Effect of ulinastatin on postoperative renal function in patients undergoing robot-assisted laparoscopic partial nephrectomy: a randomized trial

The effect of ulinastatin on acute kidney injury in patients undergoing off-pump cardiac bypass surgery

BACKGROUND

Ulinastatin, an anti-inflammatory and antioxidant trypsin inhibitor, has shown potential in mitigating acute kidney injury (AKI) and reducing serum creatinine levels after various surgeries. This retrospective study aimed to evaluate the effects of ulinastatin on AKI in patients undergoing off-pump coronary artery bypass (OPCAB) surgery.

METHODS

We hypothesized that the administration of ulinastatin could prevent AKI in OPCAB. Electrical medical records were reviewed to identify OPCAB patients between January 2015 and June 2020. The utilization of ulinastatin was randomly determined and applied during this period. Acute kidney injury was defined according to the KDIGO guideline, and its incidence was compared between the ulinastatin administration group and the control group. To investigate the effect of ulinastatin on renal function, multivariate logistic regression analysis was used to calculate propensity scores for each group.

RESULTS

A total 454 OPCAB were performed, and after following inclusion and exclusion process, 100 patients were identified in the ulinastatin group and 303 patients in the control group. Using 1:2 propensity score matching, we analyzed 100 and 200 patients in the ulinastatin and control groups. The incidence of AKI was similar between the groups (2.5% for the control group, 2.0% for the ulinastatin group, p > 0.999). However, the serum creatinine value on the first post-operative day were significantly lower in the ulinastatin group compared to the control group (0.774 ± 0.179 mg/dL vs 0.823 ± 0.216 mg/dL, P = 0.040), while no significant differences were observed for the other time points (P > 0.05). The length of ICU stay day was significantly shorter in the ulinastatin group (2.91 ± 2.81 day vs 5.22 ± 7.45 day, respectively, P < 0.001).

CONCLUSIONS

Ulinastatin did not have a significant effect on the incidence of AKI; it demonstrated the ability to reduce post-operative serum creatine levels at first post-operative day and shorten the length of ICU stay.

Effects of Ulinastatin on Postoperative Renal Function in Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass: A Prospective Cohort Study with 10-Year Follow-Up

INTRODUCTION

The present study aimed to explore the potential effect of ulinastatin on renal function and long-term survival in patients receiving cardiac surgery with cardiopulmonary bypass (CPB).

METHODS

This prospective cohort study was conducted at Fuwai Hospital, Beijing, China. Ulinastatin was applied after induction anesthesia. The primary outcome was the rate of new-onset postoperative acute kidney injury (AKI). Moreover, a 10-year follow-up was conducted until January 2021.

RESULTS

The rate of new-onset AKI was significantly lower in the ulinastatin group than in the control group (20.00 vs. 32.40%, p = 0.009). There was no significant difference in renal replacement therapy between the two groups (0.00 vs. 2.16%, p = 0.09). The postoperative plasma neutrophil gelatinase-associated lipocalin (pNGAL) and IL-6 levels were significantly lower in the ulinastatin group compared with the control group (pNGAL: p = 0.007; IL-6: p = 0.001). A significantly lower incidence of respiratory failure in the ulinastatin group compared with the control group (0.76 vs. 5.40%, p = 0.02). The nearly 10-year follow-up (median: 9.37, 95% confidence interval: 9.17-9.57) survival rates did not differ significantly between the two groups (p = 0.076).

CONCLUSIONS

Ulinastatin significantly reduced postoperative AKI and respiratory failure in patients receiving cardiac surgery with CPB. However, ulinastatin did not reduce intensive care unit and hospital stays, mortality, and long-term survival rate.

High-dose ulinastatin to prevent late-onset acute renal failure after orthotopic liver transplantation

Purpose

To compare the efficacy and safety of two distinct doses of ulinastatin on late-onset acute renal failure (LARF) following orthotopic liver transplantation (OLT).

Methods

The high-risk recipients that underwent OLT were divided into two groups according to ulinastatin dose: low-dose (LD) ulinastatin group, 0.8 million U/d; high-dose (HD) ulinastatin group, 1.6 million U/d. The primary outcome was the incidence of LARF, which was defined the newly onset acute kidney injury (AKI) stage III (KDIGO, 2012) within 7–28 post-transplant days. The second outcomes were early multiple organ retrieval assessments, length of hospital stay and safety events.

