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Balachandran M, Banneheke P, Pakavakis A, Al-Bassam W, Sarode V, Rowland M, Shehabi Y. Postoperative 20% albumin vs standard care and acute kidney injury after high-risk cardiac surgery (ALBICS): study protocol for a randomised trial. Trials 2021; 22:558. [PMID: 34419128 PMCID: PMC8380013 DOI: 10.1186/s13063-021-05519-8] [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] [Received: 04/11/2021] [Accepted: 08/06/2021] [Indexed: 11/20/2022] Open
Abstract
Background Acute kidney injury (AKI) is a common complication of cardiac surgery. Factors such as cardiopulmonary bypass, aortic cross-clamping and surgical stress may precipitate renal hypoperfusion and ischaemia, inflammation and oxidative stress are associated with development of AKI. Albumin’s pharmacological properties and widespread availability have the potential to mitigate these factors. However, the effect of albumin on cardiac surgery-associated AKI is unknown. Objective To evaluate the impact of postoperative 20% albumin infusion on kidney function after high-risk cardiac surgery. Methods We designed an open-label, multicentre, randomised controlled trial—the ALBICS study (ALBumin Infusion and acute kidney injury following Cardiac Surgery). A total of 590 patients undergoing high-risk cardiac surgery (combined procedure or estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2) will be enrolled into the study and randomly allocated to receive a postoperative 20% albumin infusion or standard care in a 1:1 ratio, stratified by centre and baseline renal function. The study fluid will be administered upon arrival in intensive care for 15 h. Patients will be followed up until 28 days after surgery or until discharge from the hospital. The primary outcome is the proportion of patients who develop AKI in both groups. Secondary outcomes to be measured are proportions of AKI stage II and III, 28-day mortality, mechanical ventilation time and length of stay in intensive care and hospital. Conclusion This trial aims to determine if a postoperative infusion of concentrated albumin reduces the risk of AKI following high-risk cardiac surgery. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12619001355167. Registered on 03 October 2019—retrospectively registered. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378383.
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Affiliation(s)
- Mayurathan Balachandran
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.
| | - Piyusha Banneheke
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Adrian Pakavakis
- Intensive Care Services, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Wisam Al-Bassam
- Intensive Care Services, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Vineet Sarode
- Intensive Care Services, Cabrini Health, Malvern, Victoria, Australia.,Cabrini Monash University Department of Medicine, Monash University, Malvern, Victoria, Australia
| | - Michael Rowland
- Department of Cardiothoracic Surgery, Barwon Health, Geelong, Victoria, Australia
| | - Yahya Shehabi
- Intensive Care Services, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.,University of New South Wales, Prince of Wales Clinical School of Medicine, Randwick, New South Wales, Australia
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Adiraju SKS, Shekar K, Fraser JF, Smith MT, Ghassabian S. Effect of cardiopulmonary bypass on cytochrome P450 enzyme activity: implications for pharmacotherapy. Drug Metab Rev 2017; 50:109-124. [PMID: 29254370 DOI: 10.1080/03602532.2017.1417423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
For patients undergoing cardiopulmonary bypass (CPB) during cardiac surgery, there are well-documented changes in the pharmacokinetics (PK) of commonly administered drugs. Although multiple factors potentially underpin these changes, there has been scant research attention on the impact of CPB to alter the activities of cytochrome P450 (CYP) isoenzymes. PK changes during cardiac surgery with CPB have the potential to adversely affect the safety and efficacy of pharmacotherapy and increase the risk of drug-drug interactions. Clinically significant changes in drug PK during CPB are likely to be prominent for drugs where CYP metabolism is a major clearance (CL) mechanism. However, clinical data from patients undergoing CPB surgery in support of this hypothesis are lacking, leaving a significant knowledge gap. In this review, we address the effects of CPB on the release of pro-inflammatory cytokines, in surgeries with and without CPB, both pre and post initiation of surgery. We reviewed literature to explore the relationship between the release of pro-inflammatory cytokines, and the expression and activities of CYP enzymes. Through this approach, we provide new insight on the effects of CPB on the PK of drugs administered to patients in the clinical setting. Future research to address this knowledge gap will have considerable impact to assist clinicians with optimizing pharmacotherapy in this patient population.
