Abstract
OBJECTIVES:
Video laparoscopic bariatric surgery is the preferred surgical technique for treating morbid obesity. However, pneumoperitoneum can pose risks to the kidneys by causing a decrease in renal blood flow. Furthermore, as in other surgical procedures, laparoscopic bariatric surgery triggers an acute inflammatory response. Neutrophil gelatinase-associated lipocalin is an early and accurate biomarker of renal injury, as well as of the inflammatory response. Anesthetic drugs could offer some protection for the kidneys and could attenuate the acute inflammatory response from surgical trauma. The objective of this study was to compare the effects of two types of anesthetics, propofol and sevoflurane, on the serum levels of neutrophil gelatinase-associated lipocalin during the perioperative period in laparoscopic bariatric surgery.
METHODS:
Sixty-four patients scheduled for laparoscopic bariatric surgery were randomized into two anesthesia groups and were administered either total intravenous anesthesia (propofol) or inhalation anesthesia (sevoflurane). In the perioperative period, blood samples were collected at three time points (before anesthesia, 6 hours after pneumoperitoneum and 24 hours after pneumoperitoneum) and urine output was measured for 24 hours. Acute kidney injuries were evaluated by examining both the clinical and laboratory parameters during the postoperative period. The differences between the groups were compared using non-parametric tests. ReBEC (http://www.ensaiosclinicos.gov.br/rg/recruiting/): RBR-8wt2fy
RESULTS:
None of the patients developed an acute kidney injury during the study and no significant differences were found between the serum neutrophil gelatinase-associated lipocalin levels of the groups during the perioperative period.
CONCLUSION:
The choice of anesthetic drug, either propofol or sevoflurane, did not affect the serum levels of neutrophil gelatinase-associated lipocalin during the perioperative period in laparoscopic bariatric surgery.
Morbid Obesity; NGAL; Bariatric Surgery; Acute Kidney Injury; Anesthesia
INTRODUCTION
The worldwide rates of surgical procedures for weight control have been increasing to
address the recent obesity epidemic (11. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach
K, et al. Bariatric Surgery. JAMA. 2004;292(14):1724-37,
http://dx.doi.org/10.1001/jama.292.14.1724.
http://dx.doi.org/10.1001/jama.292.14.17...
).
Currently, video laparoscopic bariatric surgery (VLBS) is considered the best
surgical technique for morbidly obese individuals who have health complications
associated with excess body fat (22. Dávila-Cervantes A, Borunda D, Domínguez-Cherit G,
Gamino R, Vargas-Vorackova F, González-Barranco J, et al. Open versus
laparoscopic vertical banded gastroplasty: a randomized controlled double blind
trial. Obes Surg. 2002;12(6):812-8,
http://dx.doi.org/10.1381/096089202320995619.
http://dx.doi.org/10.1381/09608920232099...
). Despite
the proven benefits of VLBS, these procedures, like any other surgery, can produce a
pattern of systemic inflammatory responses. VLBS also carries an inherent risk of
pneumoperitoneum to the kidneys due to elevated intra-abdominal pressure, which
reduces cortical capillary blood flow by increasing renal vascular resistance.
Consequently, the glomerular filtration rate (GFR) is decreased and transient
oliguria occurs (33. Cisek LJ, Gobet RM, Peters CA. Pneumoperitoneum produces
reversible renal dysfunction in animals with normal and chronically reduced
renal function. J Endourol. 1998;12(2):95-100,
http://dx.doi.org/10.1089/end.1998.12.95.
http://dx.doi.org/10.1089/end.1998.12.95...
). Rhabdomyolysis, which is
also associated with bariatric surgery, is another cause of kidney injury, but it
appears to be less problematic in VLBS than in open surgery (44. Ettinger J, Marcílio de Souza C, Ázaro E, Mello C,
Santos-Filho P, Orrico J, et al. Clinical Features of Rhabdomyolysis After Open
and Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg. 2008;18(6):635-43,
http://dx.doi.org/10.1007/s11695-007-9257-1.
http://dx.doi.org/10.1007/s11695-007-925...
). Acute kidney failure, which presents as a major elevation
in creatinine levels with oliguria, is not a common complication of VLBS when proper
preventive measures are followed during the perioperative period (44. Ettinger J, Marcílio de Souza C, Ázaro E, Mello C,
Santos-Filho P, Orrico J, et al. Clinical Features of Rhabdomyolysis After Open
and Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg. 2008;18(6):635-43,
http://dx.doi.org/10.1007/s11695-007-9257-1.
http://dx.doi.org/10.1007/s11695-007-925...
