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Martín-Fernández M, Casanova AG, Jorge-Monjas P, Morales AI, Tamayo E, López Hernández FJ. A wide scope, pan-comparative, systematic meta-analysis of the efficacy of prophylactic strategies for cardiac surgery-associated acute kidney injury. Biomed Pharmacother 2024; 178:117152. [PMID: 39047420 DOI: 10.1016/j.biopha.2024.117152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 07/07/2024] [Accepted: 07/12/2024] [Indexed: 07/27/2024] Open
Abstract
Acute kidney injury (AKI) is the most common complication of cardiac surgery. Cardiac surgery-associated AKI (CSA-AKI) is caused by systemic and renal hemodynamic impairment and parenchymal injury. Prophylaxis of CSA-AKI remains an unmet priority, for which preventive strategies based on drug therapies, hydration procedures, and remote ischemic preconditioning (RIPC) have been tested in pre-clinical and clinical studies, with variable success. Contradicting reports and scarce or insufficiently pondered information have blurred conclusions. Therefore, with an aim to contribute to consolidating the available information, we carried out a wide scope, pan-comparative meta-analysis including the accessible information about the most relevant nephroprotective approaches assayed. After a thorough examination of 1892 documents retrieved from PubMed and Web of Science, 150 studies were used for the meta-analysis. Individual odds ratios of efficacy at reducing AKI incidence, need for dialysis, and plasma creatinine elevation were obtained for each alleged protectant. Also, the combined class effect of drug families and protective strategies was also meta-analyzed. Our results show that no drug family or procedure affords substantial protection against CSA-AKI. Only, a mild but significant reduction in the incidence of CSA-AKI by preemptive treatment with dopaminergic and adrenergic drugs, vasodilators, and the RIPC technique. The integrated analysis suggests that single-drug approaches are unlikely to cope with the variety of individual pathophysiological scenarios potentially underlying CSA-AKI. Accordingly, a theragnostic approach involving the etiopathological diagnosis of kidney frailty is necessary to guide research towards the development of pharmacological combinations concomitantly and effectively addressing the key mechanisms of CSA-AKI.
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Affiliation(s)
- Marta Martín-Fernández
- Department of Cell Biology, Genetics, Histology and Pharmacology, Faculty of Medicine, Universidad de Valladolid, Valladolid 47005, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Group of Biomedical Research on Critical Care (BioCritic), Valladolid, Spain
| | - Alfredo G Casanova
- Instituto de Investigación Biomédica de Salamanca (IBSAL) de la Fundación Instituto de Ciencias de la Salud de Castilla y León (ICSCYL), Salamanca, Spain; National Network for Kidney Research REDINREN, RD016/0009/0025, Instituto de Salud Carlos III, Madrid, Spain; Department of Physiology and Pharmacology, Universidad de Salamanca (USAL), Salamanca, Spain; Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain
| | - Pablo Jorge-Monjas
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Group of Biomedical Research on Critical Care (BioCritic), Valladolid, Spain; Department of Anesthesiology and Critical Care, Clinical University Hospital of Valladolid, Valladolid, Spain; Department of Surgery, Faculty of Medicine, Universidad de Valladolid, Valladolid 47005, Spain
| | - Ana I Morales
- Group of Biomedical Research on Critical Care (BioCritic), Valladolid, Spain; Instituto de Investigación Biomédica de Salamanca (IBSAL) de la Fundación Instituto de Ciencias de la Salud de Castilla y León (ICSCYL), Salamanca, Spain; National Network for Kidney Research REDINREN, RD016/0009/0025, Instituto de Salud Carlos III, Madrid, Spain; Department of Physiology and Pharmacology, Universidad de Salamanca (USAL), Salamanca, Spain; Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain
| | - Eduardo Tamayo
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Group of Biomedical Research on Critical Care (BioCritic), Valladolid, Spain; Department of Anesthesiology and Critical Care, Clinical University Hospital of Valladolid, Valladolid, Spain; Department of Surgery, Faculty of Medicine, Universidad de Valladolid, Valladolid 47005, Spain
| | - Francisco J López Hernández
- Group of Biomedical Research on Critical Care (BioCritic), Valladolid, Spain; Instituto de Investigación Biomédica de Salamanca (IBSAL) de la Fundación Instituto de Ciencias de la Salud de Castilla y León (ICSCYL), Salamanca, Spain; National Network for Kidney Research REDINREN, RD016/0009/0025, Instituto de Salud Carlos III, Madrid, Spain; Department of Physiology and Pharmacology, Universidad de Salamanca (USAL), Salamanca, Spain; Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain.
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Chen LL, Yao YT. Remote ischemic conditioning reduces postoperative bleeding in adult cardiac surgical patients: a systematic review and meta-analysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:280-288. [PMID: 38411397 DOI: 10.23736/s0021-9509.24.12827-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
INTRODUCTION The current study was designed to systemically investigate the impact of remote ischemic conditioning (RIC) on intra- and postoperative bleeding and transfusion in patients undergoing cardiac surgery. EVIDENCE ACQUISITION We included all randomized controlled trials (RCTs) comparing RIC with control on intra- and postoperative blood loss and blood transfusion. The inclusion criteria were as follows: 1) adult patients undergoing cardiac surgery; 2) RCT; 3) perioperative administration of RIC compared to control; 4) outcomes of interest reported. Exclusion criteria included: 1) case reports, reviews, or abstracts; 2) animal or cell studies; 3) duplicate publications; 4) studies lacking information about outcomes of interest. EVIDENCE SYNTHESIS Databases search yielded 24 RCTs including 3530 patients, 1765 patients were allocated into RIC group and 1765 into control group. The current study suggested that RIC administration was associated with reduced postoperative blood loss (WMD=-57.89; 95% CI: -89.89 to -25.89; P=0.0004). RIC did not affect the volume of intraoperative blood loss (WMD=-4.02; 95% CI: -14.09 to 6.05; P=0.43), the volume of intra- and postoperative transfusion of red blood cell (RBC) (WMD=-15.66; 95% CI: -39.35 to 8.03; P=0.20), the re-exploration for bleeding (WMD=-0.01; 95% CI: -0.03 to 0.01; P=0.21). CONCLUSIONS The current study demonstrated that, RIC reduced post-operative blood loss in adult patients undergoing cardiac surgeries. It also indicated that, RIC reduced intra-operative RBC transfusion in adult patients undergoing coronary artery bypass grafting. However, RIC did not influence intra-operative bleeding, post-operative blood transfusion.
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Affiliation(s)
- Lin-Lin Chen
- Department of Anesthesiology, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, Guangdong, China
| | - Yun-Tai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China -
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Abbasciano RG, Tomassini S, Roman MA, Rizzello A, Pathak S, Ramzi J, Lucarelli C, Layton G, Butt A, Lai F, Kumar T, Wozniak MJ, Murphy GJ. Effects of interventions targeting the systemic inflammatory response to cardiac surgery on clinical outcomes in adults. Cochrane Database Syst Rev 2023; 10:CD013584. [PMID: 37873947 PMCID: PMC10594589 DOI: 10.1002/14651858.cd013584.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND Organ injury is a common and severe complication of cardiac surgery that contributes to the majority of deaths. There are no effective treatment or prevention strategies. It has been suggested that innate immune system activation may have a causal role in organ injury. A wide range of organ protection interventions targeting the innate immune response have been evaluated in randomised controlled trials (RCTs) in adult cardiac surgery patients, with inconsistent results in terms of effectiveness. OBJECTIVES The aim of the review was to summarise the results of RCTs of organ protection interventions targeting the innate immune response in adult cardiac surgery. The review considered whether the interventions had a treatment effect on inflammation, important clinical outcomes, or both. SEARCH METHODS CENTRAL, MEDLINE, Embase, conference proceedings and two trial registers were searched on October 2022 together with reference checking to identify additional studies. SELECTION CRITERIA RCTs comparing organ protection interventions targeting the innate immune response versus placebo or no treatment in adult patients undergoing cardiac surgery where the treatment effect on innate immune activation and on clinical outcomes of interest were reported. DATA COLLECTION AND ANALYSIS Searches, study selection, quality assessment, and data extractions were performed independently by pairs of authors. The primary inflammation outcomes were peak IL-6 and IL-8 concentrations in blood post-surgery. The primary clinical outcome was in-hospital or 30-day mortality. Treatment effects were expressed as risk ratios (RR) and standardised mean difference (SMD) with 95% confidence intervals (CI). Meta-analyses were performed using random effects models, and heterogeneity was assessed using I2. MAIN RESULTS A total of 40,255 participants from 328 RCTs were included in the synthesis. The effects of treatments on IL-6 (SMD -0.77, 95% CI -0.97 to -0.58, I2 = 92%) and IL-8 (SMD -0.92, 95% CI -1.20 to -0.65, I2 = 91%) were unclear due to heterogeneity. Heterogeneity for inflammation outcomes persisted across multiple sensitivity and moderator analyses. The pooled treatment effect for in-hospital or 30-day mortality was RR 0.78, 95% CI 0.68 to 0.91, I2 = 0%, suggesting a significant clinical benefit. There was little or no treatment effect on mortality when analyses were restricted to studies at low risk of bias. Post hoc analyses failed to demonstrate consistent treatment effects on inflammation and clinical outcomes. Levels of certainty for pooled treatment effects on the primary outcomes were very low. AUTHORS' CONCLUSIONS A systematic review of RCTs of organ protection interventions targeting innate immune system activation did not resolve uncertainty as to the effectiveness of these treatments, or the role of innate immunity in organ injury following cardiac surgery.
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Affiliation(s)
| | | | - Marius A Roman
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Angelica Rizzello
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Suraj Pathak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Joussi Ramzi
- Leicester Medical School, University of Leicester, Leicester, UK
| | - Carla Lucarelli
- Department of Cardiac Surgery, University of Verona, Verona, Italy
| | - Georgia Layton
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ayesha Butt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Florence Lai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Tracy Kumar
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Marcin J Wozniak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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Kashiwagi S, Mihara T, Yokoi A, Yokoyama C, Nakajima D, Goto T. Effect of remote ischemic preconditioning on lung function after surgery under general anesthesia: a systematic review and meta-analysis. Sci Rep 2023; 13:17720. [PMID: 37853024 PMCID: PMC10584824 DOI: 10.1038/s41598-023-44833-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/12/2023] [Indexed: 10/20/2023] Open
Abstract
Remote ischemic preconditioning (RIPC) protects organs from ischemia-reperfusion injury. Recent trials showed that RIPC improved gas exchange in patients undergoing lung or cardiac surgery. We performed a systematic search to identify randomized controlled trials involving RIPC in surgery under general anesthesia. The primary outcome was the PaO2/FIO2 (P/F) ratio at 24 h after surgery. Secondary outcomes were A-a DO2, the respiratory index, duration of postoperative mechanical ventilation (MV), incidence of acute respiratory distress syndrome (ARDS), and serum cytokine levels. The analyses included 71 trials comprising 7854 patients. Patients with RIPC showed higher P/F ratio than controls (mean difference [MD] 36.6, 95% confidence interval (CI) 12.8 to 60.4, I2 = 69%). The cause of heterogeneity was not identified by the subgroup analysis. Similarly, A-a DO2 (MD 15.2, 95% CI - 29.7 to - 0.6, I2 = 87%) and respiratory index (MD - 0.17, 95% CI - 0.34 to - 0.01, I2 = 94%) were lower in the RIPC group. Additionally, the RIPC group was weaned from MV earlier (MD - 0.9 h, 95% CI - 1.4 to - 0.4, I2 = 78%). Furthermore, the incidence of ARDS was lower in the RIPC group (relative risk 0.73, 95% CI 0.60 to 0.89, I2 = 0%). Serum TNFα was lower in the RIPC group (SMD - 0.6, 95%CI - 1.0 to - 0.3 I2 = 87%). No significant difference was observed in interleukin-6, 8 and 10. Our meta-analysis suggested that RIPC improved oxygenation after surgery under general anesthesia.Clinical trial number: This study protocol was registered in the University Hospital Medical Information Network (registration number: UMIN000030918), https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000035305.
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Affiliation(s)
- Shizuka Kashiwagi
- Department of Anesthesiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
- Department of Anesthesiology, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-Ku, Yokohama City, Kanagawa-Ken, 236-0004, Japan.
| | - Takahiro Mihara
- Department of Health Data Science, Yokohama City University Graduate School of Data Science, Yokohama, Japan
| | - Ayako Yokoi
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Chisaki Yokoyama
- Department of Anesthesia, Chiba Children's Hospital, Chiba, Japan
| | - Daisuke Nakajima
- Department of Anesthesiology, Yokohama City University Medical Center, Yokohama City, Japan
| | - Takahisa Goto
- Department of Anesthesiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Ortega-Trejo JA, Bobadilla NA. Is Renal Ischemic Preconditioning an Alternative to Ameliorate the Short- and Long-Term Consequences of Acute Kidney Injury? Int J Mol Sci 2023; 24:ijms24098345. [PMID: 37176051 PMCID: PMC10178892 DOI: 10.3390/ijms24098345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/21/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
Acute kidney injury (AKI) is a global health problem and has recently been recognized as a risk factor for developing chronic kidney disease (CKD). Unfortunately, there are no effective treatments to reduce or prevent AKI, which results in high morbidity and mortality rates. Ischemic preconditioning (IPC) has emerged as a promising strategy to prevent, to the extent possible, renal tissue from AKI. Several studies have used this strategy, which involves short or long cycles of ischemia/reperfusion (IR) prior to a potential fatal ischemic injury. In most of these studies, IPC was effective at reducing renal damage. Since the first study that showed renoprotection due to IPC, several studies have focused on finding the best strategy to activate correctly and efficiently reparative mechanisms, generating different modalities with promising results. In addition, the studies performing remote IPC, by inducing an ischemic process in distant tissues before a renal IR, are also addressed. Here, we review in detail existing studies on IPC strategies for AKI pathophysiology and the proposed triggering mechanisms that have a positive impact on renal function and structure in animal models of AKI and in humans, as well as the prospects and challenges for its clinical application.
