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Wilson PR, Bridges KH, Scofield M, Wilson SH. Perioperative N-acetylcysteine: evidence and indications. Pain Manag 2024; 14:385-396. [PMID: 39166871 DOI: 10.1080/17581869.2024.2388504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 07/31/2024] [Indexed: 08/23/2024] Open
Abstract
Nonopioid analgesics serve to improve analgesia and limit side effects and risks of perioperative opioids. N-acetylcysteine (NAC), the primary treatment of acetaminophen toxicity, may have perioperative indications, including analgesia. NAC impacts glutathione synthesis, oxidant scavenging, glutamate receptor modulation and neuroinflammation. Potential perioperative benefits include arrhythmia prevention after cardiac surgery, decreased contrast-induced nephropathy, improved post-transplant liver function and superior pulmonary outcomes with general anesthesia. NAC may improve perioperative analgesia, with some studies displaying a reduction in postoperative opioid use. NAC is generally well tolerated with an established safety profile. NAC administration may predispose to gastrointestinal effects, while parenteral administration may carry a risk of anaphylactoid reactions, including bronchospasm. Larger randomized trials may clarify the impact of NAC on perioperative analgesic outcomes.
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Affiliation(s)
- Phillip Ryan Wilson
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kathryn H Bridges
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael Scofield
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sylvia H Wilson
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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Karimi E, Gholizadeh M, Abdolahi M, Sedighiyan M, Salehinia F, Siri G, Asanjarani B, Yousefi A, Gandomkar H, Abdollahi H. Effect of vitamin B1 supplementation on blood creatinine and lactate levels and clinical outcomes in patients in intensive care units: a systematic review and meta-analysis of randomized controlled trials. Nutr Rev 2024; 82:804-814. [PMID: 37553224 DOI: 10.1093/nutrit/nuad096] [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] [Indexed: 08/10/2023] Open
Abstract
CONTEXT The metabolic response to stress can deplete the remaining thiamine stores, leading to thiamine deficiency. OBJECTIVE This study is the first meta-analysis of the effectiveness of thiamine supplementation on clinical and biochemical outcomes in adult patients admitted to the intensive care unit (ICU). DATA SOURCES Scopus, PubMed, and Cochrane databases were searched to select studies up to 20 November 2022. STUDY SELECTION Studies investigating the effect of thiamine supplementation on serum lactate and creatinine levels, the need for renal replacement therapy, length of ICU stay, and mortality rate in ICU patients were selected. DATA EXTRACTION After excluding studies based on title and abstract screening, 2 independent investigators reviewed the full texts of the remaining articles. In the next step, a third investigator resolved any discrepancy in the article selection process. RESULTS Of 1628 retrieved articles, 8 were selected for final analysis. This study showed that thiamine supplementation reduced the serum creatinine level (P = .03) compared with placebo. In addition, according to subgroup analysis, serum creatinine concentration was significantly lower in patients >60 years old (P < .00001). However, there was no statistically significant difference in the lactate level between the thiamine supplementation and placebo groups (P = .26). Thiamine supplementation did not decrease the risk of all-cause mortality (P = .71) or the need for renal replacement therapy (P = .14). The pooled results of eligible randomized controlled trials also showed that thiamine supplementation did not reduce the length of ICU stay in comparison to the placebo group (P = .39). CONCLUSION This meta-analysis provides evidence that thiamine supplementation has a protective effect against blood creatinine increase in ICU patients. However, further high-quality trials are needed to discover the effect of thiamine supplementation on clinical and biochemical outcomes in ICU patients. SYSTEMATIC REVIEW REGISTRATION PROSPERO no. CRD42023399710 (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=399710).
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Affiliation(s)
- Elmira Karimi
- Centre for Physical Activity and Nutrition Research, School of Exercise and Nutrition Sciences, Deakin University, Burwood, Victoria, Australia
| | - Mohammad Gholizadeh
- Faculty of Nutrition and Food Technology, Department of Clinical Nutrition, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mina Abdolahi
- Department of Clinical Nutrition, Amir Alam Hospital Complexes, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Sedighiyan
- Faculty of Nutrition and Food Technology, Department of Clinical Nutrition, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farahnaz Salehinia
- Department of Internal Medicine, Amir Alam Hospital Complexes, Tehran University of Medical Sciences, Tehran, Iran
| | - Goli Siri
- Department of Internal Medicine, Amir Alam Hospital Complexes, Tehran University of Medical Sciences, Tehran, Iran
| | - Behzad Asanjarani
- Department of Internal Medicine, Amir Alam Hospital Complexes, Tehran University of Medical Sciences, Tehran, Iran
| | - Abolghasem Yousefi
- Department of Anesthesiology, Amir Alam Hospital Complexes, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Gandomkar
- Amir Alam Hospital Complexes, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamed Abdollahi
- Department of Anesthesiology, Amir Alam Hospital Complexes, Tehran University of Medical Sciences, Tehran, Iran
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Karathanasis D, Karathanasis CR, Karaolia A. Cardiac surgery-associated acute kidney injury: The core of etiology, treatment, and prognosis. JOURNAL OF CLINICAL AND PREVENTIVE CARDIOLOGY 2022. [DOI: 10.4103/jcpc.jcpc_5_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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4
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Parpoudi S, Mantzoros I, Gkiouliava A, Kyziridis D, Makrantonakis A, Chatzakis C, Gekas C, Konstantaras D, Ioannidis O, Bitsianis S, Miliaras D, Aggelopoulos S. The effect of N-acetyl-l-cysteine on inflammation after intraperitoneal mesh placement in a potentially contaminated environment: Experimental study in the rat. Asian J Surg 2021; 45:2191-2196. [PMID: 34801356 DOI: 10.1016/j.asjsur.2021.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/05/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The use of prosthetic meshes in abdominal wall reconstruction is a well-established approach; however, in certain cases where a bowel resection coexists its application is disputed. Any underlying inflammatory process may augment adhesion formation which is a major postoperative complication. In this animal study, our aim was to investigate the effect of N-acetyl-l-cysteine (NAC) on adhesion formation and the expression of inflammatory markers when a mesh was used in a clean or a potentially contaminated environment. METHODS Sixty male Wistar rats were randomly and equally allocated in 3 groups: A, B and C. Animals in all groups underwent laparotomy, a prosthetic mesh was placed and chemoprophylaxis with ciprofloxacin was administered. In groups B and C an enterectomy was also performed. NAC was injected intraperitoneally in group C. Adhesion formation, IL-1a, IL-6, TNF-a and histological data including fibrosis, neutrophils' infiltration and neovascularization were assessed. Mesh samples were sent for cultivation. RESULTS Adhesion formation was significantly less and inflammation markers were also lower in group C compared to group B (p<0.05). Histological findings were significant for greater fibrosis, neutrophils' infiltration and neovascularization in group B compared to both group A and C. Regarding mesh cultures, more specimens were tested positive in group B (p <0.05). Outcomes between group A and C did not differ. CONCLUSION NAC effectively ameliorated adhesion formation and inflammation in a potentially septic environment where a prosthetic mesh was placed.
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Affiliation(s)
- Styliani Parpoudi
- 4th Surgical Clinic, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Mantzoros
- 4th Surgical Clinic, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anna Gkiouliava
- Anaesthesiology Department, Georgios Papanikolaou General Hospital, Thessaloniki, Greece.
| | - Dimitrios Kyziridis
- 4th Surgical Clinic, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Makrantonakis
- 4th Surgical Clinic, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christos Chatzakis
- 4th Surgical Clinic, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christos Gekas
- Orthopaedic Department, Ippokrateio Hospital, Thessaloniki, Greece
| | - Dimitrios Konstantaras
- 4th Surgical Clinic, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Orestis Ioannidis
- 4th Surgical Clinic, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stefanos Bitsianis
- 4th Surgical Clinic, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimosthenis Miliaras
- Laboratory of Histology-Embryology, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stamatios Aggelopoulos
- 4th Surgical Clinic, School of Medicine, Faculty of Health Science, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Tan YK, Luo H, Kang GS, Teoh KL, Kofidis T. N-Acetylcysteine's Renoprotective Effect in Cardiac Surgery: A Systematic Review and Meta-Analysis. Ann Thorac Cardiovasc Surg 2021; 28:138-145. [PMID: 34732600 PMCID: PMC9081465 DOI: 10.5761/atcs.oa.21-00132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To examine N-acetylcysteine's (NAC's) renoprotective effect in adult cardiac surgeryMethods: PubMed, Ovid Medline, and Embase were searched for randomized controlled trials published between January 1990 and May 2021 that investigated the effect of NAC in preventing acute kidney injury (AKI) in patients undergoing cardiac surgery. The inclusion criterion was studies that assessed the effect of NAC in comparison to placebo by measuring the incidence of AKI. RESULTS Overall meta-analytic estimates of all 10 included trials showed that NAC did not have a significant effect (odds ratio [OR]: 0.84, 95% confidence interval [CI]: 0.64-1.10) on AKI. Further subgroup analysis did not show a significant benefit of NAC in preventing AKI. CONCLUSION This meta-analysis suggests that NAC does not have a significant effect in reducing the incidence of AKI. However, there is notable heterogeneity among the included studies that could possibly account for the non-significant effect observed. It is worth noting that only one trial administered NAC high dosages perioperatively, and it is the only included trial to show a significant benefit in reducing the incidence of AKI (OR: 0.30, 95% CI: 0.11-0.81). Further studies on this dosage and duration of administration should be conducted to best elucidate the effect of administering NAC.
