Kidney transplantation and perioperative complications: a prospective cohort study
Transplante renal e complicações perioperatórias: um estudo de coorte prospectivo
Priscila Sartoretto Dal Magro, Gisele Meinerz, Valter Duro Garcia, Florentino Fernandes Mendes, Maria Eugenia Cavalheiro Marques, Elizete Keitel
Abstract
Background
Kidney transplant recipients face complex perioperative challenges due to comorbidities from chronic kidney disease. This study aimed to assess perioperative complications in kidney transplant recipients and evaluate the association between the Charlson Comorbidity Index (CCI) and complication severity using the Clavien-Dindo (CD) classification.
Methods
A prospective cohort study conducted at a tertiary hospital in South Brazil from September 2020 to March 2022, including 230 adult kidney transplant recipients. Data on demographics, comorbidities, and complications were collected. Complications were categorized using the CD scale, and their relationship with CCI was analyzed using univariate and multivariate Cox regression.
Results
Mean age was 49.2 ± 12.7 years, with 58.7% male recipients. The mean CCI score was 3.65 ± 1.5 points. Intraoperative complications occurred in 10.9% of patients, with notable issues including bleeding and airway difficulties. In the immediate postoperative period, 9.1% required urgent dialysis. In the 30-day follow-up, 57.8% had delayed graft function, 21.7% infections, 11.3% had vascular complications, and the mortality was 1.7%. CCI was not a significant predictor of severe complications; however, congestive heart failure was strongly associated with severe complications (HR = 6.6 95% CI 2.6–6.7, p < 0.001).
Conclusions
Despite a low overall comorbidity profile, kidney transplant recipients faced significant perioperative challenges. The lack of a significant association between the CCI score and severe complications suggests that traditional risk assessment tools may not fully capture the risks specific to the early postoperative period in kidney transplantation, and future research should focus on developing more refined risk assessment models for chronic kidney disease patients.
Keywords
Resumo
Introdução
Receptores de transplante renal enfrentam desafios perioperatórios complexos devido a comorbidades da doença renal crônica. Este estudo teve como objetivo avaliar complicações perioperatórias em receptores de transplante renal e avaliar a associação entre o Índice de Comorbidade de Charlson (ICC) e a gravidade das complicações usando a classificação de Clavien-Dindo (CD).
Métodos
Um estudo de coorte prospectivo conduzido em um hospital terciário no sul do Brasil de setembro de 2020 a março de 2022, incluindo 230 receptores adultos de transplante renal. Dados sobre dados demográficos, comorbidades e complicações foram coletados. As complicações foram categorizadas usando a escala CD, e sua relação com o ICC foi analisada usando regressão de Cox univariada e multivariada.
Resultados
A idade média foi de 49,2 ± 12,7 anos, com 58,7% de receptores do sexo masculino. A pontuação média do ICC foi de 3,65 ± 1,5 pontos. Complicações intraoperatórias ocorreram em 10,9% dos pacientes, com problemas notáveis, incluindo sangramento e dificuldades nas vias aéreas. No pós-operatório imediato, 9,1% necessitaram de diálise urgente. No acompanhamento de 30 dias, 57,8% apresentaram função retardada do enxerto, 21,7% infecções, 11,3% complicações vasculares e a mortalidade foi de 1,7%. O ICC não foi um preditor significativo de complicações graves; no entanto, a insuficiência cardíaca congestiva foi fortemente associada a complicações graves (HR = 6,6 IC 95% 2,6–6,7, p < 0,001).
Conclusões
Apesar de um baixo perfil geral de comorbidade, os receptores de transplante renal enfrentaram desafios perioperatórios significativos. A falta de uma associação significativa entre a pontuação do ICC e complicações graves sugere que as ferramentas tradicionais de avaliação de risco podem não capturar totalmente os riscos específicos do período pós-operatório inicial no transplante renal, e pesquisas futuras devem se concentrar no desenvolvimento de modelos de avaliação de risco mais refinados para pacientes com doença renal crônica.
