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Kaffka Genaamd Dengler SE, Mishra M, Vervoorn MT, Kernkamp J, van Tuijl S, de Jager SCA, Sluijter JPG, Doevendans PA, van der Kaaij NP. Hemofiltration Improves Blood Perfusate Conditions Leading to Improved Ex Situ Heart Perfusion. ASAIO J 2024; 70:38-43. [PMID: 37816093 DOI: 10.1097/mat.0000000000002058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023] Open
Abstract
The aim was to optimize the perfusate composition by including a hemofiltrator to the PhysioHeartplatform for ex situ heart perfusion of porcine slaughterhouse hearts. Fourteen hearts were harvested from Dutch Landrace pigs and slaughtered for human consumption. All hearts were preserved for 4 hours using static cold storage before reperfusion for 4 hours on the PhysioHeart platform. Seven hearts were assigned to the hemofiltration group, where a hemofiltrator was added to the perfusion circuit, while the control group did not receive hemofiltration. In the hemofiltration group, the perfusion fluid was filtrated for 1 hour with a flow of 1 L/hour before reperfusion. After mounting the heart, hemofiltration was maintained at 1 L/hour, and cardiac function and blood samples were analyzed at multiple time points. Preserved cardiac function was defined as a cardiac output >3.0 L/min with a mean aortic pressure >60 mm Hg and a left atrial pressure <15 mm Hg. Hemofiltration resulted in a significantly reduced potassium concentration at all time points ( p < 0.001), while sodium levels remained at baseline values ( p < 0.004). Furthermore, creatinine and ammonia levels decreased over time. Functional assessment demonstrated a reduced left atrial pressure ( p < 0.04) and a reduction of the required dobutamine dose to support myocardial function ( p < 0.003) in the hemofiltration group. Preserved cardiac function did not differ between groups. Hemofiltration results in an improved biochemical composition of the whole blood perfusate and preserves cardiac function better during normothermic perfusion based on a reduced left atrial pressure (LAP) and dobutamine requirement to support function.
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Affiliation(s)
| | - Mudit Mishra
- From the Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Laboratory of Experimental Cardiology, Department of Cardiology, University Medical Center Utrecht, Regenerative Medicine Center Utrecht, Circulatory Health Research Center, University Utrecht, Utrecht, the Netherlands
| | - Mats T Vervoorn
- From the Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jord Kernkamp
- From the Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Saskia C A de Jager
- Laboratory of Experimental Cardiology, Department of Cardiology, University Medical Center Utrecht, Regenerative Medicine Center Utrecht, Circulatory Health Research Center, University Utrecht, Utrecht, the Netherlands
| | - Joost P G Sluijter
- Laboratory of Experimental Cardiology, Department of Cardiology, University Medical Center Utrecht, Regenerative Medicine Center Utrecht, Circulatory Health Research Center, University Utrecht, Utrecht, the Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Center Utrecht, University Utrecht, Utrecht, the Netherlands
- Netherlands Heart Institute, Utrecht, the Netherlands
| | - Niels P van der Kaaij
- From the Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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Garcia-Suarez J, Garcia-Fernandez J, Martinez Lopez D, Reques L, Sanz S, Carballo D, Martin CE, Ospina VM, Villar S, Martin A, Casado M, Villafranca A, Gonzalez AI, Serrano S, Forteza A. Clinical impact of del Nido cardioplegia in adult cardiac surgery: A prospective randomized trial. J Thorac Cardiovasc Surg 2023; 166:1458-1467. [PMID: 35279289 DOI: 10.1016/j.jtcvs.2022.01.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 01/09/2022] [Accepted: 01/23/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The study objective was to assess the benefits of del Nido cardioplegia compared with cold blood cardioplegia solution in terms of myocardial protection during adult cardiac surgery. METHODS A total of 474 adult patients undergoing coronary artery bypass grafting, heart valve surgery, thoracic aortic surgery, or combined procedures were randomized to the del Nido cardioplegia group (n = 234) or the cold blood cardioplegia solution group (n = 240) after provided informed consent. The primary end points assessed inotropic support requirements, severe cardiovascular events, and troponin trend within the first 48 hours of intensive care unit stay. Reperfusion arrhythmias, aortic crossclamp and cardiopulmonary bypass times, and other clinical perioperative variables were considered as secondary end points. RESULTS No statistically significant differences were found regarding postoperative inotropic support requirements or the incidence of severe cardiovascular events. The del Nido cardioplegia group showed a higher return to spontaneous sinus rhythm (P< .001), a lower number of defibrillation attempts (P< .001), and an earlier peak troponin value in the postoperative period. Peak blood glucose levels and intravenous insulin requirements were significantly lower in the del Nido cardioplegia group. We found no significant differences regarding aortic crossclamp or cardiopulmonary bypass time. We did observe a lower incidence of postoperative stroke in the del Nido cardioplegia group (2.6% vs 6.7%; P= .035). CONCLUSIONS del Nido cardioplegia can be used safely and with comparable outcomes compared with traditional cardioplegia solutions. Additional advantages over glycemic control, reperfusion arrhythmias, and its comfortable redosing interval make del Nido an interesting alternative for myocardial protection in adult cardiac surgery. A significant decrease in postoperative stroke will require further research to shed light on the results of this study. VIDEO ABSTRACT.
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Affiliation(s)
- Jessica Garcia-Suarez
- Department of Anesthesiology and Critical Care, Puerta de Hierro University Hospital, Madrid, Spain.
