Cov txiaj ntsig ntawm Hom Kev Siv Dej Hauv Kev Ua Neej Nyob Hauv Lub Raum Hloov Pauv: Ib Qhov Chaw Ib Leeg Retrospective Cohort Study

Lub hom phiaj: 

Perioperative fluid Management nyob rau hauvcov neeg tau txais kev hloov lub raumNws yog ib qho tseem ceeb rau kev txhawb nqa cov kua dej, acid-base, thiab electrolyte tshuav nyiaj li cas yuav tsum tau ua rau graft perfusion. Txawm li cas los xij, kev xaiv ntawm intraoperative crystalloids hauvhloov raumtseem muaj teeb meem. Peb tau ua ib qho kev tshawb fawb hauv ib qho chaw rov qab los soj ntsuam qhov cuam tshuam ntawm cov kua dej intraoperative ntawm acid-base thiab electrolyte tshuav nyiaj li cas thiab graft tau tshwm sim.

Cov ntaub ntawv thiab cov txheej txheem: Peb suav nrog 282nyob pub raum hloovCov neeg tau txais los ntawm Lub Ib Hlis 2010 txog Lub Kaum Ob Hlis 2017. Cov neeg mob tau muab faib ua ob pawg raws li hom intraoperative crystalloids siv (157 cov neeg mob nyob rau hauv ib nrab-saline pawg thiab 125 cov neeg mob nyob rau hauv lub balanced crystalloid solutions group, Plasma-Lyte).

Cov txiaj ntsig:Piv nrog rau ib nrab-saline pab pawg, Plasma-lyte pab pawg pom tsawg metabolic acidosis thiab hyponatremia thaum phais. Hyperkalemia tshwm sim tsis sib txawv ntawm ob pawg. Kev hloov pauv hauv kev ua haujlwm graft tom qab kev soj ntsuam los ntawm cov ntshav urea nitrogen thiabcreatinine uatau txawv heev ntawm ob pawg. Cov neeg mob hauv pab pawg Plasma-lyte tau nthuav tawm cov glomerular filtration tsis tu ncua ntau dua li cov neeg nyob hauv ib nrab-saline pawg ntawm 1 lub hlis thiab 1 xyoo tom qab hloov pauv tom qab hloov kho cov pej xeem sib txawv.

Xaus: Intraoperative Plasma-lyte tuaj yeem ua rau muaj txiaj ntsig zoo dua ntawm cov kua qaub-puag tshuav thaum lub sijhawmhloov raum. Cov neeg mob uas tau txais Plasma-lyte pom tau tias zoo duapostoperative graft muaj nuj nqintawm 1 lub hlis thiab 1 xyoos tom qab hloov pauv. Cov kev tshawb fawb ntxiv yog xav tau los ntsuas qhov zoo tshaj plaws ntawm kev ua haujlwm ntawm cov ntshav plasma-Lyte dua lwm hom crystalloids txog cov txiaj ntsig graft.

Lo lus tseem ceeb: Hloov pauv raumKev kho kua dej, Plasma-lyte, acid-base tshuav nyiaj li cas,glomerular pom tus nqi

Nyem qhov no kom tau txais Natural organic CISTANCHE EXTRACT nrog 25% ECHINACOSIDE thiab 9% ACTEOSIDE rau lub raum ua haujlwm

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Taw qhia

Kev tswj cov dej perioperative hauv cov neeg mobhloov raumNws yog ib qho tseem ceeb kom tswj tau qhov ntim ntawm cov hlab ntsha txaus, nrog rau cov kua qaub-puag thiab electrolyte sib npaug, thiab tseem tuaj yeem cuam tshuam rau cov ntaub so ntswg perfusion thiab kev ua haujlwm. cov kua dej ntau tshaj plaws thiab siv dav rau kev tswj hwm kev tswj hwm kom tswj tau qhov ntim ntawm cov hlab ntsha zoo.4,5 Popotassium-muaj cov kua dej tuaj yeem ua rau cov neeg mob hyperkalemia thaum hloov lub raum; Yog li ntawd, NS, uas tsis muaj poov tshuaj, feem ntau yog siv thaum lub sij hawm perioperative lub raum hloov. Txawm li cas los xij, kev tswj hwm sai ntawm cov ntim loj ntawm NS tuaj yeem ua rau hyperchloremic metabolic acidosis thiab hyperkalemia tom qab.