Palavras-chave
References
1. Sugi MD, Joshi G, Maddu KK, Dahiya N, Menias CO. Imaging of Renal Transplant Complications throughout the Life of the Allograft: Comprehensive Multimodality Review. RadioGraphics. 2019;39:1327−55.
2. Axelrod DA, Schnitzler MA, Xiao H, et al. An economic assessment of contemporary kidney transplant practice. Am J Transplant. 2018;18:1168−76.
3. Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med. 1999;341:1725−30.
4. Hirata ES, Filho GA, Prates LC. Anestesia para Transplante Renal. In: Cangiani LM, Carmona MJC, Torres MLA, Ferez D, Bastos CO, Silva ED, eds. Tratado de anestesiologista SAESP, Sao Paulo: Atheneu; 2017:3347−61.
5. Levine MA, Schuler T, Gourishankar S. Complications in the 90- day postoperative period following kidney transplant and the relationship of the Charlson Comorbidity Index. Can Urol Assoc J. 2017;11:388−93.
6. KDIGO. Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant. 2009;9(Suppl 3):S1−S157.
7. Grochowiecki T, Ga»azka Z, Madej K, et al. Early Complications ˛ Related to the Transplanted Kidney After Simultaneous Pancreas and Kidney Transplantation. Transplantation Proceedings. 2014;46:2815−7.
8. Wolff T, Schumacher M, Dell-Kuster S, et al. Surgical Complications in Kidney Transplantation: No Evidence for a Learning Curve. Journal of Surgical Education. 2014;71:748−55.
9. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chronic Dis. 1987;40(5):373−83.
10. Grosso G, Corona D, Mistretta A, et al. Predictive Value of the Charlson Comorbidity Index in Kidney Transplantation. Transplant Proc. 2012;44(7):1859−63.
11. Moreira LF, Pessoa MC, Mattana DS, et al. Cultural adaptation and the Clavien-Dindo surgical complications classification translated to Brazilian Portuguese. Rev Col Bras Cir. 2016;43:141−8.
12. Prado NP, Silva CKD, Meinerz G, Kist R, Garcia VD, Keitel E. Usefulness of Kidney Donor Profile Index (KDPI) to predict graft survival in a South Brazilian Cohort. J Bras Nefrol. 2020;42:211−8.
13. Charlson ME, Carrozzino D, Guidi J, Patierno C. Charlson Comorbidity Index: A Critical Review of Clinimetric Properties. Psychother Psychosom. 2022;91:8−35.
14. Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022;136:31−81.
15. Spindola MAC, Sole D, Aun MV, et al. Update on perioperative hypersensitivity reactions: joint document of the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) − Part I: post-crisis guidelines and treatment. Revista Brasileira de Anestesiologia. 2020;70.
16. Perico N, Cattaneo D, Sayegh MH, Remuzzi G. Delayed graft function in kidney transplantation. Lancet. 2004;364:1814−27.
17. Siedlecki A, Irish W, Brennan DC. Delayed graft function in the kidney transplant. Am J Transplant. 2011;11:2279−96.
18. Rodgers RP, Levin J. A critical reappraisal of the bleeding time. Semin Thromb Hemost. 1990;16:1−20.
19. Nasr R, Chilimuri S. Preoperative Evaluation in Patients with End-Stage Renal Disease and Chronic Kidney Disease. Health Serv Insights. 2017;10:1178632917713020.
20. Nunns GR, Moore EE, Chapman MP, et al. The hypercoagulability paradox of chronic kidney disease: The role of fibrinogen. Am J Surg. 2017;214:1215−8.
21. Cheney Frederick W, Posner Karen L, Lee Lorri A, Caplan Robert A, Domino Karen B. Trends in Anesthesia-related Death and Brain Damage: A Closed Claims Analysis. Anesthesiology. 2006;105:1081−6.
22. Cook TM, Woodall N, Frerk C. Fourth National Audit P. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth. 2011;106:617−31.
23. Nadal JLY, Fernandez BG, Escobar IC, Black M, Rosenblatt WH. The palm print as a sensitive predictor of difficult laryngoscopy in diabetics. Acta Anaesthesiol Scand. 1998;42:199−203.