). However, traditional laboratory markers,
such as urea and creatinine, are not sufficiently sensitive to detect subclinical
acute kidney injuries in this population (55. Devarajan P. Review: neutrophil gelatinase-associated lipocalin:
a troponin-like biomarker for human acute kidney injury. Nephrology (Carlton).
2010;15(4):419-28,
http://dx.doi.org/10.1111/j.1440-1797.2010.01317.x.
http://dx.doi.org/10.1111/j.1440-1797.20...
).
Neutrophil gelatinase-associated lipocalin (NGAL), a 25-kDa glycoprotein in the
lipocalin family (66. Kjeldsen L, Johnsen AH, Sengelov H, Borregaard N. Isolation and
primary structure of NGAL, a novel protein associated with human neutrophil
gelatinase. J Biol Chem. 1993;268(14):10425-32.) is produced by the
epithelia of the kidneys, lungs, colon, liver, adipose tissue and inflammatory
cells. The most well-known functions of NGAL are iron transport (77. Yang J, Mori K, Li JY, Barasch J. Iron, lipocalin, and kidney
epithelia. Am J Physiol Renal Physiol.
2003;285(1):F9-18.), apoptosis regulation (88. Devireddy LR, Gazin C, Zhu X, Green MR. A Cell-Surface Receptor
for Lipocalin 24p3 Selectively Mediates Apoptosis and Iron Uptake. Cell.
2005;123(7):1293-305,
http://dx.doi.org/10.1016/j.cell.2005.10.027.
http://dx.doi.org/10.1016/j.cell.2005.10...
), infection control (99. Flo TH, Smith KD, Sato S, Rodriguez DJ, Holmes MA, Strong RK, et
al. Lipocalin 2 mediates an innate immune response to bacterial infection by
sequestrating iron. Nature. 2004;432(7019):917-21,
http://dx.doi.org/10.1038/nature03104.
http://dx.doi.org/10.1038/nature03104...
), structural development (1010. Gwira JA, Wei F, Ishibe S, Ueland JM, Barasch J, Cantley LG.
Expression of Neutrophil Gelatinase-associated Lipocalin Regulates Epithelial
Morphogenesis in Vitro. J Biol Chem. 2005;280(9):7875-82,
http://dx.doi.org/10.1074/jbc.M413192200.
http://dx.doi.org/10.1074/jbc.M413192200...
) and
renal recuperation (1111. Mori K, Lee HT, Rapoport D, Drexler IR, Foster K, Yang J, et al.
Endocytic delivery of lipocalin-siderophore-iron complex rescues the kidney from
ischemia-reperfusion injury. J Clin Invest. 2005;115(3):610-21,
http://dx.doi.org/10.1172/JCI23056.
http://dx.doi.org/10.1172/JCI23056...
). Clinical interest in
NGAL is related to the sensitivity and speed with which it is elevated in the serum
and urine after acute tubular injury, enabling the diagnosis of renal damage within
2 hours of the injurious event. In comparison, the elevation of other traditional
markers, such as creatinine, can be delayed by up to 48 hours after an acute kidney
injury (55. Devarajan P. Review: neutrophil gelatinase-associated lipocalin:
a troponin-like biomarker for human acute kidney injury. Nephrology (Carlton).
2010;15(4):419-28,
http://dx.doi.org/10.1111/j.1440-1797.2010.01317.x.
http://dx.doi.org/10.1111/j.1440-1797.20...
). Various other causes of organ
stress are also associated with NGAL elevation, which can be mediated by
pro-inflammatory cytokines (1212. Jayaraman A, Roberts KA, Yoon J, Yarmush DM, Duan X, Lee K, et
al. Identification of neutrophil gelatinase-associated lipocalin (NGAL) as a
discriminatory marker of the hepatocyte-secreted protein response to
IL-1β: a proteomic analysis. Biotechnol Bioeng. 2005;91(4):502-15,
http://dx.doi.org/10.1002/bit.20535.
http://dx.doi.org/10.1002/bit.20535...
) and is
considered a marker of a systemic inflammatory response (1313. Wang Y, Lam KSL, Kraegen EW, Sweeney G, Zhang J, Tso AWK, et al.
Lipocalin-2 Is an Inflammatory Marker Closely Associated with Obesity, Insulin
Resistance, and Hyperglycemia in Humans. Clin Chem.
2007;53(1):34-41.).
