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Zhu Z, Chi X, Chen Y, Ma X, Tang Y, Li D, Zhang M, Su D. Perioperative management of kidney transplantation in China: A national survey in 2021. PLoS One 2024; 19:e0298051. [PMID: 38354172 PMCID: PMC10866523 DOI: 10.1371/journal.pone.0298051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/17/2024] [Indexed: 02/16/2024] Open
Abstract
Perioperative anaesthesia management has an important significance for kidney transplantation; however, the related consensus remains limited. An electronic survey with 44 questions was developed and sent to the chief anaesthesiologist at 115 non-military medical centres performing kidney transplantation in China through WeChat. A response rate of 81.7% was achieved from 94 of 115 non-military medical centres, where 94.4% of kidney transplants (10404 /11026) were completed in 2021. The result showed an overview of perioperative practice for kidney transplantations in China, identify the heterogeneity, and provide evidence for improving perioperative management of kidney transplantation. Some controversial therapy, such as hydroxyethyl starch, are still widely used, while some recommended methods are not widely available. More efforts on fluid management, hemodynamical monitoring, perioperative anaesthetics, and postoperative pain control are needed to improve the outcomes. Evidence-based guidelines for standardizing clinical practice are needed.
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Affiliation(s)
- Ziyu Zhu
- Department of Anaesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiaoying Chi
- Department of Anaesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yuwen Chen
- Department of Anaesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiaowen Ma
- Department of Anaesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Ying Tang
- Department of Anaesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Dawei Li
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ming Zhang
- Department of Urology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Diansan Su
- Department of Anaesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Choo CL, Law LS, How WJ, Goh BY, Ashokka B. A systematic review and meta-analysis on the effect of goal-directed fluid therapy on postoperative outcomes in renal transplantation surgeries. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023; 52:679-694. [PMID: 38920161 DOI: 10.47102/annals-acadmedsg.202367] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
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.
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Affiliation(s)
- Caitlin Lmc Choo
- Department of Anaesthesia, National University Hospital, Singapore
| | - Lawrence Sc Law
- Department of Medicine, National University Hospital, Singapore
| | - Wen Jie How
- Department of Anaesthesia, National University Hospital, Singapore
| | - Benjamin Ys Goh
- National University Centre for Organ Transplantation, National University Hospital, Singapore
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3
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Ngai J, Keny N, James L, Katz S, Moazami N. Intraoperative Considerations and Management of Simultaneous Heart Kidney Transplantation. J Cardiothorac Vasc Anesth 2023; 37:1862-1869. [PMID: 37210325 DOI: 10.1053/j.jvca.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/21/2023] [Accepted: 05/01/2023] [Indexed: 05/22/2023]
Affiliation(s)
- Jennie Ngai
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Langone Health, New York, New York.
| | - Nikhil Keny
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Langone Health, New York, New York
| | - Les James
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Simon Katz
- NYIT College of Osteopathic Medicine, Glen Head, New York
| | - Nader Moazami
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
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4
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Patel GP, Smith SA, Romej M, McAdoo B, Wilson EA. Use of Intramuscular Ephedrine Sulfate During Kidney Transplantation. Clin Pharmacol 2023; 15:57-61. [PMID: 37387793 PMCID: PMC10305767 DOI: 10.2147/cpaa.s418124] [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: 05/08/2023] [Accepted: 06/21/2023] [Indexed: 07/01/2023] Open
Abstract
Hypotension during kidney transplantation can be common. Vasopressor use during these procedures is often avoided, with a fear of decreasing renal perfusion in the transplanted kidney. However, adequate perfusion for the rest of the body is also necessary, and given that these patients often have underlying hypertension or other comorbid conditions, an appropriate mean arterial pressure (MAP) has to be maintained. Intramuscular injections of ephedrine have been studied in the anesthesiology literature in a variety of case types, and it is seen as a safe and effective method to boost MAP. We present a case series of three patients who underwent renal transplantation and who received an intramuscular injection of ephedrine for hypotension control. The medication worked well for increasing blood pressures without apparent side effects. All three patients were followed for more than one year, and all patients had good graft function at the end of that time period. This series shows that while further research is necessary in this arena, intramuscular ephedrine may have a place in the management of persistent hypotension in the operating room during kidney transplantation.
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Affiliation(s)
- Gaurav P Patel
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Susan A Smith
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Michelle Romej
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Billynda McAdoo
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Elizabeth A Wilson
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, 30322, USA
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5
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Panchal V, Sivasubramanian BP, Samala Venkata V. Crystalloid Solutions in Hospital: A Review of Existing Literature. Cureus 2023; 15:e39411. [PMID: 37362468 PMCID: PMC10287545 DOI: 10.7759/cureus.39411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
Intravenous fluids (IVF) like normal saline (NS) and Ringer's lactate (RL) are often crucial in the management of hospitalized patients. Mishandling these fluids can lead to complications in about 20% of patients receiving them. In this review, we present the current evidence through the identification of observational studies and randomized trials that observed the optimal use of IVF. We found that NS may cause hyperchloremic metabolic acidosis in surgical patients, but there is no clear difference in mortality and long-term outcomes between NS and balanced crystalloids. Critically ill patients, particularly those in sepsis, benefit from balanced crystalloids, as high chloride content fluids like NS increase the risk of complications and mortality. In pancreatitis, NS has been shown to increase the risk of ICU admission when compared to RL; however, there is no significant difference in long-term outcomes and mortality between the fluids. RL is preferred for burns due to its isotonicity and lack of protein, preventing edema formation in an already dehydrated state. Plasma-lyte may resolve diabetic ketoacidosis faster, while prolonged NS use can lead to metabolic acidosis, acute kidney injury, and cerebral edema. In conclusion, NS, RL, and plasma-lyte are the most commonly used isotonic IVF in the hospital population. Incorrect choice of fluids in a different clinical scenario can lead to worse outcomes.
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Affiliation(s)
- Viraj Panchal
- Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College, Ahmedabad, IND
| | - Barath Prashanth Sivasubramanian
- Infectious Diseases, University of Texas Health Science Center at San Antonio, San Antonio, USA
- Internal Medicine, ESIC Medical College & PGIMSR, Chennai, IND
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Fabes J, Al Midani A, Sarna AS, Hadi DH, Naji SA, Banga NR, Jones GL, Berry PD, Wittenberg MD. Goal-Directed Haemodynamic Therapy Improves Patient Outcomes in Kidney Transplantation. Prog Transplant 2023; 33:150-155. [PMID: 36938604 DOI: 10.1177/15269248231164165] [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: 03/21/2023]
Abstract
Introduction: Kidney transplant graft function depends on optimised haemodynamics. However, high fluid volumes risk hypervolaemic complications. The Edwards Lifesciences ClearSight™ device permits fluid titration through markers of preload and beat-to-beat blood pressure monitoring. We evaluated the implementation of a novel goal-directed haemodynamic therapy protocol to determine whether patient outcomes had improved. Design: A retrospective evaluation of standard care versus goal-directed haemodynamic therapy in adults undergoing kidney transplantation was performed in a single centre between April 2016 and October 2019. Twenty-eight standard-of-care patients received intraoperative fixed-rate infusion and 28 patients received goal-directed haemodynamic therapy. The primary outcome was volume of fluid administered intraoperatively. Secondary outcomes included blood product and vasoactive drug exposure, graft and recipient outcomes. Results: Intraoperative fluid administered was significantly reduced in the goal-directed haemodynamic therapy cohort (4325 vs 2751 ml, P < .001). Exposure to vasopressor (67.9% vs 42.9%, P = .060) and blood products (17.9% vs 3.6%, P = .101) was unchanged. Immediate graft function (82.1% vs 75.0%, P = .515), dialysis requirement (14.3% vs 21.4%, P = .729) and creatinine changes post-operatively were unchanged. In the goal-directed haemodynamic therapy cohort, 1 patient had pulmonary oedema (3.6%) versus 21.4% in the standard cohort. Patients in the goal-directed haemodynamic therapy group were more likely to mobilise within 48 hours of surgery (number needed to treat = 3.5, P = .012). Conclusions: Protocolised goal-directed haemodynamic therapy in kidney transplantation was safe and may improve patient, graft, and surgical outcomes. Clinical trials assessing goal-directed approaches are needed.
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Affiliation(s)
- Jez Fabes
- 4965Royal Free London NHS Foundation Trust, London, UK.,159274Peninsula Medical School, University of Plymouth, Plymouth, UK
| | | | - Aman S Sarna
- 4965Royal Free London NHS Foundation Trust, London, UK
| | - Dina H Hadi
- 4965Royal Free London NHS Foundation Trust, London, UK
| | - Saqib A Naji
- 4965Royal Free London NHS Foundation Trust, London, UK
| | - Neal R Banga
- 4965Royal Free London NHS Foundation Trust, London, UK
| | | | - Peter D Berry
- 4965Royal Free London NHS Foundation Trust, London, UK
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Value of Central Venous Pressure Monitoring in the Patients with Sepsis-Associated Acute Kidney Injury. DISEASE MARKERS 2022; 2022:9652529. [DOI: 10.1155/2022/9652529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 11/23/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022]
Abstract
Background. Although the measurement of central venous pressure (CVP) is a common clinical tool, the role of CVP monitoring in the outcome of sepsis is controversial because threshold values of CVP are uncertain, and there are only limited data on short-term survival of patients with septic acute kidney injury (AKI). Methods. This retrospective cohort study was based on the Medical Information Mart for Intensive Care IV (MIMIC-IV) database (source of the training dataset). Multivariate regression analysis was performed to clarify the relation between CVP measurement and clinical outcomes, and a univariate regression model after propensity score matching was utilized to validate our findings. A mortality prediction model for septic AKI and a risk stratification scoring approach were developed, and the emergency intensive care unit (eICU) database was used for external validation. Results. Of the 9170 patients in the training set, 2446 (26.7%) underwent CVP measurement. No significant association was found between CVP monitoring and 28-day mortality among patients with septic AKI (odds
; 95% confidence interval 0.213-1.076,
), even after adjustments (propensity score matching;
). Length of ICU stay and hospital stay was markedly reduced in patients undergoing CVP measurement within 3 hours (median 6.2 and 10.9 days, respectively,
). The addition of the mean perfusion pressure initial, CVP, and the magnitude of the CVP change within 48 hours to the model significantly increased model discrimination (area under the receiver operating characteristic curve: 0.867 and 0.780, respectively,
). Conclusions. These findings suggest that CVP measurement alone has little effect on the outcome of septic AKI. Nonetheless, initial CVP levels and the dynamic changes in CVP within the first 48 hours after ICU admission and the mean perfusion pressure initial can improve the accuracy of outcome prediction models.
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Jung S, Kim J, Lee J, Choi SY, Joo HJ, Koo BN. Effects of the Type of Intraoperative Fluid in Living Donor Kidney Transplantation: A Single-Center Retrospective Cohort Study. Yonsei Med J 2022; 63:380-388. [PMID: 35352890 PMCID: PMC8965431 DOI: 10.3349/ymj.2022.63.4.380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 11/23/2021] [Accepted: 12/11/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Perioperative fluid management in kidney transplant recipients is crucial to supporting the fluid, acid-base, and electrolyte balance required for graft perfusion. However, the choice of intraoperative crystalloids in kidney transplantation remains controversial. We conducted a single-center retrospective cohort study to evaluate the impact of intraoperative fluids on acid-base and electrolyte balance and graft outcomes. MATERIALS AND METHODS We included 282 living donor kidney transplant recipients from January 2010 to December 2017. Patients were classified into two groups based on the type of intraoperative crystalloids used (157 patients in the half saline group and 125 patients in the balanced crystalloid solutions group, Plasma-lyte). RESULTS Compared with the half saline group, the Plasma-lyte group showed less metabolic acidosis and hyponatremia during surgery. Hyperkalemia incidence was not significantly different between the two groups. Changes in postoperative graft function assessed by blood urea nitrogen and creatinine were significantly different between the two groups. Patients in the Plasma-lyte group exhibited consistently higher glomerular filtration rates than those in the half saline group at 1 month and 1 year after transplantation after adjusting for demographic differences. CONCLUSION Intraoperative Plasma-lyte can lead to more favorable results in terms of acid-base balance during kidney transplantation. Patients who received Plasma-lyte showed superior postoperative graft function at 1 month and 1 year after transplantation. Further studies are needed to evaluate the superiority of intraoperative Plasma-lyte over other types of crystalloids in relation to graft outcomes.