| | - Javier Garcia-Fernandez
- Department of Anesthesiology and Critical Care, Puerta de Hierro University Hospital, Madrid, Spain
| | | | - Leticia Reques
- Cardiac Surgery Perfusion Department, Puerta de Hierro University Hospital, Madrid, Spain
| | - Sergio Sanz
- Department of Anesthesiology and Critical Care, Puerta de Hierro University Hospital, Madrid, Spain
| | - Daniel Carballo
- Department of Anesthesiology and Critical Care, Puerta de Hierro University Hospital, Madrid, Spain
| | | | - Victor Manuel Ospina
- Department of Cardiac Surgery, Puerta de Hierro University Hospital, Madrid, Spain
| | - Susana Villar
- Department of Cardiac Surgery, Puerta de Hierro University Hospital, Madrid, Spain
| | - Ana Martin
- Cardiac Surgery Perfusion Department, Puerta de Hierro University Hospital, Madrid, Spain
| | - Maria Casado
- Department of Anesthesiology and Critical Care, Puerta de Hierro University Hospital, Madrid, Spain
| | - Ana Villafranca
- Department of Anesthesiology and Critical Care, Puerta de Hierro University Hospital, Madrid, Spain
| | - Ana Isabel Gonzalez
- Department of Anesthesiology and Critical Care, Puerta de Hierro University Hospital, Madrid, Spain
| | - Santiago Serrano
- Department of Cardiac Surgery, Puerta de Hierro University Hospital, Madrid, Spain
| | - Alberto Forteza
- Department of Cardiac Surgery, Puerta de Hierro University Hospital, Madrid, Spain
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Ohtsubo S, Itoh T, Kawai Y, Kobayashi K, Yoshitake S, Fujimura N, Shoji Y, Ishii S. Clinical outcome of intraoperative hemodialysis using a hemoconcentrator during cardiopulmonary bypass for dialysis-dependent patients. Gen Thorac Cardiovasc Surg 2023; 71:515-524. [PMID: 36907942 DOI: 10.1007/s11748-023-01922-x] [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: 12/19/2022] [Accepted: 02/19/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVES The basic materials and structure of a hemoconcentrator incorporated into cardiopulmonary bypass (CPB) circuits are similar to those of hemodialyzers. Gravity drainage hemodiafiltration (GHDF) is an easy-to-use intraoperative renal replacement therapy (RRT) that utilizes a hemoconcentrator. This study aimed to verify whether GHDF can correct electrolyte imbalance and remove uremic toxins in dialysis-dependent patients and to evaluate the clinical outcomes of GHDF by comparing it with a conventional method of dilutional ultrafiltration (DUF). METHODS This study retrospectively compared perioperative clinical values of 41 dialysis-dependent patients (21 patients with GHDF and 20 patients with DUF) who underwent open-heart surgery. Changes in serum parameters before and after passing through the hemoconcentrator were also compared. RESULTS Compared to DUF, GHDF significantly lowered potassium, blood urea nitrogen, and creatinine levels at the outflow of the hemoconcentrator. Less catecholamine was needed to wean CPB in GHDF than in DUF. The P/F ratio (arterial blood oxygen pressure/inhaled oxygen concentration) at the end of surgery was significantly higher in GHDF than in DUF (450.8 ± 149.7 vs. 279.3 ± 153.5; p < 0.001). Postoperative intubation time was shorter in GHDF than in DUF (8.3 ± 5.9 vs. 18.7 ± 16.1 h; p = 0.006). The major morbidity and mortality rates were comparable in both groups. CONCLUSIONS GHDF removed both potassium and uremic toxins more efficiently than DUF in dialysis-dependent patients. Less catecholamine was needed to wean CPB using GHDF. It improved the immediate postoperative respiratory function and enabled earlier extubation. GHDF is a novel and effective option for intraoperative RRT in dialysis-dependent patients undergoing open-heart surgery.
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Affiliation(s)
- Satoshi Ohtsubo
- Department of Cardiovascular Surgery, Saiseikai Central Hospital, 1-4-17, Mita, Minato-ku, Tokyo, 108-0073, Japan.
| | - Takahito Itoh
- Department of Cardiovascular Surgery, Saiseikai Central Hospital, 1-4-17, Mita, Minato-ku, Tokyo, 108-0073, Japan
| | - Yujiro Kawai
- Department of Cardiovascular Surgery, Saiseikai Central Hospital, 1-4-17, Mita, Minato-ku, Tokyo, 108-0073, Japan
| | - Kanako Kobayashi
- Department of Cardiovascular Surgery, Saiseikai Central Hospital, 1-4-17, Mita, Minato-ku, Tokyo, 108-0073, Japan
| | - Shuichiro Yoshitake
- Department of Cardiovascular Surgery, Saiseikai Central Hospital, 1-4-17, Mita, Minato-ku, Tokyo, 108-0073, Japan
| | - Naoki Fujimura
- Department of Vascular Surgery, Saiseikai Central Hospital, Tokyo, Japan
| | - Yuta Shoji
- Department of Clinical Engineering, Saiseikai Central Hospital, Tokyo, Japan
| | - Shuichi Ishii
- Department of Clinical Engineering, Saiseikai Central Hospital, Tokyo, Japan
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Bierer J, Horne D, Stanzel R, Henderson M, Boulos L, Hayden JA. Continuous Ultrafiltration Enhances Recovery After Adult Cardiac Surgery With Cardiopulmonary Bypass: A Systematic Review and Meta-analysis. CJC Open 2023; 5:494-507. [PMID: 37496782 PMCID: PMC10366635 DOI: 10.1016/j.cjco.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/17/2023] [Indexed: 07/28/2023] Open
Abstract
Background Cardiac surgery with cardiopulmonary bypass is associated with systemic inflammation. Ultrafiltration used throughout the cardiopulmonary bypass time, continuously, is hypothesized to be an immunomodulatory therapy. Methods A systematic review and meta-analysis of randomized trials investigating continuous forms of ultrafiltration during adult cardiac surgery (CRD42020219309) was conducted and is reported following PRISMA guidelines. MEDLINE, Embase, CENTRAL, and Scopus were searched on November 3, 2021. The primary endpoint was operative mortality, and secondary outcomes included intensive care unit length of stay (ICU LOS), ventilation time, acute kidney injury or renal failure, and pneumonia. Each study was assessed for risk of bias using the Cochrane Risk-of Bias-Tool for Randomized Trials (RoB2) instrument. Outcomes were analyzed with inverse variance random-effects models and assessed for GRADE quality of evidence. Results Twelve randomized trials consisting of 989 adult patients undergoing coronary, valvular, or concomitant cardiac procedures were included. Compared to controls, patients receiving continuous ultrafiltration had no statistical difference in operative mortality; risk ratio of 0.32 (95% confidence interval [CI]: 0.10-1.03; P = 0.06). Reductions occurred in ICU LOS, by 7.01 hours (95% CI: 1.86-12.15; P = 0.008); ventilation time, by 2.11 hours (95% CI: 0.71-3.51; P = 0.003); and incidence of pneumonia, with a risk ratio of 0.33 (95% CI: 0.15-0.75; P = 0.008). There wasno difference in renal injury. The GRADE quality of evidence for these outcomes ranged from very low to low. Conclusions Continuous forms of ultrafiltration enhance recovery after adult cardiac surgery by reducing ICU LOS, ventilation time, and incidence of pneumonia. A multicentre randomized trial could confirm and generalize these findings.