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Affiliation(s)
- Juan Antonio Ortega-Trejo
- Molecular Physiology Unit, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico
| | - Norma A Bobadilla
- Molecular Physiology Unit, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
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Schacht S, O'Connor B, Kirschner A, Steelman K, Rosmarin DH, Rubinstein J. Review of the Cardiovascular Implications of the Social and Religious Practices Associated with Donning Phylacteries. JOURNAL OF RELIGION AND HEALTH 2023; 62:287-299. [PMID: 35028811 DOI: 10.1007/s10943-021-01478-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/03/2021] [Indexed: 06/14/2023]
Abstract
We previously published a manuscript suggesting that use of phylacteries, ritual straps worn during Jewish prayer services, affects cardiovascular and inflammatory function (Owens et al., Am J Physiol-Heart Circ Physiol, 315(6):H1748-H1758, 2018). Observed physiologic changes were associated with improved cardiac outcomes, though a direct link between phylactery use and improved cardiovascular outcomes is difficult to prove as there are a number of associated religious and spiritual practices that may confound the observed effects. In this review, we assess the scientific literature regarding religious and spiritual practices associated with phylactery in order to better understand the cardiovascular implications of the practice of donning phylacteries. We focus on key aspects traditionally associated with donning phylacteries including gathering in groups, meditation and prayer.
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Affiliation(s)
- Sydney Schacht
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML0586, Cincinnati, OH, 45267, USA
| | - Brian O'Connor
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML0586, Cincinnati, OH, 45267, USA
| | - Akiva Kirschner
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML0586, Cincinnati, OH, 45267, USA
| | - Katie Steelman
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML0586, Cincinnati, OH, 45267, USA
| | | | - Jack Rubinstein
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML0586, Cincinnati, OH, 45267, USA.
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Chen JJ, Lee TH, Kuo G, Huang YT, Chen PR, Chen SW, Yang HY, Hsu HH, Hsiao CC, Yang CH, Lee CC, Chen YC, Chang CH. Strategies for post–cardiac surgery acute kidney injury prevention: A network meta-analysis of randomized controlled trials. Front Cardiovasc Med 2022; 9:960581. [PMID: 36247436 PMCID: PMC9555275 DOI: 10.3389/fcvm.2022.960581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 09/12/2022] [Indexed: 12/05/2022] Open
Abstract
Objects Cardiac surgery is associated with acute kidney injury (AKI). However, the effects of various pharmacological and non-pharmacological strategies for AKI prevention have not been thoroughly investigated, and their effectiveness in preventing AKI-related adverse outcomes has not been systematically evaluated. Methods Studies from PubMed, Embase, and Medline and registered trials from published through December 2021 that evaluated strategies for preventing post–cardiac surgery AKI were identified. The effectiveness of these strategies was assessed through a network meta-analysis (NMA). The secondary outcomes were prevention of dialysis-requiring AKI, mortality, intensive care unit (ICU) length of stay (LOS), and hospital LOS. The interventions were ranked using the P-score method. Confidence in the results of the NMA was assessed using the Confidence in NMA (CINeMA) framework. Results A total of 161 trials (involving 46,619 participants) and 53 strategies were identified. Eight pharmacological strategies {natriuretic peptides [odds ratio (OR): 0.30, 95% confidence interval (CI): 0.19–0.47], nitroprusside [OR: 0.29, 95% CI: 0.12–0.68], fenoldopam [OR: 0.36, 95% CI: 0.17–0.76], tolvaptan [OR: 0.35, 95% CI: 0.14–0.90], N-acetyl cysteine with carvedilol [OR: 0.37, 95% CI: 0.16–0.85], dexmedetomidine [OR: 0.49, 95% CI: 0.32–0.76;], levosimendan [OR: 0.56, 95% CI: 0.37–0.84], and erythropoietin [OR: 0.62, 95% CI: 0.41–0.94]} and one non-pharmacological intervention (remote ischemic preconditioning, OR: 0.76, 95% CI: 0.63–0.92) were associated with a lower incidence of post–cardiac surgery AKI with moderate to low confidence. Among these nine strategies, five (fenoldopam, erythropoietin, natriuretic peptides, levosimendan, and remote ischemic preconditioning) were associated with a shorter ICU LOS, and two (natriuretic peptides [OR: 0.30, 95% CI: 0.15–0.60] and levosimendan [OR: 0.68, 95% CI: 0.49–0.95]) were associated with a lower incidence of dialysis-requiring AKI. Natriuretic peptides were also associated with a lower risk of mortality (OR: 0.50, 95% CI: 0.29–0.86). The results of a sensitivity analysis support the robustness and effectiveness of natriuretic peptides and dexmedetomidine. Conclusion Nine potentially effective strategies were identified. Natriuretic peptide therapy was the most effective pharmacological strategy, and remote ischemic preconditioning was the only effective non-pharmacological strategy. Preventive strategies might also help prevent AKI-related adverse outcomes. Additional studies are required to explore the optimal dosages and protocols for potentially effective AKI prevention strategies.
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Affiliation(s)
- Jia-Jin Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | | | - George Kuo
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yen-Ta Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Rung Chen
- Department of Anesthesiology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shao-Wei Chen
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Huang-Yu Yang
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hsiang-Hao Hsu
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ching-Chung Hsiao
- Department of Nephrology, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Chia-Hung Yang
- Department of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Cheng-Chia Lee
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yung-Chang Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- *Correspondence: Chih-Hsiang Chang,
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Ortona S, Barisione C, Ferrari PF, Palombo D, Pratesi G. PCSK9 and Other Metabolic Targets to Counteract Ischemia/Reperfusion Injury in Acute Myocardial Infarction and Visceral Vascular Surgery. J Clin Med 2022; 11:jcm11133638. [PMID: 35806921 PMCID: PMC9267902 DOI: 10.3390/jcm11133638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/13/2022] [Accepted: 06/17/2022] [Indexed: 12/13/2022] Open
Abstract
Ischemia/reperfusion (I/R) injury complicates both unpredictable events (myocardial infarction and stroke) as well as surgically-induced ones when transient clampage of major vessels is needed. Although the main cause of damage is attributed to mitochondrial dysfunction and oxidative stress, the use of antioxidant compounds for protection gave poor results when challenged in clinics. More recently, there is an assumption that, in humans, profound metabolic changes may prevail in driving I/R injury. In the present work, we narrowed the field of search to I/R injury in the heart/brain/kidney axis in acute myocardial infarction, major vascular surgery, and to the current practice of protection in both settings; then, to help the definition of novel strategies to be translated clinically, the most promising metabolic targets with their modulatory compounds—when available—and new preclinical strategies against I/R injury are described. The consideration arisen from the broad range of studies we have reviewed will help to define novel therapeutic approaches to ensure mitochondrial protection, when I/R events are predictable, and to cope with I/R injury, when it occurs unexpectedly.
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Affiliation(s)
- Silvia Ortona
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi, 10, 16132 Genoa, Italy; (S.O.); (D.P.); (G.P.)
| | - Chiara Barisione
- Department of Surgical and Integrated Diagnostic Sciences, University of Genoa, Viale Benedetto XV, 6, 16132 Genoa, Italy
- Correspondence: ; Tel.: +39-010-555-7881
| | - Pier Francesco Ferrari
- Department of Civil, Chemical and Environmental Engineering, University of Genoa, Via Opera Pia, 15, 16145 Genoa, Italy;
| | - Domenico Palombo
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi, 10, 16132 Genoa, Italy; (S.O.); (D.P.); (G.P.)
- Department of Surgical and Integrated Diagnostic Sciences, University of Genoa, Viale Benedetto XV, 6, 16132 Genoa, Italy
- Research Center for Biologically Inspired Engineering in Vascular Medicine and Longevity, University of Genoa, Via Montallegro, 1, 16145 Genoa, Italy
| | - Giovanni Pratesi
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi, 10, 16132 Genoa, Italy; (S.O.); (D.P.); (G.P.)
- Department of Surgical and Integrated Diagnostic Sciences, University of Genoa, Viale Benedetto XV, 6, 16132 Genoa, Italy
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Long YQ, Feng XM, Shan XS, Chen QC, Xia Z, Ji FH, Liu H, Peng K. Remote Ischemic Preconditioning Reduces Acute Kidney Injury After Cardiac Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Anesth Analg 2021; 134:592-605. [PMID: 34748518 DOI: 10.1213/ane.0000000000005804] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Results from previous studies evaluating the effects of remote ischemic preconditioning (RIPC) on morbidity and mortality after cardiac surgery are inconsistent. This meta-analysis of randomized controlled trials (RCTs) aims to determine whether RIPC improves cardiac and renal outcomes in adults undergoing cardiac surgery. METHODS PubMed, EMBASE, and Cochrane Library were comprehensively searched to identify RCTs comparing RIPC with control in cardiac surgery. The coprimary outcomes were the incidence of postoperative myocardial infarction (MI) and the incidence of postoperative acute kidney injury (AKI). Meta-analyses were performed using a random-effect model. Subgroup analyses were conducted according to volatile only anesthesia versus propofol anesthesia with or without volatiles, high-risk patients versus non-high-risk patients, and Acute Kidney Injury Network (AKIN) or Kidney Disease Improving Global Outcomes (KDIGO) criteria versus other criteria for AKI diagnosis. RESULTS A total of 79 RCTs with 10,814 patients were included. While the incidence of postoperative MI did not differ between the RIPC and control groups (8.2% vs 9.7%; risk ratio [RR] = 0.87, 95% confidence interval [CI], 0.76-1.01, P = .07, I2 = 0%), RIPC significantly reduced the incidence of postoperative AKI (22% vs 24.4%; RR = 0.86, 95% CI, 0.77-0.97, P = .01, I2 = 34%). The subgroup analyses showed that RIPC was associated with a reduced incidence of MI in non-high-risk patients, and that RIPC was associated with a reduced incidence of AKI in volatile only anesthesia, in non-high-risk patients, and in the studies using AKIN or KDIGO criteria for AKI diagnosis. CONCLUSIONS This meta-analysis demonstrates that RIPC reduces the incidence of AKI after cardiac surgery. This renoprotective effect of RIPC is mainly evident during volatile only anesthesia, in non-high-risk patients, and when AKIN or KDIGO criteria used for AKI diagnosis.
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Affiliation(s)
- Yu-Qin Long
- From the Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiao-Mei Feng
- Department of Anesthesiology, University of Utah Health, Salt Lake City, Utah.,Transitional Residency Program, Intermountain Medical Center, Murray, Utah
| | - Xi-Sheng Shan
- From the Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Qing-Cai Chen
- From the Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhengyuan Xia
- Department of Anesthesiology and Pain Medicine, University of California Davis Health, Sacramento, California
| | - Fu-Hai Ji
- From the Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California Davis Health, Sacramento, California
| | - Ke Peng
- From the Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China
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10
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Krag AE, Hvas CL, Kiil BJ, Hvas AM. Effect of Remote Ischemic Conditioning on Bleeding Complications in Surgery: A Systematic Review and Meta-Analysis. Semin Thromb Hemost 2021; 48:229-239. [PMID: 34428800 DOI: 10.1055/s-0041-1732468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Remote ischemic conditioning (RIC) is administered with an inflatable tourniquet by inducing brief, alternating cycles of limb ischemia and reperfusion. RIC possibly impacts the hemostatic system, and the intervention has been tested as protective therapy against ischemia-reperfusion injury and thrombotic complications in cardiac surgery and other surgical procedures. In the present systematic review, we aimed to investigate the effect of RIC on intraoperative and postoperative bleeding complications in meta-analyses of randomized controlled trials including adult patients undergoing surgery. A systematic search was performed on November 7, 2020 in PubMed, Embase, and the Cochrane Central Register of Controlled Trials. Randomized controlled trials comparing RIC versus no RIC in adult patients undergoing surgery that reported bleeding outcomes in English publications were included. Effect estimates with 95% confidence intervals were calculated using the random-effects model for intraoperative and postoperative bleeding outcomes. Thirty-two randomized controlled trials with 3,804 patients were eligible for inclusion. RIC did not affect intraoperative bleeding volume (nine trials; 392 RIC patients, 399 controls) with the effect estimate -0.95 [-9.90; 7.99] mL (p = 0.83). RIC significantly reduced postoperative drainage volume (seven trials; 367 RIC patients, 365 controls) with mean difference -83.6 [-134.9; -32.4] mL (p = 0.001). The risk of re-operation for bleeding was reduced in the RIC group (16 trials; 838 RIC patients, 839 controls), albeit not significantly, with the relative risk 0.65 [0.39; 1.09] (p = 0.10). In conclusion, RIC reduced postoperative bleeding measured by postoperative drainage volume in this meta-analysis of adult patients undergoing surgery.
