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Wang C, Jiang Y, Wang Q, Wang D, Jiang X, Dong N, Chen S, Chen X. Off-pump versus on-pump coronary artery bypass grafting in elderly patients at 30 days: a propensity score matching study. Postgrad Med J 2024; 100:414-420. [PMID: 38330496 DOI: 10.1093/postmj/qgad120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/27/2023] [Accepted: 11/10/2023] [Indexed: 02/10/2024]
Abstract
BACKGROUND Elderly patients are at increased risk of perioperative morbidity and mortality after conventional on-pump coronary artery bypass grafting (ONCABG). This study was to determine whether such high-risk population would benefit from off-pump coronary artery bypass grafting (OPCABG). METHODS A retrospective analysis was performed on patients aged 65 years or older who underwent isolated coronary artery bypass grafting for the first time in Wuhan Union Hospital from January 2015 to January 2021. We used propensity score matching to adjust for differences in baseline characteristics between the ONCABG and OPCABG groups. Morbidity and mortality within 30 days after surgery were compared between the two groups. All operations were performed by experienced cardiac surgeons. RESULTS A total of 511 patients (ONCABG 202, OPCABG 309) were included. After 1:1 matching, the baseline characteristics of the two groups were comparable (ONCABG 173, OPCABG 173). The OPCABG group had higher rate of incomplete revascularization (13.9% vs. 6.9%; P = .035) than the ONCABG group. However, OPCABG reduced the risk of postoperative renal insufficiency (15.0% vs. 30.1%; P = .001) and reoperation for bleeding (0.0% vs. 3.5%; P = .030). There were no significant differences in early postoperative mortality, myocardial infarction, stroke, and other outcomes between the two groups. CONCLUSIONS OPCABG is an alternative revascularization method for elderly patients. It reduces the risk of early postoperative renal insufficiency and reoperation for bleeding.
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Affiliation(s)
- Chen Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yefan Jiang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Qingpeng Wang
- Department of Cardiovascular Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430062, China
| | - Dashuai Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xionggang Jiang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Si Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xinzhong Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
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Jiang J, Liu X, Cheng Z, Liu Q, Xing W. Effect of preoperative moderate-dose statin and duration on acute kidney injury after cardiac surgery: a retrospective cohort study. Curr Med Res Opin 2024; 40:229-238. [PMID: 38146934 DOI: 10.1080/03007995.2023.2286317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 11/17/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND The impact of preoperative statin use on postoperative acute kidney injury (AKI) is uncertain. We aimed to examine the association of statin therapy before cardiac surgery with postoperative AKI. METHODS The retrospective cohort study consisted of 1581 patients undergoing cardiac surgery. Postoperative AKI were identified by the modified KDIGO definition. Propensity-score matching was employed to control for selection bias, and logistic regression was used to control for confounders. Subgroup and interaction analyses were performed to evaluate the robustness of the findings. RESULTS The overall incidence of postoperative AKI and severe AKI were 42.19% and 12.27%, respectively. Preoperative moderate-dose statin was significantly associated with a reduced incidence of postoperative AKI (28.9% vs 43.0%, OR (95%CI): 0.54 (0.38, 0.77), p < 0.001) and severe AKI (6.9% vs 13.7%, OR (95%CI): 0.46 (0.26, 0.83), p = 0.009). The beneficial effect on postoperative AKI persisted after adjusting for major confounding factors (OR (95%CI): 0.47 (0.34, 0.66)). Decreased risk of postoperative AKI was observed in patients with preoperative statin duration of 7 ∼ 14 days (OR (95%CI): 0.41 (0.25, 0.65)) and over 14 days (OR (95%CI): 0.43 (0.28, 0.65)), but not in those with preoperative statin duration of <7 days. Similar favorable effects were noted in most subgroup patients, except for those with high-risk factors such as diabetes mellitus, previous congestive cardiac failure, arrhythmia, preoperative ACEI/ARB, aortic cross-clamping or IABP. CONCLUSION Preoperative moderate-dose statin was significantly related to a decreased risk of postoperative AKI, especially in patients who received statins for a longer duration. Further large-scale multicenter randomized controlled trials are needed to ascertain the impact of statin dose, duration, and timing on postoperative AKI in cardiac surgery patients.
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Affiliation(s)
- Jicheng Jiang
- Department of Big Data Center for Cardiovascular Disease, Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, China
| | - Xinyun Liu
- Department of Big Data Center for Cardiovascular Disease, Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, China
| | - Zhaoyun Cheng
- Department of Cardiovascular Surgery, Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, China
| | - Qianjin Liu
- Department of Cardiovascular Surgery, Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, China
| | - Wenlu Xing
- Department of Big Data Center for Cardiovascular Disease, Henan Provincial People's Hospital, Central China Fuwai Hospital, Central China Fuwai Hospital of Zhengzhou University, China
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Kyo S, Murata K, Kawatou M, Minatoya K, Sunagawa GA, Masumoto H. Quiescence-inducing neurons-induced hypometabolism ameliorates acute kidney injury in a mouse model mimicking cardiovascular surgery requiring circulatory arrest. JTCVS OPEN 2022; 12:201-210. [PMID: 36590714 PMCID: PMC9801336 DOI: 10.1016/j.xjon.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 10/27/2022] [Accepted: 10/31/2022] [Indexed: 11/10/2022]
Abstract
Objectives Acute kidney injury is a serious complication after cardiovascular surgery requiring circulatory arrest. It is reported that mice can be induced into a hibernation-like hypometabolic state by stimulating a specific neuron located at the hypothalamus (quiescence-inducing neurons-induced hypometabolism [QIH]). Here, we investigated the efficacy of QIH for the amelioration of acute kidney injury in an experimental circulatory arrest using a transgenic mouse model. Methods We genetically prepared mice in which QIH can be conditionally induced (QIH-ready mice). Mice were divided into 4 groups (n = 6 for each): QIH-ready normothermia (QN), QIH-ready hypothermia (QH), control normothermia (CN), and control hypothermia (CH). After induction of QIH, left thoracotomy and descending aorta crossclamping were conducted. After reperfusion, we collected kidneys and evaluated histologic changes and serum biochemical markers, specifically neutrophil gelatinase-associated lipocalin and cystatin C, indicating early kidney injury. Results Normothermia showed higher tubular injury scores than those in hypothermia (QN vs QH [P = .0021] and CN vs CH [P < .001]). QN exhibited lower neutrophil gelatinase-associated lipocalin and cystatin C levels than those in CN (neutrophil gelatinase-associated lipocalin: CN vs QN: 1.51 ± 0.71 vs 0.82 ± 0.32; P = .0414 and cystatin C: 1.48 ± 0.39 vs 0.71 ± 0.26; P = .0015). There was no significant difference between QN and QH. Conclusions QIH partly ameliorated acute kidney injury in a mouse ischemia model even in normothermia. QIH might be a promising approach to achieving sufficient kidney protection without hypothermic circulatory arrest in the future.