Xav txog qhov muaj feem cuam tshuam rau lub raum raug mob thiab qhov tshwm sim tsis zoo, NS tau raug hloov nrog cov kev daws teeb meem crystalloid raws li ob qho tib si resuscitation thiab tu crystalloids hauv kev saib xyuas tseem ceeb thiab kev tswj xyuas cov kua dej perioperative.{{0}} Ib nrab saline tau siv. raws li cov kua dej intraoperative thaum lub raum hloov pauv hloov NS los tiv thaiv sodium retention thiab hyperchloremic metabolic acidosis hauv peb lub tsev kho mob. Ib nrab saline tuaj yeem txo qhov kev pheej hmoo ntawm hyperchloremic metabolic acidosis tab sis yuav ua rau dilutional hyponatremia. Plasma-Lyte, ib qho ntawm ntau qhov sib npaug crystalloids, yog ib qho isotonic, buffered tov nrog ib qho electrolyte muaj pes tsawg leeg zoo ib yam li tib neeg plasma.14 Plasma-lyte muaj pH ntawm 7.4 thiab muaj cov tshuaj chloride qis dua NS. Hauv peb lub tsev kho mob, muaj kev hloov pauv hauv cov kua dej intraoperative los ntawm 0.45% ib nrab saline rau Plasma-lyte.

Cov kev tshawb fawb yav dhau los tau muab piv rau kev soj ntsuam cov teebmeem ntawm NS thiab balanced crystalloids nyob rau hauv lub raum transplantation.4,9,17-19 Balanced crystalloids pom ib tug zoo metabolic profile. Cov nyhuv ntawm hom intraoperative kua hom ntawm postoperative graft muaj nuj nqi, txawm li cas los, tseem tsis paub meej. Meanwhile, nruj tswj ntawm intraoperative metabolic acidosis tau tshaj tawm los txhim kho lub raum graft muaj nuj nqi thaum ntxov.20 Txoj kev tshawb no tsom los sib piv cov teebmeem ntawm ib nrab saline thiab Plasma-lyte ntawm acid-base thiab electrolyte tshuav nyiaj li cas thiabpostoperative lub raumgraft muaj nuj nqi tom qabnyob pub raum hloov.

Cov khoom siv thiab cov txheej txheem

Kev xav txog kev ncaj ncees

Txoj kev tshawb no tau pom zoo los ntawm Pawg Saib Xyuas Kev Tshawb Fawb (IRB) ntawm Tsev Kho Mob Severance (IRB No. 4-2020-0850). Qhov yuav tsum tau muaj kev pom zoo raug zam los ntawm IRB vim yog qhov rov qab los ntawm txoj kev tshawb no.

Kawm tsim thiab cov neeg mob

Qhov no yog ib qho kev kawm ib leeg-chaw, rov qab los ntawm kev tshawb fawb. Cov ntaub ntawv tau txais los ntawm cov ntaub ntawv kho mob hluav taws xob. Cov neeg mob uas tau txais kev hloov pauv hauv lub raum nyob nruab nrab ntawm Lub Ib Hlis 2010 thiab Kaum Ob Hlis 2017 tau cuv npe, thaum cov neeg uas tau hloov pauv ntau lub cev tsis suav nrog. Cov neeg mob tau muab faib ua ob pawg raws li cov kua dej intraoperative (ib nrab saline vs. Plasma-Lyte).

