A retrospective study of the relationship between postoperative urine output and one year transplanted kidney function

Balanced Crystalloids Versus Normal Saline in Kidney Transplant Patients: An Updated Systematic Review, Meta-analysis, and Trial Sequential Analysis

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.

Effect of Remimazolam on Induction and Maintenance of General Anesthesia in Kidney Transplant Patients

Purpose

This study aims to evaluate the effect of remimazolam on induction and maintenance of general anesthesia in kidney transplant patients.

Methods

120 patients undergoing kidney transplant were divided into two groups: Propofol group (Group P) and Remimazolam group (Group R). Anesthesia induction: remimazolam had injected IV at a dose of 0.15-0.35 mg/kg in Group R, while propofol had injected IV at a dose of 2.0-2.5 mg/kg in Group P. Anesthesia maintenance: remimazolam was injected IV at a dose of 0.3-1.0 mg·kg-1·h-1 and propofol was injected IV at a dose of 1-12 mg·kg-1·h-1 in Group R, propofol was injected IV at a dose of 3-12 mg·kg-1·h-1 in Group P. All patients have the same remaining anesthesia durgs.

Results

Compared with Group P, in Group R the time of disappearance of the eyelash reflex and the time to drop to 60 in BIS was longer (P < 0.05), the time of awakening was shorted (P < 0.05), the MAP of T6 was fluctuated less (P < 0.05), the incidence of hypotension and injection pain during induction was reduced (P < 0.001), the incidence of intraoperative bradycardia during operation was reduced (P < 0.05), the dosages of sedatives drug during maintenance was reduced (P < 0.05). There was no statistically significant difference in postoperative renal function between the two groups of patients (P > 0.05).

Conclusion

Remimazolam can be safely and effectively used for the induction and maintenance of general anesthesia in kidney transplant patients.

Association Between First Post-operative Day Urine Output Following Kidney Transplantation and Short-Term and Long-Term Outcomes: A Retrospective Cohort Study

Background

The relationship between post-operative urine output (UO) following kidney transplantation and long-term graft function has not been well described.

Objective

In this study, we examined the association between decreased UO on post-operative day 1 (POD1) and post-transplant outcomes.

Design

This is a retrospective cohort study.

Setting

Atlantic Canada.

Patients

Patients from the 4 Atlantic Canadian provinces (Nova Scotia, New Brunswick, Newfoundland, and Prince Edward Island) who received a live or deceased donor kidney transplant from 2006 through 2019 through the multiorgan transplant program at the Queen Elizabeth II Health Sciences Centre (QEII) hospital in Halifax, Nova Scotia.

Measurements

Using multivariable Cox proportional hazards models, we assessed the association of low POD1 UO (defined as ≤1000 mL) with death-censored graft loss (DCGL). In secondary analyses, we used adjusted logistic regression or Cox models as appropriate to assess the impact of UO on delayed graft function (DGF), prolonged length of stay (greater than the median for the entire cohort), and death.

Results

Of the 991 patients included, 151 (15.2%) had a UO ≤1000 mL on POD1. Low UO was independently associated with DCGL (hazard ratio [HR] = 4.00, 95% confidence interval [CI] = 95% CI = 1.55-10.32), DGF (odds ratio [OR] = 45.25, 95% CI = 23.00-89.02), and prolonged length of stay (OR = 5.06, 95% CI = 2.95-8.69), but not death (HR = 0.81, 95% CI = 0.31-2.09).

Limitations

This was a single-center, retrospective, observational study and therefore has inherent limitations of generalizability, data collection, and residual confounding.

Conclusions

Overall, reduced post-operative UO following kidney transplantation is associated with an increased risk of DCGL, DGF, and prolonged hospital length of stay.

A systematic review and meta-analysis on the effect of goal-directed fluid therapy on postoperative outcomes in renal transplantation surgeries

Introduction

This systematic review and meta-analysis investigated the impact of intraoperative goal-directed therapy (GDT) compared with conventional fluid therapy on postoperative outcomes in renal transplantation recipients, addressing this gap in current literature.

Method

A systematic search of patients aged ≥18 years who have undergone single-organ primary renal transplantations up to June 2022 in PubMed, Embase, Scopus and CINAHL Plus was performed. Primary outcome examined was postoperative renal function. Secondary outcomes assessed were mean arterial pressure at graft reperfusion, intraoperative fluid volume and other postoperative complications. Heterogeneity was tested using I² test. The study protocol was registered on PROSPERO.