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Affiliation(s)
- Andreas E Krag
- Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Plastic and Breast Surgery, Aarhus University Hospital, Denmark
| | - Christine L Hvas
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | - Birgitte J Kiil
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Denmark
| | - Anne-Mette Hvas
- Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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11
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Liu Z, Zhao Y, Lei M, Zhao G, Li D, Sun R, Liu X. Remote Ischemic Preconditioning to Prevent Acute Kidney Injury After Cardiac Surgery: A Meta-Analysis of Randomized Controlled Trials. Front Cardiovasc Med 2021; 8:601470. [PMID: 33816572 PMCID: PMC8012491 DOI: 10.3389/fcvm.2021.601470] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 02/15/2021] [Indexed: 11/18/2022] Open
Abstract
Objective: Randomized controlled trials (RCTs) evaluating the influence of remote ischemic preconditioning (RIPC) on acute kidney injury (AKI) after cardiac surgery showed inconsistent results. We performed a meta-analysis to evaluate the efficacy of RIPC on AKI after cardiac surgery. Methods: Relevant studies were obtained by search of PubMed, Embase, and Cochrane's Library databases. A random-effect model was used to pool the results. Meta-regression and subgroup analyses were used to determine the source of heterogeneity. Results: Twenty-two RCTs with 5,389 patients who received cardiac surgery −2,702 patients in the RIPC group and 2,687 patients in the control group—were included. Moderate heterogeneity was detected (p for Cochrane's Q test = 0.03, I2 = 40%). Pooled results showed that RIPC significantly reduced the incidence of AKI compared with control [odds ratio (OR): 0.76, 95% confidence intervals (CI): 0.61–0.94, p = 0.01]. Results limited to on-pump surgery (OR: 0.78, 95% CI: 0.64–0.95, p = 0.01) or studies with acute RIPC (OR: 0.78, 95% CI: 0.63–0.97, p = 0.03) showed consistent results. Meta-regression and subgroup analyses indicated that study characteristics, including study design, country, age, gender, diabetic status, surgery type, use of propofol or volatile anesthetics, cross-clamp time, RIPC protocol, definition of AKI, and sample size did not significantly affect the outcome of AKI. Results of stratified analysis showed that RIPC significantly reduced the risk of mild-to-moderate AKI that did not require renal replacement therapy (RRT, OR: 0.76, 95% CI: 0.60–0.96, p = 0.02) but did not significantly reduce the risk of severe AKI that required RRT in patients after cardiac surgery (OR: 0.73, 95% CI: 0.50–1.07, p = 0.11). Conclusions: Current evidence supports RIPC as an effective strategy to prevent AKI after cardiac surgery, which seems to be mainly driven by the reduced mild-to-moderate AKI events that did not require RRT. Efforts are needed to determine the influences of patient characteristics, procedure, perioperative drugs, and RIPC protocol on the outcome.
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Affiliation(s)
- Zigang Liu
- Department of Thoracic and Cardiovascular Surgery, Shenzhen Baoan Women's and Children's Hospital, Jinan University, Guangzhou, China
| | - Yongmei Zhao
- Department of Thoracic and Cardiovascular Surgery, Shenzhen Baoan Women's and Children's Hospital, Jinan University, Guangzhou, China
| | - Ming Lei
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Beijing, China
| | - Guancong Zhao
- Department of Thoracic and Cardiovascular Surgery, Shenzhen Baoan Women's and Children's Hospital, Jinan University, Guangzhou, China
| | - Dongcheng Li
- Department of Thoracic and Cardiovascular Surgery, Shenzhen Baoan Women's and Children's Hospital, Jinan University, Guangzhou, China
| | - Rong Sun
- Department of Thoracic and Cardiovascular Surgery, Shenzhen Baoan Women's and Children's Hospital, Jinan University, Guangzhou, China
| | - Xian Liu
- Department of Thoracic and Cardiovascular Surgery, Shenzhen Baoan Women's and Children's Hospital, Jinan University, Guangzhou, China
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12
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Meersch M, Küllmar M, Pavenstädt H, Rossaint J, Kellum JA, Martens S, Klausmeyer P, Schmidt EA, Kerschke L, Zarbock A. Effects of Different Doses of Remote Ischemic Preconditioning on Kidney Damage Among Patients Undergoing Cardiac Surgery: A Single-Center Mechanistic Randomized Controlled Trial. Crit Care Med 2020; 48:e690-e697. [PMID: 32697510 DOI: 10.1097/ccm.0000000000004415] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We have previously shown that remote ischemic preconditioning reduces acute kidney injury (acute kidney injury) in high-risk patients undergoing cardiopulmonary bypass and that the protective effect is confined to patients who exhibit an increased urinary tissue inhibitor of metalloproteinases-2 and insulin-like growth factor-binding protein 7 in response to remote ischemic preconditioning. The purpose of this study was to determine the optimal intensity of remote ischemic preconditioning to induce required [tissue inhibitor of metalloproteinases-2]*[insulin-like growth factor-binding protein 7] changes and further explore mechanisms of remote ischemic preconditioning. DESIGN Observational and randomized controlled, double-blind clinical trial. SETTING University Hospital of Muenster, Germany. PATIENTS High-risk patients undergoing cardiac surgery as defined by the Cleveland Clinic Foundation Score. INTERVENTIONS In the interventional part, patients were randomized to receive either one of four different remote ischemic preconditioning doses (3 × 5 min, 3 × 7 min, 3 × 10 min remote ischemic preconditioning, or 3 × 5 min remote ischemic preconditioning + 2 × 10 min remote ischemic preconditioning in nonresponders) or sham-remote ischemic preconditioning (control). MEASUREMENTS AND MAIN RESULTS The primary endpoint of the interventional part was change in urinary [tissue inhibitor of metalloproteinases-2]*[insulin-like growth factor-binding protein 7] between pre- and postintervention. To examine secondary objectives including acute kidney injury incidence, we included an observational cohort. A total of 180 patients were included in the trial (n = 80 observational and n = 100 randomized controlled part [20 patients/group]). The mean age was 69.3 years (10.5 yr), 119 were men (66.1%). Absolute changes in [tissue inhibitor of metalloproteinases-2]*[insulin-like growth factor-binding protein 7] were significantly higher in all remote ischemic preconditioning groups when compared with controls (p < 0.01). Although we did not observe a dose-response relationship on absolute changes in [tissue inhibitor of metalloproteinases-2]*[insulin-like growth factor-binding protein 7] across the four different remote ischemic preconditioning groups, in the 15 patients failing to respond to the lowest dose, nine (60%) responded to a subsequent treatment at a higher intensity. Compared with controls, fewer patients receiving remote ischemic preconditioning developed acute kidney injury within 72 hours after surgery as defined by both Kidney Disease: Improving Global Outcomes criteria (30/80 [37.5%] vs 61/100 [61.0%]; p = 0.003). CONCLUSIONS All doses of remote ischemic preconditioning significantly increased [tissue inhibitor of metalloproteinases-2]*[insulin-like growth factor-binding protein 7] and significantly decreased acute kidney injury compared with controls. High-dose remote ischemic preconditioning could stimulate [tissue inhibitor of metalloproteinases-2]*[insulin-like growth factor-binding protein 7] increases in patients refractory to low-dose remote ischemic preconditioning.
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Affiliation(s)
- Melanie Meersch
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Mira Küllmar
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Hermann Pavenstädt
- Department of Medicine, Division D, Nephrology, University Hospital Münster, Münster, Germany
| | - Jan Rossaint
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Sven Martens
- Department of Cardiac Surgery, University of Münster, Münster, Germany
| | - Pia Klausmeyer
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Elisa A Schmidt
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Laura Kerschke
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany
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13
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Jacob KA, Leaf DE. Prevention of Cardiac Surgery-Associated Acute Kidney Injury: A Review of Current Strategies. Anesthesiol Clin 2019; 37:729-749. [PMID: 31677688 PMCID: PMC7644277 DOI: 10.1016/j.anclin.2019.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Acute kidney injury is a common and often severe postoperative complication after cardiac surgery, and is associated with poor short-term and long-term outcomes. Numerous randomized controlled trials have been conducted to investigate various strategies for prevention of cardiac surgery-associated acute kidney injury. Unfortunately, most trials that have been conducted to date have been negative. However, encouraging results have been demonstrated with preoperative administration of corticosteroids, leukocyte filtration, and administration of inhaled nitric oxide intraoperatively, and implementation of a Kidney Disease: Improving Global Outcomes bundle of care approach postoperatively. These findings require validation in large, multicenter trials.
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Affiliation(s)
- Kirolos A Jacob
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Mail Stop E03.511, PO Box 85500, Utrecht 3508 GA, the Netherlands.
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Medial Research Building Room MR416B, Boston, MA 02115, USA
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14
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Deferrari G, Bonanni A, Bruschi M, Alicino C, Signori A. Remote ischaemic preconditioning for renal and cardiac protection in adult patients undergoing cardiac surgery with cardiopulmonary bypass: systematic review and meta-analysis of randomized controlled trials. Nephrol Dial Transplant 2019; 33:813-824. [PMID: 28992285 DOI: 10.1093/ndt/gfx210] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 04/28/2017] [Indexed: 12/20/2022] Open
Abstract
Background The main aim of this systematic review was to assess whether remote ischaemic preconditioning (RIPC) protects kidneys and the heart in cardiac surgery with cardiopulmonary bypass (CPB) and to investigate a possible role of anaesthetic agents. Methods Randomized clinical trials (RCTs) on the effects of RIPC through limb ischaemia in adult patients undergoing cardiac surgery with CPB were searched (1965-October 2016) in PubMed, Cochrane Library and article reference lists. A random effects model on standardized mean difference (SMD) for continuous outcomes and the Peto odds ratio (OR) for dichotomous outcomes were used to meta-analyse data. Subgroup analyses to evaluate the effects of different anaesthetic regimens were pre-planned. Results Thirty-three RCTs (5999 participants) were included. In the whole group, RIPC did not significantly reduce the incidence of acute kidney injury (AKI), acute myocardial infarction, atrial fibrillation, mortality or length of intensive care unit (ICU) and hospital stays. On the contrary, RIPC significantly reduced the area under the curve for myocardial injury biomarkers (MIBs) {SMD -0.37 [95% confidence interval (CI) -0.53 to - 0.21]} and the composite endpoint incidence [OR 0.85 (95% CI 0.74-0.97)]. In the volatile anaesthetic group, RIPC significantly reduced AKI incidence [OR 0.57 (95% CI 0.41-0.79)] and marginally reduced ICU stay. Conversely, except for MIBs, RIPC had fewer non-significant effects under propofol with or without volatile anaesthetics. Conclusions RIPC did not consistently reduce morbidity and mortality in adults undergoing cardiac surgery with CPB. In the subgroup on volatile anaesthetics only, RIPC markedly and significantly reduced the incidence of AKI and composite endpoint as well as myocardial injury.
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Affiliation(s)
- Giacomo Deferrari
- Department of Cardionephrology, Istituto Clinico Di Alta Specialità (ICLAS), Rapallo (GE), Italy.,Department of Internal Medicine (Di.MI), University of Genoa, Genoa, Italy
| | - Alice Bonanni
- Department of Cardionephrology, Istituto Clinico Di Alta Specialità (ICLAS), Rapallo (GE), Italy.,Division of Nephrology, Dialysis and Transplantation and Laboratory on Pathophysiology of Uremia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Maurizio Bruschi
- Division of Nephrology, Dialysis and Transplantation and Laboratory on Pathophysiology of Uremia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Cristiano Alicino
- Department of Health Science (Di.S.Sal), University of Genoa, Genoa, Italy
| | - Alessio Signori
- Department of Health Science (Di.S.Sal), University of Genoa, Genoa, Italy
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15
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Owens AP, Robbins N, Saum K, Jones SM, Kirschner A, Woo JG, McCoy C, Slone S, Rothenberg ME, Urbina EM, Tranter M, Rubinstein J. Tefillin use induces remote ischemic preconditioning pathways in healthy men. Am J Physiol Heart Circ Physiol 2018; 315:H1748-H1758. [PMID: 30216115 DOI: 10.1152/ajpheart.00347.2018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The present study assessed whether tefillin use (tight, nonocclusive, wrapping of the arm) elicits a remote ischemic preconditioning (RIPC)-like effect in subjects with both acute and chronic use. RIPC, created by short bursts of ischemia-reperfusion, has not been successfully taken to the bedside. Several large population studies have found that Orthodox Jewish men (who wear tefillin almost daily) have decreased cardiovascular mortality compared with non-Orthodox counterparts. We hypothesized that tefillin use is a relevant component in triggering a preconditioning effect. Jewish men ( n = 20) were enrolled; 9 men were daily tefillin users (conditioned) and 11 men were nonusers of tefillin as controls (naïve). Subjects were evaluated for adherence to traditional Jewish practice, had vital signs measured, blood drawn for analysis of circulating cytokines and monocyte function, and underwent brachial flow-mediated dilation to evaluate vascular reactivity at baseline (basal) and after 30 min of using tefillin (acute treatment). Under basal conditions, both groups had similar peak systolic velocity (SV), diameter, and flow volume, although the conditioned group had higher SV at 120 s postdeflation ( P = 0.05). Acute tefillin use augmented artery diameter and flow volume in both groups, with conditioned subjects experiencing higher SV than control subjects at 90 and 120 s postdeflation ( P = 0.03 and P = 0.02, respectively). Conditioned subjects had decreased inflammation, monocyte migration and adhesion, and endothelial activation compared with control subjects at baseline. Acute use of tefillin did not significantly alter monocyte function in either group. In this pilot study, acute tefillin use improves vascular function, whereas chronic tefillin use is associated with an anti-inflammatory RIPC-like phenotype. NEW & NOTEWORTHY We hypothesized that tefillin use among Orthodox Jewish men (who practice a nonocclusive leather banding of their nondominant arm) will induce a remote ischemic preconditioning phenotype. Chronic use of tefillin in Orthodox Jewish men was associated with increased systolic velocity and attenuated inflammation and monocyte chemotaxis and adhesion versus Jewish men who do not wear tefillin. Acute use of tefillin in both populations augmented brachial artery diameter and blood flow but not inflammatory profiles compared with baseline.
