Creatinine Reduction Ratio Research Articles

Comparative Effects of Acetate- and Citrate-Based Dialysates on Dialysis Dose and Protein-Bound Uremic Toxins in Hemodiafiltration Patients: Exploring the Impact of Calcium and Magnesium Concentrations.

Modern hemodialysis employs weak acids as buffers to prevent bicarbonate precipitation with calcium or magnesium. Acetate, the most used acid, is linked to chronic inflammation and poor dialysis tolerance. Citrate has emerged as a potential alternative, though its effect on dialysis efficiency is not clear. This study aims to compare the efficacy of acetate- and citrate-based dialysates, focusing on protein-bound uremic toxins and dialysis doses. This single-center prospective crossover study includes prevalent patients participating in a thrice-weekly online hemodiafiltration program. Four dialysates were tested: two acetate-based (1.25 and 1.5 mmol/L calcium) and two citrate-based (1.5 mmol/L calcium with 0.5 and 0.75 mmol/L magnesium). Pre- and post-dialysis blood samples of eighteen patients were analyzed for urea, creatinine, p-cresyl sulfate, indoxyl sulfate, and albumin. Statistical significance was assessed using paired t-tests and repeated measures of ANOVA. There were no significant differences in dialysis dose (Kt), urea, creatinine, or indoxyl sulfate reduction ratios between acetate- and citrate-based dialysates. However, a significant decrease in the reduction ratio of p-cresyl sulfate was observed with the acetate dialysate containing 1.25 mmol/L calcium and the citrate dialysate with 0.5 mmol/L magnesium compared to the acetate dialysate containing 1.5 mmol/L calcium and the citrate dialysate with 0.75 mmol/L magnesium (51.56 ± 4.75 and 53.02 ± 4.52 vs. 65.25 ± 3.38 and 58.66 ± 4.16, p 0.007). No differences in dialysis dose were found between acetate- and citrate-based dialysates. However, citrate dialysates with lower calcium and magnesium concentrations may reduce the albumin displacement of p-cresyl sulfate. Further studies are needed to understand the observed differences and optimize the dialysate composition for the better clearance of protein-bound uremic toxins.

#569 Proenkephalin A 119-159 (penKid) for the early identification and risk stratification of delayed graft function following kidney transplantation

Abstract Background and Aims Delayed graft function (DGF) frequently occurs following kidney transplantation, and prolonged duration of DGF adversely affects 1-year graft function and long-term graft survival. Recently, Proenkephalin A 119-159 (penKid) was shown to reflect kidney function and predict acute kidney injury (AKI) in critically ill patients. Given the similarities between DGF in transplanted and AKI in native kidneys, we hypothesized that penKid may aid in identifying and risk-stratifying DGF post-transplantation. Method In a prospective study of 159 consecutive kidney transplant recipients at Heidelberg University Hospital from November 2021 to July 2023, penKid was quantified using an immunoluminometric assay until patient discharge. DGF was primarily defined as the necessity for dialysis within 7 days post-transplant. Additionally, penKid was examined in the context of DGF severity, discriminating the different durations of post-transplant dialysis treatment. Similarly, penKid was assessed to differentiate uptake of graft function, defined as slow or immediate by a serum creatinine reduction ratio of pre-transplant and 7 days post-transplant levels of <0.7 and ≥0.7, respectively. Results DGF, defined as the need for dialysis within the first week post-transplant, occurred in 53/159 (33.3%) patients. penKid enabled the differentiation of patients with and without DGF from the first day post-transplant onward (P < 0.001, Fig. 1), and consistently outperformed SCr in discriminating DGF from no DGF at all time points studied (P < 0.001). Additionally, penKid allowed identification of DGF severity from the first day post-transplant (P < 0.001) and early differentiation between slow and delayed graft function (AUC 0.79 [95% CI 0.68-0.90]). In a multivariate model, delta penKid from pre-transplant to the first day post-transplant emerged as the strongest predictor for DGF (C index = 0.88). On the first day post-transplant, penKid, with a cut-off at 300 pmol/L, discriminated DGF from no DGF with a sensitivity of 95.1% (95% CI 83.9–98.7) and a specificity of 56.5% (95% CI 46.3–66.2). Conclusion penKid is a promising biomarker shown to accurately differentiate DGF from no DGF as early as the first day post-transplant and to predict DGF severity, allowing for earlier intervention in these at-risk patients. Due to its high discriminatory power to identify and predict DGF post-transplantation, penKid shows great potential to accompany future studies examining the occurrence of DGF in transplant programs, where DCD is introduced into practice, machine perfusion techniques are assessed, or in trials that assess potential therapeutic interventions in patients with DGF.