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Affiliation(s)
- Ying Kiat Tan
- Department of Cardiac Surgery, Yong Loo Lin School of Medicine, Singapore, Singapore
| | - HaiDong Luo
- Department of Cardiac Thoracic & Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Giap Swee Kang
- Department of Cardiac Thoracic & Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Kristine Lk Teoh
- Department of Cardiac Thoracic & Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Theo Kofidis
- Department of Cardiac Thoracic & Vascular Surgery, National University Heart Centre, Singapore, Singapore
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Sharif S, Chen B, Brewster P, Chen T, Dworkin L, Gong R. Rationale and Design of Assessing the Effectiveness of Short-Term Low-Dose Lithium Therapy in Averting Cardiac Surgery-Associated Acute Kidney Injury: A Randomized, Double Blinded, Placebo Controlled Pilot Trial. Front Med (Lausanne) 2021; 8:639402. [PMID: 34195206 PMCID: PMC8236527 DOI: 10.3389/fmed.2021.639402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 05/14/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Burgeoning pre-clinical evidence suggests that therapeutic targeting of glycogen synthase kinase 3β (GSK3β), a convergence point of multiple cellular protective signaling pathways, confers a beneficial effect on acute kidney injury (AKI) in experimental models. However, it remains unknown if GSK3β inhibition likewise mitigates AKI in humans. Cardiac surgery associated acute kidney injury (CSA-AKI) poses a significant challenge for clinicians and currently the only treatment available is general supportive measures. Lithium, an FDA approved mood stabilizer, is the best-known GSK3β inhibitor and has been safely used for over half a century as the first line regimen to treat bipolar affective disorders. This study attempts to examine the effectiveness of short term low dose lithium on CSA-AKI in human patients. Methods/Design: This is a single center, prospective, randomized, double blinded, placebo controlled pilot study on patients undergoing cardiac surgery with cardiopulmonary bypass. Patients will be randomized to receive a small dose of lithium or placebo treatment for three consecutive days. Renal function will be measured via creatinine as well as novel AKI biomarkers. The primary outcome is incidence of AKI according to Acute Kidney Injury Network (AKIN) criteria, and secondary outcomes include receipt of new dialysis, days on dialysis, days on mechanical ventilation, infections within 1 month of surgery, and death within 90 days of surgery. Discussion: As a standard selective inhibitor of GSK3β, lithium has been shown to exert a beneficial effect on tissue repair and regeneration upon acute injury in multiple organ systems, including the central nervous system and hematopoietic system. In experimental AKI, lithium at small doses is able to ameliorate AKI and promote kidney repair. Successful completion of this study will help to assess the effectiveness of lithium in CSA-AKI and could potentially pave the way for large-scale randomized trials to thoroughly evaluate the efficacy of this novel regimen for preventing AKI after cardiac surgery. Trial Registration: This study was registered prospectively on the 17th February 2017 at ClinicalTrials.gov (NCT03056248, https://clinicaltrials.gov/ct2/show/NCT03056248?term=NCT03056248&draw=2&rank=1).
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Affiliation(s)
- Sairah Sharif
- Division of Critical Care Medicine, St Francis Hospital, New York, NY, United States.,Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Brown University School of Medicine, Providence, RI, United States
| | - Bohan Chen
- Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Brown University School of Medicine, Providence, RI, United States.,Division of Nephrology, Department of Medicine, University of Toledo Medical Center, Toledo, OH, United States
| | - Pamela Brewster
- Division of Nephrology, Department of Medicine, University of Toledo Medical Center, Toledo, OH, United States
| | - Tian Chen
- Department of Mathematics and Statistics, The University of Toledo, Toledo, OH, United States
| | - Lance Dworkin
- Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Brown University School of Medicine, Providence, RI, United States.,Division of Nephrology, Department of Medicine, University of Toledo Medical Center, Toledo, OH, United States
| | - Rujun Gong
- Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Brown University School of Medicine, Providence, RI, United States.,Division of Nephrology, Department of Medicine, University of Toledo Medical Center, Toledo, OH, United States
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7
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Pressman P, Bridge WJ, Zarka MH, Hayes AW, Clemens R. Dietary γ-Glutamylcysteine: Its Impact on Glutathione Status and Potential Health Outcomes. J Diet Suppl 2020; 19:259-270. [PMID: 33307893 DOI: 10.1080/19390211.2020.1856266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Glutathione (GSH) is a tripeptide that is readily synthesized intracellularly in humans and other mammals. More than a century of research suggests that GSH has numerous biological functions, including protection from the potential adverse events associated with reactive oxygen species (ROS) and related redox reactions that may induce oxidative stress, and that may be linked to innate detoxification processes. Normal tissue and plasma levels of GSH decline through the aging process and decrease during various disease states. While the health value of dietary GSH remains controversial, there is evidence that some metabolic intermediates, such as γ-glutamylcysteine (GGC) may function to preserve adequate GSH levels when the synthetic pathways decline in activity, and the innate antioxidant system is challenged. It is also important to recognize that among the thousands of protein-coding human genes and their respective polymorphisms, at least two genes (Gclc and Gclm) are directly involved with GSH synthesis via glutamate-cysteine ligase. This commentary examines the classic biochemistry, toxicology, safety, and clinical value of GSH and its intermediates that may be modulated by dietary supplementation.
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Affiliation(s)
| | - Wallace John Bridge
- School of Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney, Australia
| | - Martin Hani Zarka
- School of Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney, Australia
| | - A Wallace Hayes
- College of Public Health, University of South Florida, Tampa, FL, USA
| | - Roger Clemens
- International Center for Regulatory Sciences, University of Southern California, Los Angeles, CA, USA
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8
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The effects of N-acetylcysteine on inflammatory and oxidative stress biomarkers: A systematic review and meta-analysis of controlled clinical trials. Eur J Pharmacol 2020; 884:173368. [DOI: 10.1016/j.ejphar.2020.173368] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/08/2020] [Accepted: 07/13/2020] [Indexed: 01/08/2023]
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9
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Xiong T, Zhang Z, Zheng R, Huang J, Guo L. N‑acetyl cysteine inhibits lipopolysaccharide‑induced apoptosis of human umbilical vein endothelial cells via the p38MAPK signaling pathway. Mol Med Rep 2019; 20:2945-2953. [PMID: 31524245 DOI: 10.3892/mmr.2019.10526] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 07/05/2019] [Indexed: 11/06/2022] Open
Abstract
Lipopolysaccharide (LPS) can regulate the expression of apoptotic factors, including caspase‑3, Bcl‑2 and Bcl‑2‑associated X protein (Bax). Nitric oxide (NO) plays an important role in apoptosis. N‑acetyl cysteine (NAC) has been shown to exhibit antioxidant effects in vitro. However, the effects of NAC on LPS‑induced apoptosis of human umbilical vein endothelial cells (HUVECs) and the associated mechanisms are not well characterized. The present study explored the effect of NAC on LPS‑induced apoptosis of HUVECs and determined the participation of the p38 mitogen‑activated protein kinase (MAPK) pathway in the process of apoptosis. Cell viability was assessed using the Cell Counting Kit‑8 (CCK‑8) assay. The expression of caspase‑3, Bax, Bcl‑2, phosphorylated (p)‑p38MAPK/total (t‑)p38MAPK and p‑endothelial e nitric oxide synthase (eNOS)/t‑eNOS proteins were determined by western blotting. The expression levels of caspase‑3, Bax and Bcl‑2 mRNA were determined using reverse transcription‑quantitative polymerase chain reaction (RT‑qPCR). The rate of apoptosis was determined using flow cytometry. An NO detection kit (nitric reductase method) was used to determine NO concentration. The results of CCK‑8 and flow cytometric analyses showed that pretreatment of HUVECs with NAC or p38MAPK inhibitor (SB203580) attenuated LPS‑induced decrease in cell viability and increase in cell apoptosis. RT‑qPCR and western blotting showed that LPS promoted caspase‑3 and Bax expression, but inhibited that of Bcl‑2 in HUVECs; however, these effects were attenuated by pretreatment with NAC or SB203580. LPS stimulation significantly enhanced the expression of p‑p38MAPK protein and reduced the expression of p‑eNOS protein; however, these effects were attenuated by pretreatment with NAC or SB203580. NAC pretreatment attenuated LPS‑induced inhibition of NO synthesis, which was consistent with the effects of SB203580. The results demonstrated that NAC pretreatment alleviated LPS‑induced apoptosis and inhibition of NO production in HUVECs. Furthermore, these effects were proposed to be mediated via the p38MAPK signaling pathway.