General anesthesia, commonly used in procedures such as VLBS, can have protective
effects on the renal system during the intraoperative period. Though different
mechanisms, both propofol (1414. Assad AR, Delou JMA, Fonseca LM, Villela NR, Nascimento JHM,
Verçosa N, et al. The Role of KATP Channels on Propofol Preconditioning in
a Cellular Model of Renal Ischemia-Reperfusion. Anesth Analg.
2009;109(5):1486-92,
http://dx.doi.org/10.1213/ANE.0b013e3181b76396.
http://dx.doi.org/10.1213/ANE.0b013e3181...
) and
sevoflurane (1515. Kong HY, Zhu SM, Wang LQ, He Y, Xie HY, Zheng SS. Sevoflurane
Protects against Acute Kidney Injury in a Small-Size Liver Transplantation
Model. Am J Nephrol. 2010;32(4):347-55.) have appeared to reduce
renal injury in clinical-surgical and experimental injury models. Various markers
are measured serially to monitor kidney injury during the perioperative period, but
many of these markers are delayed, or they have sensitivity limitations. The purpose
of the present study was to compare the effects of two anesthetics, propofol (TIVA)
and sevoflurane (SEVO), on serum NGAL levels over a 24-hour perioperative period in
obese patients undergoing VLBS.
METHODS
This study was approved by the Committee of Research Ethics of the São Rafael
Hospital (HSR) in Salvador, Bahia, Brazil, in accordance with the national standards
of ethics on human experimentation, as well as the Helsinki Declaration of 1975 and
it was also registered at ReBEC (http://www.ensaiosclinicos.gov.br/rg/recruiting/): RBR-8wt2fy.
Informed consent was obtained from 64 morbidly obese patients who were scheduled to
undergo VLBS between October 2010 and July 2011. The surgical indications followed
the current recommendations of the Brazilian Society of Metabolic and Bariatric
Surgery (individuals who are incapable of losing weight with recognized clinical
treatments and have either a body mass index (BMI)>40 kg/m2
or>35 kg/m2 with obesity-related illnesses). The following medical
conditions were considered the exclusion criteria for the study: chronic obstructive
pulmonary disease, congestive heart failure, cancer, chronic steroid use and a GFR
<60 mL/min (as estimated by the Cockcroft-Gault equation (1616. Cockcroft DW, Gault MH. Prediction of creatinine clearance from
serum creatinine. Nephron. 1976;16:31-41,
http://dx.doi.org/10.1159/000180580.
http://dx.doi.org/10.1159/000180580...
) using lean body weight for the calculation (1717. Demirovic JA, Pai AB, Pai MP. Estimation of creatinine clearance
in morbidly obese patients. Am J Health Syst Pharm. 2009;66(7):642-8,
http://dx.doi.org/10.2146/ajhp080200.
http://dx.doi.org/10.2146/ajhp080200...
)). The gastric bypass technique was used in
all of the patients. Two teams of surgeons performed the procedures.
The patients were randomly placed into either the TIVA or SEVO group. Both groups received 5 mg of midazolam as premedication.
Induction of general anesthesia was accomplished with propofol plus fentanyl in both groups; the SEVO group received a propofol dose of 1 mg/kg (real body weight) and the TIVA group received a propofol dose calculated by a target controlled infusion pump. Fentanyl (5 mcg/kg; ideal body weight) was used in both groups.
Maintenance of general anesthesia was assured using a combination of sevoflurane plus remifentanil in the SEVO group or of propofol plus remifentanil in the TIVA group. For the SEVO group, sevoflurane was administered throughout the surgery at a dose of between 1.4% and 3% of the expiratory gas concentration. For the TIVA group, the target controlled propofol infusion was at an estimated 3 to 5 mcg/mL blood concentration. Both groups received a continuous, target-controlled remifentanil infusion (at an estimated 3 to 6 ng/mL blood concentration, according to clinical necessity).
Morphine (100 mcg/kg of ideal body weight), dipyrone (2000 mg) and ondansetron (8 mg) were administered intravenously 30 minutes before the expected termination of surgery for postoperative analgesia and nausea prevention (both groups).
Neuromuscular blocking agents were the same in both groups and a succinylcholine dose of 1 mg/kg (ideal body weight) was used to induce patients with expected difficult airways. Also, cisatracurium was employed during the procedure.