Predictors of Skeletal Muscle Index for Patients Treated With Hemodialysis

ObjectiveThere is an increased risk of skeletal muscle mass (SMM) loss among patients with stage 5 chronic kidney disease (CKD) treated with maintenance hemodialysis (MHD). The reduced SMM considerably influences the development of protein-energy wasting (PEW). Patients who develop PEW have higher hospitalization and mortality rates than those without PEW. This study determined if key variables could predict SMM Index (SMM adjusted for height) in patients receiving MHD. MethodsWe conducted a secondary analysis of cross-sectional data obtained from the Rutgers Nutrition and Kidney Database (n=178). Data were utilized to calculate both SMM and SMM Index. Univariate and multiple linear regression models explored the relationship between SMM Index and the following variables: serum albumin (ALB), Kt/V, normalized protein catabolic rate (nPCR), serum creatinine (SCr), and urea reduction ratio (URR). ResultsMost participants were Black/African American (82.9%), male (59.1%), and obese (39%), with a mean age of 55.9 ± 11.9 years. The median SGA score was 5, indicating a lower risk of malnutrition. Participants had a mean SMM of 26.4kg and a median SMM Index of 8.9kg/m2. Univariate regression modeling found URR to be a significant predictor of SMM Index, with increases in the percentage of URR predicting lower SMM Index values. The adjusted regression modeling found similar results, with increases in URR percentage predicting declines in SMM Index. ConclusionThis study found that URR was a predictor of SMM Index in patients receiving MHD. Further research is required to explore these relationships and provide clinicians with a more extensive array of tools to recognize early signs of SMM loss to prevent the progression of PEW.

Creatinine Reduction Ratio Is a Prognostic Factor for Acute Kidney Injury following Cardiac Surgery with Cardiopulmonary Bypass: A Single-Center Retrospective Cohort Study.

Acute kidney injury (AKI) after cardiac surgery is a common complication that can lead to death. We previously reported that the creatinine reduction ratio (CRR) serves as a useful prognostic factor for AKI. The primary objective of this study was to determine the predictors of AKI after surgery. The secondary objective was to determine the reliability of the CRR for short- and long-term outcomes. We retrospectively collected information about cardiac surgery patients who underwent cardiopulmonary bypass. Patients were divided into AKI and non-AKI groups based on the AKIN and RIFLE criteria. We analyzed the two groups regarding the preoperative patient data and operative information. The CRR was calculated as follows: (preoperative creatinine-postoperative creatinine)/preoperative creatinine. The prognostic factors of AKI-CS were surgery time, CPB time, aorta clamp time, platelet transfusion, and CRR < 20%. In the multivariate logistical analysis, CRR was an independent predictor of AKI (adjusted odds ratio: 0.90 [0.87-0.93], p < 0.001). However, there were no significant differences in CRR in terms of the rate of new onset chronic kidney disease (CKD). After cardiac surgery with cardiopulmonary bypass, CRR has good diagnostic power for predicting perioperative AKI. However, we cannot use it as a prognostic factor over a long-term period.

Predictive Factors Associated with Delayed Graft Function Following Renal Transplantation: A Retrospective Cohort Study

Kidney transplantation has become a routine procedure for end-stage renal disease. Although improvement in short term graft patency has been achieved, delayed graft function (DGF) is one of the important complications following kidney transplantation. DGF results from ischemia-reperfusion injury and involves a multitude of contributing elements including donor characteristics and etiology of the end-stage renal disease. The neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) are easily applicable methods for evaluation of systemic inflammation. We hypothesized that these parameters could refine the detection of the patients with DGF in post- renal transplantation and guide management. To test our hypothesis, we investigated whether the NLR, PLR, and creatinine reduction ratio CRR could serve as prognostic indicators for identifying patient cohorts at an elevated risk of negative treatment outcomes following renal transplantation. We also assessed demographic and clinical factors as an independent predictor to detect negative early graft function outcomes in patients after renal transplantation. This single center retrospective cohort trial comprising 55 patients who received a kidney graft from deceased or living donors was performed in Northern Cyprus Ministry of Health’s Dr. Burhan Nalbantoglu State Hospital, over a 6 year period. The demographic and clinical variables included age, gender, body mass index, the etiology of end-stage renal disease, kidney graft from living or deceased donors, NLR, PLR and CRR. DGF was defined as GFR&lt;60 on the 21th day following renal transplantation. Of the patients included in this study, 26 (47.3%) and 29 (52.7%) received deceased and living donor kidney transplantation, respectively. On the 21st day following transplantation, 27 patients (49%) had an eGFR&lt;60, whereas 28 patients (51%) had an GFR≥60. None of the patients had undergone dialysis within the first week after transplantation. There were no significant differences in demographic and clinical characteristics between the patients with eGFR 60 and eGFR 60. In logistic regression analysis, none of the predictors including etiology of the end-stage renal disease, source of donor, or demographic baseline characteristic were associated with DGF. We suggest that the NLR and PLR parameters are not associated with the presence of DGF after renal transplantation. Keywords: Renal transplantation, Delayed graft function, Renal failure, Glomerular filtration rate, End-stage renal disease.

