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Ju JW, Lee J, Joo S, Kim JE, Lee S, Cho YJ, Jeon Y, Nam K. Association Between Individualized Versus Conventional Blood Glucose Thresholds and Acute Kidney Injury After Cardiac Surgery: A Retrospective Observational Study. J Cardiothorac Vasc Anesth 2024; 38:1957-1964. [PMID: 38908927 DOI: 10.1053/j.jvca.2024.05.008] [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: 02/19/2024] [Revised: 05/01/2024] [Accepted: 05/03/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVES This study was designed to compare individualized and conventional hyperglycemic thresholds for the risk of acute kidney injury (AKI) after cardiac surgery. DESIGN This was an observational study. SETTING The study took place in a single-center tertiary teaching hospital. PARTICIPANTS Adult patients who underwent cardiac surgery between January 2012 and November 2021 were enrolled. MEASUREMENTS AND MAIN RESULTS Two blood glucose thresholds were used to define intraoperative hyperglycemia. While the conventional hyperglycemic threshold (CHT) was 180 mg/dL in all patients, the individualized hyperglycemic threshold (IHT) was calculated based on the preoperative hemoglobin A1c level. Various metrics of intraoperative hyperglycemia were calculated using both thresholds: any hyperglycemic episode, duration of hyperglycemia, and area above the thresholds. Postoperative AKI associations were compared using receiver operating characteristic curves and logistic regression analysis. Among the 2,427 patients analyzed, 823 (33.9%) developed AKI. The C-statistics of IHT-defined metrics (0.58-0.59) were significantly higher than those of the CHT-defined metrics (all C-statistics, 0.54; all p < 0.001). The duration of hyperglycemia (adjusted odds ratio, 1.09; 95% confidence interval, 1.02-1.16) and area above the IHT (1.003; 1.001-1.004) were significantly associated with the risk of AKI, except for the presence of any hyperglycemic episode. None of the CHT-defined metrics were significantly associated with the risk of AKI. CONCLUSIONS Individually defined intraoperative hyperglycemia better predicted postcardiac surgery AKI than universally defined hyperglycemia. Intraoperative hyperglycemia was significantly associated with the risk of AKI only for the IHT. Target blood glucose levels in cardiac surgical patients may need to be individualized based on preoperative glycemic status.
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Affiliation(s)
- Jae-Woo Ju
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jaemoon Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Somin Joo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae Eun Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seohee Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Ajou University Medical Center, Ajou University School of Medicine, Suwon, Gyeonggi Province, Republic of Korea
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Karam Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Guo Y, Qiu Y, Xue T, Zhou Y, Yan P, Liu S, Liu S, Zhao W, Zhang N. Association between glycemic variability and short-term mortality in patients with acute kidney injury: a retrospective cohort study of the MIMIC-IV database. Sci Rep 2024; 14:5945. [PMID: 38467770 PMCID: PMC10928232 DOI: 10.1038/s41598-024-56564-7] [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: 09/27/2023] [Accepted: 03/08/2024] [Indexed: 03/13/2024] Open
Abstract
Acute kidney injury (AKI) represents a significant challenge to global public health problem and is associated with poor outcomes. There is still considerable debate about the effect of mean blood glucose (MBG) and coefficient of variation (CV) of blood glucose on the short-term mortality of AKI patients. This retrospective cohort study aimed to explore the association between glycemic variability and short-term mortality in patients with AKI. Data from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database were analyzed, including 6,777 adult AKI patients. MBG and CV on the first day of ICU admission were calculated to represent the overall glycemic status and variability during the ICU stay in AKI patients. The primary outcome indicator was ICU 30-day mortality of AKI patients. Multivariate Cox regression analysis and smoothed curve fitting were used to assess the relationship between blood glucose levels and mortality. Eventually, the ICU 30-day mortality rate of AKI patients was 23.5%. The increased MBG and CV were significantly correlated with ICU 30-day mortality (hazards ratio (HR) = 1.20, 95% confidence interval (CI) 1.14-1.27; HR = 1.08, 95% CI 1.03-1.13). The smoothed curve fitting showed a U-shaped relationship between MBG on the first day of ICU admission and ICU 30-day mortality (inflection point = 111.3 mg/dl), while CV had a linear relationship with 30-day ICU mortality. Thus, we conclude that MBG and CV were significantly associated with short-term mortality in intensive care patients with AKI. Tighter glycemic control may be an effective measure to improve the prognosis of patients with AKI.
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Affiliation(s)
- Yifan Guo
- Department of Endocrinology and Nephropathy, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Yue Qiu
- Department of Endocrinology, Miyun Hospital District, The Third Affiliated Hospital of Beijing University of Chinese Medicine, Beijing, China
| | - Taiqi Xue
- Department of Endocrinology and Nephropathy, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Yi Zhou
- Department of Endocrinology and Nephropathy, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Pu Yan
- Department of Endocrinology and Nephropathy, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Shiyi Liu
- Department of Nephropathy, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Shiwei Liu
- Department of Endocrinology and Nephropathy, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China
| | - Wenjing Zhao
- Department of Nephrology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.
| | - Ning Zhang
- Department of Endocrinology and Nephropathy, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing, China.
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Cheng J, Zhou Y, Zhang Z. Increased variability of the post-operative glucose level was a predictor of mortality for recipients after liver transplantation. Asian J Surg 2023; 46:5616-5618. [PMID: 37597986 DOI: 10.1016/j.asjsur.2023.08.034] [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: 07/13/2023] [Accepted: 08/06/2023] [Indexed: 08/21/2023] Open
Affiliation(s)
- Jiangli Cheng
- Department of Respiratory Care, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, Sichuan, 610041, China.
| | - Yongfang Zhou
- Department of Respiratory Care, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, Sichuan, 610041, China.
| | - Zhongwei Zhang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Guoxue Alley 37#, Wuhou District, Chengdu, Sichuan, 610041, China.
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Qi J, Liu W, Gan L, Guo H, Xie Y, Gou L, Cai D, Zhang J, Deng J, Ren Z, Fang J, Zuo Z. Process of Glucose Increases Rather Than Constant High Glucose Was the Main Cause of Abnormal Glucose Induced Glomerulus Epithelial Cells Inflammatory Response. Int J Mol Sci 2022; 24:ijms24010600. [PMID: 36614042 PMCID: PMC9820529 DOI: 10.3390/ijms24010600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/14/2022] [Accepted: 12/22/2022] [Indexed: 12/31/2022] Open
Abstract
Abnormal glycemia is frequently along with nephritis, whose pathogenesis is unexplicit. Here, we investigated the effects of abnormal glucose on the renal glomerulus epithelial cells by stimulating immortalized bovine renal glomerulus epithelial (MDBK) cells with five different levels of glucose, including low glucose (2.5 mM for 48 h, LG), normal glucose (5 mM for 48 h, NG), high glucose (25 mM for 48 h, HG), increasing glucose (24 h of 2.5 mM glucose followed by 24 h of 25 mM, IG), and reducing glucose (24 h of 25 mM glucose followed by 24 h of 2.5 mM, RG). The results showed that LG and RG treatments had nonsignificant effects (p > 0.05) on the viability of MDBK cells. HG treatment decreased the viabilities of cells (p < 0.01) without triggering an apparent inflammatory response by activating the nox4/ROS/p53/caspase-3-mediated apoptosis pathway. IG treatment decreased the viabilities of cells significantly (p < 0.01) with high levels of pro-inflammatory cytokines IL-1β and IL-18 in the supernatant (p < 0.05) by triggering the txnip/nlrp3/gsdmd-mediated pyroptosis pathway. These results indicated that the process of glucose increase rather than the constant high glucose was the main cause of abnormal glucose-induced MDBK cell inflammatory death, prompting that the process of glycemia increases might be mainly responsible for the nephritis in diabetic nephropathy, underlining the importance of glycemic control in diabetes patients.