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Affiliation(s)
- A Phillip Owens
- Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati , Cincinnati, Ohio
| | - Nathan Robbins
- Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati , Cincinnati, Ohio
| | - Keith Saum
- Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati , Cincinnati, Ohio.,Department of Biomedical Engineering, University of Cincinnati , Cincinnati, Ohio
| | - Shannon M Jones
- Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati , Cincinnati, Ohio
| | - Akiva Kirschner
- Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati , Cincinnati, Ohio
| | - Jessica G Woo
- Department of Pediatrics, University of Cincinnati , Cincinnati, Ohio.,Division of Biostatistics and Epidemiology, University of Cincinnati , Cincinnati, Ohio
| | - Connie McCoy
- Department of Pediatrics, University of Cincinnati , Cincinnati, Ohio.,Division of Cardiology, University of Cincinnati , Cincinnati, Ohio
| | - Samuel Slone
- Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati , Cincinnati, Ohio
| | - Marc E Rothenberg
- Department of Pediatrics, University of Cincinnati , Cincinnati, Ohio.,Division of Allergy and Immunology, University of Cincinnati , Cincinnati, Ohio
| | - Elaine M Urbina
- Department of Pediatrics, University of Cincinnati , Cincinnati, Ohio.,Division of Cardiology, University of Cincinnati , Cincinnati, Ohio
| | - Michael Tranter
- Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati , Cincinnati, Ohio
| | - Jack Rubinstein
- Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati , Cincinnati, Ohio
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16
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Tan SI, Brewster DJ, Horrigan D, Sarode V. Pharmacological and non‐surgical renal protective strategies for cardiac surgery patients undergoing cardiopulmonary bypass: a systematic review. ANZ J Surg 2018; 89:296-302. [DOI: 10.1111/ans.14800] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/20/2018] [Accepted: 07/04/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Shijie Ian Tan
- Central Clinical SchoolMonash University Melbourne Victoria Australia
| | - David J. Brewster
- Cabrini Clinical SchoolCabrini Institute Melbourne Victoria Australia
- Department of MedicineCentral Clinical School, Monash University Melbourne Victoria Australia
| | - Diane Horrigan
- Cabrini LibraryCabrini Institute Melbourne Victoria Australia
| | - Vineet Sarode
- Department of MedicineCentral Clinical School, Monash University Melbourne Victoria Australia
- Department of Intensive Care MedicineCabrini Hospital Melbourne Victoria Australia
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17
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Xie J, Zhang X, Xu J, Zhang Z, Klingensmith NJ, Liu S, Pan C, Yang Y, Qiu H. Effect of Remote Ischemic Preconditioning on Outcomes in Adult Cardiac Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Studies. Anesth Analg 2018; 127:30-38. [PMID: 29210794 DOI: 10.1213/ane.0000000000002674] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Remote ischemic preconditioning (RIPC) has been demonstrated to prevent organ dysfunction in cardiac surgery patients. However, recent large, prospective, multicenter, randomized controlled trials (RCTs) had controversial results. Thus, a meta-analysis of RCTs was performed to investigate whether RIPC can reduce the incidence of acute myocardial infarction (AMI), acute kidney injury (AKI), and mortality in adult cardiac surgery patients. METHODS Study data were collected from Medline, Elsevier, Cochrane Central Register of Controlled Trials and Web of Science databases. RCTs involving the effect of RIPC on organ protection in cardiac surgery patients, which reported the concentration or total release of creatine kinase-myocardial band, troponin I/troponin T (TNI/TNT) after operation, or the incidence of AMI, AKI, or mortality, were selected. Two reviewers independently extracted data using a standardized data extraction protocol where TNI or TNT concentrations; total TNI released after cardiac surgery; and the incidence of AKI, AMI, and mortality were recorded. Review Manager 5.3 software was used to analyze the data. RESULTS Thirty trials, including 7036 patients were included in the analyses. RIPC significantly decreased the concentration of TNI/TNT (standard mean difference [SMD], -0.25 ng/mL; 95% confidence interval [CI], -0.41 to -0.048 ng/mL; P = .004), creatine kinase-myocardial band (SMD, -0.22; 95% CI, -0.07-0.35 ng/mL; P = .46), and the total TNI/TNT release (SMD, -0.49 ng/mL; 95% CI, -0.93 to -0.55 ng/mL; P = .03) in cardiac surgery patients after a procedure. However, RIPC could not reduce the incidence of AMI (relative risk, 0.89; 95% CI, 0.70-1.13; P = .34) and AKI (relative risk, 0.88; 95% CI, 0.72-1.06; P = .18), and there was also no effect of RIPC on mortality in adult cardiac surgery patients. Interestingly, subgroup analysis showed that RIPC reduced incidence of AKI and mortality of cardiac surgery patients who received volatile agent anesthesia. CONCLUSIONS Our meta-analysis demonstrated that RIPC reduced TNI/TNT release after cardiac surgery. RIPC did not significantly reduce the incidence of AKI, AMI, and mortality. However, RIPC could reduce mortality in patients receiving volatile inhalational agent anesthesia.
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Affiliation(s)
- Jianfeng Xie
- From the Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xiwen Zhang
- From the Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jingyuan Xu
- From the Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Zhongheng Zhang
- Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Zhejiang, China
| | - Nathan J Klingensmith
- Department of Surgery, Emory Critical Care Center, Emory University School of Medicine, Atlanta, Georgia
| | - Songqiao Liu
- From the Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Chun Pan
- From the Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yi Yang
- From the Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Haibo Qiu
- From the Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
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18
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Fiorentino M, Castellano G, Kellum JA. Differences in acute kidney injury ascertainment for clinical and preclinical studies. Nephrol Dial Transplant 2018; 32:1789-1805. [PMID: 28371878 DOI: 10.1093/ndt/gfx002] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 01/03/2017] [Indexed: 12/25/2022] Open
Abstract
Background Acute kidney injury (AKI) is a common clinical condition directly associated with adverse outcomes. Several AKI biomarkers have been discovered, but their use in clinical and preclinical studies has not been well examined. This study aims to investigate the differences between clinical and preclinical studies on AKI biomarkers. Methods We performed a systematic review of clinical and preclinical interventional studies that considered AKI biomarkers in enrollment criteria and/or outcome assessment and described the main differences according to their setting, the inclusion of biomarkers in the definition of AKI and the use of biomarkers as primary or secondary end points. Results In the 151 included studies (76 clinical, 75 preclinical), clinical studies have prevalently focused on cardiac surgery (38.1%) and contrast-associated AKI (17.1%), while the majority of preclinical studies have focused on ether ischemia-reperfusion injury or drug-induced AKI (42.6% each). A total of 57.8% of clinical studies defined AKI using the standard criteria and only 19.7% of these studies used AKI biomarkers in the definition of renal injury. Conversely, the majority of preclinical studies defined AKI according to the increase in serum creatinine and blood urea nitrogen, and 32% included biomarkers in that definition. The percentage of both clinical and preclinical studies with biomarkers as a primary end point has not significantly increased in the last 10 years; however, preclinical studies are more likely to use AKI biomarkers as a primary end point compared with clinical studies [odds ratio 2.31 (95% confidence interval 1.17-4.59); P = 0.016]. Conclusion Differences between clinical and preclinical studies are evident and may affect the translation of preclinical findings in the clinical setting.
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Affiliation(s)
- Marco Fiorentino
- Department of Critical Care Medicine, Center for Critical Care Nephrology, CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, University of Pittsburgh School of Medicine, Pittsburgh, USA.,Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplantation Unit, University of Bari, Bari, Italy
| | - Giuseppe Castellano
- Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplantation Unit, University of Bari, Bari, Italy
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, University of Pittsburgh School of Medicine, Pittsburgh, USA
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Abstract
PURPOSE OF REVIEW Among critically ill patients, acute kidney injury (AKI) is still a common and serious complication with a tremendous impact on short-term and long-term outcomes. The objective of this review is to discuss strategies for renal protection and prevention of AKI in ICU patients. RECENT FINDINGS It is fundamental to identify patients at risk for AKI as soon as possible and as accurately as possible. In order to achieve these goals, translational approaches implementing new biomarkers have shown promising results. Focusing on the role of potential preventive strategies, hemodynamic stabilization is the most important intervention with proven efficacy. Recent published data undermined any hope that high-dose statin therapy in statin-naïve patients could exert renoprotective effects. However, preliminary data revealed the renoprotective activity of dexmedetomidine when used as a sedative agent. Moreover, several studies demonstrated the protective effects of remote ischemic preconditioning in various organs including the kidneys. The use of balanced crystalloid instead of hyperchloremic solutions also contributes to the reduction of AKI in critically ill patients. SUMMARY To prevent AKI, it is crucial to identify patients at risk as early as possible. Establishing hemodynamic stability and an adequate intravascular volume state to ensure a sufficient perfusion pressure is the only effective therapeutic intervention. It is self-evident that nephrotoxic agents should be avoided whenever it is possible.
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20
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Liu SM, Zhao WL, Song HQ, Meng R, Li SJ, Ren CH, Ovbiagele B, Ji XM, Feng WW. Rationale and Study Design for a Single-Arm Phase IIa Study Investigating Feasibility of Preventing Ischemic Cerebrovascular Events in High-Risk Patients with Acute Non-disabling Ischemic Cerebrovascular Events Using Remote Ischemic Conditioning. Chin Med J (Engl) 2018; 131:347-351. [PMID: 29363651 PMCID: PMC5798057 DOI: 10.4103/0366-6999.223849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Acute minor ischemic stroke (AMIS) or transient ischemic attack (TIA) is a common cerebrovascular event with a considerable high recurrence. Prior research demonstrated the effectiveness of regular long-term remote ischemic conditioning (RIC) in secondary stroke prevention in patients with intracranial stenosis. We hypothesized that RIC can serve as an effective adjunctive therapy to pharmacotherapy in preventing ischemic events in patients with AMIS/TIA. This study aimed to investigate the feasibility, safety, and preliminary efficacy of daily RIC in inhibiting cerebrovascular/cardiovascular events after AMIS/TIA. Methods: This is a single-arm, open-label, multicenter Phase IIa futility study with a sample size of 165. Patients with AMIS/TIA receive RIC as an additional therapy to secondary stroke prevention regimen. RIC consists of five cycles of 5-min inflation (200 mmHg) and 5-min deflation of cuffs on bilateral upper limbs twice a day for 90 days. The antiplatelet strategy is based on individual physician's best practice: aspirin alone, clopidogrel alone, or combination of aspirin and clopidogrel. We will assess the recurrence rate of ischemic stroke/TIA within 3 months as the primary outcomes. Conclusions: The data gathered from the study will be used to determine whether a further large-scale, multicenter randomized controlled Phase II trial is warranted in patients with AMIS/TIA. Trial Registration: ClinicalTrials.gov, NCT03004820; https://www.clinicaltrials.gov/ct2/show/NCT03004820.
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Affiliation(s)
- Shi-Meng Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Wen-Le Zhao
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC 29403, USA
| | - Hai-Qing Song
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Ran Meng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Si-Jie Li
- Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing 100053, China
| | - Chang-Hong Ren
- Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing 100053, China
| | - Bruce Ovbiagele
- Department of Neurology, Medical University of South Carolina, Charleston, SC 29403, USA
| | - Xun-Ming Ji
- Department of Neurology, Xuanwu Hospital, Capital Medical University; Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Beijing 100053, China
| | - Wu-Wei Feng
- Department of Neurology, Medical University of South Carolina, Charleston, SC 29403, USA
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21
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Himmelfarb J, Chertow GM, McCullough PA, Mesana T, Shaw AD, Sundt TM, Brown C, Cortville D, Dagenais F, de Varennes B, Fontes M, Rossert J, Tardif JC. Perioperative THR-184 and AKI after Cardiac Surgery. J Am Soc Nephrol 2017; 29:670-679. [PMID: 29203473 DOI: 10.1681/asn.2017020217] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 10/16/2017] [Indexed: 02/03/2023] Open
Abstract
AKI after cardiac surgery is associated with mortality, prolonged hospital length of stay, use of dialysis, and subsequent CKD. We evaluated the effects of THR-184, a bone morphogenetic protein-7 agonist, in patients at high risk for AKI after cardiac surgery. We conducted a randomized, double-blind, placebo-controlled, multidose comparison of the safety and efficacy of perioperative THR-184 using a two-stage seamless adaptive design in 452 patients between 18 and 85 years of age who were scheduled for nonemergent cardiac surgery requiring cardiopulmonary bypass and had recognized risk factors for AKI. The primary efficacy end point was the proportion of patients who developed AKI according to Kidney Disease Improving Global Outcomes (KDIGO) criteria. The proportion of patients who developed AKI within 7 days of surgery was similar in THR-184 treatment groups and placebo groups (range, 74%-79%; P=0.43). Prespecified secondary end point analysis did not show significant differences in the severity of AKI stage (P=0.53) or the total duration of AKI (P=0.44). A composite of death, dialysis, or sustained impaired renal function by day 30 after surgery did not differ between groups (range, 11%-20%; P=0.46). Safety-related outcomes were similar across all treatment groups. In conclusion, compared with placebo, administration of perioperative THR-184 through a range of dose exposures failed to reduce the incidence, severity, or duration of AKI after cardiac surgery in high-risk patients.
