The edition · Nephrology
Dexmedetomidine cut postoperative complications in high-risk elderly surgery
A 272-patient trial in patients with a revised cardiac risk index of 3 or more found fewer complications and a shorter stay; small-donor paediatric kidney grafts were lost mostly during one centre's learning phase; and creatinine clearance turns up genetic loci that eGFR misses.
The edition in brief
A quiet nephrology day with four findings worth reading. A multicentre randomised trial enrolled 272 patients aged 60 or over with a revised cardiac risk index of 3 or more undergoing major non-cardiac surgery, giving dexmedetomidine from induction through 72 postoperative hours or matching saline: major complications across neurologic, cardiovascular, renal, pulmonary, coagulation, infectious and gastrointestinal systems within 30 days occurred in 38.2% versus 52.9% (relative risk 0.722, 95% CI 0.554–0.942, p=0.015), with one day shorter stay and a lower peak neutrophil-to-lymphocyte ratio. A single-centre cohort of 77 paediatric kidney transplants found single-kidney grafts from donors weighing 15 kg or less had 73.1% one-year graft survival against 100% from larger donors, with a CUSUM inflection at case 16 and operative time falling from 187.6 to 146.3 minutes; a meta-analysis of seven studies and 527 patients put pooled one-year graft survival at 91%. A genome-wide association meta-analysis of creatinine clearance in 58,976 people identified 16 loci, two never seen in eGFR studies, plus two female-specific loci near GPC6 and IGF1R. And imaging mass cytometry of 15 kidney biopsies found injury markers pRIPK3 and FACL4 raised in tubular and endothelial cells sitting immediately next to infiltrating T cells in both ANCA-associated vasculitis and lupus nephritis.
Small paediatric donor kidneys work, once the centre is past its learning phase
Refer paediatric recipients of small-donor kidneys to centres past their learning curve — the technique is sound and the first fifteen cases are where grafts are lost.
Creatinine clearance finds genetic loci that eGFR hides
Remember that eGFR measures filtration and muscle mass together — in a sarcopenic or malnourished patient, add cystatin C rather than trusting the creatinine-based number.
In vasculitic kidney disease, the tubules are injured where the T cells are
Read the tubulointerstitial component of a vasculitis or lupus nephritis biopsy as the prognostic finding it is — the glomerular class is not the whole report.
Hyperkalaemia on a normal ECG is still hyperkalaemia
Treat hyperkalaemia on the number, the trajectory and the context — a normal ECG does not make a potassium of 6.8 safe.
Dexmedetomidine through to 72 hours cut complications in high-risk elderly surgery
For patients over 60 with a revised cardiac risk index of 3 or more having major non-cardiac surgery, discuss a perioperative dexmedetomidine infusion continued for 72 hours with the anaesthetic team.
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