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Yoon HJ, Kim TH, Ko DE, Song JW, Min N, Ham SY. Postoperative Hypoalbuminemia as a Predictor of Acute Kidney Injury After Open Repair of Ruptured Abdominal Aortic Aneurysm. World J Surg 2023; 47:3382-3393. [PMID: 37730902 DOI: 10.1007/s00268-023-07178-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Perioperative hypoalbuminemia has a prognostic effect on mortality and morbidity in various cohorts. Patients undergoing open repair of ruptured abdominal aortic aneurysms (rAAA) are at a high risk of hypoalbuminemia due to bleeding and underlying diseases. Hence, this study aimed to investigate the predictive value of immediate postoperative hypoalbuminemia for the risk for acute kidney injury (AKI) in patients undergoing open rAAA repair. METHODS We retrospectively reviewed 143 patients who underwent open rAAA repair between January 2008 and May 2022. The patients were divided into two groups according to the presence of postoperative AKI. The perioperative serum albumin levels of the two groups were compared. The patients were further divided into two groups based on the median immediate postoperative albumin level (2.4 g/dL). The incidence of AKI was compared between the two groups. Multivariate logistic regression analysis was performed to assess the predictors of postoperative AKI. Kaplan-Meier survival curves were used to evaluate potential of AKI and albumin level as prognostic factors for mortality. RESULTS Immediate postoperative serum albumin was significantly lower in the AKI group than in the non-AKI group (2.11 ± 0.62 g/dL vs. 2.59 ± 0.62 g/dL, p < 0.001). The incidence of postoperative AKI was significantly higher in patients with albumin ≤ 2.4 g/dL than in patients with albumin > 2.4 g/dL (53.8% vs. 27.7%, p = 0.002). Immediate postoperative albumin level was an independent predictor of AKI (Odds ratio [OR], 0.310; 95% confidence interval [CI] 0.165-0.583, p < 0.001) and 1-year mortality (OR, 0.230; 95% CI 0.098-0.542, p = 0.001). CONCLUSIONS Immediate postoperative hypoalbuminemia was associated with postoperative AKI and mortality in patients with rAAA.
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Affiliation(s)
- Hei Jin Yoon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Tae-Hoon Kim
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Da Eun Ko
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jong-Wook Song
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Narhyun Min
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung Yeon Ham
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, South Korea.
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea.
- Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, 06273, South Korea.
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2
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De Paulis S, Arlotta G, Calabrese M, Corsi F, Taccheri T, Antoniucci ME, Martinelli L, Bevilacqua F, Tinelli G, Cavaliere F. Postoperative Intensive Care Management of Aortic Repair. J Pers Med 2022; 12:jpm12081351. [PMID: 36013300 PMCID: PMC9410221 DOI: 10.3390/jpm12081351] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/12/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
Vascular surgery patients have multiple comorbidities and are at high risk for perioperative complications. Aortic repair surgery has greatly evolved in recent years, with an increasing predominance of endovascular techniques (EVAR). The incidence of cardiac complications is significantly reduced with endovascular repair, but high-risk patients require postoperative ST-segment monitoring. Open aortic repair may portend a prohibitive risk of respiratory complications that could be a contraindication for surgery. This risk is greatly reduced in the case of an endovascular approach, and general anesthesia should be avoided whenever possible in the case of endovascular repair. Preoperative renal function and postoperative kidney injury are powerful determinants of short- and long-term outcome, so that preoperative risk stratification and secondary prevention are critical tasks. Intraoperative renal protection with selective renal and distal aortic perfusion is essential during open repair. EVAR has lower rates of postoperative renal failure compared to open repair, with approximately half the risk for acute kidney injury (AKI) and one-third of the risk of hemodialysis requirement. Spinal cord ischemia used to be the most distinctive and feared complication of aortic repair. The risk has significantly decreased since the beginning of aortic surgery, with advances in surgical technique and spinal protection protocols, and is lower with endovascular repair. Endovascular repair avoids extensive aortic dissection and aortic cross-clamping and is generally associated with reduced blood loss and less coagulopathy. The intensive care physician must be aware that aortic repair surgery has an impact on every organ system, and the importance of early recognition of organ failure cannot be overemphasized.