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Affiliation(s)
- Jonathan Himmelfarb
- Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington;
| | - Glenn M Chertow
- School of Medicine, Stanford University, Stanford, California
| | | | - Thierry Mesana
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Thoralf M Sundt
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Craig Brown
- Department of Cardiac Surgery, New Brunswick Heart Centre, Saint John, New Brunswick, Canada
| | - David Cortville
- Department of Cardiology, Cardiac and Vascular Research Center, McLaren Northern Michigan, Petoskey, Michigan
| | - François Dagenais
- Department of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie, Quebec City, Quebec, Canada
| | - Benoit de Varennes
- Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Manuel Fontes
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | | | - Jean-Claude Tardif
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
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22
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Yi B, Chen X, Shi H, Lin T, Lin H, Xu Y, Rong J. Remote ischaemic preconditioning reduces acute kidney injury in adult patients undergoing cardiac surgery with cardiopulmonary bypass: a meta-analysis. Eur J Cardiothorac Surg 2017; 51:616-623. [PMID: 28329336 DOI: 10.1093/ejcts/ezw372] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 10/19/2016] [Indexed: 11/14/2022] Open
Abstract
This article represents the first attempt to perform a pooled analysis about remote ischaemic preconditioning (RIPC) in reduction of acute kidney injury (AKI) of adult patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). A systematic search was performed using PubMed (1966-5 January 2016), the Cochrane Library (1996-5 January 2016), the Web of Science (1986-5 January 2016) and Chinese database (SinoMed) (1978-5 January 2016) to identify studies that have described the effect of RIPC on AKI in adult patients undergoing cardiac surgery with CPB. The outcomes used for this analysis included the incidence of AKI and the need for renal replacement therapy (RRT). Thirteen randomized controlled trials (4370 participants) were included in this analysis. RIPC significantly reduced the risk of AKI (risk ratio, 0.81; 95% confidence interval, [0.66, 0.99]; P = 0.04; I2 = 46%) for adult patients compared with control group. However, there was no significant difference with respect to the incidence of RRT between the two groups. The present meta-analysis found that RIPC may reduce the incidence of AKI among adult patients following cardiac surgery with CPB. Adequately powered trials are warranted to provide further corroboration of our findings in the future.
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Affiliation(s)
- Bin Yi
- Department of Cardiothoracic Surgery, Heart Center, The First Affiliated Hospital, Sun Yat-Sen University, and Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, China.,Department of Extracorporeal Circulation, Heart Center, The First Affiliated Hospital, Sun Yat-Sen University, and Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, China
| | - Xiang Chen
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Han Shi
- Department of Extracorporeal Circulation, Heart Center, The First Affiliated Hospital, Sun Yat-Sen University, and Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, China
| | - Tiao Lin
- Musculoskeletal Oncology Center, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Haifeng Lin
- Scientific Research Section, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yi Xu
- Department of Oncology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jian Rong
- Department of Extracorporeal Circulation, Heart Center, The First Affiliated Hospital, Sun Yat-Sen University, and Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, China
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23
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Wang Y, Bellomo R. Cardiac surgery-associated acute kidney injury: risk factors, pathophysiology and treatment. Nat Rev Nephrol 2017; 13:697-711. [DOI: 10.1038/nrneph.2017.119] [Citation(s) in RCA: 390] [Impact Index Per Article: 55.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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24
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Sun Q, Shen ZY, Duan WN, Meng QT, Xia ZY. Mechanism of myocardial ischemia/reperfusion-induced acute kidney injury through DJ-1/Nrf2 pathway in diabetic rats. Exp Ther Med 2017; 14:4201-4207. [PMID: 29104636 PMCID: PMC5658721 DOI: 10.3892/etm.2017.5095] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 06/02/2017] [Indexed: 01/28/2023] Open
Abstract
The objective of the present study was to investigate acute kidney injury (AKI) induced by myocardial ischemia/reperfusion (MIR) in diabetic rats and elucidate its underlying mechanism. A rat model of MIR was established by left anterior descending coronary artery occlusion for 30 min, followed by reperfusion for 2 h. Rats were randomly divided into four groups: i) Sham group, ii) sham + MIR group, iii) diabetic group and iv) diabetes + MIR group. Myocardial injury was detected by plasma creatine kinase isoenzyme MB and lactate dehydrogenase assays. AKI induced by MIR in diabetic rats was characterized by increases in cystatin C and β2-microglobulin levels. Oxidative stress injury was accompanied by an increase of malondialdehyde levels and a decrease of total antioxidative capacity in the renal tissues. Immunohistochemistry and western blot analysis demonstrated that the expression of DJ-1 and nuclear factor erythroid 2-related factor 2 (Nrf2) were significantly increased in the diabetes + MIR group compared with that in the sham + MIR and diabetic groups. Taken together, these results suggested that AKI induced by MIR in diabetic rats may be associated with activation of the DJ-1/Nrf2 pathway.
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Affiliation(s)
- Qian Sun
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Zi-Ying Shen
- Department of Anesthesiology, The Affiliated Hospital of The Medical College of Qingdao University, Qingdao, Shandong 266003, P.R. China
| | - Wei-Na Duan
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Qing-Tao Meng
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Zhong-Yuan Xia
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
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25
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Javaherforoosh Zadeh F, Moadeli M, Soltanzadeh M, Janatmakan F. Effect of Remote Ischemic Preconditioning on Troponin I in CABG. Anesth Pain Med 2017; 7:e12549. [PMID: 29430406 PMCID: PMC5797663 DOI: 10.5812/aapm.12549] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/04/2017] [Accepted: 08/07/2017] [Indexed: 11/27/2022] Open
Abstract
Background Elective open heart surgery is associated with troponin release in some cases due to myocyte necrosis. Objectives The aim of this study was to measure cardiac troponin I (cTnI) preoperatively in elective CABG after remote ischemic preconditioning. Methods Twenty-eight patients were selected for elective CABG. They were randomized to receive remote ischemic preconditioning (induced by three 5-min cycles of inflation with a pneumatic tourniquet and 5-min deflation between inflation episodes as reperfusion). Outcomes Primary outcomes were cardiac troponin I levels at 6 and 24 hours after the procedure, and the secondary outcomes included creatine phosphokinase, lactate dehydrogenase, and serum creatinine levels. Hemodynamic changes were evaluated between the treatment and control groups. Results Cardiac troponin I at 6 hours after preconditioning was significantly lower compared to the control group (P = 0.036), and after 24 hours, there was still a significant difference between the two groups (P < 0.05). Conclusions Remote ischemic preconditioning reduces ischemic biomarkers during coronary artery bypass graft and attenuates procedure-related cardiac troponin I release and eventually reduces cardiovascular events such as myocardial infarction, chest pain, and hemodynamic changes after cardiac surgery.
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Affiliation(s)
- Fatemeh Javaherforoosh Zadeh
- Associate Professor of Anesthesia, Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohsen Moadeli
- Assistant Professor of Anesthesia, Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Corresponding author: Mohsen Moadeli, Anesthesia Department, Imam Khomeini Hospital, Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. Tel: +98-9173160725, +98-6133743037, E-mail:
| | - Mansoor Soltanzadeh
- Professor of Anesthesia, Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Farahzad Janatmakan
- Assistant Professor of Anesthesia, Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Atanda AC, Olafiranye O. Contrast-induced acute kidney injury in interventional cardiology: Emerging evidence and unifying mechanisms of protection by remote ischemic conditioning. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 18:549-553. [PMID: 28610773 DOI: 10.1016/j.carrev.2017.06.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 05/29/2017] [Accepted: 06/02/2017] [Indexed: 11/25/2022]
Abstract
Contrast-induced acute kidney injury (CI-AKI) is a common complication of many diagnostic and therapeutic cardiovascular procedures. It is associated with longer in-hospital stay, more complicated hospitalization course, and higher in-hospital morbidity and mortality. With increasing use of contrast media in various diagnostic and interventional procedures, the prevalence of CI-AKI is expected to rise. Although pre-hydration with intravenous normal saline is recommended in patients with elevated risk of CI-AKI, this approach is often not feasible in many clinical settings. Remote ischemic conditioning (RIC), elicited by application of one or more, brief, non-injurious episodes of ischemia and reperfusion of a limb, is a promising therapy for preventing or attenuating the deleterious effects of contrast media on the kidney. Although the mechanisms of protection by RIC have not been completely defined, complex humoral, neural, and inflammatory pathways have been hypothesized to be in play. Given that RIC is non-invasive and cheap, it is attractive from clinical and economic perspective as a therapy to protect the kidney from CI-AKI. In this succinct review, we highlight the unifying mechanisms of CI-AKI and provide an overview of proposed biological mechanisms of renal protection by RIC. Emerging pre-clinical and clinical evidence in interventional cardiology is also discussed.
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Affiliation(s)
- Adebayo C Atanda
- Department of Medicine, Howard University Hospital, Washington, DC
| | - Oladipupo Olafiranye
- Heart and Vascular Institute, Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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27
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Long-term Effects of Remote Ischemic Preconditioning on Kidney Function in High-risk Cardiac Surgery Patients. Anesthesiology 2017; 126:787-798. [DOI: 10.1097/aln.0000000000001598] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Abstract
Background
In a multicenter, randomized trial, the authors enrolled patients at high-risk for acute kidney injury as identified by a Cleveland Clinic Foundation score of 6 or more. The authors enrolled 240 patients at four hospitals and randomized them to remote ischemic preconditioning or control. The authors found that remote ischemic preconditioning reduced acute kidney injury in high-risk patients undergoing cardiac surgery. The authors now report on the effects of remote ischemic preconditioning on 90-day outcomes.
Methods
In this follow-up study of the RenalRIP trial, the authors examined the effect of remote ischemic preconditioning on the composite endpoint major adverse kidney events consisting of mortality, need for renal replacement therapy, and persistent renal dysfunction at 90 days. Secondary outcomes were persistent renal dysfunction and dialysis dependence in patients with acute kidney injury.
Results
Remote ischemic preconditioning significantly reduced the occurrence of major adverse kidney events at 90 days (17 of 120 [14.2%]) versus control (30 of 120 [25.0%]; absolute risk reduction, 10.8%; 95% CI, 0.9 to 20.8%; P = 0.034). In those patients who developed acute kidney injury after cardiac surgery, 2 of 38 subjects in the remote ischemic preconditioning group (5.3%) and 13 of 56 subjects in the control group (23.2%) failed to recover renal function at 90 days (absolute risk reduction, 17.9%; 95% CI, 4.8 to 31.1%; P = 0.020). Acute kidney injury biomarkers were also increased in patients reaching the major adverse kidney event endpoint compared to patients who did not.
Conclusions
Remote ischemic preconditioning significantly reduced the 3-month incidence of a composite endpoint major adverse kidney events consisting of mortality, need for renal replacement therapy, and persistent renal dysfunction in high-risk patients undergoing cardiac surgery. Furthermore, remote ischemic preconditioning enhanced renal recovery in patients with acute kidney injury.
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28
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Ravingerova T, Farkasova V, Griecsova L, Carnicka S, Murarikova M, Barlaka E, Kolar F, Bartekova M, Lonek L, Slezak J, Lazou A. Remote preconditioning as a novel "conditioning" approach to repair the broken heart: potential mechanisms and clinical applications. Physiol Res 2017; 65 Suppl 1:S55-64. [PMID: 27643940 DOI: 10.33549/physiolres.933392] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Remote ischemic preconditioning (RIPC) is a novel strategy of protection against ischemia-reperfusion (IR) injury in the heart (and/or other organs) by brief episodes of non-lethal IR in a distant organ/tissue. Importantly, RIPC can be induced noninvasively by limitation of blood flow in the extremity implying the applicability of this method in clinical situations. RIPC (and its delayed phase) is a form of relatively short-term adaptation to ischemia, similar to ischemic PC, and likely they both share triggering mechanisms, whereas mediators and end-effectors may differ. It is hypothesized that communication between the signals triggered in the remote organs and protection in the target organ may be mediated through substances released from the preconditioned organ and transported via the circulation (humoral pathways), by neural pathways and/or via systemic anti-inflammatory and antiapoptotic response to short ischemic bouts. Identification of molecules involved in RIPC cascades may have therapeutic and diagnostic implications in the management of myocardial ischemia. Elucidation of the mechanisms of endogenous cardioprotection triggered in the remote organ could lead to the development of diverse pharmacological RIPC mimetics. In the present article, the authors provide a short overview of RIPC-induced protection, proposed underlying mechanisms and factors modulating RIPC as a promising cardioprotective strategy.
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Affiliation(s)
- T Ravingerova
- Institute for Heart Research, Slovak Academy of Sciences, Bratislava, Slovak Republic.
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29
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Maldonado Y, Weiner MM, Ramakrishna H. Remote Ischemic Preconditioning in Cardiac Surgery: Is There a Proven Clinical Benefit? J Cardiothorac Vasc Anesth 2017; 31:1910-1915. [PMID: 28711313 DOI: 10.1053/j.jvca.2017.03.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Yasdet Maldonado
- Department of Anesthesiology, Allegheny General Hospital, Pittsburgh, PA
| | - Menachem M Weiner
- Department of Anesthesiology, The Mount Sinai Hospital, New York, NY
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Phoenix, AZ.