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Key Words
- AAV8, adeno-associated virus 8
- AKI, acute kidney injury
- CH, control hypothermia
- CN, control normothermia
- CNO, clozapine-N-oxide
- DHCA, deep hypothermic circulatory arrest
- NGAL, neutrophil gelatinase-associated lipocalin
- Q neurons, quiescence-inducing neurons
- Q neurons-induced hypometabolism
- QH, quiescence-inducing neurons-induced hypometabolism-ready hypothermia
- QIH, quiescence-inducing neurons-induced hypometabolism
- QN, quiescence-inducing neurons-induced hypometabolism-ready normothermia
- QRFP, pyroglutamylated RFamide peptide
- TA, ambient temperature
- TB, body temperature
- Vo2, the rate of oxygen consumption
- acute kidney injury
- circulatory arrest
- hibernation
- iCre, codon-improved Cre recombinase
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Affiliation(s)
- Shoichi Kyo
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kozue Murata
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Clinical Translational Research Program, RIKEN Center for Biosystems Dynamics Research, Kobe, Japan
- Institute for Advancement of Clinical and Translational Science, Kyoto University Hospital, Kyoto, Japan
| | - Masahide Kawatou
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Genshiro A. Sunagawa
- Laboratory for Molecular Biology of Aging, RIKEN Center for Biosystems Dynamics Research, Kobe, Japan
- Laboratory for Hibernation Biology, RIKEN Center for Biosystems Dynamics Research, Kobe, Japan
| | - Hidetoshi Masumoto
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Clinical Translational Research Program, RIKEN Center for Biosystems Dynamics Research, Kobe, Japan
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Early and Long-Term Outcomes after On-Pump and Off-Pump Coronary-Artery Bypass Grafting in Patients with Severe Left Ventricular Dysfunction and a Giant Left Ventricle. J Cardiovasc Dev Dis 2022; 9:jcdd9090298. [PMID: 36135443 PMCID: PMC9502700 DOI: 10.3390/jcdd9090298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: No previous studies comparing the outcomes between off-pump coronary artery bypass grafting (off-pump CABG, OPCAB) and on-pump CABG (ONCAB) have been performed in patients with severe left ventricular dysfunction (LVD) and a giant left ventricle. We aimed to investigate whether such patients could benefit from OPCAB. Methods: From January 2011 to January 2021, a total of 98 patients with severe LVD and a giant left ventricle underwent isolated CABG (ONCAB 46, OPCAB 52) in Wuhan Union Hospital. The clinical data were collected retrospectively and propensity score matching was performed to adjust baseline characteristics. Results: After propensity matching, the two groups were comparable in baseline variables. The OPCAB group had a higher rate of incomplete revascularization than the ONCAB group (25.0% vs. 9.1%; p = 0.047). The 30-day mortality was similar between the matched groups (4.5% vs. 4.5%; p = 1.000) but the OPCAB group had a lower risk of postoperative IABP usage (9.1% vs. 25.0%; p = 0.047) and renal insufficiency (11.4% vs. 29.5%; p = 0.034). The long-term probability of survival (log-rank test, p = 0.450) was similar between the two groups but the OPCAB group had a lower probability of major adverse cardiovascular events (log-rank test, p = 0.038). Conclusions: For patients with severe LVD and a giant left ventricle, OPCAB reduced early postoperative complications while sacrificing long-term quality of life compared to those having ONCAB.
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Wang C, Jiang Y, Song Y, Wang Q, Tian R, Wang D, Dong N, Jiang X, Chen S, Chen X. Off-pump or on-pump coronary artery bypass at 30 days: A propensity matched analysis. Front Cardiovasc Med 2022; 9:965648. [PMID: 35979017 PMCID: PMC9376244 DOI: 10.3389/fcvm.2022.965648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionThis study was to determine whether coronary artery bypass grafting without cardiopulmonary bypass (off-pump CABG, OPCAB) could reduce early postoperative mortality and major complications compared with conventional coronary artery bypass grafting with cardiopulmonary bypass (on-pump CABG, ONCAB) by experienced surgeons.Material and methodsFrom January 2016 to June 2020, isolated CABG was performed in 1200 patients (ONCAB 429, OPCAB 771) in Wuhan Union Hospital. The propensity score matching was used to adjust for differences in baseline characteristics between the ONCABG and OPCABG groups. After 1:1 matching, 404 pairs for each group were selected to compare outcomes within 30 days after surgery. All the operations were completed by experienced surgeons that had completed more than 500 on-pump and 200 off-pump CABG, respectively.ResultsAfter propensity matching, the two groups were comparable in terms of preoperative characteristics. The OPCAB group had less vein graft (2.5 ± 1.0 vs. 2.7 ± 0.9; P < 0.001) and a higher rate of incomplete revascularization (12.4 vs. 8.2%; P < 0.049) than the ONCAB group. There was no significant difference in early postoperative mortality between ONCAB and OPCAB groups (2.2 vs. 2.2%; P = 1.00). However, patients in the OPCAB group had a lower risk of postoperative stroke (1.5 vs. 4.7%; P = 0.008), new-onset renal insufficiency (8.9 vs. 18.8%; P < 0.001), respiratory failure (2.2 vs. 7.2%; P = 0.001), reoperation for bleeding (0.5 vs. 2.7%; P = 0.001), and required less ventilator assistance time (33.4 ± 37.9 h vs. 51.0 ± 66.1 h; P < 0.001) and intensive care unit (ICU) time (3.7 ± 2.7 days vs. 4.8 ± 4.3 days; P < 0.001).ConclusionsIn our study, patients undergoing OPCAB had fewer postoperative complications and a faster recovery. It is a feasible and safe surgical approach to achieve revascularization when performed by experienced surgeons.
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Affiliation(s)
- Chen Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yefan Jiang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yu Song
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qingpeng Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rui Tian
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dashuai Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xionggang Jiang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Xionggang Jiang
| | - Si Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Si Chen
| | - Xinzhong Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Xinzhong Chen
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Davidson JA, Robison J, Khailova L, Frank BS, Jaggers J, Ing RJ, Lawson S, Iguidbashian J, Ali E, Treece A, Soranno DE, Osorio-Lujan S, Klawitter J. Metabolomic profiling demonstrates evidence for kidney and urine metabolic dysregulation in a piglet model of cardiac surgery-induced acute kidney injury. Am J Physiol Renal Physiol 2022; 323:F20-F32. [PMID: 35532069 PMCID: PMC9236877 DOI: 10.1152/ajprenal.00039.2022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Acute kidney injury (AKI) is a common cause of morbidity after congenital heart disease surgery. Progress on diagnosis and therapy remains limited, however, in part due to poor mechanistic understanding and a lack of relevant translational models. Metabolomic approaches could help identify novel mechanisms of injury and potential therapeutic targets. In the present study, we used a piglet model of cardiopulmonary bypass with deep hypothermic circulatory arrest (CPB/DHCA) and targeted metabolic profiling of kidney tissue, urine, and serum to evaluate metabolic changes specific to animals with histological acute kidney injury. CPB/DHCA animals with acute kidney injury were compared with those without acute kidney injury and mechanically ventilated controls. Acute kidney injury occurred in 10 of 20 CPB/DHCA animals 4 h after CPB/DHCA and 0 of 7 control animals. Injured kidneys showed a distinct tissue metabolic profile compared with uninjured kidneys (R2 = 0.93, Q2 = 0.53), with evidence of dysregulated tryptophan and purine metabolism. Nine urine metabolites differed significantly in animals with acute kidney injury with a pattern suggestive of increased aerobic glycolysis. Dysregulated metabolites in kidney tissue and urine did not overlap. CPB/DHCA strongly affected the serum metabolic profile, with only one metabolite that differed significantly with acute kidney injury (pyroglutamic acid, a marker of oxidative stress). In conclusion, based on these findings, kidney tryptophan and purine metabolism are candidates for further mechanistic and therapeutic investigation. Urine biomarkers of aerobic glycolysis could help diagnose early acute kidney injury after CPB/DHCA and warrant further evaluation. The serum metabolites measured at this early time point did not strongly differentiate based on acute kidney injury. NEW & NOTEWORTHY This project explored the metabolic underpinnings of postoperative acute kidney injury (AKI) following pediatric cardiac surgery in a translationally relevant large animal model of cardiopulmonary bypass with deep hypothermic circulatory arrest. Here, we present novel evidence for dysregulated tryptophan catabolism and purine catabolism in kidney tissue and increased urinary glycolysis intermediates in animals who developed histological AKI. These pathways represent potential diagnostic and therapeutic targets for postoperative AKI in this high-risk population.