Results

A total of 174 recipients were included (LD ulinastatin group, n = 55; HD ulinastatin group, n = 119). There was no significant difference in the incidence of LARF between LD (8/55, 14.50%) and HD (9/119, 7.56%) ulinastatin groups (HD vs. LD, HR, 0.49; 95%CI, 0.17–1.37; p = .1295). Multivariate Cox proportion risk regression model revealed HD ulinastatin (HR, 0.57; 95%CI, 0.38–0.98; p = .0464) was an independent protective factor for LARF. Early lactate level, oxygenation, AKI stage, graft function, and sequential organ failure assessment [SOFA] score were significantly improved in HD ulinastatin group versus LD ulinastatin group. No significant adverse events were observed in either group.

Conclusions

Higher dose of ulinastatin (1.6 million U/d) might be preferable to prevent LARF after OLT, and it may contribute to the enhancement of early multiple organ recovery and thus attenuate the incidence of LARF.

Ulinastatin alleviates cerebral ischemia-reperfusion injury in rats by activating the Nrf-2/HO-1 signaling pathway

Background

Ulinastatin, a urinary trypsin inhibitor, is one of the widely used auxiliary drugs in the rescue of acute circulatory failure. This study aims to explore the protective mechanisms of ulinastatin on cerebral ischemia-reperfusion (I/R) injury.

Methods

A cerebral MCAO was established with middle cerebral artery occlusion (MCAO) in Sprague Dawley (SD) rats. Western blotting was employed to show protein expression. Oxidative stress markers [reactive oxygen species (ROS), superoxide dismutase (SOD), malondialdehyde (MDA), and glutathione (GSH)] and inflammatory cytokines (IL-6, IL-1β, and IL-18) were analyzed to show oxidative stress and inflammation. Hematoxylin and eosin (HE) and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) and triphenyltetrazolium chloride (TTC) staining were applied to show brain injury.

Results

HE, TUNEL and TTC staining indicated that ulinastatin significantly ameliorated cerebral I/R injury and reduced apoptotic cells in the MCAO brain tissue. Ulinastatin also reduced the MCAO-induced expression of intercellular adhesion molecule 1(ICAM-1)/caspase-3. Additionally, the highly expressed ROS, MDA and inflammatory cytokines (IL-6, IL-1β and IL-18) were significantly suppressed, and the inhibited SOD and GSH were recovered with ulinastatin treatment. Consequently, the expression of nuclear factor erythroid-2-related factor 2 (Nrf2)/heme oxygenase-1 (HO-1) (which was significantly inhibited by MCAO) was re-activated by ulinastatin and/or TBHQ (an Nrf-2 activator), and treatment with ML-385 (an Nrf-2 inhibitor) blocked the inhibition of apoptosis, inflammation, and oxidative stress by ulinastatin. Our results indicate that the Nrf-2/HO-1 signaling pathway may be involved in the pharmacological mechanism of ulinastatin in cerebral I/R injury.

Conclusions

Ulinastatin protected against inflammation and oxidative stress in cerebral I/R injuries via activation of the Nrf-2/HO-1 signaling pathway.

Development of a risk scoring system for predicting acute kidney injury after minimally invasive partial and radical nephrectomy: a retrospective study

BACKGROUND

Acute kidney injury after partial or radical nephrectomy remains an unsolved problem even when using minimally invasive techniques. We aimed to identify risk factors for acute kidney injury (AKI) after minimally invasive nephrectomy and to develop a clinical risk scoring system.

METHODS

Medical records of 1762 patients who underwent minimally invasive laparoscopic or robot-assisted laparoscopic partial (n = 1009) or radical (n = 753) nephrectomy from December 2005 to November 2018 were reviewed. Candidate risk factors were screened using univariate analysis and ranked using linear discriminant analysis; top ranking factors were incorporated into a multivariate logistic regression model. Then, the final clinical scoring system was created based on the estimated odds ratios.