Perioperative hydration was provided identically to both groups. A 0.9% NaCl solution
was administered as an infusion of 18 mL/kg (ideal body weight) for the first hour,
14 mL/kg (ideal body weight) for the second and third hours and 10 mL/kg (ideal body
weight) for subsequent hours. Blood samples for measuring creatinine and NGAL were
collected at three time points: M0, immediately before anesthesia induction; M1, 6
hours after pneumoperitoneum was established; and M2, 24 hours after
pneumoperitoneum. Creatinine was measured by an automated chromatographic technique
immediately after the blood sample was collected. NGAL was measured by the
enzyme-linked immunosorbent assay (ELISA) technique (NGAL rapid ELISA kit; BioPorto,
Gentofte, Denmark), which was retrospectively conducted on serum stored at
-80°C. The patients underwent bladder catheterization after anesthesia was
induced to measure 24 hours of urine output. The GFR at the M1 and M2 time points
was calculated by the Cockcroft-Gault equation, using lean body weight (1717. Demirovic JA, Pai AB, Pai MP. Estimation of creatinine clearance
in morbidly obese patients. Am J Health Syst Pharm. 2009;66(7):642-8,
http://dx.doi.org/10.2146/ajhp080200.
http://dx.doi.org/10.2146/ajhp080200...
). Blood pressure levels were measured every
five minutes via a non-invasive method (oscillometry) and the average mean arterial
pressure was calculated at the following time points relative to surgery: before
anesthesia induction, after tracheal intubation, during pneumoperitoneum, after
pneumoperitoneum deflation and after tracheal extubation. The intra-abdominal
pressure during pneumoperitoneum was limited to 14 cm H2O in all of the
patients. Capillary blood glucose was monitored
(Accu-Chek, Roche Diagnostics GmbH Sandhofer
Strasse 116 D-68305 Mannheim, Germany) before anesthesia induction and then every
hour during surgery.
Statistical analysis
The sample size was calculated using estimates in the literature regarding the mean and standard deviation for NGAL levels in obese patients. To achieve power of 80% with a 5% significance level and a difference of 33% in mean NGAL serum levels, the sample size was estimated as 30 patients per group. The means of the independent continuous variables were compared between the groups by the Mann-Whitney test and Wilcoxon's test was used to compare the dependent variables within the same group (at different time points). The chi-square test and Fisher's exact test were used to analyze the categorical variables. Differences with p-values <0.05 were considered significant.
RESULTS
Sixty-eight patients were initially considered candidates for participation in the study; however, 4 patients were excluded before the random selection stage because they refused to participate, or their surgeries were cancelled. Of the 64 patients who were randomly selected, all of them completed the study in two equally distributed groups of 32 individuals each.
There were no significant differences between the groups in terms of the anthropometric data, sex distribution, associated diseases, duration of pneumoperitoneum, baseline GFR or average intra-abdominal pressure (Table 1).
As shown in Table 2, the serum levels of NGAL were not influenced by the type of anesthesia that was used (TIVA vs. SEVO) at any of the analyzed time points. No changes in the NGAL levels were observed during the periods between M0 and M1, between M1 and M2 or between M0 and M2 in either the individual patients or in the groups when they were analyzed separately.
The median neutrophil gelatinase-associated lipocalin levels (ng/mL) (1st and 3rd quartiles) before anesthesia, 6 hours after pneumoperitoneum and 24 hours after pneumoperitoneum in all of the patients, separated according to type of anesthesia, total intravenous or inhalation anesthesia sevoflurane.
No difference was found in the occurrence of the “risk of renal injury” between the two anesthesia groups during the periods measured and no patients were classified as having “renal injury” using the RIFLE criteria (Table 3).
DISCUSSION
Morbidly obese patients present a perioperative risk for acute kidney injury due to
various factors. The causes for the occurrence of acute kidney damage found in the
literature included the following: the production of bioactive substances by adipose
tissues (1818. Hunley TE, Ma L-J, Kon V. Scope and mechanisms of
obesity-related renal disease. Curr Opin Nephrol Hypertens. 2010;19(3):227-34,
http://dx.doi.org/10.1097/MNH.0b013e3283374c09.
http://dx.doi.org/10.1097/MNH.0b013e3283...
); an increase in the
intra-abdominal pressure due to visceral fat accumulation; and tubular damage
induced by rhabdomyolysis during surgery (44. Ettinger J, Marcílio de Souza C, Ázaro E, Mello C,
Santos-Filho P, Orrico J, et al. Clinical Features of Rhabdomyolysis After Open
and Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg. 2008;18(6):635-43,
http://dx.doi.org/10.1007/s11695-007-9257-1.
http://dx.doi.org/10.1007/s11695-007-925...