Demographics, perioperative fluid intake, and acid-base and electrolyte balance were compared between the two groups. Acid-base and electrolyte balance during surgery were recorded after induction of anesthesia (T0), reperfusion (T1), and during the immediate postoperative period (T2). Postoperative electrolyte concentrations were recorded on postoperative days (PODs) 1, 2, and 7. Daily urine volume and fluid balance were recorded until POD 2. Postoperative kidney graft function on PODs 1, 2, and 7 was assessed using serum blood urea nitrogen (BUN), creatinine, and estimated glomerular filtration rate (eGFR). eGFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation.21 The eGFR values were calculated until 1 year post-transplantation to monitor graft outcomes. Delayed graft function was defined as the need for dialysis during the first week after transplantation. Renal biopsies were performed in cases of acute allograft dysfunction (>30% increase in serum creatinine levels, compared with the baseline value or proteinuria of >500 mg / hnub). Allograft biopsy kuaj tau ua tiav siv lub teeb, immunofluorescent, thiab electron microscopy. Tag nrho cov biopsy-pov thawj mob tsis lees paub hauv thawj 3 lub hlis tom qab hloov pauv tau raug coj mus rau hauv tus account hauv kev txheeb xyuas cov ntaub ntawv.

Intraoperative saib xyuas

Intraoperative anesthetic tswj tau ua raws li cov txheej txheem kev cai ntawm lub chaw. Kev siv tshuaj loog tau raug ntxias nrog 1.5–2.5 mg / kg propofol thiab 0.6 mg / kg ntawm rocuronium thiab tau khaws cia nrog sevoflurane lossis desflurane (0.85–1.2 yam tsawg kawg nkaus alveolar concentration). Remifentanil tau infused tas li ntawm tus nqi ntawm {{10}}.1–{14}}.3 ug/kg/min thaum phais. Cov hlab ntsha radial tau ua catheterized rau kev soj ntsuam ntshav siab tas li thiab kuaj ntshav cov roj ntsha. Txawm li cas los xij 0.45% ib nrab saline lossis Plasma-Lyte tau siv los ua cov kua dej ua haujlwm kho mob. Cov tshuaj ib nrab-saline suav nrog sodium (77 mEq / L) thiab chloride (77 mEq / L). Plasma-Lyte (Plasma tov A, CJ Pharmaceutical, Seoul, Republic of Kauslim) muaj sodium (140 mEq / L), potassium (5 mEq / L), magnesium (3 mEq / L), chloride (98 mEq / L), acetate (27 mEq / L), thiab gluconate (23 mEq / L). Kev xaiv cov kua dej intraoperative tau txiav txim siab los ntawm peb lub koom haum cov txheej txheem, uas tau hloov los ntawm 0.45% ib nrab saline rau Plasma-lyte tom qab kev sib tham nrog cov kws phais thiab cov tshuaj loog. Kev tswj cov kua dej tau coj los ntawm lub hauv paus venous siab thiab kho los ntawm cov zis tso zis tom qab reperfusion ntawm lub raum graft.

Kev kho mob tom qab phais

Kev kho mob tom qab phais tau ua raws li cov txheej txheem kev cai ntawm peb lub koom haum. Txog thaum tso tawm, {{0}}.45% ib nrab saline thiab 0.9% NS nrog sodium bicarbonate (6 mEq / L) tau siv hloov pauv thaum lub sij hawm tom qab phais hauv ob pawg, nyob ntawm seb cov qib sodium hauv cov ntshav. Cov tshuaj tiv thaiv kab mob uas siv hauv peb lub tsev kho mob tau nthuav tawm hauv Daim Ntawv Ntxiv 1 (tsuas yog online).