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Affiliation(s)
- Ting Xiong
- Department of Prosthodontics, Hospital of Stomatology Affiliated to Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Zhenzhen Zhang
- Department of Prosthodontics, Hospital of Stomatology Affiliated to Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Rui Zheng
- Department of Prosthodontics, Hospital of Stomatology Affiliated to Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Jialin Huang
- Department of Prosthodontics, Hospital of Stomatology Affiliated to Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Ling Guo
- Department of Prosthodontics, Hospital of Stomatology Affiliated to Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
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Moore EM, Bellomo R, Nichol AD. The Meaning of Acute Kidney Injury and Its Relevance to Intensive Care and Anaesthesia. Anaesth Intensive Care 2019. [DOI: 10.1177/0310057x1204000604] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- E. M. Moore
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Student, Department of Epidemiology and Preventive Medicine, Monash University
| | - R. Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - A. D. Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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11
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O'Kane D, Baldwin GS, Bolton DM, Ischia JJ, Patel O. Preconditioning against renal ischaemia reperfusion injury: the failure to translate to the clinic. J Nephrol 2019; 32:539-547. [PMID: 30635875 DOI: 10.1007/s40620-019-00582-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 01/03/2019] [Indexed: 12/22/2022]
Abstract
Acute kidney injury (AKI) as a result of ischaemia-reperfusion represents a major healthcare burden worldwide. Mortality rates from AKI in hospitalized patients are extremely high and have changed little despite decades of research and medical advances. In 1986, Murry et al. demonstrated for the first time the phenomenon of ischaemic preconditioning to protect against ischaemia-reperfusion injury (IRI). This seminal finding paved the way for a broad body of research, which attempted to understand and ultimately harness this phenomenon for human application. The ability of preconditioning to limit renal IRI has now been demonstrated in multiple different animal models. However, more than 30 years later, a safe and consistent method of protecting human organs, including the kidneys, against IRI is still not available. This review highlights agents which, despite strong preclinical data, have recently failed to reduce AKI in human trials. The multiple reasons which may have contributed to the failure to translate some of the promising findings to clinical therapies are discussed. Agents which hold promise in the clinic because of their recent efficacy in preclinical large animal models are also reviewed.
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Affiliation(s)
- Dermot O'Kane
- Department of Surgery, Austin Health, The University of Melbourne, Studley Rd., Heidelberg, VIC, 3084, Australia
- Department of Urology, Austin Health, Heidelberg, VIC, Australia
| | - Graham S Baldwin
- Department of Surgery, Austin Health, The University of Melbourne, Studley Rd., Heidelberg, VIC, 3084, Australia
| | - Damien M Bolton
- Department of Surgery, Austin Health, The University of Melbourne, Studley Rd., Heidelberg, VIC, 3084, Australia
- Department of Urology, Austin Health, Heidelberg, VIC, Australia
| | - Joseph J Ischia
- Department of Surgery, Austin Health, The University of Melbourne, Studley Rd., Heidelberg, VIC, 3084, Australia
- Department of Urology, Austin Health, Heidelberg, VIC, Australia
| | - Oneel Patel
- Department of Surgery, Austin Health, The University of Melbourne, Studley Rd., Heidelberg, VIC, 3084, Australia.
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Zhang R, Wang Y, Pan L, Tian H. N-Acetylcysteine potentiates the haemodynamic-improving effect of sildenafil in a rabbit model of acute pulmonary thromboembolism via the p38 MAPK pathway. Clin Exp Pharmacol Physiol 2018; 46:163-172. [PMID: 30289994 DOI: 10.1111/1440-1681.13039] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 09/27/2018] [Accepted: 10/01/2018] [Indexed: 02/05/2023]
Abstract
The current study aimed to investigate the effects of sildenafil and N-acetylcysteine (NAC) on the haemodynamics in a rabbit model of acute pulmonary thromboembolism (APT). We developed an APT model using healthy male China big-ear rabbits (2.7 ± 0.4 kg). The rabbits were divided into five groups subjected to various interventions. We recorded the haemodynamic parameters and assessed the oxidative stress and lipid peroxidation response in the groups. Additionally, we detected apoptosis-associated molecules, FoxO1, Bad and Bcl-2, in the lung tissue. Gelatine zymography was used to detect matrix metalloproteinase (MMP) activity in bronchoalveolar lavage (BLA). Pulmonary artery endothelial cells were isolated, and their apoptosis rates and MMP activity were assayed. N-acetylcysteine potentiated the haemodynamic-improving effect of sildenafil and significantly inhibited the oxidative stress response. N-acetylcysteine combined with sildenafil decreased MMP-2 and MMP-9 activity and NO consumption and inhibited apoptosis of pulmonary arterial endothelial cells. Moreover, NAC combined with sildenafil inhibited the expression of MCP-1 and p-p38 MAPK. Thus, NAC potentiates the haemodynamic-improving effect of sildenafil in a rabbit model of acute pulmonary thromboembolism via the MCP-1 and p38 MAPK signalling pathway. This study may provide a promising treatment method for APT.
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Affiliation(s)
- Ruipeng Zhang
- Department of Peripheral Angiopathy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Department of Vascular Surgery, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, China
| | - Yang Wang
- Department of Hepatobiliary Surgery, Xian Yang Central Hospital, Xian Yang, Shaanxi, China
| | - Longfei Pan
- Department of Peripheral Angiopathy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.,Department of Emergency Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Hongyan Tian
- Department of Peripheral Angiopathy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
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Abstract
Post-operative acute kidney injury (AKI) is a common complication of surgery with significant short- and long-term adverse consequences. The adoption of diagnostic criteria for AKI (RIFLE, AKIN and KDIGO) has facilitated comparison of data reported by different centres, confirming that even mild AKI is associated with excess mortality. It remains unclear whether this is caused by the kidney injury itself or whether AKI is simply a marker of underlying disease severity. There is no trial evidence to support the use of any specific therapeutic intervention in post-operative AKI. Best current treatment is, therefore, preventative by optimizing hydration and avoidance of nephrotoxins, emphasizing the importance of earlier detection and identification of individuals at high risk for AKI. In this review, we examine the latest literature on the management of post-operative AKI in adult patients, specifically the diagnosis and definition of AKI, epidemiology and pathogenesis and risk stratification in cardiac and non-cardiac surgery. We also review the latest evidence on pharmacological and non-pharmacological interventions.
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Affiliation(s)
- S Bell
- Renal Unit, Ninewells Hospital, Dundee DD1 9SY, Scotland
| | - V C Ross
- Renal Unit, Ninewells Hospital, Dundee DD1 9SY, Scotland
| | - K A Zealley
- Department of Anaesthetics, Ninewells Hospital, Dundee DD1 SY, Scotland
| | - F Millar
- Department of Anaesthetics, Ninewells Hospital, Dundee DD1 SY, Scotland
| | - C Isles
- Renal Unit, Dumfries and Galloway Royal Infirmary, Dumfries, Scotland
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Demiselle J, Lerolle N. Traitement non dialytique de l’insuffisance rénale aiguë. Nephrol Ther 2017; 13 Suppl 1:S7-S11. [DOI: 10.1016/j.nephro.2017.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 01/08/2017] [Indexed: 01/09/2023]
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15
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Mei M, Zhao HW, Pan QG, Pu YM, Tang MZ, Shen BB. Efficacy of N-Acetylcysteine in Preventing Acute Kidney Injury After Cardiac Surgery: A Meta-Analysis Study. J INVEST SURG 2017; 31:14-23. [PMID: 28060555 DOI: 10.1080/08941939.2016.1269853] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE To evaluate whether perioperative N-acetylcysteine (NAC) administration reduces the risk of cardiac surgery associated acute kidney injury (CSA-AKI). MATERIALS AND METHODS A systematic literature review (Medline, PubMed, Cochrane, Biomedical central, Google Scholar) identified 10 studies (1391 patients; 695 NAC and 696 placebo) that compared the efficacy and adverse effects of perioperative NAC administration for CSA-AKI prevention in adults undergoing elective cardiac surgery. Meta-analysis was performed using Comprehensive Meta-Analysis statistical software. RESULTS Patients in the NAC-treated and placebo groups had similar rate of CSA-AKI occurrence, change in creatinine levels, as well as the in-hospital mortality rate (RR = 0.841, 95% CI = 0.691 to 1.023, p = 0.083; pooled difference in means = -0.328, 95% CI = -0.712 to 0.056, p = 0.094; RR = 0.741, 95% CI = 0.388 to 1.418, p = 0.366, respectively). CONCLUSIONS Our study does not support perioperative NAC administration as a mean to reduce the risk of CSA-AKI.
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Affiliation(s)
- Mei Mei
- a Department of Kidney , Southwest Hospital, Third Military Medical University , Chongqing 400038 , P.R. China
| | - Hong-Wen Zhao
- a Department of Kidney , Southwest Hospital, Third Military Medical University , Chongqing 400038 , P.R. China
| | - Qian-Guang Pan
- a Department of Kidney , Southwest Hospital, Third Military Medical University , Chongqing 400038 , P.R. China
| | - You-Min Pu
- a Department of Kidney , Southwest Hospital, Third Military Medical University , Chongqing 400038 , P.R. China
| | - Mao-Zhi Tang
- a Department of Kidney , Southwest Hospital, Third Military Medical University , Chongqing 400038 , P.R. China
| | - Bing-Bing Shen
- a Department of Kidney , Southwest Hospital, Third Military Medical University , Chongqing 400038 , P.R. China
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16
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Ichai C, Vinsonneau C, Souweine B, Armando F, Canet E, Clec’h C, Constantin JM, Darmon M, Duranteau J, Gaillot T, Garnier A, Jacob L, Joannes-Boyau O, Juillard L, Journois D, Lautrette A, Muller L, Legrand M, Lerolle N, Rimmelé T, Rondeau E, Tamion F, Walrave Y, Velly L. Acute kidney injury in the perioperative period and in intensive care units (excluding renal replacement therapies). Ann Intensive Care 2016; 6:48. [PMID: 27230984 PMCID: PMC4882312 DOI: 10.1186/s13613-016-0145-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 04/19/2016] [Indexed: 12/17/2022] Open
Abstract
Acute kidney injury (AKI) is a syndrome that has progressed a great deal over the last 20 years. The decrease in urine output and the increase in classical renal biomarkers, such as blood urea nitrogen and serum creatinine, have largely been used as surrogate markers for decreased glomerular filtration rate (GFR), which defines AKI. However, using such markers of GFR as criteria for diagnosing AKI has several limits including the difficult diagnosis of non-organic AKI, also called "functional renal insufficiency" or "pre-renal insufficiency". This situation is characterized by an oliguria and an increase in creatininemia as a consequence of a reduction in renal blood flow related to systemic haemodynamic abnormalities. In this situation, "renal insufficiency" seems rather inappropriate as kidney function is not impaired. On the contrary, the kidney delivers an appropriate response aiming to recover optimal systemic physiological haemodynamic conditions. Considering the kidney as insufficient is erroneous because this suggests that it does not work correctly, whereas the opposite is occurring, because the kidney is healthy even in a threatening situation. With current definitions of AKI, normalization of volaemia is needed before defining AKI in order to avoid this pitfall.
