The Intrarenal Vascular Resistance Parameters Measured by Duplex Doppler Ultrasound Shortly After Kidney Transplantation in Patients With Immediate, Slow, and Delayed Graft Function

doi:10.1016/j.transproceed.2005.12.013

Transplantation Proceedings

Volume 38, Issue 1, January–February 2006, Pages 42-45

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Abstract

Background

Evaluation of pulsatility (PI) and resistive (RI) indexes by duplex Doppler ultrasound shortly after kidney transplantation reflects the exacerbation of interstitial edema. The aim of study was to characterize factors that influence PI and RI in patients with immediate (IGF), slow (SGF), or delayed (DGF) kidney graft function.

Patients and methods

PI and RI were measured in 200 transplanted patients at 2 to 4 days postoperatively. We excluded patients with acute rejection episodes within the first month. IGF, which was defined as serum creatinine <264 μmol/L at 3 days, SGF, which was defined as creatinine >264 μmol/L by day 3 with a maximum of one dialysis, and DGF, which was defined as more than 1 dialysis were observed in 33.3%, 41.5%, and 25.2% of patients, respectively. The examined donor parameters were age, hypotensive episodes, catecholamine infusion, central venous pressure, and glomerular filtration rate. The recipient factors were age, history of hypertension, diabetes mellitus, ischemic heart disease, and stroke. Additionally cold ischemia time (CIT), HLA mismatch, and PRA were analyzed.

Results

The lowest PI and RI values were observed among patients with IGF (PI 1.37 [1.28 to 1.46]; RI 0.72 [0.69 to 0.74]); moderate values in SGF (PI 1.65 [1.52 to 1.78]; RI 0.78 [0.76 to 0.80]) and the highest values in DGF (PI 2.09 [1.83 to 2.35]; RI 0.83 [0.80 to 0.86]) differences that were highly significant. Hypotensive episodes and catecholamine infusion in the preharvest period had essential impacts on PI or RI values in the early posttransplant period. There was no significant correlation between PI or RI values and CIT. A slower ATN resolution was observed in DGF patients with higher PI values.

Conclusion

Ischemic injury, which occured mainly prior to organ harvesting, played a dominant role determining intrarenal resistance in the early posttransplant period.

Section snippets

Patients and methods

Two hundred adult patients (73 women and 127 men) transplanted between January 1, 2002, and March 31, 2005, were enrolled in the study. The mean age of the recipients was 42 ± 12 years. The mean pretransplant dialysis duration was 35 ± 35 months, 198 patients received cyclosporine (n = 153) or tacrolimus (n = 47) combined with azathioprine (n = 117) or mycophenolate mofetil (n = 65) or sirolimus (n = 16) plus prednisone, 26 received basiliximab, and 2 antithymocytic globulin as additional

Results

Of 171 recipients, 57 (33.3%) experienced IGF; 71 (41.5%), SGF; and 43 (25.2%), DGF. Significant differences in PI and RI value were observed between these groups (P < .001) (Fig 1, Fig 2). The lowest PI and RI values were observed among patients with IGF [PI 1.37 (1.28 to 1.46); RI 0.72 (0.69 to 0.74)]; moderate values in SGF [PI 1.65 (1.52 to 1.78); RI 0.78 (0.76 to 0.80)] and the highest values in DGF [PI 2.09 (1.83 to 2.35); RI 0.83 (0.80 to 0.86)]. The ROC analyses showed that a PI value

Discussion

Doppler sonography is a useful tool in the evaluation of kidney graft insufficiency in the early posttransplant period.6, 8 However, increased intrarenal resistance is observed both in acute rejection episodes and in acute tubular necrosis. Even repeated Doppler measurements are not sufficient to differentiate these clinical conditions.9, 10 Therefore, we did not include patients with acute rejection episodes during the first month. Thus, we analyzed a group of patients with kidney grafts