Naples Prognostic Score for Graft Functions After Renal Transplantation: A Retrospective Analysis.

BACKGROUND The Naples prognostic score is a comprehensive measure of patients' inflammation and nutritional status, consisting of serum albumin, total cholesterol, neutrophil/lymphocyte ratio (NLR), and lymphocyte/monocyte ratio (LMR). We compared the Naples prognostic scores of kidney transplant patients with a creatinine reduction ratio of less than 30% vs those with greater than 30%. MATERIAL AND METHODS We conducted a retrospective study on 93 patients who received kidney transplants at our hospital from January 2020 to January 2023. Naples prognostic scores were used to calculate the preoperative condition of transplant recipients. The patients were divided into 2 groups based on their creatinine reduction ratio on the second day after surgery. Group A consisted of patients with a ratio above 30%, while group B consisted of those with a ratio below 30%. RESULTS Our analysis revealed that the total cholesterol and albumin values of groups A and B showed no substantial difference. Group B had clearly more patients with Naples prognostic score 3-4 compared to the other group (P=0.032). Multivariate analysis determined that patients with Naples prognostic score 3-4 had a 3.151-fold higher likelihood of experiencing creatinine reduction below 30% (95% CI 1.209-8.215, P value 0.019). CONCLUSIONS The preoperative inflammatory and nutritional status of patients may have an impact on the functioning of grafts during the postoperative period. A high Naples prognostic score may be linked with a decrease in creatinine reduction ratio in post-transplant kidneys, which could lead to graft dysfunction.

Causes of Graft Dysfunction in Live Related Kidney Transplantation in a Tertiary Care Hospital.

Introduction: Renal transplantation remains the treatment of choice for end-stage renal disease (ESRD). Graft dysfunction or adverse events following renal transplantation are associated not only with short &amp; long term graft outcome, but also with patient survival. Living kidney donation is a scheduled event that offers the advantage of optimal preparation for the recipient and donor. Restoration &amp; preservation of renal function post transplant depends on many factors. Attempts should therefore been made to improve early graft function by a variety of mechanical, pharmacological and organ allocation strategies. Objectives: To identify the causes of graft dysfunction in renal allograft recipients. Method: In this prospective study, a total of 40 renal allograft recipients as well as 40 donors were evaluated. ESRD patients and kidney donors preoperative details and clinical parameters were recorded in structured questionnaire. Peroperative variables like induction with antibody, cold ischemia time, warm ischemia time, peroperative hypotension, peroperative blood transfusion, peroperative urine production were recorded. Early postoperative clinical variables like BP, hourly urine production, temperature were monitored and biochemical Hb%, Tc, Dc, ESR, blood urea, serum creatinine, s. electrolytes, cyclosporin level (C2 level), urine RME &amp; CS and imaging USG of transplanted kidney and duplex study of renal vessels were done. On the basis of creatinine reduction ratio(CRR) on post transplant day 7, renal allograft recipients were divided into IGF and RGF/graft dysfunction group respectively and evaluation and causes of graft dysfunction were recorded. Data were processed and analyzed using computer software SPSS (Statistical package for social science) version 12. Results: The mean age of donors was 39.15±10.09 years with a male female ratio 1:1.7. The mean age of renal allograft recipients was 32.30±8.85 years with a male to female ratio of 3.5:1. Among 40 patients, 52.5% recipients had IGF and 47.5% had RGF. At day 7 posttransplantation period mean serum creatinine in IGF group was 130.10±14.45 ìmol/L and in RGF group was 237.32±123.85 ìmol/L which was statistically strongly significant (p value &lt;0.0001). Regarding causes of graft dysfunction at day 7 post transplant period, cold ischemia time (p value 0.043) and postoperative urine production within 6 hours (p value 0.0001) were found statistically significant. Conclusion: This study showed that 52.5% renal allograft recipient had IGF and 47.5 % renal allograft recipient had graft dysfunction(RGF). Significant causes of graft dysfunction were long cold ischemia time in minute and peroperative urine production in ml within 6 hours after anastomosis of vessels. Mugda Med Coll J. 2022; 5(2): 60-66