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Affiliation(s)
- Carole Ichai
- />Service de Réanimation Polyvalente, IRCAN (Inserm U1081, CNRS UMR7284 et CHU de Nice, Hôpital Pasteur 2, 30 Voie Romaine, CHU de Nice, 06000 Nice, France
| | | | - Bertrand Souweine
- />Service de Réanimation Polyvalente, CHU de Nice, 30 Voie Romaine, 06000 Nice, France
| | - Fabien Armando
- />Service de Réanimation médicale, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Emmanuel Canet
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
| | - Christophe Clec’h
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital d’Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France
| | - Jean-Michel Constantin
- />Département de Médecine périopératoire, Hôpital Estaing, CHU de Clermont-Ferrand, 1 place Louis Aubrac, 63000 Clermont-Ferrand, France
| | - Michaël Darmon
- />Service de réanimation, hôpital de la Charité, CHU de Saint-Etienne, 44 rue Pointe Cadet, 42100 Saint-Etienne, France
| | - Jacques Duranteau
- />Département d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Kremlin-Bicêtre, 78, rue de la division du général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Théophille Gaillot
- />Service de Pédiatrie, hôpital Sud, CHU de Rennes, 16 Bd Bulgarie, 35203 Rennes, France
| | - Arnaud Garnier
- />Service de Pédiatrie, Néphrologie, hôpital des Enfants, CHU de Toulouse, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex, France
| | - Laurent Jacob
- />Service d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Saint-Louis, 1, Avenue Claude-Vellefaux, 75010 Paris, France
| | - Olivier Joannes-Boyau
- />Service d’Anesthésie Réanimation II, Hôpital du Haut-Lévêque, CHU de Bordeaux, 33600 Pessac, France
| | - Laurent Juillard
- />Service de néphrologie-dialyse, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
| | - Didier Journois
- />Service de réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Européen Georges Pompidou, 20, rue Leblanc, 75908 Paris, France
| | - Alexandre Lautrette
- />Service de réanimation, hôpital Gabriel Montpied, CHU de Clermont-Ferrand, 58 rue Montalemberg, 63003 Clermont-Ferrand, France
| | - Laurent Muller
- />Service de réanimation, hôpital Carémeau, CHU de Nîmes, 4 rue du Professeur Robert-Debré, 30029 Nîmes, France
| | - Matthieu Legrand
- />Service d’anesthésie-réanimation, hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1, Avenue Claude-Vellefaux, 75010 Paris, France
| | - Nicolas Lerolle
- />Service de réanimation, centre hospitalier universitaire, CHU d’Angers, 4 rue Larrey, 49100 Angers, France
| | - Thomas Rimmelé
- />Service d’anesthésie réanimation, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
| | - Eric Rondeau
- />Service de néphrologie, hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France
| | - Fabienne Tamion
- />Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
| | - Yannick Walrave
- />Service de Réanimation Polyvalente, CHU de Nice, 30 Voie Romaine, 06000 Nice, France
| | - Lionel Velly
- />Service d’anesthésie-réanimation, hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, 13385 Marseille Cedex 5, France
| | - Société française d’anesthésie et de réanimation (Sfar)
- />Service de Réanimation Polyvalente, IRCAN (Inserm U1081, CNRS UMR7284 et CHU de Nice, Hôpital Pasteur 2, 30 Voie Romaine, CHU de Nice, 06000 Nice, France
- />Service de Réanimation, Hôpital Marc Jacquet, 77000 Melun, France
- />Service de Réanimation Polyvalente, CHU de Nice, 30 Voie Romaine, 06000 Nice, France
- />Service de Réanimation médicale, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital d’Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France
- />Département de Médecine périopératoire, Hôpital Estaing, CHU de Clermont-Ferrand, 1 place Louis Aubrac, 63000 Clermont-Ferrand, France
- />Service de réanimation, hôpital de la Charité, CHU de Saint-Etienne, 44 rue Pointe Cadet, 42100 Saint-Etienne, France
- />Département d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Kremlin-Bicêtre, 78, rue de la division du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- />Service de Pédiatrie, hôpital Sud, CHU de Rennes, 16 Bd Bulgarie, 35203 Rennes, France
- />Service de Pédiatrie, Néphrologie, hôpital des Enfants, CHU de Toulouse, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex, France
- />Service d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Saint-Louis, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service d’Anesthésie Réanimation II, Hôpital du Haut-Lévêque, CHU de Bordeaux, 33600 Pessac, France
- />Service de néphrologie-dialyse, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Européen Georges Pompidou, 20, rue Leblanc, 75908 Paris, France
- />Service de réanimation, hôpital Gabriel Montpied, CHU de Clermont-Ferrand, 58 rue Montalemberg, 63003 Clermont-Ferrand, France
- />Service de réanimation, hôpital Carémeau, CHU de Nîmes, 4 rue du Professeur Robert-Debré, 30029 Nîmes, France
- />Service d’anesthésie-réanimation, hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service de réanimation, centre hospitalier universitaire, CHU d’Angers, 4 rue Larrey, 49100 Angers, France
- />Service d’anesthésie réanimation, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de néphrologie, hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France
- />Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
- />Service d’anesthésie-réanimation, hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, 13385 Marseille Cedex 5, France
| | - Société de réanimation de langue française (SRLF)
- />Service de Réanimation Polyvalente, IRCAN (Inserm U1081, CNRS UMR7284 et CHU de Nice, Hôpital Pasteur 2, 30 Voie Romaine, CHU de Nice, 06000 Nice, France
- />Service de Réanimation, Hôpital Marc Jacquet, 77000 Melun, France
- />Service de Réanimation Polyvalente, CHU de Nice, 30 Voie Romaine, 06000 Nice, France
- />Service de Réanimation médicale, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital d’Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France
- />Département de Médecine périopératoire, Hôpital Estaing, CHU de Clermont-Ferrand, 1 place Louis Aubrac, 63000 Clermont-Ferrand, France
- />Service de réanimation, hôpital de la Charité, CHU de Saint-Etienne, 44 rue Pointe Cadet, 42100 Saint-Etienne, France
- />Département d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Kremlin-Bicêtre, 78, rue de la division du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- />Service de Pédiatrie, hôpital Sud, CHU de Rennes, 16 Bd Bulgarie, 35203 Rennes, France
- />Service de Pédiatrie, Néphrologie, hôpital des Enfants, CHU de Toulouse, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex, France
- />Service d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Saint-Louis, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service d’Anesthésie Réanimation II, Hôpital du Haut-Lévêque, CHU de Bordeaux, 33600 Pessac, France
- />Service de néphrologie-dialyse, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Européen Georges Pompidou, 20, rue Leblanc, 75908 Paris, France
- />Service de réanimation, hôpital Gabriel Montpied, CHU de Clermont-Ferrand, 58 rue Montalemberg, 63003 Clermont-Ferrand, France
- />Service de réanimation, hôpital Carémeau, CHU de Nîmes, 4 rue du Professeur Robert-Debré, 30029 Nîmes, France
- />Service d’anesthésie-réanimation, hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service de réanimation, centre hospitalier universitaire, CHU d’Angers, 4 rue Larrey, 49100 Angers, France
- />Service d’anesthésie réanimation, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de néphrologie, hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France
- />Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
- />Service d’anesthésie-réanimation, hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, 13385 Marseille Cedex 5, France
| | - Groupe francophone de réanimation et urgences pédiatriques (GFRUP)
- />Service de Réanimation Polyvalente, IRCAN (Inserm U1081, CNRS UMR7284 et CHU de Nice, Hôpital Pasteur 2, 30 Voie Romaine, CHU de Nice, 06000 Nice, France
- />Service de Réanimation, Hôpital Marc Jacquet, 77000 Melun, France
- />Service de Réanimation Polyvalente, CHU de Nice, 30 Voie Romaine, 06000 Nice, France
- />Service de Réanimation médicale, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital d’Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France
- />Département de Médecine périopératoire, Hôpital Estaing, CHU de Clermont-Ferrand, 1 place Louis Aubrac, 63000 Clermont-Ferrand, France
- />Service de réanimation, hôpital de la Charité, CHU de Saint-Etienne, 44 rue Pointe Cadet, 42100 Saint-Etienne, France
- />Département d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Kremlin-Bicêtre, 78, rue de la division du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- />Service de Pédiatrie, hôpital Sud, CHU de Rennes, 16 Bd Bulgarie, 35203 Rennes, France
- />Service de Pédiatrie, Néphrologie, hôpital des Enfants, CHU de Toulouse, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex, France
- />Service d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Saint-Louis, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service d’Anesthésie Réanimation II, Hôpital du Haut-Lévêque, CHU de Bordeaux, 33600 Pessac, France
- />Service de néphrologie-dialyse, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Européen Georges Pompidou, 20, rue Leblanc, 75908 Paris, France
- />Service de réanimation, hôpital Gabriel Montpied, CHU de Clermont-Ferrand, 58 rue Montalemberg, 63003 Clermont-Ferrand, France
- />Service de réanimation, hôpital Carémeau, CHU de Nîmes, 4 rue du Professeur Robert-Debré, 30029 Nîmes, France
