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Mede AI, Milne GL, Wei D, Smith DK, Smith LE. NAD+ Biosynthesis Impairment and Acute Kidney Injury after Major Vascular Surgery. Antioxidants (Basel) 2023; 12:821. [PMID: 37107195 PMCID: PMC10135380 DOI: 10.3390/antiox12040821] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
Acute kidney injury (AKI) is a serious complication after vascular surgery. Reduced synthesis of nicotinamide adenine dinucleotide (NAD+) from tryptophan is associated with an increased risk of AKI in critically ill patients, patients hospitalized with COVID-19, and cardiac surgery patients, and is marked by elevated urinary quinolinate and quinolinate to tryptophan ratios. We measured quinolinate concentrations in vascular surgery patients to determine if impaired NAD+ synthesis was associated with AKI in this patient population. Eight preoperative and eight postoperative vascular surgery patients who developed AKI were selected from a parent study to participate in this single-center case-control study. They were matched with controls who did not develop AKI based on age, sex, BMI, eGFR, hypertension, and diabetes. Urinary quinolinate and tryptophan concentrations were measured at anesthetic induction and on postoperative day one. Two-sided Mann-Whitney U tests were used to compare quinolinate and quinolinate to tryptophan ratios. Multivariate linear regression modeling was used to estimate the relationship between quinolinate and serum creatinine. There was no difference in preoperative or postoperative urine quinolinate concentrations or the preoperative quinolinate to tryptophan ratio between patients that did and did not develop AKI (p = 0.07, 0.50, and 0.32, respectively). However, postoperative quinolinate to tryptophan ratios were higher in AKI patients (p = 0.04). Further, after adjustment for AKI risk factors, higher preoperative quinolinate concentrations and higher postoperative quinolinate to tryptophan ratios were associated with greater postoperative creatinine increases (p = 0.04 and 0.04, respectively). These data suggest that impaired NAD+ synthesis may contribute to AKI development in vascular surgery patients.
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Affiliation(s)
- Annmarie I. Mede
- Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Ginger L. Milne
- Departments of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Departments of Pharmacology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Dawei Wei
- Departments of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Derek K. Smith
- Departments of Biostatistics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Loren E. Smith
- Departments of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
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Argalious MY, Makarova N, Leone A, Cywinski J, Farag E. Association of Body Mass Index and Postoperative Acute Kidney Injury in Patients Undergoing Laparoscopic Surgery. Ochsner J 2017; 17:224-232. [PMID: 29026353 PMCID: PMC5625979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Whether the deleterious effects of carbon dioxide pneumoperitoneum on the kidneys are exacerbated in the obese population remains unknown. We hypothesized that increased body mass index (BMI) is associated with an increased incidence of postoperative acute kidney injury (AKI) in patients undergoing noncardiac laparoscopic surgery. METHODS Following institutional review board approval, we analyzed data on 8,543 adult patients with American Society of Anesthesiologists physical status scores of I-IV who had inpatient noncardiac laparoscopic surgery from 2005-2014. Because the exposure (current BMI) is a chronic condition, we a priori assumed that diabetes mellitus, hypertension, coronary artery disease, and chronic obstructive pulmonary disease might mediate the effect of obesity on outcome. Our primary analysis was a proportional odds logistic regression model with current BMI as a predictor and AKI as an ordinal outcome. RESULTS After controlling for potential confounding variables, the odds of developing a more serious level of AKI was 7% (95% CI 0%, 15%) greater with a 5-unit increase in BMI (P=0.05). When the analysis was adjusted for the a priori mediators in an attempt to estimate the pure effect of BMI on AKI, the result was no longer significant (Wald test P=0.35), with the residual effect of BMI of 3% (95% CI -4%, 11%). CONCLUSION We found a marginal association between BMI and an increased risk of developing AKI in adult patients after having noncardiac laparoscopic surgery. The BMI effect became insignificant when potential mediator variables were considered. The association of BMI and AKI after noncardiac laparoscopic surgery is likely mediated through components of the metabolic syndrome.