24. Giquel J, Rodriguez-Blanco YF, Matadial C, Candiotti K. Diabetes mellitus in anaesthesia. Br J Diabetes Vasc Dis. 2012;12:60−4.
25. Dias PC, Henriques P, Anjos LAD, Burlandy L. Obesity and public policies: the Brazilian government’s definitions and strategies. Cad Saude Publica. 2017;33:e00006016.
26. IBGE. Instituto Brasileiro de Geografia e Estatística. Pesquisa de Orcamentos Familiares 2008-2009: antropometria e estado ¸ nutricional de criancas, adolescentes e adultos do Brasil.; 2010. ¸ Available at: https://biblioteca.ibge.gov.br/visualizacao/livros/liv45419.pdf.
27. Thota B, Jan KM, Oh MW, Moon TS. Airway management in patients with obesity. Saudi J Anaesth. 2022;16:76−81.
28. Nociti JR. Mortalidade associada a anestesia: estudos epidemiologicos. Braz J Anesthesiol. 1991;41:3 −7.
29. Koye DN, Magliano DJ, Nelson RG, Pavkov ME. The Global Epidemiology of Diabetes and Kidney Disease. Adv Chronic Kidney Dis. 2018;25:121−32.
30. Robertshaw HJ, Hall GM. Diabetes mellitus: anaesthetic management*. Anaesthesia. 2006;61:1187−90.
31. Humar A, Matas AJ. Surgical complications after kidney transplantation. Semin Dial. 2005;18:505−10.
32. Harris M, Chung F. Complications of General Anesthesia. Clin Plast Surg. 2013;40:503−13.
33. Olsen VDR, Borges FK, Goldraich LA, et al. Limited Predictive Role of the Revised Cardiac Risk Index in Kidney Transplant: Single Center Evaluation and Comparison with International Literature. Curr Probl Cardiol. 2021;46:100908.
34. Freitas MHB, Lima LC, Couceiro TCM, Silva WB, Andrade JM, Freitas MHB. Perioperative factors associated with delayed graft function in renal transplant patients. J Bras Nefrol. 2018;40:360−5.
35. de Sandes-Freitas TV, Mazzali M, Manfro RC, et al. Exploring the causes of the high incidence of delayed graft function after kidney transplantation in Brazil: a multicenter study. Transpl Int. 2021;34:1093−104.
36. Bodro M, Sanclemente G, Lipperheide I, et al. Impact of urinary tract infections on short-term kidney graft outcome. Clin Microbiol Infect. 2015;21. 1104.e1-8.
37. Goldman JD, Julian K. Urinary tract infections in solid organ transplant recipients: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019;33:e13507.
38. Fishman JA. Infection in Organ Transplantation. Am J Transplant. 2017;17:856−79.
39. van den Berg TAJ, Minnee RC, Lisman T, et al. Perioperative antithrombotic therapy does not increase the incidence of early postoperative thromboembolic complications and bleeding in kidney transplantation - a retrospective study. Transpl Int. 2019;32:418−30.
40. Salamin P, Deslarzes-Dubuis C, Longchamp A, et al. Predictive Factors of Surgical Complications in the First Year Following Kidney Transplantation. Ann Vasc Surg. 2022;83:142−51.
41. Moghadamyeghaneh Z, Chen LJ, Alameddine M, et al. A nationwide analysis of re-operation after kidney transplant. Can Urol Assoc J. 2017;11. E425-e30.
42. Lempinen M, Stenman J, Kyllonen L, Salmela K. Surgical compli- € cations following 1670 consecutive adult renal transplantations: A single center study. Scand J Surg. 2015;104:254−9.
43. Lai GS, Li JR, Wang SS, et al. Influence of Surgical Complications on Outcomes in Kidney Transplantation Patients. In Vivo. 2023;37:2796−802.
44. Rodríguez-Espinosa D, Broseta JJ, Rosario A, et al. Challenges in perioperative blood transfusions in kidney transplantation and the need for Patient Blood Management. Blood Transfus. 2024;22:206−12.
Submitted date:
12/16/2023
Accepted date:
08/27/2024
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