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Affiliation(s)
- Stefano De Paulis
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
- Correspondence:
| | | | | | - Filippo Corsi
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
| | | | | | - Lorenzo Martinelli
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | | | - Giovanni Tinelli
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Franco Cavaliere
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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3
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Abstract
Despite substantial advances in anesthesia safety within the past decades, perioperative mortality remains a prevalent problem and can be considered among the top causes of death worldwide. Acute organ failure is a major risk factor of morbidity and mortality in surgical patients and develops primarily as a consequence of a dysregulated inflammatory response and insufficient tissue perfusion. Neurological dysfunction, myocardial ischemia, acute kidney injury, respiratory failure, intestinal dysfunction, and hepatic impairment are among the most serious complications impacting patient outcome and recovery. Pre-, intra-, and postoperative arrangements, such as enhanced recovery after surgery programs, can contribute to lowering the occurrence of organ dysfunction, and mortality rates have improved with the advent of specialized intensive care units and advances in procedures relating to extracorporeal organ support. However, no specific pharmacological therapies have proven effective in the prevention or reversal of perioperative organ injury. Therefore, understanding the underlying mechanisms of organ dysfunction is essential to identify novel treatment strategies to improve perioperative care and outcomes for surgical patients. This review focuses on recent knowledge of pathophysiological and molecular pathways leading to perioperative organ injury. Additionally, we highlight potential therapeutic targets relevant to the network of events that occur in clinical settings with organ failure.
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Affiliation(s)
- Catharina Conrad
- From the Department of Anesthesiology, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas.,Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Holger K Eltzschig
- From the Department of Anesthesiology, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas
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4
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Krasinski Z, Krasińska B, Olszewska M, Pawlaczyk K. Acute Renal Failure/Acute Kidney Injury (AKI) Associated with Endovascular Procedures. Diagnostics (Basel) 2020; 10:diagnostics10050274. [PMID: 32370193 PMCID: PMC7277506 DOI: 10.3390/diagnostics10050274] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/27/2020] [Accepted: 04/30/2020] [Indexed: 01/14/2023] Open
Abstract
AKI is one of the most common yet underdiagnosed postoperative complications that can occur after any type of surgery. Contrast-induced nephropathy (CIN) is still poorly defined and due to a wide range of confounding individual variables, its risk is difficult to determine. CIN mainly affects patients with underlying chronic kidney disease, diabetes, sepsis, heart failure, acute coronary syndrome and cardiogenic shock. Further research is necessary to better understand pathophysiology of contrast-induced AKI and consequent implementation of effective prevention and therapeutic strategies. Although many therapies have been tested to avoid CIN, the only potent preventative strategy involves aggressive fluid administration and reduction of contrast volume. Regardless of surgical technique—open or endovascular—perioperative AKI is associated with significant morbidity, mortality and cost. Endovascular procedures always require administration of a contrast media, which may cause acute tubular necrosis or renal vascular embolization leading to renal ischemia and as a consequence, contribute to increased number of post-operative AKIs.
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Affiliation(s)
- Zbigniew Krasinski
- Department of Vascular, Endovascular Surgery, Angiology and Phlebology, Poznan University of Medical Sciences, 61-848 Poznan, Poland;
| | - Beata Krasińska
- Department of Hypertension, Angiology and Internal Disease, Poznan University of Medical Sciences, 61-848 Poznan, Poland;
| | - Marta Olszewska
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, 60-355 Poznan, Poland;
| | - Krzysztof Pawlaczyk
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, 60-355 Poznan, Poland;
- Correspondence:
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5
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Ostermann M, Cennamo A, Meersch M, Kunst G. A narrative review of the impact of surgery and anaesthesia on acute kidney injury. Anaesthesia 2020; 75 Suppl 1:e121-e133. [PMID: 31903567 DOI: 10.1111/anae.14932] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The epidemiology of peri-operative acute kidney injury varies depending on the definition, type of surgery and acute and chronic comorbidities. Haemodynamic instability, disturbance of the microcirculation, endothelial dysfunction, inflammation and tubular cell injury are the main factors contributing to the pathogenesis. There are no specific therapies. The most effective strategies to protect renal function during the peri-operative period are: the avoidance of nephrotoxic insults; optimisation of haemodynamics; prevention of hypotension; and meticulous fluid management, including avoidance of both hypovolaemia and hypervolaemia. Peri-operative acute kidney injury is associated with an increased risk of short- and long-term postoperative complications, including a longer stay in hospital, development of premature chronic kidney disease and increased mortality. Resource utilisation and healthcare costs are also higher. In future, the development of advanced clinical prediction scores, new imaging and monitoring techniques and the application of new biomarkers for acute kidney injury have the prospect of identifying acute kidney injury earlier and allowing a more personalised management approach with the aim of reducing the global burden of acute kidney injury.
