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Liao YC, Chang CC, Chen CY, Liu CC, Liao CC, Shih YRV, Lin CS. Preoperative renal insufficiency predicts postoperative adverse outcomes in a mixed surgical population: a retrospective matched cohort study using the NSQIP database. Int J Surg 2023; 109:752-759. [PMID: 36974714 PMCID: PMC10389524 DOI: 10.1097/js9.0000000000000278] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 01/27/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND The incidence of chronic kidney disease is increasing, but most cases are not diagnosed until the accidental finding of abnormal laboratory data or the presentation of severe symptoms. Patients with chronic kidney disease are reported to have an increased risk of postoperative mortality and morbidities, but previous studies mainly targeted populations undergoing cardiovascular surgery. The authors aimed to evaluate the risk of postoperative mortality and complications in a surgical population with preoperative renal insufficiency (RI). MATERIALS AND METHODS This retrospective cohort study used data from the National Surgical Quality Improvement Program database between 2013 and 2018 to evaluate the risk of postoperative morbidity and mortality in the surgical population. Patients with estimated glomerular filtration rate less than 60 ml/min/1.73 m 2 were defined as the RI group. Propensity score matching methods and multivariate logistic regression were used to calculate the risk of postoperative morbidity and mortality. RESULTS After propensity score matching, 502 281 patients were included in the RI and non-RI groups. The RI group had a higher risk of 30-day in-hospital mortality (odds ratio: 1.54, 95% CI: 1.49-1.58) than the non-RI group. The RI group was associated with a higher risk of postoperative complications, including myocardial infarction, stroke, pneumonia, septic shock, and postoperative bleeding. The RI group was also associated with an increased risk of prolonged ventilator use for over 48 h, readmission, and reoperation. CONCLUSION Patients with preoperative RI have an increased risk of postoperative 30-day mortality and complications. RI group patients with current dialysis, estimated glomerular filtration rate less than or equal to 30 ml/min/1.73 m 2 or concomitant anemia had an elevated risk of postoperative mortality.
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Affiliation(s)
| | - Chuen-Chau Chang
- Department of Anesthesiology
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chien-Yu Chen
- Department of Anesthesiology
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chih-Chung Liu
- Department of Anesthesiology
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chien-Chang Liao
- Department of Anesthesiology
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Ru Vernon Shih
- Department of Orthopedic Surgery, Duke University, Durham, North Carolina, USA
| | - Chao-Shun Lin
- Department of Anesthesiology
- Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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2
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Incidence and Associations of Acute Kidney Injury after General Thoracic Surgery: A System Review and Meta-Analysis. J Clin Med 2022; 12:jcm12010037. [PMID: 36614838 PMCID: PMC9821434 DOI: 10.3390/jcm12010037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/11/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
(1) Background: Acute kidney injury (AKI) is related to adverse outcomes in critical illness and cardiovascular surgery. In this study, a systematic literature review and meta-analysis was carried out to evaluate the incidence and associations of AKI as a postoperative complication of thoracic (including lung resection and esophageal) surgical procedures. (2) Methods: Adopting a systematic strategy, the electronic reference databases (PubMed, EMBASE, and Cochrane Library) were searched for articles researching postoperative renal outcomes that were diagnosed using RIFLE, AKIN or KDIGO consensus criteria in the context of a thoracic operation. A random-effects model was applied to estimate the incidence of AKI and, where reported, the pooled relative risk of mortality and non-renal complications after AKI. The meta-analysis is registered in PROSPERO under the number CRD42021274166. (3) Results: In total, 20 studies with information gathered from 34,826 patients after thoracic surgery were covered. Comprehensively, the incidence of AKI was estimated to be 8.8% (95% CI: 6.7−10.8%). A significant difference was found in the mortality of patients with and without AKI (RR = 2.93, 95% CI: 1.79−4.79, p < 0.001). Additionally, in patients experiencing AKI, cardiovascular and respiratory complications were more common (p = 0.01 and p < 0.001, respectively). (4) Conclusions: AKI is a common complication associated with adverse outcomes following general thoracic surgery. An important issue in perioperative care, AKI should be considered as a highly significant prognostic indicator and an attractive target for potential therapeutic interventions, especially in high-risk populations.
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Piastra M, Tempera A, De Carolis MP, Pezza L, Genovese O, Benassi C, Morena TC, Picconi E, Zito G, De Rosa G, Conti G, De Luca D. Neonatal Life-Threatening Nonoliguric Hyperkalemia Under Therapeutic Hypothermia. Ther Hypothermia Temp Manag 2021; 11:238-241. [PMID: 34619071 DOI: 10.1089/ther.2021.0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
To illustrate our experience with two cases of neonatal life-threatening hyperkalemia during therapeutic hypothermia (TH) despite a normal acid-base status, urine output, and preserved renal function. Clinical cases are presented from Pediatric Intensive Care Unit (PICU) admission to the onset of the hyperkalemia, with related complications and after resolution. Similar cases were not retrieved from a critical review of pertinent literature. Severe hyperkalemia pathophysiology and risk factors have been debated. Two full-term adequate for weight female neonates were admitted to PICU because of perinatal asphyxia who underwent TH. Prenatal history was completely uneventful, nor hereditary genetic conditions were reported; moreover, long-term follow-up ruled out any metabolic or renal disease. Despite an accurate evaluation of previous clinical series and literature on TH and perinatal asphyxia, these hyperkalemic episodes remain unexplained. The hypoxic-ischemic insult may affect multiple organs, mainly central nervous system, heart, lung, and kidneys; acute muscle breakdown and consequent rising of myoglobin may also have a precipitating role in acute kidney failure (AKF) and hyperkalemia. Electrolyte imbalance is a possible finding as a consequence of combined cell injury and AKF. In contrast, an isolated severe hyperkalemia is exceedingly rare in nonoliguric neonates.
