marius C. van den Heuvel
- Department of Pathology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Michel M. R. F. Struys
- Department of Anaesthesiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
- Department of Anesthesia, Ghent University, Ghent, Belgium
| | - Ton Lisman
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Robert A. Pol
- Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
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Non-opioid analgesic use and concerns for impaired organ protection. Br J Anaesth 2018; 120:403-405. [PMID: 29406189 DOI: 10.1016/j.bja.2017.11.070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/06/2017] [Accepted: 11/16/2017] [Indexed: 12/15/2022] Open
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Response to: 'Postoperative pulmonary complications, pulmonary and systemic inflammatory responses after lung resection surgery with prolonged one-lung ventilation. Randomised controlled trial comparing intravenous and inhalational anaesthesia'. Br J Anaesth 2018; 120:411-412. [PMID: 29406195 DOI: 10.1016/j.bja.2017.12.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Beck-Schimmer B, Schadde E, Schläpfer M. Volatile anaesthetics and organ protection in kidney transplantation: finally, a randomized controlled trial! Br J Anaesth 2017; 118:643-644. [DOI: 10.1093/bja/aex094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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