- />Service d’anesthésie-réanimation, hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service de réanimation, centre hospitalier universitaire, CHU d’Angers, 4 rue Larrey, 49100 Angers, France
- />Service d’anesthésie réanimation, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de néphrologie, hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France
- />Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
- />Service d’anesthésie-réanimation, hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, 13385 Marseille Cedex 5, France
| | - Société française de néphrologie (SFN)
- />Service de Réanimation Polyvalente, IRCAN (Inserm U1081, CNRS UMR7284 et CHU de Nice, Hôpital Pasteur 2, 30 Voie Romaine, CHU de Nice, 06000 Nice, France
- />Service de Réanimation, Hôpital Marc Jacquet, 77000 Melun, France
- />Service de Réanimation Polyvalente, CHU de Nice, 30 Voie Romaine, 06000 Nice, France
- />Service de Réanimation médicale, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital d’Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France
- />Département de Médecine périopératoire, Hôpital Estaing, CHU de Clermont-Ferrand, 1 place Louis Aubrac, 63000 Clermont-Ferrand, France
- />Service de réanimation, hôpital de la Charité, CHU de Saint-Etienne, 44 rue Pointe Cadet, 42100 Saint-Etienne, France
- />Département d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Kremlin-Bicêtre, 78, rue de la division du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- />Service de Pédiatrie, hôpital Sud, CHU de Rennes, 16 Bd Bulgarie, 35203 Rennes, France
- />Service de Pédiatrie, Néphrologie, hôpital des Enfants, CHU de Toulouse, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex, France
- />Service d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Saint-Louis, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service d’Anesthésie Réanimation II, Hôpital du Haut-Lévêque, CHU de Bordeaux, 33600 Pessac, France
- />Service de néphrologie-dialyse, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Européen Georges Pompidou, 20, rue Leblanc, 75908 Paris, France
- />Service de réanimation, hôpital Gabriel Montpied, CHU de Clermont-Ferrand, 58 rue Montalemberg, 63003 Clermont-Ferrand, France
- />Service de réanimation, hôpital Carémeau, CHU de Nîmes, 4 rue du Professeur Robert-Debré, 30029 Nîmes, France
- />Service d’anesthésie-réanimation, hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service de réanimation, centre hospitalier universitaire, CHU d’Angers, 4 rue Larrey, 49100 Angers, France
- />Service d’anesthésie réanimation, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de néphrologie, hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France
- />Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
- />Service d’anesthésie-réanimation, hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, 13385 Marseille Cedex 5, France
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Acute kidney injury in the perioperative period and in intensive care units (excluding renal replacement therapies). Anaesth Crit Care Pain Med 2016; 35:151-65. [PMID: 27235292 DOI: 10.1016/j.accpm.2016.03.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Ibrahim ES, Sharawy A. Effectiveness of intravenous infusion of N-acetylcysteine in cirrhotic patients undergoing major abdominal surgeries. Saudi J Anaesth 2015; 9:272-8. [PMID: 26240545 PMCID: PMC4478819 DOI: 10.4103/1658-354x.154706] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Postoperative acute kidney injury (AKI) is common in patients with chronic liver disease. We prospectively evaluated effectiveness of the N-acetylcysteine (NAC) in preserving postoperative renal functions in cirrhotic patients undergoing major abdominal surgeries. MATERIALS AND METHODS A total of 60 cirrhotic patients child A to B were randomized into two groups of 30 each. NAC groupwas received intravenous infusion of NAC (1200 mg/12h starting immediately before surgery and continued for 72h h postoperative) and controls group received a similar volume of glucose 5% solution as a a placebo. Systemic hemodynamics, hepatic and renal functions, serum cystatin C and cystatin C glomerular filtration rate (GFR) (GFR) were compared between both groups. RESULTS Serum level of cystatin C was raised significantly above the basal value at postoperative day 1 and day 3 associated with significantly decreased in cystatin C GFR below the basal value in the control group (P = 0.001). 6 (20%) (PP = 0.03) in control group developed AKI based on cystatin C GFR criteria (GFR <55 ml/min/1.73m(2)). Mean values of alanine aminotransferase and aspartate aminotransferase were increased significantly above the basal values in both groups, but the increases were significantly lower in NAC group (P = 0.00). Chest infection was significantly lower associated with shorter hospital stay in the NAC group than the control group. CONCLUSION Intravenous administration of NAC NAC in cirrhotic patients undergoing major abdominal surgeries reduces the incidence of cystatin C GFR-based AKI, postoperative renal and liver functions were well-preserved and improved outcome.
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Affiliation(s)
- Eman Sayed Ibrahim
- Department of Anesthesia, National Liver Institute, Menofeya University, Menofeya, Egypt
| | - Ahmed Sharawy
- Department of Clinical Pathology, National Liver Institute, Menofeya University, Menofeya, Egypt
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Ozaydin M, Peker T, Akcay S, Uysal BA, Yucel H, Icli A, Erdogan D, Varol E, Dogan A, Okutan H. Addition of N-acetyl cysteine to carvedilol decreases the incidence of acute renal injury after cardiac surgery. Clin Cardiol 2014; 37:108-14. [PMID: 24672814 DOI: 10.1002/clc.22227] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Oxidative stress and inflammation during cardiac surgery may be associated with acute renal injury (ARI). N-acetyl cysteine (NAC) and carvedilol have antioxidant and anti-inflammatory properties. HYPOTHESIS A combination of carvedilol and NAC should decrease the incidence of ARI more than metoprolol or carvedilol. METHODS Patients undergoing cardiac surgery were randomized to metoprolol, carvedilol, or carvedilol plus NAC. End points were occurrence of ARI and change in preoperative to postoperative peak creatinine levels. RESULTS ARI incidence was lower in the carvedilol plus NAC group compared with the metoprolol (21.0% vs 42.1%; P = 0.002) or carvedilol (21.0% vs 38.6%; P = 0.006) groups, but was similar between the metoprolol and carvedilol groups (P = 0.62). Preoperative and postoperative day 1 creatinine levels were similar among the metoprolol (1.02 [0.9-1.2] and 1.2 [0.92-1.45]) the carvedilol (1.0 [0.88-1.08] and 1.2 [0.9-1.5]) and the carvedilol plus NAC groups (1.06 [0.9-1.18] and 1.1 [1.0-1.21] mg/dL; all P values >0.05). Postoperative day 3, day 5, and peak creatinine levels were lower in the carvedilol plus NAC group (1.11 [1.0-1.23], 1.14 [1.0-1.25] and 1.15 [1.0-1.25]) as compared with the metoprolol (1.4 [1.3-1.49], 1.3 [1.0-1.54] and 1.3 [1.0-1.54]) or carvedilol groups (1.2 [1.0-1.52], 1.25 [1.0-1.52] and 1.25 [1.0-1.55] mg/dL; all P values <0.05), but were similar between the metoprolol and carvedilol groups (all P values >0.05). CONCLUSIONS Combined carvedilol and NAC decreased ARI incidence as compared with carvedilol or metoprolol. No difference was detected between carvedilol and metoprolol.
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Barajas-Espinosa A, Basye A, Jesse E, Yan H, Quan D, Chen CA. Redox activation of DUSP4 by N-acetylcysteine protects endothelial cells from Cd²⁺-induced apoptosis. Free Radic Biol Med 2014; 74:188-199. [PMID: 24973647 PMCID: PMC4146716 DOI: 10.1016/j.freeradbiomed.2014.06.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 06/16/2014] [Accepted: 06/17/2014] [Indexed: 02/07/2023]
Abstract
Redox imbalance is a primary cause of endothelial dysfunction (ED). Under oxidant stress, many critical proteins regulating endothelial function undergo oxidative modifications that lead to ED. Cellular levels of glutathione (GSH), the primary reducing source in cells, can significantly regulate cell function via reversible protein thiol modification. N-acetylcysteine (NAC), a precursor for GSH biosynthesis, is beneficial for many vascular diseases; however, the detailed mechanism of these benefits is still not clear. From HPLC analysis, NAC significantly increases both cellular GSH and tetrahydrobiopterin levels. Immunoblotting of endothelial NO synthase (eNOS) and DUSP4, a dual-specificity phosphatase with a cysteine as its active residue, revealed that both enzymes are upregulated by NAC. EPR spin trapping further demonstrated that NAC enhances NO generation from cells. Long-term exposure to Cd(2+) contributes to DUSP4 degradation and the uncontrolled activation of p38 and ERK1/2, leading to apoptosis. Treatment with NAC prevents DUSP4 degradation and protects cells against Cd(2+)-induced apoptosis. Moreover, the increased DUSP4 expression can redox-regulate the p38 and ERK1/2 pathways from hyperactivation, providing a survival mechanism against the toxicity of Cd(2+). DUSP4 gene knockdown further supports the hypothesis that DUSP4 is an antioxidant gene, critical in the modulation of eNOS expression, and thus protects against Cd(2+)-induced stress. Depletion of intracellular GSH by buthionine sulfoximine makes cells more susceptible to Cd(2+)-induced apoptosis. Pretreatment with NAC prevents p38 overactivation and thus protects the endothelium from this oxidative stress. Therefore, the identification of DUSP4 activation by NAC provides a novel target for future drug design.