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Affiliation(s)
| | - Natalya Makarova
- Department of Quantitative Health Science, Cleveland Clinic, Cleveland, OH
| | - Alexander Leone
- Department of General Anesthesia, Cleveland Clinic, Cleveland, OH
| | - Jacek Cywinski
- Department of General Anesthesia, Cleveland Clinic, Cleveland, OH
| | - Ehab Farag
- Department of General Anesthesia, Cleveland Clinic, Cleveland, OH
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Nathan DP, Tang GL. The impact of chronic renal insufficiency on vascular surgery patient outcomes. Semin Vasc Surg 2015; 27:162-9. [PMID: 26073826 DOI: 10.1053/j.semvascsurg.2015.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Renal insufficiency is associated with an increased incidence of poor outcomes, including cardiovascular events and death, in the general population. Renal dysfunction appears to have a particularly negative impact in patients undergoing vascular surgery and endovascular therapy. Although the exact mechanism is unknown, increased levels of inflammatory and biochemical modulators associated with adverse cardiovascular outcomes, as well as endothelial dysfunction, appear to play a role in the association between renal insufficiency and adverse outcomes. Outcomes after the surgical and endovascular treatment of abdominal aortic aneurysms, carotid disease, and peripheral arterial disease are all negatively affected by renal insufficiency. Patients with renal dysfunction may warrant intervention for the treatment of critical limb ischemia and symptomatic carotid stenosis, given the comparatively worse outcomes associated with medical management. Open repair of aortic aneurysms and carotid intervention for asymptomatic disease in patients with severe renal dysfunction should be performed with significant caution, as the risks of repair may outweigh the benefits in this population. Further study is needed to better delineate the risks of medical management for these conditions in patients with coexisting severe renal dysfunction. Lastly, current guidelines for the management of vascular diseases, including objective performance goals for critical limb ischemia, are likely not applicable in patients with severe renal insufficiency.
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Affiliation(s)
- Derek P Nathan
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Gale L Tang
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA; VA Puget Sound Health Care System, Surgical Services 112, 1660 S. Columbian Way, Seattle, WA 98108.
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Leung KCW, Pannu N, Tan Z, Ghali WA, Knudtson ML, Hemmelgarn BR, Tonelli M, James MT. Contrast-associated AKI and use of cardiovascular medications after acute coronary syndrome. Clin J Am Soc Nephrol 2014; 9:1840-8. [PMID: 25318754 DOI: 10.2215/cjn.03460414] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES AKI after coronary angiography is associated with poor long-term outcomes. The relationship between contrast-associated AKI and subsequent use of prognosis-modifying cardiovascular medications is unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A cohort study of 5911 participants 66 years of age or older with acute coronary syndrome who received a coronary angiogram in Alberta, Canada was performed between November 1, 2002, and November 30, 2008. AKI was identified according to Kidney Disease Improving Global Outcomes AKI criteria. RESULTS In multivariable logistic regression models, compared with participants without AKI, those with stages 1 and 2-3 AKI had lower odds of subsequent use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker within 120 days of hospital discharge (adjusted odds ratio, 0.65; 95% confidence interval, 0.53 to 0.80 and odds ratio, 0.34; 95% confidence interval, 0.23 to 0.48, respectively). Subsequent statin and β-blockers use within 120 days of hospital discharge was significantly lower among those with stages 2-3 AKI (adjusted odds ratio, 0.44; 95% confidence interval, 0.31 to 0.64 and odds ratio, 0.46; 95% confidence interval, 0.31 to 0.66, respectively). These associations were consistently seen in patients with diabetes mellitus, heart failure, low baseline eGFR, and albuminuria; 952 participants died during subsequent follow-up after hospital discharge (mean=3.1 years). The use of each class of cardiovascular medication was associated with lower mortality, including among those who had experienced AKI. CONCLUSIONS Strategies to optimize the use of cardiac medications in people with AKI after coronary angiography might improve care.