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Affiliation(s)
- Marco Piastra
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Institute of Anesthesia and Intensive Care, Catholic University of the Sacred Heart of Rome, Rome, Italy
| | - Alessia Tempera
- Neonatal Intensive Care Unit, Maternal-Fetal Department, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Maria Pia De Carolis
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lucilla Pezza
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Orazio Genovese
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Cristina Benassi
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tony C Morena
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Enzo Picconi
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Gabriella De Rosa
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giorgio Conti
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Institute of Anesthesia and Intensive Care, Catholic University of the Sacred Heart of Rome, Rome, Italy
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, Centre Antoine Beclere, Paris-Saclay University Hospitals APHP, Paris, Ile-de France, France.,Physiopathology and Therapeutic Innovation Unit INSERUM U999 Paris, Université Paris-Saclay APHP, Ile-de France, France
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4
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Gumbert SD, Kork F, Jackson ML, Vanga N, Ghebremichael SJ, Wang CY, Eltzschig HK. Perioperative Acute Kidney Injury. Anesthesiology 2020; 132:180-204. [PMID: 31687986 PMCID: PMC10924686 DOI: 10.1097/aln.0000000000002968] [Citation(s) in RCA: 145] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Perioperative organ injury is among the leading causes of morbidity and mortality of surgical patients. Among different types of perioperative organ injury, acute kidney injury occurs particularly frequently and has an exceptionally detrimental effect on surgical outcomes. Currently, acute kidney injury is most commonly diagnosed by assessing increases in serum creatinine concentration or decreased urine output. Recently, novel biomarkers have become a focus of translational research for improving timely detection and prognosis for acute kidney injury. However, specificity and timing of biomarker release continue to present challenges to their integration into existing diagnostic regimens. Despite many clinical trials using various pharmacologic or nonpharmacologic interventions, reliable means to prevent or reverse acute kidney injury are still lacking. Nevertheless, several recent randomized multicenter trials provide new insights into renal replacement strategies, composition of intravenous fluid replacement, goal-directed fluid therapy, or remote ischemic preconditioning in their impact on perioperative acute kidney injury. This review provides an update on the latest progress toward the understanding of disease mechanism, diagnosis, and managing perioperative acute kidney injury, as well as highlights areas of ongoing research efforts for preventing and treating acute kidney injury in surgical patients.
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Affiliation(s)
- Sam D. Gumbert
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Felix Kork
- Department of Anaesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Maisie L. Jackson
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Naveen Vanga
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Semhar J. Ghebremichael
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Christy Y. Wang
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Holger K. Eltzschig
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030
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5
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Vongsumran N, Buranapin S, Manosroi W. Standardized Glycemic Management versus Conventional Glycemic Management and Postoperative Outcomes in Type 2 Diabetes Patients Undergoing Elective Surgery. Diabetes Metab Syndr Obes 2020; 13:2593-2601. [PMID: 32801810 PMCID: PMC7383109 DOI: 10.2147/dmso.s262444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/02/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Optimized postoperative blood glucose control can minimize postoperative complications. Conventional perioperative glycemic control protocol (CG), which has been routinely used in our institution, lacks detailed perioperative glycemic management. A new standardized glycemic control protocol (SG) was designed which employs frequent postoperative monitoring of blood glucose, more tightly targeted blood glucose control, and adjustment of insulin dosage prior to surgery. This study compared the efficacy of postoperative glycemic control and complications with the two protocols, CG and SG. PATIENTS AND METHODS Three hundred and eighty type 2 diabetes patients who underwent elective surgeries were included in the study. Of those, 182 patients with CG were identified retrospectively as a historical control cohort. Additional 198 patients with SG were prospectively enrolled. Covariate imbalance was controlled using propensity score matching. Outcomes were evaluated using regression analysis clustered by type of surgery. RESULTS The SG group had lower mean levels of postoperative 24-hr blood glucose than the CG group (β =-8.6 mg/dL; 95% CI (-16.5 to -7.9), p=0.042). In SG group, the incidence of ICU admission and of acute kidney injury after surgery was lower than in the CG group (OR 0.36; 95% CI (0.18-0.74), p=0.005 and OR=0.59; 95% CI (0.41-0.85), p=0.005, respectively). There was no significant difference in postoperative hypoglycemia, infection, cardiovascular complications, stroke, or mortality rate between the two groups. CONCLUSION For type 2 diabetes patients undergoing elective surgery, the SG protocol is more effective in controlling blood glucose. The protocol can also reduce the incidence of some postoperative complications compared to CG with no increased risk of hypoglycemia.
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Affiliation(s)
- Nuttawut Vongsumran
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai50200, Thailand
| | - Supawan Buranapin
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai50200, Thailand
| | - Worapaka Manosroi
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai50200, Thailand
- Correspondence: Worapaka Manosroi Tel +66 53 936453 Email
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Impact on Outcomes across KDIGO-2012 AKI Criteria According to Baseline Renal Function. J Clin Med 2019; 8:jcm8091323. [PMID: 31466281 PMCID: PMC6780552 DOI: 10.3390/jcm8091323] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/19/2019] [Accepted: 08/23/2019] [Indexed: 12/17/2022] Open
Abstract
Acute kidney injury (AKI) and Chronic Kidney Disease (CKD) are global health problems. The pathophysiology of acute-on-chronic kidney disease (AoCKD) is not well understood. We aimed to study clinical outcomes in patients with previous normal (pure acute kidney injury; P-AKI) or impaired kidney function (AoCKD) across the 2012 Kidney Disease Improving Global Outcomes (KDIGO) AKI classification. We performed a retrospective study of patients with AKI, divided into P-AKI and AoCKD groups, evaluating clinical and epidemiological features, distribution across KDIGO-2012 criteria, in-hospital mortality and need for dialysis. One thousand, two hundred and sixty-nine subjects were included. AoCKD individuals were older and had higher comorbidity. P-AKI individuals fulfilled more often the serum creatinine (SCr) ≥ 3.0× criterion in AKI-Stage3, AoCKD subjects reached SCr ≥ 4.0 mg/dL criterion more frequently. AKI severity was associated with in-hospital mortality independently of baseline renal function. AoCKD subjects presented higher mortality when fulfilling AKI-Stage1 criteria or SCr ≥ 3.0× criterion within AKI-Stage3. The relationship between mortality and associated risk factors, such as the net increase of SCr or AoCKD status, fluctuated depending on AKI stage and stage criteria sub-strata. AoCKD patients that fulfil SCr increment rate criteria may be exposed to more severe insults, possibly explaining the higher mortality. AoCKD may constitute a unique clinical syndrome. Adequate staging criteria may help prompt diagnosis and administration of appropriate therapy.