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Affiliation(s)
- Joel Bierer
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - David Horne
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Roger Stanzel
- Department of Clinical Perfusion, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Mark Henderson
- Department of Clinical Perfusion, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Leah Boulos
- Maritime SPOR SUPPORT Unit, Halifax, Nova Scotia, Canada
| | - Jill A. Hayden
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
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Cytoprotective remedies for ameliorating nephrotoxicity induced by renal oxidative stress. Life Sci 2023; 318:121466. [PMID: 36773693 DOI: 10.1016/j.lfs.2023.121466] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/27/2023] [Accepted: 01/27/2023] [Indexed: 02/11/2023]
Abstract
AIMS Nephrotoxicity is the hallmark of anti-neoplastic drug metabolism that causes oxidative stress. External chemical agents and prescription drugs release copious amounts of free radicals originating from molecular oxidation and unless sustainably scavenged, they stimulate membrane lipid peroxidation and disruption of the host antioxidant mechanisms. This review aims to provide a comprehensive collection of potential cytoprotective remedies in surmounting the most difficult aspect of cancer therapy as well as preventing renal oxidative stress by other means. MATERIALS AND METHODS Over 400 published research and review articles spanning several decades were scrutinised to obtain the relevant data which is presented in 3 categories; sources, mechanisms, and mitigation of renal oxidative stress. KEY-FINDINGS Drug and chemical-induced nephrotoxicity commonly manifests as chronic or acute kidney disease, nephritis, nephrotic syndrome, and nephrosis. Renal replacement therapy requirements and mortalities from end-stage renal disease are set to rapidly increase in the next decade for which 43 different cytoprotective compounds which have the capability to suppress experimental nephrotoxicity are described. SIGNIFICANCE The renal system performs essential homeostatic functions that play a significant role in eliminating toxicants, and its accumulation and recurrence in nephric tissues results in tubular degeneration and subsequent renal impairment. Global statistics of the latest chronic kidney disease prevalence is 13.4 % while the end-stage kidney disease requiring renal replacement therapy is 4-7 million per annum. The remedial compounds discussed herein had proven efficacy against nephrotoxicity manifested consequent to impaired antioxidant mechanisms in preclinical models produced by renal oxidative stress activators.
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Milne B, Gilbey T, Kunst G. Perioperative Management of the Patient at High-Risk for Cardiac Surgery-Associated Acute Kidney Injury. J Cardiothorac Vasc Anesth 2022; 36:4460-4482. [PMID: 36241503 DOI: 10.1053/j.jvca.2022.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/27/2022] [Accepted: 08/22/2022] [Indexed: 11/11/2022]
Abstract
Acute kidney injury (AKI) is one of the most common major complications of cardiac surgery, and is associated with increased morbidity and mortality. Cardiac surgery-associated AKI has a complex, multifactorial etiology, including numerous factors such as primary cardiac dysfunction, hemodynamic derangements of cardiac surgery and cardiopulmonary bypass, and the possibility of a large volume of blood transfusion. There are no truly effective pharmacologic therapies for the management of AKI, and, therefore, anesthesiologists, intensivists, and cardiac surgeons must remain vigilant and attempt to minimize the risk of developing renal dysfunction. This narrative review describes the current state of the scientific literature concerning the specific aspects of cardiac surgery-associated AKI, and presents it in a chronological fashion to aid the perioperative clinician in their approach to this high-risk patient group. The evidence was considered for risk prediction models, preoperative optimization, and the intraoperative and postoperative management of cardiac surgery patients to improve renal outcomes.
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Affiliation(s)
- Benjamin Milne
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research Academic Clinical Fellow, King's College London, London, United Kingdom
| | - Tom Gilbey
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research Academic Clinical Fellow, King's College London, London, United Kingdom
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular Medicine and Metabolic Medicine and Sciences, King's College London, British Heart Foundation Centre of Excellence, Faculty of Life Sciences and Medicine, London, United Kingdom.
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Kandil OA, Motawea KR, Darling E, Riley JB, Shah J, Elashhat MAM, Searles B, Aiash H. Ultrafiltration and cardiopulmonary bypass associated acute kidney injury: A systematic review and meta-analysis. Clin Cardiol 2021; 44:1700-1708. [PMID: 34837387 PMCID: PMC8715396 DOI: 10.1002/clc.23750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/05/2021] [Accepted: 11/09/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Cardiopulmonary bypass is known to raise the risk of acute kidney injury (AKI). Previous studies have identified numerous risk factors of cardiopulmonary bypass including the possible impact of perioperative ultrafiltration. However, the association between ultrafiltration (UF) and AKI remains conflicting. Thus, we conducted a meta-analysis to further examine the relationship between UF and AKI. HYPOTHESIS Ultrafiltration during cardiac surgery increases the risk of developping Acute kidney Injury. METHODS We searched PubMed, Web of Science, EBSCO, and SCOPUS through July 2021. The RevMan (version 5.4) software was used to calculate the pooled risk ratios (RRs) and mean differences along with their associated confidence intervals (95% CI). RESULTS We identified 12 studies with a total of 8005 patients. There was no statistically significant difference in the incidence of AKI between the group who underwent UF and the control group who did not (RR = 0.90, 95% CI = 0.64-1). Subgroup analysis on patients with previous renal insufficiency also yielded nonsignificant difference (RR = 0.84, 95% CI = 0.53 -1.33, p = .47). Subgroup analysis based on volume of ultrafiltrate removed (> or <2900 ml) was not significant and did not increase the AKI risk as predicted (RR = 0.82, 95% CI = 0.63 -1.07, p = .15). We also did subgroup analysis according to the type of UF and again no significant difference in AKI incidence between UF groups and controls was observed in either the conventional ultrafiltration (CUF), modified ultrafiltration (MUF), zero-balanced ultrafiltration (ZBUF), or combined MUF and CUF subgroups. CONCLUSION UF in cardiac surgery is not associated with increased AKI incidence and may be safely used even in baseline chronic injury patients.
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Affiliation(s)
- Omneya A Kandil
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Karam R Motawea
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Edward Darling
- Department of Cardiovascular Perfusion, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Jeffrey B Riley
- Department of Cardiovascular Perfusion, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Jaffer Shah
- Medical Research Center, Kateb University, Kabul, Afghanistan
| | | | - Bruce Searles
- Department of Cardiovascular Perfusion, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Hani Aiash
- Department of Cardiovascular Perfusion, State University of New York Upstate Medical University, Syracuse, New York, USA.,Department of Family Medicine, Faculty of Medicine, Suez Canal University, Ismailia, Egypt.,Department of Surgery, State University of New York Upstate Medical University, Syracuse, New York, USA
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Assessment and Prognosis in CSA-AKI Using Novel Kidney Injury Biomarkers: A Prospective Observational Study. BIOLOGY 2021; 10:biology10090823. [PMID: 34571700 PMCID: PMC8470477 DOI: 10.3390/biology10090823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is a need for early diagnostic solutions for cardiac surgery associated acute kidney injury (CSA-AKI) as serum creatinine changes do not occur dynamically enough. Moreover, new approaches are needed for kidney protective strategy in patients undergoing cardiac surgery procedures; Methods: Samples of serum and urine were taken from the selected group of patients undergoing elective cardiac surgery procedures. The aim of this study was to assess the utility of specific inflammation and kidney injury biomarkers in the early diagnostic of CSA-AKI and in the prognosis of long-term postoperative kidney function; Results: At 6 h after weaning from cardiopulmonary bypass, there were significant differences in IL-6, IL-8, TNF-α, MMP-9 and NGAL concentrations in patients with CSA-AKI, compared to the control group. Serum IL-8 and urine NGAL 6 h after weaning from CPB proved to be independent acute kidney injury predictors. The TNF-α, MMP-9, IL-18, TIMP-1 and MMP-9/TIMP-1 ratio in the early postoperative period correlated with long-term kidney function impairment; Conclusions: Novel kidney injury biomarkers are an eligible tool for early diagnosis of CSA-AKI. They are also reliable indicators of long-term postoperative kidney function impairment risk after cardiac surgery procedures.
