Association of high intra-patient variability in tacrolimus exposure with calcineurin inhibitor nephrotoxicity in kidney transplantation.

Tacrolimus intra-patient variability (IPV) is a novel predictive marker for long-term kidney transplantation outcomes. We examined the association between IPV and calcineurin inhibitor (CNI) nephrotoxicity and the impact of pharmacogenes on CNI nephrotoxicity and IPV. Among kidney transplant recipients at our hospital between January 2013 and December 2015, the records of 80 patients who underwent 1-year protocol renal allograft biopsy and agreed to donate blood samples for genetic analysis were retrospectively reviewed. The cohort was divided into the low and high IPV groups based on a coefficient variability cutoff value (26.5%). In multivariate analysis, the IPV group was involved in determining CNI nephrotoxicity (HR 4.55; 95% CI 0.05-0.95; p = 0.043). The 5-year graft survival was superior in the low IPV group than in the high IPV group (100% vs 92.4% respectively, p = 0.044). Analysis of the time above therapeutic range (TATR) showed higher CNI nephrotoxicity in the high IPV with high TATR group than in the low IPV with low TATR group (35.7% versus 6.7%, p = 0.003). Genetic analysis discovered that CYP3A4 polymorphism (rs2837159) was associated with CNI nephrotoxicity (HR 28.23; 95% CI 2.2-355.9; p = 0.01). In conclusion, high IPV and CYP3A4 polymorphisms (rs2837159) are associated with CNI nephrotoxicity.

Trends of Blood Transfusion According to Diseases in Korea: A 10-Year Nationwide Cohort Study.

Introduction: Recent guidelines recommend restrictive red blood cell transfusion; therefore, hospitals have started introducing and implementing patient blood management programs. This is the first study to analyze changes in the trends of blood transfusions in the whole population over the past 10 years according to sex, age group, blood component, disease, and hospital type. Methods: This cohort study analyzed blood transfusion records for 10 years, from January 2009 to December 2018, using nationwide population-based data from the Korean National Health Insurance Service-Health Screening Cohort database. Results: The proportion of transfusion procedures conducted in the total population has increased constantly for 10 years. Although its proportion in the age group of 10-79 years decreased, the total number of transfusions increased significantly due to the increase in the population and proportion of transfusions in those aged 80 years or older. Furthermore, the proportion of multicomponent transfusion procedures increased in this age group, which was greater than that of transfusions. The most common disease among transfusion patients in 2009 was cancer, of which gastrointestinal (GI) cancer accounted for more than half, followed by trauma and hematologic diseases (GI cancers > trauma > other cancers > hematologic diseases). The proportion of patients with GI cancer decreased, whereas that of trauma and hematologic diseases increased over the 10 years, with trauma becoming the most common disease type in 2018 (trauma > GI cancers > hematologic diseases > other cancers). Although transfusion rates per hospitalization decreased, the total number of inpatients increased, thus increasing the number of blood transfusions in all types of hospitals. Discussion/Conclusions: The proportion of transfusion procedures in the total population increased owing to the increase in the total number of transfusions in patients aged 80 years or older. The proportion of patients with trauma and hematologic diseases has also increased. Moreover, the total number of inpatients has been increasing, which subsequently increases the number of blood transfusions performed. Specific management strategies targeting these groups may improve blood management.

Is the platelet function test effective in predicting blood loss in patients undergoing hepatic resection?

Purpose: The platelet function analyzer (PFA)-100/200 is widely used to assess platelet function. However, its role in predicting the perioperative risk of bleeding in patients undergoing liver resection remains controversial. Therefore, we aimed to ascertain whether the platelet function test could be useful in predicting bleeding risk in patients undergoing hepatic surgery. Methods: The study participants were patients who underwent hepatectomy for hepatocellular carcinoma at our hospital over a period of 10 years from January 1, 2010 to May 31, 2020. PFA-200 values of these patients were divided into 2 groups; normal (n = 333) and prolonged (n = 39). Results: There were no significant differences regarding the volumes of calculated blood loss during surgery between the normal and prolonged PFA groups (879.55 ± 1,046.50 mL vs. 819.74 ± 912.64 mL, respectively; P = 0.733); intraoperative RBC transfusion (0.52 ± 2.02 units vs. 0.26 ± 1.02 units, P = 0.419) and postoperative RBC transfusion (0.24 ± 1.17 units vs. 0.46 ± 1.97 units, P = 0.306) were similar between the 2 groups, respectively. Multivariate analysis revealed no association between PFA closure time and calculated blood loss (hazard ratio, 1.06; P = 0.881). Moreover, there was no association between PFA closure time and preoperative laboratory results or assessment of tool-related liver function in multivariate analysis. Conclusion: There was no correlation between the amount of blood loss and platelet function in patients who underwent liver resection. In patients undergoing liver resection who are not managed on antiplatelet agents or do not have chronic kidney disease, the use of routine PFA is not recommended.

Comparison between autogenous brachial-brachial upper-arm elevated direct arteriovenous fistulas and prosthetic brachial-antecubital indirect forearm arteriovenous grafts.

OBJECTIVES: The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guidelines recommend forearm arteriovenous grafts (AVGs) as an alternative procedure to transposed basilic vein fistulas for providing secondary access during hemodialysis. Recently, autogenous elevated brachial-brachial vein fistulas (BVE) have become increasingly popular. The aim of this study was to compare the outcomes of BVE and forearm loop AVG (AVG) for secondary access in hemodialysis. METHODS: We retrospectively reviewed the medical records of patients who had received a BVE or forearm AVG at a single center from January 2015 to April 2019. In total, 19 BVE were created via two-stage operations and two via a one-stage operation; 53 forearm AVG's were performed. RESULTS: The AVG group was twice as likely to suffer loss of primary patency compared with the BVE group (odds ratio [OR], 2.666; 95% confidence interval [CI], 1.108-6.412; p = 0.029) per the multivariate analysis. The primary patency and primary assisted patency of the BVE group were superior those of the AVG group, except for secondary patency (p = 0.02, p = 0.07, p = 0.879, respectively). In subgroup analysis, there were no significant differences in primary, primary assisted, or secondary patency between AVG and BVE when brachial vein was used for AVG outflow. In addition, no significant differences were noted regarding the infection rate (12.5% vs 12.3%, p = 0.331, severity >0), postoperative bleeding rate (14.5% vs 3.5%, p = 0.191, severity >1), early thrombus rate (0.0% vs 10.5%, p = 0.122), and early failure rate (7% vs 4.8%, p = 0.591). CONCLUSIONS: The primary patency and primary assisted patency rates of BVE were significantly better than those observed in AVGs, but the complication rates were similar. The appropriate procedure to provide vascular access should be determined by the individual patient's condition and the surgical skill of the operating surgeon.