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Berkowitz RJ, Engoren MC, Mentz G, Sharma P, Kumar SS, Davis R, Kheterpal S, Sonnenday CJ, Douville NJ. Intraoperative risk factors of acute kidney injury after liver transplantation. Liver Transpl 2022; 28:1207-1223. [PMID: 35100664 PMCID: PMC9321139 DOI: 10.1002/lt.26417] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/06/2022] [Accepted: 01/10/2022] [Indexed: 01/13/2023]
Abstract
Acute kidney injury (AKI) is one of the most common complications of liver transplantation (LT). We examined the impact of intraoperative management on risk for AKI following LT. In this retrospective observational study, we linked data from the electronic health record with standardized transplant outcomes. Our primary outcome was stage 2 or 3 AKI as defined by Kidney Disease Improving Global Outcomes guidelines within the first 7 days of LT. We used logistic regression models to test the hypothesis that the addition of intraoperative variables, including inotropic/vasopressor administration, transfusion requirements, and hemodynamic markers improves our ability to predict AKI following LT. We also examined the impact of postoperative AKI on mortality. Of the 598 adult primary LT recipients included in our study, 43% (n = 255) were diagnosed with AKI within the first 7 postoperative days. Several preoperative and intraoperative variables including (1) electrolyte/acid-base balance disorder (International Classification of Diseases, Ninth Revision codes 253.6 or 276.x and International Classification of Diseases, Tenth Revision codes E22.2 or E87.x, where x is any digit; adjusted odds ratio [aOR], 1.917, 95% confidence interval [CI], 1.280-2.869; p = 0.002); (2) preoperative anemia (aOR, 2.612; 95% CI, 1.405-4.854; p = 0.002); (3) low serum albumin (aOR, 0.576; 95% CI, 0.410-0.808; p = 0.001), increased potassium value during reperfusion (aOR, 1.513; 95% CI, 1.103-2.077; p = 0.01), and lactate during reperfusion (aOR, 1.081; 95% CI, 1.003-1.166; p = 0.04) were associated with posttransplant AKI. New dialysis requirement within the first 7 days postoperatively predicted the posttransplant mortality. Our study identified significant association between several potentially modifiable variables with posttransplant AKI. The addition of intraoperative data did not improve overall model discrimination.
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Affiliation(s)
- Rachel J. Berkowitz
- Surgical Analytics and Population HealthData Analytics and ReportingLurie Children’s Hospital of ChicagoChicagoIllinoisUSA
| | - Milo C. Engoren
- Department of AnesthesiologyMichigan MedicineAnn ArborMichiganUSA
| | - Graciela Mentz
- Department of AnesthesiologyMichigan MedicineAnn ArborMichiganUSA
| | - Pratima Sharma
- Division of GastroenterologyDepartment of Internal MedicineMichigan MedicineAnn ArborMichiganUSA
| | - Sathish S. Kumar
- Department of AnesthesiologyMichigan MedicineAnn ArborMichiganUSA
| | - Ryan Davis
- Department of AnesthesiologyMichigan MedicineAnn ArborMichiganUSA
| | - Sachin Kheterpal
- Department of AnesthesiologyMichigan MedicineAnn ArborMichiganUSA
| | - Christopher J. Sonnenday
- Division of Transplantation SurgeryDepartment of SurgeryMichigan MedicineAnn ArborMichiganUSA,School of Public HealthUniversity of MichiganAnn ArborMichiganUSA
| | - Nicholas J. Douville
- Department of AnesthesiologyMichigan MedicineAnn ArborMichiganUSA,Institute of Healthcare Policy & InnovationUniversity of MichiganAnn ArborMichiganUSA
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Park JW, Kim EK, Lee J, Chung SH, Boo G, Do SH. Effect of Intraoperative Magnesium Sulfate Administration on Blood Glucose Control following Total Joint Arthroplasty in Patients with Diabetes. J Clin Med 2022; 11:jcm11113040. [PMID: 35683428 PMCID: PMC9181658 DOI: 10.3390/jcm11113040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/19/2022] [Accepted: 05/26/2022] [Indexed: 11/25/2022] Open
Abstract
Magnesium deficiency, which is known to be highly prevalent among patients with diabetes, has been associated with insulin resistance and poor glucose control. Here, we aimed to investigate the effects of intraoperative magnesium administration on postoperative glucose control in patients with diabetes. We retrospectively reviewed the medical records of patients with type 2 diabetes who had undergone total joint arthroplasty at a tertiary hospital, where intraoperative magnesium sulfate injections were frequently performed for postoperative analgesia. The patients were grouped based on whether treated with magnesium or not (magnesium vs. control groups). We investigated postoperative blood glucose levels and sliding scale insulin requirements. After propensity matching, 170 patients were allotted to each group. Both the mean glucose level and the incidence of a mean glucose level of >200mg/dL were significantly lower in the magnesium group than in the control group (p = 0.040 and 0.013, respectively). There was also a lower insulin requirement in the magnesium group (p = 0.043). Multivariate logistic regression revealed that magnesium treatment was significantly related to a less frequent incidence of a mean blood glucose level of >200 mg/dL (p = 0.047). This study demonstrated that magnesium sulfate infusion was associated with an improved postoperative blood glucose profile in patients with diabetes.
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Affiliation(s)
- Jin-Woo Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.-W.P.); (J.L.); (G.B.)
| | - Eun-Kyoung Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul 03080, Korea;
| | - Jiyoun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.-W.P.); (J.L.); (G.B.)
| | - Seung Hyun Chung
- Department of Anesthesiology and Pain Medicine, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu 11759, Korea;
| | - Gihong Boo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.-W.P.); (J.L.); (G.B.)
| | - Sang-Hwan Do
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam 13620, Korea; (J.-W.P.); (J.L.); (G.B.)
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul 03080, Korea;
- Correspondence: ; Tel.: +82-31-787-7501
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Yang J, Cheng Y, Wang R, Wang B. Association Between Serum Osmolality and Acute Kidney Injury in Critically Ill Patients: A Retrospective Cohort Study. Front Med (Lausanne) 2021; 8:745803. [PMID: 34722583 PMCID: PMC8553934 DOI: 10.3389/fmed.2021.745803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/21/2021] [Indexed: 02/05/2023] Open
Abstract
Purposes: Acute kidney injury (AKI) is a common complication in critically ill patients and is usually associated with poor outcomes. Serum osmolality has been validated in predicting critically ill patient mortality. However, data about the association between serum osmolality and AKI is still lacking in ICU. Therefore, the purpose of the present study was to investigate the association between early serum osmolality and the development of AKI in critically ill patients. Methods: The present study was a retrospective cohort analysis based on the medical information mart for intensive care III (MIMIC-III) database. 20,160 patients were involved in this study and divided into six subgroups according to causes for ICU admission. The primary outcome was the incidence of AKI after ICU admission. The association between early serum osmolality and AKI was explored using univariate and multivariate logistic regression analyses. Results: The normal range of serum osmolality was 285–300 mmol/L. High serum osmolality was defined as serum osmolality >300 mmol/L and low serum osmolality was defined as serum osmolality <285 mmol/L. Multivariate logistic regression indicated that high serum osmolality was independently associated with increased development of AKI with OR = 1.198 (95% CL = 1.199–1.479, P < 0.001) and low serum osmolality was also independently associated with increased development of AKI with OR = 1.332 (95% CL = 1.199–1.479, P < 0.001), compared with normal serum osmolality, respectively. Conclusions: In critically ill patients, early high serum osmolality and low serum osmolality were both independently associated with an increased risk of development of AKI.