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Prophylactic dialysis improves short-term clinical outcome in patients with non-dialysis-dependent chronic kidney disease undergoing cardiac surgery: a meta-analysis of randomized controlled trials. Coron Artery Dis 2021; 31:e73-e79. [PMID: 34115642 PMCID: PMC8638820 DOI: 10.1097/mca.0000000000001080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Several studies have reported that prophylactic dialysis can reduce the mortality of non-dialysis-dependent chronic kidney disease (CKD) patients after cardiac surgery. However, the results of complications in these randomized controlled trials (RCTs) were not consistent. We aimed to perform a meta-analysis to systematically evaluate the effect of prophylactic dialysis in these non-dialysis-dependent CKD patients. Methods We systematically searched Medline, Embase, Cochrane’s Library and other online sources for related RCTs. Effects of prophylactic dialysis on the incidence of 30 days’ mortality and postoperative complications were analyzed. Results Four RCTs comprising 395 patients were included, all of them treated by coronary artery bypass grafting. Treatment of preoperative and intraoperative prophylactic dialysis significantly reduced the rate of 30-day all-cause mortality (risk ratio [RR]: 0.27, 95% confidence interval [CI], 0.13–0.58, P < 0.001, I2 = 0%) and the incidence of pulmonary complications (RR: 0.39, 95% CI, 0.20–0.77, P = 0.007, I2 = 0%), low cardiac output (RR: 0.29, 95% CI, 0.09–0.99, P = 0.05, I2 = 0%), and acute kidney injury (RR: 0.19, 95% CI: 0.07–0.52, P = 0.001, I2 = 0%). However, there were no statistically significant differences between the dialysis group and the control group in gastrointestinal bleeding, sepsis or multiple organ failure, wound infection, arrhythmia, transient neurologic deficit, stroke and re-exploration for bleeding. Conclusion Prophylactic dialysis can improve the 30-day clinical outcomes of non-dialysis-dependent CKD patients undergoing cardiac surgery, it was associated with the 30-day mortality benefit and led to a decrease in the incidence of pulmonary complications, as well as low cardiac output, and acute kidney injury.
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Zero-Balance Ultrafiltration during Cardiopulmonary Bypass Is Associated with Decreased Urine Output. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2021; 53:27-37. [PMID: 33814603 DOI: 10.1182/ject-2000016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 01/06/2021] [Indexed: 11/20/2022]
Abstract
Zero-balance ultrafiltration (ZBUF) during cardiopulmonary bypass (CPB) has been purported to reduce pro-inflammatory mediators during cardiac surgery. However, its clinical benefit is equivocal and its effect on renal function unknown. The purpose of this study was to examine the effect of ZBUF on urine output in adult patients undergoing CPB. Following institutional review board approval, 98,953 records from a national registry of adult patients at 215 U.S. hospitals between January 2016 and September 2019 were reviewed. Groups were stratified according to ZBUF use. Anuric patients were excluded from the study as they were patients with missing data on urine output, ultrafiltration use, or ZBUF volume. The primary endpoint was intraoperative urine output normalized to body weight and procedure duration (total operative time). Final analysis of this endpoint was carried out using a linear mixed-effects regression model adjusting for patient and procedural characteristics, as well as practice patterns associated with surgeons and perfusionists. There was a significant 16.1% reduction in median urine output for ZBUF patients (.94 [.54, 1.47] mL/kg/h) vs. the non-ZBUF group (1.12 [.70,-1.73] mL/kg/h), p < .001. After statistically adjusting for patient and procedural characteristics, each liter of ZBUF volume was associated with an estimated change in intraoperative urine output of -.03 mL/kg/h (95% CI: [-.04 to -.02], p < .001). The median ZBUF volume was 1,550 [1,000, 2,600] mL, and when ZBUF was used, conventional ultrafiltration (CUF) was more likely to be used as well (88.4% vs. 44.8%, p < .001). ZBUF patients had median asanguineous volume and crystalloid cardioplegia nearly two times more than non-ZBUF patients, and had slightly higher red blood cell transfusions (17.6% vs. 16.3%, p < .05). The application of ZBUF during CPB was associated with patients having lower urine output and significantly higher use of CUF. Further research is required to determine if these results are reproducible in prospective clinical studies.
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Pajares MA, Margarit JA, García-Camacho C, García-Suarez J, Mateo E, Castaño M, López Forte C, López Menéndez J, Gómez M, Soto MJ, Veiras S, Martín E, Castaño B, López Palanca S, Gabaldón T, Acosta J, Fernández Cruz J, Fernández López AR, García M, Hernández Acuña C, Moreno J, Osseyran F, Vives M, Pradas C, Aguilar EM, Bel Mínguez AM, Bustamante-Munguira J, Gutiérrez E, Llorens R, Galán J, Blanco J, Vicente R. Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:183-231. [PMID: 33541733 DOI: 10.1016/j.redar.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 01/28/2023]
Abstract
The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.