RESULTS

The incidence of acute kidney injury after partial or radical nephrectomy was 20.3 and 61.6%, respectively. Risk factors incorporated into the scoring system included: size of the parenchymal mass removed (3 < parenchymal mass ≤ 4 cm, 1 point; 4 < parenchymal mass ≤ 6 cm, 3 points; parenchymal mass > 6 cm, 5 points), male sex (2 points), diabetes mellitus (1 point), warm ischemia time ≥ 25 min (1 point), and immediate postoperative neutrophil count ≥ 12,000 µl^-1 (1 point) in patients with partial nephrectomy, and sex (male, 10 points; female, 7 points) in patients with radical nephrectomy. For risk scores of 0-4, 5-6, 7, 8-9, and 10 points, the probabilities of acute kidney injury were approximately 10, 20, 40, 60, and 80%, respectively. The predictive accuracy of the scoring system was 0.827 (95% CI 0.789-0.865).

CONCLUSION

Our risk scoring system could help clinicians identify those at risk of acute kidney injury after minimally invasive partial or radical nephrectomy, thereby optimizing postoperative management.

Effect of Diabetes Mellitus on Acute Kidney Injury after Minimally Invasive Partial Nephrectomy: A Case-Matched Retrospective Analysis

Postoperative acute kidney injury (AKI) is still a concern in partial nephrectomy (PN), even with the development of minimally invasive technique. We aimed to compare AKI incidence between patients with and without diabetes mellitus (DM) and to determine the predictive factors for postoperative AKI. This case-matched retrospective study included 884 patients with preoperative creatinine levels ≤1.4 mg/dL who underwent laparoscopic or robot-assisted laparoscopic PN between December 2005 and May 2018. Propensity score matching was employed to match patients with and without DM in a 1:3 ratio (101 and 303 patients, respectively). Of 884 patients, 20.4% had postoperative AKI. After propensity score matching, the incidence of postoperative AKI in DM and non-DM patients was 30.7% and 14.9%, respectively (P < 0.001). In multivariate analysis, male sex and warm ischemia time (WIT) >25 min were significantly associated with postoperative AKI in patients with and without DM. In patients with DM, hemoglobin A1c (HbA1c) >7% was a predictive factor for AKI, odds ratio (OR) = 4.59 (95% CI, 1.47⁻14.36). In conclusion, DM increased the risk of AKI after minimally invasive PN; male sex, longer WIT, and elevated HbA1c were independent risk factors for AKI in patients with DM.

Multi-organ protection of ulinastatin in traumatic cardiac arrest model

Background

Post-cardiac arrest syndrome, which has no specific curative treatment, contributes to the high mortality rate of victims who suffer traumatic cardiac arrest (TCA) and initially can be resuscitated. In the present study, we investigated the potential of ulinastatin to mitigate multiple organ injury after resuscitation in a swine TCA model.

Methods

Twenty-one male pigs were subjected to hemodynamic shock (40% estimated blood loss in 20 min) followed by cardiac arrest (electrically induced ventricular fibrillation) and respiratory suspension for 5 min, and finally manual resuscitation. At 5 min after resuscitation, pigs were randomized to receive 80,000 U/kg ulinastatin (n = 7) or the same volume of saline (n = 9) in the TCA group. Pigs in the sham group (n = 5) were not exposed to bleeding or cardiac arrest. At baseline and at 1, 3, and 6 h after the return of spontaneous circulation, blood samples were collected and assayed for tumor necrosis factor-alpha, interleukin 6, and other indicators of organ injury. At 24 h after resuscitation, pigs were sacrificed and apoptosis levels were assessed in samples of heart, brain, kidney, and intestine.

Results

One pig died in the ulinastatin group and one pig died in the TCA group; the remaining animals were included in the final analysis. TCA and resuscitation caused significant increases in multiple organ function biomarkers in serum, increases in tumor necrosis factor-alpha, and interleukin 6 in serum and increases in the extent of apoptosis in key organs. All these increases were lower in the ulinastatin group.

Conclusion

Ulinastatin may attenuate multiple organ injury after TCA, which should be explored in clinical studies.

Electronic supplementary material

The online version of this article (10.1186/s13017-018-0212-3) contains supplementary material, which is available to authorized users.