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Affiliation(s)
- Jie Yang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yisong Cheng
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Ruoran Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Bo Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
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Milani S, Jafari M, Afzal Aghaee M, Sabzevari A. Correlation of Deceased Donor Factors to Postreperfusion Severe Hyperglycemia in Adult Patients Undergoing Liver Transplant. EXP CLIN TRANSPLANT 2021; 19:1058-1062. [PMID: 34387155 DOI: 10.6002/ect.2021.0140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES In this study, our objective was to identify perioperative factors associated with postreperfusion severe hyperglycemia, with a particular focus on deceased donor factors. MATERIALS AND METHODS Perioperative data from 100 patients without diabetes who were undergoing liver transplant from deceased donors were reviewed. Mean blood glucose levels were calculated at each liver transplant surgical phase, with a cutoff level of 12.7 mmol/L (230 mg/dL) during the neo-hepatic phase defined as postreperfusion severe hyperglycemia. Patients were divided into those with and without postreperfusion severe hyperglycemia. Selected perioperative variables were compared between the 2 groups. RESULTS Of 100 patients, 55 developed postreperfusion severe hyperglycemia. Among donor variables, a statistically significant difference between groups was only shown for graft-to-recipient liver weight ratio (P < .001). With regard to preoperative recipient variables, the 2 groups showed a significant difference in mean age (P = .001). Patients in the postreperfusion severe hyperglycemia group required significantly more packed red blood cell transfusions (P = .002), sodium bicarbonate (P = .054), and vasopressors (P = .002) during the operation. Moreover, in terms of laboratory findings, although the last arterial pH was acceptable in both groups, a last lower arterial pH was observed in patients with postreperfusion severe hyperglycemia (P = .011). Higher mean blood glucose levels were detected in the postre - perfusion hyperglycemia group during the preanhepatic and anhepatic phases (P = .024, P = .001, respectively). CONCLUSIONS In patients undergoing liver transplant, incidence of postreperfusion severe hyperglycemia was influenced by graft-to-recipient liver weight ratio. Furthermore, postreperfusion severe hyperglycemia was associated with intraoperative clinical and laboratory disturbances in liver transplant recipients.
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Affiliation(s)
- Soheila Milani
- From the Department of Anesthesia and Intensive Care, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Derakhshan P, Khatibi A, Faiz SHR, Rahimzadeh P, Nouri N. Comparison of the effect of insulin glargine and regular insulin on perioperative glycemic control in patients with type 2 diabetes mellitus under insulin treatment during vitrectomy surgery under general anesthesia: A randomized clinical trial study. Med J Islam Repub Iran 2021; 35:31. [PMID: 34211933 PMCID: PMC8236081 DOI: 10.47176/mjiri.35.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Indexed: 11/23/2022] Open
Abstract
Background: Perioperative glycemic control is an important factor in the clinical management of a patient with diabetes mellitus under surgery. Poorly controlled long-term hyperglycemia not only predisposes individuals to systemic complications of diabetes mellitus and cardiovascular morbidity but also increases the risk of anesthesia and weakens the outcome of the surgery. Given the importance of the issue and the limited studies on glucose control using insulin glargine during surgery, we aimed to investigate the effects of glargine on glucose control in patients with diabetes mellitus during vitrectomy surgery.
Methods: This randomized, double-blind trial was conducted in two groups of 35 patients with diabetes mellitus under treatment with insulin. In the control group, the patients received regular insulin based on the blood glucose and the sliding scale, and in the intervention group, they received insulin glargine (0.3 unit/kg) before surgery. From the start of the operation up to 3 hours of the surgery blood glucose of the patients was measured every 45 minutes and once 6 hours after the operation, and if needed, the regular insulin was injected. Data were analyzed using SPSS 16. Frequency, percentage, mean, and standard deviation (SD) were used to describe the data. To compare the quantitative variables, the independent t-test or U-Mann-Whitney test was used. For comparison of the qualitative variables, Chi-square test or Fischer's exact test and repeated measure ANOVA was employed. The significance level (P-value) was considered as p<0.05.
Results: Use of insulin glargine was associated with significantly lower blood glucose levels compared to regular insulin at 90-minutes (p=0.004), 135 minutes (p=0.001), and 6 hours after the operation (p=0.005).
Conclusion: Glycemic control using glargine compared to regular insulin has a better performance with less need for surplus insulin dose administration during surgery.
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Affiliation(s)
- Pooya Derakhshan
- Anesthesiology Department, Rasool Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Khatibi
- Anesthesiology Department, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Hamid Reza Faiz
- Anesthesiology Department, Rasool Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Poupak Rahimzadeh
- Anesthesiology Department, Rasool Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Nasrin Nouri
- Anesthesiology Department, Fatima Plastic And Reconstructive Surgery Hospital, Iran University of Medical Sciences, Tehran, Iran
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Wilke TJ, Fremming BA, Brown BA, Markin NW, Kassel CA. 2020 Clinical Update in Liver Transplantation. J Cardiothorac Vasc Anesth 2021; 36:1449-1457. [PMID: 33653578 PMCID: PMC7865096 DOI: 10.1053/j.jvca.2021.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 02/01/2021] [Indexed: 12/13/2022]
Abstract
The gold standard treatment of end-stage liver disease continues to be liver transplantation (LT). The challenges of LT require skilled anesthesiologists to anticipate physiologic changes associated with end-stage liver disease and surgical considerations that affect multiple organ systems. While on the waiting list, patients may be placed on new anticoagulation medications that can confound already complex coagulopathy in LT patients. Pain management often is an afterthought for such a complex procedure, but appropriate medications can help control pain while limiting opioid medications. Surgical stress and medications for immunosuppression can affect perioperative glucose management in ways that have implications for patient and graft survival. The coronavirus disease 2019 pandemic in 2020 provided a new challenge for anesthesiologists. The uncertainty of the novel respiratory virus challenged providers beyond just LT patients.
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Affiliation(s)
- Trevor J Wilke
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE
| | - Bradley A Fremming
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE
| | - Brittany A Brown
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE
| | - Nicholas W Markin
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE
| | - Cale A Kassel
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE.
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Joosten A, Lucidi V, Ickx B, Van Obbergh L, Germanova D, Berna A, Alexander B, Desebbe O, Carrier FM, Cherqui D, Adam R, Duranteau J, Saugel B, Vincent JL, Rinehart J, Van der Linden P. Intraoperative hypotension during liver transplant surgery is associated with postoperative acute kidney injury: a historical cohort study. BMC Anesthesiol 2021; 21:12. [PMID: 33430770 PMCID: PMC7798188 DOI: 10.1186/s12871-020-01228-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/27/2020] [Indexed: 12/12/2022] Open
Abstract
Background Acute kidney injury (AKI) occurs frequently after liver transplant surgery and is associated with significant morbidity and mortality. While the impact of intraoperative hypotension (IOH) on postoperative AKI has been well demonstrated in patients undergoing a wide variety of non-cardiac surgeries, it remains poorly studied in liver transplant surgery. We tested the hypothesis that IOH is associated with AKI following liver transplant surgery. Methods This historical cohort study included all patients who underwent liver transplant surgery between 2014 and 2019 except those with a preoperative creatinine > 1.5 mg/dl and/or who had combined transplantation surgery. IOH was defined as any mean arterial pressure (MAP) < 65 mmHg and was classified according to the percentage of case time during which the MAP was < 65 mmHg into three groups, based on the interquartile range of the study cohort: “short” (Quartile 1, < 8.6% of case time), “intermediate” (Quartiles 2–3, 8.6–39.5%) and “long” (Quartile 4, > 39.5%) duration. AKI stages were classified according to a “modified” “Kidney Disease: Improving Global Outcomes” (KDIGO) criteria. Logistic regression modelling was conducted to assess the association between IOH and postoperative AKI. The model was run both as a univariate and with multiple perioperative covariates to test for robustness to confounders. Results Of the 205 patients who met our inclusion criteria, 117 (57.1%) developed AKI. Fifty-two (25%), 102 (50%) and 51 (25%) patients had short, intermediate and long duration of IOH respectively. In multivariate analysis, IOH was independently associated with an increased risk of AKI (adjusted odds ratio [OR] 1.05; 95%CI 1.02–1.09; P < 0.001). Compared to “short duration” of IOH, “intermediate duration” was associated with a 10-fold increased risk of developing AKI (OR 9.7; 95%CI 4.1–22.7; P < 0.001). “Long duration” was associated with an even greater risk of AKI compared to “short duration” (OR 34.6; 95%CI 11.5-108.6; P < 0.001). Conclusions Intraoperative hypotension is independently associated with the development of AKI after liver transplant surgery. The longer the MAP is < 65 mmHg, the higher the risk the patient will develop AKI in the immediate postoperative period, and the greater the likely severity. Anesthesiologists and surgeons must therefore make every effort to avoid IOH during surgery.