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Affiliation(s)
- Seungho Jung
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jeongmin Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Juhan Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Su Youn Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Ji Joo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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Balancing the tug of war: intraoperative and postoperative management of multiorgan transplantation. Curr Opin Organ Transplant 2022; 27:57-63. [PMID: 34939965 DOI: 10.1097/mot.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Multiorgan heart transplants (MOHT) have steadily increased and account for approximately 4% of all heart transplants performed. Although long-term outcomes of MOHT are similar to heart transplant alone, perioperative management remains an issue with nearly double the rate of prolonged hospitalization. Better understanding of hemodynamic environments encountered and appropriate therapeutic targets can help improve perioperative management. RECENT FINDINGS Accurate and precise hemodynamic monitoring allows for early identification of complications and prompt assessment of therapeutic interventions. This can be achieved with a multimodal approach using traditional monitoring tools, such a pulmonary artery catheter and arterial line in conjunction with transesophageal echocardiography. Specific targets for optimizing graft perfusion are determined by phase of surgery and organ combination. In some circumstances, the surgical sequence of transplant can help mitigate or avoid certain detrimental hemodynamic environments. SUMMARY With better understanding of the array of hemodynamic environments that can develop during MOHT, we can work to standardize hemodynamic targets and therapeutic interventions to optimize graft perfusion. Effectively navigating this perioperative course with multimodal monitoring including transesophageal echocardiography can mitigate impact of complications and reduce prolonged hospitalization associated with MOHT.
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Prajapati M, Trivedi V, Prajapati D, Bhosale G, Nayak J, Panchal H. Is Inferior vena cava diameter, a reliable indicator for fluid status in end-stage renal disease patients? - A prospective observational study. INDIAN JOURNAL OF TRANSPLANTATION 2022. [DOI: 10.4103/ijot.ijot_32_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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11
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Fayed A, ALKouny A, ALHarbi M, ALTheaby A, Aboalsamh G. Crystalloid fluids and delayed graft function in kidney transplant: A cohort study. Saudi J Anaesth 2022; 16:38-44. [PMID: 35261587 PMCID: PMC8846252 DOI: 10.4103/sja.sja_334_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/07/2021] [Accepted: 06/08/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Normal saline is commonly used in the perioperative kidney transplant period; its high chloride content can cause hyperchloremic metabolic acidosis giving a possible advantage to balanced electrolyte solutions due to their lower chloride content. The evidence regarding the best practices in fluid management during kidney transplantation and its effect on the incidence of delayed graft function (DGF) is still limited. Materials and Methods: One hundred thirty-eight patients were included and followed up for seven days after surgery. Administered crystalloid type and volume were compared among patients with and without DGF, along with additional patient and surgical variables. To investigate whether intraoperative fluid type/amount influence DGF, patients were categorized into three groups: those who received mainly (>50%) lactated Ringer's solution, normal saline, or plasmaLyte. A logistic regression analysis was used to define variables independently correlated with DGF, and odds ratios (OR) with a 95% confidence interval (CI) were reported. Results: The incidence of DGF was 8.7%. Cold ischemia time independently increased the odds of DGF (OR = 1.006 (95% CI: 1.002–1.011) while fluid type (saline versus PlasmaLyte OR = 5.28, 95% CI: 0.76–36.88) or amount (OR = 1.00, 95% CI: 1.00–1.01) did not significantly modify the odds of DGF. Central venous pressure, systolic blood pressure, and mean arterial pressure were higher in the non-DGF group, but this was not statistically significant (P > 0.05). Significant intraoperative acidosis developed in patients who received normal saline compared to those in PlasmaLyte and lactated Ringer's groups; however, acid–base balance and electrolytes did not vary significantly between the DGF and non-DGF groups. Conclusion: DGF was primarily influenced by surgical factors such as cold ischemia time, whereas intraoperative fluid type or amount did not affect DGF incidence.
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12
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Groves HK, Lee H. Perioperative Management of Renal Failure and Renal Transplant. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00019-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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13
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Perez Jimenez P, Kim SJ, McCluskey SA. Fluid management for kidney transplantation: is it really about more or less? Can J Anaesth 2021; 69:13-17. [PMID: 34782997 DOI: 10.1007/s12630-021-02131-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 08/29/2021] [Accepted: 08/31/2021] [Indexed: 10/19/2022] Open
Affiliation(s)
- Paula Perez Jimenez
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada.,Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - S Joseph Kim
- Department of Medicine (Nephrology), University of Toronto, Toronto, ON, Canada.,Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Stuart A McCluskey
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada. .,MultiOrgan Transplant Program, Toronto General Hospital, University Health Network, Eaton North 4-421, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
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14
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Kannan G, Loganathan S, Kajal K, Hazarika A, Sethi S, Sen IM, Subramanyam R, Singh S. The effect of pulse pressure variation compared with central venous pressure on intraoperative fluid management during kidney transplant surgery: a randomized controlled trial. Can J Anaesth 2021; 69:62-71. [PMID: 34750747 DOI: 10.1007/s12630-021-02130-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 07/19/2021] [Accepted: 07/29/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Traditionally, fluid administration during kidney transplant surgery is guided by central venous pressure (CVP) despite its limited reliability as a parameter for assessing intravascular fluid volume, particularly in patients with cardiovascular diseases. The recommended goals at graft reperfusion are a mean arterial pressure of 90 mm Hg and a CVP of 12-14 mm Hg. This approach may increase the risk of significant adverse effects due to volume overload. Perioperative fluid therapy guided by dynamic indices of fluid responsiveness has been shown to optimize intravascular volume and prevent complications associated with overzealous administration of fluids in major abdominal surgeries. We hypothesized that pulse pressure variation (PPV)-guided fluid administration would result in better optimization of intravascular fluid volume compared with a CVP-guided strategy during kidney transplant surgery. METHODS In this single-centre randomized double blinded trial, 77 end-stage renal disease patients, who underwent kidney transplant surgery under general anesthesia with epidural analgesia, were randomized to receive either CVP-guided (n = 35) or PPV-guided (n = 35) fluid therapy using predefined hemodynamic endpoints. The primary outcome was the total volume of intraoperative fluids administered. Secondary outcomes were intraoperative hemodynamic changes, serum lactate levels, serum creatinine, need for dialysis within the first week, creatinine elimination ratio, and incidence of immediate and delayed graft dysfunction. RESULTS Results were analyzed for 70 patients. Eighty percent of the patients underwent living-related donor allograft kidney transplant. Operative variables related to donor characteristics, duration of surgery, graft cold ischemia time, and blood loss were comparable in both groups. The mean (standard deviation) volume of intravenous fluids administered intraoperatively was 1,346 (337) mL in the PPV-guided group vs 1,901 (379) mL in the CVP-guided group (difference in means, 556 mL; 95% confidence interval, 385 to 727; P = 0.001). There were no significant differences in secondary outcomes between the two groups. CONCLUSION Pulse pressure variation -guided fluid administration significantly decreased the total volume of crystalloids compared with CVP-guided fluid therapy during the intraoperative period in patients who underwent kidney transplant surgery. Nevertheless, our study was underpowered to detect differences in secondary outcomes. TRIAL REGISTRATION www.ctri.nic.in (CTRI/2018/01/011638); registered 31 January 2018.
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Affiliation(s)
- Gowtham Kannan
- Department of Anesthesiology and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sekar Loganathan
- Department of Anesthesiology and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kamal Kajal
- Department of Anesthesiology and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Amarjyoti Hazarika
- Department of Anesthesiology and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sameer Sethi
- Department of Anesthesiology and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Indu Mohini Sen
- Department of Anesthesiology and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajeev Subramanyam
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sarbpreet Singh
- Department of Kidney Transplant Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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15
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do Nascimento Junior P, Dohler LE, Ogawa CMU, de Andrade LGM, Braz LG, Módolo NSP. Effects of Plasma-Lyte® and 0.9% saline in renal function after deceased-donor kidney transplant: a randomized controlled trial. Braz J Anesthesiol 2021; 72:711-719. [PMID: 34563559 DOI: 10.1016/j.bjane.2021.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 08/10/2021] [Accepted: 08/28/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The influence of different crystalloid solutions infused during deceased-donor kidney transplant on the incidence of delayed graft function remains unclear. We investigated the influence of Plasma-Lyte® vs. 0.9% saline on the incidence of delayed graft function in deceased-donor kidney transplant recipients. METHODS We conducted a single-blind randomized controlled trial of 104 patients aged 18 to 65 years who underwent deceased-donor kidney transplant under general anesthesia. Patients were randomly assigned to receive either Plasma-Lyte® (n = 52) or 0.9% saline (n = 52), at the same infusion volume, for intraoperative fluid replacement. The primary outcome was the occurrence of delayed graft function. Secondary outcomes included metabolic and electrolytic changes at the end of surgery. RESULTS Two patients in the Plasma-Lyte® group and one in the 0.9% saline group died postoperatively and were not included for analysis. The incidence of delayed graft function in Plasma-Lyte® and 0.9% saline groups were 60.0% (95% Confidence Interval [95% CI 46.2-72.4]) and 74.5% (95% CI 61.1-84.4), respectively (p = 0.140). Mean (standard deviation) values of immediate postoperative pH and serum chloride levels in Plasma-Lyte® and 0.9% saline groups were 7.306 (0.071) and 7.273 (0.061) (p = 0.013), and 99.6 (4.2) mEq.L-1 and 103.3 (5.6) mEq.L-1, respectively (p < 0.001). All other postoperative metabolic and electrolyte variables were not statistically different at the immediate postoperative period (p > 0.05). CONCLUSION In deceased-donor kidney transplant recipients, the incidence of delayed graft function is not influenced by Plasma-Lyte® or 0.9% saline used for intraoperative fluid replacement.
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Affiliation(s)
- Paulo do Nascimento Junior
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, Botucatu, SP, Brazil.
| | - Lucas Esteves Dohler
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, Botucatu, SP, Brazil
| | - Cindy Midori Uchida Ogawa
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, Botucatu, SP, Brazil
| | - Luís Gustavo Modelli de Andrade
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Hospital das Clínicas, Programa de Transplante Renal, Botucatu, SP, Brazil
| | - Leandro Gobbo Braz
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, Botucatu, SP, Brazil
| | - Norma Sueli Pinheiro Módolo
- Universidade Estadual Paulista (UNESP), Faculdade de Medicina de Botucatu, Departamento de Especialidades Cirúrgicas e Anestesiologia, Botucatu, SP, Brazil
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16
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Harbell MW, Kraus MB, Bucker-Petty SA, Harbell JW. Intraoperative fluid management and kidney transplantation outcomes: A retrospective cohort study. Clin Transplant 2021; 35:e14489. [PMID: 34546602 DOI: 10.1111/ctr.14489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients undergoing kidney transplantation traditionally receive liberal amounts of fluid during surgery. However, excessive fluids can lead to fluid overload and ileus. In this retrospective cohort study, we compared the effect of restrictive versus liberal fluid therapy on kidney transplantation outcomes. METHODS Patients who underwent deceased-donor kidney transplantation at Mayo Clinic from January 2014 to March 2019 were included. Those who received <3 L of intravenous fluids intraoperatively were categorized as "restrictive;" those who received ≥3 L were categorized as "liberal." The primary outcome was incidence of delayed graft function (DGF). Secondary outcomes included length of stay, readmission within 30 days, time to return of bowel function, and incidence of postoperative complications. RESULTS Of the 1171 patients included, 557 were in the restrictive group and 614 in the liberal group. The mean (SD) fluid intake was 2.17 (.54) L in the restrictive group and 3.67 (.68) L in the liberal group (P<.001). There was no difference in DGF (relative risk, 1.03; P = .56), length of stay (P = .34), readmission (P = .80), return of bowel function (P = .71), or other postoperative complications. CONCLUSIONS Intraoperative restrictive fluid therapy during kidney transplantation was not associated with DGF or worse outcomes when compared with liberal fluid therapy.