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7
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Ortega-Loubon C, Fernández-Molina M, Pañeda-Delgado L, Jorge-Monjas P, Carrascal Y. Predictors of Postoperative Acute Kidney Injury after Coronary Artery Bypass Graft Surgery. Braz J Cardiovasc Surg 2019; 33:323-329. [PMID: 30184028 PMCID: PMC6122763 DOI: 10.21470/1678-9741-2017-0251] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 04/26/2018] [Indexed: 11/15/2022] Open
Abstract
Objective The aims of this study were to identify the risk factors associated with
acute kidney injury (AKI) after isolated surgical revascularization with
cardiopulmonary bypass and to develop a model to predict the appearance of
postoperative AKI. Methods A total of 435 adult patients who underwent primary isolated coronary artery
bypass graft (CABG) surgery, from 2012 to 2016, in the Clinic University
Hospital of Valladolid (Spain) were enrolled. AKI was defined according to
the risk, injury, failure, loss, and end-stage (RIFLE) criteria. Data were
collected from hospital electronic medical records. Multiple logistic
regression analysis was used to identify risk factors. Results The prevalence of AKI was 12.4%. Multivariate analysis identified age (odds
ratio [OR], 1.056; 95% confidence interval [CI],
1.016-1.098; P=0.005), hypertension (OR, 3.078; 95% CI,
1.151-8.230; P=0.018), low ejection fraction (EF) (OR,
6.785; 95% CI, 2.080-22.135; P=0.001), estimated glomerular
filtration rate (eGFR) (OR, 1.017; 95% CI, 1.005-1.028;
P=0.014), EuroSCORE II (OR, 1.049; 95% CI, 1.004-1.096;
P=0.033), and no intake of calcium-channel blockers
(CCB) (OR, 4.892; 95% CI, 1.496-16.025; P=0.022) as risk
factors for AKI. These risk factors were included in a model to predict
postoperative AKI with an area under a receiver operating characteristic
curve of 0.783±0.036 (95% CI, 0.713-0.854;
P<0.0001). Conclusion Age, hypertension, low EF, eGFR, EuroSCORE II, and no intake of CCB were
independent risk factors for postoperative AKI. These factors provide an
easy and accurate model to predict postoperative AKI in patients undergoing
cardiac surgery.
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Affiliation(s)
| | | | - Lucía Pañeda-Delgado
- Department of Cardiac Surgery, Clinic University Hospital of Valladolid, Valladolid, Spain
| | - Pablo Jorge-Monjas
- Department of Anesthesia, Clinic University Hospital of Valladolid, Valladolid, Spain
| | - Yolanda Carrascal
- Department of Cardiac Surgery, Clinic University Hospital of Valladolid, Valladolid, Spain
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8
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Protective effect of hydroxysafflor yellow A against acute kidney injury via the TLR4/NF-κB signaling pathway. Sci Rep 2018; 8:9173. [PMID: 29907783 PMCID: PMC6003992 DOI: 10.1038/s41598-018-27217-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 05/24/2018] [Indexed: 12/20/2022] Open
Abstract
This study aimed to evaluate the protective effect of hydroxysafflor yellow A (HSYA) on ischemia/reperfusion (I/R)-induced acute kidney injury via the TLR4/NF-κB pathway, both in vitro and in vivo. Rats were subjected to removal of the right kidney and I/R injury to the left kidney. Rats subjected to renal I/R injury were treated with HSYA at 0.5 h prior to I/R injury. Renal function, histopathological analysis, and cells apoptosis were measured in vivo. In vitro, proximal renal tubular cells (HK-2) were subjected to hypoxia/reoxygenation (H/R). Apoptotic cell death and inflammatory cytokines, Toll-like receptor 4 (TLR4), and nuclear factor (NF)-κB expression were determined. Treatment of I/R rats with HSYA markedly reduced the levels of serum creatinine and blood urea nitrogen, attenuated renal cell apoptosis, alleviated changes in renal tissue morphology, and reduced IL-1β, TNF-α, and caspase-3 release. In vitro, HSYA effectively decreased NF-κB p65 and inflammatory cytokines, such as IL-1β, TNF-α, and IL-6. Thus, HSYA can protect renal function from I/R injury by ameliorating acute kidney injury and partly by promoting tubular cell survival via the TLR4/NF-κB pathway. These results suggest that HSYA can be used to prevent I/R-induced acute kidney injury.
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Strauch J, Wendt D, Diegeler A, Heimeshoff M, Hofmann S, Holzhey D, Oertel F, Wahlers T, Kurucova J, Thoenes M, Deutsch C, Bramlage P, Schröfel H. Balloon-expandable transapical transcatheter aortic valve implantation with or without predilation of the aortic valve: results of a multicentre registry†. Eur J Cardiothorac Surg 2017; 53:771-777. [DOI: 10.1093/ejcts/ezx397] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 10/22/2017] [Indexed: 11/15/2022] Open
Affiliation(s)
- Justus Strauch
- Clinic for Cardiosurgery and Thoracic Surgery, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Germany
| | - Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center, Essen, Germany
| | - Anno Diegeler
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | | | - Steffen Hofmann
- Schuechtermann-Klinik, Cardiac Centre Osnabrück-Bad Rothenfelde, Rothenfelde, Germany
| | - David Holzhey
- Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | | | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Cologne, Germany
| | | | | | - Cornelia Deutsch
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Holger Schröfel
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany
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10
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Ortega-Loubon C, Fernández-Molina M, Carrascal-Hinojal Y, Fulquet-Carreras E. Cardiac surgery-associated acute kidney injury. Ann Card Anaesth 2017; 19:687-698. [PMID: 27716701 PMCID: PMC5070330 DOI: 10.4103/0971-9784.191578] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Cardiac surgery-associated acute kidney injury (CSA-AKI) is a well-recognized complication resulting with the higher morbid-mortality after cardiac surgery. In its most severe form, it increases the odds ratio of operative mortality 3-8-fold, length of stay in the Intensive Care Unit and hospital, and costs of care. Early diagnosis is critical for an optimal treatment of this complication. Just as the identification and correction of preoperative risk factors, the use of prophylactic measures during and after surgery to optimize renal function is essential to improve postoperative morbidity and mortality of these patients. Cardiopulmonary bypass produces an increased in tubular damage markers. Their measurement may be the most sensitive means of early detection of AKI because serum creatinine changes occur 48 h to 7 days after the original insult. Tissue inhibitor of metalloproteinase-2 and insulin-like growth factor-binding protein 7 are most promising as an early diagnostic tool. However, the ideal noninvasive, specific, sensitive, reproducible biomarker for the detection of AKI within 24 h is still not found. This article provides a review of the different perspectives of the CSA-AKI, including pathogenesis, risk factors, diagnosis, biomarkers, classification, postoperative management, and treatment. We searched the electronic databases, MEDLINE, PubMed, EMBASE using search terms relevant including pathogenesis, risk factors, diagnosis, biomarkers, classification, postoperative management, and treatment, in order to provide an exhaustive review of the different perspectives of the CSA-AKI.
