Renal function after laparoscopic cholecystectomy and analgesia with tramadol and dipyrone or ketorolac

Tiago Pechutti Medeiros, Pedro Thadeu Galvão Vianna, Leopoldo Muniz da Silva, Lídia Raquel de Carvalho, Gilberto Elias Wady, Leandro Gobbo Braz, Yara Marcondes Machado Castiglia

Department of Anesthesiology, Botucatu Medical School, UNESP-Universidade Estadual Paulista, Botucatu, Brazil;.
Department of Biostatics, Institute of Biosciences, UNESP-Universidade Estadual Paulista, Botucatu, Brazil.
Graduate Program in Anesthesiology, Botucatu Medical School, UNESP-Universidade Estadual Paulista, Botucatu, Brazil.
Mercy Hospital, S?o Carlos, Brazil.
S?o Luiz Hospital, S?o Paulo, Brazil.

DOI: 10.4236/health.2013.511A1005                

Abstract

Background: Laparoscopic cholecystectomy (LC) reduces surgical trauma and hospital stay, but requires effective and safe postoperative analgesia. This prospective and double-blind study investigated the effects of analgesia with tramadol combined with either dipyrone or ketorolac on the postoperative renal function of patients submitted to LC. Methods: Pre-and post-operatively (PO), estimated glomerular filtration rates (GFR), obtained by two formulas dependent on blood Cr and one on blood cystatin C values, and tubular enzymuria—alkaline phosphatase (AP), γ-glutamiltransferase (γ-GT)— were determined in well hydrated patients who underwent LC and analgesia with tramadol combined with either dipyrone (Dipyrone, n = 63) or ketorolac (Ketorolac, n = 63). Upon discharge from the post-anesthetic care unit (PACU), pain (through Verbal Numerical Scale—VNS) and need for rescue analgesia with morphine were evaluated. Results: There was hemodilution PO, which made GFR profile analysis more difficult—those dependent on Cr increased and statistically correlated, but those dependent on cystatin C did not change. There was a significant PO increase in AP in the Dipyrone and Ketorolac groups, and in the product of the both enzymes in the Ketorolac group. Upon PACU discharge, the Dipyrone group showed signifi

cantly higher VNS scores than the Ketorolac group. All patients received morphine PO, and the total dose needed for pain control differed between groups, but without statistical significance. Conclusions: The association of tramadol with dipyrone or ketorolac in well hydrated patients submitted to LC had similar analgesic effectiveness in the PACU. Postoperatively, the effect on GFR may have been masked by hemodilution, and enzymuria was discreetly enhanced when ketorolac was used.

Keywords

Kidney Function Tests; Pneumoperitoneum; Biological Markers; Cystatin C; Ketorolac; Analgesia