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Affiliation(s)
- Jesse A Davidson
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Justin Robison
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, United States
| | - Ludmila Khailova
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Benjamin S Frank
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - James Jaggers
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Richard J Ing
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Scott Lawson
- Heart Institute, Children's Hospital Colorado, Aurora, CO, United States
| | - John Iguidbashian
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Eiman Ali
- Heart Institute, Children's Hospital Colorado, Aurora, CO, United States
| | - Amy Treece
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Danielle E Soranno
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Suzanne Osorio-Lujan
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jelena Klawitter
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
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7
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Experimental models of acute kidney injury for translational research. Nat Rev Nephrol 2022; 18:277-293. [PMID: 35173348 DOI: 10.1038/s41581-022-00539-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2022] [Indexed: 12/20/2022]
Abstract
Preclinical models of human disease provide powerful tools for therapeutic discovery but have limitations. This problem is especially apparent in the field of acute kidney injury (AKI), in which clinical trial failures have been attributed to inaccurate modelling performed largely in rodents. Multidisciplinary efforts such as the Kidney Precision Medicine Project are now starting to identify molecular subtypes of human AKI. In addition, over the past decade, there have been developments in human pluripotent stem cell-derived kidney organoids as well as zebrafish, rodent and large animal models of AKI. These organoid and AKI models are being deployed at different stages of preclinical therapeutic development. However, the traditionally siloed, preclinical investigator-driven approaches that have been used to evaluate AKI therapeutics to date rarely account for the limitations of the model systems used and have given rise to false expectations of clinical efficacy in patients with different AKI pathophysiologies. To address this problem, there is a need to develop more flexible and integrated approaches, involving teams of investigators with expertise in a range of different model systems, working closely with clinical investigators, to develop robust preclinical evidence to support more focused interventions in patients with AKI.
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Vuong TA, Rana MS, Moore B, Cronin J, Ceneri NM, Sinha P, Deutsch N, Matisoff AJ. Association Between Exogenous Nitric Oxide Given During Cardiopulmonary Bypass and the Incidence of Postoperative Kidney Injury in Children. J Cardiothorac Vasc Anesth 2021; 36:2352-2357. [PMID: 34776350 DOI: 10.1053/j.jvca.2021.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/03/2021] [Accepted: 10/06/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare the incidence and severity of acute kidney injury (AKI) after cardiac surgery with cardiopulmonary bypass and the administration of exogenous nitric oxide in children. DESIGN A retrospective cohort study. SETTING A single institution, university hospital. PARTICIPANTS All children younger than 18 years of age who underwent surgery with cardiopulmonary bypass. INTERVENTIONS Medical records of all eligible patients between January 4, 2017, and June 28, 2019, were reviewed. Patients were divided into two groups based on whether they received exogenous nitric oxide. MEASUREMENTS AND MAIN RESULTS The primary endpoint was a change in serum creatinine level, defined as the difference between the preoperative creatinine and peak postoperative creatinine. The secondary endpoint was the incidence and severity of postoperative AKI. A difference-in-difference method using fixed-effect multiple linear regression was carried out to compare the difference in maximum serum creatinine changes between the control and intervention groups. Five hundred ninety-one patients were included in the analysis: 298 (50.5%) in the control group and 293 (49.5%) in the intervention group. Control and intervention groups did not vary significantly in terms of baseline characteristics except for bypass time. After adjusting for all baseline variables, there was no statistically significant difference in the increase in serum creatinine between the control and the intervention groups (0.01 [95% CI: -0.03, 0.05], p = 0.545). CONCLUSIONS This single-center, retrospective, cohort study found no change in the incidence and severity of postoperative AKI after the administration of nitric oxide into the cardiopulmonary bypass circuit in children.
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Affiliation(s)
- Thoai A Vuong
- The George Washington University School of Medicine and Health Sciences, Division of Cardiac Anesthesia, Children's National Hospital, Washington, DC.
| | - Md Sohel Rana
- Children's National Hospital, Joseph E. Robert, Jr., Center for Surgical Care, Washington, DC
| | - Brenna Moore
- The George Washington University School of Medicine and Health Sciences, MD Candidate, Washington, DC
| | - Jessica Cronin
- The George Washington University School of Medicine and Health Sciences, Division of Anesthesia and Perioperative Medicine, Children's National Hospital, Washington, DC
| | - Nicolle M Ceneri
- The George Washington University School of Medicine and Health Sciences, MD Candidate, Washington, DC
| | - Pranava Sinha
- The George Washington University School of Medicine and Health Sciences, Division of Cardiovascular Surgery, Children's National Hospital, Washington, DC
| | - Nina Deutsch
- The George Washington University School of Medicine and Health Sciences, Division of Cardiac Anesthesia, Children's National Hospital, Washington, DC
| | - Andrew J Matisoff
- The George Washington University School of Medicine and Health Sciences, Division of Cardiac Anesthesia, Children's National Hospital, Washington, DC
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Bari G, Érces D, Varga G, Szűcs S, Varga Z, Bogáts G, Boros M. Methane inhalation reduces the systemic inflammatory response in a large animal model of extracorporeal circulation. Eur J Cardiothorac Surg 2020; 56:135-142. [PMID: 30649294 DOI: 10.1093/ejcts/ezy453] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 12/04/2018] [Accepted: 12/05/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Extracorporeal circulation induces cellular and humoral inflammatory reactions, thus possibly leading to detrimental secondary inflammatory responses. Previous data have demonstrated the bioactive potential of methane and confirmed its anti-inflammatory effects in model experiments. Our goal was to investigate the in vivo consequences of exogenous methane administration on extracorporeal circulation-induced inflammation. METHODS Two groups of anaesthetized Vietnamese minipigs (non-treated and methane treated, n = 5 each) were included. Standard central cannulation was performed, and extracorporeal circulation was maintained for 120 min without cardiac arrest or ischaemia, followed by an additional 120-min observation period with haemodynamic monitoring. In the methane-treated group, 2.5% v/v methane-normoxic air mixture was added to the oxygenator sweep gas. Blood samples through the central venous line and tissue biopsies from the heart, ileum and kidney were taken at the end point to determine the whole blood superoxide production (chemiluminometry) and the activity of xanthine-oxidoreductase and myeloperoxidase, with substrate-specific reactions. RESULTS Methane treatment resulted in significantly higher renal blood flow during the extracorporeal circulation period compared to the non-treated group (63.9 ± 16.4 vs 29.0 ± 9.3 ml/min). Whole blood superoxide production (548 ± 179 vs 1283 ± 193 Relative Light Unit (RLU)), ileal myeloperoxidase (2.23 ± 0.2 vs 3.26 ± 0.6 mU/(mg protein)) and cardiac (1.5 ± 0.6 vs 4.7 ± 2.5 pmol/min/mg), ileal (2.2 ± 0.6 vs 7.0 ± 3.4 pmol/min/mg) and renal (1.2 ± 0.8 vs 13.3 ± 8.0 pmol/min/mg) xanthine-oxidoreductase activity were significantly lower in the treated group. CONCLUSIONS The addition of bioactive gases, such as methane, through the oxygenator of the extracorporeal circuit represents a novel strategy to influence the inflammatory effects of extracorporeal perfusion in cardiac surgical procedures.