O006 A randomised trial of normothermic machine perfusion versus static cold storage in donation after circulatory death renal transplantation

Abstract Introduction Kidneys from donation after circulatory death (DCD) donors are more susceptible to cold storage (CS) injury and have a high risk of delayed graft function (DGF). This trial is the first to compare normothermic machine perfusion (NMP) to conventional CS in DCD kidney transplantation. Methods In a multicentre randomised control trial, DCD kidneys were randomised to either NMP or CS. NMP kidneys were perfused for 60min with an oxygenated red-cell-based solution (36.0°C) The primary end point was DGF defined as the requirement for dialysis in the first 7days post-transplant. Secondary outcome measures included renal function up to 12 months posttransplant and patient/ graft survival. For all outcome measures a logistic regression model was used adjusted for cold ischaemic time, donor age, left/right kidney and centre. Results February 2016-March 2020, 338 kidneys were randomised into the trial. Twenty-five kidneys did not undergo NMP due to logistical/technical difficulties but were included in an intention-to-treat analysis. Twenty-seven kidneys in the NMP and 21 in the CS group where not transplanted and excluded; 143 NMP and 147 CS kidneys were analysed. There was no significant difference in the rate of DGF (NMP 61% vs CS 58%; P=0.624). Secondary outcome measures demonstrated a significantly higher creatinine reduction ratio day 2(CRR2) (P=0.035) and significantly lower levels of serum creatinine across all timepoints in the NMP group (P=0.024). Conclusion A short end period of NMP did not reduce rates of DGF in DCD kidneys. Secondary outcome measures suggest that NMP may improve renal function. Take-home message This is the first randomised controlled trial of normothermic machine perfusion (NMP) in clinical transplantation. The results suggest that NMP may improve the renal function of DCD kidneys.

The role of hypothermic machine perfusion in selecting renal grafts with advanced histological score.

BackgroundFew studies explored the role of hypothermic machine perfusion (HMP) in the sub‐group of non‐standard renal grafts with a biopsy‐proven advanced histological impairment. This study aimed to investigate the role of HMP in grafts with a Karpinski Score >3 in terms of the need for dialysis, creatinine reduction ratio at day‐7 (CRR7), and 3‐year graft survival.MethodsTwenty‐three perfused grafts with Karpinski Score >3 evaluated between November 2017 and December 2018 were retrospectively analyzed and compared with a control group of 32 non‐perfused grafts transplanted between January 2014 and October 2017.ResultsAfter transplantation, perfused grafts had fewer cases requiring dialysis (8.7% vs. 34.4%; p = 0.051), a better reduction in serum creatinine (median at 7 days: 2.2 vs. 4.3 mg/dl; p = 0.045), and shorter length of hospital stay (median 11 vs. 15 days; p = 0.01). Three‐year death‐censored graft survival was better in the perfused cases (91.3% vs. 77.0%; p = 0.16).In perfused grafts, initial renal resistance (RR) had the best predictive value for renal function recovery after the first week, as defined by CRR7 ≤ 70% (AUC = 0.83; p = 0.02). A cut‐off value of 0.5 mm Hg/ml/min showed a sensitivity of 82.4%, a specificity of 83.3%, and diagnostic odds ratio = 23.4. After dividing the entire population into a Low‐RR (n = 8) and a High‐RR Group (n = 15), more cases with CRR7 ≤ 70% were reported in the latter group (86.7 vs. 13.3%; p = 0.03).ConclusionHMP yielded promising results in kidneys with Karpinski Score >3. Initial RR should be of interest in selecting non‐standard organs for single kidney transplantation even in impaired histology.

RELATIONSHIP BETWEEN WARM ISCHEMIC TIME AND RESISTIVE INDEX ON CREATININ REDUCTION RATIO DAY TWO AFTER LIVING KIDNEY DONOR TRANSPLANTATION

Kidney transplantation (KT) may improve kidney function, via filtration, excretion, and hormonal function better than other kidney replacement therapies. Many factors may cause graft rejection or delayed graft function which may decrease the prognosis for graft survival. This study aims to determine associated factors of serum creatinine reduction ratio day 2 (CRR2) after living kidney donor transplants. This research used a retrospective cohort study design, with total sampling based on complete documents was done. A total 44 respondents (from 2012 to January 2020) and 22 respondents (based on the complete Resistive Index (RI) were recorded since 2018). Early Graft Function was defined using CRR2. Immediate Graft Function (IGF) was defined if CRR2 &gt; 30% and Delayed Graft Function (DGF) if CRR2 ≤ 30%. The results of Multiple logistic regression analysis from 44 samples showed that Warm Ischemic Time (WIT) ≤ 40 minutes was significantly associated with IGF (OR 10.78; 95%CI: 1.66 to 70.16; p=0.01). A result with 22 samples showed that, only RI ≤ 0.7was significantly associated with IGF (OR 0.11; 95%CI: 0.03-0.41; p=0.002). In conclusion, WIT and RI influence on EGF with parameters CRR2 of living-donors. KT Patients with WIT ≤40 minutes and RI ≤0.7 had a higher risk of IGF.