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Early function as principal correlate of graft survival. A multivariate analysis of 200 cadaveric renal transplants treated with a protocol incorporating antilymphocyte globulin and cyclosporine
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Predictive value of the renal resistive index in the immediate postoperative period after kidney transplantation on short- and long-term graft and patient outcomes
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We also confirmed that DCD donated grafts have an increased risk on DGF compared to DBD donors, but that there is no difference in long-term kidney function and graft survival [17,18]. Most studies that investigated the relationship between the early RI and DGF also define DGF as the need for dialysis during the first week posttransplant [9,10,12,19-22]. Their analyses had similar conclusions; limitations of these studies were using RI as a categorical variable (low versus high), limited sample size, measurement in a later phase after kidney transplantation, varied exclusion criteria, use of only one definition of DGF and not assessing different donor subgroups.
During the postoperative stay in the intensive care unit after kidney transplantation, the renal resistive index (RI) is routinely measured. An increased RI, measured months posttransplant, is associated with a higher mortality. We wanted to investigate the value of the RI immediately posttransplant in predicting both short- and long-term outcome.
We performed a retrospective single-center study. The RI was collected <48 h posttransplant in patients undergoing kidney transplantations between 2005 and 2014. Short-term outcome was evaluated by delayed graft function (DGF). The long-term endpoints were kidney function and mortality at 30 days, 1 year and 5 years.
We included 478 recipients, 91.4% of whom reached the end of the 5-year follow-up. A higher RI < 48 h posttransplant was significantly associated with DGF. This association was particularly strong in patients receiving grafts from donors after brain death and expanded criteria donors. A higher RI also correlated with mortality and death with functioning graft but not with graft failure. After adjustment for confounders, we found an association between increased RI and DGF, but not with long-term kidney function or mortality.
The RI routinely measured <48 h posttransplant is an independent predictor of short-term kidney function.
Organ-specific metabolic profiles of the liver and kidney during brain death and afterwards during normothermic machine perfusion of the kidney
2020, American Journal of Transplantation
We investigated metabolic changes during brain death (BD) using hyperpolarized magnetic resonance (MR) spectroscopy and ex vivo graft glucose metabolism during normothermic isolated perfused kidney (IPK) machine perfusion. BD was induced in mechanically ventilated rats by inflation of an epidurally placed catheter; sham-operated rats served as controls. Hyperpolarized [1-¹³C]pyruvate MR spectroscopy was performed to quantify pyruvate metabolism in the liver and kidneys at 3 time points during BD, preceded by injecting hyperpolarized[1-¹³C]pyruvate. Following BD, glucose oxidation was measured using tritium-labeled glucose (d-6-3H-glucose) during IPK reperfusion. Quantitative polymerase chain reaction and biochemistry were performed on tissue/plasma. Immediately following BD induction, lactate increased in both organs (liver: eµ_d0.21, 95% confidence interval [CI] [−0.27, −0.15]; kidney: eµ_d0.26, 95% CI [−0.40, −0.12]. After 4 hours of BD, alanine production decreased in the kidney (eµ_d0.14, 95% CI [0.03, 0.25], P < .05). Hepatic lactate and alanine profiles were significantly different throughout the experiment between groups (P < .01). During IPK perfusion, renal glucose oxidation was reduced following BD vs sham animals (eµ_d0.012, 95% CI [0.004, 0.03], P < .001). No differences in enzyme activities were found. Renal gene expression of lactate-transporter MCT4 increased following BD (P < .01). In conclusion, metabolic processes during BD can be visualized in vivo using hyperpolarized magnetic resonance imaging and with glucose oxidation during ex vivo renal machine perfusion. These techniques can detect differences in the metabolic profiles of the liver and kidney following BD.
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Renal resistive index as a predictive factor of delayed graft function: A meta-analysis
2019, Transplantation Reviews
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In addition, in order to define the predictive nature of RRI, its diagnostic accuracy was separately calculated including only the studies which performed their measurements early in the postoperative period (≤5 days after transplantation). Fourteen studies [35–48] were finally included to the present systematic review, with a total of 2741 kidney transplant recipients. Among them 695 were diagnosed with delayed graft function, while the rest 2046 patients served as the control group.
Delayed graft function represents a major complication of kidney transplantation, leading to high rates of short and long-term morbidity. The aim of the present meta-analysis is to assess the role of renal resistive index measurement in the post-transplant period and evaluate its efficacy in the prediction of delayed graft function.