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Affiliation(s)
- Gábor Bari
- Department of Cardiac Surgery, University of Szeged, Szeged, Hungary
| | - Dániel Érces
- Institute for Surgical Research, University of Szeged, Szeged, Hungary
| | - Gabriella Varga
- Institute for Surgical Research, University of Szeged, Szeged, Hungary
| | - Szilárd Szűcs
- Institute for Surgical Research, University of Szeged, Szeged, Hungary
| | - Zoltán Varga
- Institute for Surgical Research, University of Szeged, Szeged, Hungary
| | - Gábor Bogáts
- Department of Cardiac Surgery, University of Szeged, Szeged, Hungary
| | - Mihály Boros
- Institute for Surgical Research, University of Szeged, Szeged, Hungary
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Feirer N, Dieterlen MT, Klaeske K, Kiefer P, Oßmann S, Salameh A, Borger MA, Hoyer A. Impact of Custodiol-N cardioplegia on acute kidney injury after cardiopulmonary bypass. Clin Exp Pharmacol Physiol 2019; 47:640-649. [PMID: 31869857 DOI: 10.1111/1440-1681.13236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/28/2019] [Accepted: 12/18/2019] [Indexed: 11/30/2022]
Abstract
Myocardial protection during cardiopulmonary bypass (CPB) can be achieved using cardioplegic solutions. Although, acute kidney injury (AKI) is a common complication following CPB, the effects of cardioplegic solutions on AKI have rarely been investigated. Within this study, the effects of the cardioplegic solutions histidine-tryptophan-ketoglutarate (HTK; Custodiol) and HTK-N (Custodiol-N) on AKI in a large animal model were compared. Therefore, Landrace pigs underwent median sternotomy, CPB at 34°C, 90 minutes of cardiac arrest and 120 minutes of reperfusion. Animals were randomized for single-shot cardioplegia with either HTK (n = 10) or HTK-N (n = 10). Renal biopsies and sera were analyzed to determine AKI biomarkers and apoptosis. Compared to HTK, HTK-N induced a decreased extent of proximal tubule swelling (48.3 ± 1.6 µm vs 52.3 ± 1.1 µm, P = .05) and decreased cytochrome c release (0.26 ± 0.04 vs 0.46 ± 0.08, P = .04) without reaching statistical significance due to Bonferroni correction. Comparing baseline and postreperfusion levels, the hemoglobin (Hb) and blood calcium levels were lower in HTK-N (Hbbaseline : 6.0 ± 0.6 mmol/L, Hbreperfusion : 6.2 ± 0.7 mmol/L, P = .12; Ca2+ baseline : 1.36 ± 0.05 mmol/L, Ca2+ reperfusion : 1.28 ± 0.05 mmol/L, P = .16) compared to the HTK group (Hbbaseline : 5.9 ± 0.4 mmol/L, Hbreperfusion : 4.7 ± 0.8 mmol/L, P < .01; Ca2+ baseline : 1.34 ± 0.07 mmol/L, Ca2+ reperfusion : 1.24 ± 0.06 mmol/L, P < .01). The present study showed that HTK-N could positively affect the kidney during CPB. Hb and calcium levels were stabilized. A statistical trend was found showing that AKI-related proximal tubule swelling and cytochrome c release were diminished.
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Affiliation(s)
- Nina Feirer
- Department of Cardiac Surgery, University of Leipzig, Heart Center Leipzig, Leipzig, Germany
| | - Maja-Theresa Dieterlen
- Department of Cardiac Surgery, University of Leipzig, Heart Center Leipzig, Leipzig, Germany
| | - Kristin Klaeske
- Department of Cardiac Surgery, University of Leipzig, Heart Center Leipzig, Leipzig, Germany
| | - Philipp Kiefer
- Department of Cardiac Surgery, University of Leipzig, Heart Center Leipzig, Leipzig, Germany
| | - Susann Oßmann
- Department of Cardiac Surgery, University of Leipzig, Heart Center Leipzig, Leipzig, Germany
| | - Aida Salameh
- Clinic for Pediatric Cardiology, University of Leipzig, Heart Center Leipzig, Leipzig, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, University of Leipzig, Heart Center Leipzig, Leipzig, Germany
| | - Alexandro Hoyer
- Department of Cardiac Surgery, University of Leipzig, Heart Center Leipzig, Leipzig, Germany
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11
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Alkaline Phosphatase Treatment of Acute Kidney Injury in an Infant Piglet Model of Cardiopulmonary Bypass with Deep Hypothermic Circulatory Arrest. Sci Rep 2019; 9:14175. [PMID: 31578351 PMCID: PMC6775126 DOI: 10.1038/s41598-019-50481-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 09/13/2019] [Indexed: 01/11/2023] Open
Abstract
Acute kidney injury (AKI) is associated with prolonged hospitalization and mortality following infant cardiac surgery, but therapeutic options are limited. Alkaline phosphatase (AP) infusion reduced AKI in phase 2 sepsis trials but has not been evaluated for cardiac surgery-induced AKI. We developed a porcine model of infant cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA) to investigate post-CPB/DHCA AKI, measure serum/renal tissue AP activity with escalating doses of AP infusion, and provide preliminary assessment of AP infusion for prevention of AKI. Infant pigs underwent CPB with DHCA followed by survival for 4 h. Groups were treated with escalating doses of bovine intestinal AP (1, 5, or 25U/kg/hr). Anesthesia controls were mechanically ventilated for 7 h without CPB. CPB/DHCA animals demonstrated histologic and biomarker evidence of AKI as well as decreased serum and renal tissue AP compared to anesthesia controls. Only high dose AP infusion significantly increased serum or renal tissue AP activity. Preliminary efficacy evaluation demonstrated a trend towards decreased AKI in the high dose AP group. The results of this dose-finding study indicate that AP infusion at the dose of 25U/kg/hr corrects serum and tissue AP deficiency and may prevent AKI in this piglet model of infant CPB/DHCA.
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12
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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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13
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Aujla H, Kumar T, Woźniak M, Dott W, Sullo N, Joel-David L, Morris T, Brookes C, Barber S, Murphy GJ. Effect of sildenafil (Revatio) on postcardiac surgery acute kidney injury: a randomised, placebo-controlled clinical trial: the REVAKI-2 trial protocol. Open Heart 2018; 5:e000838. [PMID: 30364431 PMCID: PMC6196934 DOI: 10.1136/openhrt-2018-000838] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 06/08/2018] [Accepted: 07/24/2018] [Indexed: 11/22/2022] Open
Abstract
Introduction Acute kidney injury (AKI) is a common and severe complication of cardiac surgery. The administration of pharmacological renoprotective agents during the perioperative period could prevent or reduce the severity of AKI and improve clinical outcomes. Experimental studies suggest that sildenafil may have therapeutic potential for the prevention of AKI. This trial will test the hypothesis that postoperative AKI will be reduced in cardiac surgery patients if they receive sildenafil compared with placebo. Methods and analysis Adult cardiac surgery patients 18 years of age or above undergoing cardiac surgery with cardiopulmonary bypass and cardioplegic arrest at a single tertiary cardiac centre in the UK will be randomised in a 1:1 ratio to receive either sildenafil or placebo. The primary outcome is serum creatinine concentration measured at preoperation and daily for up to 7 days postoperatively. Secondary outcomes will include measures of inflammation, organ injury, volumes of blood transfused and resource use. Allocation concealment, internet-based randomisation stratified by operation type, and blinding of outcome assessors will reduce the risk of bias. A sample size of 112 patients will have a 90% power to detect a mean difference of 10 μmol/L for serum creatinine values between treatment and placebo control groups with an alpha value of 0.05. Ethics and dissemination The trial protocol was approved by a UK ethics committee (reference 15/YH/0489). The trial findings will be disseminated in scientific journals and meetings. Trial registration number ISRCTN18386427.
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Affiliation(s)
- Hardeep Aujla
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Cardiovascular Theme, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Tracy Kumar
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Cardiovascular Theme, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Marcin Woźniak
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Cardiovascular Theme, University of Leicester, Glenfield Hospital, Leicester, UK
| | - William Dott
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Cardiovascular Theme, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Nikol Sullo
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Cardiovascular Theme, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Lathishia Joel-David
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Cardiovascular Theme, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Thomas Morris
- Leicester Clinical Trials Unit, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Cassandra Brookes
- Leicester Clinical Trials Unit, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Shaun Barber
- Leicester Clinical Trials Unit, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Gavin James Murphy
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Cardiovascular Theme, University of Leicester, Glenfield Hospital, Leicester, UK
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14
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Evans RG, Lankadeva YR, Cochrane AD, Marino B, Iguchi N, Zhu MZL, Hood SG, Smith JA, Bellomo R, Gardiner BS, Lee C, Smith DW, May CN. Renal haemodynamics and oxygenation during and after cardiac surgery and cardiopulmonary bypass. Acta Physiol (Oxf) 2018; 222. [PMID: 29127739 DOI: 10.1111/apha.12995] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/02/2017] [Accepted: 11/06/2017] [Indexed: 12/12/2022]
Abstract
Acute kidney injury (AKI) is a common complication following cardiac surgery performed on cardiopulmonary bypass (CPB) and has important implications for prognosis. The aetiology of cardiac surgery-associated AKI is complex, but renal hypoxia, particularly in the medulla, is thought to play at least some role. There is strong evidence from studies in experimental animals, clinical observations and computational models that medullary ischaemia and hypoxia occur during CPB. There are no validated methods to monitor or improve renal oxygenation during CPB, and thus possibly decrease the risk of AKI. Attempts to reduce the incidence of AKI by early transfusion to ameliorate intra-operative anaemia, refinement of protocols for cooling and rewarming on bypass, optimization of pump flow and arterial pressure, or the use of pulsatile flow, have not been successful to date. This may in part reflect the complexity of renal oxygenation, which may limit the effectiveness of individual interventions. We propose a multi-disciplinary pathway for translation comprising three components. Firstly, large-animal models of CPB to continuously monitor both whole kidney and regional kidney perfusion and oxygenation. Secondly, computational models to obtain information that can be used to interpret the data and develop rational interventions. Thirdly, clinically feasible non-invasive methods to continuously monitor renal oxygenation in the operating theatre and to identify patients at risk of AKI. In this review, we outline the recent progress on each of these fronts.
