Perioperative hemoglobin decrement as an independent risk of poor early graft function in kidney transplantation.

OBJECTIVE: Perioperative change of hemoglobin concentration (Hb) was associated with acute kidney injury in patients who underwent non-cardiac surgery, but has never been investigated in kidney transplant patients. This study aimed to observe the effects of perioperative Hb change on early graft function in kidney transplant recipients. RESULTS: A total of 269 kidney transplant patients were enrolled, of whom 98 (36.4%) developed poor early graft function (PEGF), and 171 (63.6%) had immediate graft function. Comparing two groups, patients with PEGF had a greater decremental change of Hb (-1.60 [-2.38,-0.83] vs. -0.70 [-1.35,0.20] g/dL, respectively; p < 0.001). A Hb cut-point of -1.35 g/dL was obtained from ROC analysis. Multivariate analysis showed that perioperative Hb decrement greater than 1.35 g/dL was an independent risk of PEGF (adjusted OR of 2.52, 95% CI 1.11-5.72; p = 0.026). Subgroup analysis revealed deceased donor kidney transplant (DDKT; n = 126) (adjusted OR of 2.89, 95% CI 1.11-7.55; p = 0.029), but not living donor kidney transplantation (LDKT; n = 143) (adjusted OR of 1.68, 95% CI 0.23-12.15; p = 0.606), was influenced by the perioperative Hb decrement. In conclusion, this study suggests that decremental change in perioperative Hb greater than 1.35 g/dL may serve as a modifiable factor of PEGF in DDKT.

Effects of Desflurane and Sevoflurane anesthesia on regulatory T cells in patients undergoing living donor kidney transplantation: a randomized intervention trial.

BACKGROUND: Volatile anesthetic agents used during surgery have immunomodulatory effects which could affect postoperative outcomes. Recognizing that regulatory T cells (Tregs) plays crucial roles in transplant tolerance and high peripheral blood Tregs associated with stable kidney graft function, knowing which volatile anesthetic agents can induce peripheral blood Tregs increment would have clinical implications. This study aimed to compare effects of desflurane and sevoflurane anesthesia on peripheral blood Tregs induction in patients undergoing living donor kidney transplantation. METHODS: A prospective, randomized, double-blind trial in living donor kidney transplant recipients was conducted at a single center, tertiary-care, academic university hospital in Thailand during August 2015 - June 2017. Sixty-six patients were assessed for eligibility and 40 patients who fulfilled the study requirement were equally randomized and allocated to desflurane versus sevoflurane anesthesia during transplant surgery. The primary outcome included absolute changes of peripheral blood CD4+CD25+FoxP3+Tregs which measured by flow cytometry and expressed as the percentage of the total population of CD4+ T lymphocytes at pre-exposure (0-h) and post-exposure (2-h and 24-h) to anesthetic gas. P-value < 0.05 denoted statistical significance. RESULTS: Demographic data were comparable between groups. No statistical difference of peripheral blood Tregs between desflurane and sevoflurane groups observed at the baseline pre-exposure (3.6 ± 0.4% vs. 3.1 ± 0.4%; p = 0.371) and 2-h post-exposure (3.0 ± 0.3% vs. 3.5 ± 0.4%; p = 0.319). At 24-h post-exposure, peripheral blood Tregs was significantly higher in desflurane group (5.8 ± 0.5% vs. 4.1 ± 0.3%; p = 0.008). Within group analysis showed patients receiving desflurane, but not sevoflurane, had 2.7% increase in peripheral blood Treg over 24-h period (p < 0.001). CONCLUSION: This study provides the clinical trial-based evidence that desflurane induced peripheral blood Tregs increment after 24-h exposure, which could be beneficial in the context of kidney transplantation. Mechanisms of action and clinical advantages of desflurane anesthesia based on Treg immunomodulation should be investigated in the future. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02559297 . Registered 22 September 2015 - retrospectively registered.

Systematic comparison of four point-of-care methods versus the reference laboratory measurement of hemoglobin in the surgical ICU setting: a cross-sectional method comparison study.

BACKGROUND: Transfusion decision during the perioperative period mostly relies on the point-of-care testing for Hb measurement. This study aimed systematically compared four point-of-care methods with the central laboratory measurement of hemoglobin (LHb) regarding the accuracy, precision, and assay practicality to identify the preferred point-of-care method during the perioperative period. METHODS: This cross-sectional method comparison study was conducted in the surgical intensive care unit at Ramathibodi Hospital, Thailand, from September 2015 to July 2016. Four point-of-care methods, i.e., capillary hematocrit (HctCap), HemoCue Hb201+, iSTAT with CG8+ cartridge, and SpHb from Radical-7 pulse co-oximeter were carried out when LHb was ordered. Pearson correlation and Bland-Altman analyses were performed to assess the accuracy and precision, while the workload, turnaround time, and the unit cost were evaluated for the method practicality. RESULTS: Thirty-five patients were enrolled, corresponding to 48 blood specimens for analyses, resulting in the measured hemoglobin of 11.2 ± 1.9 g/dL by LHb. Ranking by correlation (r), mean difference (bias) and 95% limit of agreement (LOA) showed the point-of-care methods from the greater to the less performance as followed, iSTAT-LHb pair (r = 0.941; bias 0.15 (95% LOA; - 1.41, 1.12) g/dL), HemoCue-LHb pair (r = 0.922; bias - 0.18 (95% LOA; - 1.63, 1.28) g/dL), SpHb-LHb pair (r = 0.670; bias 0.13 (95% LOA; - 3.12, 3.39) g/dL) and HctCap-LHb pair (r = 0.905; bias 0.46 (95% LOA; - 1.16, 2.08) g/dL). Considering the practicality, all point-of-care methods had less workload and turnaround time than LHb, but only HemoCue and HctCap had lower unit cost. CONCLUSION: This study identified HemoCue as the suitable point-of-care method for the sole purpose of Hb measurement in the surgical ICU setting, while iSTAT should be considered when additional data is needed.