Creatinine reduction ratio on postoperative day 2 predicts long-term outcomes after living donor kidney transplantation.

To evaluate the relationship between the creatinine reduction ratio between postoperative days 1 and 2 and post-transplantation clinical outcomes after living donor kidney transplantation. Clinical data of patients who underwent living donor kidney transplantation at Jichi Medical University Hospital, Tochigi, Japan, between 2006 and 2019 were retrieved. The creatinine reduction ratio between postoperative days 1 and 2 was calculated based on the formula: (Cre1 - Cre2) × 100/Cre1; patients were then classified into either the slow graft function (creatinine reduction ratio between postoperative days 1 and 2 ≤30%) or immediate graft function (creatinine reduction ratio between postoperative days 1 and 2 >30%) group. We carried out the log-rank test and multivariate Cox proportional hazards regression analyses to assess graft survival and rejection-free survival, and the unpaired t-test and multivariate linear regression to assess post-transplantation estimated glomerular filtration rates. Multivariate analyses used age, sex, dialysis duration, ABO compatibility, donor-specific antibody positivity and medically complex living donors as explanatory variables. Of the 272 patients, 30 and 242 were in the slow graft function and immediate graft function groups, respectively. Multivariate Cox proportional hazards regression analyses showed a significantly higher incidence of overall and death-censored graft loss in the slow graft function group than the immediate graft function group. The frequency of rejection after 1 week post-transplantation did not differ within the groups. Post-transplantation estimated glomerular filtration rates tended to decline earlier in the slow graft function group than in the immediate graft function group; however, the difference was not statistically significant. The creatinine reduction ratio between postoperative days 1 and 2 could potentially predict long-term outcomes after living donor kidney transplantation. Using the creatinine reduction ratio between postoperative days 1 and 2 and other conventional indicators might allow accurate risk classification and appropriate therapeutic interventions.

Comparison of two regional citrate anticoagulation modalities for continuous renal replacement therapy by a prospective analysis of safety, workload, effectiveness, and cost.

Currently, regional citrate anticoagulation (RCA) is the preferred approach for continuous renal replacement therapy (CRRT), and several RCA protocols are commercially available. This study was aimed at comparing two RCA modalities for CRRT in terms of safety, workload, effectiveness, and costs. We prospectively evaluated two different RCA approaches in patients admitted to our intensive care unit (ICU) who needed CRRT. Patients with acute liver failure were excluded. We compared a hypertonic sodium-citrate solution 136 mmol/L added before the filter as anticoagulant during bicarbonate continuous hemodialysis (RCA-CVVHD) versus citrate-buffered replacement fluid 13.3 mmol/L infused by predilution setting in continuous venovenous hemofiltration (RCA-CVVH). Alkalosis, calcium homeostasis, nursing workload, filter lifespan, urea-creatinine metabolic control, and costs were recorded. Forty-five and 31 patients who underwent RCA-CVVH and RCA-CVVHD, respectively, were included. Alkalosis-free time distributions were significantly different in favor of a higher alkalosis incidence in the RCA-CVVHD group (log-rank test χ2(1)=8.18, P=0.004). Multivariable analysis showed that RCA-CVVHD was associated with a longer filter lifespan (HR=0.47; 95% CI: 0.28-0.78), higher total cost (1362 CHF [782-1901] vs. 976 CHF [671-1353], P<0.001), and higher number of anticoagulation adjustments (9 [IQR, 4-14] vs. 2 [IQR, 1-4]). The mean urea and creatinine reduction ratios at the first 24 hours were significantly higher in the RCA-CVVHD group. Calcium homeostasis and filter downtime were similar in the two groups. Pre-filter hypertonic sodium-citrate solution (136 mmol/L) results in longer filter patency and improves depuration effectiveness. However, compared to RCA-CVVHF, it causes metabolic alkalosis and increases nursing interventions and cost.