Results

A total of 2459 studies were identified. Seven eligible studies on 607 patients were included. Subgroup assessments revealed potential renal protective benefits of GDT, with patients receiving cadaveric grafts showing lower serum creatinine on postoperative days 1 and 3, and patients monitored with arterial waveform analysis devices experiencing lower incidences of postoperative haemodialysis. Overall analysis found GDT resulted in lower incidence of tissue oedema (risk ratio [RR] 0.34, 95% CI 0.15-0.78, P=0.01) and respiratory complications (RR 0.39, 95% CI 0.17-0.90, P=0.03). However, quality of data was deemed low given inclusion of non-randomised studies, presence of heterogeneities and inconsistencies in defining outcomes measures.

Conclusion

While no definitive conclusions can be ascertained given current limitations, this review highlights potential benefits of using GDT in renal transplantation recipients. It prompts the need for further standardised studies to address limitations discussed in this review.

Association of Postoperative Urinary Output in the First 24 Hours with Delayed Graft Function After Living and Deceased Donor Kidney Transplant: A Systematic Review

Context: Delayed graft function (DGF) is an important clinical outcome following renal transplantation; therefore, it is important to be correctly diagnosed. The DGF is thought to correlate with the first 24-hour urine output (UOP1), and this clinical sign is expected to predict DGF. Objectives: This study aimed to discover whether the UOP1 correlates significantly to the DGF incidence and can be a DGF predicting factor. Data Sources: This study compared the incidence of DGF with the UOP1 reported by studies obtained from the electronic databases, namely MEDLINE, Cochrane, and EBSCO. Studies that performed multivariate or bivariate analysis and/or reported sensitivity and specificity were included in this review. Results: A total of 1719 studies were obtained from the database search, and 2 studies were enrolled from other sources. Out of 1721 studies, 9 studies were recruited in this review, 5 of which reported sensitivity and specificity. Overall, nine of these studies had a low to moderate risk of bias. Almost all studies reported a significant relationship between the UOP1 and DGF. All studies agreed that the UOP1 is a sensitive predictive factor in predicting DGF. The specificity reported by the studies examined in this review varied greatly. The use of optimum cut-off in each study is considered to be the cause of this variability. Conclusions: The UOP1 is significantly related to the incidence of DGF and is a proper parameter for the prediction of DGF events.

Development and validation of a nomogram to predict the mortality risk in elderly patients with ARF

Background

Acute respiratory failure (ARF) is a life-threatening complication in elderly patients. We developed a nomogram model to explore the risk factors of prognosis and the short-term mortality in elderly patients with ARF.

Methods

A total of 759 patients from MIMIC-III database were categorized into the training set and 673 patients from our hospital were categorized into the validation set. Demographical, laboratory variables, SOFA score and APS-III score were collected within the first 24 h after the ICU admission. A 30-day follow-up was performed for all patients.

Results

Multivariate logistic regression analysis showed that the heart rate, respiratoryrate, systolic pressure, SPO₂, albumin and 24 h urine output were independent prognostic factors for 30-day mortality in ARF patients. A nomogram was established based on above independent prognostic factors. This nomogram had a C-index of 0.741 (95% CI [0.7058-0.7766]), and the C-index was 0.687 (95% CI [0.6458-0.7272]) in the validation set. The calibration curves both in training and validation set were close to the ideal model. The SOFA had a C-index of 0.653 and the APS-III had a C-index of 0.707 in predicting 30-day mortality.

Conclusion

Our nomogram performed better than APS-III and SOFA scores and should be useful as decision support on the prediction of mortality risk in elderly patients with ARF.

Phase 3 trial Design of the Hepatocyte Growth Factor Mimetic ANG-3777 in Renal Transplant Recipients With Delayed Graft Function

Introduction

One-third of kidney transplantation patients experience acute kidney injury (AKI) resulting in delayed graft function (DGF), associated with increased risk of graft failure and mortality. Preclinical and phase 2 data indicate that treatment with ANG-3777 (formerly BB3), a hepatocyte growth factor (HGF) mimetic, may improve long-term kidney function and reduce health care resource use and cost, but these data require validation in a phase 3 randomized controlled trial.

Methods

The Graft Improvement Following Transplant (GIFT) trial is a multicenter, double-blind randomized controlled trial, designed to determine the efficacy and safety of ANG-3777 in renal transplantation patients showing signs of DGF. Subjects are randomized 1:1 to ANG-3777 (2 mg/kg) administered intravenously once daily for 3 consecutive days starting within 30 hours after transplantation, or to placebo.

Results

The primary endpoint is estimated glomerular filtration rate (eGFR) at 12 months. Secondary endpoints include proportion of subjects with eGFR >30 at days 30, 90, 180, and 360; proportion of subjects whose graft function is slow, delayed, or primary nonfunction; length of hospitalization; and duration of dialysis through day 30. Adverse events are assessed throughout the study.

Conclusion

GIFT will generate data that are important to advancing treatment of DGF in this medically complex population.