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Affiliation(s)
- R. G. Evans
- Cardiovascular Disease Program Biomedicine Discovery Institute and Department of Physiology Monash University Melbourne Vic. Australia
| | - Y. R. Lankadeva
- Florey Institute of Neuroscience and Mental Health University of Melbourne Melbourne Vic. Australia
| | - A. D. Cochrane
- Department of Cardiothoracic Surgery Monash Health Monash University Melbourne Vic. Australia
- Department of Surgery School of Clinical Sciences at Monash Health Monash University Melbourne Vic. Australia
| | - B. Marino
- Department of Perfusion Services Austin Hospital Heidelberg Vic. Australia
| | - N. Iguchi
- Florey Institute of Neuroscience and Mental Health University of Melbourne Melbourne Vic. Australia
| | - M. Z. L. Zhu
- Department of Cardiothoracic Surgery Monash Health Monash University Melbourne Vic. Australia
- Department of Surgery School of Clinical Sciences at Monash Health Monash University Melbourne Vic. Australia
| | - S. G. Hood
- Florey Institute of Neuroscience and Mental Health University of Melbourne Melbourne Vic. Australia
| | - J. A. Smith
- Department of Cardiothoracic Surgery Monash Health Monash University Melbourne Vic. Australia
- Department of Surgery School of Clinical Sciences at Monash Health Monash University Melbourne Vic. Australia
| | - R. Bellomo
- Department of Intensive Care Austin Hospital Heidelberg Vic. Australia
| | - B. S. Gardiner
- School of Engineering and Information Technology Murdoch University Perth WA Australia
- Faculty of Engineering and Mathematical Sciences The University of Western Australia Perth WA Australia
| | - C.‐J. Lee
- School of Engineering and Information Technology Murdoch University Perth WA Australia
- Faculty of Engineering and Mathematical Sciences The University of Western Australia Perth WA Australia
| | - D. W. Smith
- Faculty of Engineering and Mathematical Sciences The University of Western Australia Perth WA Australia
| | - C. N. May
- Florey Institute of Neuroscience and Mental Health University of Melbourne Melbourne Vic. Australia
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15
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Qureshi SH, Patel NN, Murphy GJ. Vascular endothelial cell changes in postcardiac surgery acute kidney injury. Am J Physiol Renal Physiol 2017; 314:F726-F735. [PMID: 29357431 DOI: 10.1152/ajprenal.00319.2017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Acute kidney injury (AKI) is common complication of cardiac surgery; however, the phenotype of this condition is poorly defined. The aim of this study was to characterize changes in endothelial structure and function that underlie postcardiopulmonary bypass (post-CPB) AKI. Adult pigs ( n = 16) were randomized to undergo the following procedures ( n = 8 per group): group 1: sham operation, neck dissection with 2.5 h of general anesthesia; and group 2: CPB, 2.5 h of cardiopulmonary bypass. CPB resulted in the depletion of specific epitopes of glycosaminoglycans side chains of the endothelial glycocalyx: Dolichos biflorus agglutinin: mean difference (MD) [95% confidence interval (CI)], P value: -0.26 (-0.42, -0.09), P = 0.0024, Triticum vulgaris (wheat germ) agglutinin: -0.83 (-1.2, -0.38), P = 0.0005, and Ulex europaeus agglutinin 1: -0.25 (-0.49, -0.009), P = 0.041; endothelial membrane protein: thrombomodulin: -3.13 (-5.6, -0.65), P = 0.02; and adherens junction: VE-cadherin: -1.06 (-1.98, -0.145), P = 0.02. CPB also resulted in reductions in microvascular cortical perfusion: -0.62 (-1.02, -0.22), P = 0.006, and increased renal cortex adenosine levels: 2.32 (0.83, 3.8), P = 0.0059. These changes were accompanied by significant reduction in creatinine clearance at 1.5 h postintervention, MD 95% CI; -51.7 (-99.7, -3.7), P = 0.037, and at 24 h, MD (95% CI): -47.3 (-87.7, -7.6), P = 0.023, and proteinuria immediately postintervention MD (95% CI): 18.79 (2.17, 35.4), P = 0.03 vs. sham. In our experimental CPB model, endothelial injury was associated with loss of autoregulation, increase in microvascular permeability, and reduced glomerular filtration. Interventions that promote endothelial homeostasis may have clinical utility in the prevention of postcardiac surgery AKI.
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Affiliation(s)
- Saqib H Qureshi
- University of Leicester, Clinical Sciences Wing, Glenfield General Hospital , Leicester , United Kingdom
| | - Nishith N Patel
- National Heart and Lung Institute, Hammersmith Hospital Campus, Imperial College London , London , United Kingdom
| | - Gavin J Murphy
- University of Leicester, Clinical Sciences Wing, Glenfield General Hospital , Leicester , United Kingdom
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16
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Park JY, Park JH, Lee SS, Ri HS, Kim HJ, Choi YM, Choi YJ, Yoon JU. The Association of Preoperative Body Mass Index with Acute Kidney Injury in Liver Transplantation Recipients: A Retrospective Study. Korean J Crit Care Med 2017; 32:265-274. [PMID: 31723645 PMCID: PMC6786735 DOI: 10.4266/kjccm.2017.00178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 06/20/2017] [Accepted: 06/26/2017] [Indexed: 01/22/2023] Open
Abstract
Background Liver transplantation (LT) is a complicated procedure with a high incidence of postoperative acute kidney injury (AKI). Previous studies indicate that even transient or mild post-LT AKI can result in critical conditions, including prolonged stays in hospitals and intensive care units and increased morbidity and mortality. The aim of this study was to investigate the association between body mass index (BMI) and occurrence of AKI in LT recipients. Methods Medical data from 203 patients who received LT surgery from January 2010 to August 2016 in a single university hospital setting were retrospectively collected and analyzed. Patients were classified as either underweight (BMI <20 kg/m2) or normal weight (20 ≤ BMI < 30 kg/m2). Demographic data, anesthetic methods, complications, and perioperative laboratory test values of each patient were assessed. Propensity analyses and logistic regression were performed to evaluate the association between BMI and post-LT AKI. Results There was no significant difference in occurrence of post-LT AKI between underweight and normal weight patients. The underweight patient group had significantly longer hospital stay compared with the normal weight patient group (P = 0.023). Conclusions BMI classification was neither a positive nor negative predictor of postoperative AKI occurrence. However, patients with lower BMI had significantly longer hospital stay compared with their counterparts. Although our study was limited by its retrospective design, our observations suggest that lower BMI might play a role in post-LT AKI.