POS-770 “SLOW AND STEADY MAY NOT ALWAY WIN THE RACE “ –SHORT TERM OUTCOMES OF SLOW GRAFT FUNCTION POST RENAL TRANSPLANT - A SINGLE CENTRE EXPERIENCE

It is well established that delayed graft function (DGF), traditionally defined as the requirement of dialysis within the first week of transplant, is associated with poorer graft outcomes as compared to immediate graft function (IGF). A subset of patients do not have immediate graft function, but rather have a slower decrease in serum creatinine, not requiring dialysis, termed as slow graft function. Outcomes of this group of patients have not often been studied and most studies have classified this group of patients as having Immediate graft function (IGF) for comparison with patients with DGF. Our aim was to assess short term outcomes of these patients with slow graft function and to identify risk factors, if any among the cohort. Study setting: Kasturba Medical College, Manipal, a tertiary care centre in South India providing healthcare services to a predominantly rural population Type of study: Retrospective, ObservationalStudy Period: January 2016 to April 2018 Sample Size: 70 Renal allograft recipients Slow graft function was defined as per previous studies as follows 1)Creatinine > 3 mg/dl at Post-op day 5 or > 2.5mg/dl at day 72)Creatinine >1.5 and creatinine reduction ratio (CRR) < 20% between Post-op day 1 and post-op day 3Patients with DGF were not included in this study. Demographics related to recipient and donor, biopsy-proven acute rejections, short term outcomes in terms of graft function(serum creatinine and eGFR) at 1 year and 2 years follow up were documented and analysed. The transplants were predominantly living donor ( 88.6% ) and ABO compatible ( 97.1%) with a median follow up of 30 months (IQR 25-40) . 27 out of 70 transplanted patients (38.6%) were characterized as having slow graft function (SGF) as per the definitions and criteria used from earlier studies (Table 1: Baseline characteristics) . On univariate analysis, patients with SGF had lower GFR at 1 year (p-value – 0.028), higher number of biopsy-proven acute rejections over the median follow up period ( 48.1% versus 25.5 %; p-value – 0.039). The number of transplant patients with graft dysfunction at 1 year ( eGFR <60 ml/min) and 2 years were also statistically significant (Table 2: Univariate Analysis). Donor age and donor GFR ( measured by DTPA) were not significantly associated with SGF though numerically median donor age was higher and donor GFR was lower. The subset of patients with SGF may have adverse short term outcomes as compared to those with immediate graft function. A higher incidence of biopsy-proven rejection and higher number of patients with graft dysfunction at 2 years was seen in this cohort. Long term outcomes assessment and identification of risk factors leading to SGF needs to be studied and may help to better risk stratify and manage these patients for better outcomes.

COMPARAÇÃO DA EVOLUÇÃO PÓS-OPERATÓRIA PRECOCE EM PACIENTES SUBMETIDOS A TRANSPLANTE RENAL COM RINS DE DOADORES VIVOS E FALECIDOS, NA CIDADE DE CASCAVEL-PR

O transplante renal é o tratamento de escolha para muitos pacientes que sofrem de insuficiência renal terminal e possui poucas contraindicações. Existem dois tipos de doadores: os falecidos e os vivos. A legislação brasileira permite, no caso de doadores vivos, a doação entre parentes de até quarto grau, já no caso de doação proveniente de doador falecido, o receptor precisa estar inscrito na lista única de receptores de rim do seu estado e aguardar um rim compatível oriundo de indivíduos que foram a óbito devido à morte encefálica. As técnicas cirúrgicas de ambos os casos possuem suas singularidades. No doador vivo, a retirada do rim ocorre simultaneamente à preparação do receptor, ou seja, o tempo de isquemia entre a retirada do rim do doador até chegar ao receptor é mínima. Já quando o doador é falecido, o órgão precisa ser preservado até chegar ao seu devido receptor, sendo que o tempo de isquemia não deve ultrapassar 36-48 horas em solução de conservação. Será realizado um estudo exploratório do tipo descritivo com coleta de dados em prontuários médicos localizados no Hospital Salete e na clínica Renalclin na cidade de Cascavel no Paraná. Foram avaliados 40 prontuários médicos, sendo 14 de transplante intervivos e 26 de doador falecido. A média da evolução da diurese do grupo com doadores vivos manteve-se sempre acima das médias do grupo de doadores falecidos. Já em relação a razão de redução da creatinina (CCR2), o grupo intevivos obteve função imediata do enxerto, enquanto o grupo de doadores cadáveres obteve função retardada do enxerto. O presente trabalho tem como objetivo fazer um comparativo entre a evolução pós-operatória imediata até a alta de pacientes submetidos a transplante renal com rins de doadores falecidos e vivos, utilizando dados como a evolução da creatinina e da diurese e o tempo de internamento, avaliando se há diferenças significativas entre o grupo que recebeu o rim de doador vivo e o grupo de doador cadáver e se essas divergências estão de acordo com a literatura mundial.

Early predictive value of baseline renal transplant scintigraphy in pediatric patients.