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Affiliation(s)
- Alexandre Joosten
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium. .,Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France.
| | - Valerio Lucidi
- Department of Digestive Surgery, Unit of Hepatobiliary Surgery and Liver Transplantation, Erasme hospital, Cliniques Universitaires de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Brigitte Ickx
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Luc Van Obbergh
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Desislava Germanova
- Department of Digestive Surgery, Unit of Hepatobiliary Surgery and Liver Transplantation, Erasme hospital, Cliniques Universitaires de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Antoine Berna
- Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Brenton Alexander
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Olivier Desebbe
- Department of Anesthesiology and Perioperative Medicine, Sauvegarde Clinic, Ramsay Santé, Lyon, France
| | - Francois-Martin Carrier
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Daniel Cherqui
- Department of Hepatobiliary Surgery, Paul Brousse Hospital, Villejuif, France
| | - Rene Adam
- Department of Hepatobiliary Surgery, Paul Brousse Hospital, Villejuif, France
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Paul Brousse Hospital, Assistance Publique Hôpitaux de Paris (APHP), 12 Avenue Paul Vaillant Couturier, 94800, Villejuif, France
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Joseph Rinehart
- Department of Anesthesiology and Perioperative Care, University of California Irvine, Irvine, California, USA
| | - Philippe Van der Linden
- Department of Anesthesiology, Brugmann Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
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Saadat-Gilani K, Zarbock A, Meersch M. Perioperative Renoprotection: Clinical Implications. Anesth Analg 2020; 131:1667-1678. [DOI: 10.1213/ane.0000000000004995] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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13
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Lee S, Nam S, Bae J, Cho YJ, Jeon Y, Nam K. Intraoperative hyperglycemia in patients with an elevated preoperative C-reactive protein level may increase the risk of acute kidney injury after cardiac surgery. J Anesth 2020; 35:10-19. [PMID: 32886199 DOI: 10.1007/s00540-020-02849-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 08/21/2020] [Indexed: 01/04/2023]
Abstract
PURPOSE The effect of hyperglycemia on acute kidney injury (AKI) in patients undergoing cardiac surgery is unclear and may involve as yet unexplored factors. We hypothesized differential effects of intraoperative hyperglycemia on AKI after cardiac surgery depending on baseline inflammatory status, as reflected by the C-reactive protein (CRP) level. METHODS This retrospective study included patients who underwent cardiac surgery seen at our hospital from 2008 to 2018. Patients were classified into four groups according to their preoperative CRP level (≥ 1 or < 1 mg/dl) and their intraoperative time-weighted average glucose concentration (> 140 or ≤ 140 mg/dl): low CRP and normoglycemia, low CRP and hyperglycemia, high CRP and normoglycemia, and high CRP and hyperglycemia. The data were analyzed by multivariable logistic regression analysis. RESULTS The data of 3625 patients were analyzed. The logistic regression showed that patients in the high CRP and hyperglycemia group had a significantly higher risk of AKI than patients in the low CRP and normoglycemia group [odds ratio (OR), 1.58; 95% confidence interval (CI) 1.10-2.27], low CRP with hyperglycemia group (OR, 1.69; 95% CI 1.16-2.47) and high CRP with normoglycemia group (OR, 1.50; 95% CI 1.01-2.23). CONCLUSIONS Intraoperative hyperglycemia in patients with an elevated preoperative CRP level was significantly related to an increased risk of AKI after cardiac surgery. Individualized perioperative glycemic control may therefore be necessary in these patients.
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Affiliation(s)
- Seohee Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Seungpyo Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Jinyoung Bae
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Karam Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea.
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Repetitive Intermittent Hyperglycemia Drives the M1 Polarization and Inflammatory Responses in THP-1 Macrophages Through the Mechanism Involving the TLR4-IRF5 Pathway. Cells 2020; 9:cells9081892. [PMID: 32806763 PMCID: PMC7463685 DOI: 10.3390/cells9081892] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/08/2020] [Accepted: 08/10/2020] [Indexed: 02/07/2023] Open
Abstract
Repetitive intermittent hyperglycemia (RIH) is an independent risk factor for complications associated with type-2 diabetes (T2D). Glucose fluctuations commonly occur in T2D patients with poor glycemic control or following intensive therapy. Reducing blood glucose as well as glucose fluctuations is critical to the control of T2D and its macro-/microvascular complications. The interferon regulatory factor (IRF)-5 located downstream of the nutrient sensor toll-like receptor (TLR)-4, is emerging as a key metabolic regulator. It remains unclear how glucose fluctuations may alter the IRF5/TLR4 expression and inflammatory responses in monocytes/macrophages. To investigate this, first, we determined IRF5 gene expression by real-time qRT-PCR in the white adipose tissue samples from 39 T2D and 48 nondiabetic individuals. Next, we cultured THP-1 macrophages in hypo- and hyperglycemic conditions and compared, at the protein and transcription levels, the expressions of IRF5, TLR4, and M1/M2 polarization profile and inflammatory markers against control (normoglycemia). Protein expression was assessed using flow cytometry, ELISA, Western blotting, and/or confocal microscopy. IRF5 silencing was achieved by small interfering RNA (siRNA) transfection. The data show that adipose IRF5 gene expression was higher in T2D than nondiabetic counterparts (p = 0.006), which correlated with glycated hemoglobin (HbA1c) (r = 0.47/p < 0.001), homeostatic model assessment of insulin resistance (HOMA-IR) (r = 0.23/p = 0.03), tumor necrosis factor (TNF)-α (r = 0.56/p < 0.0001), interleukin (IL)-1β (r = 0.40/p = 0.0009), and C-C motif chemokine receptor (CCR)-2 (r = 0.49/p < 0.001) expression. IRF5 expression in macrophages was induced/upregulated (p < 0.05) by hypoglycemia (3 mM/L), persistent hyperglycemia (15 mM/L–25 mM/L), and RIH/glucose fluctuations (3–15 mM/L) as compared to normoglycemia (5 mM/L). RIH/glucose fluctuations also induced M1 polarization and an inflammatory profile (CD11c, IL-1β, TNF-α, IL-6, and monocyte chemoattractant protein (MCP)-1) in macrophages. RIH/glucose fluctuations also drove the expression of matrix metalloproteinase (MMP)-9 (p < 0.001), which is a known marker for cardiovascular complication in T2D patients. Notably, all these changes were counteracted by IRF5 silencing in macrophages. In conclusion, RIH/glucose fluctuations promote the M1 polarization and inflammatory responses in macrophages via the mechanism involving TLR4-IRF5 pathway, which may have significance for metabolic inflammation.
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Gameiro J, Branco T, Lopes JA. Artificial Intelligence in Acute Kidney Injury Risk Prediction. J Clin Med 2020; 9:jcm9030678. [PMID: 32138284 PMCID: PMC7141311 DOI: 10.3390/jcm9030678] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/26/2020] [Accepted: 02/28/2020] [Indexed: 12/23/2022] Open
Abstract
Acute kidney injury (AKI) is a frequent complication in hospitalized patients, which is associated with worse short and long-term outcomes. It is crucial to develop methods to identify patients at risk for AKI and to diagnose subclinical AKI in order to improve patient outcomes. The advances in clinical informatics and the increasing availability of electronic medical records have allowed for the development of artificial intelligence predictive models of risk estimation in AKI. In this review, we discussed the progress of AKI risk prediction from risk scores to electronic alerts to machine learning methods.
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Affiliation(s)
- Joana Gameiro
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal;
- Correspondence:
| | - Tiago Branco
- Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal;
| | - José António Lopes
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal;
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Samji NS, Heda R, Satapathy SK. Peri-transplant management of nonalcoholic fatty liver disease in liver transplant candidates . Transl Gastroenterol Hepatol 2020; 5:10. [PMID: 32190778 DOI: 10.21037/tgh.2019.09.09] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 09/23/2019] [Indexed: 12/12/2022] Open
Abstract
The incidence of non-alcoholic fatty liver disease (NAFLD) is rapidly growing, affecting 25% of the world population. Non-alcoholic steatohepatitis (NASH) is the most severe form of NAFLD and affects 1.5% to 6.5% of the world population. Its rising incidence will make end-stage liver disease (ESLD) due to NASH the number one indication for liver transplantation (LT) in the next 10 to 20 years, overtaking Hepatitis C. Patients with NASH also have a high prevalence of associated comorbidities such as type 2 diabetes, obesity, metabolic syndrome, cardiovascular disease, and chronic kidney disease (CKD), which must be adequately managed during the peritransplant period for optimal post-transplant outcomes. The focus of this review article is to provide a comprehensive overview of the unique challenges these patients present in the peritransplant period, which comprises the pre-transplant, intraoperative, and immediate postoperative periods.
