|Year : 2021 | Volume
| Issue : 1 | Page : 14-18
Comparison of histidine-tryptophan-ketoglutarate solution versus ringer lactate as perfusion fluid in live donor renal transplant - A randomised controlled trial
Ambuj Agarwal1, Deepesh Benjamin Kenwar2, Ashish Sharma2, Sarbpreet Singh2, W Sujata3
1 Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Renal Transplant, Post Graduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Biochemistry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||24-Jun-2020|
|Date of Acceptance||28-Nov-2020|
|Date of Web Publication||31-Mar-2021|
Dr. Deepesh Benjamin Kenwar
Department of Renal Transplant, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Objective: Ringer's lactate (RL) was one of the perfusion fluid used in renal transplants, which were replaced by perfusion fluid with an intracellular composition like histidine-tryptophan-ketoglutarate (HTK) solution. These are preferred in cadaveric renal transplants. However, there are no guidelines for live-related donor renal transplant. We study whether HTK solution is better than RL solution, an extracellular composition fluid in preserving allograft in live-related donor renal transplantation. Materials and Methods: A single-blinded randomized trial comparing HTK solution and RL solution in 80 patients undergoing live-related donor renal transplantation from July 2017 to June 2018. The outcome was measured in serum cystatin C and plasma malondialdehyde (MDA) and serum creatinine for 30 days. Results: In 19 cases, surgeons preferred HTK solution as perfusion fluid due to the presence of multiple arteries; hence, these cases are removed from analysis due to deviation from the study protocol. Four patients in the HTK group and five patients in the RL group were excluded due to loss to follow-up. Recipient age, sex, and donor age, sex, and basic disease were comparable in both groups. The higher warm ischemia in the HTK group (5.58 min [standard deviation (SD) 1.44 min]) as compared to the RL group (5.00 min [SD 1.12 min]) with P 0.096. Similarly, the longer cold ischemia in the HTK group (82.00 min [SD 21.31 min]) as compared to the RL group (70.32 min [SD 24.56 min]) with P 0.783. 8.3% rejection in the HTK group and 17.9% rejection in the RL group. Serum cystatin C, marker of glomerular filtration was comparable, HTK group ((3.75 ± 1.98 mg/l) and RL (3.94 ± 1.68 mg/l) with P 0.714. The plasma MDA marker of ischemia-reperfusion injury was also comparable HTK group (80.16 ± 80.08 ng/ml) and RL group (61.50 ± 92.23 ng/ml) with a P 0.446. Fall in serum creatinine was significantly more in the HTK group than RL. At the end of 30 days, both groups had similar levels of serum creatinine level. Conclusion: Graft perfused by HTK solution and RL solution at our center had comparable 30-day outcomes. Although none of the differences was statistically significant, the HTK group had consistently better metrics in terms of fall in creatinine and serum cystatin C despite a trend to longer ischemia times and higher plasma MDA levels.
Keywords: Histidine-tryptophan-ketoglutarate, live donor renal transplant, plasma malondialdehyde, Ringer's lactate, serum cystatin C
|How to cite this article:|
Agarwal A, Kenwar DB, Sharma A, Singh S, Sujata W. Comparison of histidine-tryptophan-ketoglutarate solution versus ringer lactate as perfusion fluid in live donor renal transplant - A randomised controlled trial. Indian J Transplant 2021;15:14-8
|How to cite this URL:|
Agarwal A, Kenwar DB, Sharma A, Singh S, Sujata W. Comparison of histidine-tryptophan-ketoglutarate solution versus ringer lactate as perfusion fluid in live donor renal transplant - A randomised controlled trial. Indian J Transplant [serial online] 2021 [cited 2021 Jun 21];15:14-8. Available from: https://www.ijtonline.in/text.asp?2021/15/1/14/312755
| Introduction|| |
Although several organ preservation solutions are available, the goals of each are similar: Prevent cellular edema, delay cell destruction, decrease metabolism, control acidosis, and provide metabolic substrates. Simple hypothermia is adequate for preserving the viability of the grafted organ for a short duration by diminishing metabolic activity and curtailing oxygen demand, but metabolism continues. When longer preservation is required, perfusion fluids with a composition similar to intercellular fluid would be better able to maintain cellular homeostasis. However, these solutions are either costly or not readily available in our country. Histidine-tryptophan-ketoglutarate (HTK) solution is reported to have an advantage of lower viscosity and improved clearance of microvasculature. In many developing countries, Ringer's lactate (RL) solution has been used as a perfusion fluid since the early days of transplantation as its electrolyte content is similar to plasma.,
The purpose of this study was to compare the effect of the two organ preservation solutions, HTK and RL on early graft function in terms of serum creatinine, serum cystatin C (an alternate biomarker of filtration), and plasma malondialdehyde (MDA) (a biomarker of ischemia-reperfusion injury).
| Materials and Methods|| |
The study was conducted as a single-blinded prospective randomized controlled trial in the Department of Renal Transplant Surgery for 1 year from July 2017 to June 2018 after clearance by the institute ethics committee on February 23, 2017.
The inclusion criteria of the study were patient undergoing first-time live donor transplants.