).
Temporary oliguria is also a well-documented complication of laparoscopy,
particularly in morbidly obese patients (1919. Nguyen NT, Perez RV, Fleming N, Rivers R, Wolfe BM. Effect of
prolonged pneumoperitoneum on intraoperative urine output during laparoscopic
gastric bypass. J Am Coll Surg. 2002;195(4):476-83,
http://dx.doi.org/10.1016/S1072-7515(02)01321-2.
http://dx.doi.org/10.1016/S1072-7515(02)...
).
The primary factors causing kidney injury during laparoscopic procedures were
abdominal insufflation pressure and the length of pneumoperitoneum exposure (2020. Khoury W, Schreiber L, Szold A, Klausner J, Wienbroum A. Renal
oxidative stress following CO2-pneumoperitoneum-like conditions. Surg Endosc.
2009;23(4):776-82, http://dx.doi.org/10.1007/s00464-008-0054-2.
http://dx.doi.org/10.1007/s00464-008-005...
). A decrease in the cortical blood flow, as
well as an increase in vascular resistance and transient ischemia, was commonly
observed under experimental conditions, but these effects were usually associated
with elevated insufflation pressure of the abdominal cavity (>15 mm Hg) (2020. Khoury W, Schreiber L, Szold A, Klausner J, Wienbroum A. Renal
oxidative stress following CO2-pneumoperitoneum-like conditions. Surg Endosc.
2009;23(4):776-82, http://dx.doi.org/10.1007/s00464-008-0054-2.
http://dx.doi.org/10.1007/s00464-008-005...
) and they were typically reversible by
ending the pneumoperitoneum (1919. Nguyen NT, Perez RV, Fleming N, Rivers R, Wolfe BM. Effect of
prolonged pneumoperitoneum on intraoperative urine output during laparoscopic
gastric bypass. J Am Coll Surg. 2002;195(4):476-83,
http://dx.doi.org/10.1016/S1072-7515(02)01321-2.
http://dx.doi.org/10.1016/S1072-7515(02)...
).
In 15.6% of the patients at time point M1 and 1.6% of the patients at time point M2,
we found temporary changes in the urine volume and serum creatinine levels that were
sufficiently large to be classified as at “risk” using the RIFLE
criteria; there was no significant difference between the types of anesthesia (Table 3). All of the individuals
classified as at “risk” of renal injury using the RIFLE criteria at M1
had their classifications reversed to normal in M2. No patients were considered at
risk according to the RIFLE classification at hospital discharge. Similarly, in a
study by Ettinger et al. (44. Ettinger J, Marcílio de Souza C, Ázaro E, Mello C,
Santos-Filho P, Orrico J, et al. Clinical Features of Rhabdomyolysis After Open
and Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg. 2008;18(6):635-43,
http://dx.doi.org/10.1007/s11695-007-9257-1.
http://dx.doi.org/10.1007/s11695-007-925...
), the authors
could not find any cases of acute tubular necrosis (creatinine elevation criteria)
in 58 morbidly obese patients who underwent VLBS under similar conditions. We also
observed that the serum NGAL levels were not significantly different at the three
different time points at which they were measured over the 24 hours of the
perioperative period (Table 2).
Similarly, Micalli et al. (2121. Micali S, Silver RI, Kaufman HS, Douglas VD, Marley GM, Partin
AW, et al. Measurement of urinary N-acetyl-β-D-glucosaminidase to assess
renal ischemia during laparoscopic operations. Surg Endosc. 1999;13(5):503-6,
http://dx.doi.org/10.1007/s004649901022.
http://dx.doi.org/10.1007/s004649901022...
) did not
observe any changes in the urinary levels of N-acetyl-β-D-glucosaminidase, a
urinary marker of renal injury, in patients who had undergone surgical laparoscopy.
In our study, low intra-abdominal pressures were used during the surgical procedures
(the pneumoperitoneum was limited to 14 mm Hg), which might have contributed to the
absence of observable clinical damage to the renal system.
As seen in Table 2, the type of general
anesthesia (TIVA vs. SEVO) did not influence the serum NGAL levels
at any time during the evaluated perioperative period. Both propofol and sevoflurane
are anti-inflammatory agents because they decrease the production of the nuclear
transcription factor (NF-kB) (1515. Kong HY, Zhu SM, Wang LQ, He Y, Xie HY, Zheng SS. Sevoflurane
Protects against Acute Kidney Injury in a Small-Size Liver Transplantation
Model. Am J Nephrol. 2010;32(4):347-55.,2222. Sánchez-Conde P, Rodríguez-López JM, Nicolás
JL, Lozano FS, García-Criado FJ, Cascajo C, et al. The comparative
abilities of propofol and sevoflurane to modulate inflammation and oxidative
stress in the kidney after aortic cross-clamping. Anesth Analg.