The value of baseline renal transplant scintigraphy (RTS) with technetium-99m diethylenetriaminepentaacetic acid (Tc-DTPA) performed within 2 days after transplantation in predicting early renal transplant outcome in pediatric recipients was assessed in this study. Baseline RTS of 48 pediatric patients were studied retrospectively. Hilson's perfusion index, graft index (GI), time between peak perfusion and iliac artery (ΔP), and the ratios of peak perfusion to plateau (P : Pl), to peak iliac artery (P : A), and to peak uptake (P : U) were obtained. In 14 patients younger than 9 years old, because of faint visualization of iliac artery, the perfusion indices and GI could not be calculated. The 'Bedside Schwartz' formula was used for calculation of follow-up estimated glomerular filtrate rate (eGFR) values. The need for dialysis in the first week or decreasing serum creatinine of less than 10%/day during 3 consecutive days after the transplantation was accepted as delayed graft function (DGF). The patients, whose creatinine reduction ratio was less than 70% on day 7 after transplantation without DGF, were accepted as slow graft function (SGF). The means of GI, P : U, and Hilson's perfusion index were significantly high in SGF/DGF (n=10). GI and P : U had very high accuracy in the diagnosis of DGF/SGF (area under the curve>0.90). A strong correlation was found between P : U and same day and between GI and day 15 eGFR values. GI, P : U, and P : A were significant for the prediction of follow-up eGFR of less than 60 ml/min/1.73 m. GI was more accurate than the others. Our experience in this study underlines the importance of RTS, especially with the use of GI and P : U, which are very valuable in diagnosing DGF/SGF and predicting early transplant outcome in pediatric recipients.

Intraoperative Renal Perfusion in Kidney Transplantation

Aim To explore whether intraoperative direct measurement of renal flows reflect ischemia/reperfusion injury and identify grafts at risk of inferior outcome in kidney transplantation, we conducted an observational retrospective single-center study. Methods Intraoperative direct transit-time flow measurements of renal artery flow (RAF) in mL/min were obtained immediately after graft reperfusion (M1) and prior to skin closure (M2). Patients were divided into the following 4 outcome groups: delayed graft function in patients requiring dialysis within postoperative day 7, non-dialysis requiring delayed graft function in patients with creatinine reduction ratio between postoperative days 1 to 2 (CRR2) ≤30%, immediate graft function (CRR2 >30%), and patients with vascular complications. Median and interquartile ranges are reported. Results 68 kidney transplants were included with a median follow-up of 12.6 (8.1-19.9) months. 16 living donors (LD), 35 donation after brain death donors (DBD) and 17 donation after cardiac death donors (DCD). Renal artery flow was available in 15 patients at M1 and in all 68 included patients at M2. An increase of flow between M1 and M2 was observed in 73% of cases. Living donors showed significantly higher flows than deceased donors (Table 1). A creatinine reduction ratio between postoperative days 1 to 2 ≤30% was observed in all delayed graft function patients requiring dialysis or not and in 3 out of 4 vascular complication patients. Renal artery flow at M2 in these patients was significantly lower compared to immediate graft function patients: 259 (181-344) vs 419.5 (247-551), p=0.0065. Renal artery flow at M2 showed a negative correlation with recipient age (r=-0.28, p=0.002) but not with donor age (r=-0.23, p=0.058). No PNF or irreversible rejection were observed. Graft loss occurred in 3 patients because of 2 renal artery thrombosis and 1 renal vein thrombosis in the early postoperative period. Normal curves with low flow or high resistance were observed at M1 with reduction of resistance at M2 (Table 2). In 2 patients experiencing post-transplant arterial complications initial flows were normal or even high with a reduction of the flows at M2 (M2/M1 ≤1). The patient with postoperative renal vein thrombosis did not show any intraoperative findings in the arterial measurements. Conclusions Our results demonstrates different flows according to graft quality. Patients receiving living donor grafts and with immediate graft function showed significantly higher intraoperative renal artery flows. Intraoperative direct renal artery flow measurement in kidney transplantation identified transplants at risk for worse outcome.