Exclusion criteria of the study were complex vascular anatomy requiring prolonged bench reconstruction estimated >3 h, cadaveric transplant, repeat implantation, nonadherence of the study protocol. Eighty first-time renal transplant recipients were included in this study. The procedures adhered to the ethical guidelines of the Declaration of Helsinki.
The subjects were randomized to receive one of the two hypothermic perfusion fluids, lactated Ringer's solution and HTK solution. After laparoscopic donor nephrectomy, the retrieved kidney was placed in ice slush and flushed with 500 ml cold perfusion fluid at 4°C–8°C before proceeding with back table surgery. The kidney was then transplanted on to the recipient iliac vessels, either to the internal iliac artery or the external iliac artery.
Venous blood samples for serum cystatin C (automated chemiluminescence kit, Medicon Hallas S. A) and MDA (double antibody sandwich enzyme-linked immunosorbent assay [ELISA] kit, Qayee Biotechnology Co. Ltd.) testing were taken on the postoperative day (POD) 0 at 2 h after reperfusing the allograft kidney. The serum creatinine was measured on POD 0, 1, 2, 3, 4, 5, 6, 7, 14, and 30.
The recipients received triple-drug immunosuppression with tacrolimus, mycophenolate, and prednisolone. Tacrolimus dosing was adjusted to maintain therapeutic drug levels between 6 and 12 ng/ml.
Quantitative continuous variables over a period of time were compared using repeated measure ANOVA test with 5% significance, while continuous variables were compared using independent t-test with 5% significance. Qualitative variables were compared using the Pearson Chi-square test and Fischer's exact test with 5% significance.
The patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names, initials would not be published, and all standard protocols will be followed to conceal their identity.
The ethical clearance was taken from PGIMER ethics committee on February 23, 2017, with IRB number INT/IEC/2017/86. All protocols were followed as per Declaration of Helsinki.
| Results|| |
Eighty patients were enrolled for the study, of which nineteen such cases excluded from the analysis due to deviation from the study protocol when surgeons preferred to use HTK solution when donors had multiple arteries. Four patients in the HTK group and five patients in the RL group were excluded due to loss to follow-up. After completion of the study, there were a total of 54 patients left, with 28 (45.9%) patients in the HTK group and 33 (54.1%) patients in the RL group.
Demographic parameters and HLA match were comparable in both groups [Table 1].
The most common cause of end-stage renal failure in transplant patients at our center was hypertension (32.6%), chronic glomerulonephritis (30.8%), diabetes (11.5%), and immunoglobulins A nephropathy (9.6%). The incidence of end-stage renal disease causes was comparable across the two groups. The higher warm ischemia in the HTK group (5.58 min [standard deviation (SD) 1.44 min]) as compared to the RL group (5.00 min [SD 1.12 min]) was not statistically significant (P 0.096). Similarly, the longer cold ischemia in the HTK group (82.00 min [SD 21.31 min]) as compared to the RL group (70.32 min [SD 24.56 min]) was not statistically significant (P 0.783).
In most cases (41, 78.8%), urine appeared within 5 min of return of blood flow. One kidney in the HTK group had arterial vasospasm at the time of declamping. One kidney suffered hypoperfusion due to systemic hypotension in HTK. One kidney suffered hypoperfusion due to an intimal flap in the HTK group. Thirty-one patients had a high tacrolimus level (>12 ng/dl, 59.6%) which required tacrolimus dose reduction and a total of seven biopsy-proven acute rejections (13.5%) with two patients in the HTK group (8.3%) and five patients in the RL group (17.9%) [Table 2]. The difference in the rejection rates was not statistically significant (P 0.316) [Table 3].
Serum cystatin C measurement used as a surrogate marker of glomerular filtration postoperatively was not statistically different (P = 0.714) between the two groups; 3.75 ± 1.98 mg/l in the HTK group and 3.94 ± 1.68 mg/l in the RL group despite the slightly higher (but not statistically significant) warm ischemic time and cold ischemia time (CIT) in HTK group. A similar comparison has seen with plasma MDA concentrations, which was taken as a marker of ischemia-reperfusion injury, with HTK group (80.16 ± 80.08 ng/ml) and RL group (61.50 ± 92.23 ng/ml) with a P value of 0.446 [Table 3].
The early graft function of the kidney was assessed with serum creatinine. Fall in serum creatinine was significantly higher in the HTK group on POD 0 and 1. In the rest of the PODs, both groups show similar trends in graft functioning [Figure 1] and [Table 4].
|Figure 1: Showing fall of the serum creatinine level of two groups over a period of 1 month with x-line representing in days, and y-line representing in mean serum creatinine level|
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|Table 4: Comparison of the mean of serum creatinine in both groups over a period of 1 month|
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| Discussion|| |
Ischemia time remains one of the main factors affecting renal allograft outcomes and is probably one of the main reasons why live donor transplants have a better outcome than deceased donor transplants. It was hypothesized that when transit time between nephrectomy and implantation was minimal as in live donor transplants, only cooling of the kidneys would suffice, but intracellular electrolyte imbalance due to cold ischemia was not accounted for. The net result is that cellular metabolism is not completely arrested but disordered and retarded as different enzyme systems are affected unequally by the lower temperatures. The development of organ preservation solutions has been driven by the need to mitigate these deleterious effects of cold ischemia.