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30
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Nederlof R, Weber NC, Juffermans NP, de Mol BAMJ, Hollmann MW, Preckel B, Zuurbier CJ. A randomized trial of remote ischemic preconditioning and control treatment for cardioprotection in sevoflurane-anesthetized CABG patients. BMC Anesthesiol 2017; 17:51. [PMID: 28356068 PMCID: PMC5372281 DOI: 10.1186/s12871-017-0330-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 02/24/2017] [Indexed: 01/29/2023] Open
Abstract
Background Remote ischemic preconditioning (RIPC) efficacy is debated. Possibly, because propofol, which has a RIPC-inhibiting action, is used in most RIPC trials. It has been suggested that clinical efficacy is, however, present with volatile anesthesia in the absence of propofol, although this is based on one phase 1 trial only. Therefore, in the present study we further explore the relation between RIPC and cardioprotection with perioperative anesthesia restricted to sevoflurane and fentanyl, in CABG patients without concomitant procedures. Methods In a single-center study, we aimed to randomize 46 patients to either RIPC (3x5 min inflation of a blood pressure cuff around the arm) or control treatment (deflated cuff around the arm). Blood samples were obtained before and after RIPC to evaluate potential RIPC-induced mediators (Interleukin (IL)-6, IL-10, Tumor Necrosis Factor-α, Macrophage Inhibitory Factor). An atrial tissue sample was obtained at cannulation of the appendix of the right atrium for determination of mitochondrial bound hexokinase II (mtHKII) and other survival proteins (Akt and AMP-activated protein kinase α). In blood samples taken before and 6, 12 and 24 h after surgery cardiac troponin T (cTnT) and C-reactive protein (CRP) were determined. Surgery was strictly performed under sevoflurane anesthesia (no propofol). Results We actually randomized 16 patients to control treatment and 13 patients to RIPC. The mean 24 h area under the curve (AUC) cTnT was 11.44 (standard deviation 4.66) in the control group and 10.90 (standard deviation 4.73) in the RIPC group (mean difference 0.54, 95% CI −3.06 to 4.13; p = 0.76). The mean 24 h AUC CRP was 1319 (standard deviation 92) in the control group and 1273 (standard deviation 141) in the RIPC group (mean difference 46.2, 95% CI −288 to 380; p = 0.78). RIPC was without effect on survival proteins in atrial tissue samples obtained before surgery (mitochondrial hexokinase, Akt and AMPK) and inflammatory mediators obtained before and immediately after RIPC (IL-6, IL-10, TNF-α, macrophage migration inhibitory factor). Conclusion Many factors can interfere with the outcome of RIPC. Trying to correct for this led to strict inclusion criteria, which, in combination with a decreased institutional frequency of CABG without concomitant procedures and a change in institutional anesthetic regimen away from volatile anesthetics towards total intravenous anesthesia, caused slow inclusion and halting of this trial after 3 years, before target inclusion could be reached. Therefore this study is underpowered to prove its primary goal that RIPC reduced AUC cTnT by < 25%. Nevertheless, we have shown that the effect of RIPC on 24 h AUC cTnT, in cardiac surgery with anesthesia during surgery restricted to sevoflurane/fentanyl (no propofol), was between a decrease of 27% and an increase of 36%. These findings are not in line with previous studies in this field. Trial registration The Netherlands Trial Register: NTR2915; Registered 25 Mei 2011.
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Affiliation(s)
- Rianne Nederlof
- Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Department of Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Nina C Weber
- Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Department of Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Bas A M J de Mol
- Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Department of Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Benedikt Preckel
- Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Department of Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Coert J Zuurbier
- Laboratory of Experimental Intensive Care and Anesthesiology (L.E.I.C.A.), Department of Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands. .,Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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31
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Zhou C, Bulluck H, Fang N, Li L, Hausenloy DJ. Age and Surgical Complexity impact on Renoprotection by Remote Ischemic Preconditioning during Adult Cardiac Surgery: A Meta analysis. Sci Rep 2017; 7:215. [PMID: 28303021 PMCID: PMC5428278 DOI: 10.1038/s41598-017-00308-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 02/16/2017] [Indexed: 01/31/2023] Open
Abstract
We aimed to conduct an up-to-date meta-analysis to comprehensively assess the renoprotective effect of remote ischemic preconditioning (RIPC) in patients undergoing adult cardiac surgery. 21 randomized controlled trials (RCTs) with a total of 6302 patients were selected and identified. Compared with controls, RIPC significantly reduced the incidence of acute kidney injury (AKI) [odds ratio (OR) = 0.79; P = 0.02; I2 = 38%], and in particular, AKI stage I (OR = 0.65; P = 0.01; I2 = 55%). RIPC significantly shortened mechanical ventilation (MV) duration [weighted mean difference (WMD) = −0.79 hours; P = 0.002; I2 = 53%), and reduced intensive care unit (ICU) stay (WMD = −0.23 days; P = 0.07; I2 = 96%). Univariate meta-regression analyses showed that the major sources of heterogeneity for AKI stage I were age (coefficient = 0.06; P = 0.01; adjusted R2 = 0.86) and proportion of complex surgery (coefficient = 0.02; P = 0.03; adjusted R2 = 0.81). Subsequent multivariate regression and subgroup analyses also confirmed these results. The present meta-analysis suggests that RIPC reduces the incidence of AKI in adults undergoing cardiac surgery and this benefit was more pronounced in younger patients undergoing non-complex cardiac surgery. RIPC may also shorten MV duration and ICU stay. Future RCTs tailored for those most likely to benefit from RIPC warrants further investigation.
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Affiliation(s)
- Chenghui Zhou
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Heerajnarain Bulluck
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London, WC1E 6HX, UK.,The National Institute of Health Research University College London Hospitals Biomedical Research Centre, London, UK.,National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore, Singapore
| | - Nengxin Fang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Lihuan Li
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.
| | - Derek J Hausenloy
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London, WC1E 6HX, UK.,The National Institute of Health Research University College London Hospitals Biomedical Research Centre, London, UK.,National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore, Singapore.,Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore, Singapore, Singapore
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Menting TP, Wever KE, Ozdemir‐van Brunschot DMD, Van der Vliet DJA, Rovers MM, Warle MC. Ischaemic preconditioning for the reduction of renal ischaemia reperfusion injury. Cochrane Database Syst Rev 2017; 3:CD010777. [PMID: 28258686 PMCID: PMC6464274 DOI: 10.1002/14651858.cd010777.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Ischaemia reperfusion injury can lead to kidney dysfunction or failure. Ischaemic preconditioning is a short period of deprivation of blood supply to particular organs or tissue, followed by a period of reperfusion. It has the potential to protect kidneys from ischaemia reperfusion injury. OBJECTIVES This review aimed to look at the benefits and harms of local and remote ischaemic preconditioning to reduce ischaemia and reperfusion injury among people with renal ischaemia reperfusion injury. SEARCH METHODS We searched Cochrane Kidney and Transplant's Specialised Register to 5 August 2016 through contact with the Information Specialist using search terms relevant to this review. SELECTION CRITERIA We included all randomised controlled trials measuring kidney function and the role of ischaemic preconditioning in patients undergoing a surgical intervention that induces kidney injury. Kidney transplantation studies were excluded. DATA COLLECTION AND ANALYSIS Studies were assessed for eligibility and quality; data were extracted by two independent authors. We collected basic study characteristics: type of surgery, remote ischaemic preconditioning protocol, type of anaesthesia. We collected primary outcome measurements: serum creatinine and adverse effects to remote ischaemic preconditioning and secondary outcome measurements: acute kidney injury, need for dialysis, neutrophil gelatinase-associated lipocalin, hospital stay and mortality. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. MAIN RESULTS We included 28 studies which randomised a total of 6851 patients. Risk of bias assessment indicated unclear to low risk of bias for most studies. For consistency regarding the direction of effects, continuous outcomes with negative values, and dichotomous outcomes with values less than one favour remote ischaemic preconditioning. Based on high quality evidence, remote ischaemic preconditioning made little or no difference to the reduction of serum creatinine levels at postoperative days one (14 studies, 1022 participants: MD -0.02 mg/dL, 95% CI -0.05 to 0.02; I2 = 21%), two (9 studies, 770 participants: MD -0.04 mg/dL, 95% CI -0.09 to 0.02; I2 = 31%), and three (6 studies, 417 participants: MD -0.05 mg/dL, 95% CI -0.19 to 0.10; I2 = 68%) compared to control.Serious adverse events occurred in four patients receiving remote ischaemic preconditioning by iliac clamping. It is uncertain whether remote ischaemic preconditioning by cuff inflation leads to increased adverse effects compared to control because the certainty of the evidence is low (15 studies, 3993 participants: RR 3.47, 95% CI 0.55 to 21.76; I2 = 0%); only two of 15 studies reported any adverse effects (6/1999 in the remote ischaemic preconditioning group and 1/1994 in the control group), the remaining 13 studies stated no adverse effects were observed in either group.Compared to control, remote ischaemic preconditioning made little or no difference to the need for dialysis (13 studies, 2417 participants: RR 0.85, 95% CI 0.37 to 1.94; I2 = 60%; moderate quality evidence), length of hospital stay (8 studies, 920 participants: MD 0.17 days, 95% CI -0.46 to 0.80; I2 = 49%, high quality evidence), or all-cause mortality (24 studies, 4931 participants: RR 0.86, 95% CI 0.54 to 1.37; I2 = 0%, high quality evidence).Remote ischaemic preconditioning may have slightly improved the incidence of acute kidney injury using either the AKIN (8 studies, 2364 participants: RR 0.76, 95% CI 0.57 to 1.00; I2 = 61%, high quality evidence) or RIFLE criteria (3 studies, 1586 participants: RR 0.91, 95% CI 0.75 to 1.12; I2 = 0%, moderate quality evidence). AUTHORS' CONCLUSIONS Remote ischaemic preconditioning by cuff inflation appears to be a safe method, and probably leads to little or no difference in serum creatinine, adverse effects, need for dialysis, length of hospital stay, death and in the incidence of acute kidney injury. Overall we had moderate-high certainty evidence however the available data does not confirm the efficacy of remote ischaemic preconditioning in reducing renal ischaemia reperfusion injury in patients undergoing major cardiac and vascular surgery in which renal ischaemia reperfusion injury may occur.
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Affiliation(s)
- Theo P Menting
- Radboud University Nijmegen Medical CentreDepartment of SurgeryGeert Grooteplein Zuid 10NijmegenGelderlandNetherlands6525 GA
| | - Kimberley E Wever
- Radboud University Nijmegen Medical CentreDepartment of SurgeryGeert Grooteplein Zuid 10NijmegenGelderlandNetherlands6525 GA
| | - Denise MD Ozdemir‐van Brunschot
- Radboud University Nijmegen Medical CentreDepartment of SurgeryGeert Grooteplein Zuid 10NijmegenGelderlandNetherlands6525 GA
| | - Daan JA Van der Vliet
- Radboud University Nijmegen Medical CentreDepartment of SurgeryGeert Grooteplein Zuid 10NijmegenGelderlandNetherlands6525 GA
| | - Maroeska M Rovers
- Radboud University Nijmegen Medical CentreDepartment of Operating RoomsHp 630, route 631PO Box 9101NijmegenNetherlands6500 HB
| | - Michiel C Warle
- Radboud University Nijmegen Medical CentreDepartment of SurgeryGeert Grooteplein Zuid 10NijmegenGelderlandNetherlands6525 GA
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Pierce B, Bole I, Patel V, Brown DL. Clinical Outcomes of Remote Ischemic Preconditioning Prior to Cardiac Surgery: A Meta-Analysis of Randomized Controlled Trials. J Am Heart Assoc 2017; 6:JAHA.116.004666. [PMID: 28219918 PMCID: PMC5523764 DOI: 10.1161/jaha.116.004666] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Multiple randomized controlled trials of remote ischemic preconditioning (RIPC) prior to cardiac surgery have failed to demonstrate clinical benefit. The aim of this updated meta‐analysis was to evaluate the effect of RIPC on outcomes following cardiac surgery. Methods and Results Searches of PubMed, Cochrane, EMBASE, and Web of Science databases were performed for 1970 to December 13, 2015. Randomized controlled trials comparing RIPC with a sham procedure prior to cardiac surgery performed with cardiopulmonary bypass were assessed. All‐cause mortality, acute kidney injury (AKI), and myocardial infarction were the primary outcomes of interest. We identified 21 trials that randomized 5262 patients to RIPC or a sham procedure prior to undergoing cardiac surgery. The majority of patients were men (72.6%) and the mean or median age ranged from 42.3 to 76.3 years. Of the 9 trials that evaluated mortality, 188 deaths occurred out of a total of 4210 randomized patients, with 96 deaths occurring in 2098 patients (4.6%) randomized to RIPC and 92 deaths occurring in 2112 patients (4.4%) randomized to a sham control procedure, demonstrating no significant reduction in all‐cause mortality (risk ratio [RR], 0.987; 95% CI, 0.653–1.492, P=0.95). Twelve studies evaluated AKI in 4209 randomized patients. In these studies, AKI was observed in 516 of 2091 patients (24.7%) undergoing RIPC and in 577 of 2118 patients (27.2%) randomized to a sham procedure. RIPC did not result in a significant reduction in AKI (RR, 0.839; 95% CI, 0.703–1.001 [P=0.052]). In 6 studies consisting of 3799 randomized participants, myocardial infarction occurred in 237 of 1891 patients (12.5%) randomized to RIPC and in 282 of 1908 patients (14.8%) randomized to a sham procedure, resulting in no significant reduction in postoperative myocardial infarction (RR, 0.809; 95% CI, 0.615–1.064 [P=0.13]). A subgroup analysis was performed a priori based on previous studies suggesting that propofol may mitigate the protective benefits of RIPC. Three studies randomized patients undergoing cardiac surgery to RIPC or sham procedure in the absence of propofol anesthesia. Most of these patients were men (60.3%) and the mean or median age ranged from 57.0 to 70.6 years. In this propofol‐free subgroup of 434 randomized patients, 71 of 217 patients (32.7%) who underwent RIPC developed AKI compared with 103 of 217 patients (47.5%) treated with a sham procedure. In this cohort, RIPC resulted in a significant reduction in AKI (RR, 0.700; 95% CI, 0.527–0.930 [P=0.014]). In studies of patients who received propofol anesthesia, 445 of 1874 (23.7%) patients randomized to RIPC developed AKI compared with 474 of 1901 (24.9%) who underwent a sham procedure. The RR for AKI was 0.928 (95% CI, 0.781–1.102; P=0.39) for RIPC versus sham. There was no significant interaction between the two subgroups (P=0.098). Conclusions RIPC does not reduce morbidity or mortality in patients undergoing cardiac surgery with cardiopulmonary bypass. In the subgroup of studies in which propofol was not used, a reduction in AKI was seen, suggesting that propofol may interact with the protective effects of RIPC. Future studies should evaluate RIPC in the absence of propofol anesthesia.