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Affiliation(s)
- M Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, London, UK
| | - A Cennamo
- Department of Critical Care, Guy's and St Thomas' Hospital, London, UK
| | - M Meersch
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany
| | - G Kunst
- Department of Anaesthesia, King's College London, King's College Hospital, London, UK.,School of Cardiovascular Medicine and Sciences, King's College London, British Heart Foundation Centre of Excellence, London, UK
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6
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Abstract
How to cite this article: Bhosale SJ, Kulkarni AP. Preventing Perioperative Acute Kidney Injury. Indian J Crit Care Med 2020;24(Suppl 3):S126–S128.
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Affiliation(s)
- Shilpushp J Bhosale
- Division of Critical Care Medicine, Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
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7
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Wang Z, Salih E, Igwebuike C, Mulhern R, Bonegio RG, Havasi A, Borkan SC. Nucleophosmin Phosphorylation as a Diagnostic and Therapeutic Target for Ischemic AKI. J Am Soc Nephrol 2019; 30:50-62. [PMID: 30573638 DOI: 10.1681/asn.2018040401] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 10/18/2018] [Indexed: 02/04/2023] Open
Abstract
Background Ischemic AKI lacks a urinary marker for early diagnosis and an effective therapy. Differential nucleophosmin (NPM) phosphorylation is a potential early marker of ischemic renal cell injury and a therapeutic target.Methods Differential NPM phosphorylation was assessed by mass spectrometry in NPM harvested from murine and human primary renal epithelial cells, fresh kidney tissue, and urine before and after ischemic injury. The biologic behavior and toxicity of NPM was assessed using phospho-NPM mutant proteins that either mimic stress-induced or normal NPM phosphorylation. Peptides designed to interfere with NPM function were used to explore NPM as a therapeutic target.Results Within hours of stress, virtually identical phosphorylation changes were detected at distinct serine/threonine sites in NPM harvested from primary renal cells, tissue, and urine. A phosphomimic NPM protein that replicated phosphorylation under stress localized to the cytosol, formed monomers that interacted with Bax, a cell death protein, coaccumulated with Bax in isolated mitochondria, and significantly increased cell death after stress; wild-type NPM or a phosphomimic NPM with a normal phosphorylation configuration did not. Three renal targeted peptides designed to interfere with NPM at distinct functional sites significantly protected against cell death, and a single dose of one peptide administered several hours after ischemia that would be lethal in untreated mice significantly reduced AKI severity and improved survival.Conclusions These findings establish phosphorylated NPM as a potential early marker of ischemic AKI that links early diagnosis with effective therapeutic interventions.
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Affiliation(s)
- Zhiyong Wang
- Renal Section, Boston University Medical Center, Boston, Massachusetts; and
| | - Erdjan Salih
- Department of Periodontology, Goldman School of Dentistry, Boston University, Boston, Massachusetts
| | | | - Ryan Mulhern
- Renal Section, Boston University Medical Center, Boston, Massachusetts; and
| | - Ramon G Bonegio
- Renal Section, Boston University Medical Center, Boston, Massachusetts; and
| | - Andrea Havasi
- Renal Section, Boston University Medical Center, Boston, Massachusetts; and
| | - Steven C Borkan
- Renal Section, Boston University Medical Center, Boston, Massachusetts; and
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8
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Saito J, Tokita T, Takashima R, Kawaguchi J, Midorikawa Y, Noguchi S, Hahisba E, Hirota K. Usefulness of Continuous Renal Replacement Therapy During an Intra-Aortic Balloon Occlusion in Patients With Ruptured Abdominal Aortic Aneurysms. J Cardiothorac Vasc Anesth 2018; 33:2237-2240. [PMID: 30401597 DOI: 10.1053/j.jvca.2018.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Junichi Saito
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.