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Affiliation(s)
- Naga Swetha Samji
- Tennova Cleveland Hospital, 2305 Chambliss Ave NW, Cleveland, TN, USA
| | - Rajiv Heda
- University of Tennessee Health Science Center, College of Medicine, Memphis, TN, USA
| | - Sanjaya K Satapathy
- Division of Hepatology and Sandra Atlas Bass Center for Liver Diseases, Northwell Health, Manhasset, NY, USA
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Kumar SS, Pelletier SJ, Shanks A, Thompson A, Sonnenday CJ, Picton P. Intraoperative glycemic control in patients undergoing Orthotopic liver transplant: a single center prospective randomized study. BMC Anesthesiol 2020; 20:3. [PMID: 31901245 PMCID: PMC6942664 DOI: 10.1186/s12871-019-0918-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 12/23/2019] [Indexed: 01/04/2023] Open
Abstract
Background Perioperative hyperglycemia is associated with poor outcomes yet evidence to guide intraoperative goals and treatment modalities during non-cardiac surgery are lacking. End-stage liver disease is associated with altered glucose homeostasis; patients undergoing liver transplantation display huge fluctuations in blood glucose (BG) and represent a population of great interest. Here, we conduct a randomized trial to compare the effects of strict versus conventional glycemic control during orthotopic liver transplant (OLT). Methods Following approval by the Institutional Review Board of the University of Michigan Medical School and informed consent, 100 adult patients undergoing OLT were recruited. Patients were randomized to either strict (target BG 80–120 mg/dL) or conventional (target BG 180–200 mg/dL) BG control with block randomization for diabetic and nondiabetic patients. The primary outcomes measured were 1-year patient and graft survival assessed on an intention to treat basis. Graft survival is defined as death or needing re-transplant (www.unos.org). Three and 5-year patient and graft survival, infectious and biliary complications were measured as secondary outcomes. Data were examined using univariate methods and Kaplan-Meir survival analysis. A sensitivity analysis was performed to compare patients with a mean BG of ≤120 mg/dL and those > 120 mg/dL regardless of treatment group. Results There was no statistically significant difference in patient survival between conventional and strict control respectively;1 year, 88% vs 88% (p-0.99), 3 years, 86% vs 84% (p- 0.77), 5 years, 82% vs 78. % (p-0.36). Graft survival was not different between conventional and strict control groups at 1 year, 88% vs 84% (p-0.56), 3 years 82% vs 76% (p-0.46), 5 years 78% vs 70% (p-0.362). Conclusion There was no difference in patient or graft survival between intraoperative strict and conventional glycemic control during OLT. Trial registration Clinical trial number and registry: www.clinicaltrials.gov NCT00780026. This trial was retrospectively registered on 10/22/2008.
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Affiliation(s)
- Sathish S Kumar
- Department of Anesthesiology, Michigan Medicine, 1H247 UH, 1500 East Medical Center Drive, SPC 5048, Ann Arbor, MI, 48109-5048, USA.
| | - Shawn J Pelletier
- University of Virginia, 1215 Lee st, Charlottesville, VA, 22908, USA
| | - Amy Shanks
- Department of Anesthesiology, Michigan Medicine, 1H247 UH, 1500 East Medical Center Drive, SPC 5048, Ann Arbor, MI, 48109-5048, USA
| | - Aleda Thompson
- Department of Anesthesiology, Michigan Medicine, 1H247 UH, 1500 East Medical Center Drive, SPC 5048, Ann Arbor, MI, 48109-5048, USA
| | | | - Paul Picton
- Department of Anesthesiology, Michigan Medicine, 1H247 UH, 1500 East Medical Center Drive, SPC 5048, Ann Arbor, MI, 48109-5048, USA
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Santana-Santos E, Kanke PH, Vieira RDCA, Oliveira LBD, Ferretti-Rebustini REDL, Menezes AFD, Barreto ÍDDC, Hajjar LA. Impacto do controle glicêmico intensivo na lesão renal aguda: ensaio clínico randomizado. ACTA PAUL ENFERM 2019. [DOI: 10.1590/1982-0194201900083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Resumo Objetivo Avaliar o impacto do controle glicêmico intensivo na redução da incidência de lesão renal aguda em pacientes adultos submetidos à cirurgia cardíaca. Métodos Ensaio clínico randomizado que avaliou 95 pacientes submetidos a duas estratégias de controle glicêmico. Os pacientes foram randomizados para o grupo intervenção (GI), com a meta de manutenção da glicemia pós-operatória entre 90 e 110 mg/dl. Nos pacientes alocados no grupo convencional (GC) o objetivo era a manutenção da glicemia entre 140 e 180 mg/dl. O ajuste da dose de insulina foi baseado em medições de glicose no sangue arterial não diluído, em intervalos de uma hora por meio de um sistema de monitoramento de glicose e beta-cetona no sangue. Resultados A incidência de LRA foi de 53,7% (KDIGO estágios 1, 2 ou 3). Não houve diferença significante entre os grupos quanto ao desfecho primário (p=0,294). Entretanto, observou-se maior frequência de recuperação da função renal (p=0,010), na alta da UTI (p=0,028) e alta hospitalar (p=0,048) entre os pacientes submetidos ao controle glicêmico convencional. A utilização do controle glicêmico intensivo esteve associada com maior tempo de permanência na UTI (p=0,031). O número de episódios de hipoglicemia foi semelhante nos dois grupos (1,6 ± 0,9 vs. 1,3 ± 0,6, p=0,731), demonstrando a segurança das estratégias utilizadas. Conclusão Não se observou o impacto do controle glicêmico intensivo na redução da incidência de lesão renal aguda. Em contrapartida, os pacientes tratados no GC apresentaram maior frequência de recuperação da função renal.
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Rodriguez-Buitrago A, Basem A, Okwumabua E, Enata N, Evans A, Pennings J, Karacay B, Rice MJ, Obremskey W. Hyperglycemia as a risk factor for postoperative early wound infection after bicondylar tibial plateau fractures: Determining a predictive model based on four methods. Injury 2019; 50:2097-2102. [PMID: 31371170 DOI: 10.1016/j.injury.2019.07.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 06/06/2019] [Accepted: 07/23/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Identify a glucose threshold that would put patients with isolated bicondylar tibial plateau fractures at risk of early wound infection (i.e. < 90 days). DESIGN Retrospective review of medical records. SETTING Academic American College of Surgeons (ACS) Level 1 trauma center. PATIENTS Adult patients between 2010 and 2015 with an operatively treated isolated bicondylar tibial plateau fracture and at least three glucose measurements during their hospitalization. MAIN OUTCOME MEASUREMENT To predict infection using four different methods: maximum preoperative blood glucose (PBG), maximum blood glucose (MGB), Hyperglycemic Index (HGI), and Time-Weighted Average Glucose (TWAG). RESULTS 126/381 patients met our inclusion criteria. Fifteen (12%) patients had an open fracture and 30/126 (23%) developed an infection. Median glucose for each predictive method studied was 114 (IQR 101.2-137.8) mg/dL for PBG, 144 (IQR 119-169.8) mg/dL for MBG, 0.8 (IQR 0.20-1.60) mmol/L for HGI, and 120.4 (IQR 106.0-135.6) mg/dL for TWAG. As expected, infected patients had higher PBG, MGB, and TWAG. HGI was similar in both groups. None of these differences prove to be statistically significant (p > .05). Logistic regression models for all the methods showed that having an open fracture was the strongest predictor of infection. CONCLUSION It is well known that stress-induced hyperglycemia increases the risk of infection, we present and compare four models that have been used in other medical fields. In our study, none of the methods presented identified a glucose threshold that would increase the risk of infection in patients with bicondylar tibial plateau fractures. LEVEL OF EVIDENCE Retrospective review, Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Andres Rodriguez-Buitrago
- Division of Orthopaedic Trauma, Vanderbilt Medical Center, 1215st Avenue South, Nashville, TN, 37212, United States; Universidad del Rosario, School of Medicine and Health Sciences, Bogotá, Colombia.