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Affiliation(s)
- M A Pajares
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España.
| | - J A Margarit
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - C García-Camacho
- Unidad de Perfusión del Servicio de Cirugía Cardiaca, Hospital Universitario Puerta del Mar,, Cádiz, España
| | - J García-Suarez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro, Madrid, España
| | - E Mateo
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - M Castaño
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - C López Forte
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J López Menéndez
- Servicio de Cirugía Cardiaca, Hospital Ramón y Cajal, Madrid, España
| | - M Gómez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - M J Soto
- Unidad de Perfusión, Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - S Veiras
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
| | - E Martín
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - B Castaño
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario de Toledo, Toledo, España
| | - S López Palanca
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - T Gabaldón
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - J Acosta
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - J Fernández Cruz
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - A R Fernández López
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Virgen Macarena, Sevilla, España
| | - M García
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - C Hernández Acuña
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - J Moreno
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - F Osseyran
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - M Vives
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - C Pradas
- Servicio de Cirugía Cardiaca, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - E M Aguilar
- Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Madrid, España
| | - A M Bel Mínguez
- Servicio de Cirugía Cardiaca, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J Bustamante-Munguira
- Servicio de Cirugía Cardiaca, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - E Gutiérrez
- Servicio de Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - R Llorens
- Servicio de Cirugía Cardiovascular, Hospiten Rambla, Santa Cruz de Tenerife, España
| | - J Galán
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J Blanco
- Unidad de Perfusión, Servicio de Cirugía Cardiovascular, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - R Vicente
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
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12
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Thompson CP, Jagdale A, Walcott G, Iwase H, Foote JB, Cron RQ, Hara H, Cleveland DC, Cooper DKC. A perspective on the potential detrimental role of inflammation in pig orthotopic heart xenotransplantation. Xenotransplantation 2021; 28:e12687. [PMID: 33786912 DOI: 10.1111/xen.12687] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/26/2021] [Accepted: 03/18/2021] [Indexed: 02/06/2023]
Abstract
There is a critical shortage of deceased human donor organs for transplantation. The need is perhaps most acute in neonates and infants with life-threatening congenital heart disease, in whom mechanical support devices are largely unsuccessful. If orthotopic (life-supporting) heart transplantation (OHTx) were consistently successful in the genetically engineered pig-to-nonhuman primate (NHP) model, a clinical trial of bridging with a pig heart in such patients might be justified. However, the results of pig OHTx in NHPs have been mixed and largely poor. We hypothesise that a factor is the detrimental effects of the inflammatory response that is known to develop (a) during any surgical procedure that requires cardiopulmonary bypass, and (b) immediately after an NHP recipient is exposed to a pig xenograft. We suggest that the combination of these two inflammatory responses has a direct detrimental effect on pig heart graft function, but also, and possibly of more importance, on recipient baboon pulmonary function, which further impacts survival of the pig heart graft. In addition, the inflammatory response almost certainly adversely impacts the immune response to the graft. If our hypothesis is correct, the potential steps that could be taken to reduce the inflammatory response or its effects (with varying degrees of efficacy) include (a) white blood cell filtration, (b) complement depletion or inactivation, (c) immunosuppressive therapy, (d) high-dose corticosteroid therapy, (e) cytokine/chemokine-targeted therapy, (f) ultrafiltration or CytoSorb hemoperfusion, (g) reduction in the levels of endogenous catecholamines, (h) triiodothyronine therapy and (i) genetic engineering of the organ-source pig. Prevention of the inflammatory response, or attenuation of its effects, by judicious anti-inflammatory therapy may contribute not only to early survival of the recipient of a genetically engineered pig OHTx, but also to improved long-term pig heart graft survival. This would open the possibility of initiating a clinical trial of genetically engineered pig OHTx as a bridge to allotransplantation.
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Affiliation(s)
- Charles P Thompson
- Xenotransplantation Program, Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Abhijit Jagdale
- Xenotransplantation Program, Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gregory Walcott
- Department of Medicine/Cardiovascular Diseases, the University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hayato Iwase
- Xenotransplantation Program, Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeremy B Foote
- Department of Microbiology and Animal Resources Program, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Randall Q Cron
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hidetaka Hara
- Xenotransplantation Program, Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David C Cleveland
- Division of Cardiothoracic Surgery, Children's Hospital of Alabama, and Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David K C Cooper
- Xenotransplantation Program, Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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13
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Margarit JA, Pajares MA, García-Camacho C, Castaño-Ruiz M, Gómez M, García-Suárez J, Soto-Viudez MJ, López-Menéndez J, Martín-Gutiérrez E, Blanco-Morillo J, Mateo E, Hernández-Acuña C, Vives M, Llorens R, Fernández-Cruz J, Acosta J, Pradas-Irún C, García M, Aguilar-Blanco EM, Castaño B, López S, Bel A, Gabaldón T, Fernández-López AR, Gutiérrez-Carretero E, López-Forte C, Moreno J, Galán J, Osseyran F, Bustamante-Munguira J, Veiras S, Vicente R. Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP). CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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14
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García-Camacho C, Marín-Paz AJ, Lagares-Franco C, Abellán-Hervás MJ, Sáinz-Otero AM. Continuous ultrafiltration during extracorporeal circulation and its effect on lactatemia: A randomized controlled trial. PLoS One 2020; 15:e0242411. [PMID: 33227001 PMCID: PMC7682870 DOI: 10.1371/journal.pone.0242411] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 10/30/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction Hyperlactatemia occurs during or after extracorporeal circulation in the form of lactic acidosis, increasing the risk of postoperative complications and the mortality rate. The aim of this study was to evaluate whether continuous high-volume hemofiltration with volume replacement through a polyethersulfone filter during the extracorporeal circulation procedure decreases postoperative lactatemia and its consequences. Materials and methods This was a randomized controlled trial. Patients were randomly divided into two groups of 32: with or without continuous high-volume hemofiltration through a polyethersulfone membrane. Five patients were excluded from each group during the study period. The sociodemographic characteristics, filter effects, and blood lactate levels at different times during the procedure were evaluated. Secondary endpoints were studied, such as the reduction in the intubation time and time spent in ICU. Results Lactatemia measurements performed during the preoperative and intraoperative phases were not significantly different between the two groups. However, the blood lactate levels in the postoperative period and at 24 hours in the intensive care unit showed a significant reduction and a possible clinical benefit in the hemofiltered group. Following extracorporeal circulation, the mean lactate level was higher (difference: 0.77 mmol/L; CI 0.95: 0.01–1.53) in the nonhemofiltered group than in the hemofiltered group (p<0.05). This effect was greater at 24 hours (p = 0.019) in the nonhemofiltered group (difference: 1.06 mmol/L; CI 0.95: 0.18–1.93) than in the hemofiltered group. The reduction of lactatemia is associated with a reduction of inflammatory mediators and intubation time, with an improvement in liver function. Conclusions The use and control of continuous high-volume hemofiltration through a polyethersulfone membrane during heart-lung surgery could potencially prevent postoperative complications. The reduction of lactatemia implied a reduction in intubation time, a decrease in morbidity and mortality in the intensive care unit and a shorter hospital stay.
