Acute kidney injury in patients operated on for type A acute aortic dissection: incidence, risk factors and short-term outcomes

Prediction of acute kidney injury incidence following acute type A aortic dissection surgery with novel biomarkers: a prospective observational study

BACKGROUND

Acute kidney injury (AKI) is a prevalent complication following acute type A aortic dissection (ATAAD) surgery and is closely associated with unfavorable prognostic outcomes. Hence, the development of a robust and efficient diagnostic approach to identify high-risk patients is of paramount importance.

METHODS

We conducted a prospective study involving 328 patients who underwent ATAAD surgery at our institution, comprising three distinct cohorts. In addition, 52 patients undergoing alternative cardiopulmonary surgeries and 37 healthy individuals were enrolled as control groups. Employing proteomic analysis, we initially identified plasma proteins potentially linked to AKI occurrence within the plasma proteomic cohort. Subsequent validation was performed in an independent cohort. Utilizing predictors derived from multivariate logistic regression analysis, a nomogram was meticulously formulated and its efficacy was validated in the model construction cohort.

RESULTS

Proteomics revealed significant elevation of plasma levels of S100A8/A9, pentraxin 3 (PTX3), and chitinase 3-like 1 (CHI3L1) immediately post-surgery in patients who developed ATAAD surgery-associated AKI (ASA-AKI). Receiver operating characteristic (ROC) curves demonstrated impressive predictive performance of S100A8/A9, PTX3, and CHI3L1 at 0 h post-surgery, yielding area under the curve (AUC) values of 0.823, 0.786, and 0.803, respectively, for ASA-AKI prediction. Furthermore, our findings exhibited positive correlations between plasma levels of S100A8/A9, PTX3, CHI3L1, and urinary neutrophil gelatinase-associated lipocalin (NGAL) at 0 h post-surgery, along with correlations between plasma S100A8/A9, CHI3L1 levels, and the Cleveland Clinic score. A logistic regression model incorporating plasma S100A8/A9, PTX3, CHI3L1 levels, urinary NGAL levels, and the Cleveland Clinic score facilitated the construction of a predictive nomogram for ASA-AKI. This nomogram demonstrated robust discriminative ability, achieving an AUC of 0.963 in the model construction cohort.

CONCLUSIONS

Our study underscored the augmentation of plasma S100A8/A9, PTX3, and CHI3L1 levels immediately post-surgery in patients developing ASA-AKI. The incorporation of these three biomarkers, in conjunction with the Cleveland Clinic score and NGAL, into a nomogram demonstrated commendable predictive efficacy. This presents a practical tool for identifying patients at an elevated risk of AKI following ATAAD surgery.

The preoperative plasma histamine level as a possible protective biomarker for postoperative acute kidney injury

Acute kidney injury (AKI) is a life-threatening complication of acute type A aortic dissection (ATAAD) patients. Increasing evidence suggests that histamine ameliorates the pathology of renal injury. However, data on the association between histamine levels and postoperative AKI in ATAAD patients are limited. The purpose of our study was to explore the incidence and independent risk factors of postoperative AKI, with special emphasis on the relationship between preoperative plasma histamine levels and the severity of postoperative ATAAD-AKI. This retrospective single-center study evaluated 160 patients with ATAAD admitted to the Beijing Anzhen Hospital aortic surgery database between April 2020 and December 2021. Univariate and multivariate logistic regression analyses were performed to determine the potential risk factors for postoperative ATAAD-AKI. A subgroup analysis was performed to investigate the association between preoperative plasma histamine levels and the severity of postoperative ATAAD-AKI or continuous renal replacement therapy (CRRT). ATAAD-AKI occurred in 84 of 160 patients (52.5%), including 32 with stage 1 (38.1%), 14 with stage 2 (16.7%), 38 with stage 3 (45.2%), and 34 (21.3%) received postoperative CRRT. The in-hospital mortality rate was 19.0% (16/84) in the AKI group and 2.6% (2/76) in the non-AKI group (P = .02). Preoperative lower plasma histamine levels (odds ratio [OR], 1.31; 95% confidence interval [CI], 1.10-1.52; P = .004) were an important factor related to postoperative ATAAD-AKI in multivariate logistic regression analysis. Subgroup analysis revealed that low preoperative plasma histamine level was independently associated with postoperative ATAAD-AKI (stage 3) (OR, 1.38; 95% CI, 1.10-1.73; P = .005) and CRRT (OR, 1.44; 95% CI, 1.13-1.79; P = .008). Low preoperative plasma histamine level was an independent prognostic indicator of postoperative AKI in patients with ATAAD, especially for postoperative AKI (stage 3) and CRRT. Preoperative plasma histamine levels may serve as potential protective biomarkers of postoperative ATAAD-AKI.