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Affiliation(s)
- Brian Pierce
- Hospitalist Division, Washington University School of Medicine, St. Louis, MO
| | - Indra Bole
- Hospitalist Division, Washington University School of Medicine, St. Louis, MO
| | - Vaiibhav Patel
- Hospitalist Division, Washington University School of Medicine, St. Louis, MO
| | - David L Brown
- Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
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Ho PWL, Pang WF, Szeto CC. Remote ischaemic pre-conditioning for the prevention of acute kidney injury. Nephrology (Carlton) 2017; 21:274-85. [PMID: 26370466 DOI: 10.1111/nep.12614] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 08/23/2015] [Accepted: 08/24/2015] [Indexed: 01/02/2023]
Abstract
Acute kidney injury (AKI) is a common complication associated with high morbidity and mortality in hospitalized patients. One potential mechanism underlying renal injury is ischaemia/reperfusion injury (IRI), which attributed the organ damage to the inflammatory and oxidative stress responses induced by a period of renal ischaemia and subsequent reperfusion. Therapeutic strategies that aim at minimizing the effect of IRI on the kidneys may prevent AKI and improve clinical outcomes significantly. In this review, we examine the technique of remote ischaemic preconditioning (rIPC), which has been shown by several trials to confer organ protection by applying transient, brief episodes of ischaemia at a distant site before a larger ischaemic insult. We provide an overview of the current clinical evidence regarding the renoprotective effect of rIPC in the key clinical settings of cardiac or vascular surgery, contrast-induced AKI, pre-existing chronic kidney disease (CKD) and renal transplantation, and discuss key areas for future research.
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Affiliation(s)
- Phoebe Wing-Lam Ho
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Wing-Fai Pang
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Cheuk-Chun Szeto
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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Olafiranye O, Ladejobi A, Wayne M, Martin-Gill C, Althouse AD, Sharbaugh MS, Guyette FX, Reis SE, Kellum JA, Toma C. Renal Protection Using Remote Ischemic Peri-Conditioning During Inter-Facility Helicopter Transport of Patients With ST-Segment Elevation Myocardial Infarction: A Retrospective Study. J Interv Cardiol 2016; 29:603-611. [PMID: 27813282 DOI: 10.1111/joic.12351] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess the impact of remote ischemic peri-conditioning (RIPC) during inter-facility air medical transport of ST-segment elevation myocardial infarction (STEMI) patients on the incidence of acute kidney injury (AKI) following primary percutaneous coronary intervention (pPCI). BACKGROUND STEMI patients who receive pPCI have an increased risk of AKI for which there is no well-defined prophylactic therapy in the setting of emergent pPCI. METHODS Using the ACTION Registry-GWTG, we evaluated the impact of RIPC applied during inter-facility helicopter transport of STEMI patients from non-PCI capable hospitals to 2 PCI-hospitals in the United States between March, 2013 and September, 2015 on the incidence of AKI following pPCI. AKI was defined as ≥0.3 mg/dL increase in creatinine within 48-72 hours after pPCI. RESULTS Patients who received RIPC (n = 127), compared to those who did not (n = 92), were less likely to have AKI (11 of 127 patients [8.7%] vs. 17 of 92 patients [18.5%]; adjusted odds ratio = 0.32, 95% CI 0.12-0.85, P = 0.023) and all-cause in-hospital mortality (2 of 127 patients [1.6%] vs. 7 of 92 patients [7.6%]; adjusted odds ratio = 0.14, 95% CI 0.02-0.86, P = 0.034) after adjusting for socio-demographic and clinical characteristics. There was no difference in hospital length of stay (3 days [interquartile range, 2-4] vs. 3 days [interquartile range, 2-5], P = 0.357) between the 2 groups. CONCLUSION RIPC applied during inter-facility helicopter transport of STEMI patients for pPCI is associated with lower incidence of AKI and in-hospital mortality. The use of RIPC for renal protection in STEMI patients warrants further in depth investigation.
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Affiliation(s)
- Oladipupo Olafiranye
- Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Adetola Ladejobi
- Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Max Wayne
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrew D Althouse
- Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael S Sharbaugh
- Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Steven E Reis
- Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Catalin Toma
- Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Honore PM, Jacobs R, Spapen HD. Remote ischemic preconditioning to prevent cardiac surgery-related acute kidney injury: how far away from a breakthrough? ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:314. [PMID: 27668234 DOI: 10.21037/atm.2016.08.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Patrick M Honore
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Rita Jacobs
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Herbert D Spapen
- ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Zhang Y, Zhang X, Chi D, Wang S, Wei H, Yu H, Li Q, Liu B. Remote Ischemic Preconditioning for Prevention of Acute Kidney Injury in Patients Undergoing On-Pump Cardiac Surgery: A Systematic Review and Meta-Analysis. Medicine (Baltimore) 2016; 95:e3465. [PMID: 27631199 PMCID: PMC5402542 DOI: 10.1097/md.0000000000003465] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Remote ischemic preconditioning (RIPC) may attenuate acute kidney injury (AKI). However, results of studies evaluating the effect of RIPC on AKI after cardiac surgery have been controversial and contradictory.The aim of this meta-analysis is to examine the association between RIPC and AKI after on-pump cardiac surgery.The authors searched relevant studies in PubMed, EMBASE, and the Cochrane Library through December 2015.We considered for inclusion all randomized controlled trials that the role of RIPC in reducing AKI and renal replacement therapy (RRT) among patients underwent on-pump cardiac surgical procedures.We collected the data on AKI, initiation of RRT, serum creatinine (sCr) levels, and in-hospital mortality. Random- and fixed-effect models were used for pooling data.Nineteen trials including 5100 patients were included. The results of this meta-analysis showed a significant benefit of RIPC for reducing the incidence of AKI after cardiac interventions (odds ratio [OR] = 0.84; 95% confidence interval [CI], 0.73-0.98; P = 0.02). No significant difference was found in the incidence of RRT between RIPC and control (OR, 0.76, 95% CI, 0.46-1.24; P = 0.36). In addition, compared with standard medical care, RIPC showed no significant difference in postoperative sCr (IV 0.07; 95% CI, -0.03 to 0.16; P = 0.20; postoperative day 1; IV 0.00; 95% CI, -0.08 to 0.09; P = 0.92; postoperative day 2; IV 0.04; 95% CI, -0.05 to 0.12; P = 0.39; postoperative day 3), and in-hospital mortality (OR, 1.21, 95% CI, 0.64-2.30; P = 0.56).According to the results from present meta-analysis, RIPC was associated with a significant reduction AKI after on-pump cardiac surgery but incidence of RRT, postoperative sCr, and in-hospital mortality. Further high-quality randomized controlled trials and experimental researches comparing RIPC are desirable.
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Affiliation(s)
- Yabing Zhang
- From the Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan (YZ, XZ, DC, SW, HY, QL, BL), and Department of Anesthesiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou (HW), China
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Abstract
The mortality from acute myocardial infarction (AMI) remains significant, and the prevalence of post-myocardial infarction heart failure is increasing. Therefore, cardioprotection beyond timely reperfusion is needed. Conditioning procedures are the most powerful cardioprotective interventions in animal experiments. However, ischemic preconditioning cannot be used to reduce infarct size in patients with AMI because its occurrence is not predictable; several studies in patients undergoing surgical coronary revascularization report reduced release of creatine kinase and troponin. Ischemic postconditioning reduces infarct size in most, but not all, studies in patients undergoing interventional reperfusion of AMI, but may require direct stenting and exclusion of patients with >6 hours of symptom onset to protect. Remote ischemic conditioning reduces infarct size in patients undergoing interventional reperfusion of AMI, elective percutaneous or surgical coronary revascularization, and other cardiovascular surgery in many, but not in all, studies. Adequate dose-finding phase II studies do not exist. There are only 2 phase III trials, both on remote ischemic conditioning in patients undergoing cardiovascular surgery, both with neutral results in terms of infarct size and clinical outcome, but also both with major problems in trial design. We discuss the difficulties in translation of cardioprotection from animal experiments and proof-of-concept trials to clinical practice. Given that most studies on ischemic postconditioning and all studies on remote ischemic preconditioning in patients with AMI reported reduced infarct size, it would be premature to give up on cardioprotection.
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Affiliation(s)
- Gerd Heusch
- From the Institute for Pathophysiology (G.H.) and Clinic for Cardiology (T.R.), West German Heart and Vascular Center, University School of Medicine Essen, Essen, Germany
| | - Tienush Rassaf
- From the Institute for Pathophysiology (G.H.) and Clinic for Cardiology (T.R.), West German Heart and Vascular Center, University School of Medicine Essen, Essen, Germany
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Abstract
OBJECTIVE In this study, we will review the most recently proposed mechanisms for remote ischemic preconditioning and summarize the past 10 years of clinical studies, as well as potential reasons for why, despite over 20 years of research on remote ischemic preconditioning, it is not routinely used in the pediatric critical care patient. In addition, future directions for remote ischemic preconditioning research will be discussed. DATA SOURCES We searched the PubMed database for relevant literature. STUDY SELECTION AND DATA EXTRACTION In PubMed, the search terms "ischemic preconditioning" and "remote preconditioning" were used. Randomized controlled trials published from 2006 until the present time that used a blood pressure cuff to induce remote ischemic preconditioning were included. We also reviewed the reference lists of the articles found in the PubMed search and included those thought to contribute to the objectives. All studies pertaining to remote ischemic preconditioning that included pediatric patients were reviewed. DATA SYNTHESIS AND CONCLUSIONS Differences in study outcomes in the effect of remote ischemic preconditioning on organ protection have been reported and may have played a large role in limiting the translation of findings into routine clinical practice. Ongoing efforts to protocolize the remote ischemic preconditioning technique in large multicenter trials with clearly delineated patient risk groups, including the use of biomarkers for enrichment, may help to ultimately determine if this procedure can be safely and effectively used for critically ill children.
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Abstract
OBJECTIVE Acute kidney injury is a common complication in critically ill patients and is associated with increased morbidity and mortality. Sepsis, major surgery, and nephrotoxic drugs are the most common causes of acute kidney injury. There is currently no effective strategy available to prevent or treat acute kidney injury. Therefore, novel treatment regimens are required to decrease acute kidney injury prevalence and to improve clinical outcomes. Remote ischemic preconditioning, triggered by brief episodes of ischemia and reperfusion applied in distant tissues or organs before the injury of the target organ, attempts to invoke adaptive responses that protect against acute kidney injury. We sought to evaluate the clinical evidence for remote ischemic preconditioning as a potential strategy to protect the kidney and to review the underlying mechanisms in light of recent studies. DATA SOURCES We searched PubMed for studies reporting the effect of remote ischemic preconditioning on kidney function in surgical patients (search terms: "remote ischemic preconditioning," "kidney function," and "surgery"). We also reviewed bibliographies of relevant articles to identify additional citations. STUDY SELECTION Published studies, consisting of randomized controlled trials, are reviewed. DATA EXTRACTION The authors used consensus to summarize the evidence behind the use of remote ischemic preconditioning. DATA SYNTHESIS In addition, the authors suggest patient populations and clinical scenarios in which remote ischemic preconditioning might be best applied. CONCLUSIONS Several experimental and clinical studies have shown tissue-protective effects of remote ischemic preconditioning in various target organs, including the kidneys. Remote ischemic preconditioning may offer a novel, noninvasive, and inexpensive treatment strategy for decreasing acute kidney injury prevalence in high-risk patients. Although many new studies have further advanced our knowledge in this area, the appropriate intensity of remote ischemic preconditioning, its mechanisms of action, and the role of biomarkers for patient selection and monitoring are still unknown.
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O'Neal JB, Shaw AD, Billings FT. Acute kidney injury following cardiac surgery: current understanding and future directions. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:187. [PMID: 27373799 PMCID: PMC4931708 DOI: 10.1186/s13054-016-1352-z] [Citation(s) in RCA: 326] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Acute kidney injury (AKI) complicates recovery from cardiac surgery in up to 30 % of patients, injures and impairs the function of the brain, lungs, and gut, and places patients at a 5-fold increased risk of death during hospitalization. Renal ischemia, reperfusion, inflammation, hemolysis, oxidative stress, cholesterol emboli, and toxins contribute to the development and progression of AKI. Preventive strategies are limited, but current evidence supports maintenance of renal perfusion and intravascular volume while avoiding venous congestion, administration of balanced salt as opposed to high-chloride intravenous fluids, and the avoidance or limitation of cardiopulmonary bypass exposure. AKI that requires renal replacement therapy occurs in 2–5 % of patients following cardiac surgery and is associated with 50 % mortality. For those who recover from renal replacement therapy or even mild AKI, progression to chronic kidney disease in the ensuing months and years is more likely than for those who do not develop AKI. Cardiac surgery continues to be a popular clinical model to evaluate novel therapeutics, off-label use of existing medications, and nonpharmacologic treatments for AKI, since cardiac surgery is fairly common, typically elective, provides a relatively standardized insult, and patients remain hospitalized and monitored following surgery. More efficient and time-sensitive methods to diagnose AKI are imperative to reduce this negative outcome. The discovery and validation of renal damage biomarkers should in time supplant creatinine-based criteria for the clinical diagnosis of AKI.