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Affiliation(s)
- Carlos García-Camacho
- Cardiovascular Surgery Unit, Puerta del Mar University Hospital, Andalusian Health Service, Cadiz, Andalusia, Spain
| | - Antonio-Jesús Marín-Paz
- Nursing and Physiotherapy Department, Faculty of Nursing, University of Cadiz, Algeciras, Spain
- * E-mail:
| | - Carolina Lagares-Franco
- Department of Statistics and Operative Research, University of Cadiz, Cadiz, Andalusia, Spain
| | - María-José Abellán-Hervás
- Nursing and Physiotherapy Department, Faculty of Nursing and Physiotherapy, University of Cadiz, Cadiz, Spain
| | - Ana-María Sáinz-Otero
- Nursing and Physiotherapy Department, Faculty of Nursing and Physiotherapy, University of Cadiz, Cadiz, Spain
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15
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Rosenbaum AN, Ternus BW, Pahwa S, Stulak JM, Clavell AL, Schettle SD, Behfar A, Jentzer JC. Risk of Liver Dysfunction After Left Ventricular Assist Device Implantation. Ann Thorac Surg 2020; 111:1961-1967. [PMID: 33058819 DOI: 10.1016/j.athoracsur.2020.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/21/2020] [Accepted: 08/05/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Incident liver dysfunction after left ventricular assist device implantation has been previously associated with adverse outcomes, yet data on perioperative risk markers are sparse. METHODS We retrospectively reviewed consecutive patients undergoing continuous-flow left ventricular assist device implant between 2007 and 2017 at a single institution. Perioperative variables were evaluated by univariate modeling and adjusted for false discovery rate. Variables most significantly associated with incident Interagency Registry for Mechanically Assisted Circulatory Support-defined liver dysfunction (INT-LD) were evaluated using logistic regression and optimal cutpoints were defined. One-year survival was evaluated using Kaplan-Meier analysis. RESULTS We included 359 patients (79% male; mean age 59 ± 13 years; 46% ischemic; 64% destination therapy). Lower right ventricular stroke work index at the time of right heart catheterization, higher right atrial pressure 6 hours after right heart catheterization, higher preoperative total bilirubin, longer cardiopulmonary bypass time, and greater volume of intraoperative ultrafiltration were most strongly associated with incident INT-LD (adjusted P < .01 for each). Initial right ventricular stroke work index less than 460 mm Hg∗mL/m2 (odds ratio [OR] 4.6; 95% confidence interval [CI], 2.3 to 9.4), 6-hour right heart catheterization 14 mm Hg or greater (OR 4.3; 95% CI, 2.1 to 8.8), cardiopulmonary bypass time longer than 137 minutes (OR 3.3; 95% CI, 1.8 to 6.2; P < .01 for all), ultrafiltration more than 2.95 L (OR 3.7; 95% CI, 2 to 6.8), and total bilirubin greater than 1.4 mg/dL (OR 2.7; 95% CI, 1.4 to 5) were each strongly associated with risk of INT-LD, which was associated with decreased unadjusted 1-year survival (P < .001). CONCLUSIONS Right ventricular stroke work index, right heart catheterization, cardiopulmonary bypass time, and ultrafiltration were each more strongly associated with elevated risk of INT-LD after left ventricular assist device implant than total bilirubin. Therefore, optimization of right ventricular hemodynamics and minimizing cardiopulmonary bypass time and ultrafiltration could potentially reduce the risk of liver dysfunction, but these observations require prospective validation.
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Affiliation(s)
- Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin, Madison, Wisconsin.
| | - Bradley W Ternus
- Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin, Madison, Wisconsin
| | - Siddharth Pahwa
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Alfredo L Clavell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | - Sarah D Schettle
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota; VanCleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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16
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Tidbury N, Browning N, Shaw M, Morgan M, Kemp I, Matata B. Neutrophil Gelatinase-associated Lipocalin as a Marker of Postoperative Acute Kidney Injury Following Cardiac Surgery in Patients with Preoperative Kidney Impairment. Cardiovasc Hematol Disord Drug Targets 2020; 19:239-248. [PMID: 30987577 DOI: 10.2174/1871529x19666190415115106] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 03/08/2019] [Accepted: 03/22/2019] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Acute kidney injury (AKI) is a serious complication of cardiac surgery. The current 'gold standard' for determining AKI is change in serum creatinine and urine output, however, this change occurs relatively late after the actual injury occurs. Identification of new biomarkers that detect early AKI is required. Recently, new biomarkers, such as the NephroCheck® Test and AKIRisk have also been tested and found to be good indicators of AKI. Neutrophil gelatinase-associated lipocalin (NGAL) has shown promise in paediatric patients but has displayed varied results in adult populations, particularly post cardiac surgery. The aim of this study was to assess the value of urinary NGAL as a biomarker of AKI in patients with pre-existing renal impairment (eGFR >15ml/min to eGFR<60ml/min). METHODS A post-hoc analysis of urinary NGAL concentrations from 125 patients with pre-existing kidney impairment, who participated in a randomised trial of haemofiltration during cardiac surgery, was undertaken. Urinary NGAL was measured using ELISA at baseline, post-operatively and 24 and 48 hours after surgery, and serum creatinine was measured pre and postoperatively and then at 24, 48, 72 and 96 hours as routine patient care. NGAL concentrations were compared in patients with and without AKI determined by changes in serum creatinine concentrations. A Kaplan-Meier plot compared survival for patients with or without AKI and a Cox proportional hazards analysis was performed to identify factors with the greatest influence on survival. RESULTS Following surgery, 43% of patients developed AKI (based on KDIGO definition). Baseline urinary NGAL was not found to be significantly different between patients that did and did not develop AKI. Urinary NGAL concentration was increased in all patients following surgery, regardless of whether they developed AKI and was also significant between groups at 24 (p=0.003) and 48 hours (p<0.0001). Urinary NGAL concentrations at 48 hours correlated with serum creatinine concentrations at 48 hours (r=0.477, p<0.0001), 72 hours (r=0.488, p<0.0001) and 96 hours (r=0.463, p<0.0001). Urinary NGAL at 48 hours after surgery strongly predicted AKI (AUC=0.76; P=0.0001). A Kaplan- Meier plot showed that patients with postoperative AKI had a significantly lower 7-year survival compared with those without AKI. Postoperative urinary NGAL at 48 hours >156ng/mL also strongly predicted 7-year survival. However, additive EuroSCORE, age, current smoking and post-operative antibiotics usage were distinctly significantly more predictive of 7-year survival as compared with postoperative urinary NGAL at 48 hours >156ng/mL. CONCLUSIONS Our study demonstrated that postoperative urinary NGAL levels at 48 hours postsurgery strongly predicts the onset or severity of postoperative AKI based on KDIGO classification in patients with preoperative kidney impairment and were also strongly related to 7-year survival.