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Affiliation(s)
- Monica W Harbell
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Molly B Kraus
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | | | - Jack W Harbell
- Division of Transplant and Hepatobiliary Surgery, Mayo Clinic, Scottsdale, Arizona, USA.,Transplant Center, Mayo Clinic Hospital, Phoenix, Arizona, USA
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17
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Wagener G, Bezinover D, Wang C, Kroepfl E, Diaz G, Giordano C, West J, Kindscher JD, Moguilevitch M, Nicolau-Raducu R, Planinsic RM, Rosenfeld DM, Lindberg S, Schumann R, Pivalizza EG. Fluid Management During Kidney Transplantation: A Consensus Statement of the Committee on Transplant Anesthesia of the American Society of Anesthesiologists. Transplantation 2021; 105:1677-1684. [PMID: 33323765 DOI: 10.1097/tp.0000000000003581] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intraoperative fluid management may affect the outcome after kidney transplantation. However, the amount and type of fluid administered, and monitoring techniques vary greatly between institutions and there are limited prospective randomized trials and meta-analyses to guide fluid management in kidney transplant recipients. METHODS Members of the American Society of Anesthesiologists (ASA) committee on transplantation reviewed the current literature on the amount and type of fluids (albumin, starches, 0.9% saline, and balanced crystalloid solutions) administered and the different monitors used to assess fluid status, resulting in this consensus statement with recommendations based on the best available evidence. RESULTS Review of the current literature suggests that starch solutions are associated with increased risk of renal injury in randomized trials and should be avoided in kidney donors and recipients. There is no evidence supporting the routine use of albumin solutions in kidney transplants. Balanced crystalloid solutions such as Lactated Ringer are associated with less acidosis and may lead to less hyperkalemia than 0.9% saline solutions. Central venous pressure is only weakly supported as a tool to assess fluid status. CONCLUSIONS These recommendations may be useful to anesthesiologists making fluid management decisions during kidney transplantation and facilitate future research on this topic.
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Affiliation(s)
| | | | - Cynthia Wang
- Greater Los Angeles VA Healthcare System, Los Angeles, CA
| | | | | | | | - James West
- Methodist-LeBonheur Healthcare Memphis, TN
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18
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Jia H, Huang F, Zhang X, Cheng J, Chen J, Wu J. Early perioperative fluid overload is associated with adverse outcomes in deceased donor kidney transplantation. Transpl Int 2021; 34:1862-1874. [PMID: 34053132 DOI: 10.1111/tri.13926] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/24/2021] [Accepted: 05/15/2021] [Indexed: 10/21/2022]
Abstract
Kidney transplant recipients are often treated with a large volume of infusion to attain adequate graft perfusion in the early perioperative period. However, it remains unknown whether this fluid therapy is renal responsive or a contributing factor to fluid overload complications. We conducted a retrospective cohort analysis of all recipients who received deceased donor kidney transplantation at an academic teaching hospital from January 2015 to April 2019. Our exposure of interest was early perioperative fluid balance. The primary outcome was graft function at 1, 6, and 12 months after transplantation. The secondary outcome was cardiopulmonary and gastrointestinal complications. Fluid balance was not significantly correlated with graft function in short- or long-term periods. Postoperative complications were higher in recipients with increased fluid balance. Delayed graft function was significantly related to cardiopulmonary and gastrointestinal complications. Cardiovascular disease and high BMI of recipients were strong risk factors for cardiopulmonary complications. Fluid overload was prevalent in the early perioperative period of kidney transplantation. It did not promote renal recovery, but was associated with a high risk of complications. Our findings might be a useful indicator to optimize the perioperative fluid management of kidney transplant recipients.
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Affiliation(s)
- Hanying Jia
- Kidney Disease Center, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China.,Key Laboratory of Nephropathy, Hangzhou, China.,Kidney Disease Immunology Laboratory, the Third-Grade Laboratory, State Administration of Traditional Chinese Medicine of China, Hangzhou, China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health of China, Hangzhou, China.,Institute of Nephropathy, Zhejiang University, Hangzhou, China
| | - Fuhan Huang
- HuZhou Central Hospital, Affiliated Hospital of HuZhou Normal University, HuZhou, China
| | - Xing Zhang
- Kidney Disease Center, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China.,Key Laboratory of Nephropathy, Hangzhou, China.,Kidney Disease Immunology Laboratory, the Third-Grade Laboratory, State Administration of Traditional Chinese Medicine of China, Hangzhou, China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health of China, Hangzhou, China.,Institute of Nephropathy, Zhejiang University, Hangzhou, China
| | - Jun Cheng
- Kidney Disease Center, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China.,Key Laboratory of Nephropathy, Hangzhou, China.,Kidney Disease Immunology Laboratory, the Third-Grade Laboratory, State Administration of Traditional Chinese Medicine of China, Hangzhou, China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health of China, Hangzhou, China.,Institute of Nephropathy, Zhejiang University, Hangzhou, China
| | - Jianghua Chen
- Kidney Disease Center, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China.,Key Laboratory of Nephropathy, Hangzhou, China.,Kidney Disease Immunology Laboratory, the Third-Grade Laboratory, State Administration of Traditional Chinese Medicine of China, Hangzhou, China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health of China, Hangzhou, China.,Institute of Nephropathy, Zhejiang University, Hangzhou, China
| | - Jianyong Wu
- Kidney Disease Center, College of Medicine, The First Affiliated Hospital, Zhejiang University, Hangzhou, China.,Key Laboratory of Nephropathy, Hangzhou, China.,Kidney Disease Immunology Laboratory, the Third-Grade Laboratory, State Administration of Traditional Chinese Medicine of China, Hangzhou, China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health of China, Hangzhou, China.,Institute of Nephropathy, Zhejiang University, Hangzhou, China
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19
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McGahan RK, Tang JE, Iyer MH, Flores AS, Gorelik LA. Combined Liver Kidney Transplant in Adult Patient With Alagille Syndrome and Pulmonary Hypertension. Semin Cardiothorac Vasc Anesth 2021; 25:191-195. [DOI: 10.1177/10892532211008742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
In this article, we describe a case of a 33-year-old female with Alagille syndrome complicated by bilateral branch pulmonary artery stenosis resulting in moderate pulmonary hypertension, end-stage liver disease complicated by portal hypertension, and chronic renal disease who presented for combined liver-kidney transplant. Alagille syndrome is an autosomal dominant disease affecting the liver, heart, and kidneys. Multidisciplinary preoperative evaluation was performed with a team consisting of a congenital heart disease cardiologist, a cardiac anesthesiologist, a nephrologist, and a transplant surgeon. We describe Alagille syndrome and our intraoperative management. To our knowledge, this is the first description of a combined liver-kidney transplant in an adult patient with Alagille syndrome.
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Affiliation(s)
- Rose K. McGahan
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jonathan E. Tang
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Manoj H. Iyer
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
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20
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Collange O, Tacquard C, Oulehri W, Biehler J, Moulin B, Mertes PM, Lejay A, Caillard S. Hemodynamic Management During Kidney Transplantation: A French Survey. Transplant Proc 2021; 53:1450-1453. [PMID: 33563473 DOI: 10.1016/j.transproceed.2021.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/25/2020] [Accepted: 01/08/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hypovolemia or excess fluid load during kidney transplantation may have detrimental effects on the recipient and graft. The aim of our survey was to examine hemodynamic monitoring during kidney transplantation (KT) in French KT centers. BASIC PROCEDURES The online survey covered the organization of anesthesia, the type of hemodynamic monitoring available in each center, the frequency of use of each hemodynamic parameter, and the hemodynamic algorithm used to manage fluid administration. MAIN FINDINGS Twenty-four centers answered the survey (70% of all the 34 French KT centers) and reported performing 2029 KTs in 2016. Anesthesia for KT was performed either by a general team (n = 12, 48%) or less often, by a specific team during open hours (n = 7, 28%), a specific 24-hour/24-hour team (n = 5, 20%), or an emergency team (n = 1, 4%). The centers reported that up to 8 different hemodynamic monitoring techniques were available for KT. Central venous pressure (CVP) is the most frequently used hemodynamic parameter (1278 KT, 63%). Among the 17 centers using CVP monitoring, 9 had no specific algorithm and the other 8 centers used a different algorithm to manage fluids with CVP. The total fluids administered during KT varied from 1000 mL to 3500 mL. CONCLUSIONS CVP was still the main hemodynamic parameter used in France during KT in 2016. Our results suggest that a large randomized controlled trial should be performed to specifically address the question of hemodynamic management during KT.
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Affiliation(s)
- Olivier Collange
- Department of Anesthesia, Critical Care and and Perioperative Medicine, Nouvel Hôpital Civil, University Hospitals of Strasbourg, Strasbourg, France; Research team 3072, Physiology Institute, FMTS (Fédération de Médecine Translationnelle), Faculty of Medicine, University of Strasbourg, Strasbourg, France.
| | - Charles Tacquard
- Department of Anesthesia, Critical Care and and Perioperative Medicine, Nouvel Hôpital Civil, University Hospitals of Strasbourg, Strasbourg, France; Research team 3072, Physiology Institute, FMTS (Fédération de Médecine Translationnelle), Faculty of Medicine, University of Strasbourg, Strasbourg, France; Unité INSERM 1255, EFS Grand-Est, Strasbourg, France
| | - Walid Oulehri
- Department of Anesthesia, Critical Care and and Perioperative Medicine, Nouvel Hôpital Civil, University Hospitals of Strasbourg, Strasbourg, France; Research team 3072, Physiology Institute, FMTS (Fédération de Médecine Translationnelle), Faculty of Medicine, University of Strasbourg, Strasbourg, France
| | - Jérome Biehler
- Department of Anesthesia, Critical Care and and Perioperative Medicine, Nouvel Hôpital Civil, University Hospitals of Strasbourg, Strasbourg, France
| | - Bruno Moulin
- Department of Nephrology and Kidney Transplantation, Nouvel Hôpital Civil, University Hospitals of Strasbourg, Strasbourg, France
| | - Paul-Michel Mertes
- Department of Anesthesia, Critical Care and and Perioperative Medicine, Nouvel Hôpital Civil, University Hospitals of Strasbourg, Strasbourg, France; Research team 3072, Physiology Institute, FMTS (Fédération de Médecine Translationnelle), Faculty of Medicine, University of Strasbourg, Strasbourg, France
| | - Anne Lejay
- Research team 3072, Physiology Institute, FMTS (Fédération de Médecine Translationnelle), Faculty of Medicine, University of Strasbourg, Strasbourg, France; Department of Vascular Surgery and Kidney Transplantation, Nouvel Hôpital Civil, University Hospitals of Strasbourg, Strasbourg, France
| | - Sophie Caillard
- Department of Nephrology and Kidney Transplantation, Nouvel Hôpital Civil, University Hospitals of Strasbourg, Strasbourg, France
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21
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Reiterer C, Hu K, Sljivic S, Falkner von Sonnenburg M, Fleischmann E, Kabon B. The effect of mannitol on oxidation-reduction potential in patients undergoing deceased donor renal transplantation-A randomized controlled trial. Acta Anaesthesiol Scand 2021; 65:162-168. [PMID: 32966587 PMCID: PMC7821012 DOI: 10.1111/aas.13713] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 08/31/2020] [Accepted: 09/14/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Mannitol, an osmotic diuretic, is proposed to be an oxygen radical scavenger. Mannitol is often used in renal transplantation to attenuate oxidative stress and thus to protect renal graft function. We tested the hypothesis that mannitol reduces overall oxidative stress during deceased donor renal transplantation. METHODS We randomly assigned 34 patients undergoing deceased donor renal transplantation to receive a solution of mannitol or placebo shortly before graft reperfusion until the end of surgery. We evaluated oxidative stress by measuring the static oxidative-reduction potential (sORP) and the capacity of the oxidative-reduction potential (cORP). sORP and cORP were measured pre-operatively, before and within 10 minutes after graft reperfusion, and post-operatively. RESULTS Seventeen patients were enrolled in the mannitol group and 17 patients were enrolled in the placebo group. Mannitol had no significant effect on sORP (148.5 mV [136.2; 160.2]) as compared to placebo (143.6 mV [135.8; 163.2], P = .99). There was also no significant difference in cORP between the mannitol (0.22 µC [0.16; 0.36]) and the placebo group (0.22 µC [0.17; 0.38], P = .76). CONCLUSION Mannitol showed no systemic redox scavenging effects during deceased donor renal transplantation. To evaluate the direct effect of mannitol on the renal graft further studies are needed. TRIAL REGISTRATION ClinicalTrials.gov NCT02705573.