Medline, Scopus, Cochrane Central Register of Controlled Trials CENTRAL, Clinicaltrials.gov and Google Scholar databases were systematically searched. Statistical analysis was performed with Review Manager 5.3, R 3.4.3 and Open Meta-Analyst software.
Fourteen studies were included with a total of 2741 kidney recipients. Patients with delayed graft function presented significantly higher rates of elevated renal resistive index (Odds Ratio: 1.96, 95% CI: [1.37, 2.81]). Also, renal resistive index values were significantly higher in patients with delayed graft function compared both to those with slow (Mean Difference: 0.04, 95% CI: [0.01, 0.07]) and immediate (Mean Difference: 0.10, 95% CI: [0.07, 0.12]) graft function. The pooled sensitivity for the detection of delayed graft function was estimated at 47.2% (95% CI: [30.9, 64.2]), the specificity at 69.3% (95% CI: [54.1, 81.2]) and the area under the curve at 0.613.
The present meta-analysis suggests the promising role of renal resistive index evaluation early after kidney transplantation, since its high values were significantly associated with higher incidence of delayed graft function. Future large-scale studies should define the most appropriate cut-off value and should incorporate renal resistive index in combined models in order to achieve optimal predictive accuracy.
Use of Intraoperative Duplex Ultrasound and Resistance Index Reduces Complications in Living Renal Donor Transplantation
2018, Transplantation Proceedings
The treatment of choice in end-stage renal disease is transplantation. Hemodynamic disturbances can evoke graft loss, while early ultrasound identification of vascular problems improves outcome. The aim of this study was to identify differences in postoperative complications with and without systematic intraoperative Doppler ultrasound use.
The primary outcome was the postoperative rate of complications and the secondary aim was to find a predictive resistance index cut-off value, which would show where surgical reintervention was necessary. Over a 10-year period, 108 renal transplants were performed from living donors at our institution. In group 1 (n = 67), intraoperative duplex ultrasound and intraparenchymatous resistance index measurements assessed patients, while in group 2 (n = 41), no ultrasound was performed.
There were no intergroup differences in the overall postoperative complication rate or in benefit to graft or patient survival with Doppler use. However, significantly more vascular complications (10% vs 0%, P = .02) and more acute rejections (37% vs 10%) occurred in group 2 than in group 1. Therefore, an intraoperative cut-off value of the resistance index 0.5 was proposed to justify immediate surgical revision.
This is the first report demonstrating benefits of systematic intraoperative Doppler ultrasound on postoperative complications in renal transplantation from living donors. Our results support surgical revision with a resistance index <0.5.
Towards non-invasive diagnostic techniques for early detection of acute renal transplant rejection: A review
2017, Egyptian Journal of Radiology and Nuclear Medicine
The kidney is a very important complicated filtering organ of the body. When the kidney reaches stage 5 chronic kidney disease, end stage renal failure, the preeminent therapy is renal transplantation. Although it is the best form of treatment, lack of kidney donors is still challenging. Therefore, all efforts should be employed to prolong the survival rate of the transplanted kidney. However, graft dysfunction (e.g., acute rejection) is one of the serious barriers to long term kidney transplant survival. Currently, graft dysfunction’s gold standard of diagnosis is renal biopsy. Although renal biopsy is helpful, it is not preferred due to its invasive nature, high morbidity rates, and expensiveness. Therefore, noninvasive imaging techniques have become the subject of extensive research and interest, giving a strong promise to replace, or at least to decrease, biopsy usage in diagnosing graft dysfunction. This survey will discuss not only the current diagnosis and treatment of graft dysfunction but also the state-of-the-art imaging techniques in detecting acute renal transplant rejection.

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Renal transplantationIschemia-reperfusion injuryThe Intrarenal Vascular Resistance Parameters Measured by Duplex Doppler Ultrasound Shortly After Kidney Transplantation in Patients With Immediate, Slow, and Delayed Graft Function

Abstract

Background

Patients and methods

Results

Conclusion

Section snippets

Patients and methods

Results

Discussion

Transplant Proc

Transplant Proc

Eur J Radiol

Eur J Radiol

Early function as principal correlate of graft survival. A multivariate analysis of 200 cadaveric renal transplants treated with a protocol incorporating antilymphocyte globulin and cyclosporine

Transplantation

Renal transplantation
Ischemia-reperfusion injury
The Intrarenal Vascular Resistance Parameters Measured by Duplex Doppler Ultrasound Shortly After Kidney Transplantation in Patients With Immediate, Slow, and Delayed Graft Function