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Affiliation(s)
- N Tidbury
- Liverpool Heart & Chest Hospital NHS Foundation Trust, University of Liverpool, Liverpool L14 3PE, United Kingdom
| | - N Browning
- Liverpool Heart & Chest Hospital NHS Foundation Trust, University of Liverpool, Liverpool L14 3PE, United Kingdom
| | - M Shaw
- Liverpool Heart & Chest Hospital NHS Foundation Trust, University of Liverpool, Liverpool L14 3PE, United Kingdom
| | - M Morgan
- Liverpool Heart & Chest Hospital NHS Foundation Trust, University of Liverpool, Liverpool L14 3PE, United Kingdom
| | - I Kemp
- Liverpool Heart & Chest Hospital NHS Foundation Trust, University of Liverpool, Liverpool L14 3PE, United Kingdom
| | - B Matata
- Liverpool Heart & Chest Hospital NHS Foundation Trust, University of Liverpool, Liverpool L14 3PE, United Kingdom.,Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool L14 3PE, United Kingdom
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Pan S, Chen Y, Zhang X, Xie Y. The JAK2/STAT3 pathway is involved in dexmedetomidine-induced myocardial protection in rats undergoing cardiopulmonary bypass. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:483. [PMID: 32395527 PMCID: PMC7210156 DOI: 10.21037/atm.2020.03.67] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Many studies have reported that dexmedetomidine protects organs from ischemia/reperfusion-induced injury. However, the mechanism of this protective effect remains inconclusive. Methods Rats were randomly divided into 6 groups (n=8). Rats in the sham group were not subjected to cardiopulmonary bypass (CPB) while rats in the other groups underwent CPB for 2 h. Groups L and H received a low and a high dose of dexmedetomidine, respectively. Rats in group AG490 received 10 mg/kg of the Janus kinase 2 (JAK2) inhibitor, AG490, 30 min before anesthesia. Plasma levels of the inflammatory cytokines, interleukin (IL)-6 and IL-10, were measured by enzyme-linked immunosorbent (ELISA), and the apoptosis rate of myocardial cells, the expression of JAK2 and signal transducer and activator of transcription (STAT)3 mRNA, and the protein expression of JAK2, STAT3, pJAK2, pSTAT3, and caspase-3 were analyzed in myocardial tissues by real-time quantitative polymerase chain reaction (qRT-PCR), western blotting, and immunohistochemistry. Results We observed that, in both group L and group H, the level of IL-6 decreased (P<0.05), and the apoptosis rate of myocardial cells were reduced (P<0.05) compared to those in the CPB group. Moreover, qRT-PCR results revealed that dexmedetomidine administration reduced the expression of JAK2 and STAT3 mRNA (P<0.05); pJAK2 and pSTAT3 (P<0.05) protein levels were also reduced as assessed by western blotting and immunohistochemistry (P<0.05). Conclusions Dexmedetomidine treatment reduced CPB-related myocardial injury by inhibiting inflammatory reactions and myocardial apoptosis, and can be a potential therapy in CPB-related surgery.
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Affiliation(s)
- Sining Pan
- Department of Anesthesiology, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - Yanhua Chen
- Department of Anesthesiology of Cardiovascular Institute, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - Xu Zhang
- Department of Anesthesiology, the Second Affiliated Hospital of Guilin Medical University, Guilin 541199, China
| | - Yubo Xie
- Department of Anesthesiology, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
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18
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Gholampour Dehaki M, Niknam S, Bakhshandeh H, Azarfarin R. Zero‐balance ultrafiltration of the priming blood modifies the priming components and improves the clinical outcome in infants undergoing cardiopulmonary bypass: A randomized controlled trial. Artif Organs 2019; 44:288-295. [DOI: 10.1111/aor.13559] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 07/09/2019] [Accepted: 08/13/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Maziar Gholampour Dehaki
- Department of Pediatric Cardiac Surgery Rajaei Cardiovascular Medical and Research Center Tehran Iran
| | - Sana Niknam
- Department of Clinical Research Development Unit of Besat Hospital Hamadan University of Medical Sciences Medical School Hamadan Iran
| | - Hooman Bakhshandeh
- Department of Epidemiology and Biostatistics Rajaei Cardiovascular Medical and Research Center Tehran Iran
| | - Rasoul Azarfarin
- Department of Cardiac Anesthesia Rajaei Cardiovascular Medical and Research Center Tehran Iran
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19
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Vives M, Hernandez A, Parramon F, Estanyol N, Pardina B, Muñoz A, Alvarez P, Hernandez C. Acute kidney injury after cardiac surgery: prevalence, impact and management challenges. Int J Nephrol Renovasc Dis 2019; 12:153-166. [PMID: 31303781 PMCID: PMC6612286 DOI: 10.2147/ijnrd.s167477] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 05/29/2019] [Indexed: 12/14/2022] Open
Abstract
Acute kidney injury (AKI) is a major medical problem that is of particular concern after cardiac surgery. Perioperative AKI is independently associated with an increase in short-term morbidity, costs of treatment, and long-term mortality. In this review, we explore the definition of cardiac surgery-associated acute kidney injury (CSA-AKI) and identify diverse mechanisms and risk factors contributing to the renal insult. Current theories of the pathophysiology of CSA-AKI and description of its clinical course will be addressed in this review. Data on the most promising renal protective strategies in cardiac surgery, from well-designed studies, will be scrutinized. Furthermore, diagnostic tools such as novel biomarkers of AKI and their potential utility will be discussed.
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Affiliation(s)
- M Vives
- Department of Anesthesiology & Critical Care, Clinical Research Lead, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Institut d´Investigació Biomédica de Girona (IDIBGI), Girona, Spain
| | - A Hernandez
- Department of Anesthesia & Critical Care, Grupo Policlinica, Ibiza, Spain
| | - F Parramon
- Department of Anesthesiology & Critical Care Chief, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Girona, Spain
| | - N Estanyol
- Department of Anesthesiology & Critical Care Chief, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Girona, Spain
| | - B Pardina
- Department of Anesthesiology & Critical Care Chief, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Girona, Spain
| | - A Muñoz
- Department of Anesthesiology & Critical Care Chief, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Girona, Spain
| | - P Alvarez
- Department of Cardiac Surgery, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Girona, Spain
| | - C Hernandez
- Department of Anesthesiology & Critical Care Chief, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Girona, Spain
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20
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Mongero LB, Tesdahl EA, Stammers A, Weinstein S. The influence of ultrafiltration on red blood cell transfusion during cardiopulmonary bypass. Perfusion 2018; 34:303-309. [DOI: 10.1177/0267659118821026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Ultrafiltration during cardiopulmonary bypass (CPB) reduces fluid overload and inflammatory mediators in open-heart surgery and is thought to reduce the risk of red blood cell (RBC) transfusion. We evaluated its effectiveness in reducing RBC transfusions in a large population undergoing cardiac surgery, among patients in general as well as by gender. Methods: We analyzed 40,650 propensity-matched adult cardiac surgery cases conducted over a 61-month period at 195 hospitals. We assessed the risk of intraoperative transfusion (⩾1 unit RBC) according to body surface area (BSA)-normalized ultrafiltration volume via mixed-effects binary logistic regression. Our statistical model controlled for 12 demographic and operative variables as well as for center level tendencies in ultrafiltration use and intraoperative RBC transfusion. In light of recent findings on gender and risk of transfusion, we also included an interaction effect between gender and ultrafiltration volume (UV). Results: Ultrafiltration was associated with an increased crude rate of RBC transfusion (32.1% vs. 28.1%, p<0.001), but equivalent crude median hematocrit change from first in operating room to nadir on bypass (−11% in both groups, p = 0.133). After controlling for patient, operative and site-level characteristics, we found no statistically significant effect on transfusion rate by volume of ultrafiltrate removed nor did we find statistical support for any gender-specific effect of ultrafiltration. Conclusions: Ultrafiltration is not associated with a reduction of risk of RBC transfusion during cardiac surgery. The use of ultrafiltration as a method for reducing intraoperative RBC transfusion warrants further study.