| | - Takaharu Tokita
- Department of Anesthesiology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Ryo Takashima
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Jun Kawaguchi
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yoko Midorikawa
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Satoko Noguchi
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eiji Hahisba
- Division of Intensive Care Unit, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kazuyoshi Hirota
- Department of Anesthesiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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9
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Nonaka T, Kimura N, Hori D, Sasabuchi Y, Nakano M, Yuri K, Sanui M, Matsumoto H, Yamaguchi A. Predictors of Acute Kidney Injury Following Elective Open and Endovascular Aortic Repair for Abdominal Aortic Aneurysm. Ann Vasc Dis 2018; 11:298-305. [PMID: 30402179 PMCID: PMC6200611 DOI: 10.3400/avd.oa.18-00029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Objective: To investigate the predictors of acute kidney injury (AKI) following surgery for abdominal aortic aneurysm. Materials and Methods: Subjects were 642 non-hemodialysis patients (open aortic repair [OAR] group, n=453; endovascular aortic repair [EVAR] group, n=189) who underwent elective surgery between 2009 and 2015. AKI was assessed according to the Kidney Disease Improving Global Outcomes criteria. In-hospital mortality and incidence of AKI were compared between the OAR and EVAR groups. The effect of AKI on outcomes and predictors of AKI were examined in both groups. Results: In-hospital mortalities were 0.7% (3/453) in the OAR group and 0.5% (1/189) in the EVAR group. The incidence of AKI increased in the OAR group (14.1% vs. 3.7%, P<0.01). In the OAR group, in-hospital mortality (0% vs. 4.7%, P<0.01) increased in patients with AKI. In the OAR group, hemoglobin level <10 g/dL, estimated glomerular filtration rate <60 mL/min/1.73 m2, operation time >300 min, history of ischemic heart disease, and amount of bleeding >1,000 mL were predictors of AKI. In the EVAR group, amount of transfusion>1,000 mL was a predictor of AKI, but AKI was not found to worsen outcomes. Conclusion: AKI affected outcomes of OAR. Knowledge of predictors may optimize perioperative care.
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Affiliation(s)
- Takao Nonaka
- Department of Cardiovascular Surgery, Jichi Medical University, Saitama, Japan
| | - Naoyuki Kimura
- Department of Cardiovascular Surgery, Jichi Medical University, Saitama, Japan
| | - Daijiro Hori
- Department of Cardiovascular Surgery, Jichi Medical University, Saitama, Japan
| | - Yusuke Sasabuchi
- Data Science Center, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Mitsunori Nakano
- Department of Cardiovascular Surgery, Jichi Medical University, Saitama, Japan
| | - Koichi Yuri
- Department of Cardiovascular Surgery, Jichi Medical University, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, Saitama, Japan
| | - Harunobu Matsumoto
- Department of Cardiovascular Surgery, Jichi Medical University, Saitama, Japan
| | - Atsushi Yamaguchi
- Department of Cardiovascular Surgery, Jichi Medical University, Saitama, Japan
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10
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Hobson C, Lysak N, Huber M, Scali S, Bihorac A. Epidemiology, outcomes, and management of acute kidney injury in the vascular surgery patient. J Vasc Surg 2018; 68:916-928. [PMID: 30146038 PMCID: PMC6236681 DOI: 10.1016/j.jvs.2018.05.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 05/13/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Conventional clinical wisdom has often been nihilistic regarding the prevention and management of acute kidney injury (AKI), despite its being a frequent and morbid complication associated with both increased mortality and cost. Recent developments have shown that AKI is not inevitable and that changes in management of patients can reduce both the incidence and morbidity of perioperative AKI. The purpose of this narrative review was to review the epidemiology and outcomes of AKI in patients undergoing vascular surgery using current consensus definitions, to discuss some of the novel emerging risk stratification and prevention techniques relevant to the vascular surgery patient, and to describe a standardized perioperative pathway for the prevention of AKI after vascular surgery. METHODS We performed a critical review of the literature on AKI in the vascular surgery patient using the PubMed and MEDLINE databases and Google Scholar through September 2017 using web-based search engines. We also searched the guidelines and publications available online from the organizations Kidney Disease: Improving Global Outcomes and the Acute Dialysis Quality Initiative. The search terms used included acute kidney injury, AKI, epidemiology, outcomes, prevention, therapy, and treatment. RESULTS The reported epidemiology and outcomes associated with AKI have been evolving since the publication of consensus criteria that allow accurate identification of mild and moderate AKI. The incidence of AKI after major vascular surgery using current criteria is as high as 49%, although there are significant differences, depending on the type of procedure performed. Many tools have become available to assess and to stratify the risk for AKI and to use that information to prevent AKI in the surgical patient. We describe a standardized clinical assessment and management pathway for vascular surgery patients, incorporating current risk assessment and preventive strategies to prevent AKI and to decrease its complications. Patients without any risk factors can be managed in a perioperative fast-track pathway. Those patients with positive risk factors are tested for kidney stress using the urinary biomarker TIMP-2•IGFBP7, and care is then stratified according to the result. Management follows current Kidney Disease: Improving Global Outcomes guidelines. CONCLUSIONS AKI is a common postoperative complication among vascular surgery patients and has a significant impact on morbidity, mortality, and cost. Preoperative risk assessment and optimal perioperative management guided by that risk assessment can minimize the consequences associated with postoperative AKI. Adherence to a standardized perioperative pathway designed to reduce risk of AKI after major vascular surgery offers a promising clinical approach to mitigate the incidence and severity of this challenging clinical problem.