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Affiliation(s)
- Santosh Kumar Sreevatsav Adiraju
- a Centre for Integrated Preclinical Drug Development, Centre for Clinical Research, Faculty of Medicine , The University of Queensland , Brisbane , QLD , Australia
| | - Kiran Shekar
- b Critical Care Research Group , The Prince Charles Hospital and The University of Queensland , Brisbane , QLD , Australia
| | - John F Fraser
- b Critical Care Research Group , The Prince Charles Hospital and The University of Queensland , Brisbane , QLD , Australia
| | - Maree T Smith
- a Centre for Integrated Preclinical Drug Development, Centre for Clinical Research, Faculty of Medicine , The University of Queensland , Brisbane , QLD , Australia.,c School of Pharmacy, Faculty of Health and Behavioral Sciences , The University of Queensland , Brisbane , QLD , Australia
| | - Sussan Ghassabian
- a Centre for Integrated Preclinical Drug Development, Centre for Clinical Research, Faculty of Medicine , The University of Queensland , Brisbane , QLD , Australia
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Greenberg JH, Whitlock R, Zhang WR, Thiessen-Philbrook HR, Zappitelli M, Devarajan P, Eikelboom J, Kavsak PA, Devereaux PJ, Shortt C, Garg AX, Parikh CR. Interleukin-6 and interleukin-10 as acute kidney injury biomarkers in pediatric cardiac surgery. Pediatr Nephrol 2015; 30:1519-27. [PMID: 25877915 PMCID: PMC4537680 DOI: 10.1007/s00467-015-3088-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 02/06/2015] [Accepted: 03/05/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Children undergoing cardiac surgery may exhibit a pronounced inflammatory response to cardiopulmonary bypass (CPB). Inflammation is recognized as an important pathophysiologic process leading to acute kidney injury (AKI). The aim of this study was to evaluate the association of the inflammatory cytokines interleukin (IL)-6 and IL-10 with AKI and other adverse outcomes in children after CPB surgery. METHODS This is a sub-study of the Translational Research Investigating Biomarker Endpoints in AKI (TRIBE-AKI) cohort, including 106 children ranging in age from 1 month to 18 years undergoing CPB. Plasma IL-6 and IL-10 concentrations were measured preoperatively and postoperatively [day 1 (within 6 h after surgery) and day 3]. RESULTS Stage 2/3 AKI, defined by at least a doubling of the baseline serum creatinine concentration or dialysis, was diagnosed in 24 (23%) patients. The preoperative IL-6 concentration was significantly higher in patients with stage 2/3 AKI [median 2.6 pg/mL, interquartile range (IQR) 2.6 0.6-4.9 pg/mL] than in those without stage 2/3 AKI (median 0.6 pg/mL, IQR 0.6-2.2 pg/mL) (p = 0.03). After adjustment for clinical and demographic variables, the highest preoperative IL-6 tertile was associated with a sixfold increased risk for stage 2/3 AKI compared with the lowest tertile (adjusted odds ratio 6.41, 95 % confidence interval 1.16-35.35). IL-6 and IL-10 levels increased significantly after surgery, peaking postoperatively on day 1. First postoperative IL-6 and IL-10 measurements did not significantly differ between patients with stage 2/3 AKI and those without stage 2/3 AKI. The elevated IL-6 level on day 3 was associated with longer hospital stay (p = 0.0001). CONCLUSIONS Preoperative plasma IL-6 concentration is associated with the development of stage 2/3 AKI and may be prognostic of resource utilization.
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Affiliation(s)
- Jason H. Greenberg
- Department of Pediatrics, Section of Nephrology, Yale University School of Medicine, New Haven, CT,Program of Applied Translational Research, Yale University School of Medicine, New Haven, CT
| | - Richard Whitlock
- Division of Cardiac Surgery, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - William R. Zhang
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, CT
| | | | - Michael Zappitelli
- Department of Pediatrics, Division of Pediatric Nephrology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Prasad Devarajan
- Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - John Eikelboom
- Division of Cardiac Surgery, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Peter A. Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - PJ Devereaux
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Colleen Shortt
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amit X. Garg
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
| | - Chirag R. Parikh
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, CT,Department of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, CT and VA Medical Center, West Haven, CT
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