| | - Attum Basem
- Division of Orthopaedic Trauma, Vanderbilt Medical Center, 1215st Avenue South, Nashville, TN, 37212, United States.
| | - Ebubechi Okwumabua
- Meharry Medical College, 1005 Dr DB Todd Jr Blvd, Nashville, TN, 37208, United States.
| | - Nichelle Enata
- Meharry Medical College, 1005 Dr DB Todd Jr Blvd, Nashville, TN, 37208, United States.
| | - Adam Evans
- Meharry Medical College, 1005 Dr DB Todd Jr Blvd, Nashville, TN, 37208, United States.
| | - Jacquelyn Pennings
- Department of Orthopaedics, Vanderbilt Medical Center, 1215 21st Avenue South, Nashville, TN, 37212, United States.
| | - Bernes Karacay
- Department of Orthopaedics, Vanderbilt Medical Center, 1215 21st Avenue South, Nashville, TN, 37212, United States.
| | - Mark John Rice
- Department of Anesthesiology, Vanderbilt Medical Center, 1215 21st Avenue South, Nashville, TN, 37212, United States.
| | - William Obremskey
- Division of Orthopaedic Trauma, Vanderbilt Medical Center, 1215st Avenue South, Nashville, TN, 37212, United States.
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Waskowski J, Pfortmueller CA, Erdoes G, Buehlmann R, Messmer AS, Luedi MM, Schmidli J, Schefold JC. Mannitol for the Prevention of Peri-Operative Acute Kidney Injury: A Systematic Review. Eur J Vasc Endovasc Surg 2019; 58:130-140. [PMID: 31078413 DOI: 10.1016/j.ejvs.2019.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 02/04/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE/BACKGROUND Post-operative acute kidney injury (AKI) is a frequent peri-operative complication that negatively affects morbidity and mortality. Mannitol is frequently used peri-operatively for renal protection, although evidence for its use is ambiguous. A systematic review was conducted to clarify whether there is evidence supporting peri-operative mannitol administration for the prevention of post-operative AKI. METHODS A systematic literature search was performed in MEDLINE/Pubmed, Embase, the Cochrane Library, Clinical Trials registry, and the Cochrane Central Register of Controlled Trials (CENTRAL). Eligibility criteria were (i) population (studies involving adult patients undergoing surgery or a related intervention); (ii) intervention (intravenous mannitol administered in either the pre- or intra-operative period with comparison to controls); and (iii) predefined outcomes (post-operative AKI or respective renal end points/surrogates). RESULTS In total, 1,538 articles published between January 1990 and October 2018 were identified. After checking for eligibility, 22 studies, including 17 prospective and/or randomised controlled trials and five retrospective studies, were included. The investigations involved various fields of surgery, such as aortic surgery, cardiac surgery with cardiopulmonary bypass, and urological procedures, including partial nephrectomy. Significant heterogeneity, limited sample size, and mostly short follow up periods were noted. CONCLUSION Given the available evidence, the peri-operative use of mannitol to prevent AKI cannot be considered an evidence based intervention in cardiac surgery, partial nephrectomy, and/or other major surgery. Further research is required with a focus on patients at high risk of post-operative AKI.
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Affiliation(s)
- Jan Waskowski
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Carmen A Pfortmueller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gabor Erdoes
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roman Buehlmann
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anna S Messmer
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jürg Schmidli
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Incidence and Impact of Acute Kidney Injury after Liver Transplantation: A Meta-Analysis. J Clin Med 2019; 8:jcm8030372. [PMID: 30884912 PMCID: PMC6463182 DOI: 10.3390/jcm8030372] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/05/2019] [Accepted: 03/14/2019] [Indexed: 02/06/2023] Open
Abstract
Background: The study’s aim was to summarize the incidence and impacts of post-liver transplant (LTx) acute kidney injury (AKI) on outcomes after LTx. Methods: A literature search was performed using the MEDLINE, EMBASE and Cochrane Databases from inception until December 2018 to identify studies assessing the incidence of AKI (using a standard AKI definition) in adult patients undergoing LTx. Effect estimates from the individual studies were derived and consolidated utilizing random-effect, the generic inverse variance approach of DerSimonian and Laird. The protocol for this systematic review is registered with PROSPERO (no. CRD42018100664). Results: Thirty-eight cohort studies, with a total of 13,422 LTx patients, were enrolled. Overall, the pooled estimated incidence rates of post-LTx AKI and severe AKI requiring renal replacement therapy (RRT) were 40.7% (95% CI: 35.4%–46.2%) and 7.7% (95% CI: 5.1%–11.4%), respectively. Meta-regression showed that the year of study did not significantly affect the incidence of post-LTx AKI (p = 0.81). The pooled estimated in-hospital or 30-day mortality, and 1-year mortality rates of patients with post-LTx AKI were 16.5% (95% CI: 10.8%–24.3%) and 31.1% (95% CI: 22.4%–41.5%), respectively. Post-LTx AKI and severe AKI requiring RRT were associated with significantly higher mortality with pooled ORs of 2.96 (95% CI: 2.32–3.77) and 8.15 (95%CI: 4.52–14.69), respectively. Compared to those without post-LTx AKI, recipients with post-LTx AKI had significantly increased risk of liver graft failure and chronic kidney disease with pooled ORs of 3.76 (95% CI: 1.56–9.03) and 2.35 (95% CI: 1.53–3.61), respectively. Conclusion: The overall estimated incidence rates of post-LTx AKI and severe AKI requiring RRT are 40.8% and 7.0%, respectively. There are significant associations of post-LTx AKI with increased mortality and graft failure after transplantation. Furthermore, the incidence of post-LTx AKI has remained stable over the ten years of the study.
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Intraoperative glucose variability, but not average glucose concentration, may be a risk factor for acute kidney injury after cardiac surgery: a retrospective study. Can J Anaesth 2019; 66:921-933. [DOI: 10.1007/s12630-019-01349-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 01/18/2019] [Accepted: 01/18/2019] [Indexed: 12/15/2022] Open
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Tamura T, Yatabe T, Namikawa T, Hanazaki K, Yokoyama M. Glucose control using a closed-loop device decreases inflammation after cardiovascular surgery without increasing hypoglycemia risk. J Artif Organs 2018; 22:154-159. [PMID: 30456660 DOI: 10.1007/s10047-018-1082-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 11/04/2018] [Indexed: 02/05/2023]
Affiliation(s)
- Takahiko Tamura
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan.
| | - Tomoaki Yatabe
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan.
| | - Tsutomu Namikawa
- Department of Surgery, Kochi Medical School, Nankoku, Kochi, Japan
| | | | - Masataka Yokoyama
- Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
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Huang CJ, Chang CH, Cheng KW, Chen CL, Wu SC, Shih TH, Yang SC, Lee YE, Huang CE, Jawan B, Wang CH, Juang SE. Correlation Between Blood Transfusion and Blood Glucose Levels in Adult Living Donor Liver Transplantation. Transplant Proc 2018; 50:2645-2647. [PMID: 30401367 DOI: 10.1016/j.transproceed.2018.02.203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 02/19/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND To evaluate the effect of dextrose contained in banked blood products on the changes of blood glucose levels in adult living donor liver transplantation patients retrospectively. METHODS Four hundred seventy-seven patients were divided into a non-blood transfusion (BT) group (G1) and a BT group (G2). The changes in blood glucose levels during the operation were compared using a Mann-Whitney U test, and a P value less than .05 was regarded as significant. RESULTS No significant changes were detected in blood glucose levels after anesthesia, during dissection phase, in the anhepatic phase, or after reperfusion between the groups. Estimated blood loss for G1 (n = 89) and G2 (n = 388) were 718 ± 514 and 5804 ± 877 mL respectively, G1 had no blood transfusion but G2 had received 4350 ± 6230 mL leukocyte-poor red blood cell transfusion, the pre- and end operation hemoglobin for G1 and G2 were 13.2 ± 2.0, 10.2 ± 1.9 and 10.1 ± 1.6, 10.2 ± 1.9 mg/dL respectively, indicating that they were not under or over transfused. CONCLUSION When banked blood products are used to replace ongoing blood loss, the dextrose contained in citrate-phosphate-dextrose-adenine seems to have no effect on the changes in the blood glucose levels of the recipients.