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Affiliation(s)
| | - Neesh Pannu
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Zhi Tan
- Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; and
| | - William A Ghali
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; and
| | | | - Brenda R Hemmelgarn
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; and
| | | | - Matthew T James
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; and
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Argalious MY, Dalton JE, Sreenivasalu T, O'Hara J, Sessler DI. The association of preoperative statin use and acute kidney injury after noncardiac surgery. Anesth Analg 2013; 117:916-923. [PMID: 23354338 DOI: 10.1213/ane.0b013e31828175ab] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Our objective was to examine the association between preoperative statin therapy and the incidence of postoperative acute kidney injury (AKI) in patients undergoing elective noncardiac surgery. METHODS We analyzed the electronic records of 57,246 patients who had elective noncardiac surgery at the Cleveland Clinic Main Campus between December 2004 and March 2010. Patients were divided into 2 groups depending on preoperative therapy with statin drugs. Our primary outcome was AKI, defined as "risk," "injury," or "failure" using the RIFLE (Risk, Injury, Failure, Loss, and End-stage Kidney) criteria. Secondary outcomes included postoperative dialysis and all-cause hospital mortality. Each statin user was matched to a nonuser based on propensity scores. The propensity scores were estimated using a multivariable logistic regression model, incorporating all available baseline potential confounders. After the propensity-matching procedure, we performed final analyses for the primary and secondary outcomes. For the primary analysis, we used a univariable logistic regression model to estimate the odds ratio (OR) (and 95% confidence intervals) for AKI, postoperative dialysis, and hospital mortality between matched statin users and nonusers. RESULTS Of the total group, 23,745 records were unusable because of missing data. Among the remaining 28,508 patients analyzed, the overall incidence of AKI was 6.1%. Three hundred sixty-one of 4805 statin users (7.5%) and 1377 of 23,703 nonusers (5.8%) experienced AKI. The incidence of postoperative dialysis was 0.05%. Six statin users (0.12%) and 8 nonusers (0.03%) required dialysis postoperatively. The incidence of hospital mortality was 0.62%. Mortality was observed for 47 patients (1.0%) and 130 patients (0.5%), respectively. Among 4172 matched pairs, the incidence (95% confidence interval) of AKI was 7.1% (6.2%, 8.1%) in the matched statin users and 8.0% (7.1%, 9.0%) in the nonusers, corresponding to an OR of 0.88 (0.75, 1.03), which was not statistically significant (P = 0.12, χ(2) test). The secondary outcomes were also not significantly different in matched statin users and nonusers. Postoperative dialysis was required for 0.10% (0.02%, 0.33%) and 0.12% (0.04%, 0.37%) of patients in the respective groups (OR = 0.80 [0.16, 3.70]; P = 0.74). Hospital mortality occurred in 1.0% (0.7%, 1.5%) and 1.3% (0.9%, 1.8%) of patients, respectively (OR = 0.76 [0.47, 1.20]; P = 0.18). CONCLUSIONS Our data did not support the hypothesis that preoperative statin therapy in doses routinely used to treat hypercholesterolemia is associated with a change in the incidence of AKI, postoperative dialysis, or hospital mortality in patients undergoing noncardiac surgery.
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Affiliation(s)
- Maged Y Argalious
- From the Department of General Anesthesia, Anesthesiology Institute, and Departments of Quantitative Health Science and Outcomes Research, Cleveland Clinic, Cleveland, Ohio
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Lanaspa MA, Sanchez-Lozada LG, Choi YJ, Cicerchi C, Kanbay M, Roncal-Jimenez CA, Ishimoto T, Li N, Marek G, Duranay M, Schreiner G, Rodriguez-Iturbe B, Nakagawa T, Kang DH, Sautin YY, Johnson RJ. Uric acid induces hepatic steatosis by generation of mitochondrial oxidative stress: potential role in fructose-dependent and -independent fatty liver. J Biol Chem 2012; 287:40732-44. [PMID: 23035112 DOI: 10.1074/jbc.m112.399899] [Citation(s) in RCA: 494] [Impact Index Per Article: 41.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Uric acid is an independent risk factor in fructose-induced fatty liver, but whether it is a marker or a cause remains unknown. RESULTS Hepatocytes exposed to uric acid developed mitochondrial dysfunction and increased de novo lipogenesis, and its blockade prevented fructose-induced lipogenesis. CONCLUSION Rather than a consequence, uric acid induces fatty liver SIGNIFICANCE Hyperuricemic people are more prone to develop fructose-induced fatty liver. Metabolic syndrome represents a collection of abnormalities that includes fatty liver, and it currently affects one-third of the United States population and has become a major health concern worldwide. Fructose intake, primarily from added sugars in soft drinks, can induce fatty liver in animals and is epidemiologically associated with nonalcoholic fatty liver disease in humans. Fructose is considered lipogenic due to its ability to generate triglycerides as a direct consequence of the metabolism of the fructose molecule. Here, we show that fructose also stimulates triglyceride synthesis via a purine-degrading pathway that is triggered from the rapid phosphorylation of fructose by fructokinase. Generated AMP enters into the purine degradation pathway through the activation of AMP deaminase resulting in uric acid production and the generation of mitochondrial oxidants. Mitochondrial oxidative stress results in the inhibition of aconitase in the Krebs cycle, resulting in the accumulation of citrate and the stimulation of ATP citrate lyase and fatty-acid synthase leading to de novo lipogeneis. These studies provide new insights into the pathogenesis of hepatic fat accumulation under normal and diseased states.
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Affiliation(s)
- Miguel A Lanaspa
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado, Denver, CO 80045, USA.
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