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Affiliation(s)
- Alma Barajas-Espinosa
- Department of Emergency Medicine, College of Medicine, The Ohio State University, Columbus OH, 43210 USA
| | - Ariel Basye
- Department of Emergency Medicine, College of Medicine, The Ohio State University, Columbus OH, 43210 USA
| | - Erin Jesse
- Department of Emergency Medicine, College of Medicine, The Ohio State University, Columbus OH, 43210 USA
| | - Haixu Yan
- Department of Emergency Medicine, College of Medicine, The Ohio State University, Columbus OH, 43210 USA
| | - David Quan
- Department of Emergency Medicine, College of Medicine, The Ohio State University, Columbus OH, 43210 USA
| | - Chun-An Chen
- Corresponding Author: Chun-An (Andy) Chen, Department of Emergency Medicine, 760 Prior Hall 376 W 10 Ave Columbus, OH 43210, Tel. 614-366-6380, Fax. 614-293-3124,
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Mao H, Katz N, Ariyanon W, Blanca-Martos L, Adýbelli Z, Giuliani A, Danesi TH, Kim JC, Nayak A, Neri M, Virzi GM, Brocca A, Scalzotto E, Salvador L, Ronco C. Cardiac Surgery-Associated Acute Kidney Injury. Blood Purif 2014; 37 Suppl 2:34-50. [DOI: 10.1159/000361062] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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High Dose of N-Acetylcystein Prevents Acute Kidney Injury in Chronic Kidney Disease Patients Undergoing Myocardial Revascularization. Ann Thorac Surg 2014; 97:1617-23. [DOI: 10.1016/j.athoracsur.2014.01.056] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 01/15/2014] [Accepted: 01/17/2014] [Indexed: 11/22/2022]
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Abstract
Up to 30% of patients undergoing cardiac surgery develop AKI, with 1% requiring RRT. AKI is an independent risk factor for morbidity and mortality. Postoperatively, even minimal changes in serum creatinine are associated with a substantial increase in mortality. No intervention has been definitely proven effective in reducing kidney injury. The successful prevention and management of AKI involves identifying patients at risk for AKI, recognizing subtle abnormalities in a timely manner, performing basic clinical assessments, and responding appropriately to data obtained. With that in mind, in this Attending Rounds, a woman with AKI in the setting of cardiac surgery is presented to highlight the use of history, physical exam, hemodynamic monitoring, laboratory data trends, and urine indices in establishing the correct diagnosis and appropriate management.
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Affiliation(s)
- Ashita J Tolwani
- Division of Nephrology, University of Alabama, Birmingham, Alabama
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Ghatanatti R, Teli A, Tirkey SS, Bhattacharya S, Sengupta G, Mondal A. Role of renal biomarkers as predictors of acute kidney injury in cardiac surgery. Asian Cardiovasc Thorac Ann 2013; 22:234-41. [DOI: 10.1177/0218492313502028] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Cardiac surgery is unique in using cardiopulmonary bypass in various clinical scenarios. Injury of vital organs is unavoidable in the perioperative period. Acute kidney injury is a consequence of the systemic inflammatory response after bypass, emboli, ischemia, and low cardiac output states, reportedly occurring in 30%–40% of open heart surgeries. Acute kidney injury is associated with increased morbidity, mortality, and cost. Many preventive measures (off-pump procedures, decreased crossclamp time, pulsatile flow, adequate hydration) are taken in the perioperative period to avoid organ injury, but in vain. Traditionally, blood urea, serum creatinine, and creatinine clearance rate were applied for prediction of acute kidney injury. The recent emergence of biomarkers such as neutrophil gelatinase-associated lipocalin, cystatin C, liver-type fatty acid binding protein, interleukin-18, kidney injury molecule-1, and tetrahydrobiopterin have helped in detecting acute kidney injury long before the rise of serum creatinine. These biomarkers can also be used as tools for predicting therapeutic effects in acute kidney injury and for monitoring drug toxicity. This review consolidates the knowledge of biomarkers and their application in acute kidney injury management.
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Affiliation(s)
- Ravi Ghatanatti
- Department of Cardiothoracic and Vascular Surgery, SSKM Hospital and IPGME&R Kolkata, India
| | - Anita Teli
- Department of Physiology, BLDE University, Shri BM Patil Medical College, Bijapur, Karnataka, India
| | | | - Subhankar Bhattacharya
- Department of Cardiothoracic and Vascular Surgery, SSKM Hospital and IPGME&R Kolkata, India
| | - Gautam Sengupta
- Department of Cardiothoracic and Vascular Surgery, SSKM Hospital and IPGME&R Kolkata, India
| | - Ansuman Mondal
- Department of Cardiothoracic and Vascular Surgery, SSKM Hospital and IPGME&R Kolkata, India
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Mao H, Katz N, Ariyanon W, Blanca-Martos L, Adýbelli Z, Giuliani A, Danesi TH, Kim JC, Nayak A, Neri M, Virzi GM, Brocca A, Scalzotto E, Salvador L, Ronco C. Cardiac surgery-associated acute kidney injury. Cardiorenal Med 2013; 3:178-199. [PMID: 24454314 PMCID: PMC3884176 DOI: 10.1159/000353134] [Citation(s) in RCA: 157] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common and serious postoperative complication of cardiac surgery requiring cardiopulmonary bypass (CPB), and it is the second most common cause of AKI in the intensive care unit. Although the complication has been associated with the use of CPB, the etiology is likely multifactorial and related to intraoperative and early postoperative management including pharmacologic therapy. To date, very little evidence from randomized trials supporting specific interventions to protect from or prevent AKI in broad cardiac surgery populations has been found. The definition of AKI employed by investigators influences not only the incidence of CSA-AKI, but also the identification of risk variables. The advent of novel biomarkers of kidney injury has the potential to facilitate the subclinical diagnosis of CSA-AKI, the assessment of its severity and prognosis, and the early institution of interventions to prevent or reduce kidney damage. Further studies are needed to determine how to optimize cardiac surgical procedures, CPB parameters, and intraoperative and early postoperative blood pressure and renal blood flow to reduce the risk of CSA-AKI. No pharmacologic strategy has demonstrated clear efficacy in the prevention of CSA-AKI; however, some agents, such as the natriuretic peptide nesiritide and the dopamine agonist fenoldopam, have shown promising results in renoprotection. It remains unclear whether CSA-AKI patients can benefit from the early institution of such pharmacologic agents or the early initiation of renal replacement therapy.