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Affiliation(s)
- Charles Hobson
- Department of Surgery, Malcom Randall VAMC, Gainesville, Fla; Department of Health Services Research, Management and Policy, University of Florida, Gainesville, Fla
| | - Nicholas Lysak
- Department of Surgery, College of Medicine, University of Florida, Gainesville, Fla
| | - Matthew Huber
- Department of Medicine, College of Medicine, University of Florida, Gainesville, Fla
| | - Salvatore Scali
- Department of Surgery, Malcom Randall VAMC, Gainesville, Fla; Department of Surgery, College of Medicine, University of Florida, Gainesville, Fla
| | - Azra Bihorac
- Department of Medicine, College of Medicine, University of Florida, Gainesville, Fla; Precision and Intelligent Systems in Medicine (PrismaP), University of Florida, Gainesville, Fla.
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11
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Jalalzadeh H, van Leeuwen CF, Indrakusuma R, Balm R, Koelemay MJW. Systematic review and meta-analysis of the risk of bowel ischemia after ruptured abdominal aortic aneurysm repair. J Vasc Surg 2018; 68:900-915. [PMID: 30146037 DOI: 10.1016/j.jvs.2018.05.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/14/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Outcomes after repair of ruptured abdominal aortic aneurysm (RAAA) have improved in the last decade. It is unknown whether this has resulted in a reduction of postoperative bowel ischemia (BI). The primary objective was to determine BI prevalence after RAAA repair. Secondary objectives were to determine its major sequelae and differences between open repair (OR) and endovascular aneurysm repair (EVAR). METHODS This systematic review (PROSPERO CRD42017055920) followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. MEDLINE and Embase were searched for studies published from 2005 until 2018. The methodologic quality of observational studies was assessed with the Methodological Index for Non-Randomized Studies (MINORS) tool. The quality of the randomized controlled trials (RCTs) was assessed with the Cochrane Collaboration's tool for assessing risk of bias. BI prevalence and rates of BI as cause of death, reoperation, and bowel resection were estimated with meta-analyses with a random-effects model. Differences between OR and EVAR were estimated with pooled risk ratios with 95% confidence intervals (CIs). Changes over time were assessed with Spearman rank test (ρ). Publication bias was assessed with a funnel plot analysis. RESULTS A total of 101 studies with 52,670 patients were included; 72 studies were retrospective cohort studies, 14 studies were prospective cohort studies, 12 studies were retrospective administrative database studies, and 3 studies were RCTs. The overall methodologic quality of the RCTs was high, but that of observational studies was low. The pooled prevalence of BI ranged from of 0.08 (95% CI, 0.07-0.09) in database studies to 0.10 (95% CI, 0.08-0.12) in cohort studies. The risk of BI was higher after OR than after EVAR (risk ratio, 1.79; 95% CI, 1.25-2.57). The pooled rate of BI as cause of death was 0.04 (95% CI, 0.03-0.05), and that of BI as cause of reoperation and bowel resection ranged between 0.05 and 0.07. BI prevalence did not change over time (ρ, -0.01; P = .93). The funnel plot analysis was highly suggestive of publication bias. CONCLUSIONS The prevalence of clinically relevant BI after RAAA repair is approximately 10%. Approximately 5% of patients undergoing RAAA repair suffer from severe consequences of BI. BI is less prevalent after EVAR than after OR.
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Affiliation(s)
- Hamid Jalalzadeh
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands.