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Affiliation(s)
- Ju Yeon Park
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jung-Hyun Park
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Su Sung Lee
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyun-Su Ri
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hye-Jin Kim
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Yun Mi Choi
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Yoon Ji Choi
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Ji-Uk Yoon
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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17
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Abstract
OBJECTIVES The objectives of this review are to discuss the pathophysiology of the pro-inflammatory response to the cardiopulmonary bypass circuit, the impact of ischemia reperfusion injury on post-operative organ function, the compensatory anti-inflammatory response and the evidence for immune-modulatory strategies and their impact on outcomes. DATA SOURCE MEDLINE, PubMed. CONCLUSION Innovations such as the development of more biocompatible surfaces and miniaturized circuits, as well as the increasing expertise of surgeons, anesthesiologists and perfusionists has transformed cardiac surgery and the use of cardiopulmonary bypass into a relatively routine procedure with favorable outcomes. Despite these refinements, the attendant inflammatory response to bypass, ischemia reperfusion injury and the compensatory anti-inflammatory response contribute to post-operative morbidity and mortality. Additional studies are needed to further delineate the impact of immunomodulatory strategies on outcomes.
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18
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Skrypnyk NI, Siskind LJ, Faubel S, de Caestecker MP. Bridging translation for acute kidney injury with better preclinical modeling of human disease. Am J Physiol Renal Physiol 2016; 310:F972-84. [PMID: 26962107 PMCID: PMC4889323 DOI: 10.1152/ajprenal.00552.2015] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 03/04/2016] [Indexed: 12/14/2022] Open
Abstract
The current lack of effective therapeutics for patients with acute kidney injury (AKI) represents an important and unmet medical need. Given the importance of the clinical problem, it is time for us to take a few steps back and reexamine current practices. The focus of this review is to explore the extent to which failure of therapeutic translation from animal studies to human studies stems from deficiencies in the preclinical models of AKI. We will evaluate whether the preclinical models of AKI that are commonly used recapitulate the known pathophysiologies of AKI that are being modeled in humans, focusing on four common scenarios that are studied in clinical therapeutic intervention trials: cardiac surgery-induced AKI; contrast-induced AKI; cisplatin-induced AKI; and sepsis associated AKI. Based on our observations, we have identified a number of common limitations in current preclinical modeling of AKI that could be addressed. In the long term, we suggest that progress in developing better preclinical models of AKI will depend on developing a better understanding of human AKI. To this this end, we suggest that there is a need to develop greater in-depth molecular analyses of kidney biopsy tissues coupled with improved clinical and molecular classification of patients with AKI.
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Affiliation(s)
- Nataliya I Skrypnyk
- Division of Nephology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Leah J Siskind
- Department of Pharmacology and Toxicology, James Graham Brown Cancer Center, University of Louisville, Louisville, Kentucky; and
| | - Sarah Faubel
- Renal Division, University of Colorado Denver and Denver Veterans Affairs Medical Center, Aurora, Colorado
| | - Mark P de Caestecker
- Division of Nephology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee;
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19
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Funamoto M, Masumoto H, Takaori K, Taki T, Setozaki S, Yamazaki K, Minakata K, Ikeda T, Hyon SH, Sakata R. Green Tea Polyphenol Prevents Diabetic Rats From Acute Kidney Injury After Cardiopulmonary Bypass. Ann Thorac Surg 2016; 101:1507-13. [DOI: 10.1016/j.athoracsur.2015.09.080] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 09/14/2015] [Accepted: 09/21/2015] [Indexed: 12/28/2022]
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20
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Satterly SA, Salgar S, Hoffer Z, Hempel J, DeHart MJ, Wingerd M, Raywin H, Stallings JD, Martin M. Hydrogen sulfide improves resuscitation via non-hibernatory mechanisms in a porcine shock model. J Surg Res 2015; 199:197-210. [PMID: 25956183 DOI: 10.1016/j.jss.2015.04.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 03/11/2015] [Accepted: 04/01/2015] [Indexed: 01/23/2023]
Abstract
BACKGROUND Hydrogen sulfide (H2S) has been demonstrated to induce a "suspended animation-like" state in rodent models by reversible inhibition of cellular respiration and marked metabolic suppression and has been proposed as a potential pharmacologic adjunct to resuscitation from shock states. There are few data currently available about the mechanisms and efficacy of H2S in larger animals or humans. We examined H2S as a pharmacologic adjunct to resuscitation in a porcine model of severe traumatic shock. METHODS Twenty-one adult swine were assigned to three study arms: sham, H2S, and saline vehicle controls (SC). All pigs underwent laparotomy and instrumentation, and the two study arms then underwent a 35% controlled hemorrhage followed by 50 min of truncal ischemia via aortic cross-clamp. H2S (5 mg/kg) or saline was administered immediately before reperfusion, followed by 6 h of resuscitation. Resuscitation requirements, laboratory parameters, end-organ histology, and inflammatory product gene expression (by reverse transcription-polymerase chain reaction) were measured and compared between groups. RESULTS All animals survived to the 6-h postresuscitation time point. Both treatment arms demonstrated severe shock characterized by fluid and vasopressor requirements, metabolic acidosis, and hypotension compared with sham animals. Animals treated with H2S demonstrated significantly lower resuscitative requirements (total epinephrine 727 versus 3052 μg; P < 0.05), decreased fluid requirements, and lower serum lactate levels (7 versus 10 mmol/L) versus SC. Cardiac output was slightly decreased with H2S treatment but all other hemodynamic and metabolic parameters were equivalent between H2S and C groups. Serum liver and kidney biomarkers were unchanged, but administration of H2S was associated with a significant improvement in histopathologic liver and kidney injury scores compared with SC (both P < 0.05). Both study groups demonstrated significantly increased gene expression of hypoxia-inducible factor 1α and nitric oxide synthase (endogenous nitric oxide synthase, inducible nitric oxide synthase [iNOS]2, iNOS3) relative to sham animals. However, H2S was associated with increased expression of hypoxia-inducible factor 1α and decreased iNOS2 levels compared with SC. CONCLUSIONS Administration of H2S in a large-animal model of severe traumatic shock resulted in a significant decrease in resuscitative requirements, decreased metabolic acidosis, and less end-organ histologic injury compared with standard resuscitation. H2S did not induce profound metabolic suppression as seen in rodents, and appears to have alternative mechanisms of action in large animals.
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Affiliation(s)
- Steven A Satterly
- Department of Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Shashikumar Salgar
- Department of Clinical Investigation, Madigan Army Medical Center, Tacoma, Washington
| | - Zachary Hoffer
- Department of Pathology, Madigan Army Medical Center, Tacoma, Washington
| | - James Hempel
- Department of Pathology, Madigan Army Medical Center, Tacoma, Washington
| | - Mary J DeHart
- Department of Clinical Investigation, Madigan Army Medical Center, Tacoma, Washington
| | - Mark Wingerd
- Department of Clinical Investigation, Madigan Army Medical Center, Tacoma, Washington
| | - Huang Raywin
- Department of Clinical Investigation, Madigan Army Medical Center, Tacoma, Washington
| | - Jonathan D Stallings
- Department of Clinical Investigation, Madigan Army Medical Center, Tacoma, Washington
| | - Matthew Martin
- Department of Surgery, Madigan Army Medical Center, Tacoma, Washington; Trauma and Acute Care Surgery Service, Legacy Emanuel Medical Center, Portland, Oregon.
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21
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A novel minimal invasive mouse model of extracorporeal circulation. Mediators Inflamm 2015; 2015:412319. [PMID: 25705092 PMCID: PMC4325217 DOI: 10.1155/2015/412319] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 01/12/2015] [Accepted: 01/12/2015] [Indexed: 02/05/2023] Open
Abstract
Extracorporeal circulation (ECC) is necessary for conventional cardiac surgery and life support, but it often triggers systemic inflammation that can significantly damage tissue. Studies of ECC have been limited to large animals because of the complexity of the surgical procedures involved, which has hampered detailed understanding of ECC-induced injury. Here we describe a minimally invasive mouse model of ECC that may allow more extensive mechanistic studies. The right carotid artery and external jugular vein of anesthetized adult male C57BL/6 mice were cannulated to allow blood flow through a 1/32-inch external tube. All animals (n = 20) survived 30 min ECC and subsequent 60 min observation. Blood analysis after ECC showed significant increases in levels of tumor necrosis factor α, interleukin-6, and neutrophil elastase in plasma, lung, and renal tissues, as well as increases in plasma creatinine and cystatin C and decreases in the oxygenation index. Histopathology showed that ECC induced the expected lung inflammation, which included alveolar congestion, hemorrhage, neutrophil infiltration, and alveolar wall thickening; in renal tissue, ECC induced intracytoplasmic vacuolization, acute tubular necrosis, and epithelial swelling. Our results suggest that this novel, minimally invasive mouse model can recapitulate many of the clinical features of ECC-induced systemic inflammatory response and organ injury.