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Affiliation(s)
- Huijuan Mao
- Department of Nephrology, Ospedale San Bortolo, Vicenza, Italy
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Nevin Katz
- Department of Surgery, Johns Hopkins University, Baltimore, Md., USA
| | - Wassawon Ariyanon
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Cardiometabolic Centre, BNH Hospital, Bangkok, Thailand
| | - Lourdes Blanca-Martos
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
- Department of Nephrology, Hospital Universitario Carlos Haya, Málaga, Spain
| | - Zelal Adýbelli
- Department of Nephrology, Ospedale San Bortolo, Vicenza, Italy
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
| | - Anna Giuliani
- Department of Nephrology, Ospedale San Bortolo, Vicenza, Italy
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | | | - Jeong Chul Kim
- Department of Nephrology, Ospedale San Bortolo, Vicenza, Italy
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
| | - Akash Nayak
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
- Department of Chemical Engineering and Economics BITS Pilani, Pilani, India
| | - Mauro Neri
- Department of Nephrology, Ospedale San Bortolo, Vicenza, Italy
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
| | - Grazia Maria Virzi
- Department of Nephrology, Ospedale San Bortolo, Vicenza, Italy
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
| | - Alessandra Brocca
- Department of Nephrology, Ospedale San Bortolo, Vicenza, Italy
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
| | - Elisa Scalzotto
- Department of Nephrology, Ospedale San Bortolo, Vicenza, Italy
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
| | - Loris Salvador
- Department of Cardiac Surgery, Ospedale San Bortolo, Vicenza, Italy
| | - Claudio Ronco
- Department of Nephrology, Ospedale San Bortolo, Vicenza, Italy
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
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Landoni G, Rodseth RN, Santini F, Ponschab M, Ruggeri L, Székely A, Pasero D, Augoustides JG, Del Sarto PA, Krzych LJ, Corcione A, Slullitel A, Cabrini L, Le Manach Y, Almeida RM, Bignami E, Biondi-Zoccai G, Bove T, Caramelli F, Cariello C, Carpanese A, Clarizia L, Comis M, Conte M, Covello RD, De Santis V, Feltracco P, Giordano G, Pittarello D, Gottin L, Guarracino F, Morelli A, Musu M, Pala G, Pasin L, Pezzoli I, Paternoster G, Remedi R, Roasio A, Zucchetti M, Petrini F, Finco G, Ranieri M, Zangrillo A. Randomized Evidence for Reduction of Perioperative Mortality. J Cardiothorac Vasc Anesth 2012; 26:764-72. [PMID: 22726656 DOI: 10.1053/j.jvca.2012.04.018] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Indexed: 02/08/2023]
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Szakmany T, Hauser B, Radermacher P. N-acetylcysteine for sepsis and systemic inflammatory response in adults. Cochrane Database Syst Rev 2012; 2012:CD006616. [PMID: 22972094 PMCID: PMC6517277 DOI: 10.1002/14651858.cd006616.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Death is common in systemic inflammatory response syndrome (SIRS) or sepsis-induced multisystem organ failure and it has been thought that antioxidants such as N-acetylcysteine could be beneficial. OBJECTIVES We assessed the clinical effectiveness of intravenous N-acetylcysteine for the treatment of patients with SIRS or sepsis. SEARCH METHODS We searched the following databases: Cochrane Central Register of Clinical Trials (CENTRAL) (The Cochrane Library 2011, Issue 12); MEDLINE (January 1950 to January 2012); EMBASE (January 1980 to January 2012); CINAHL (1982 to January 2012); the NHS Trusts Clinical Trials Register and Current Controlled Trials (www.controlled-trials.com); LILACS; KoreaMED; MEDCARIB; INDMED; PANTELEIMON; Ingenta; ISI Web of Knowledge and the National Trials Register to identify all relevant randomized controlled trials available for review. SELECTION CRITERIA We included only randomized controlled trials (RCTs) in the meta-analysis. DATA COLLECTION AND ANALYSIS We independently performed study selection, quality assessment and data extraction. We estimated risk ratios (RR) for dichotomous outcomes. We measured statistical heterogeneity using the I(2) statistic. MAIN RESULTS We included 41 fully published studies (2768 patients). Mortality was similar in the N-acetylcysteine group and the placebo group (RR 1.06, 95% CI 0.79 to 1.42; I(2) = 0%). Neither did N-acetylcysteine show any significant effect on length of stay, duration of mechanical ventilation or incidence of new organ failure. Early application of N-acetylcysteine to prevent the development of an oxidato-inflammatory response did not affect the outcome, nor did late application that is after 24 hours of developing symptoms. Late application was associated with cardiovascular instability. AUTHORS' CONCLUSIONS Overall, this meta-analysis puts doubt on the safety and utility of intravenous N-acetylcysteine as an adjuvant therapy in SIRS and sepsis. At best, N-acetylcysteine is ineffective in reducing mortality and complications in this patient population. At worst, it can be harmful, especially when administered later than 24 hours after the onset of symptoms, by causing cardiovascular depression. Unless future RCTs provide evidence of treatment effect, clinicians should not routinely use intravenous N-acetylcysteine in SIRS or sepsis and academics should not promote its use.
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Affiliation(s)
- Tamas Szakmany
- Department of Anaesthesia, Cwm Taf NHS Trust, Royal Glamorgan Hospital, Llantrisant, UK.
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29
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Abstract
Acute kidney injury (AKI) is a serious complication for the critically ill patient. The term has been increasingly adopted over recent years as efforts have been made to capture and better define mild to severe renal dysfunction. Persistent AKI can lead to the subsequent development of renal failure recognized as an important determinant of morbidity and mortality in the critically ill patient. This article explores the clinical implications of AKI for the critically ill patient and how this can have a profound influence on the principal presenting disease and expected outcome.
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Arora P, Kolli H, Nainani N, Nader N, Lohr J. Preventable Risk Factors for Acute Kidney Injury in Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2012; 26:687-97. [DOI: 10.1053/j.jvca.2012.03.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Indexed: 11/11/2022]
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Calvert S, Shaw A. Perioperative acute kidney injury. Perioper Med (Lond) 2012; 1:6. [PMID: 24764522 PMCID: PMC3886265 DOI: 10.1186/2047-0525-1-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 07/04/2012] [Indexed: 01/04/2023] Open
Abstract
Acute kidney injury (AKI) is a serious complication in the perioperative period, and is consistently associated with increased rates of mortality and morbidity. Two major consensus definitions have been developed in the last decade that allow for easier comparison of trial evidence. Risk factors have been identified in both cardiac and general surgery and there is an evolving role for novel biomarkers. Despite this, there has been no real change in outcomes and the mainstay of treatment remains preventive with no clear evidence supporting any therapeutic intervention as yet. This review focuses on definition, risk factors, the emerging role of biomarkers and subsequent management of AKI in the perioperative period, taking into account new and emerging strategies.
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Affiliation(s)
| | - Andrew Shaw
- Dept of Anesthesiology and Critical Care Medicine, Duke University Medical Center/Durham VAMC, Durham, USA
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32
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Renal dysfunction and CABG. Curr Opin Pharmacol 2012; 12:181-8. [DOI: 10.1016/j.coph.2012.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Revised: 01/30/2012] [Accepted: 02/23/2012] [Indexed: 12/27/2022]
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Patel NN, Rogers CA, Angelini GD, Murphy GJ. Pharmacological therapies for the prevention of acute kidney injury following cardiac surgery: a systematic review. Heart Fail Rev 2011; 16:553-67. [PMID: 21400231 DOI: 10.1007/s10741-011-9235-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Post-cardiac surgery acute kidney injury (AKI) is common and is associated with a significant increase in morbidity and mortality. We aimed to systematically review randomised trials that assessed the renoprotective utility of pharmacological agents in patients undergoing cardiac surgery. We searched PubMed, Embase and the Cochrane Central Register of Controlled Trials for randomised controlled trials comparing renoprotective pharmacological interventions with control in adult patients undergoing cardiac surgery with cardiopulmonary bypass. We extracted data for mortality, need for renal replacement therapy (RRT), incidence of AKI, and creatinine clearance at 24-48 h. About 49 randomised controlled trials involving 4605 patients were included. Pharmacological interventions included dopamine, fenoldopam, calcium channel antagonists, natriuretic peptides, diuretics, and N-acetylcysteine. Most trials were of poor quality, with small sample sizes, under-reporting of randomisation procedure, allocation concealment and method of blinding. No pharmacological intervention significantly reduced mortality. Fenoldopam and Atrial Natriuretic Peptide (ANP) reduced the need for renal replacement therapy by 5% (NNT 20, 95% CI 11.3, 83.0) and 3.5% (NNT 29, 95% CI 17.1, 84.4), respectively. Brain Natriuretic Peptide resulted in a 10% reduction in the incidence of AKI (NNT 11, 95% CI 6.2, 32.0). Dopamine caused a significant reduction in creatinine clearance (-4.26 ml/min, 95% CI -7.14, -1.39). The quality of studies that have assessed pharmacological renoprotective agents in cardiac surgery is generally poor. Fenoldopam, ANP and BNP show evidence of renoprotection. Randomised studies evaluating the effect of novel renoprotective agents that are powered to detect clinically relevant differences in outcomes are required.
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Affiliation(s)
- Nishith N Patel
- Queen's Building, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, BS2 8HW, UK
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Mariscalco G, Lorusso R, Dominici C, Renzulli A, Sala A. Acute Kidney Injury: A Relevant Complication After Cardiac Surgery. Ann Thorac Surg 2011; 92:1539-47. [DOI: 10.1016/j.athoracsur.2011.04.123] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Revised: 04/27/2011] [Accepted: 04/29/2011] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) is a serious complication that significantly increases morbidity, mortality and cost of care after cardiac surgery. In this review we identify the current literature that addresses strategies for renal protection and the prevention of AKI after cardiac surgery. RECENT FINDINGS Even with aggressive medical care and renal replacement therapy (RRT) the morbidity, mortality and cost of postoperative AKI after cardiac surgery is substantial. An emphasis on preventive strategies would therefore appear to be the most cost-effective approach. Recent literature offers hope that as our understanding of the pathogenesis of AKI after cardiac surgery continues to improve, new directions for the prevention and amelioration of AKI will emerge. Approaches to the prevention of postoperative AKI include careful risk stratification of patients, allowing adequate recovery following a prior AKI, consideration of less extensive surgical procedures, avoidance of cardiopulmonary bypass, minimizing injury from radiocontrast dyes or other nephrotoxic agents, and optimizing cardiovascular function and oxygen delivery. Early identification of AKI and prompt, judicious application of RRT may also improve outcomes. Interest in pharmacologic renoprotection is currently directed toward statins and sodium bicarbonate. SUMMARY Postoperative AKI is a serious complication after cardiac surgery. Therapeutic interventions and RRT have limited influence on the outcome of AKI, and a preventive strategy remains the mainstay to attenuate its impact.