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Affiliation(s)
- Christian Reiterer
- Department of Anaesthesia Intensive Care Medicine and Pain Medicine Medical University of Vienna Vienna Austria
| | - Karin Hu
- Clinical Department of Nephrology and Dialysis Medical University of Vienna Vienna Austria
| | - Samir Sljivic
- Department of Anaesthesia Intensive Care Medicine and Pain Medicine Medical University of Vienna Vienna Austria
| | | | - Edith Fleischmann
- Department of Anaesthesia Intensive Care Medicine and Pain Medicine Medical University of Vienna Vienna Austria
| | - Barbara Kabon
- Department of Anaesthesia Intensive Care Medicine and Pain Medicine Medical University of Vienna Vienna Austria
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22
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Sahu S, Sam A, Ponnappan K. Fluid management in kidney disease patients for nontransplant and transplantation surgeries. BALI JOURNAL OF ANESTHESIOLOGY 2021. [DOI: 10.4103/bjoa.bjoa_203_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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23
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Mannitol and renal graft injury in patients undergoing deceased donor renal transplantation - a randomized controlled clinical trial. BMC Nephrol 2020; 21:307. [PMID: 32723374 PMCID: PMC7388216 DOI: 10.1186/s12882-020-01961-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 07/17/2020] [Indexed: 02/07/2023] Open
Abstract
Background Ischaemia/reperfusion (I/R) injury is associated with renal tissue damage during deceased donor renal transplantation. The effect of mannitol to reduce I/R injury during graft reperfusion in renal transplant recipients is based on weak evidence. We evaluated the effect of mannitol to reduce renal graft injury represented by 16 serum biomarkers, which are indicators for different important pathophysiological pathways. Our primary outcome were differences in biomarker concentrations between the mannitol and the placebo group 24 h after graft reperfusion. Additionally, we performed a linear mixed linear model to account biomarker concentrations before renal transplantation. Methods Thirty-four patients undergoing deceased donor renal transplantation were randomly assigned to receive either 20% mannitol or 0.9% NaCl placebo solution before, during, and after graft reperfusion. Sixteen serum biomarkers (MMP1, CHI3L1, CCL2, MMP8, HGF, GH, FGF23, Tie2, VCAM1, TNFR1, IGFBP7, IL18, NGAL, Endostatin, CystC, KIM1) were measured preoperatively and 24 h after graft reperfusion using Luminex assays and ELISA. Results Sixteen patients in each group were analysed. Tie2 differed 24 h after graft reperfusion between both groups (p = 0.011). Change of log2 transformed concentration levels over time differed significantly in four biomarkers (VCAM1,Endostatin, KIM1, GH; p = 0.007; p = 0.013; p = 0.004; p = 0.033; respectively) out of 16 between both groups. Conclusion This study showed no effect of mannitol on I/R injury in patients undergoing deceased renal transplantation. Thus, we do not support the routinely use of mannitol to attenuate I/R injury. Trial registration NCT02705573. Registered on 10th March 2016.
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24
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De Cassai A, Bond O, Marini S, Panciera G, Furian L, Neri F, Andreatta G, Rigotti P, Feltracco P. [Pulse pressure variation guided fluid therapy during kidney transplantation: a randomized controlled trial]. Rev Bras Anestesiol 2020; 70:194-201. [PMID: 32534731 DOI: 10.1016/j.bjan.2020.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/13/2020] [Accepted: 02/15/2020] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Kidney transplantation is the gold-standard treatment for end stage renal disease. Although different hemodynamic variables, like central venous pressure and mean arterial pressure, have been used to guide volume replacement during surgery, the best strategy still ought to be determined. Respiratory arterial Pulse Pressure Variation (PPV) is recognized to be a good predictor of fluid responsiveness for perioperative hemodynamic optimization in operating room settings. The aim of this study was to investigate whether a PPV-guided fluid management strategy is better than a liberal fluid strategy during kidney transplantation surgeries. Identification of differences in urine output in the first postoperative hour was the main objective of this study. METHODS We conducted a prospective, single blind, randomized controlled trial. We enrolled 40 patients who underwent kidney transplantation from deceased donors. Patients randomized in the PPV Group received fluids whenever PPV was higher than 12%, patients in the Free Fluid Group received fluids following our institutional standard care protocol for kidney transplantations (10mL.kg-1.h-1). RESULTS Urinary output was similar at every time-point between the two groups, urea was statistically different from the third postoperative day with a peak at the fourth postoperative day and creatinine showed a similar trend, being statistically different from the second postoperative day. Urea, creatinine and urine output were not different at the hospital discharge. CONCLUSION PPV-guided fluid therapy during kidney transplantation significantly improves urea and creatinine levels in the first week after kidney transplantation surgery.
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Affiliation(s)
- Alessandro De Cassai
- University of Padova, Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, Padova, Itália.
| | - Ottavia Bond
- University of Padova, Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, Padova, Itália
| | - Silvia Marini
- University of Padova, Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, Padova, Itália
| | - Giulio Panciera
- University of Padova, Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, Padova, Itália
| | - Lucrezia Furian
- Padua University Hospital, Department of Surgery, Oncology and Gastroenterology, Kidney and Pancreas Transplant Unit, Pádua, Itália
| | - Flavia Neri
- Padua University Hospital, Department of Surgery, Oncology and Gastroenterology, Kidney and Pancreas Transplant Unit, Pádua, Itália
| | - Giulio Andreatta
- University of Padova, Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, Padova, Itália
| | - Paolo Rigotti
- Padua University Hospital, Department of Surgery, Oncology and Gastroenterology, Kidney and Pancreas Transplant Unit, Pádua, Itália
| | - Paolo Feltracco
- University of Padova, Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, Padova, Itália
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De Cassai A, Bond O, Marini S, Panciera G, Furian L, Neri F, Andreatta G, Rigotti P, Feltracco P. Pulse pressure variation guided fluid therapy during kidney transplantation: a randomized controlled trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 32534731 PMCID: PMC9373208 DOI: 10.1016/j.bjane.2020.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose Kidney transplantation is the gold-standard treatment for end stage renal disease. Although different hemodynamic variables, like central venous pressure and mean arterial pressure, have been used to guide volume replacement during surgery, the best strategy still ought to be determined. Respiratory arterial Pulse Pressure Variation (PPV) is recognized to be a good predictor of fluid responsiveness for perioperative hemodynamic optimization in operating room settings. The aim of this study was to investigate whether a PPV guided fluid management strategy is better than a liberal fluid strategy during kidney transplantation surgeries. Identification of differences in urine output in the first postoperative hour was the main objective of this study. Methods We conducted a prospective, single blind, randomized controlled trial. We enrolled 40 patients who underwent kidney transplantation from deceased donors. Patients randomized in the “PPV” group received fluids whenever PPV was higher than 12%, patients in the “free fluid” group received fluids following our institutional standard care protocol for kidney transplantations (10 mL.kg-1. h-1). Results Urinary output was similar at every time-point between the two groups, urea was statistically different from the third postoperative day with a peak at the fourth postoperative day and creatinine showed a similar trend, being statistically different from the second postoperative day. Urea, creatinine and urine output were not different at the hospital discharge. Conclusion PPV guided fluid therapy during kidney transplantation significantly improves urea and creatinine levels in the first week after kidney transplantation surgery.
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26
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Prevention of Ischemia-Reperfusion Injury in Human Kidney Transplantation: A Meta-Analysis of Randomized Controlled Trials. Nephrourol Mon 2020. [DOI: 10.5812/numonthly.101590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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27
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Monárrez-Espino J, Ramírez-Santana I, Aguilar-Madrid G, Ramírez-García G. Identification of Factors Associated With Acute Tubular Necrosis Following Kidney Transplant in Northern Mexico: Increased Risk With Cold Ischemia After 8 Hours. Transplant Proc 2020; 52:1110-1117. [PMID: 32169365 DOI: 10.1016/j.transproceed.2020.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 02/05/2020] [Indexed: 12/14/2022]
Abstract
AIM To identify potential risk factors associated with the incidence of acute tubular necrosis (ATN) following kidney transplant in a sample of patients from northern Mexico. METHODS Secondary analysis of data extracted from clinical files of patients who underwent a kidney transplant between 2000 and 2017 at Christus Muguerza Hospital in the city of Chihuahua. The final sample with complete data included 485 patients. ATN was diagnosed in 13.2% of patients using pathologic, clinical, and laboratory criteria. Adjusted odds ratio (ORs) with 95% CIs from multivariate binary logistic regression were used to identify predictors of ATN. RESULTS Only 4 of 21 variables analyzed remained statistically significant in the final adjusted model. Cold and warm ischemia followed time-trend patterns with higher odds with longer ischemia times. For cold ischemia, compared with 0 to 240 minutes, ORs were 1.32 (95% CI, 0.49-3.51) for 241-480 minutes, 4.87 (95% CI, 2.29-10.3) for 481-960 minutes, and 10.0 (95% CI, 2.86-35.0) for > 960 minutes; for warm ischemia, compared with 40 to 59 minutes, these were 6.27 (95% CI, 1.95-20.8) for 60-70 minutes and 10.32 (95% CI, 1.95-54.4) for 71-110 minutes. Hypotension during surgery was associated with a higher chance of ATN (OR, 15.9; 95% CI, 4.97-50.9). When the recipients' age was 30 years or older, the probability also increased significantly (OR, 2.88; 95% CI, 1.09-7.57). The final model fitted well and explained 27% of the probability to develop ATN after a kidney transplant. CONCLUSION Shortening the duration of ischemia and avoiding hypotension during surgery is essential to prevent ATN following a kidney transplant.
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Affiliation(s)
- Joel Monárrez-Espino
- Department of Health Research, Christus Muguerza Hospital, Chihuahua, Mexico; Public Health Research Group, Claustro Universitario, Chihuahua, Mexico.