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Affiliation(s)
- C-J Huang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - C-H Chang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - K-W Cheng
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - C-L Chen
- Department of Surgery and Liver Transplantation Program, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - S-C Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - T-H Shih
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - S-C Yang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Y-E Lee
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - C-E Huang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - B Jawan
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - C-H Wang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - S-E Juang
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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Perioperative insulin therapy. ASIAN BIOMED 2018. [DOI: 10.1515/abm-2018-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Surgical patients commonly develop hyperglycemia secondary to the neuroendocrine stress response. Insulin treatment of hyperglycemia is required to overcome the perioperative catabolic state and acute insulin resistance. Besides its metabolic actions on glucose metabolism, insulin also displays nonmetabolic physiological effects. Preoperative glycemic assessment, maintenance of normoglycemia, and avoidance of glucose variability are paramount to optimize surgical outcomes. This review discusses the basic physiology and effects of insulin as well as practical issues pertaining to its management during the perioperative period.
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Shanks AM, Woodrum DT, Kumar SS, Campbell DA, Kheterpal S. Intraoperative hyperglycemia is independently associated with infectious complications after non-cardiac surgery. BMC Anesthesiol 2018; 18:90. [PMID: 30025516 PMCID: PMC6053803 DOI: 10.1186/s12871-018-0546-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 06/20/2018] [Indexed: 01/04/2023] Open
Abstract
Background Perioperative hyperglycemia and its associated increase in morbidity and mortality have been well studied in the critical care and cardiac surgery literature. However, there is little data regarding the impact of intraoperative hyperglycemia on post-operative infectious complications in non-cardiac surgery. Methods All National Surgery Quality Improvement Program patients undergoing general, vascular, and urological surgery at our tertiary care center were reviewed. After integrating intraoperative glucose measurements from our intraoperative electronic health record, we categorized patients as experiencing mild (8.3–11.0 mmol/L), moderate (11.1–16.6 mmol/L), and severe (≥ 16.7 mmol/L) intraoperative hyperglycemia. Using multiple logistic regression to adjust for patient comorbidities and surgical factors, we evaluated the association of hyperglycemia with the primary outcome of postoperative surgical site infection, pneumonia, urinary tract infection, or sepsis within 30 days. Results Of 13,954 patients reviewed, 3150 patients met inclusion criteria and had an intraoperative glucose measurement. 49% (n = 1531) of patients experienced hyperglycemia and 15% (n = 482) patients experienced an infectious complication. Patients with mild (adjusted odds ratio 1.30, 95% confidence interval [1.01 to 1.68], p-value = 0.04) and moderate hyperglycemia (adjusted odds ratio 1.57, 95% confidence interval [1.08–2.28], p-value = 0.02) had a statistically significant risk-adjusted increase in infectious complications. The model c-statistic was 0.72 [95% confidence interval 0.69–0.74]. Conclusions This is one of the first studies to demonstrate an independent relationship between intraoperative hyperglycemia and postoperative infectious complications. Future studies are needed to evaluate a causal relationship and impact of treatment. Electronic supplementary material The online version of this article (10.1186/s12871-018-0546-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amy M Shanks
- Department of Anesthesiology, Michigan Medicine, 1500 E. Medical Center Dr., SPC 5048, Ann Arbor, MI, 48109, USA.
| | - Derek T Woodrum
- Department of Anesthesiology, Michigan Medicine, 1500 E. Medical Center Dr., SPC 5048, Ann Arbor, MI, 48109, USA
| | - Sathish S Kumar
- Department of Anesthesiology, Michigan Medicine, 1500 E. Medical Center Dr., SPC 5048, Ann Arbor, MI, 48109, USA
| | - Darrell A Campbell
- Department of Surgery, Michigan Medicine, 1500 E. Medical Center Dr., SPC 5825, Ann Arbor, MI, 48109, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, Michigan Medicine, 1500 E. Medical Center Dr., SPC 5048, Ann Arbor, MI, 48109, USA
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Paka P, Lieber SR, Lee RA, Desai CS, Dupuis RE, Barritt AS. Perioperative glucose management and outcomes in liver transplant recipients: A qualitative systematic review. World J Transplant 2018; 8:75-83. [PMID: 29988867 PMCID: PMC6033739 DOI: 10.5500/wjt.v8.i3.75] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 02/20/2018] [Accepted: 04/01/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To investigate the relationship between post-liver transplantation (LT) glycemic control and LT outcomes. METHODS A qualitative systematic review on relevant prospective interventions designed to control glucose levels including insulin protocols. Studies investigating an association between glycemic control and post-LT outcomes such as mortality, graft rejection, and infection rate were reviewed. PubMed, EMBASE, and other databases were searched through October 2016. RESULTS Three thousands, six hundreds and ninety-two patients from 14 studies were included. Higher mortality rate was seen when blood glucose (BG) ≥ 150 mg/dL (P = 0.05). BG ≥ 150 mg/dL also led to higher rates of infection. Higher rates of graft rejection were seen at BG > 200 mg/dL (P < 0.001). Mean BG ≥ 200 mg/dL was associated with more infections (P = 0.002). Nurse-initiated protocols and early screening strategies have shown a reduction in negative post-LT outcomes. CONCLUSION Hyperglycemia in the perioperative period is associated with poor post-LT outcomes. Only a few prospective studies have designed interventions aimed at managing post-LT hyperglycemia, post-transplant diabetes mellitus (PTDM) and their impact on post-LT outcomes.
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Affiliation(s)
- Prani Paka
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Sarah R Lieber
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Ruth-Ann Lee
- Division of Abdominal Transplant, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC 27599, United States
| | - Chirag S Desai
- Division of Abdominal Transplant, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC 27599, United States
| | - Robert E Dupuis
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Alfred Sidney Barritt
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, United States
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Intermittent High Glucose Exacerbates A-FABP Activation and Inflammatory Response through TLR4-JNK Signaling in THP-1 Cells. J Immunol Res 2018; 2018:1319272. [PMID: 29850615 PMCID: PMC5925160 DOI: 10.1155/2018/1319272] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 02/15/2018] [Accepted: 03/19/2018] [Indexed: 01/01/2023] Open
Abstract
Background Glucose fluctuation confers additional risks on diabetes-related vascular diseases, but the underlying mechanisms are unknown. Macrophage activation mediated by TLR4-JNK signaling plays an important role during the progress of diabetes. In the present study, we hypothesize that glucose fluctuation results in macrophage inflammation through TLR4-JNK signaling pathways. Methods THP-1 cells were treated with normal glucose (5 mM), constant high glucose (25 mM), and intermittent high glucose (rotation per 6 h in 5 mM or 25 mM) for 24 h. The mRNA and protein expression levels of TLR4, p-JNK, and adipocyte fatty acid-binding protein (A-FABP) were determined, and the proinflammatory cytokines TNF-α and IL-1β were quantified. Results In constant high glucose, TLR4 expression and JNK phosphorylation levels increased, and this effect was more pronounced in intermittent high glucose. Accordingly, the expression of A-FABP and the release of the proinflammatory cytokines TNF-α and IL-1β also increased in response to constant high glucose, an effect that also was more evident in intermittent high glucose. The inhibition of p-JNK by SP600125 did not attenuate TLR4 expression, but totally inhibited both A-FABP expression and the production of the proinflammatory cytokines TNF-α and IL-1β in both constant and intermittent high glucose. Conclusions Intermittent high glucose potentiates A-FABP activation and inflammatory responses via TLR4/p-JNK signaling in THP-1 cells. These findings suggest a more detrimental impact of glucose fluctuation on macrophage inflammation in diabetes-related vascular diseases than thus far generally assumed.