Risk factors for acute kidney injury after Stanford type A aortic dissection repair surgery: a systematic review and meta-analysis

Background: Risk factors for acute kidney injury (AKI) after Stanford type A aortic dissection (TAAD) repair are inconsistent in different studies. This meta-analysis systematically analyzed the risk factors so as to early identify the therapeutic targets for preventing AKI.

Methods: Studies exploring risk factors for AKI after TAAD repair were searched from four databases from inception to June 2022. The synthesized incidence and risk factors of AKI and its impact on mortality were calculated.

Results: Twenty studies comprising 8223 patients were included. The synthesized incidence of postoperative AKI was 50.7%. Risk factors for AKI included cardiopulmonary bypass (CPB) time >180 min [odds ratio (OR), 4.89, 95% confidence interval (CI), 2.06–11.61, I² = 0%], prolonged operative time (>7 h) (OR, 2.73, 95% CI, 1.95–3.82, I² = 0), advanced age (per 10 years) (OR, 1.34, 95% CI, 1.21–1.49, I² = 0], increased packed red blood cells (pRBCs) transfusion perioperatively (OR, 1.09, 95% CI, 1.07–1.11, I² = 42%), elevated body mass index (per 5 kg/m²) (OR, 1.23, 95% CI, 1.18–1.28, I² = 42%) and preoperative kidney injury (OR, 3.61, 95% CI, 2.48–5.28, I² = 45%). All results were meta-analyzed using fixed-effects model finally (p < 0.01). The in-hospital or 30-day mortality was higher in patients with postoperative AKI than in that without AKI [risk ratio (RR), 3.12, 95% CI, 2.54–3.85, p < 0.01].

Conclusions: AKI after TAAD repair increased the in-hospital or 30-day mortality. Reducing CPB time and pRBCs transfusion, especially in elderly or heavier weight patients, or patients with preoperative kidney injury were important to prevent AKI after TAAD repair surgery.

Prediction model of acute kidney injury after different types of acute aortic dissection based on machine learning

Objective

A clinical prediction model for postoperative combined Acute kidney injury (AKI) in patients with Type A acute aortic dissection (TAAAD) and Type B acute aortic dissection (TBAAD) was constructed by using Machine Learning (ML).

Methods

Baseline data was collected from Acute aortic division (AAD) patients admitted to First Affiliated Hospital of Xinjiang Medical University between January 1, 2019 and December 31, 2021. (1) We identified baseline Serum creatinine (SCR) estimation methods and used them as a basis for diagnosis of AKI. (2) Divide their total datasets randomly into Training set (70%) and Test set (30%), Bootstrap modeling and validation of features using multiple ML methods in the training set, and select models corresponding to the largest Area Under Curve (AUC) for follow-up studies. (3) Screening of the best ML model variables through the model visualization tools Shapley Addictive Explanations (SHAP) and Recursive feature reduction (REF). (4) Finally, the pre-screened prediction models were evaluated using test set data from three aspects: discrimination, Calibration, and clinical benefit.

Results

The final incidence of AKI was 69.4% (120/173) in 173 patients with TAAAD and 28.6% (81/283) in 283 patients with TBAAD. For TAAAD-AKI, the Random Forest (RF) model showed the best prediction performance in the training set (AUC = 0.760, 95% CI:0.630–0.881); while for TBAAD-AKI, the Light Gradient Boosting Machine (LightGBM) model worked best (AUC = 0.734, 95% CI:0.623–0.847). Screening of the characteristic variables revealed that the common predictors among the two final prediction models for postoperative AKI due to AAD were baseline SCR, Blood urea nitrogen (BUN) and Uric acid (UA) at admission, Mechanical ventilation time (MVT). The specific predictors in the TAAAD-AKI model are: White blood cell (WBC), Platelet (PLT) and D dimer at admission, Plasma The specific predictors in the TBAAD-AKI model were N-terminal pro B-type natriuretic peptide (BNP), Serum kalium, Activated partial thromboplastin time (APTT) and Systolic blood pressure (SBP) at admission, Combined renal arteriography in surgery. Finally, we used in terms of Discrimination, the ROC value of the RF model for TAAAD was 0.81 and the ROC value of the LightGBM model for TBAAD was 0.74, both with good accuracy. In terms of calibration, the calibration curve of TAAAD-AKI's RF fits the ideal curve the best and has the lowest and smallest Brier score (0.16). Similarly, the calibration curve of TBAAD-AKI's LightGBM model fits the ideal curve the best and has the smallest Brier score (0.15). In terms of Clinical benefit, the best ML models for both types of AAD have good Net benefit as shown by Decision Curve Analysis (DCA).