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	London, E.T., HO, H.S., Neuhaus, A.M., Wolfe, B.M., Rudich, S.M. and Perez, R.V. (2000) Effect of intravascular volume expansion on renal function during prolonged CO2 pneumoperitoneum. Annals of Surgery, 231, 195-201. http://dx.doi.org/10.1097/00000658-200002000-00007
[2]	Lindstrom, P., Wadstrom, J., Ollerstam, A., Johnsson, C. and Persson, A.E. (2003) Effects of increased intra-abdominal pressure and volume expansion on renal function in rat. Nephrology Dialysis Transplantation, 18, 2269-2277. http://dx.doi.org/10.1093/ndt/gfg362
[3]	Demyttenaere, S., Feldman, L.S. and Fried, G.M. (2007) Effect of pneumoperitoneum on renal perfusion and function: A systematic review. Surgical Endoscopy, 21, 152-160. http://dx.doi.org/10.1007/s00464-006-0250-x
[4]	Michaloliakou, C., Chung, F. and Sharma, S. (1996) Preoperative multimodal analgesia facilitates recovery after ambulatory laparoscopic cholecistectomy. Anesthesia & Analgesia, 82, 44-51.
[5]	Burkle, H., Dunbar, S. and Van Aken, H. (1996) Remifentanil: A novel, short-acting μ-opioid. Anesthesia & Analgesia, 83, 646-651.
[6]	Grond, S. and Sablotzki, A. (2004) Clinical pharmacology of tramadol. Clinical Pharmacokinetics, 43, 879-923. http://dx.doi.org/10.2165/00003088-200443130-00004
[7]	Nagaoka, E., Minmi, K., Shiga, Y., Uezono, Y., Shiraishi, M., Aoyama, K. and Shigematsu, A. (2002) Tramadol has no effect on cortical renal blood flow despite increased serum catecholamine levels in anesthetized rats: Implications for analgesia in renal insufficiency. Anesthesia & Analgesia, 94, 619-625. http://dx.doi.org/10.1097/00000539-200203000-00026
[8]	Koppert, W. and Scmelz, M. (2007) The impact of opioid-induced hyperalgesia for postoperative pain. Best Practice & Research Clinical Anaesthesiology, 21, 65-83. http://dx.doi.org/10.1016/j.bpa.2006.12.004
[9]	Kurumbail, R.G., Stevens, A.M., Gierse, J.K., McDonald, J.J., Stegeman, R.A., Pak, J.Y., Gildehaus, D., Miyashiro, J.M., Penning, T.D., Seibert, K., Isakson, P.C. and Stallings, W.C. (1996) Structural basis for selective inhibition of cuclooxygenase-2 by anti-inflammatory agents. Nature, 384, 644-648. http://dx.doi.org/10.1038/384644a0
[10]	Dunn, M.J. and Zambraski, E.J. (1980) Renal effects of drugs that inhibit prostaglandin synthesis. Kidney International, 18, 609-622. http://dx.doi.org/10.1038/ki.1980.179
[11]	De Souza Silva, M., Castiglia, Y.M., Vianna, P.T., Viero, R.M., Braz, J.R. and Cassetari, M.L. (2006) Rat model of depending prostaglandin renal state: Effect of ketoprofen. Renal Failure, 28, 77-84. http://dx.doi.org/10.1080/08860220500461294
[12]	Coll, E., Botey, A., Alvarez, L., Poch, E., Quinto, L., Saurina, A., Vera, M., Piera, C. and Darnell, A. (2000) Serum cystatin C as a new marker for noninvasive estimation of glomerular filtration rate and as a marker for early renal impairment. American Journal of Kidney Diseases, 36, 29-34. http://dx.doi.org/10.1053/ajkd.2000.8237
[13]	Knight, E.L., Verhave, J.C., Spiegelman, D., Hillege, H.L., Zeeuw, D.D., Curhan, G.C. and de Jong, P.E. (2004) Factors influencing serum cystatin C levels other than renal function and the impact on renal function measurement. Kidney International, 65, 1416-1421. http://dx.doi.org/10.1111/j.1523-1755.2004.00517.x
[14]	Jung, K. and Burchardt, U. (1987) Urinary enzymes in research and in clinical medicine. Report on a symposium of the Humboldt-Universitat Berlin and the Bezirkskrankenhaus Frankfurt/Oder in Frankfurt/Oder, 22-25 April 1987. Journal of Clinical Chemistry & Clinical Biochemistry, 25, 823-828.