2008;106(2):371-8,
http://dx.doi.org/10.1213/ane.0b013e318160580b.
http://dx.doi.org/10.1213/ane.0b013e3181...
), which is considered a transcriptional
inducer of pro-inflammatory interleukins, such as interleukins 1 and 6 (2323. Tak PP, Firestein GS. NF-κB: a key role in inflammatory
diseases. J Clin Invest. 2001;107(1):7-11,
http://dx.doi.org/10.1172/JCI11830.
http://dx.doi.org/10.1172/JCI11830...
) and of NGAL itself (2424. Bolignano D, Donato V, Lacquaniti A, Fazio MR, Bono C, Coppolino
G, et al. Neutrophil gelatinase-associated lipocalin (NGAL) in human neoplasias:
A new protein enters the scene. Cancer Lett. 2010;288(1):10-6,
http://dx.doi.org/10.1016/j.canlet.2009.05.027.
http://dx.doi.org/10.1016/j.canlet.2009....
). Through different mechanisms, both sevoflurane and
propofol exert protective effects on the kidneys: propofol decreased the tissue
damage caused by oxidative stress (2525. Wang H, Zhou H, Chen C, Zhang X, Cheng G. Propofol attenuation
of renal ischemia/reperfusion injury involves heme oxygenase-1. Acta Pharmacol
Sin. 2007;28:1175-80,
http://dx.doi.org/10.1111/j.1745-7254.2007.00566.x.
http://dx.doi.org/10.1111/j.1745-7254.20...
) and in
renal ischemia models, sevoflurane provided pharmacological preconditioning (1515. Kong HY, Zhu SM, Wang LQ, He Y, Xie HY, Zheng SS. Sevoflurane
Protects against Acute Kidney Injury in a Small-Size Liver Transplantation
Model. Am J Nephrol. 2010;32(4):347-55.,2626. Julier K, da Silva R, Garcia C, Bestmann L, Frascarolo P,
Zollinger A, et al. Preconditioning by Sevoflurane Decreases Biochemical Markers
for Myocardial and Renal Dysfunction in Coronary Artery Bypass Graft Surgery: A
Double-blinded, Placebo-controlled, Multicenter Study. Anesthesiology.
2003;98(6):1315-27,
http://dx.doi.org/10.1097/00000542-200306000-00004.
http://dx.doi.org/10.1097/00000542-20030...
).
However, there has been no consensus in the literature regarding the more effective
drug for kidney protection.
Although VLBS carries a risk of acute kidney injury, proper perioperative care
greatly reduces its occurrence and traditional laboratory markers do not have
sufficient accuracy to identify subclinical damage. NGAL is a sensitive, specific
and early biomarker of acute kidney injury that has been tested under many clinical
conditions and it allows for diagnosing renal damage within two hours of the
injurious event (55. Devarajan P. Review: neutrophil gelatinase-associated lipocalin:
a troponin-like biomarker for human acute kidney injury. Nephrology (Carlton).
2010;15(4):419-28,
http://dx.doi.org/10.1111/j.1440-1797.2010.01317.x.
http://dx.doi.org/10.1111/j.1440-1797.20...
). In our study, there were
no significant differences in the perioperative blood levels of this highly accurate
biomarker between groups using propofol or sevoflurane to maintain general
anesthesia during VLBS.
The type of general anesthesia (TIVA vs. SEVO) did not influence serum NGAL levels during the perioperative period in VLBS. Therefore, with regard to the risk of acute kidney injury, both types of anesthesia were equally safe during this surgery.
ACKNOWLEDGMENTS
Funding for this research was provided by the FAPESP (São Paulo State Research Foundation) under research grant number 2010/17300-9. We thank Dr. Liliana Ronzoni, the director of the São Rafael Hospital (HSR), for supporting this study, as well as, Dr. Ricardo Ribeiro of the Center of Biotechnology and Cell Therapy (CBTC) at HSR and Jussara Silveira of the clinical pathology laboratory at HSR for their valuable aid.
REFERENCES
-
1Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric Surgery. JAMA. 2004;292(14):1724-37, http://dx.doi.org/10.1001/jama.292.14.1724.
