Renal impact of fluid management with colloids: a comparative review.

BACKGROUND AND OBJECTIVES: Colloids such as hydroxyethyl starch (HES), gelatin, dextran and albumin are useful for maintaining renal perfusion and function. The comparative renal effects of colloids have not been previously reviewed. METHODS: Computer searches of the MEDLINE and EMBASE bibliographic databases and the Cochrane Library were conducted using the search terms: colloids; hetastarch; gelatin; dextrans; serum albumin; kidney failure; cardiac surgical procedures; and kidney transplantation. Relevant studies were also sought through hand searching and examination of reference lists. Results of identified studies were qualitatively summarized with account taken for potential confounding factors. RESULTS: The three artificial colloids HES, gelatin and dextran all exhibited troublesome renal side-effects. Randomized trials have demonstrated adverse renal effects of HES in sepsis and surgery. Undesirable renal effects are common to all available HES solutions regardless of molecular weight, substitution or C2/C6 ratio. While some of its effects may be less severe than those of HES, gelatin also can adversely affect the kidney. A negative renal impact of dextran is well-established, although this colloid is now less extensively used than formerly. As the normal endogenous colloid, albumin exhibits a wide margin of renal safety, although albumin overdose needs to be avoided. Albumin also appears to exert protective effects on the kidney such as inhibition of apoptosis and scavenging of reactive oxygen species. CONCLUSIONS: Colloids display important differences in their actions on the kidney. These contrasting renal effects should be considered in making fluid management decisions.

Stretch expanded polytetrafluoroethylene graft with intrawall radial support system: an advance in vascular access graft design.

Vascular access expanded polytetrafluoroethylene (ePTFE) grafts with external support systems consisting of parallel rings or in a spiral configuration are designed to resist kinking and compression at the apex of loop grafts or when crossing a joint. However, during the implantation procedure, the rings or spiral must be removed from the portion of the graft that is cut to allow the graft to be divided at the desired angle and suture the anastomosis. A new ePTFE graft (Intering) with an intrawall radial support system and a smooth lumen permits easy division of the support segments at the chosen angle. Moreover, minimal resistance is encountered during suturing of the graft. The results of early experience with Intering grafts crossing the elbow joint, in short-segment revisions, and in primary forearm loop configurations are encouraging.

Post-OKT3 induction therapy CD complex response predicts renal allograft rejection.

CD complex response to cessation of induction with OKT3 may be predictive of rejection. Twenty-seven patients receiving renal allografts and OKT3 induction immunosuppression were retrospectively analyzed for CD complex repopulation and allograft rejection. Flow cytometric monitoring was utilized in all patients. Responder status groups were identified based on CD complex repopulation, with fast responders demonstrating CD complex repopulation above the determined cohort mean. Slow responders had repopulation below this mean. Student's t test yielded P<0.01 (CD2), P<0.02 (CD3), and P<0.01 (CD8). Nonresponder patients were identified with repopulation below the mean, but flat compared with depletion. All nine fast responders lost their graft or were treated for rejection. No slow responder experienced graft loss or rejection episodes. One nonresponder was treated for rejection. CD complex activity following OKT3 cessation correlates with future rejection. Identification of responder status provides insight into propensity to reject, allowing individual tailoring of immunosuppression to patient response.