Estrategias perioperatorias de protección renal en el trasplante hepático

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Abstract

La insuficiencia renal es una de las complicaciones más comunes e importantes en los receptores de trasplante hepático. Se ha descrito que ocurre con una incidencia del 17 % al 95 %. Esta complicación se asocia a una estancia prolongada en la unidad de cuidados intensivos, necesidad de diálisis posoperatoria, complicaciones infecciosas, rechazo agudo y aumento de la mortalidad. Las causas de deterioro de la función renal difieren entre los períodos pre y posoperatorio. Mediante la identificación de los pacientes con riesgo de desarrollo de una insuficiencia renal aguda y la implantación precoz de estrategias de protección renal es posible frenar la progresión de disfunción renal y mejorar los resultados a largo plazo de los receptores de trasplante hepático.

Translated abstract

Renal failure is one of the most common and major complications in liver transplant recipients. It has been reported to occur at an incidence of 17% to 95%. This complication is associated with prolonged hospital stay in the intensive care unit, the need for postoperative dialysis, infectious complications, acute rejection, and increased mortality. The causes of renal function deterioration differ in the preoperative and postoperative periods. By identifying patients at risk of developing chronic renal failure and by implementing strategies for renal protection at an early stage, it is possible to slow down the progression of renal failure and improve the long-term outcomes in liver transplant recipients.

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Serum cystatin C is superior to serum creatinine as a marker of kidney function: a meta-analysis.

Vikas R. Dharnidharka, Charles Kwon, Gary Stevens (2002)

Serum cystatin C (Cys C) has been proposed as a simple, accurate, and rapid endogenous marker of glomerular filtration rate (GFR) in research and clinical practice. However, there are conflicting reports regarding the superiority of Cys C over serum creatinine (Cr), with a few studies suggesting no significant difference. We performed a meta-analysis of available data from various studies to compare the accuracy of Cys C and Cr in relation to a reference standard of GFR. A bibliographic search showed 46 articles until December 31, 2001. We also retrieved data from eight other studies presented and published in abstract form. The overall correlation coefficient for the reciprocal of serum Cys C (r = 0.816; 95% confidence interval [CI], 0.804 to 0.826) was superior to that of the reciprocal of serum Cr (r = 0.742; 95% CI, 0.726 to 0.758; P < 0.001). Similarly, receiver operating characteristic (ROC)-plot area under the curve (AUC) values for 1/Cys C had greater identity with the reference test for GFR (mean ROC-plot AUC for Cys C, 0.926; 95% CI, 0.892 to 0.960) than ROC-plot AUC values for 1/Cr (mean ROC-plot AUC for serum Cr, 0.837; 95% CI, 0.796 to 0.878; P < 0.001). Immunonephelometric methods of Cys C assay produced significantly greater correlations than other assay methods (r = 0.846 versus r = 0.784; P < 0.001). In this meta-analysis using currently available data, serum Cys C is clearly superior to serum Cr as a marker of GFR measured by correlation or mean ROC-plot AUC. Copyright 2002 by the National Kidney Foundation, Inc.

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Pere Ginès, Robert W. Schrier (2009)

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Effects of saline, mannitol, and furosemide to prevent acute decreases in renal function induced by radiocontrast agents.

Keith R. Solomon, Raquel Raick P. da Silva, Daniela S P Silva … (1994)

Injections of radiocontrast agents are a frequent cause of acute decreases in renal function, occurring most often in patients with chronic renal insufficiency and diabetes mellitus. We prospectively studied 78 patients with chronic renal insufficiency (mean [+/- SD] serum creatinine concentration, 2.1 +/- 0.6 mg per deciliter [186 +/- 53 mumol per liter]) who underwent cardiac angiography. The patients were randomly assigned to receive 0.45 percent saline alone for 12 hours before and 12 hours after angiography, saline plus mannitol, or saline plus furosemide. The mannitol and furosemide were given just before angiography. Serum creatinine was measured before and for 48 hours after angiography, and urine was collected for 24 hours after angiography. An acute radiocontrast-induced decrease in renal function was defined as an increase in the base-line serum creatinine concentration of at least 0.5 mg per deciliter (44 mumol per liter) within 48 hours after the injection of radiocontrast agents. Twenty of the 78 patients (26 percent) had an increase in the serum creatinine concentration of at least 0.5 mg per deciliter after angiography. Among the 28 patients in the saline group, 3 (11 percent) had such an increase in serum creatinine, as compared with 7 of 25 in the mannitol group (28 percent) and 10 of 25 in the furosemide group (40 percent) (P = 0.05). The mean increase in serum creatinine 48 hours after angiography was significantly greater in the furosemide group (P = 0.01) than in the saline group. In patients with chronic renal insufficiency who are undergoing cardiac angiography, hydration with 0.45 percent saline provides better protection against acute decreases in renal function induced by radiocontrast agents than does hydration with 0.45 percent saline plus mannitol or furosemide.