» http://dx.doi.org/10.1001/jama.292.14.1724 -
2Dávila-Cervantes A, Borunda D, Domínguez-Cherit G, Gamino R, Vargas-Vorackova F, González-Barranco J, et al. Open versus laparoscopic vertical banded gastroplasty: a randomized controlled double blind trial. Obes Surg. 2002;12(6):812-8, http://dx.doi.org/10.1381/096089202320995619.
» http://dx.doi.org/10.1381/096089202320995619 -
3Cisek LJ, Gobet RM, Peters CA. Pneumoperitoneum produces reversible renal dysfunction in animals with normal and chronically reduced renal function. J Endourol. 1998;12(2):95-100, http://dx.doi.org/10.1089/end.1998.12.95.
» http://dx.doi.org/10.1089/end.1998.12.95 -
4Ettinger J, Marcílio de Souza C, Ázaro E, Mello C, Santos-Filho P, Orrico J, et al. Clinical Features of Rhabdomyolysis After Open and Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg. 2008;18(6):635-43, http://dx.doi.org/10.1007/s11695-007-9257-1.
» http://dx.doi.org/10.1007/s11695-007-9257-1 -
5Devarajan P. Review: neutrophil gelatinase-associated lipocalin: a troponin-like biomarker for human acute kidney injury. Nephrology (Carlton). 2010;15(4):419-28, http://dx.doi.org/10.1111/j.1440-1797.2010.01317.x.
» http://dx.doi.org/10.1111/j.1440-1797.2010.01317.x -
6Kjeldsen L, Johnsen AH, Sengelov H, Borregaard N. Isolation and primary structure of NGAL, a novel protein associated with human neutrophil gelatinase. J Biol Chem. 1993;268(14):10425-32.
-
7Yang J, Mori K, Li JY, Barasch J. Iron, lipocalin, and kidney epithelia. Am J Physiol Renal Physiol. 2003;285(1):F9-18.
-
8Devireddy LR, Gazin C, Zhu X, Green MR. A Cell-Surface Receptor for Lipocalin 24p3 Selectively Mediates Apoptosis and Iron Uptake. Cell. 2005;123(7):1293-305, http://dx.doi.org/10.1016/j.cell.2005.10.027.
» http://dx.doi.org/10.1016/j.cell.2005.10.027 -
9Flo TH, Smith KD, Sato S, Rodriguez DJ, Holmes MA, Strong RK, et al. Lipocalin 2 mediates an innate immune response to bacterial infection by sequestrating iron. Nature. 2004;432(7019):917-21, http://dx.doi.org/10.1038/nature03104.
» http://dx.doi.org/10.1038/nature03104 -
10Gwira JA, Wei F, Ishibe S, Ueland JM, Barasch J, Cantley LG. Expression of Neutrophil Gelatinase-associated Lipocalin Regulates Epithelial Morphogenesis in Vitro. J Biol Chem. 2005;280(9):7875-82, http://dx.doi.org/10.1074/jbc.M413192200.
» http://dx.doi.org/10.1074/jbc.M413192200 -
11Mori K, Lee HT, Rapoport D, Drexler IR, Foster K, Yang J, et al. Endocytic delivery of lipocalin-siderophore-iron complex rescues the kidney from ischemia-reperfusion injury. J Clin Invest. 2005;115(3):610-21, http://dx.doi.org/10.1172/JCI23056.
» http://dx.doi.org/10.1172/JCI23056 -
12Jayaraman A, Roberts KA, Yoon J, Yarmush DM, Duan X, Lee K, et al. Identification of neutrophil gelatinase-associated lipocalin (NGAL) as a discriminatory marker of the hepatocyte-secreted protein response to IL-1β: a proteomic analysis. Biotechnol Bioeng. 2005;91(4):502-15, http://dx.doi.org/10.1002/bit.20535.
» http://dx.doi.org/10.1002/bit.20535 -
13Wang Y, Lam KSL, Kraegen EW, Sweeney G, Zhang J, Tso AWK, et al. Lipocalin-2 Is an Inflammatory Marker Closely Associated with Obesity, Insulin Resistance, and Hyperglycemia in Humans. Clin Chem. 2007;53(1):34-41.
-
14Assad AR, Delou JMA, Fonseca LM, Villela NR, Nascimento JHM, Verçosa N, et al. The Role of KATP Channels on Propofol Preconditioning in a Cellular Model of Renal Ischemia-Reperfusion. Anesth Analg. 2009;109(5):1486-92, http://dx.doi.org/10.1213/ANE.0b013e3181b76396.