| | - Carlijn F van Leeuwen
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
| | - Reza Indrakusuma
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
| | - Ron Balm
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
| | - Mark J W Koelemay
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
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12
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Ambler GK, Mariam NBG, Sadat U, Coughlin PA, Loftus IM, Boyle JR. Weekend effect in non-elective abdominal aortic aneurysm repair. BJS Open 2017; 1:158-164. [PMID: 29951618 PMCID: PMC5989979 DOI: 10.1002/bjs5.24] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 09/14/2017] [Indexed: 11/11/2022] Open
Abstract
Background The ‘weekend effect’ describes the phenomenon where patient outcomes appear worse for those admitted at the weekend. It has been used recently to justify significant changes in UK health policy. Recent evidence has suggested that the effect may be due to a combination of inadequate correction for confounding factors and inaccurate coding. The effects of these factors were investigated in patients with acute abdominal aortic aneurysm (AAA). Methods Patients undergoing non‐elective AAA repair entered into the UK National Vascular Registry from January 2013 until December 2015 were included in a case–control study. The patients were divided according to whether they were treated during the week (Monday 08.00 hours to Friday 17.00 hours) or at the weekend. Data extracted included demographics, co‐morbidities, preoperative medications and baseline blood test results, as well as outcomes. Coding issues were investigated by looking at patients treated for ruptured, symptomatic or asymptomatic AAA within the non‐elective cohort. The primary outcome was in‐hospital mortality. Secondary outcomes included length of inpatient stay, and cardiac, respiratory and renal complications. Results The mortality rate appeared to be higher at the weekend (odds ratio (OR) 1·69, 95 per cent c.i. 1·47 to 1·94; P < 0·001), but this effect disappeared when confounding factors and coding issues were corrected for (corrected OR for ruptured AAA 1·09, 0·92 to 1·29; P = 0·330). Differences in outcomes were similar for prolonged length of hospital stay (uncorrected OR 1·21, 95 per cent c.i. 1·06 to 1·37, P = 0·005; corrected OR for ruptured AAA 1·06, 0·91 to 1·10, P = 0·478), and morbidity outcomes. Conclusion After appropriate correction for confounding factors and coding effects, there was no evidence of a significant weekend effect in the treatment of non‐elective AAA in the UK.
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Affiliation(s)
- G K Ambler
- Division of Population Medicine Cardiff University Cardiff UK.,South East Wales Vascular Network, Aneurin Bevan University Health Board, Royal Gwent Hospital Newport UK
| | - N B G Mariam
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - U Sadat
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - P A Coughlin
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - I M Loftus
- Saint George's Vascular Institute University of London London UK
| | - J R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust Cambridge UK
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13
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Jalalzadeh H, Indrakusuma R, Vogt L, van Beek SC, Vahl AC, Wisselink W, Koelemay MJ, Balm R. Long-term survival after acute kidney injury following ruptured abdominal aortic aneurysm repair. J Vasc Surg 2017; 66:1712-1718.e2. [DOI: 10.1016/j.jvs.2017.04.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 04/17/2017] [Indexed: 11/26/2022]
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14
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Abstract
Acute kidney injury (AKI) is a common complication in surgical patients and is associated with increases in mortality, an increased risk for chronic kidney disease and hemodialysis after discharge, and increased cost. Better understanding of the risk factors that contribute to perioperative AKI has led to improved AKI prediction and will eventually lead to improved prevention of AKI, mitigation of injury when AKI occurs, and enhanced recovery in patients who sustain AKI. The development of advanced clinical prediction scores for AKI, new imaging techniques, and novel biomarkers for early detection of AKI provides new tools toward these ends.
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Jalalzadeh H, van Beek SC, Indrakusuma R, Bemelman WA, Busch OR, Balm R. Lasagna plots to visualize results in surgical studies. Int J Surg 2017; 43:119-125. [PMID: 28578083 DOI: 10.1016/j.ijsu.2017.05.063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/19/2017] [Accepted: 05/29/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND A lasagna plot is a graphical tool that can display multiple longitudinal outcomes. To our knowledge, lasagna plots have not been used in publications of surgical studies before. The objective of this study was to demonstrate the results of surgical randomized controlled trials (RCTs) with lasagna plots in order to assess whether this can lead to new observations of the data presented in the original studies. MATERIAL AND METHODS Lasagna plots were created with R for an RCT comparing endovascular and open repair for patients with a ruptured abdominal aortic aneurysm (AJAX trial), an RCT comparing laparoscopy or open surgery combined with either fast track or standard care for patients with colon cancer (LAFA trial) and an RCT comparing preoperative biliary drainage and early surgery for patients with pancreatic cancer (DROP trial). RESULTS Regarding the AJAX trial, the original article had reported the rate of outcomes at 30 days after repair in two tables. The plots additionally demonstrated the moments of occurrence, increase and decrease of multiple outcomes such as renal replacement therapy and occurrence of death within one plot. These observations were not presented in the original article. The lasagna plots of the LAFA and DROP trial revealed similar new observations on multiple longitudinal outcomes. CONCLUSION By revealing new observations of the previously published data, lasagna plots generate new hypotheses and theories regarding the outcomes. As such, lasagna plots may be a useful addition to traditional tables and figures and could improve the interpretation of results.