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Chu DI, Lim R, Heydrick S, Gainsbury ML, Abdou R, D’Addese L, Reed KL, Stucchi AF, Becker JM. N-acetyl-l-cysteine decreases intra-abdominal adhesion formation through the upregulation of peritoneal fibrinolytic activity and antioxidant defenses. Surgery 2011; 149:801-12. [DOI: 10.1016/j.surg.2011.02.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 02/17/2011] [Indexed: 10/18/2022]
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Wang G, Bainbridge D, Martin J, Cheng D. N-acetylcysteine in Cardiac Surgery: Do the Benefits Outweigh the Risks? A Meta-Analytic Reappraisal. J Cardiothorac Vasc Anesth 2011; 25:268-75. [DOI: 10.1053/j.jvca.2010.04.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Indexed: 02/05/2023]
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Anderson SM, Park ZH, Patel RV. Intravenous N-Acetylcysteine in the Prevention of Contrast Media-Induced Nephropathy. Ann Pharmacother 2011; 45:101-7. [DOI: 10.1345/aph.1p275] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objective Ti define the clinical role of intravenous N-acetylcysteine for prophylaxis of contrast-induced nephropathy (CIN). Data Sources: Randomized controlled clinical trials were identified using a search of MEDLINE (1990-September 2010) with the search terms acetylcysteine, N-acetylcysteine, NAC, intravenous, IV, nephropathy, nephrotoxic, radiocontrast, contrast, and media. The search was limited to studies published in English. Additional pertinent literature was retrieved by reviewing references of the articles obtained in the initial search. Data Synthesis: N-Acetylcysteine is a vasodilator and antioxidant that has been investigated for the prevention of CIN. In the majority of clinical trials, neither oral nor intravenous N-acetyIcysteine has demonstrated clinical benefits at preventing CIN. The pharmacodynamic and pharmacokinetic profiles of intravenous N-acetylcysteine are significantly different from those of the oral product in that intravenous administration bypasses extensive first-pass metabolism. Studies have suggested that N-acetylcysteine directly affects serum creatinine levels in a way that is not associated with improvement of kidney function. Only intravenous N-acetylcysteine doses that were higher than the oral doses showed potential benefits, but they were associated with significant adverse events. Furthermore, the study populations were heterogeneous, including patients with various levels of kidney function and other risk factors, and the clinical definition of CIN was not well established. Conclusions: NO conclusive evidence has shown that intravenous N-acetyl-cysteine is safe and effective in preventing CIN. Further clinical trials to define its role are warranted.
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Affiliation(s)
- Spencer M Anderson
- Molecular Pharmacology and Biological Chemistry, Northwestern University, Argonne, IL; School of Pharmacy and Health Professions, Creighton University, Omaha, NE
| | - Zoon H Park
- Department of Pharmacy Services, Swedish Covenant Hospital, Chicago, IL
| | - Ramesh V Patel
- Department of Pharmacy Services, Swedish Covenant Hospital
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Harley CB, Liu W, Blasco M, Vera E, Andrews WH, Briggs LA, Raffaele JM. A natural product telomerase activator as part of a health maintenance program. Rejuvenation Res 2010; 14:45-56. [PMID: 20822369 DOI: 10.1089/rej.2010.1085] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Most human cells lack sufficient telomerase to maintain telomeres, hence these genetic elements shorten with time and stress, contributing to aging and disease. In January, 2007, a commercial health maintenance program, PattonProtocol-1, was launched that included a natural product-derived telomerase activator (TA-65®, 10-50 mg daily), a comprehensive dietary supplement pack, and physician counseling/laboratory tests at baseline and every 3-6 months thereafter. We report here analysis of the first year of data focusing on the immune system. Low nanomolar levels of TA-65® moderately activated telomerase in human keratinocytes, fibroblasts, and immune cells in culture; similar plasma levels of TA-65® were achieved in pilot human pharmacokinetic studies with single 10- to 50-mg doses. The most striking in vivo effects were declines in the percent senescent cytotoxic (CD8(+)/CD28(-)) T cells (1.5, 4.4, 8.6, and 7.5% at 3, 6, 9, and 12 months, respectively; p = not significant [N.S.], 0.018, 0.0024, 0.0062) and natural killer cells at 6 and 12 months (p = 0.028 and 0.00013, respectively). Most of these decreases were seen in cytomegalovirus (CMV) seropositive subjects. In a subset of subjects, the distribution of telomere lengths in leukocytes at baseline and 12 months was measured. Although mean telomere length did not increase, there was a significant reduction in the percent short (<4 kbp) telomeres (p = 0.037). No adverse events were attributed to PattonProtocol-1. We conclude that the protocol lengthens critically short telomeres and remodels the relative proportions of circulating leukocytes of CMV(+) subjects toward the more "youthful" profile of CMV(-) subjects. Controlled randomized trials are planned to assess TA-65®-specific effects in humans.
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Ashworth A, Webb ST. Does the prophylactic administration of N-acetylcysteine prevent acute kidney injury following cardiac surgery? Interact Cardiovasc Thorac Surg 2010; 11:303-8. [PMID: 20570977 DOI: 10.1510/icvts.2010.232413] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'does prophylactic administration of N-acetylcysteine (NAC) prevent acute kidney injury (AKI) following cardiac surgery?' More than 60 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The administration of NAC prior intravenous radioactive contrast has been shown to reduce the incidence of contrast-induced nephropathy. There have been two recent meta-analyses and several randomised controlled trials (RCTs) and investigating the effectiveness of prophylactic administration of NAC in the prevention of AKI following cardiac surgery. The RCTs have investigated the use of NAC to prevent AKI in low-risk patients, high-risk patients and high-risk patients with pre-existing chronic kidney disease. The meta-analyses and RCTs demonstrated that the prophylactic administration of NAC did not reduced the incidence of AKI, postoperative complications, postoperative interventions, mortality or length of ICU stay. We conclude that prophylactic administration of NAC does not prevent AKI or reduce mortality following cardiac surgery.
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Affiliation(s)
- Alan Ashworth
- Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge CB23 3RE, UK
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Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology,American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons,and Society for Vascular Medicine. J Am Coll Cardiol 2010; 55:e27-e129. [PMID: 20359588 DOI: 10.1016/j.jacc.2010.02.015] [Citation(s) in RCA: 1002] [Impact Index Per Article: 71.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Talay S, Abanoz M, Kaygin MA, Dag O, Halici U, Ay D, Yücel SM, Erkut B. Incidence of postoperative acute renal failure among violence-related cardiovascular trauma patients: a review of our experience in 117 cases. Ren Fail 2010; 32:480-5. [PMID: 20446788 DOI: 10.3109/08860221003675278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The purpose of this retrospective study was to determine the incidence of renal failure and hemodialysis (HD) in postoperative period after cardiovascular surgery associated with trauma. METHODS One hundred and seventeen cases of violence-related cardiovascular trauma patients had emergent surgery between 1996 and 2009. Cases were reviewed in three main groups: Cardiac trauma in 11 patients (Group A), vascular trauma in 78 patients (Group B), and cardiovascular trauma in 28 patients (Group C). Postoperative incidence of HD requirements with acute renal failure (ARF) was investigated in these groups of patients postoperatively. RESULTS Multiorgan deficiency developed in 10 patients from Group A, in 45 patients from Group B, and in 26 patients from Group C. Overall mortality was 81 cases in 117 patients. Total hospitalization periods were 21 +/- 2, 17 +/- 3, and 27 +/- 1 days for Group A, Group B, and Group C, respectively. HD administrations were indicated in 3 patients in Group A, 41 patients in Group B, and 9 patients in Group C. No statistically significant difference presented in any study parameter between groups. CONCLUSIONS Cardiovascular trauma is a common reason for emergent cardiovascular surgery. Postoperative renal failure occurs among these patients in a wide percentage. We strongly advocate a close and detailed follow-up of renal functions in these patients during the hospitalization period and immediate HD at indication.
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Affiliation(s)
- Süreyya Talay
- Department of Cardiovascular Surgery, Erzurum Regional Teaching and Research Hospital, Erzurum, Turkey
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Effects of N-acetylcysteine on renal dysfunction in neonates undergoing the arterial switch operation. J Thorac Cardiovasc Surg 2010; 139:956-61. [DOI: 10.1016/j.jtcvs.2009.09.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2009] [Revised: 08/05/2009] [Accepted: 09/15/2009] [Indexed: 11/30/2022]
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Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010; 121:e266-369. [PMID: 20233780 DOI: 10.1161/cir.0b013e3181d4739e] [Citation(s) in RCA: 1182] [Impact Index Per Article: 84.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
PURPOSE OF REVIEW To review recent advances in understanding of the occurrence, pathophysiology, prophylaxis and treatment of cardiac surgery-associated acute kidney injury (AKI). RECENT FINDINGS New definitions and prompt diagnostic tools, enhanced risk stratification strategies, avoidance of nephrotoxins and procedure selection are all areas in which recent contributions to the literature have improved perioperative care for cardiac surgery patients. Although evidence continues to confirm the adverse effects of extreme hemodilution and transfusion as part of cardiac surgery, the previously believed advantages of tight perioperative glucose control for the kidney are being questioned in recent studies. Although very little evidence from randomized trials in cardiac surgery populations supports specific interventions to protect or prevent AKI, recent reports indicate reduced AKI associated with some procedural innovations, and the hope that promising findings for agents such as sodium bicarbonate that require further study may yield effective therapies. SUMMARY The vexing problem of AKI following cardiac surgery is common and unsolved. Clinical strategies that stress avoidance rather than treatment remain the mainstay of effective management of patients at high renal risk.
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Perioperative risk assessment, prevention, and treatment of acute kidney injury. Int Anesthesiol Clin 2009; 47:89-105. [PMID: 19820480 DOI: 10.1097/aia.0b013e3181b47e98] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Pathophysiologie, Prophylaxe und Therapie von Herzchirurgie-assoziierten Nierenfunktionsstörungen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2009. [DOI: 10.1007/s00398-009-0743-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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