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Thongprayoon C, Cheungpasitporn W, Srivali N, Kittanamongkolchai W, Greason KL, Kashani KB. Incidence and risk factors of acute kidney injury following transcatheter aortic valve replacement. Nephrology (Carlton) 2017; 21:1041-1046. [PMID: 26714182 DOI: 10.1111/nep.12704] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 12/20/2015] [Indexed: 12/24/2022]
Abstract
AIM This study aimed to determine the incidence and risk factors of acute kidney injury (AKI) following transcatheter aortic valve replacement (TAVR). METHODS We included all adult patients undergoing TAVR for aortic stenosis from 1 January 2008 to 30 June 2014 at a tertiary referral hospital. AKI was defined based on Kidney Disease: Improving Global Outcomes criteria. We performed a multivariate logistic regression to identify factors associated with post-procedural AKI occurrence. RESULTS Three hundred eighty-six patients met the inclusion criteria, of which 106 (28%) developed AKI. In multivariate analysis, AKI development was independently associated with a transapical approach (odds ratio (OR), 2.81; 95% confidence interval (CI), 1.72-4.65 compared with transfemoral approach) and the need for an intra-aortic balloon pump (OR, 9.11; 95% CI, 1.77-68.29). Higher baseline renal function (OR, 0.78 per 10 mL/min per 1.73 m2 increment in glomerular filtration rate; 95% CI, 0.68-0.87) was significantly associated with a decreased risk of AKI. After adjustment for the Society of Thoracic Surgeons' risk score, post-procedural AKI development remained significantly associated with an increased in-hospital (OR, 4.74; 95% CI, 1.39-18.48) and 6-month mortality (OR, 4.66; 95% CI, 2.32-9.63). CONCLUSION In a cohort of patients undergoing TAVR for aortic stenosis, AKI commonly occurred and was significantly associated with increased mortality. Baseline renal function, procedure approach and the need for circulatory support were important predictive factors for post-procedural AKI occurrence.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Narat Srivali
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Kevin L Greason
- Division of Cardiovascular Surgery, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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12
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Skarupskienė I, Adukauskienė D, Kuzminskienė J, Rimkutė L, Balčiuvienė V, Žiginskienė E, Kuzminskis V, Adukauskaitė A, Pentiokinienė D, Bumblytė IA. Mortality prediction in patients with acute kidney injury requiring renal replacement therapy after cardiac surgery. Medicina (B Aires) 2017; 53:217-223. [DOI: 10.1016/j.medici.2017.06.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 06/16/2017] [Accepted: 06/26/2017] [Indexed: 01/12/2023] Open
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13
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Kim JW, Sim HT, Yoo JS, Kim DJ, Cho KR. Results of Protocol-based Perioperative Management in Off-Pump Coronary Artery Bypass Grafting for Patients with Non-dialysis-dependent Chronic Kidney Disease. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 49:427-434. [PMID: 27965919 PMCID: PMC5147467 DOI: 10.5090/kjtcs.2016.49.6.427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/21/2016] [Accepted: 03/02/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent studies have demonstrated the benefits of off-pump coronary bypass grafting over the on-pump technique in patients with chronic kidney disease (CKD). To further reduce the risk of acute kidney injury and the need for renal replacement therapy, even in patients undergoing off-pump coronary artery bypass grafting, we adopted protocol-based perioperative management for patients with CKD. METHODS From December 2012 to March 2015, 265 patients underwent isolated off-pump coronary artery bypass grafting. To analyze renal function in a stable condition, we excluded 12 dialysis-dependent end stage renal failure and 10 emergency or urgent cases. Among the remaining 243 patients, 208 patients had normal kidney function (normal group), and 35 patients had CKD (CKD group). Minimizing contrast exposure, ensuring adequate hydration, using strict drug dosage adjustment, and optimizing hemodynamic status were key elements of the protocol for the CKD group. RESULTS The risk of acute kidney injury was about ×3 higher in the CKD group than in the normal group (p=0.01). Estimated glomerular filtration rates and serum creatinine levels deteriorated until the third postoperative day in the CKD group. However, by adopting protocol-based perioperative management, this transient renal dysfunction recovered to preoperative levels by the fifth postoperative day without requiring renal replacement therapy in all cases. CONCLUSION Off-pump coronary bypass surgery combined with this protocol-based perioperative management strategy in patients with non-dialysis-dependent CKD could mostly be performed without renal replacement therapy.