[15]	Larsson, A., Malm, J., Grubb, A. and Hansson, L.O. (2004) Calculation of glomerular filtration rate expressed in mL/min from plasma cystatin C values in mg/L. Scandinavian Journal of Clinical & Laboratory Investigation, 64, 25-30. http://dx.doi.org/10.1080/00365510410003723
[16]	Madero, M., Sarnak, M.J. and Stevens, L.A. (2006) Serum cystatin C as a marker of glomerular filtration rate. Current Opinion in Nephrology and Hypertension, 15, 610-616. http://dx.doi.org/10.1097/01.mnh.0000247505.71915.05
[17]	Levey, A.S., Bosch, J.P., Lewis, J.B., Greene, T., Rogers, N. and Roth, D. (1999) A more accurate method to estimate glomerular filtration rate from serum creatinine: A new prediction equation. Annals of Internal Medicine, 30, 461-470. http://dx.doi.org/10.7326/0003-4819-130-6-199903160-00002
[18]	Cockcroft, D.W. and Gault, M.H. (1976) Prediction of creatinine clearance from serum creatinine. Nephron, 16, 31-41. http://dx.doi.org/10.1159/000180580
[19]	Ost, M.C., Tan, B.J. and Lee, B.R. (2005) Urological laparoscopy: Basic physiological considerations and immunological consequences. Journal of Urology, 174, 1183-1188. http://dx.doi.org/10.1097/01.ju.0000173102.16381.08
[20]	Miki, Y., Iwase, K., Kamiike, E., Taniguchi, E., Sakaguchi, K., Sumimura, J., Matsuda, H. and Nagai, I. (1997) Laparoscopic cholecystectomy and time-course changes in renal function. Surgical Endoscopy, 11, 838-841. http://dx.doi.org/10.1007/s004649900466
[21]	Yuksel, H., Darcan, S., Kabasakal, C., Cura, A., Mir, S. and Mavi, E. (1998) Effect of enalapril on proteinuria, phosphaturia, and calciuria in insulin-dependent diabetes. Pediatric Nephrology, 12, 648-650. http://dx.doi.org/10.1007/s004670050520
[22]	Lee, A., Cooper, M.G., Craig, J.C., Knight, J.F. and Keneally, J.P. (2007) Effects of nonsteroidal anti-inflammatory drugs on postoperative renal function in adults with normal renal function. Cochrane Database of Systematic Reviews, 2, CD002765.
[23]	Kellen, M., Aronson, S., Roizen, M.F., Barnard, J. and Thisted, R.A. (1994) Predictive and diagnostic tests of renal failure: A review. Anesthesia & Analgesia, 78, 134-142. http://dx.doi.org/10.1213/00000539-199401000-00022
[24]	Westhuyzen, J., Endre, Z.H., Reece, G., Reith, D.M., Saltissi, D. and Morgan, T.J. (2003) Measurement of tubular enzimuria facilitates early detection of acute renal impairment in the intensive care unit. Nephrology Dialysis Transplantation, 18, 543-551. http://dx.doi.org/10.1093/ndt/18.3.543
[25]	Goldsmith, S.R. (1988) Baroreceptor-mediated suppression of osmotically stimulated vasopressin in normal humans. Journal of Applied Physics, 65, 1226-1230.
[26]	Julier, K., Silva, R., Garcia, C., Bestmann, L., Frascarolo, P., Zollinger, A., Chassot, P.-G., Schmid, E.R., Turina, M.I., von Segesser, L.K., Pasch, T., Spahn, D.R. and Zaugg, M. (2003) 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, 98, 1315-1327. http://dx.doi.org/10.1097/00000542-200306000-00004
[27]	Youssef, M.A. and saleh Al-Mulhim, A. (2007) Effects of different anesthetic techniques on antidiuretic hormone secretion during laparoscopic cholecystectomy. Surgical Endoscopy, 21, 1543-1548. http://dx.doi.org/10.1007/s00464-006-9166-8
[28]	Meyer, P., Pernet, P., Hejblum, G., Baudel, J.L., Maury, E., Offenstadt, G. and Guidet, B. (2008) Haemodilution induced by hydroxyethyl starches 130/0.4 is similar in septic and non-septic patients. Acta Anaesthesiologica Scandinavica, 52, 229-235. http://dx.doi.org/10.1111/j.1399-6576.2007.01521.x