Reports indicated that simple modifications of RL solution such as by Tan et al. were adequate with 1 year patient and graft survival of 98.6% and 98.1%, respectively. Simple Ringer' lactate solution as used by Prasad et al. appeared to be as effective as a dedicated organ preservation solution such as Euro-Collins in renal preservation in live donor transplants provided ischemia time was kept short.
In this study, despite the higher warm and CIT, although not statistically significant, the HTK group has comparable outcomes as the RL group with similar levels of ischemia-reperfusion injury, immediate graft function and graft outcomes at 1 month. These findings indicate either superiority of HTK solution in preserving the renal allograft or there may be the possibility of a threshold, below which choice of a solution does not affect graft outcome. In the study conducted by Prasad et al., warm and CIT of RL groups and Euro-Collins groups was comparable with comparable outcome in term serum creatinine over a period of 1 year, indicating RL can be used as perfusion fluid alternative to Euro-Collins provided the cold ischemia was <80 min.
Even after randomization, a difference of 12 min in CIT in both groups is not statistically significant in this study; a larger study might be able to clarify further. There are factors other than ischemia time which can affect both early and delayed graft function, include artery vasospasm, renal hypo-perfusion, high tacrolimus trough level, technical faults, and rejection. These factors were present in insignificant level to affect any change in outcome from perfusion due to different fluids except high tacrolimus level and rejection. While high tacrolimus levels could have been a confounding factor in the fall in serum creatinine as it was present in nearly half the subjects, the incidence of this was not significantly different between the two groups.
Graft rejections were higher in the RL group compared to the HTK group (17.9% vs. 8.3%); however, it did not reach statistical significance. There might be a justification of a higher rejection rate in the RL group, which can be investigated on a large-scale study, as there is no study to justify this phenomenon.
Serum cystatin C has been suggested as an alternative biomarker of filtration. Serum cystatin C is a 13.4-kDa cysteine protease inhibitor produced by all nucleated cells at a constant rate, undergoes no tubular secretion, and does not return to the circulation after freely filtered by glomeruli. The mean of serum cystatin C of the HTK group was 3.75 ± 1.98 mg/l and the RL group was 3.94 ± 1.68 mg/l. The study conducted by Hall et al. had shown the serum cystatin C value in POD 0 was 3.3 ± 1.0 mg/l in case of immediate graft functioning and 4.2 ± 1.5 mg/l in case of delayed graft functioning. Based on the above study, grafts perfused with either RL or HTK solutions had shown no effects on posttransplant glomerular filtration as measured by serum cystatin C.
During transplantation, ischemia-reperfusion injury of the graft kidney induces oxidative stress in the recipient, which was measured by proxy using plasma MDA, a marker of lipid peroxidation. The mean plasma MDA in the HTK group was 80.16 ± 80.09 ng/ml and the RL group was 61.50 ± 92.23 ng/ml, which was comparable and consistent with higher warm and CIT of HTK solutions group compared to RL group. In the study conducted by Kumar et al., the plasma MDA after live donor renal transplant on POD 0 was 3.32 ± 1.09 μmol/l. With a molecular weight of 72.063 g, the plasma MDA was 239.04 ± 78.48 ng/ml. The huge difference can be determined with a different approach to plasma MDA measurement, thiobarbituric acid reactive substances assay kit read spectrophotometrically in the study by Kumar et al., whereas ELISA in our study.
Early graft function was measured by serum creatinine over a period of 30 days. When both HTK and RL groups were compared, the fall in serum creatinine was rapid in HTK solution perfused kidney. At the end of 30 days, no significant difference seen was in serum creatinine in both groups, although the serum creatinine of the RL group remained slightly higher. Interestingly, the longer ischemic times and lower levels of serum creatinine in the HTK group, even though not statistically significant, taken together can perhaps be interpreted as leading to the conclusion that HTK solution might be the better perfusion fluid as compared to RL. This is similar to the randomized study conducted by Prasad et al., reporting that the percentage fall of serum creatinine in the first postoperative week was significantly more in the Euro-Collins than in the RL group. Graft function was significantly better in the first 6 months in the Euro-Collin group compared to the RL group, although this difference disappeared after 6 months.
| Conclusion|| |
Graft perfused by HTK solution and RL solution at our center had comparable 30-day outcomes. Interestingly, although none of the differences were statistically significant. The HTK group had consistently better metrics in terms of fall in creatinine and serum cystatin C despite a trend to longer ischemia times and higher plasma MDA levels.
Small sample size, limited resources restricting repeated the evaluation of biomarkers, higher rejection rate in the RL group compared to the HTK group with no statistical difference are the limitations of the study. The data from this study signify the need for further studies with a larger subset of patients to define the precise role of RL solution as perfusion fluid.
Financial support and sponsorship
Financial support of Rs. 50,000 from Indian Council of Medical Research as a part of financial support for MD/MS thesis yearly programme.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]