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Kim J, Pyeon T, Choi JI, Kang JH, Song SW, Bae HB, Jeong S. A retrospective study of the relationship between postoperative urine output and one year transplanted kidney function. BMC Anesthesiol 2019; 19:231. [PMID: 31847814 PMCID: PMC6916447 DOI: 10.1186/s12871-019-0904-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 12/03/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Kidney transplantation (KT) is the most obvious method of treating a patient with end-stage renal disease. In the early stages of KT, urine production is considered a marker of successful reperfusion of the kidney after anastomosis. However, there is no clear conclusion about the relationship between initial urine output after KT and 1-year renal function. Thus, we investigated the factors that affect 1-year kidney function after KT, including urine output. METHODS This retrospective study investigated the relationship between urine output in the 3 days after KT and transplanted kidney prognosis after 1-year. In total, 291 patients (129 living-donor and 162 deceased-donor transplant recipients) were analyzed; 24-h urine volume per body weight (in kilograms) was measured for 3 days postoperatively. The estimated glomerular filtration rate (eGFR), determined by the Modification of Diet in Renal Disease algorithm, was used as an index of renal function. Patients were grouped according to eGFR at 1-year after KT: a good residual function group, eGFR ≥60, and a poor residual function group, eGFR < 60. RESULT Recipients' factors affecting 1-year eGFR include height (P = 0.03), weight (P = 0.00), and body mass index (P = 0.00). Donor factors affecting 1-year eGFR include age (P = 0.00) and number of human leukocyte antigen (HLA) mismatches (P = 0.00). The urine output for 3 days after KT (postoperative day 1; 2 and 3) was associated with 1-year eGFR in deceased-donor (P = 0.00; P = 0.00 and P = 0.01). And, postoperative urine output was associated with the occurrence of delayed graft function (area under curve (AUC) = 0.913; AUC = 0.984 and AUC = 0.944). CONCLUSION Although postoperative urine output alone is not enough to predict 1-year GFR, the incidence of delayed graft function can be predicted. Also, the appropriate urine output after KT may differ depending on the type of the transplanted kidney. TRIAL REGISTRATION Clinical Research Information Service of the Korea National Institute of Health in the Republic of Korea (KCT0003571).
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Affiliation(s)
- Joungmin Kim
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School; Chonnam National University Hospital, 42 Jebong-ro Dong-gu, Gwangju, 61469, South Korea
| | - Taehee Pyeon
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School; Chonnam National University Hospital, 42 Jebong-ro Dong-gu, Gwangju, 61469, South Korea
| | - Jeong Il Choi
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School; Chonnam National University Hospital, 42 Jebong-ro Dong-gu, Gwangju, 61469, South Korea
| | - Jeong Hyeon Kang
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School; Chonnam National University Hospital, 42 Jebong-ro Dong-gu, Gwangju, 61469, South Korea
| | - Seung Won Song
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School; Chonnam National University Hospital, 42 Jebong-ro Dong-gu, Gwangju, 61469, South Korea
| | - Hong-Beom Bae
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School; Chonnam National University Hospital, 42 Jebong-ro Dong-gu, Gwangju, 61469, South Korea.
| | - Seongtae Jeong
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School; Chonnam National University Hospital, 42 Jebong-ro Dong-gu, Gwangju, 61469, South Korea.
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Aytekin S, Dinç B, Ertuğ Z, Hadimioğlu N, Aytekin EÇ. Perioperative Comparison of Preemptive and Non-Preemptive Renal Transplant Recipients. Turk J Anaesthesiol Reanim 2019; 48:102-107. [PMID: 32259140 PMCID: PMC7101187 DOI: 10.5152/tjar.2019.34033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 05/18/2019] [Indexed: 11/22/2022] Open
Abstract
Objective Preemptive transplantation cannot be performed for all patients because of the limited number of donors. This study aimed to evaluate the perioperative effects of dialysis before renal transplantation. Methods In this study, we retrospectively investigated 666 patients who underwent kidney transplantation at our centre. We divided patients into two groups: patients with pre-transplant dialysis (67.3%, n=448) and patients with preemptive transplant (32.7%, n=218). We carried out preoperative, intraoperative and postoperative comparisons between groups. Results No difference was observed in terms of intraoperative blood transfusion, crystalloid and colloid requirement, inotropic-vasopressor agent administration and hemodynamic parameters between the patients with pre-transplant dialysis and preemptive transplant. It was observed that dialysis requirement, delayed graft function and acute rejection development were significantly higher during the postoperative period in patients who underwent dialysis before transplantation. In patients with non-preemptive transplant, the decrease of serum creatinine levels at the first postoperative month was more prominent when compared to patients with preemptive transplant; however, that difference disappeared in the first year follow-up. No significant difference was found for serum albumin levels and proteinuria alterations of the patients in long-term follow-up. Additionally, patient and graft survival comparisons between patients with non-preemptive and preemptive transplant on three-year follow-up revealed no significant difference. Conclusion We think that preemptive transplantation treatment is a better option for patients with end-stage renal failure since patients with preemptive transplantation appear to have less metabolic function impairment, complication risk and more successful outcomes in terms of cost-effectiveness.
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Affiliation(s)
- Sami Aytekin
- Department of Anaesthesiology and Reanimation, Akdeniz University School of Medicine, Antalya, Turkey
| | - Bora Dinç
- Department of Anaesthesiology and Reanimation, Akdeniz University School of Medicine, Antalya, Turkey
| | - Zeki Ertuğ
- Department of Anaesthesiology and Reanimation, Akdeniz University School of Medicine, Antalya, Turkey
| | - Necmiye Hadimioğlu
- Department of Anaesthesiology and Reanimation, Akdeniz University School of Medicine, Antalya, Turkey
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Intraoperative Fluid Restriction is Associated with Functional Delayed Graft Function in Living Donor Kidney Transplantation: A Retrospective Cohort Analysis. J Clin Med 2019; 8:jcm8101587. [PMID: 31581669 PMCID: PMC6832291 DOI: 10.3390/jcm8101587] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/13/2019] [Accepted: 09/23/2019] [Indexed: 12/11/2022] Open
Abstract
Background: In 2016 we observed a marked increase in functional delayed graft function (fDGF) in our living donor kidney transplantation (LDKT) recipients from 8.5% in 2014 and 8.8% in 2015 to 23.0% in 2016. This increase coincided with the introduction of a goal-directed fluid therapy (GDFT) protocol in our kidney transplant recipients. Hereupon, we changed our intraoperative fluid regimen to a fixed amount of 50 mL/kg body weight (BW) and questioned whether the intraoperative fluid regimen was related to this increase in fDGF. Methods: a retrospective cohort analysis of all donors and recipients in our LDKT program between January 2014–February 2017 (n = 275 pairs). Results: Univariate analysis detected various risk factors for fDGF. Dialysis dependent recipients were more likely to develop fDGF compared to pre-emptively transplanted patients (p < 0.001). Recipients developing fDGF received less intraoperative fluid (36 (25.9–50.0) mL/kg BW vs. 47 (37.3–55.6) mL/kg BW (p = 0.007)). The GDFT protocol resulted in a reduction of intraoperative fluid administration on average by 850 mL in total volume and 21% in mL/kg BW compared to our old protocol (p < 0.001). In the unadjusted analysis, a higher intraoperative fluid volume in mL/kg BW was associated with a lower risk for the developing fDGF (OR 0.967, CI (0.941–0.993)). After adjustment for the confounders, prior dialysis and the use of intraoperative noradrenaline, the relationship of fDGF with fluid volume was still apparent (OR 0.970, CI (0.943–0.998)). Conclusion: Implementation of a GDFT protocol led to reduced intraoperative fluid administration in the LDKT recipients. This intraoperative fluid restriction was associated with the development of fDGF.
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Arslantas R, Dogu Z, Cevik BE. Normal Saline Versus Balanced Crystalloid Solutions for Kidney Transplantation. Transplant Proc 2019; 51:2262-2264. [DOI: 10.1016/j.transproceed.2019.03.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/17/2019] [Accepted: 03/12/2019] [Indexed: 10/26/2022]
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Exposure to Hyperchloremia Is Associated with Poor Early Recovery of Kidney Graft Function after Living-Donor Kidney Transplantation: A Propensity Score-Matching Analysis. J Clin Med 2019; 8:jcm8070955. [PMID: 31269662 PMCID: PMC6678624 DOI: 10.3390/jcm8070955] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 06/25/2019] [Accepted: 07/01/2019] [Indexed: 12/11/2022] Open
Abstract
The effects of hyperchloremia on kidney grafts have not been investigated in patients undergoing living-donor kidney transplantation (LDKT). In this study, data from 200 adult patients undergoing elective LDKT between January 2016 and December 2017 were analyzed after propensity score (PS) matching. The patients were allocated to hyperchloremia and non-hyperchloremia groups according to the occurrence of hyperchloremia (i.e., ≥110 mEq/L) immediately after surgery. Poor early graft recovery was defined as estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 during the first 48 hours after surgery. After PS matching, no significant differences in perioperative recipient or donor graft parameters were observed between groups. Although the total amount of crystalloid fluid infused during surgery did not differ between groups, the proportions of main crystalloid fluid type used (i.e., 0.9% normal saline vs. Plasma Solution-A) did. The eGFR increased gradually during postoperative day (POD) 2 in both groups. However, the proportion of patients with eGFR > 60 mL/min/1.73 m2 on POD 2 was higher in the non-hyperchloremia group than in the hyperchloremia group. In this PS-adjusted analysis, hyperchloremia was significantly associated with poor graft recovery on POD 2. In conclusion, exposure to hyperchloremia may have a negative impact on early graft recovery in LDKT.
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Morkane CM, Fabes J, Banga NR, Berry PD, Kirwan CJ. Perioperative management of adult cadaveric and live donor renal transplantation in the UK: a survey of national practice. Clin Kidney J 2019; 12:880-887. [PMID: 31807303 PMCID: PMC6885684 DOI: 10.1093/ckj/sfz017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Indexed: 02/01/2023] Open
Abstract
Background There is a limited evidence base and no national consensus regarding the perioperative management of patients undergoing renal transplantation. We developed an electronic survey to capture an overview of renal transplant perioperative practice across UK renal transplant centres and determine the need for future guidelines on patient management. Methods A 29-question survey was developed to encompass the entire renal transplant perioperative pathway and input was sought from clinicians with expertise in renal transplant surgery, anaesthesia, nephrology and intensive care. The survey was sent to lead renal anaesthetists at each of the 23 transplant centres across the UK. Results A 96% response rate was achieved with 22 out of 23 centres returning complete responses. There was limited evidence of guideline-based approaches to preoperative workup. Questions regarding intraoperative fluid management, blood pressure targets, vasopressor administration and central venous pressure (CVP) monitoring identified a broad range of practice. Of note, the routine use of goal-directed fluid therapy based on cardiac output estimation was reported in six (27.3%) centres, while nine centres (40.9%) continue to target a specific CVP intraoperatively. In all, 12 (54.5%) centres perform transversus abdominis plane blocks with fentanyl-based patient-controlled analgesia as the most common mode of postoperative analgesia. A single centre reported a renal transplant-specific Enhanced Recovery after Surgery programme for cadaveric organ recipients. Conclusions This questionnaire highlighted a high degree of heterogeneity in current UK practice as regards the perioperative management of renal transplant recipients. Development of evidence-based national consensus guidelines to standardize the perioperative care of these patients is recommended in order to improve patient outcomes and focus areas of future research.