Association of Slow Graft Function with Long-Term Outcomes in Kidney Transplant Recipients

BackgroundWhether slow graft function (SGF) represents an intermediate phenotype between immediate graft function (IGF) and delayed graft function (DGF) in kidney transplant recipients is unknown.Material/MethodsIn a retrospective cohort analysis of 1,222 kidney transplant recipients, we classified patients as having IGF, SGF, and DGF using two different schemas. SGF was defined as serum creatinine (Cr) ≥3.0 mg/dL by postoperative day 5 in Schema 1, and in Schema 2, SGF was defined as Cr >1.5 mg/dL plus a creatinine reduction ratio <20% between postoperative days 1 and 3. A complementary log-log model was used to examine the association of graft function with graft survival and patient survival.ResultsMean age of study patients was 51.5±13.3 years, 59.9% were male, and 66.7% were white. In Schema 1, SGF and DGF were associated with comparable increases in risk of graft failure compared to IGF (hazard ratio (HR) 1.46, 95% confidence intervals (CI) 1.02–2.10 for SGF and HR 1.56, CI 1.11–2.22 for IGF); estimates were similar for Schema 2 (HR 1.52, CI 1.05–2.20 for SGF and HR 1.54, CI 1.10–2.17 for IGF). However, for mortality, outcomes for SGF were similarly to IGF, both SGF and IGF were associated with lower risk relative to DGF (HR 0.54, CI 0.36–0.80 for SGF in Schema 1; HR 0.58, CI 0.39–0.85 for SGF in Schema 2).ConclusionsThese findings suggest that SGF may be a marker for graft failure but not for mortality, and SGF may therefore represent a phenotype separate from IGF and DGF.

Central venous pressure monitoring in living donor kidney recipients does not affect immediate graft function: A propensity score analysis.

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. 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. 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. In this single-center analysis, immediate post-transplant renal function was not associated with the use of intraoperative CVP monitoring.

Using creatinine reduction ratio as a predictor for delayed graft function of kindey transplant recipients from donor of cardiac death

Objective: To explore the relationship between creatinine reduction ratio (CRR) and delayed graft function among kidney transplant recipients from donor of cardiac death (DCD). To define the value of CRR to predict delayed graft function (DGF) in early post-transplant period. Method: 86 patients were included, who received renal transplantation from DCD during Jan 1(st) 2011 to Jun 30(th) 2016. We performed a retrospective study and collected creatinine data within 3 days post-operation and marked them with Cr1, Cr2 , Cr3, and then calculated creatinine reduction ratio day-2 (CRR 2) =(Cr1-Cr2)/Cr1×100% and creatinine reduction ratio day-3 (CRR 3)=[(Cr1-Cr2)/Cr1+ (Cr2-Cr3)/Cr2]/2×100%. Patients were divided into two groups by DGF or not. We compared the CRR differenc between DGF group and no DGF group, and drew the receiver operating characteristic curve (ROC curve) to find out the cut-off value to predict delayed graft function. Results: Among 86 patients, DGF appeared in 17 patients. The incidence of DGF was 19.8%. The CRR 2 of patients in no DGF group was (37.5±17.4)% while patients in DGF group was (2.0±24.8)% (P<0.001). The CRR 3 of patients in no DGF group was (32.5±13.1)%, while patients in DGF group was (6.8±17.1)% (P<0.001). Acorrding to ROC curve, when cut-off value of CRR 2 was defined as <20.7%, the predicted value of DGF was the best, sensitivity was 85.5%, specificity was 76.5%, and area under the curve was 0.876. In the same way, when CRR 3 was defined as <17.6%, sensitivity was 89.9%, specificity was 76.5%, area under the curve was 0.872. Conclusion: It is reliable to predict DGF by CRR during early post-operative period. CRR shows high sensitivity and specificity and it is simple. It could guide the adjustion of immunosuppressive regimen, prevent early rejection and improve prognosis.

Comparison of hemodialysis with medium cut-off dialyzer and on-line hemodiafiltration on the removal of small and middle-sized molecules .

Recent data suggest that the use of medium cut-off (MCO) dialyzers in hemodialysis (HD) promotes greater clearance and reduction ratio (RR) for myoglobin and other large-sized molecules than on-line hemodiafiltration (ol-HDF), but its effects on β2-microglobulin are not clear. We compared RR and clearances of small and middle-sized molecules between high-flux ol-HDF and MCO (Theranova) dialyzer in HD (MCO-HD) as well as nutritional parameters. We retrospectively analyzed 10 patients treated first with ol-HDF who were thereafter switched to MCO-HD over a 1-year period. Three dialysis sessions in each 6-month period were examined. We calculated RR and clearance of small and middle-sized molecules. There was no significant difference between ol-HDF and MCO-HD for median serum albumin and prealbumin level, mean KT/V, mean urea and creatinine RR, mean β2-microglobulin (81 ± 5 vs. 81 ± 6%, p = 0.72) and myoglobin (60 ± 9% vs. 61 ± 7%, p = 0.59), RR or clearances. The use of MCO (Theranova) dialyzer in HD produces similar removal of urea, creatinine, β2-microglobulin and myoglobin as does ol-HDF, with good tolerance profile and without modification of nutritional status. .