Kev txheeb xyuas kev txheeb xyuas Nruam hloov pauv tau nthuav tawm raws li txhais tau tias ± tus qauv sib txawv lossis qhov nruab nrab (interquartile ranges). Categorical variables raug nthuav tawm raws li cov zaus thiab proportions. Kev sib piv ntawm pab pawg tau ua los ntawm kev sib tw t-kev ywj pheej lossis kev xeem Mann-Whitney U rau qhov sib txawv tsis tu ncua thiab Fisher qhov tseeb kev xeem lossis chi-square xeem rau categorical variables. Cov qauv sib xyaw ua ke tau siv los kho thawj qhov ntsuas qhov tseem ceeb ntawm ob pawg los tshuaj xyuas cov kev hloov pauv hauv perioperative acid-base balance, electrolytes, thiab tsis cuam tshuam nrog rau lub raum graft function. Thawj qhov tseem ceeb ntawm txhua qhov ntsuas tau raug coj los ua covariates. Yog tias muaj qhov sib txawv ntawm cov yam ntxwv hauv paus nruab nrab ntawm ob pawg, peb tau kho qhov sib txawv los ntawm kev suav nrog cov kev hloov pauv hauv paus raws li covariates hauv cov qauv. Nonparametric longitudinal tsom xam siv nparLD pob hauv R tau ua. Bonferroni kho tau siv rau ntau qhov kev sib piv. Kev txheeb xyuas qhov sib txawv thiab sib txawv tsis sib txawv ntawm cov kab rov tav tau ua los ntsuas cov yam ntxwv cuam tshuam nrog kev ua haujlwm graft ntawm 1 lub hlis thiab 1 xyoo tom qab hloov pauv. Kev pheej hmoo pom tau tias muaj feem cuam tshuam nrog rau lub raum graft muaj nuj nqi hauv kev tshuaj ntsuam tsis txawv txav lossis cov uas suav tias yog cov tshuaj muaj feem cuam tshuam tau suav nrog hauv kev tshuaj xyuas ntau yam sib txawv. Txhua qhov kev txheeb xyuas tau ua tiav siv Kev Tshawb Fawb Txog Kev Tshawb Fawb (SAS) statistical software (version 9.1.3. SAS Institute Inc., Cary, NC, USA) thiab R version 4.0.2 (R Foundation for Statistical Computing, Vienna , Austria). P tus nqi<0.05 were considered statistically significant.

TSEEM CEEB

Ntawm 282 tus neeg mob suav nrog hauv txoj kev tshawb no, 157 tau txais ib nrab aline thiab 125 tau txais Plasma-lyte thaum hloov lub raum. Qhov tseem ceeb ntawm cov pej xeem sib txawv tau pom ntawm cov pab pawg, suav nrog cov hnub nyoog tau txais, tus neeg pub khoom eGFR, ABO-incom patible pub dawb, graft raum qhov hnyav rau tus neeg tau txais lub cev qhov hnyav piv, thiab tus nqi ntawm cov kua dej thaum lub sij hawm phais (Table 1). Tsis muaj qhov sib txawv tseem ceeb hauv kev ncua sij hawm graft ua haujlwm thiab kev tsis lees paub ntawm cov pab pawg.

Perioperative acid-base tshuav nyiaj li cas tau pom qhov sib txawv tseem ceeb ntawm ob pawg tom qab kho thawj qhov ntsuas qhov tseem ceeb los ntawm cov qauv sib xyaw linear (Table 2). Preoperative tag nrho CO2 qib tau nce siab dua hauv ib nrab-saline pawg (p= 0.003). Txawm li cas los xij, tag nrho cov qib CO2 thaum lub sijhawm phais tau nce siab dua hauv pawg Plasma-lyte. Qhov nruab nrab serum bicarbonate concentration (kev siv ntau yam, 21-28 mmol / L) yog qhov siab dua hauv cov pab pawg Plasma-lyte dua li ntawm ib nrab-saline pawg, txawm tias nyob rau hauv lub cev muaj zog thaum lub sijhawm rov ua dua (19.29 ± 2.46 mmol / L vs 22.93). ± 3.48 mmol / L, p<0.001) and immediate postoperative periods (18.68±2.53 mmol/L vs. 21.85± 2.84 mmol/L, p<0.001). Base excess in the extracellular fluid was also significantly higher in the Plasma-lyte group than in the half-saline group during surgery. Sodium bicarbonate was administered in one patient in the half-saline group and no patients in the Plasma-lyte group (data not shown).