[29]	Herget-Rosenthal, S., Feldkamp, T., Volbracht, L. and Kribben, A. (2004) Measurement of urinary cystatin C by particle-enhanced nephelometric immunoassay: Precision, interferences, stability, and reference range. Annals of Clinical Biochemistry, 41, 111-118. http://dx.doi.org/10.1258/000456304322879980
[30]	Dharnidharka, V.R., Kwon, C. and Stevens, G. (2002) Serum cystatin C is superior to serum creatinine as a marker of kidney function: A meta-analysis. American Journal of Kidney Diseases, 40, 221-226. http://dx.doi.org/10.1053/ajkd.2002.34487
[31]	Roos, J.F., Doust, J., Tett, S.E. and Kirkpatrick, C.M. (2007) Diagnostic accuracy of cystatin C compared to serum creatinine for the estimation of renal dysfunction in adults and children—A meta-analysis. Clinical Biochemistry, 40, 383-391. http://dx.doi.org/10.1016/j.clinbiochem.2006.10.026
[32]	Randers, E. and Erlandsen, E.J. (1999) Serum cystatin C as an endogenous marker of the renal function—A review. Clinical Chemistry and Laboratory Medicine, 37, 389-395. http://dx.doi.org/10.1515/CCLM.1999.064
[33]	Coll, E., Botey, A., Alvarez, L., Poch, E., Quinto, L., Saurina, A., Vera, M., Piera, C. and Darnell, A. (2000) Serum cystatin C as a new marker for noninvasive estimation of glomerular filtration rate and as a marker for early renal impairment. American Journal of Kidney Diseases, 36, 29-34. http://dx.doi.org/10.1053/ajkd.2000.8237
[34]	Da Silva Melo, D.A., Saciura, V.C., Poloni, J.A., Oliveira, C.S., Filho, J.C., Padilha, R.Z., Reichel, C.L., Neto, E.J., Oliveira, R.M., D’avila, L.C., Kessler, A. and de Oliveira, J.R. (2006) Evaluation of renal enzymuria and cellular excretion as an marker of acute nephrotoxicity due to an overdose of paracetamol in Wistar rats. Clinica Chimica Acta, 373, 88-91. http://dx.doi.org/10.1016/j.cca.2006.05.006
[35]	Stevens, L.A., Coresh, J., Greene, T. and Levey, A.S. (2006) Medical progress: Assessing kidney function— Measured and estimated glomerular filtration rate. New England Journal of Medicine, 354, 2473-2483. http://dx.doi.org/10.1056/NEJMra054415
[36]	Ren, Y., Garvin, J.L., Liu, R. and Carretero, O.A. (2009) Cross-talk between arterioles and tubules in the kidney. Pediatric Nephrology, 24, 31-35. http://dx.doi.org/10.1007/s00467-008-0852-8
[37]	Hong, J.Y. (2005) The effect of preoperative ketorolac on WBC response and pain in laparoscopic surgery for endometriosis. Yonsei Medical Journal, 46, 812-817. http://dx.doi.org/10.3349/ymj.2005.46.6.812
[38]	El-Tahan, M.R., Warda, O.M., Yasseen, A.M., Attallah, M.M. and Matter, M.K. (2007) A randomized study of the effects of preoperative ketorolac on general anaesthesia for caesarean section. International Journal of Obstetric Anesthesia, 16, 214-220. http://dx.doi.org/10.1016/j.ijoa.2007.01.012
[39]	Lobetti, R.G. and Joubert, K.E. (2000) Effect of administration of nonsteroidal anti-inflammatory drugs before surgery on renal function in clinically normal dogs. American Journal of Veterinary Research, 61, 1501-1507. http://dx.doi.org/10.2460/ajvr.2000.61.1501
[40]	Carvalho, B., Lemmens, H.J., Ting, V. and Angst, M.S. (2013) Postoperative subcutaneous instillation of low-dose ketorolac but not hydromorphone reduces wound exudate concentrations of interleukin-6 and interleukin-10 and improves analgesia following cesarean delivery. Journal of Pain, 14, 48-56. http://dx.doi.org/10.1016/j.jpain.2012.10.002