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Affiliation(s)
- Hamid Jalalzadeh
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Sytse C van Beek
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Reza Indrakusuma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Ron Balm
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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Tang Y, Chen J, Huang K, Luo D, Liang P, Feng M, Chai W, Fung E, Lan HY, Xu A. The incidence, risk factors and in-hospital mortality of acute kidney injury in patients after abdominal aortic aneurysm repair surgery. BMC Nephrol 2017; 18:184. [PMID: 28569144 PMCID: PMC5452373 DOI: 10.1186/s12882-017-0594-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 05/18/2017] [Indexed: 12/02/2022] Open
Abstract
Background Acute kidney injury (AKI) is a severe complication associated with abdominal aortic aneurysm (AAA) repair. In this study, we evaluated the incidence, risk factors and in-hospital mortality of AKI in patients after the AAA repair surgery. Methods A total of 314 Chinese AAA patients who underwent endovascular aneurysm repair (EVAR) or open aneurysm repair (OPEN) were enrolled in this study. AKI was diagnosed according to the 2012 KDIGO criteria. Logistic regression modeling was used to explore risk factors of AKI, while risk factors associated with in-hospital mortality in AKI patients were investigated using Cox proportional hazards model and Kaplan-Meier analysis, respectively. Multicollinearity analysis was performed to identify the collinearity between the variables before logistic regression analysis and Cox proportional hazards analysis. Results Among 314 patients, 94 (29.9%) developed AKI after AAA repair surgery. Severity of AKI and ruptured AAA were independently associated with an increase in in-hospital mortality in AKI patients after AAA repair. Kaplan-Meier analysis identified severity of AKI as being negatively associated with hospital survival in AKI patients. Risk factors associated with AKI included cardiovascular disease (OR 3.169, 95% confidence interval (CI) 1.538 to 6.527, P = 0.002), decreased eGFR (OR 0.965, 95%CI 0.954 to 0.977, P < 0.001), ruptured AAA (OR 2.717, 95%CI 1.320 to 5.592, P = 0.007), renal artery involvement (OR 2.903, 95%CI 1.219 to 6.912, P = 0.016) and OPEN (OR 2.094, 95%CI 1.048 to 4.183, P = 0.036). Further subgroup analysis identified OPEN as an important risk factor of AKI in ruptured AAA patients but not in ruptured AAA patients. The incidence of AKI was significantly lower in EVAR than in OPEN (27.1% vs. 42.8%) and, similarly lower in nonruptured AAA than in ruptured AAA (26.2% vs. 48.1%). Conclusion One-third of AAA patients developed AKI after repair surgery. Severity of AKI was associated with reduced survival rate in AAA patients who developed postoperative AKI. Decreased preoperative creatinine clearance, cardiovascular disease, ruptured AAA and OPEN were independent risk factors for postoperative AKI in all 314 AAA patients. Although a lower rate of incident AKI was observed in EVAR compared with OPEN, subgroup analysis of ruptured AAA versus nonruptured AAA showed that EVAR was an independent protective factor for AKI only in ruptured AAA patients but not in nonruptured AAA patients.
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Affiliation(s)
- Ying Tang
- Department of Nephrology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou, China
| | - Junzhe Chen
- Department of Nephrology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou, China
| | - Kai Huang
- Department of Nephrology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou, China
| | - Dan Luo
- Department of Nephrology, The People's Hospital of Meishan City, Meishan, China
| | - Peifen Liang
- Department of Nephrology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou, China
| | - Min Feng
- Department of Nephrology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou, China
| | - Wenxin Chai
- Faculty of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Erik Fung
- Department of Medicine and Therapeutics, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hui Yao Lan
- Department of Medicine and Therapeutics, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong.
| | - Anping Xu
- Department of Nephrology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou, China.