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Hur M, Nam K, Jo WY, Kim G, Kim WH, Bahk JH. Association Between Elevated Echocardiographic Index of Left Ventricular Filling Pressure and Acute Kidney Injury After Off-Pump Coronary Artery Surgery. Circ J 2017; 82:857-865. [PMID: 29212963 DOI: 10.1253/circj.cj-17-0660] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The ratio of the early transmitral flow velocity to early diastolic velocity of the mitral annulus (E/e') is an echocardiographic index of mean left ventricular (LV) filling pressure. We investigated the association between the preoperative E/e' ratio and postoperative acute kidney injury (AKI) during off-pump coronary artery bypass surgery (OPCAB).Methods and Results:We reviewed 585 patients who underwent OPCAB and with preserved LV ejection fraction determined by preoperative echocardiography. AKI was determined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Multivariable logistic regression analysis was performed. E/e' was also analyzed as 3 categories (E/e' <8, 8≤E/e'≤15, and E/e' >15) and as a continuous variable. A propensity score analysis was used to match the patients with E/e' >15 and E/e' ≤15. A preoperative E/e' >15 was an independent predictor for AKI (odds ratio 3.01, 95% confidence interval 1.40-6.17). E/e' >15 was also an independent predictor for AKI when E/e' was analyzed with 3 categories or as a continuous variable. In the matched sample, the incidence of AKI and 1-year mortality was significantly higher in patients with E/e' >15. CONCLUSIONS Among patients undergoing OPCAB with preserved LV systolic function, a preoperative E/e' ratio >15 was an independent predictor of postoperative AKI. Measurement of the preoperative E/e' ratio may help to assess the risk of postoperative AKI.
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Affiliation(s)
- Min Hur
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital
| | - Karam Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital
| | - Woo Young Jo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital
| | - Gahyun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital
| | - Jae-Hyon Bahk
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital
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Nie S, Tang L, Zhang W, Feng Z, Chen X. Are There Modifiable Risk Factors to Improve AKI? BIOMED RESEARCH INTERNATIONAL 2017; 2017:5605634. [PMID: 28744467 PMCID: PMC5514336 DOI: 10.1155/2017/5605634] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 04/26/2017] [Accepted: 05/23/2017] [Indexed: 02/07/2023]
Abstract
Acute kidney injury (AKI) is a common critical syndrome, with high morbidity and mortality. Patients with AKI typically have an adverse prognosis, from incident chronic kidney disease (CKD), progression to end-stage renal disease (ESRD), subsequent cardiovascular disease, and ultimately death. However, there is currently no effective therapy for AKI. Early detection of risk factors for AKI may offer a good approach to prevention or early intervention. Traditional risk factors include extreme age, many common comorbid diseases, such as preexisting CKD, some specific exposures, such as sepsis, and exposure to some nephrotoxic agents. Recently, several novel risk factors for AKI, such as hyperuricemia, hypoalbuminemia, obesity, anemia, and hyperglycemia, have been identified. The underlying mechanisms between these nontraditional risk factors and AKI and whether their correction can reduce AKI occurrence remain to be clarified. This review describes the current epidemiology of AKI, summarizes its outcome, outlines the traditional risk profile, and finally highlights some recently identified novel risk factors.
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Affiliation(s)
- Sasa Nie
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing 100853, China
| | - Li Tang
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing 100853, China
| | - Weiguang Zhang
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing 100853, China
| | - Zhe Feng
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing 100853, China
| | - Xiangmei Chen
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing 100853, China
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Preoperative aspirin use and acute kidney injury after cardiac surgery: A propensity-score matched observational study. PLoS One 2017; 12:e0177201. [PMID: 28472145 PMCID: PMC5417712 DOI: 10.1371/journal.pone.0177201] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 04/24/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The association between preoperative aspirin use and postoperative acute kidney injury (AKI) in cardiovascular surgery is unclear. We sought to evaluate the effect of preoperative aspirin use on postoperative AKI in cardiac surgery. METHODS A total of 770 patients who underwent cardiovascular surgery under cardiopulmonary bypass were reviewed. Perioperative clinical parameters including preoperative aspirin administration were retrieved. We matched 108 patients who took preoperative aspirin continuously with patients who stopped aspirin more than 7 days or did not take aspirin for the month before surgery. The parameters used in the matching included variables related to surgery type, patient's demographics, underlying medical conditions and preoperative medications. RESULTS In the first seven postoperative days, 399 patients (51.8%) developed AKI, as defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria and 128 patients (16.6%) required hemodialysis. Most patients took aspirin 100 mg once daily (n = 195, 96.5%) and the remaining 75 mg once daily. Multivariable analysis showed that preoperative maintenance of aspirin was independently associated with decreased incidence of postoperative AKI (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.21-0.98, P = 0.048; after propensity score matching: OR 0.39, 95% CI 0.22-0.67, P = 0.001). Preoperative maintenance of aspirin was associated with less incidence of AKI defined by KDIGO both in the entire and matched cohort (n = 44 [40.7%] vs. 69 [63.9%] in aspirin and non-aspirin group, respectively in matched sample, relative risk [RR] 0.64, 95% CI 0.49, 0.83, P = 0.001). Preoperative aspirin was associated with decreased postoperative hospital stay after matching (12 [9-18] days vs. 16 [10-25] in aspirin and non-aspirin group, respectively, P = 0.038). Intraoperative estimated or calculated blood loss using hematocrit difference and estimated total blood volume showed no difference according to aspirin administration in both entire and matched cohort. CONCLUSIONS Preoperative low dose aspirin administration without discontinuation was protective against postoperative AKI defined by KDIGO criteria independently in both entire and matched cohort. Preoperative aspirin was also associated with decreased hemodialysis requirements and decreased postoperative hospital stay without increasing bleeding. However, differences in AKI and hospital stay were not associated with in-hospital mortality.
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de Haan JE, Hoorn EJ, de Geus HRH. Acute kidney injury after liver transplantation: Recent insights and future perspectives. Best Pract Res Clin Gastroenterol 2017. [PMID: 28624104 DOI: 10.1016/j.bpg.2017.03.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Acute kidney injury (AKI) is a common postoperative complication after liver transplantation (LT). The occurrence of postoperative AKI after LT (Post-LT AKI) is associated with inferior patient and graft outcomes. Post-LT AKI is multifactorial in origin and has been related to the severity of liver disease, pre-LT renal dysfunction, graft quality, perioperative events and toxicity of immunosuppressive therapy. Furthermore it is thought that hepatic ischaemia reperfusion injury might be a driving force in the aetiology of post-LT AKI. Novel biomarkers for AKI are emerging and can be useful for early identification and characterization of AKI. There is a clear need for strategies aimed at preventing or treating post-LT AKI. Several pharmacological and non-pharmacological interventions have been studied, but so far failed to show any benefit in the prevention of post-LT AKI. Further studies are needed to develop and evaluate new interventions aimed at preventing post-LT AKI and improve patient outcomes.
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Affiliation(s)
- Jubi E de Haan
- Department of Adult Intensive Care, Erasmus MC University Medical Centre, Rotterdam, The Netherlands.
| | - Ewout J Hoorn
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Hilde R H de Geus
- Department of Adult Intensive Care, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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Sakai T, Zerillo J. Noteworthy Literature Published in 2016 for Abdominal Organ Transplantation Anesthesiologists. Semin Cardiothorac Vasc Anesth 2017; 21:58-69. [PMID: 28100111 DOI: 10.1177/1089253216688536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
More than 3000 peer-reviewed publications on the topic of liver transplantation were published in 2016. The goal of this article is to provide a concise review of pertinent literature for anesthesiologists who participate in liver transplantation. The authors selected and presented 33 articles published in 2016 on the topics of MELD policy; cardiovascular, pulmonary, and renal issues; coagulation and transfusion; anesthetic agents; hemodynamic monitors; acute liver failure; and donor issues.
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Affiliation(s)
- Tetsuro Sakai
- 1 University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeron Zerillo
- 2 Icahn School of Medicine at Mount Sinai, New York, NY, USA
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