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Affiliation(s)
- Clare M Morkane
- Division of Surgery and Interventional Science (University College London) & Royal Free Perioperative Research Group, Department of Anaesthesia, Royal Free Hospital, London, UK
| | - Jez Fabes
- Division of Surgery and Interventional Science (University College London) & Royal Free Perioperative Research Group, Department of Anaesthesia, Royal Free Hospital, London, UK
| | - Neal R Banga
- Department of Renal Transplant Surgery, Royal Free Hospital, London, UK
| | - Peter D Berry
- Department of Anaesthesia, Royal Free Hospital, London, UK
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Cavaleri M, Veroux M, Palermo F, Vasile F, Mineri M, Palumbo J, Salemi L, Astuto M, Murabito P. Perioperative Goal-Directed Therapy during Kidney Transplantation: An Impact Evaluation on the Major Postoperative Complications. J Clin Med 2019; 8:jcm8010080. [PMID: 30642015 PMCID: PMC6351933 DOI: 10.3390/jcm8010080] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/03/2019] [Accepted: 01/07/2019] [Indexed: 12/29/2022] Open
Abstract
Background: Kidney transplantation is considered the first-choice therapy in end-stage renal disease (ESRD) patients. Despite recent improvements in terms of outcomes and graft survival in recipients, postoperative complications still concern the health-care providers involved in the management of those patients. Particularly challenging are cardiovascular complications. Perioperative goal-directed fluid-therapy (PGDT) and hemodynamic optimization are widely used in high-risk surgical patients and are associated with a significant reduction in postoperative complication rates and length of stay (LOS). The aim of this work is to compare the effects of perioperative goal-directed therapy (PGDT) with conventional fluid therapy (CFT) and to determine whether there are any differences in major postoperative complications rates and delayed graft function (DGF) outcomes. Methods: Prospective study with historical controls. Two groups, a PGDT and a CFT group, were used: The stroke volume (SV) optimization protocol was applied for the PGDT group throughout the procedure. Conventional fluid therapy with fluids titration at a central venous pressure (CVP) of 8–12 mmHg and mean arterial pressure (MAP) >80 mmHg was applied to the control group. Postoperative data collection including vital signs, weight, urinary output, serum creatinine, blood urea nitrogen, serum potassium, and assessment of volemic status and the signs and symptoms of major postoperative complications occurred at 24 h, 72 h, 7 days, and 30 days after transplantation. Results: Among the 66 patients enrolled (33 for each group) similar physical characteristics were proved. Good functional recovery was evident in 92% of the CFT group, 98% of the PGDT group, and 94% of total patients. The statistical analysis showed a difference in postoperative complications as follows: Significant reduction of cardiovascular complications and DGF episodes (p < 0.05), and surgical complications (p < 0.01). There were no significant differences in pulmonary or other complications. Conclusions: PGDT and SV optimization effectively influenced the rate of major postoperative complications, reducing the overall morbidity and thus the mortality in patients receiving kidney transplantation.
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Affiliation(s)
- Marco Cavaleri
- Department of Anaesthesia and Intensive Care, "Sant' Elia" Hospital, via L.Russo 6, 93100 Caltanissetta, Italy.
| | - Massimiliano Veroux
- Vascular Surgery and Organ Transplant Unit, Department of Medical and Surgical Sciences and Advanced technologies "G F Ingrassia", University Hospital "G.Rodolico", University of Catania, via Santa Sofia 78, 95123 Catania, Italy.
| | - Filippo Palermo
- Department of Clinical and Molecular Biomedicine, University of Catania, via Palermo 636, 95123 Catania, Italy.
| | - Francesco Vasile
- School of Anaesthesia and Intensive Care, University Hospital "G.Rodolico", University of Catania, via Santa Sofia 78, 95123 Catania, Italy.
| | - Mirko Mineri
- School of Anaesthesia and Intensive Care, University Hospital "G.Rodolico", University of Catania, via Santa Sofia 78, 95123 Catania, Italy.
| | - Joseph Palumbo
- School of Anaesthesia and Intensive Care, University Hospital "G.Rodolico", University of Catania, via Santa Sofia 78, 95123 Catania, Italy.
| | - Lorenzo Salemi
- School of Anaesthesia and Intensive Care, University Hospital "G.Rodolico", University of Catania, via Santa Sofia 78, 95123 Catania, Italy.
| | - Marinella Astuto
- Department of Anaesthesia and Intensive Care, University Hospital "G.Rodolico", University of Catania, via Santa Sofia 78, 95123 Catania, Italy.
| | - Paolo Murabito
- Department of Anaesthesia and Intensive Care, University Hospital "G.Rodolico", University of Catania, via Santa Sofia 78, 95123 Catania, Italy.
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Freitas MHBD, Lima LC, Couceiro TCDM, Silva WBD, Andrade JMD, Freitas MHBD. Perioperative factors associated with delayed graft function in renal transplant patients. ACTA ACUST UNITED AC 2018; 40:360-365. [PMID: 30106428 PMCID: PMC6534009 DOI: 10.1590/2175-8239-jbn-2018-0020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 06/12/2018] [Indexed: 12/03/2022]
Abstract
Introduction: Successful renal transplant and consequent good graft function depend on a
good surgical technique, an anesthetic that ensures the hemodynamic
stability of the receiver, and appropriate conditions of graft and
recipient. Several factors can interfere with the perfusion of the graft and
compromise its viability. The objective of this study was to evaluate
perioperative factors associated with delayed graft function (DGF) in renal
transplantation patients. Methods: This is a historical cohort study of patients who underwent renal
transplantation between 2011 and 2013. Three hundred and ten transplants
were analyzed. DGF was defined as the need for dialysis during the first
week post-transplant. Logistic regression with a stepwise technique was used
to build statistical models. Results: Multivariate analysis revealed the following risk factor for DGF: combined
anesthesia technique (OR = 3.81, 95%CI, 1.71 to 9.19), a fluid regimen <
50 mL·kg-1 (OR = 3.71, 95%CI, 1.68 to 8.61), dialysis for more
than 60 months (OR = 4.77, 95%CI, 1.93 to 12.80), basiliximab (OR = 3.34,
95%CI, 1.14 to 10.48), cold ischemia time > 12 hour (OR = 5.26, 95%CI,
2.62 to 11.31), living donor (OR = 0.19, 95%CI, 0.02 to 0.65), and early
diuresis (OR = 0.02, 95%CI, 0.008 to 0.059). The accuracy of this model was
92.6%, calculated using the area under the ROC curve. The incidence of DGF
in the study population was 76.1%. Conclusions: Combined anesthesia technique, dialysis for more than 60 months, basiliximab,
and cold ischemia time > 12 hours are risk factor for DGF, while liberal
fluid regimens and kidneys from living donors are protective factors.
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Goh CYY, Hume-Smith H, Kessaris N, Marks SD. A case series of perioperative variables in relation to short-term outcomes in pediatric renal transplant recipients. Pediatr Transplant 2018; 22:e13198. [PMID: 29729082 DOI: 10.1111/petr.13198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2018] [Indexed: 12/01/2022]
Abstract
Multiple perioperative variables have been shown in existing literature to influence long-term outcomes of pediatric RTx, such as allograft survival. Their impact on short-term outcomes is not as well-documented. This case series aims to investigate the effects of nine perioperative variables on two short-term outcomes in pRTR: 1-week post-operative eGFR and post-operative LOS. A total of 73 pRTR transplanted over 3 years from 2012 to 2014 at a single center were studied retrospectively and statistical analyses were performed. There was higher 1-week post-operative eGFR in pRTR who received living donor transplants compared to those who received deceased donor transplants (P=.01), with mean eGFR of 135 mL/min/1.73 m2 and 82 mL/min/1.73 m2 , respectively. Aorta-IVC anastomosis was associated with longer LOS compared to iliac vessel anastomosis (P=.03), with median LOS of 19 and 13 days, respectively. There were no significant effects on 1-week eGFR or LOS of the seven other variables: pRTR age and gender, donor age, preoperative donor SBP, intraoperative mean CVP before graft perfusion, intraoperative median SBP z score after graft perfusion, and intraoperative fluid volume. Living donor transplants were associated with higher 1-week post-operative eGFR compared to deceased donor transplants. Aorta-IVC anastomosis was significantly associated with longer LOS compared to iliac vessel anastomosis.
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Affiliation(s)
| | - Helen Hume-Smith
- Department of Anaesthesia, Great Ormond Street Hospital for Children, London, UK
| | - Nicos Kessaris
- Department of Renal Transplantation, Guy's Hospital, London, UK
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children, London, UK.,University College London Great Ormond Street Institute of Child Health, London, UK
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Rodríguez Faba O, Boissier R, Budde K, Figueiredo A, Taylor CF, Hevia V, Lledó García E, Regele H, Zakri RH, Olsburgh J, Breda A. European Association of Urology Guidelines on Renal Transplantation: Update 2018. Eur Urol Focus 2018; 4:208-215. [PMID: 30033070 DOI: 10.1016/j.euf.2018.07.014] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 06/21/2018] [Accepted: 07/11/2018] [Indexed: 12/20/2022]
Abstract
CONTEXT The European Association of Urology (EAU) panel on renal transplantation (RT) has released an updated version of the RT guidelines. OBJECTIVE To present the 2018 EAU guidelines on RT. EVIDENCE ACQUISITION A broad and comprehensive scoping exercise was performed, encompassing all areas of RT guidelines published between January 1, 2007, and May 31, 2016. Databases covered by the search included Medline, Embase, and the Cochrane Libraries. Previous guidelines were updated, and levels of evidence and grades of recommendation were assigned. EVIDENCE SYNTHESIS It is strongly recommended to offer pure or hand-assisted laparoscopic/retroperitoneoscopic surgery as the preferential technique for living donor nephrectomy. Decisions on the acceptance of a donor organ should not be based on histological findings alone since this might lead to an unnecessarily high rate of discarded grafts. For ureterovesical anastomosis, a Lich-Gregoir-like extravesical technique protected by a ureteral stent is the preferred technique for minimisation of urinary tract complications. It is also strongly recommended to perform initial rejection prophylaxis with a combination therapy comprising a calcineurin inhibitor (preferably tacrolimus), mycophenolate, steroids, and an induction agent (either basiliximab or anti-thymocyte globulin). The long version of the guidelines is available at the EAU website (http://uroweb.org/guidelines). CONCLUSIONS These abridged EAU guidelines present updated information on the clinical and surgical management of RT for incorporation into clinical practice. PATIENT SUMMARY The European Association of Urology has released the renal transplantation guidelines. The implementation of minimally invasive surgery for organ retrieval and the latest evidence on transplant surgery as well as on immunosuppressive regimens are key factors for minimisation of rejection and achievement of long-term graft survival.
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Affiliation(s)
- Oscar Rodríguez Faba
- Department of Urology, Fundació Puigvert, Autonomous University of Barcelona, Barcelona, Spain.
| | - Romain Boissier
- Aix-Marseille University, Marseille, France; Department of Urology & Renal Transplantation, La Conception University Hospital, Assistance-Publique Marseille, France
| | - Klemens Budde
- Department of Nephrology, Charité Medical University Berlin, Berlin, Germany
| | - Arnaldo Figueiredo
- Department of Urology and Renal Transplantation, Coimbra University Hospital, Coimbra, Portugal
| | - Claire Fraser Taylor
- Department of Urology and Transplant, St Georges NHS Trust Hospitals, London, UK
| | - Vital Hevia
- Urology Department, Hospital Universitario Ramón y Cajal, Alcalá University, Madrid, Spain
| | - Enrique Lledó García
- Department of Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Heinz Regele
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Rhana Hassan Zakri
- Department of Urology and Transplant, Guy's & St Thomas' NHS Trust Hospitals, London, UK
| | - Jonathon Olsburgh
- Department of Urology and Transplant, Guy's & St Thomas' NHS Trust Hospitals, London, UK
| | - Alberto Breda
- Department of Urology, Fundació Puigvert, Autonomous University of Barcelona, Barcelona, Spain
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Adelmann D, Bicknell L, Niemann CU, Feiner J, Roll GR, Burdine L, Whitlock EL. Central venous pressure monitoring in living donor kidney recipients does not affect immediate graft function: A propensity score analysis. Clin Transplant 2018. [PMID: 29526051 DOI: 10.1111/ctr.13238] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND During kidney transplantation, intraoperative fluid management can affect post-transplant graft function. It is unclear whether or not central venous pressure (CVP) monitoring is required to guide fluid therapy during kidney transplantation. METHODS We compared post-transplant graft function in recipients of living donor kidney transplants between August 2006 and March 2009 based on the use or absence of intraoperative CVP monitoring. Graft function, assessed using the creatinine reduction ratio on postoperative day 2 (CCR2), was evaluated by multivariable linear regression analysis and in a propensity-matched cohort. RESULTS Two hundred and ninety patients were included in the analysis. Central venous pressure was monitored in 84 patients (29%). There was no difference in post-transplant graft function, as measured by CCR2, between patients with and without CVP monitoring in both unadjusted and multivariable-adjusted analyses. There were also no statistically significant differences in CCR2, delayed graft function, or 3-month renal function between those monitored with CVP and those without, in the propensity-matched cohort. CONCLUSIONS In this single-center analysis, immediate post-transplant renal function was not associated with the use of intraoperative CVP monitoring.