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Acute kidney injury after open and endovascular elective repair for infrarenal abdominal aortic aneurysms. J Vasc Surg 2016; 64:928-933.e1. [DOI: 10.1016/j.jvs.2016.02.048] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 02/18/2016] [Indexed: 11/23/2022]
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18
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Acute kidney injury predicts mortality after endovascular aortic repair. Eur J Vasc Endovasc Surg 2015; 50:431. [DOI: 10.1016/j.ejvs.2015.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 05/05/2015] [Indexed: 11/17/2022]
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Incidence and Outcomes of Severe Renal Impairment Following Ruptured Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2015; 50:443-9. [PMID: 26188721 DOI: 10.1016/j.ejvs.2015.06.024] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 06/01/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Acute kidney injury (AKI) following ruptured abdominal aortic aneurysm (rAAA) repair is common and multifactorial. A standard definition of AKI after endovascular repair (EVAR), the Aneurysm Renal Injury Score (ARISe), has been proposed to facilitate standardised reporting and thus improve understanding of this issue. METHODS Data were collected retrospectively on AKI in a prospectively maintained database of all patients treated for rAAA in a single tertiary referral centre since the availability of routine out of hours emergency EVAR. The ARISe score was used to describe the degree of AKI and factors which correlated with poor renal outcomes were assessed. RESULTS Two-hundred and five patients were treated between January 2006 and April 2014. Of these, 125 were treated with open repair (OSR) and 80 were treated with EVAR. Severe AKI (defined as ARISe score ≥3) occurred in 36% of patients. After correction for confounders, patients treated with OSR were significantly more likely to develop severe AKI (43% vs. 26%, p = .02). There was no significant difference in preoperative serum creatinine between groups, but increased preoperative serum creatinine was strongly associated with severe AKI postoperatively (p < .001). Age, sex, endograft type, and preoperative CT scanning were not associated with differences in renal outcomes. Clamp position above renal arteries was predictive of severe AKI in patients treated with OSR (p < .01). Patients suffering severe AKI had significantly higher mortality at 30 days and 12 months (28% vs. 5% and 44% vs. 13%, p < .001 for both comparisons). CONCLUSION Severe AKI is common following successful repair of rAAA. In this large case series of high-risk patients, OSR was associated with significantly higher rates of severe AKI compared with EVAR, despite the increased dose of contrast involved in EVAR and the older age of these patients. In turn, severe AKI was associated with higher mortality rates.
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Huber M, Ozrazgat-Baslanti T, Thottakkara P, Efron PA, Feezor R, Hobson C, Bihorac A. Mortality and Cost of Acute and Chronic Kidney Disease after Vascular Surgery. Ann Vasc Surg 2015; 30:72-81.e1-2. [PMID: 26187703 DOI: 10.1016/j.avsg.2015.04.092] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 04/21/2015] [Accepted: 04/30/2015] [Indexed: 01/12/2023]
Abstract
BACKGROUND Both acute kidney injury (AKI) and chronic kidney disease (CKD) are common yet underappreciated risk factors for adverse perioperative outcomes. We hypothesize that AKI and CKD are associated with similar increases in 90-day mortality and cost in patients undergoing major vascular surgery. METHODS We used multivariable regression analyses to evaluate the associations between AKI and CKD and incremental 90-day mortality and hospital cost in a single-center cohort of 3646 adult patients undergoing major vascular surgery. We defined AKI using Kidney Disease: Improving Global Outcomes criteria as change in creatinine ≥ 0.3 mg/dL or ≥ 50% increase from the reference value. CKD was determined from medical history. Regression models were adjusted for demographic and socioeconomic characteristics, comorbid conditions, surgery type, and postoperative complications. RESULTS The prevalence of kidney disease among vascular surgery patients is high with 49% of patients developing AKI during hospitalization and 17% presenting with CKD on admission. In risk-adjusted logistic regression analysis, perioperative AKI (odds ratio 2.2, 95% confidence interval 1.5-3.3) was the most significant predictor of 90-day mortality. The risk-adjusted average cost was significantly higher for patients with any type of kidney disease. The incremental cost of having any type of kidney disease ranged from $9100 to $19,100, even after adjustment for underlying comorbidities and other postoperative complications. CONCLUSIONS Kidney disease after major vascular surgery is associated with significant increases in 90-day mortality and cost with the highest risk observed among patients with AKI regardless of previous CKD.
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Affiliation(s)
- Matthew Huber
- Department of Anesthesiology, University of Florida, Gainesville, FL
| | | | - Paul Thottakkara
- Department of Anesthesiology, University of Florida, Gainesville, FL
| | - Philip A Efron
- Department of Surgery, University of Florida, Gainesville, FL
| | - Robert Feezor
- Department of Surgery, University of Florida, Gainesville, FL
| | - Charles Hobson
- Department of Surgery, Malcom Randall VA Medical Center, Gainesville, FL; Department of Health Services Research, Management, and Policy, University of Florida, Gainesville, FL
| | - Azra Bihorac
- Department of Anesthesiology, University of Florida, Gainesville, FL.
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