Conclusion

We successfully constructed and validated clinical prediction models for the occurrence of AKI after surgery in TAAAD and TBAAD patients using different ML algorithms. The main predictors of the two types of AAD-AKI are somewhat different, and the strategies for early prevention and control of AKI are also different and need more external data for validation.

The long-term impact of acute renal failure after aortic arch replacement for acute type A aortic dissection

OBJECTIVE

To determine the long-term impact of developing acute renal failure (ARF) on survival after open aortic arch reconstruction for acute type A aortic dissection (ATAAD).

METHODS

This was an observational study of consecutive aortic surgeries from 2007 to 2021. Patients with ATAAD were identified via a prospectively maintained institutional database and were stratified by the presence or absence of postoperative ARF (by RIFLE criteria). Kaplan-Meier survival estimation and multivariable Cox regression analysis were performed.

RESULTS

A total of 601 patients undergoing open surgery for ATAAD were identified, of which 516 (85.9%) did not develop postoperative ARF, while 85 (14.1%) developed ARF, with a median follow-up time of 4.6 years (1.6, 7.9). Baseline characteristics were similar across each group, except for higher rates of branch vessel malperfusion and lower preoperative ejection fraction in the ARF group. Patients with ARF underwent more total arch replacement and elephant trunk procedures, with longer cardiopulmonary bypass and circulatory arrest times than patients without ARF. ARF was associated with worse short-term outcomes, including increased in-hospital mortality, prolonged mechanical ventilation, higher rates of sepsis, more blood transfusions, and longer length of hospital stay. Unadjusted Kaplan-Meier survival estimates were significantly lower in the ARF group, compared to the group without ARF (p < .001, log-rank test). After multivariable adjustment, the development of postoperative ARF was significantly associated with an increased hazard of death over the study's follow-up time-period (hazard ratio: 2.74, 95% confidence interval: 1.95, 3.86, p < .001).

CONCLUSIONS

ARF is a highly morbid postoperative event that may adversely impact long-term survival after aortic surgery.

Acute renal failure after acute type A aortic dissection repair. Insidious postoperative complication with poor short- and long-term prognosis

Acute type A aortic dissection (ATAAD) is a life-threatening aortic disease. Many systems and organs are affected by malperfusion which presents preoperatively and postoperatively. Postoperative acute renal failure after ATAAD constitutes a severe and insidious complication. Acute renal damage is observed in many patients with ATAAD preoperatively and it burdens the renal function postoperatively. Renal replacement therapy represents an additional risk factor for short-, mid-, and long-term outcomes after ATAAD repair. Brown et al.'s present study highlight the clinical significance of this complication. Also, they remind us of the importance of optimizing perioperative renal protective strategies in patients undergoing ATAAD repair.

Surgical outcomes of acute type A aortic dissection in dialysis patients: lessons learned from a single-center’s experience

There is a paucity of data describing the safety and efficacy of acute type A aortic dissection (ATAAD) repair surgeries in dialysis patients. Our study aimed to investigated the influence of dialysis on early and late outcomes in end-stage renal disease (ESRD) patients who received repair surgery for ATAAD. A total of 882 ATAAD patients who received emergency aortic dissection repair at our center from January 2015 to December 2019 were retrospectively screened in this study and divided into the dialysis group (n = 16) and the non-dialysis group (n = 866), depending on whether they required dialysis for preoperative ESRD. No significant difference of age, preoperative hemodynamics, organ ischemia conditions, operative variables as well as the 30-Day mortality and in-hospital complications was discovered between two groups. However, the survival rates and the proportion of late aortic event (sudden death and reoperation) free population at 1 and 3 years after surgery were significantly decreased in dialysis patients compared to non-dialysis patients. Our study indicated that the short-term surgical outcomes of ATAAD in dialysis patients were comparable to non-dialysis patient. However, the dialysis patients were associated with a worse long-term prognosis.