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Affiliation(s)
- Jason B O'Neal
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Frederic T Billings
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Sardar P, Chatterjee S, Kundu A, Samady H, Owan T, Giri J, Nairooz R, Selzman CH, Heusch G, Gersh BJ, Abbott JD, Mukherjee D, Fang JC. Remote ischemic preconditioning in patients undergoing cardiovascular surgery: Evidence from a meta-analysis of randomized controlled trials. Int J Cardiol 2016; 221:34-41. [PMID: 27400294 DOI: 10.1016/j.ijcard.2016.06.325] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/27/2016] [Accepted: 06/29/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Remote ischemic preconditioning (RIPC) has been associated with reduced risk of myocardial injury in patients undergoing cardiovascular surgery, but uncertainty about clinical outcomes remains, particularly in the light of 2 recent large randomized clinical trials (RCTs) which were neutral. We performed a meta-analysis to evaluate the efficacy of RIPC on clinically relevant outcomes in patients undergoing cardiovascular surgery. METHODS We searched PubMed, Cochrane CENTRAL, EMBASE, EBSCO, Web of Science and CINAHL databases from inception through November 30, 2015. RCTs that compared the effects of RIPC vs. control in patients undergoing cardiac and/or vascular surgery were selected. We calculated summary random-effect odds ratios (ORs) and 95% confidence intervals (CI). RESULTS The analysis included 5652 patients from 27 RCTs. RIPC reduced the risk of myocardial infarction (MI) (OR 0.72, 95% CI, 0.52 to 1.00; p=0.05; number needed to treat (NNT)=42), acute renal failure (OR 0.73, 95% CI, 0.53 to 1.00; p=0.05; NNT=44) as well as the composite of all cause mortality, MI, stroke or acute renal failure (OR 0.60, 95% CI, 0.39 to 0.90; p=0.01; NNT=25). No significant difference between RIPC and the control groups was observed for the outcome of all-cause mortality (OR 1.10, 95% CI, 0.81 to 1.51). Randomization to RIPC group was also associated with significantly shorter hospital stay (weighted mean difference -0.15days; 95% CI -0.27 to -0.03days). CONCLUSIONS RIPC did not decrease overall mortality, but was associated with less MI and acute renal failure and shorter hospitalizations in patients undergoing cardiac or vascular surgery.
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Affiliation(s)
- Partha Sardar
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, United States.
| | - Saurav Chatterjee
- St Luke's-Roosevelt Hospital of the Mount Sinai Health System, New York, NY, United States
| | - Amartya Kundu
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Habib Samady
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Theophilus Owan
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, United States
| | - Jay Giri
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Ramez Nairooz
- University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, UT,United States
| | - Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, Hufelandstr. 55, 45122 Essen, Germany
| | - Bernard J Gersh
- Division of Cardiovascular Diseases, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN, United States
| | - J Dawn Abbott
- Division of Cardiology, Brown Medical School, Rhode Island Hospital, Providence, RI, United States
| | | | - James C Fang
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, United States
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Li B, Lang X, Cao L, Wang Y, Lu Y, Feng S, Yang Y, Chen J, Jiang H. Effect of remote ischemic preconditioning on postoperative acute kidney injury among patients undergoing cardiac and vascular interventions: a meta-analysis. J Nephrol 2016; 30:19-33. [PMID: 27091767 PMCID: PMC5316401 DOI: 10.1007/s40620-016-0301-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 03/25/2016] [Indexed: 12/17/2022]
Abstract
It is currently controversial whether remote ischemic preconditioning (RIPC) reduces the incidence of acute kidney injury (AKI) in patients undergoing cardiovascular interventions. The main objective of this meta-analysis was to investigate whether RIPC provides renal protection for patients undergoing cardiac or vascular surgery. We searched the PubMed database (1966-Oct 2015), Embase database (1966-Oct 2015), Google Scholar, Cochrane Library, ClinicalTrials Database and Open Grey. Then we conducted a meta-analysis of the randomized controlled trials that met the inclusion criteria of our study. The interventions included use of an inflatable tourniquet around the limbs or cross-clamping of the iliac arteries before surgery (RIPC groups) and general cardiovascular intervention (control groups). The main outcomes examined included the incidence of AKI; changes in acute kidney injury biomarkers; and use of renal replacement therapy. Other outcomes examined included in-hospital mortality and the lengths of hospital stay and intensive care unit (ICU) stay. Finally, we screened 26 eligible studies containing 6699 patients who underwent cardiac or vascular interventions with RIPC (n = 3343) or without RIPC (n = 3356). The AKI incidence was decreased in the RIPC group as was the length of ICU stay. There were no differences in the changes in AKI biomarkers, use of renal replacement therapy or in-hospital mortality between the two groups. Remote ischemic preconditioning may decrease the occurrence of AKI in cardiovascular surgery patients. Since studies included have a significant heterogeneity, meta-analyses using a stricter inclusion criteria are needed to clarify the renoprotection effect of RIPC.
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Affiliation(s)
- Bingjue Li
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Xiabing Lang
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Luxi Cao
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Yuchen Wang
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Yingying Lu
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Shi Feng
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Yi Yang
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Jianghua Chen
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Hong Jiang
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China. .,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China. .,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China. .,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China.
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45
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Remote ischemic conditioning for kidney protection: A meta-analysis. J Crit Care 2016; 33:224-32. [PMID: 26936039 DOI: 10.1016/j.jcrc.2016.01.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 12/30/2015] [Accepted: 01/31/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Results from randomized controlled trials (RCTs) concerning kidney effect of remote ischemic conditioning (RIC) are inconsistent. METHODS We searched for relevant studies in Medline, Embase, the Cochrane Library, Google Scholar and Chinese database (SinoMed), as well as relevant references from their inception to November 2015. We performed a systematic review and meta-analysis of all eligible RCTs of RIC with kidney events. RESULTS We included 37 RCTs from 2007 to 2015 involving 8168 patients. Pooled analyses of all RCTs showed RIC significantly reduced the incidence of investigator-defined acute kidney injury (AKI) compared with control groups (RR 0.84, 95% CI 0.73-0.96, P = .009) (I(2) = 25%). However, the difference was not significant when only RIFLE (Risk, Injury, Failure, Loss, End Stage), AKIN (Acute Kidney Injury Network), or KDIGO (Kidney Disease Improving Global Outcomes) criteria were applied to the definition of AKI (RR 0.87, 95% CI 0.74-1.02, P = .08) (I(2) = 22%). In subgroup analysis, RIC showed a significant benefit on reducing investigator-defined AKI in patients following percutaneous coronary intervention (RR 0.64, 95% CI 0.46-0.87), but not after cardiac surgery (RR 0.93, 95% CI 0.82-1.06). There was no difference for changes in the incidence of renal replacement therapy, estimated glomerular filtration rate or serum creatinine. CONCLUSIONS RIC might be beneficial for the prevention of investigator-defined AKI; however, the effect is likely small. Moreover, due to lack of an effect on use of renal replacement therapy, estimated glomerular filtration rate, RIFLE, AKIN, or KDIGO-defined AKI, and serum creatinine, the evidence for RIC is not robust. Finally, recent large-scale RCTs of RIC focusing on patient-centered outcomes do not support the wider application of RIC.
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46
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Remote ischemic preconditioning in aortic valve surgery: Results of a randomized controlled study. J Cardiol 2016; 67:36-41. [DOI: 10.1016/j.jjcc.2015.06.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 05/13/2015] [Accepted: 06/01/2015] [Indexed: 02/06/2023]
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47
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Zhao BC, Deng WT, Li BC, Deng QW, Xia ZQ, Li YY, Liu KX. Remote ischemic preconditioning for preventing acute kidney injury following cardiovascular surgery: A meta-analysis with trial sequential analysis. Int J Cardiol 2016; 203:842-4. [DOI: 10.1016/j.ijcard.2015.11.081] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 11/08/2015] [Indexed: 01/07/2023]
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48
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Walsh M, Whitlock R, Garg AX, Légaré JF, Duncan AE, Zimmerman R, Miller S, Fremes S, Kieser T, Karthikeyan G, Chan M, Ho A, Nasr V, Vincent J, Ali I, Lavi R, Sessler DI, Kramer R, Gardner J, Syed S, VanHelder T, Guyatt G, Rao-Melacini P, Thabane L, Devereaux PJ. Effects of remote ischemic preconditioning in high-risk patients undergoing cardiac surgery (Remote IMPACT): a randomized controlled trial. CMAJ 2015; 188:329-336. [PMID: 26668200 DOI: 10.1503/cmaj.150632] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2015] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Remote ischemic preconditioning is a simple therapy that may reduce cardiac and kidney injury. We undertook a randomized controlled trial to evaluate the effect of this therapy on markers of heart and kidney injury after cardiac surgery. METHODS Patients at high risk of death within 30 days after cardiac surgery were randomly assigned to undergo remote ischemic preconditioning or a sham procedure after induction of anesthesia. The preconditioning therapy was three 5-minute cycles of thigh ischemia, with 5 minutes of reperfusion between cycles. The sham procedure was identical except that ischemia was not induced. The primary outcome was peak creatine kinase-myocardial band (CK-MB) within 24 hours after surgery (expressed as multiples of the upper limit of normal, with log transformation). The secondary outcome was change in creatinine level within 4 days after surgery (expressed as log-transformed micromoles per litre). Patient-important outcomes were assessed up to 6 months after randomization. RESULTS We randomly assigned 128 patients to remote ischemic preconditioning and 130 to the sham therapy. There were no significant differences in postoperative CK-MB (absolute mean difference 0.15, 95% confidence interval [CI] -0.07 to 0.36) or creatinine (absolute mean difference 0.06, 95% CI -0.10 to 0.23). Other outcomes did not differ significantly for remote ischemic preconditioning relative to the sham therapy: for myocardial infarction, relative risk (RR) 1.35 (95% CI 0.85 to 2.17); for acute kidney injury, RR 1.10 (95% CI 0.68 to 1.78); for stroke, RR 1.02 (95% CI 0.34 to 3.07); and for death, RR 1.47 (95% CI 0.65 to 3.31). INTERPRETATION Remote ischemic precnditioning did not reduce myocardial or kidney injury during cardiac surgery. This type of therapy is unlikely to substantially improve patient-important outcomes in cardiac surgery. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT01071265.
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Affiliation(s)
- Michael Walsh
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Richard Whitlock
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Amit X Garg
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Jean-François Légaré
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Andra E Duncan
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Robert Zimmerman
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Scott Miller
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Stephen Fremes
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Teresa Kieser
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Ganesan Karthikeyan
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Matthew Chan
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Anthony Ho
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Vivian Nasr
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Jessica Vincent
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Imtiaz Ali
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Ronit Lavi
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Daniel I Sessler
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Robert Kramer
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Jeff Gardner
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Summer Syed
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Tomas VanHelder
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Gordon Guyatt
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Purnima Rao-Melacini
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - Lehana Thabane
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
| | - P J Devereaux
- Population Health Research Institute (Walsh, Whitlock, Vincent, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; McMaster University (Walsh, Whitlock, Syed, VanHelder, Guyatt, Rao-Melacini, Thabane, Devereaux), Hamilton, Ont.; London Health Sciences Centre (Garg, Lavi), Western University, London, Ont.; Dalhousie University (Légaré), Halifax, NS; Cleveland Clinic (Duncan, Nasr, Sessler), Cleveland, Ohio; Maine Medical Center (Zimmerman, Kramer), Portland, Me.; Wake Forest University (Miller, Gardner), Winston-Salem, NC; Sunnybrook Health Sciences Centre (Fremes), University of Toronto, Toronto, Ont.; University of Calgary (Kieser, Ali), Calgary, Alta.; All India Institute of Medical Sciences (Karthikeyan), New Delhi, India; The Chinese University of Hong Kong (Chan, Ho), Hong Kong SAR, China
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49
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Lau G, Wald R, Sladen R, Mazer CD. Acute Kidney Injury in Cardiac Surgery and Cardiac Intensive Care. Semin Cardiothorac Vasc Anesth 2015; 19:270-87. [DOI: 10.1177/1089253215593177] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute kidney injury (AKI) is a serious postoperative complication following cardiac surgery. Despite the incidence of AKI requiring temporary renal replacement therapy being low, it is nonetheless associated with high morbidity and mortality. Therefore, preventing AKI associated with cardiac surgery can dramatically improve outcomes in these patients. The pathogenesis of AKI is multifactorial and many attempts to prevent or treat renal injury have been met with limited success. In this article, we will discuss the incidence and risk factors for cardiac surgery associated AKI, including the pathophysiology, potential biomarkers of injury, and treatment modalities.
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Affiliation(s)
- Gary Lau
- Glenfield Hospital, Groby Road, Leicester, UK
| | - Ron Wald
- Department of Medicine, Keenan Research Center at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Robert Sladen
- College of Physicians & Surgeons of Columbia University, New York, NY, USA
| | - C. David Mazer
- Department of Anesthesia, Keenan Research Center at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
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50
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Macedo E, Mehta RL. Renal injury: Preventing organ dysfunction--is preconditioning still an option? Nat Rev Nephrol 2015; 12:8-9. [PMID: 26616537 DOI: 10.1038/nrneph.2015.192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Etienne Macedo
- Division of Nephrology, University of São Paulo Medical School, Avenida Doutor Eneas Carvalho de Aguiar, 44, São Paulo, SP 05403-000, Brasil
| | - Ravindra L Mehta
- Department of Medicine, University of California San Diego, 200 West Arbor Drive, MC8342, San Diego, California 92103, USA
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