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Affiliation(s)
- Dieter Adelmann
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Leonie Bicknell
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Claus U Niemann
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA.,Division of Transplantation, Department of Surgery, University of California, San Francisco, CA, USA
| | - John Feiner
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Garrett R Roll
- Division of Transplantation, Department of Surgery, University of California, San Francisco, CA, USA
| | - Lyle Burdine
- Division of Transplantation, Department of Surgery, University of California, San Francisco, CA, USA
| | - Elizabeth L Whitlock
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
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Nagrebetsky A, Dutton RP, Ehrenfeld JM, Urman RD. Variation in Frequency of Intraoperative Arterial, Central Venous and Pulmonary Artery Catheter Placement During Kidney Transplantation: An Analysis of Invasive Monitoring Trends. J Med Syst 2018; 42:66. [PMID: 29497856 DOI: 10.1007/s10916-018-0920-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 02/19/2018] [Indexed: 11/24/2022]
Abstract
The rapidly increasing number of kidney transplantations warrants assessment of anesthesia care in this patient population. We explored the frequency of arterial catheter (AC), central venous catheter (CVC) and pulmonary artery catheter (PAC) placement during kidney transplantation in the USA using data from the National Anesthesia Clinical Outcomes Registry (NACOR) and assessed the between-facility variation in the frequency of catheter placement. We defined cases of kidney transplantation using Agency for Healthcare Research and Quality Clinical Classification Software. Placement of AC, CVC and PAC was defined by respective Current Procedural Terminology codes. The frequency of vascular catheter placement across facility types was compared using Pearson χ2 test. We identified 10,580 cases of kidney transplantation performed in 100 facilities from January 1, 2010 to December 31, 2014. Placement of an AC was reported in 1700 (16.1%), CVC in 2580 (24.4%) and PAC in 50 (0.5%) of cases. The frequency of placement of specific types of catheters was statistically different across facility types (p < 0.001). Within individual facilities that reported at least 50 cases of kidney transplantation, the percentages of cases performed with AC, CVC and PAC ranged from 0% to 86%, 0% to 90% and 0% to 3%, respectively. Considerable between-facility variation in the frequency of AC, CVC and PAC placement during kidney transplantation raises concerns about the need for better practice standardization. Excess invasive monitoring may represent a safety risk as well as unnecessary additional cost. If kidney transplantation can be safely performed without an AC, CVC or PAC in most patients, facilities with above-average catheter placement rates may have an opportunity for measurable reduction in catheter-related perioperative complications. Optimizing perioperative monitoring is an important component of ensuring high functioning, high-value medical systems.
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Affiliation(s)
| | | | | | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital/Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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Calixto Fernandes MH, Schricker T, Magder S, Hatzakorzian R. Perioperative fluid management in kidney transplantation: a black box. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:14. [PMID: 29368625 PMCID: PMC5784708 DOI: 10.1186/s13054-017-1928-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 12/21/2017] [Indexed: 01/14/2023]
Abstract
The incidence of delayed graft function in patients undergoing kidney transplantation remains significant. Optimal fluid therapy has been shown to decrease delayed graft function after renal transplantation. Traditionally, the perioperative volume infusion regimen in this patient population has been guided by central venous pressure as an estimation of the patient’s volume status and mean arterial pressure, but this is based on sparse evidence from mostly retrospective observational studies. Excessive volume infusion to the point of no further fluid responsiveness can damage the endothelial glycocalyx and is no longer considered to be the best approach. However, achievement of adequate flow to maintain sufficient tissue perfusion without maximization of cardiac filling remains a challenge. Novel minimally invasive technologies seem to reliably assess volume responsiveness, heart function and perfusion adequacy. Prospective comparative clinical studies are required to better understand the use of dynamic analyses of flow parameters for adequate fluid management in kidney transplant recipients. We review perioperative fluid assessment techniques and discuss conventional and novel monitoring strategies in the kidney transplant recipient.
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Affiliation(s)
| | - Thomas Schricker
- Department of Anesthesia, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Sheldon Magder
- Department of Critical Care Medicine, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Roupen Hatzakorzian
- Department of Anesthesia, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada.,Department of Critical Care Medicine, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
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41
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Abstract
Kidney transplants are the most common solid organ abdominal transplant and are occasionally performed simultaneously with pancreas transplants in diabetic patients. Preoperative evaluation of potential transplant recipients should focus on the potential for occult cardiovascular disease while also screening for other signs of end-organ dysfunction. Intraoperatively, it is of utmost importance to ensure adequate graft perfusion to limit the risk of postoperative graft dysfunction or rejection. Postoperative care of the kidney or pancreas transplant patient should focus on ensuring normalization of volume status, electrolyte concentrations, and glycemic control.
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Affiliation(s)
- Aaron M Mittel
- Department of Anesthesiology, Columbia University Medical Center, College of Physicians & Surgeons, Columbia University, PH 527-B, 630 West 168th Street, New York, NY 10032, USA
| | - Gebhard Wagener
- Department of Anesthesiology, Columbia University Medical Center, College of Physicians & Surgeons, Columbia University, PH 527-B, 630 West 168th Street, New York, NY 10032, USA.
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Michelet D, Brasher C, Marsac L, Zanoun N, Assefi M, Elghoneimi A, Dauger S, Dahmani S. Intraoperative hemodynamic factors predicting early postoperative renal function in pediatric kidney transplantation. Paediatr Anaesth 2017; 27:927-934. [PMID: 28736994 DOI: 10.1111/pan.13201] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND The anesthetic management of kidney transplantation in children remains somewhat empirical. The goal of the present study was to investigate intraoperative hemodynamic factors affecting posttransplantation kidney function. METHODS We performed a retrospective analysis of data from patients undergoing kidney transplantation in our pediatric teaching hospital from 2000 to 2014. Data collected included: donor and recipient demographic data, recipient comorbidities, fluids administered intraoperatively, and intraoperative blood pressure and central venous pressure. The main outcome of the study was the creatinine clearance at day 1 corrected to a body surface area of 1.73 m². Analysis was performed using Classification Tree Analysis with 10-fold cross-validation. RESULTS One hundred and two patients were included. The following predictors of increased postoperative creatinine clearance at day 1 were identified: decreasing recipient weight, mean blood pressure-to-weight ratio 10 minutes after reperfusion, reduced cold ischemia duration, and increased intraoperative albumin infusion. Increased creatinine clearance was observed when mean blood pressure-to-weight ratio 10 minutes after reperfusion was ≥4.3 in patients weighing 13-21 kg and ≥2.5 in those ≥22 kg. Overall, the model explained 64% (and at cross-validation 60%) of creatinine clearance variability at day 1. CONCLUSION Intraoperative hemodynamics during kidney transplantation should be optimized in order to increase mean blood pressure according to values indicated by our analyses. Cold ischemia duration should be shortened as far as possible.
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Affiliation(s)
- Daphné Michelet
- Department of Anesthesia, Intensive care and Pain Management, Robert Debré University Hospital, Paris Diderot University, Paris Sorbonne Cité, Paris, France.,Paris Diderot University (Paris VII), PRES Paris Sorbonne Cité, Paris, France
| | - Christopher Brasher
- Department of Anesthesia & Pain Management, Royal Children's Hospital, Melbourne, Australia.,Anesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Lucile Marsac
- Department of Anesthesia, Intensive care and Pain Management, Robert Debré University Hospital, Paris Diderot University, Paris Sorbonne Cité, Paris, France.,Paris Diderot University (Paris VII), PRES Paris Sorbonne Cité, Paris, France
| | - Nabil Zanoun
- Department of Anesthesia, Intensive care and Pain Management, Robert Debré University Hospital, Paris Diderot University, Paris Sorbonne Cité, Paris, France.,Paris Diderot University (Paris VII), PRES Paris Sorbonne Cité, Paris, France
| | - Mona Assefi
- Department of Anesthesia, Intensive care and Pain Management, Robert Debré University Hospital, Paris Diderot University, Paris Sorbonne Cité, Paris, France.,Paris Diderot University (Paris VII), PRES Paris Sorbonne Cité, Paris, France
| | - Alaa Elghoneimi
- Paris Diderot University (Paris VII), PRES Paris Sorbonne Cité, Paris, France.,Department of general and urological surgery, Robert Debré University Hospital, Paris Diderot University, Paris Sorbonne Cité, Paris, France.,DHU PROTECT, INSERM U1141, Robert Debré University Hospital, Paris, France
| | - Stephane Dauger
- Paris Diderot University (Paris VII), PRES Paris Sorbonne Cité, Paris, France.,DHU PROTECT, INSERM U1141, Robert Debré University Hospital, Paris, France.,Departement of Paediatric Intensive Care, Robert Debré University Hospital, Paris Diderot University, Paris Sorbonne Cité, Paris, France
| | - Souhayl Dahmani
- Department of Anesthesia, Intensive care and Pain Management, Robert Debré University Hospital, Paris Diderot University, Paris Sorbonne Cité, Paris, France.,Paris Diderot University (Paris VII), PRES Paris Sorbonne Cité, Paris, France.,DHU PROTECT, INSERM U1141, Robert Debré University Hospital, Paris, France
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Association Between Delayed Graft Function and Graft Loss in Donation After Cardiac Death Kidney Transplants-A Paired Kidney Registry Analysis. Transplantation 2017; 101:1139-1143. [PMID: 28538652 DOI: 10.1097/tp.0000000000001323] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Delayed graft function (DGF) is an established complication after donation after cardiac death (DCD) kidney transplants, but the impact of DGF on graft outcomes is uncertain. To minimize donor variability and bias, a paired donor kidney analysis was undertaken where 1 kidney developed DGF and the other did not develop DGF using data from the Australia and New Zealand Dialysis and Transplant Registry. METHODS Using paired DCD kidney data from the Australia and New Zealand Dialysis and Transplant Registry, we examined the association between DGF, graft and patient outcomes between 1994 and 2012 using adjusted Cox regression models. RESULTS Of the 74 pairs of DCD kidneys followed for a median of 1.9 years (408 person-years), a greater proportion of recipients with DGF had experienced overall graft loss and death-censored graft loss at 3 years compared with those without DGF (14% vs 4%, P = 0.04 and 11% vs 0%, P < 0.01, respectively). Compared with recipients without DGF, the adjusted hazard ratio for overall graft loss at 3 years for recipients with DGF was 4.31 (95% confidence interval [95% CI], 1.13-16.44). The adjusted hazard ratio for acute rejection and all-cause mortality at 3 years in recipients who have experienced DGF were 0.98 (95% CI, 0.96-1.01) and 1.70 (95% CI, 0.36-7.93), respectively, compared with recipients without DGF. CONCLUSIONS Recipients of DCD kidneys with DGF experienced a higher incidence of overall and death-censored graft loss compared with those without DGF. Strategies aim to reduce the risk of DGF could potentially improve graft survival in DCD kidney transplants.