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Affiliation(s)
- Jeong-Won Kim
- Department of Thoracic and Cardiovascular Surgery, Sejong Heart Institute, Sejong General Hospital
| | - Hyung Tae Sim
- Department of Thoracic and Cardiovascular Surgery, Sejong Heart Institute, Sejong General Hospital
| | - Jae Suk Yoo
- Department of Thoracic and Cardiovascular Surgery, Sejong Heart Institute, Sejong General Hospital
| | - Dong Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Sejong Heart Institute, Sejong General Hospital
| | - Kwang Ree Cho
- Department of Thoracic and Cardiovascular Surgery, Sejong Heart Institute, Sejong General Hospital
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Kališnik JM, Hrovat E, Hrastovec A, Žibert J, Jerin A, Skitek M, Santarpino G, Klokocovnik T. Creatinine, Neutrophil Gelatinase-Associated Lipocalin, and Cystatin C in Determining Acute Kidney Injury After Heart Operations Using Cardiopulmonary Bypass. Artif Organs 2016; 41:481-489. [PMID: 27862029 DOI: 10.1111/aor.12779] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 04/05/2016] [Accepted: 05/11/2016] [Indexed: 12/21/2022]
Abstract
Acute kidney injury (AKI) represents frequent complication after cardiac surgery using cardiopulmonary bypass (CPB). In the hope to enhance earlier more reliable characterization of AKI, we tested the utility of neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C (CysC) in addition to standard creatinine for early determination of AKI after cardiac surgery using CPB. Forty-one patients met the inclusion criteria. Arterial blood samples collected after induction of general anesthesia were used as baseline, further sampling occurred at CPB termination, 2 h after CPB, on the first and second day after surgery. According to AKIN classification 18 patients (44%) developed AKI (AKI1-2 groups) and 23 (56%) did not (non-AKI group). Groups were similar regarding demographics and operative characteristics. CysC levels differed already preoperatively (non-AKI vs. AKI2; P = 0.045; AKI1 vs. AKI2; P = 0.011), while postoperatively AKI2 group differed on the first day and AKI1 on the second regarding non-AKI group (P = 0.004; P = 0.021, respectively). NGAL and creatinine showed significant difference already 2 h after CPB between groups AKI2 and non-AKI and later on the first postoperative day between groups AKI1 and AKI2 (P = 0.028; P = 0.014, respectively). This study shows similar performance of early plasma creatinine and NGAL in patients with preserved preoperative renal function. It demonstrates that creatinine, as well as NGAL, differentiate subsets of patients developing AKI of clinically more advanced grade early after 2 h, also when used single and uncombined.
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Affiliation(s)
- Jurij Matija Kališnik
- Department of Cardiovascular Surgery, University Medical Center, Ljubljana, Slovenia.,Department of Cardiac Surgery, Paracelsus Medical University Nuremberg, Germany
| | - Eva Hrovat
- Department of Cardiovascular Surgery, University Medical Center, Ljubljana, Slovenia
| | - Alenka Hrastovec
- Department of Anesthesiology, University Medical Center, Ljubljana
| | - Janez Žibert
- Faculty of Health Sciences, University of Ljubljana, Ljubljana
| | - Aleš Jerin
- Department of Clinical Chemistry and Biochemistry, University Medical Centre, Ljubljana, Slovenia
| | - Milan Skitek
- Department of Clinical Chemistry and Biochemistry, University Medical Centre, Ljubljana, Slovenia
| | - Giuseppe Santarpino
- Department of Cardiac Surgery, Paracelsus Medical University Nuremberg, Germany
| | - Tomislav Klokocovnik
- Department of Cardiovascular Surgery, University Medical Center, Ljubljana, Slovenia
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Bang JY, Lee J, Oh J, Song JG, Hwang GS. The Influence of Propofol and Sevoflurane on Acute Kidney Injury After Colorectal Surgery. Anesth Analg 2016; 123:363-70. [DOI: 10.1213/ane.0000000000001274] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Jia Y, Zhao J, Liu M, Li B, Song Y, Li Y, Wen A, Shi L. Brazilin exerts protective effects against renal ischemia-reperfusion injury by inhibiting the NF-κB signaling pathway. Int J Mol Med 2016; 38:210-6. [PMID: 27247107 PMCID: PMC4899020 DOI: 10.3892/ijmm.2016.2616] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 05/19/2016] [Indexed: 01/28/2023] Open
Abstract
Renal ischemia-reperfusion (I/R) injury is associated with high morbidity and mortality as there is currently no available effective therapeutic strategy with which to treat this injury. Thus, the aim of this study was to investigate the potential protective effects of brazilin, a major active component of the Chinese medicine Caesalpinia sappan L., against renal I/R injury in vitro and in vivo. Rats were subjected to removal of the right kidney and I/R injury to the left kidney (ischemia for 45 min followed by reperfusion for 24 h). Treatment with brazilin (30 mg/kg, administered intravenously at 30 min prior to ischemia) led to the reversal of I/R-induced changes in serum creatinine (Scr) and blood urea nitrogen (BUN) levels, and also attenuated the histopathological damage induced by I/R. Furthermore, TUNEL assay revealed that brazilin reduced cell necrosis, and significantly decreased the expression of tumor necrosis factor (TNF)-α and interleukin (IL)-1β in renal tissue. Moreover, HK-2 cells were used in order to elucidate the mechanisms responsible for the protective effects of brazilin. The levels of phosphorylated IκBα and the nuclear translocation of nuclear factor-κB (NF-κB) were all evidently decreased by brazilin. These findings suggested that pre-treatment with brazilin protects against I/R-induced renal damage and suppresses the inflammatory response by inhibiting the activation of the NF-κB signaling pathway.
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Affiliation(s)
- Yanyan Jia
- Department of Pharmacy, General Hospital of Guangzhou Military Command of PLA, Guangzhou, Guangdong 510010, P.R. China
| | - Jinyi Zhao
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Meiyou Liu
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Bingling Li
- Department of Pharmacy, General Hospital of Guangzhou Military Command of PLA, Guangzhou, Guangdong 510010, P.R. China
| | - Ying Song
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Yuwen Li
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Aidong Wen
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Lei Shi
- Department of Pharmacy, General Hospital of Guangzhou Military Command of PLA, Guangzhou, Guangdong 510010, P.R. China
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Saito S, Uchino S, Takinami M, Uezono S, Bellomo R. Postoperative blood pressure deficit and acute kidney injury progression in vasopressor-dependent cardiovascular surgery patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:74. [PMID: 27013056 PMCID: PMC4806486 DOI: 10.1186/s13054-016-1253-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 02/23/2016] [Indexed: 12/29/2022]
Abstract
Background In vasopressor-dependent patients who had undergone cardiovascular surgery, we examined whether those with progression of acute kidney injury (AKI) had a greater difference (deficit) between premorbid and within-ICU hemodynamic pressure-related parameters compared to those without AKI progression. Methods We assessed consecutive adults who underwent cardiovascular surgery and who stayed in our ICU for at least 48 hours and received vasopressor support for more than 4 hours. We obtained premorbid and vasopressor-associated, time-weighted average values for hemodynamic pressure-related parameters (systolic [SAP], diastolic [DAP], and mean arterial pressure [MAP]; central venous pressure [CVP], mean perfusion pressure [MPP], and diastolic perfusion pressure [DPP]) and calculated deficits in those values. We defined AKI progression as an increase of at least one Kidney Disease: Improving Global Outcomes stage. Results We screened 159 patients who satisfied the inclusion criteria and identified 76 eligible patients. Thirty-six patients (47 %) had AKI progression. All achieved pressure-related values were similar between patients with or without AKI progression. However, deficits in DAP (P = 0.027), MPP (P = 0.023), and DPP (P = 0.002) were significantly greater in patients with AKI progression. Conclusions Patients with AKI progression had greater DAP, MPP, and DPP deficits compared to patients without AKI progression. Such deficits might be modifiable risk factors for the prevention of AKI progression.