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22
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Ghorbel MT, Patel NN, Sheikh M, Angelini GD, Caputo M, Murphy GJ. Changes in renal medulla gene expression in a pre-clinical model of post cardiopulmonary bypass acute kidney injury. BMC Genomics 2014; 15:916. [PMID: 25331815 PMCID: PMC4210505 DOI: 10.1186/1471-2164-15-916] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 10/08/2014] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common and serious complication of cardiac surgery using cardiopulmonary bypass (CPB). The pathogenesis is poorly understood and the study of AKI in rodent models has not led to improvements in clinical outcomes. We sought to determine the changes in renal medullary gene expression in a novel and clinically relevant porcine model of CPB-induced AKI. RESULTS Adult pigs (n = 12 per group) were randomised to undergo sham procedure, or 2.5 hours CPB. AKI was determined using biochemical (Cr51 EDTA clearance, CrCl, urinary IL-18 release) and histological measures. Transcriptomic analyses were performed on renal medulla biopsies obtained 24 hours post intervention or from sham group. Microarray results were validated with real-time polymerase chain reaction and Western Blotting.Of the transcripts examined, 66 were identified as differentially expressed in CPB versus Sham pig's kidney samples, with 19 (29%) upregulated and 47 (71%) down-regulated. Out of the upregulated and downregulated transcripts 4 and 16 respectively were expression sequence tags (EST). The regulated genes clustered into three classes; Immune response, Cell adhesion/extracellular matrix and metabolic process. Upregulated genes included Factor V, SLC16A3 and CKMT2 whereas downregulated genes included GST, CPE, MMP7 and SELL. CONCLUSION Post CPB AKI, as defined by clinical criteria, is characterised by molecular changes in renal medulla that are associated with both injury and survival programmes. Our observations highlight the value of large animal models in AKI research and provide insights into the failure of findings in rodent models to translate into clinical progress.
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Affiliation(s)
- Mohamed T Ghorbel
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Level 7, Bristol Royal Infirmary; Upper Maudlin Street, Bristol BS2 8HW, UK.
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Sleeman P, Patel NN, Lin H, Walkden GJ, Ray P, Welsh GI, Satchell SC, Murphy GJ. High fat feeding promotes obesity and renal inflammation and protects against post cardiopulmonary bypass acute kidney injury in swine. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R262. [PMID: 24172587 PMCID: PMC4056797 DOI: 10.1186/cc13092] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Accepted: 10/10/2013] [Indexed: 01/07/2023]
Abstract
Introduction Obesity confers a survival advantage in the critically ill and in patients undergoing cardiac surgery. We explored whether an obesogenic high fat diet could confer protection against post cardiopulmonary bypass (CPB) acute kidney injury (AKI) in a swine model. Methods In this study, 28 anaesthetised adult female Landrace White swine (55 to 70 kg) were allocated into a 4 group design to either 2.5 hours of CPB or Sham operation with or without pre-procedural high fat (HF) feeding containing 15% lard, 1.5% cholesterol and 1% cholic acid for 12-weeks (Groups: Sham, CPB, CPB + HF and Sham + HF). Our primary endpoint was creatinine clearance measured at 1.5 and 24 hours post intervention. This is a validated index of the glomerular filtration rate (GFR) in swine and an endpoint used in our clinical studies. Secondary endpoints included measures of systemic and renal inflammation, endothelial homeostasis, tubular injury and dysfunction, and inflammatory cell signalling. Differences between groups were calculated using analysis of variance with adjustment for baseline differences for repeated measures. Results CPB in pigs fed a normal chow diet resulted in AKI. This was characterised by reductions in GFR sustained for up to 24 hours post injury relative to Sham operated pigs fed a normal diet; mean difference 50.2 ml/min (95% CI 5.9 to 94.4). Post CPB AKI was also characterised by renal inflammation, parallel activation of both pro-inflammatory (NF-kB, iNOS) and pro-survival pathways (pAkt, p70s6k, HIF-1α) and apoptosis. Pigs fed a 12-week high fat diet developed obesity and hyperlipidaemia. This was associated with increased redox sensitive pro-inflammatory and anti-apoptotic signalling, and tubular epithelial cell proliferation. High fat feeding also protected swine against post CPB AKI; mean difference in creatinine clearance CPB - CPB + HF −65.3 ml/min (95% CI −106.9 to −23.7), by preserving endothelial homeostasis and function, and preventing the reductions in GFR, loss of ATP and tubular apoptosis that characterise the extension phase of AKI in swine at 24 hours post injury. Reno-protection was not attributed to pAkt signaling. Conclusions A high fat diet promoted obesity and renal inflammation and prevented post CPB AKI in swine. This study provides insights into the obesity paradox and the failure of anti-inflammatory interventions to improve clinical outcomes in patients at risk of post cardiac surgery AKI.
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Nitric oxide delivery during cardiopulmonary bypass reduces postoperative morbidity in children—a randomized trial. J Thorac Cardiovasc Surg 2013; 146:530-6. [DOI: 10.1016/j.jtcvs.2012.09.100] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 08/10/2012] [Accepted: 09/13/2012] [Indexed: 11/24/2022]
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Satterly SA, Martin M, Wingerd M, Hempel J, Hoffer Z, Stallings JD. Flutamide fails to reduce resuscitation requirements in a porcine ischemia-reperfusion model. J Surg Res 2013; 184:472-9. [PMID: 23791438 DOI: 10.1016/j.jss.2013.04.083] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 04/12/2013] [Accepted: 04/30/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hemorrhagic shock and subsequent resuscitation can lead to ischemia-reperfusion injury, followed by multiorgan failure and death. Flutamide, a vasoactive nonsteroidal antiandrogen compound, is thought to improve tissue and organ perfusion. We tested whether administration of flutamide-cyclodextrin (FLU-CYD) alters physiologic parameters or resuscitation requirements in a porcine model of severe acidosis and shock secondary to combined hemorrhage + ischemia-reperfusion injury. METHODS AND MATERIALS Fifteen male pigs underwent a 35% blood-volume hemorrhage. Ischemia was induced by cross-clamping the supraceliac aorta for 50 min followed by reperfusion and resuscitation. FLU-CYD complex was administered during aortic clamping. Fluid resuscitation and epinephrine were titrated by protocol to maintain mean arterial pressure ≥40 mm Hg for 6 h. Sequential laboratory results were obtained and serum levels of FLU and 2-hydroxy-flutamide (FLUOH) were measured by mass spectrometry. RESULTS Mean requirements for injured control swine were 14.6 (± 1.21 standard error of the mean [SEM]) L crystalloid saline and 0.59 (± 0.29 SEM) g epinephrine, compared with 16.30 (± 1.33 SEM) L and 0.54 (± 0.16 SEM) g, respectively, in the FLU-CYD group (both P > 0.05). There were no significant differences in central hemodynamics between control and experimental groups. No significant differences for pH, bicarbonate, fibrinogen, or international normalized ratio were evident. FLU-CYD resuscitation was associated with a significant increase in lactate levels compared with controls (10.1 versus 5.7 mmol/L, P < 0.05). Histologic injury was significantly increased in the livers of FLU-CYD compared with sham (P = 0.022). High serum levels of FLU and the active metabolite FLUOH were measurable throughout the resuscitation period. CONCLUSIONS Flutamide failed to show any benefit to resuscitation in a model of severe injury and was associated with increased acidosis, hemodilution, and liver injury compared with standard crystalloid resuscitation.