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Collange O, Jazaerli L, Lejay A, Biermann C, Caillard S, Moulin B, Chakfe N, Severac F, Schaeffer M, Mertes PM, Steib A. Intraoperative Pleth Variability Index Is Linked to Delayed Graft Function After Kidney Transplantation. Transplant Proc 2017; 48:2615-2621. [PMID: 27788791 DOI: 10.1016/j.transproceed.2016.06.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 06/22/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Delayed graft function (DGF) is an early postoperative complication of kidney transplantation (KT) predisposing to acute rejection and lower graft survival. Intraoperative arterial hypotension and hypovolemia are associated with DGF. Central venous pressure (CVP) is used to estimate volemia but its reliability has been criticized. Pleth variability index (PVI) is a hemodynamic parameter predicting fluid responsiveness. The aim of this study was to examine the relationship between intraoperative PVI and CVP values and the occurrence of DGF. METHODS This was a prospective, noninterventional, observational, single-center study. All consecutive patients with KT from deceased donors were included. Recipients received standard, CVP, and PVI monitoring. Intraoperative hemodynamic parameters were recorded from recipients at 5 time points during KT. RESULTS Forty patients were enrolled. There was a poor correlation between PVI and CVP values (r2 = 0.003; P = .44). Immediate graft function and DGF patients had similar hemodynamic values during KT, with the exception of PVI values, which were significantly higher in the DGF group. In particular, a PVI >9% before unclamping of the renal artery was the only predictive parameter of DGF in our multivariate analysis (P = .02). CONCLUSIONS This study suggests that PVI values >9% during KT are associated with the occurrence of DGF.
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Affiliation(s)
- O Collange
- Pôle d'Anesthésie, Réanimations Chirurgicales, Service d'Aide Médicale Urgente-Service Mobile d'Urgence et de Réanimation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France; Fédération de Médecine Translationnelle de Strasbourg, Strasbourg, France.
| | - L Jazaerli
- Pôle d'Anesthésie, Réanimations Chirurgicales, Service d'Aide Médicale Urgente-Service Mobile d'Urgence et de Réanimation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - A Lejay
- Fédération de Médecine Translationnelle de Strasbourg, Strasbourg, France; Service de Chirurgie Vasculaire et de Transplantation Rénale, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - C Biermann
- Pôle d'Anesthésie, Réanimations Chirurgicales, Service d'Aide Médicale Urgente-Service Mobile d'Urgence et de Réanimation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - S Caillard
- Service de Néphrologie-Transplantation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - B Moulin
- Service de Néphrologie-Transplantation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - N Chakfe
- Service de Chirurgie Vasculaire et de Transplantation Rénale, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - F Severac
- Département de Santé Publique, Secteur Méthodologie et Biostatistique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - M Schaeffer
- Département de Santé Publique, Secteur Méthodologie et Biostatistique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - P-M Mertes
- Pôle d'Anesthésie, Réanimations Chirurgicales, Service d'Aide Médicale Urgente-Service Mobile d'Urgence et de Réanimation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France; Fédération de Médecine Translationnelle de Strasbourg, Strasbourg, France
| | - A Steib
- Pôle d'Anesthésie, Réanimations Chirurgicales, Service d'Aide Médicale Urgente-Service Mobile d'Urgence et de Réanimation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France; Fédération de Médecine Translationnelle de Strasbourg, Strasbourg, France
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45
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Intraoperative Management of the Kidney Transplant Recipient. CURRENT TRANSPLANTATION REPORTS 2017. [DOI: 10.1007/s40472-017-0142-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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46
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Sachin S, Rajesh MC, Ramdas EK. Anesthesia for bench surgery. Anesth Essays Res 2016; 10:680-683. [PMID: 27746573 PMCID: PMC5062213 DOI: 10.4103/0259-1162.186615] [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] Open
Abstract
Surgical removal of the kidney tumor outside the body, (ex vivo renal bench surgery) followed by auto transplantation is an emerging and often done procedure to reconstruct the urinary tract. It possesses immense challenges to both the anesthesiologists and the surgeons. The risks are multiplied if you are performing the surgery on a solitary functioning kidney. Here, we are describing the anesthetic management of 70-year-old male post nephrectomy patient undergoing renal auto transplantation by bench surgery. Our primary goals for perioperative management were to maintain a stable hemodynamics throughout the procedure, to reduce fluid overload during the period of extracorporeal surgery, to maintain perfusion for the transplanted solitary kidney, to control bleeding to a minimum, and to provide adequate analgesia for the patient. We made use of a balanced anesthetic technique and stringent monitoring standards to bring forth a successful outcome for the patient. At the end of his hospital stay, patient went home with a healthy, normally functioning kidney.
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Affiliation(s)
- S Sachin
- Department of Anaesthesia, BMH, Kozhikode, Kerala, India
| | - M C Rajesh
- Department of Anaesthesia, BMH, Kozhikode, Kerala, India
| | - E K Ramdas
- Department of Anaesthesia, BMH, Kozhikode, Kerala, India
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Taylor K, Lorenzo A, Mertens L, Dragulescu A. Pilot study on the feasibility of limited focused real-time echocardiography during pediatric renal transplantation. Pediatr Transplant 2016; 20:778-82. [PMID: 27235185 DOI: 10.1111/petr.12726] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2016] [Indexed: 11/30/2022]
Abstract
Pediatric renal transplantation protocols describe supraphysiological blood pressure and CVP to optimize graft perfusion. Ideal CVP and blood pressure targets in children are uncertain and difficult to achieve and/or sustain without incurring morbidity. We correlated intra-operative ECHO with standard monitoring to assess intravascular volume at critical intra-operative stages. A feasibility pilot study of real-time limited ECHO images during four critical stages of pediatric renal transplantation (baseline; venous and arterial clamps on; clamps off; 5-10 min post-clamp release) was conducted. Simultaneous CVP, SBP and DBP measurements were obtained with ECHO images. A surgeon blinded to the ECHO study assessed the quality of graft perfusion. Thirteen patients (nine TTE and four TEE) were enrolled. The CI increased in all patients at vascular clamp removal and the post-resuscitation period (average increase in CI 20%, range 8-49%). SBP, DBP and CVP were inconsistent. ECHO data confirmed an appropriate CI increase even when the targeted CVP and BP values described in protocols were not achieved. The surgeons were satisfied with graft perfusion in 12 of 13 cases, with one locally obstructed vessel. We suggested that aiming for fixed targets in CVP and BP is not necessary to augment CI and encourage good renal perfusion.
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Affiliation(s)
- Katherine Taylor
- Department of Anesthesia, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Armando Lorenzo
- Department of Urology, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Luc Mertens
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andreea Dragulescu
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
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Rajakumar A, Gupta S, Malleeswaran S, Varghese J, Kaliamoorthy I, Rela M. Anaesthesia and intensive care for simultaneous liver-kidney transplantation: A single-centre experience with 12 recipients. Indian J Anaesth 2016; 60:476-83. [PMID: 27512163 PMCID: PMC4966351 DOI: 10.4103/0019-5049.186025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background and Aims: The perioperative management of patients presenting for simultaneous liver and kidney transplantation (SLKT) is a complex process. We analysed SLKTs performed in our institution to identify preoperative, intraoperative and post-operative challenges encountered in the management. Methods: We retrospectively studied the case records of 12 patients who underwent SLKT between 2009 and 2014 and analysed details of pre-operative evaluation and optimisation, intraoperative anaesthetic management and the implications of use of perioperative continuous renal replacement therapy (CRRT) and the post-operative course of these patients. Results: Of the total 12 cases, 4 were under 16 years of age. The indications for SLKT were primary hyperoxaluria (5), congenital hepatic fibrosis with polycystic kidney disease (2), ethanol-related end-stage liver disease (ESLD) with hepatorenal syndrome type 1 (1). Four patients had ESLD with end-stage renal disease due to other causes. Six recipients received live donor grafts and 6 patients received cadaveric grafts. Seven patients received intraoperative CRRT. Mean duration of surgery was 12.5 h. Cardiac output monitors used were trans-oesophageal echocardiogram (2), pulmonary artery catheter (1) and pulse contour cardiac output monitor (3). There was 1 sepsis-related mortality on 7th post-operative day. Conclusion: A thorough pre-operative evaluation and optimisation, knowledge and anticipation of potential problems, and meticulous intraoperative fluid management guided by appropriate monitoring and use of CRRT when needed can help in achieving successful outcomes.
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Affiliation(s)
- Akila Rajakumar
- Department of Liver Transplant Anaesthesia and Intensive Care, Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India
| | - Shiwalika Gupta
- Department of Liver Transplant Anaesthesia and Intensive Care, Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India
| | - Selvakumar Malleeswaran
- Department of Liver Transplant Anaesthesia and Intensive Care, Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India
| | - Joy Varghese
- Department of Hepatology, Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India
| | - Ilankumaran Kaliamoorthy
- Department of Liver Transplant Anaesthesia and Intensive Care, Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India
| | - Mohamed Rela
- Department of Hepatobiliary and Liver Transplant Surgery, Institute of Liver Disease and Transplantation, Global Health City, Chennai, Tamil Nadu, India; Department of Hepatobiliary and Liver Transplant Surgery, Institute of Liver Studies, King's College, London
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49
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Abstract
BACKGROUND The ideal intravenous fluid for kidney transplantation has not been defined, despite the common use of normal saline during the peri-operative period. The high chloride content of normal saline is associated with an increased risk of hyperchloraemic metabolic acidosis, which may in turn increase the risk of hyperkalaemia and delayed graft function. Balanced electrolyte solutions have a lower chloride content which may decrease this risk and avoid the need for dialysis due to hyperkalaemia in the immediate post-transplant period. Randomised controlled trials (RCTs) addressing this issue have used biochemical outcomes to compare fluids and have been underpowered to address patient-centred outcomes such as delayed graft function. OBJECTIVES To examine the effect of lower-chloride solutions versus normal saline on delayed graft function, hyperkalaemia and acid-base status in kidney transplant recipients. SEARCH METHODS We searched the Cochrane Kidney and Transplant's Specialised Register to 26 November 2015 through contact with the Information Specialist using search terms relevant to this review. SELECTION CRITERIA RCTs of kidney transplant recipients that compared peri-operative intravenous lower-chloride solutions to normal saline were included. DATA COLLECTION AND ANALYSIS Two independent investigators assessed studies for eligibility and risk of bias. Data from individual studies were extracted using standardised forms and pooled according to a published protocol. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. MAIN RESULTS Six studies (477 participants) were included in the review. All participants were adult kidney transplant recipients and 70% of participants underwent live-donor kidney transplantation. The overall risk of bias was low for selection bias and unclear for remaining domains. There was no difference in the risk of delayed graft function (3 studies, 298 participants: RR 1.03, 95% CI 0.62 to 1.70) or hyperkalaemia (2 studies, 199 participants: RR 0.48, 95% CI 0.04 to 6.10) for participants who received balanced electrolyte solutions compared to normal saline. Intraoperative balanced electrolyte solutions compared to normal saline were associated with higher blood pH (3 studies, 193 participants: MD 0.07, 95% CI 0.05 to 0.09), higher serum bicarbonate (3 studies, 215 participants: MD 3.02 mEq/L, 95% CI 2.00 to 4.05) and lower serum chloride (3 studies, 215 participants: MD -9.93 mmol/L, 95% CI -19.96 to 0.11). There were four cases of graft loss in the normal saline group and one in the balanced electrolyte solution group, and four cases of acute rejection in the normal saline group compared to two cases in the balanced electrolyte solution group. AUTHORS' CONCLUSIONS Balanced electrolyte solutions are associated with less hyperchloraemic metabolic acidosis compared to normal saline, however it remains uncertain whether lower-chloride solutions lead to improved graft outcomes compared to normal saline.
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Affiliation(s)
- Susan Wan
- The University of SydneyCentral Clinical SchoolSydneyNSWAustralia2006
| | - Matthew A Roberts
- Monash UniversityEastern Health Clinical SchoolBox HillVICAustralia3128
| | - Peter Mount
- Austin HealthDepartment of Nephrology145 Studley RoadMelbourneVICAustralia3084
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50
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Mayhew D, Ridgway D, Hunter JM. Update on the intraoperative management of adult cadaveric renal transplantation. BJA Educ 2016. [DOI: 10.1093/bjaceaccp/mkv013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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