Vasopressor Starting Dose and Association with Hemodynamic Goals, Renal Replacement Therapy, and Mortality

Aim: There are no consensus recommendations for the starting dose of vasopressors in septic shock. The aim of this study was to evaluate the starting dose of vasopressors on hemodynamic, renal, and overall outcomes. Study Design, Materials, Methods: This was a retrospective, single center cohort study from January 2016 to June 2018. The primary outcome of this study was to compare low-dose versus high-dose initial vasopressors and the impact on the attainment of MAP at 6 hours in septic shock patients. We determine groups by evaluating the per-kilogram starting dose of vasopressors (mcg/kg/min) for the entire cohort and divided the cohort into two based on the median starting dose. Low-dose was below the median starting dose and high-dose was above the median starting dose. Bivariate analysis and multivariate linear and logistic regression analysis were completed to evaluate outcomes that were significantly associated with the MAP at 6 hours, development of renal failure needing continuous renal replacement therapy, and mortality. Results: Patients who received high-dose initial vasopressors had a significant higher average MAP at 6 hours (57.9 mmHg vs 51mmHg; P = 0.003) and a lower rate of CRRT requirements (20.7% vs. 51.7%; P = 0.014). Each 0.01 mcg/kg/min increase in starting dose led to a 0.7 mmHg increase in MAP at 6 hours (95% CI 0.037 to 1.175; P = 0.001). Every 0.01 mcg/kg/minute increase in starting vasopressor dose was associated with 1% decreased odds of needing RRT (95% CI 0.0005 to 0.98; P = 0.049). The need for CRRT was significantly associated with mortality (OR=6.1;95% CI 1.23 to 33.3; P = 0.027)

Three year outcomes following positive cross match renal transplantation despite failure to convert to Negative Flow Cross Match after Desensitization

Desensitization allows successful transplantation of patients with a positive crossmatch (PXM) against their live donor. We evaluated outcomes following PXM renal transplant despite failure to convert to negative flow cytometric crossmatch (FCXM) after desensitization. Patients that underwent desensitization before PXM transplant between 1/1/00 and 11/1/11 were identified for analysis. Patients who received a transplant despite failure to convert to negative FCXM were identified as the not converted group. Patients who converted to negative FCXM after desensitization comprised the converted group control arm. 108 patients were desensitized before PXM transplant, (not converted group=42; converted group=66). Mean eGFR was comparable between groups at all time points, and 3-year eGFR was 57.8 mL/min vs. 57.1 mL/min, p=0.91. Patients with eGFR < 30mL/min at 3 years did not differ significantly (28% vs. 14%, p=0.15). Biopsy-proven rejection rates were numerically higher within the not converted group for each type of rejection and time point, but the values did not differ significantly. Opportunistic infections rates were comparable. Patient survival (95% vs. 91%) and death-censored allograft survival (84% vs. 95%, p=0.07) were similar between arms at 3 years post-transplant

Impact of a pharmacy‐led nursing education on discharge opioid prescribing after kidney transplant

A major contributor to the opioid epidemic is prescribing in the postoperative setting. There remains the need for opioid stewardship both postoperatively and upon discharge in kidney transplant recipients. In October 2017, pharmacist-led education was given to all transplant nursing staff at a single center with the goal of optimizing postoperative pain control through education and empowerment of nurses. Furthermore, the education focus was to advance nursing knowledge, enhance patient assessment, and reform patient education. Clinical pharmacists continued to work with the transplant team to base a patient's discharge analgesia on inpatient analgesia use. This study assessed the impact of the nursing education on discharge analgesic prescribing patterns after kidney transplant admission. Opioid prescribing on transplant discharge was significantly lower after the education (pre 68.3% vs post 11.1%, P <.001). Transplant admission was shortened by 1 day (6 vs 5 days, P =.03). Over time, a significant downtrend in opioid prescribing was observed on discharge from 86.1% in 2015 to 49.6% in 2017 and 8.5% in 2018 (P <.001). If opioid therapy was required on discharge in the posteducation group, tramadol was predominantly prescribed (7/13 opioid prescriptions, 53.9%). Thus, opioid minimization and pain management using nonopioid analgesic prescribing on discharge are feasible in an adult kidney transplant population with proper nursing collaboration and education

Body-composition changes in the Comprehensive Assessment of Long-term Effects of Reducing Intake of Energy (CALERIE)-2 study: A 2-y randomized controlled trial of calorie restriction in nonobese humans

Background: Calorie restriction (CR) retards aging and increases longevity in many animal models. However, it is unclear whether CR can be implemented in humans without adverse effects on body composition.Objective: We evaluated the effect of a 2-y CR regimen on body composition including the influence of sex and body mass index (BMI; in kg/m2) among participants enrolled in CALERIE-2 (Comprehensive Assessment of Long-term Effects of Reducing Intake of Energy), a multicenter, randomized controlled trial.Design: Participants were 218 nonobese (BMI: 21.9-28.0) adults aged 21-51 y who were randomly assigned to 25% CR (CR, n = 143) or ad libitum control (AL, n = 75) in a 2:1 ratio. Measures at baseline and 12 and 24 mo included body weight, waist circumference, fat mass (FM), fat-free mass (FFM), and appendicular mass by dual-energy X-ray absorptiometry; activity-related energy expenditure (AREE) by doubly labeled water; and dietary protein intake by self-report. Values are expressed as means ± SDs.Results: The CR group achieved 11.9% ± 0.7% CR over 2-y and had significant decreases in weight (-7.6 ± 0.3 compared with 0.4 ± 0.5 kg), waist circumference (-6.2 ± 0.4 compared with 0.9 ± 0.5 cm), FM (-5.4 ± 0.3 compared with 0.5 ± 0.4 kg), and FFM (-2.0 ± 0.2 compared with -0.0 ± 0.2 kg) at 24 mo relative to the AL group (all between-group P < 0.001). Moreover, FFM as a percentage of body weight at 24 mo was higher, and percentage of FM was lower in the CR group than in the AL. AREE, but not protein intake, predicted preservation of FFM during CR (P < 0.01). Men in the CR group lost significantly more trunk fat (P = 0.03) and FFM expressed as a percentage of weight loss (P < 0.001) than women in the CR group.Conclusions: Two years of CR had broadly favorable effects on both whole-body and regional adiposity that could facilitate health span in humans. The decrements in FFM were commensurate with the reduced body mass; although men in the CR group lost more FFM than the women did, the percentage of FFM in the men in the CR group was higher than at baseline. CALERIE was registered at clinicaltrials.gov as NCT00427193