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Affiliation(s)
- Shinjiro Saito
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8471, Japan.
| | - Shigehiko Uchino
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Masanori Takinami
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Shoichi Uezono
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8471, Japan
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Road, Melbourne, VIC, 3084, Australia
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Efficacy and safety of perioperative sodium bicarbonate therapy for cardiac surgery-associated acute kidney injury: a meta-analysis. J Cardiovasc Pharmacol 2016; 65:130-6. [PMID: 25264756 DOI: 10.1097/fjc.0000000000000169] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Urinary alkalinization with sodium bicarbonate infusion can theoretically protect against the mechanisms of acute kidney injury (AKI). Controversy exists regarding whether sodium bicarbonate infusion can reduce the incidence of AKI from cardiac surgery. A meta-analysis was conducted to show the efficacy and safety of perioperative sodium bicarbonate use for preventing AKI in patients undergoing cardiac surgery. DATA SOURCES PubMed, CBM, EMBASE, CENTRAL, and Cochrane renal group specialized register were searched for pertinent studies. STUDY SELECTION Randomized controlled trails and prospective observational cohort studies that compared sodium bicarbonate with sodium chloride or blank control in cardiac surgery with cardiopulmonary bypass were included. Exclusion criteria were duplicate publications, nonadult studies, oral administration of sodium bicarbonate, retrospective analyses, and studies with small sample size (n < 50) or with no data on AKI. DATA EXTRACTION Study end points, study design, population, operation information, and sodium bicarbonate doses were extracted. DATA SYNTHESIS Data from 1673 patients in 5 randomized trials and 1 prospective observational cohort study were analyzed. The analysis showed that sodium bicarbonate did not reduce the incidence of postoperative AKI and the need for renal replacement therapy. Postoperative ventilation time, hospital length of stay, hospital death, and mortality within 90 days had no statistical difference between 2 groups. Time in intensive care unit was even slightly longer in the experimental group. CONCLUSIONS Urinary alkalinization using sodium bicarbonate infusion failed to reduce the incidence rate of AKI or other outcomes in patients undergoing cardiac surgery. This intervention might even prolong intensive care unit stay.
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Freeland K, Hamidian Jahromi A, Duvall LM, Mancini MC. Postoperative blood transfusion is an independent predictor of acute kidney injury in cardiac surgery patients. J Nephropathol 2015; 4:121-6. [PMID: 26457259 PMCID: PMC4596296 DOI: 10.12860/jnp.2015.23] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 05/12/2015] [Indexed: 01/24/2023] Open
Abstract
Background: Acute kidney injury (AKI) is a serious complication of cardiac surgery with cardiopulmonary bypass (CPB) which increases postoperative morbidity and mortality.
Objectives: The study was designed to assess the incidence of AKI and associated risk factors in patients undergoing CPB ancillary to coronary artery bypass grafting (CABG), valve surgery, and combined CABG and valve surgery.
Patients and Methods: This Intuitional Review Board (IRB) approved retrospective study included patients with normal preoperative kidney function (Serum creatinine [sCr] <2.0 mg/dl) who underwent cardiac surgery with CPB between 2012 and 2014. Patients were divided into 2 groups: group I: Patients with cardiac surgery associated AKI (CS-AKI) (postoperative sCr >2 mg/dl with a minimal doubling of baseline sCr) and group II: Patients with a normal postoperative kidney function. Demographic data, body mass index (BMI), co-morbidities, hematologic/biochemical profiles, preoperative ejection fraction (%EF), blood transfusion history, and operative data were compared between the groups. Mean arterial pressure (MAP) was recorded during the operation and in the postoperative period. Δ-MAP was defined as the difference between pre-CPB-MAP and the CPB-MAP.
Results: 241 patients matched the inclusion criteria (CS-AKI incidence = 8.29%). Age, gender, BMI, %EF, and co-morbidities were not predictors of CS-AKI (P > 0.05). High preoperative sCr (P = 0.047), type of procedure (P = 0.04), clamp time (P = 0.003), pump time (P = 0.005) and history of blood transfusion within 14 days postsurgery (P = 0.0004) were associated with risk of CS-AKI. Pre-CPB-MAP, CPB-MAP, Δ-MAP, and ICU-MAP were not significantly different between the 2 groups. Male gender (OR: 5.53; P = 0.048), age>60 (OR: 4.54; P = 0.027) and blood transfusion after surgery (OR: 5.25; P = 0.0054) were independent predictors for postoperative AKI.
Conclusions: Age, gender and blood transfusion were independent predictors of cardiac surgery associated AKI.