» http://dx.doi.org/10.1213/ANE.0b013e3181b76396 -
15Kong HY, Zhu SM, Wang LQ, He Y, Xie HY, Zheng SS. Sevoflurane Protects against Acute Kidney Injury in a Small-Size Liver Transplantation Model. Am J Nephrol. 2010;32(4):347-55.
-
16Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16:31-41, http://dx.doi.org/10.1159/000180580.
» http://dx.doi.org/10.1159/000180580 -
17Demirovic JA, Pai AB, Pai MP. Estimation of creatinine clearance in morbidly obese patients. Am J Health Syst Pharm. 2009;66(7):642-8, http://dx.doi.org/10.2146/ajhp080200.
» http://dx.doi.org/10.2146/ajhp080200 -
18Hunley TE, Ma L-J, Kon V. Scope and mechanisms of obesity-related renal disease. Curr Opin Nephrol Hypertens. 2010;19(3):227-34, http://dx.doi.org/10.1097/MNH.0b013e3283374c09.
» http://dx.doi.org/10.1097/MNH.0b013e3283374c09 -
19Nguyen NT, Perez RV, Fleming N, Rivers R, Wolfe BM. Effect of prolonged pneumoperitoneum on intraoperative urine output during laparoscopic gastric bypass. J Am Coll Surg. 2002;195(4):476-83, http://dx.doi.org/10.1016/S1072-7515(02)01321-2.
» http://dx.doi.org/10.1016/S1072-7515(02)01321-2 -
20Khoury W, Schreiber L, Szold A, Klausner J, Wienbroum A. Renal oxidative stress following CO2-pneumoperitoneum-like conditions. Surg Endosc. 2009;23(4):776-82, http://dx.doi.org/10.1007/s00464-008-0054-2.
» http://dx.doi.org/10.1007/s00464-008-0054-2 -
21Micali S, Silver RI, Kaufman HS, Douglas VD, Marley GM, Partin AW, et al. Measurement of urinary N-acetyl-β-D-glucosaminidase to assess renal ischemia during laparoscopic operations. Surg Endosc. 1999;13(5):503-6, http://dx.doi.org/10.1007/s004649901022.
» http://dx.doi.org/10.1007/s004649901022 -
22Sánchez-Conde P, Rodríguez-López JM, Nicolás JL, Lozano FS, García-Criado FJ, Cascajo C, et al. The comparative abilities of propofol and sevoflurane to modulate inflammation and oxidative stress in the kidney after aortic cross-clamping. Anesth Analg. 2008;106(2):371-8, http://dx.doi.org/10.1213/ane.0b013e318160580b.
» http://dx.doi.org/10.1213/ane.0b013e318160580b -
23Tak PP, Firestein GS. NF-κB: a key role in inflammatory diseases. J Clin Invest. 2001;107(1):7-11, http://dx.doi.org/10.1172/JCI11830.
» http://dx.doi.org/10.1172/JCI11830 -
24Bolignano D, Donato V, Lacquaniti A, Fazio MR, Bono C, Coppolino G, et al. Neutrophil gelatinase-associated lipocalin (NGAL) in human neoplasias: A new protein enters the scene. Cancer Lett. 2010;288(1):10-6, http://dx.doi.org/10.1016/j.canlet.2009.05.027.
» http://dx.doi.org/10.1016/j.canlet.2009.05.027 -
25Wang H, Zhou H, Chen C, Zhang X, Cheng G. Propofol attenuation of renal ischemia/reperfusion injury involves heme oxygenase-1. Acta Pharmacol Sin. 2007;28:1175-80, http://dx.doi.org/10.1111/j.1745-7254.2007.00566.x.
» http://dx.doi.org/10.1111/j.1745-7254.2007.00566.x -
26Julier K, da Silva R, Garcia C, Bestmann L, Frascarolo P, Zollinger A, et al. Preconditioning by Sevoflurane Decreases Biochemical Markers for Myocardial and Renal Dysfunction in Coronary Artery Bypass Graft Surgery: A Double-blinded, Placebo-controlled, Multicenter Study. Anesthesiology. 2003;98(6):1315-27, http://dx.doi.org/10.1097/00000542-200306000-00004.
» http://dx.doi.org/10.1097/00000542-200306000-00004
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No potential conflict of interest was reported.
Publication Dates
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Publication in this collection
Oct 2014
History
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Received
10 Nov 2013 -
Reviewed
14 Jan 2014 -
Accepted
26 Apr 2014