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Affiliation(s)
- Steven A Satterly
- Department of Surgery, Madigan Healthcare System, Tacoma, Washington 98431, USA
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26
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Thomas AC. Animal models for studying vein graft failure and therapeutic interventions. Curr Opin Pharmacol 2012; 12:121-6. [PMID: 22281067 DOI: 10.1016/j.coph.2012.01.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Accepted: 01/05/2012] [Indexed: 11/25/2022]
Abstract
Vein grafts have been extensively used to bypass blockages in arteries, but are themselves subject to early closure by thrombosis or later obstruction by vein graft disease (neointimal hyperplasia and remodelling). Animal models are a crucial means of testing potential therapeutic and surgical interventions to prevent graft stenosis and occlusion. This review outlines many of the animal models of vein grafting. Recent studies include targeted gene therapy to prevent acute vein graft thrombosis and the use of folic acid to limit graft failure in diabetic pigs.
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Affiliation(s)
- Anita C Thomas
- Bristol Heart Institute, University of Bristol, Bristol, BS2 8HW, United Kingdom.
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Patel NN, Lin H, Toth T, Jones C, Ray P, Welsh GI, Satchell SC, Sleeman P, Angelini GD, Murphy GJ. Phosphodiesterase-5 inhibition prevents postcardiopulmonary bypass acute kidney injury in swine. Ann Thorac Surg 2011; 92:2168-76. [PMID: 21983073 DOI: 10.1016/j.athoracsur.2011.07.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Revised: 06/30/2011] [Accepted: 07/11/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute kidney injury after cardiac surgery is common, has no effective treatments, and is associated with adverse outcomes. The aim of this study was to determine whether administration of the phosphodiesterase-5 inhibitor sildenafil citrate (SDF) would prevent the development of post-cardiopulmonary bypass (CPB) acute kidney injury in swine. METHODS Adult pigs (n = 8 per group) were randomized to undergo sham procedure, CPB, or CPB plus administration of SDF, with recovery and reassessment at 24 hours. RESULTS Cardiopulmonary bypass resulted in a significant reduction in creatinine clearance relative to sham pigs (mean difference CPB versus sham, -47.9 mL/min; 95% confidence interval [CI]: -93.7 to -2.2; p = 0.039). This was prevented by the administration of SDF during CPB (mean difference CPB+SDF versus CPB, +55.6 mL/min; 95% CI: +6.5 to +104.7; p = 0.024). Cardiopulmonary bypass also resulted in a significant rise in the urinary biomarker interleukin-18 compared with sham procedures (mean difference 209.3 pg/mL; 95% CI: 120.6 to 298.1; p < 0.001) that was prevented by SDF administration. Post-CPB kidney injury was associated with vascular endothelial injury and dysfunction, reduced nitric oxide bioavailability, medullary hypoxia, cortical adenosine triphosphate depletion, inflammation, and evidence of proximal tubule epithelial cell stress manifest as phenotypic change. Administration of SDF to CPB pigs preserved nitric oxide bioavailability and prevented endothelial dysfunction, regional hypoxia, inflammation, and tubular changes. CONCLUSIONS In this model, phosphodiesterase-5 inhibition using SDF prevented post-CPB acute kidney injury by the preservation of nitric oxide bioavailability, and warrants evaluation as a renoprotective agent in clinical trials.
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Affiliation(s)
- Nishith N Patel
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, United Kingdom
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Prevention of post-cardiopulmonary bypass acute kidney injury by endothelin A receptor blockade. Crit Care Med 2011; 39:793-802. [PMID: 21220998 DOI: 10.1097/ccm.0b013e318206d563] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether administration of a specific endothelin A receptor antagonist, sitaxsentan sodium, would prevent the development of post-cardiopulmonary bypass acute kidney injury in swine. DESIGN Experimental study. SETTING Cardiovascular Research Institute. INTERVENTIONS Adult pigs (n = 8 per group) were randomized to undergo a sham procedure, cardiopulmonary bypass, or cardiopulmonary bypass plus administration of endothelin A receptor antagonist (RA), with recovery and reassessment at 24 hrs. MEASUREMENTS AND MAIN RESULTS Cardiopulmonary bypass resulted in a significant reduction in creatinine clearance relative to sham pigs (mean difference for cardiopulmonary bypass vs. sham, -50.3 mL/min [95% confidence interval -89.2 to -11.4 mL/min], p = .008). This was reversed by the administration of endothelin A RA during cardiopulmonary bypass (mean difference for cardiopulmonary bypass + endothelin A RA vs. cardiopulmonary bypass, +43.3 mL/min [95% confidence interval +3.3 to +83.4 mL/min], p = .030). Cardiopulmonary bypass also resulted in a significant rise in the specific urinary biomarker of acute kidney injury interleukin-18 compared to sham procedures (mean difference +209 pg/mL [95% confidence interval +119 to +299 pg/mL], p < .001) that was reversed by endothelin A receptor antagonist administration. Post-cardiopulmonary bypass kidney injury was associated with vascular endothelial injury and dysfunction, reduced nitric oxide bioavailability, inflammation, and a significant increase in the expression of the paracrine vasoconstrictors adenosine and endothelin-1. In post-cardiopulmonary bypass kidneys at 24 hrs there was persistent hypoxia at the level of the outer medulla, cortical adenosine triphosphate depletion, and evidence of proximal tubule epithelial cell stress manifest as phenotypic change. There was no evidence of acute tubular necrosis. Administration of endothelin A RA to cardiopulmonary bypass pigs reversed endothelial dysfunction, regional hypoxia, inflammation, and tubular changes. CONCLUSION In this model, post-cardiopulmonary bypass acute kidney injury is associated with endothelial dysfunction, regional tissue hypoxia, and proximal tubular epithelial cell stress but not acute tubular necrosis. Antagonism of the endothelin-1 A receptor reversed these changes and may represent a therapeutic target for the prevention of post-cardiac surgery acute kidney injury.
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Patel NN, Lin H, Toth T, Welsh GI, Jones C, Ray P, Satchell SC, Sleeman P, Angelini GD, Murphy GJ. Reversal of anemia with allogenic RBC transfusion prevents post-cardiopulmonary bypass acute kidney injury in swine. Am J Physiol Renal Physiol 2011; 301:F605-14. [PMID: 21653630 DOI: 10.1152/ajprenal.00145.2011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Anemia during cardiopulmonary bypass (CPB) is strongly associated with acute kidney injury in clinical studies; however, reversal of anemia with red blood cell (RBC) transfusions is associated with further renal injury. To understand this paradox, we evaluated the effects of reversal of anemia during CPB with allogenic RBC transfusion in a novel large-animal model of post-cardiac surgery acute kidney injury with significant homology to that observed in cardiac surgery patients. Adult pigs undergoing general anesthesia were allocated to a Sham procedure, CPB alone, Sham+RBC transfusion, or CPB+RBC transfusion, with recovery and reassessment at 24 h. CPB was associated with dilutional anemia and caused acute kidney injury in swine characterized by renal endothelial dysfunction, loss of nitric oxide (NO) bioavailability, vasoconstriction, medullary hypoxia, cortical ATP depletion, glomerular sequestration of activated platelets and inflammatory cells, and proximal tubule epithelial cell stress. RBC transfusion in the absence of CPB also resulted in renal injury. This was characterized by endothelial injury, microvascular endothelial dysfunction, platelet activation, and equivalent cortical tubular epithelial phenotypic changes to those observed in CPB pigs, but occurred in the absence of severe intrarenal vasoconstriction, ATP depletion, or reductions in creatinine clearance. In contrast, reversal of anemia during CPB with RBC transfusion prevented the reductions in creatinine clearance, loss of NO bioavailability, platelet activation, inflammation, and epithelial cell injury attributable to CPB although it did not prevent the development of significant intrarenal vasoconstriction and endothelial dysfunction. In conclusion, contrary to the findings of observational studies in cardiac surgery, RBC transfusion during CPB protects pigs against acute kidney injury. Our study underlines the need for translational research into indications for transfusion and prevention strategies for acute kidney injury.
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Affiliation(s)
- Nishith N Patel
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, UK
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