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Affiliation(s)
- Kristofer Freeland
- Department of Surgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | | | - Lucas Maier Duvall
- Department of Surgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Mary Catherine Mancini
- Department of Surgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
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Dobson GP. Addressing the Global Burden of Trauma in Major Surgery. Front Surg 2015; 2:43. [PMID: 26389122 PMCID: PMC4558465 DOI: 10.3389/fsurg.2015.00043] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 08/17/2015] [Indexed: 12/18/2022] Open
Abstract
Despite a technically perfect procedure, surgical stress can determine the success or failure of an operation. Surgical trauma is often referred to as the "neglected step-child" of global health in terms of patient numbers, mortality, morbidity, and costs. A staggering 234 million major surgeries are performed every year, and depending upon country and institution, up to 4% of patients will die before leaving hospital, up to 15% will have serious post-operative morbidity, and 5-15% will be readmitted within 30 days. These percentages equate to around 1000 deaths and 4000 major complications every hour, and it has been estimated that 50% may be preventable. New frontline drugs are urgently required to make major surgery safer for the patient and more predictable for the surgeon. We review the basic physiology of the stress response from neuroendocrine to genomic systems, and discuss the paucity of clinical data supporting the use of statins, beta-adrenergic blockers and calcium-channel blockers. Since cardiac-related complications are the most common, particularly in the elderly, a key strategy would be to improve ventricular-arterial coupling to safeguard the endothelium and maintain tissue oxygenation. Reduced O2 supply is associated with glycocalyx shedding, decreased endothelial barrier function, fluid leakage, inflammation, and coagulopathy. A healthy endothelium may prevent these "secondary hit" complications, including possibly immunosuppression. Thus, the four pillars of whole body resynchronization during surgical trauma, and targets for new therapies, are: (1) the CNS, (2) the heart, (3) arterial supply and venous return functions, and (4) the endothelium. This is termed the Central-Cardio-Vascular-Endothelium (CCVE) coupling hypothesis. Since similar sterile injury cascades exist in critical illness, accidental trauma, hemorrhage, cardiac arrest, infection and burns, new drugs that improve CCVE coupling may find wide utility in civilian and military medicine.
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Affiliation(s)
- Geoffrey P Dobson
- Heart, Trauma and Sepsis Research Laboratory, Australian Institute of Tropical Health and Medicine, College of Medicine and Dentistry, James Cook University , Townsville, QLD , Australia
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21
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Nascimento MSD, Aguiar TC, Silva AVED, Duarte TTDP, Magro MCDS. Lesão renal aguda no pós-operatório de cirurgia cardíaca. ACTA PAUL ENFERM 2015. [DOI: 10.1590/1982-0194201500062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objetivo Identificar a ocorrência de lesão renal aguda em pós-operatório de cirurgia cardíaca. Métodos Estudo de coorte prospectivo que incluiu 51 pacientes expostos a cirurgia de revascularização do miocárdio, troca valvar ou cirurgia combinada (revascularização do miocárdio e troca valvar), sem antecedentes de doença renal e de transplante renal e que foram acompanhados desde o pré-operatório até 72 horas de pós-operatório. Foi definido como lesão renal aguda o aumento de 0,3mg/dL em tempo menor ou igual a 48 horas ou aumento de 1,5 a 1,9 vez da creatinina basal, ou ainda redução do fluxo urinário <0,5mL/kg/h por 6 horas. Foi utilizada a classificação Kidney Disease: Improving Global Outcomes (KDIGO). Resultados A classificação KDIGO sinalizou 92,2% dos pacientes com disfunção renal. O critério fluxo urinário dessa classificação isoladamente mostrou que 31,4% dos pacientes apresentaram disfunção renal no estágio de risco, 33,3% no estágio de lesão renal, e 21,6% no estágio de falência renal. Pelo critério creatinina sérica, foram identificados 27,5% no estágio de risco e, nos estágios de lesão e falência renal, foram identificados 3,9% pacientes em cada. Conclusão Um percentual elevado de pacientes em pós-operatório de cirurgia cardíaca (revascularização miocárdica e troca valvar) progrediu com lesão renal aguda.
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Cooper CM, Fenves AZ. Before you call renal: Acute kidney injury for hospitalists. J Hosp Med 2015; 10:403-8. [PMID: 25628039 DOI: 10.1002/jhm.2325] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 12/18/2014] [Accepted: 12/21/2014] [Indexed: 11/08/2022]
Abstract
Acute kidney injury is a clinical problem of growing incidence in hospitalized patients. It increases the risk of poor outcomes, length of stay and the cost of hospitalization. Successful management of acute kidney injury requires early recognition and diagnosis through detailed medical history, careful physical exam, judicious use of laboratory and radiologic tests and timely renal consultation. Subsequent management is tailored to the likely mechanism of injury with emphasis on limiting both further injury and systemic consequences. A common sense approach to acute kidney injury is essential for hospitalists aiming to limit further injury, prevent acute complications and lessen the risk of chronic morbidity.
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Affiliation(s)
- Cynthia M Cooper
- Inpatient Clinician Educator Service, Hospital Medicine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew Z Fenves
- Inpatient Clinician Educator Service, Hospital Medicine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Ejaz AA, Mohandas R. Are diuretics harmful in the management of acute kidney injury? Curr Opin Nephrol Hypertens 2014; 23:155-60. [PMID: 24389731 DOI: 10.1097/01.mnh.0000441150.17202.be] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW To assess the role of diuretics in acute kidney injury (AKI) and their effectiveness in preventing AKI, achieving fluid balance, and decreasing progression to chronic kidney disease (CKD). RECENT FINDINGS Diuretics are associated with increased risk for AKI. The theoretical advantage of diuretic-induced preservation of renal medullary oxygenation to prevent AKI has not been proven. A higher cumulative diuretic dose during the dialysis period can cause hypotension and increase mortality in a dose-dependent manner. Data on the use of forced euvolemic diuresis to prevent AKI remains controversial. Positive fluid balance has emerged as an independent predictor of adverse outcomes. Post-AKI furosemide dose had a favorable effect on mortality due in part to the reduction of positive fluid balance. There are exciting experimental data suggesting that spironolactone may prevent AKI once an ischemic insult has occurred and thus prevent the progression to CKD. SUMMARY Diuretics are ineffective and even detrimental in the prevention and treatment of AKI, and neither shorten the duration of AKI, nor reduce the need for renal replacement therapy. Diuretics have an important role in volume management in AKI, but they are not recommended for the prevention of AKI. There is increased emphasis on the prevention of progression of AKI to CKD.