Hyponatremia (sodium<130 mmol/L) occurred more frequently in the half-saline group during the reperfusion period (p<0.001), immediate postoperative period (p<0.001), and POD 1 (p=0.032) (Table 3). Hyperchloremia (chloride >110 mmol/L) occurred more frequently in the half-saline group on POD 2 and 7, although there were no significant differences between the groups (p=0.163 and 0.067, respectively). Hyperkalemia (potassium >5.5 mmol/L) at the reperfusion period occurred in five patients in the half-saline group and one patient in the Plasma-lyte group, although the difference was not statistically significant (p>0.999).

Cov tsis muaj feem cuam tshuam nrog kev ua haujlwm tom qab lub raum graft muaj nyob rau hauv Table 4. Peb tau ua cov qauv sib xyaw ua ke tom qab kho qhov sib txawv ntawm cov yam ntxwv hauv qab ntawm ob pawg los sib piv cov tsis. Lub hnub nyoog tau txais, tsis yog eGFR, ABO-incompatible pub, graft lub raum qhov hnyav rau tus neeg tau txais lub cev qhov hnyav piv, tus nqi ntawm cov kua dej thaum lub sij hawm phais, thiab hom dej intraoperative (ib nrab saline vs. Plasma-lyte) tau suav nrog cov teebmeem ruaj khov los ntsuas cov nyhuv ntawm cov kua dej ntawm lub raum postoperative graft ua haujlwm dhau sijhawm. BUN tau qis dua ntawm lub sijhawm tom qab phais tas li (p<0.001), and creatinine was lower at the immediate postoperative period (p<0.001) and POD 1 (p=0.024). Urine volume was higher in the Plasma-lyte group at PODs 1 and 2 (p<0.001 for both). A significant difference was observed in BUN (p<0.001) and creatinine (p<0.001) change between groups over time (Fig. 1). As shown in Fig. 2, we found a significant difference between groups in eGFR change over time until 1-year after transplantation (p=0.006).

eGFR ntawm 1 lub hlis yog siab dua hauv pawg Plasma-lyte (72.77 ± 23.67 vs. 61.83 ± 20.05, p<0.001). Graft function measured by eGFR at 1 month after transplantation was associated with sex, intraoperative Plasma-lyte use, recipient age, donor age, donor graft kidney weight to recipient body weight ratio, acute rejection, and donor eGFR in the univariable model. In the adjusted model, patients who received Plasma-lyte during the intraoperative period exhibited a 9.156 mL/min/1.73 m2 higher eGFR at 1 month after transplantation (Table 5). eGFR at 6 months and 1 year was also higher in the Plasma-lyte group (74.04±19.27 vs. 63.92±18.64, p<0.001 and 71.83±19.65 vs. 66.20±19.80, p=0.018, respectively). Follow-up eGFR measured at 1 year post-transplantation was associated with sex, intraoperative Plasma-lyte use, donor age, donor graft kidney weight to recipient body weight ratio, acute rejection, and donor eGFR in the univariable model. Multivariable analysis revealed that intraoperative Plasma-lyte use was associated with a 4.452 mL/min/1.73 m2 higher eGFR at 1 year after transplantation (Table 6). Male sex was not significantly associated with eGFR at 1 month and 1 year after transplantation in multivariable analysis (p=0.093 and p=0.842, respectively).

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Nyem qhov no kom tau txais Natural organic CISTANCHE EXTRACT nrog 25% ECHINACOSIDE thiab 9% ACTEOSIDE rau lub raum ua haujlwm