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21
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Leow EH, Chan YH, Ng YH, Lim JKB, Nakao M, Lee JH. Prevention of Acute Kidney Injury in Children Undergoing Cardiac Surgery: A Narrative Review. World J Pediatr Congenit Heart Surg 2018; 9:79-90. [PMID: 29310552 DOI: 10.1177/2150135117743211] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Children undergoing cardiac surgery are at risk of developing acute kidney injury (AKI). Preventing cardiac surgery-associated AKI (CS-AKI) is important as it is associated with increased early- and long-term mortality and morbidity. Targeting modifiable risk factors (eg, avoiding poor renal perfusion, nephrotoxic drugs, and fluid overload) reduces the risk of CS-AKI. There is currently no strong evidence for the routine use of pharmacological approaches (eg, aminophylline, dexmedetomidine, fenoldopam, and steroids) to prevent CS-AKI. There is robust evidence to support the role of early peritoneal dialysis as a nonpharmacologic approach to prevent CS-AKI.
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Affiliation(s)
- Esther Huimin Leow
- 1 Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yoke Hwee Chan
- 2 Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore.,3 Duke-NUS School of Medicine, Singapore, Singapore
| | - Yong Hong Ng
- 1 Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Joel Kian Boon Lim
- 1 Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Masakazu Nakao
- 4 Department of Paediatric Cardiothoracic Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jan Hau Lee
- 2 Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore.,3 Duke-NUS School of Medicine, Singapore, Singapore
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22
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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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23
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Chen Y, Zhang X, Zhang B, He G, Zhou L, Xie Y. Dexmedetomidine reduces the neuronal apoptosis related to cardiopulmonary bypass by inhibiting activation of the JAK2-STAT3 pathway. Drug Des Devel Ther 2017; 11:2787-2799. [PMID: 29033541 PMCID: PMC5628699 DOI: 10.2147/dddt.s140644] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Cardiopulmonary bypass (CPB) constitutes one of the primary methodologies pertaining to cardiac surgery. However, this form of surgery can cause damage to the body. Many studies have reported that dexmedetomidine confers cerebral protection. In this study, we aimed to investigate the effect and mechanism of dexmedetomidine on neuronal apoptosis caused by CPB. Here, rats were treated with different doses of dexmedetomidine by intravenous infusion 2 hours after CPB. We observed that dexmedetomidine treatment to rats reduces the S100β, NSE levels in plasma, and neuronal apoptosis following CPB in a dose-dependent manner. Furthermore, we observed that the beneficial effect of dexmedetomidine treatment following CPB was associated with a reduction in IL6, an inflammatory cytokine in plasma and cortex. Our results suggest that dexmedetomidine provides neuroprotective effects by inhibiting inflammation and reducing neuronal apoptosis. There was a correlation between the protective effect on the brain and the dose of dexmedetomidine. In addition, dexmedetomidine administration inhibits phosphorylation of JAK2 and STAT3 proteins in the hippocampus of rats 2 hours after CPB. Therefore, we speculate that the JAK2–STAT3 pathway plays an important role in the neuroprotective effects of dexmedetomidine following brain injury induced by CPB.
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Affiliation(s)
- Yanhua Chen
- Department of Anesthesiology, Cardiovascular Institute
| | - Xu Zhang
- Department of Anesthesiology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | | | - Guodong He
- Department of Anesthesiology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lifang Zhou
- Department of Anesthesiology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yubo Xie
- Department of Anesthesiology, the First Affiliated Hospital of Guangxi Medical University, Nanning, China
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24
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To beat acute kidney injury, you need to keep your eye on the goal. J Thorac Cardiovasc Surg 2017; 153:126-127. [DOI: 10.1016/j.jtcvs.2016.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 09/16/2016] [Indexed: 11/18/2022]
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25
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A pilot goal-directed perfusion initiative is associated with less acute kidney injury after cardiac surgery. J Thorac Cardiovasc Surg 2016; 153:118-125.e1. [PMID: 27832832 DOI: 10.1016/j.jtcvs.2016.09.016] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 09/03/2016] [Accepted: 09/07/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND We sought to determine whether a pilot goal-directed perfusion initiative could reduce the incidence of acute kidney injury after cardiac surgery. METHODS On the basis of the available literature, we identified goals to achieve during cardiopulmonary bypass (including maintenance of oxygen delivery >300 mL O2/min/m2 and reduction in vasopressor use) that were combined into a goal-directed perfusion initiative and implemented as a quality improvement measure in patients undergoing cardiac surgery at Johns Hopkins during 2015. Goal-directed perfusion initiative patients were matched to controls who underwent cardiac surgery between 2010 and 2015 using propensity scoring across 15 variables. The primary and secondary outcomes were the incidence of acute kidney injury and the mean increase in serum creatinine within the first 72 hours after cardiac surgery. RESULTS We used the goal-directed perfusion initiative in 88 patients and matched these to 88 control patients who were similar across all variables, including mean age (61 years in controls vs 64 years in goal-directed perfusion initiative patients, P = .12) and preoperative glomerular filtration rate (90 vs 83 mL/min, P = .34). Controls received more phenylephrine on cardiopulmonary bypass (mean 2.1 vs 1.4 mg, P < .001) and had lower nadir oxygen delivery (mean 241 vs 301 mL O2/min/m2, P < .001). Acute kidney injury incidence was 23.9% in controls and 9.1% in goal-directed perfusion initiative patients (P = .008); incidences of acute kidney injury stage 1, 2, and 3 were 19.3%, 3.4%, and 1.1% in controls, and 5.7%, 3.4%, and 0% in goal-directed perfusion initiative patients, respectively. Control patients exhibited a larger median percent increase in creatinine from baseline (27% vs 10%, P < .001). CONCLUSIONS The goal-directed perfusion initiative was associated with reduced acute kidney injury incidence after cardiac surgery in this pilot study.
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