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Affiliation(s)
- A Ahsan Ejaz
- Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville, Florida, USA
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Abstract
OBJECTIVE Hemolysis, occurring during cardiopulmonary bypass, is associated with lipid peroxidation and postoperative acute kidney injury. Acetaminophen inhibits lipid peroxidation catalyzed by hemeproteins and in an animal model attenuated rhabdomyolysis-induced acute kidney injury. This pilot study tests the hypothesis that acetaminophen attenuates lipid peroxidation in children undergoing cardiopulmonary bypass. DESIGN Single-center prospective randomized double-blinded study. SETTING University-affiliated pediatric hospital. PATIENTS Thirty children undergoing elective surgical correction of a congenital heart defect. INTERVENTIONS Patients were randomized to acetaminophen (OFIRMEV [acetaminophen] injection; Cadence Pharmaceuticals, San Diego, CA) or placebo every 6 hours for four doses starting before the onset of cardiopulmonary bypass. MEASUREMENT AND MAIN RESULTS Markers of hemolysis, lipid peroxidation (isofurans and F2-isoprostanes), and acute kidney injury were measured throughout the perioperative period. Cardiopulmonary bypass was associated with a significant increase in free hemoglobin (from a prebypass level of 9.8 ± 6.2 mg/dL to a peak of 201.5 ± 42.6 mg/dL postbypass). Plasma and urine isofuran and F2-isoprostane concentrations increased significantly during surgery. The magnitude of increase in plasma isofurans was greater than the magnitude in increase in plasma F2-isoprostanes. Acetaminophen attenuated the increase in plasma isofurans compared with placebo (p = 0.02 for effect of study drug). There was no significant effect of acetaminophen on plasma F2-isoprostanes or urinary makers of lipid peroxidation. Acetaminophen did not affect postoperative creatinine, urinary neutrophil gelatinase-associated lipocalin, or prevalence of acute kidney injury. CONCLUSION Cardiopulmonary bypass in children is associated with hemolysis and lipid peroxidation. Acetaminophen attenuated the increase in plasma isofuran concentrations. Future studies are needed to establish whether other therapies that attenuate or prevent the effects of free hemoglobin result in more effective inhibition of lipid peroxidation in patients undergoing cardiopulmonary bypass.
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Nearman H, Klick JC, Eisenberg P, Pesa N. Perioperative Complications of Cardiac Surgery and Postoperative Care. Crit Care Clin 2014; 30:527-55. [DOI: 10.1016/j.ccc.2014.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Kindgen-Milles D. [Acute kidney injury in the perioperative setting]. Med Klin Intensivmed Notfmed 2014; 109:324-30. [PMID: 24844158 DOI: 10.1007/s00063-014-0348-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 03/10/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Perioperative acute kidney injury (AKI) is common and is associated with adverse clinical outcomes, excess mortality, and an increased risk for chronic renal failure. Recommendations to prevent perioperative AKI include the early identification of patients at risk, the avoidance of nephrotoxic drugs, and early goal-directed haemodynamic stabilization. The major causes for perioperative AKI are severe sepsis and septic shock, hypovolemia, bleeding and cardiac failure. POSSIBLE RENAL REPLACEMENT MODALITIES The choice of modality, i.e. intermittent or continuous renal replacement (CRRT) therapy, can be made based on local resources. However, surgical patients frequently have impaired haemodynamics, a decreased pulmonary function and require removal of large amounts of fluid. In such cases, CRRT offers improved haemodynamic stability and volume control. Frequently, patients must be transferred to the operating theatre for redo procedures. Here, slow-extended daily dialysis treatments of 8-12 h can deliver a high dialysis dose with good haemodynamic stability at reduced costs. Surgical patients per se have an increased risk of bleeding. Regional citrate anticoagulation is a new and effective mode of anticoagulation which significantly reduces bleeding risk and transfusion requirements. CONCLUSION Data from a recent meta-analysis show that, in surgical patients, mortality is reduced when renal replacement therapy is started early. In certain surgical diseases, i.e. acute occlusive disease of the abdominal aorta (Leriche's syndrome) following surgical reperfusion, patients are at risk of severe metabolic acidosis and life-threatening hyperkalemia. In such cases, intraoperative dialysis using a mobile batch system can help to avoid these complications by delivering an effective dialysis therapy at the time of reperfusion.
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Affiliation(s)
- D Kindgen-Milles
- Klinik für Anästhesiologie, Interdisziplinäre Operative Intensivstation, Zentrum für Operative Medizin I, Universitätsklinikum Düsseldorf, Heinrich-Heine Universität Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland,
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Chen YT, Tsai TH, Yang CC, Sun CK, Chang LT, Chen HH, Chang CL, Sung PH, Zhen YY, Leu S, Chang HW, Chen YL, Yip HK. Exendin-4 and sitagliptin protect kidney from ischemia-reperfusion injury through suppressing oxidative stress and inflammatory reaction. J Transl Med 2013; 11:270. [PMID: 24161164 PMCID: PMC4231365 DOI: 10.1186/1479-5876-11-270] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 09/27/2013] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND This study tested the hypothesis that exendin-4 and sitagliptin can effectively protect kidney from acute ischemia-reperfusion (IR) injury. METHODS Adult SD-rats (n = 48) equally divided into group 1 (sham control), group 2 (IR injury), group 3 [IR + sitagliptin 600 mg/kg at post-IR 1, 24, 48 hr)], and group 4 [IR + exendin-4 10 μm/kg at 1 hr after procedure] were sacrificed after 24 and 72 hrs (n = 6 at each time from each group) following clamping of bilateral renal pedicles for 60 minutes (groups 2-4). RESULTS Serum creatinine level and urine protein to creatinine ratio were highest in group 2 and lowest in group 1 (all p < 0.001) without notable differences between groups 3 and 4. Kidney injury score, expressions of inflammatory biomarkers at mRNA (MMP-9, TNF-α, IL-1β, PAI-1), protein (TNF-α, NF-κB and VCAM-1), and cellular (CD68+) levels in injured kidneys at 24 and 72 hr showed an identical pattern compared to that of creatinine level in all groups (all p < 0.0001). Expressions of oxidized protein, reactive oxygen species (NOX-1, NOX-2), apoptosis (Bax, caspase-3 and PARP), and DNA damage marker (γH2AX+) of IR kidney at 24 and 72 hrs exhibited a pattern similar to that of inflammatory mediators among all groups (all p < 0.01). Renal expression of glucagon-like peptide-1 receptor, and anti-oxidant biomarkers at cellular (GPx, GR) and protein (NQO-1, HO-1, GPx) levels at 24 and 72 hr were lowest in group 1, significantly lower in group 2 than in groups 3 and 4 (all p < 0.01). CONCLUSION Exendin-4 and sitagliptin provided significant protection for the kidneys against acute IR injury.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Hon-Kan Yip
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Dapi Road, Niaosung Dist,, Kaohsiung city 83301, Taiwan.
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