Identification of risk factors for postoperative stage 3 acute kidney injury in patients who received surgical repair for acute type A aortic dissection

BACKGROUND

Acute kidney injury (AKI) is a serious complication that often occurred after acute type A aortic dissection (ATAAD) surgery. Previous studies proved that the Kidney Disease Improving Global Outcomes (KDIGO) defined stage 3 AKI was associated with lower long-term survival rate. However, the risk factors for developing stage 3 AKI had not been identified. The aim of the study was to explore the risk factors for developing KDIGO stage 3 after ATAAD operation.

METHODS

This study included 993 patients who received ATAAD operation from 2014 to 2019 at the Nanjing Drum Tower Hospital. Postoperative AKI was diagnosed according to the KDIGO criteria. Multivariate logistic regression analyses were applied to identify risk factors for stage 3 AKI. Kaplan-Meier survival analyses and Cox proportional hazards regression model were conducted to explore the association between different AKI stages and postoperative survival rate.

RESULTS

The mean age of all enrolled patients was 53.0 ± 13.1 years. A total of 236 (23.8%) patients suffered postoperative stage 3 AKI including 165 patients who required renal replacement therapy. Advanced age (odds ratio [OR] 1.031; 95% confidence interval [CI] 1.005-1.057; P = 0.018), prolonged cardiopulmonary bypass (CPB) duration (OR 1.010; 95% CI 1.002-1.018; P = 0.013), and higher drainage volume 24 h after surgery (OR 1.000; 95% CI 1.000-1.001; P = 0.033) were identified as independent risk factors for developing stage 3 AKI. In addition, our result showed that the mortality rate was correlated significantly with the severity of AKI defined by KDIGO criteria and the Cox regression analysis showed that only stage 3 AKI, but not stage 1 and 2, was an independent risk factor for mortality (Hazard ratio 10.365, 95% CI 4.208 to 25.528; P < 0.001) after adjusting for important confounding factors.

CONCLUSIONS

Our study suggested that stage 3 postoperative AKI was significantly associated with decreased postoperative survival rate after ATAAD surgery. Advanced age, increased CPB duration and drainage volume 24 h after surgery were identified as risk factors for developing stage 3 AKI.

Risk factors for 30-day mortality in patients who received DeBakey type I aortic dissection repair surgery

Objective

This study aimed to identify risk factors for 30-day mortality in patients who received DeBakey type I aortic dissection (AD) repair surgery.

Methods

A total of 830 consecutive patients who received acute DeBakey type I AD surgery between 2014 and 2019 were included in the study. The associations between 30-day mortality and perioperative parameters were examined in order to identify risk factors.

Results

Our data suggested that the overall 30-day mortality rate of all enrolled patients was 11.7%. Unsurprisingly, non-survivors were older and more frequently accompanied with histories of cardiovascular diseases. For intraoperative parameters, the prevalence of coronary artery bypass grafting and cardiopulmonary bypass times were increased in non-survivors. In addition, acute kidney injury (AKI), dialysis, stroke, and deep sternal wound infection were more commonly seen among non-survivors. The multivariate logistic regression analysis suggested that cardiovascular disease history, preoperative D-dimer level, drainage volume 24 h after surgery, and postoperative AKI were independent risk factors for 30-day mortality after DeBakey type I aortic dissection repair surgery.

Conclusions

Our study demonstrated that cardiovascular disease history, preoperative D-dimer level, drainage volume 24 h after surgery as well as postoperative AKI were risk factors for 30-day mortality after DeBakey type I aortic dissection repair surgery.

Hepatic dysfunction in patients who received acute DeBakey type I aortic dissection repair surgery: incidence, risk factors, and long-term outcomes

BACKGROUND

Hepatic dysfunction (HD) increases the morbidity and mortality rates after cardiac surgery. However, few studies have investigated the association between HD and acute DeBakey type I aortic dissection (ADIAD) surgery. This retrospective study aimed to identify risk factors for developing HD in patients who received acute type I aortic dissection repair and its consequences.

METHODS

A total of 830 consecutive patients who received ADIAD surgery from January 2014 to December 2019 at our center were screened for this study. The End-Stage Liver Disease (MELD) score more than 14 was applied to identify postoperative HD. Logistic regression model was applied to identify risk factors for postoperative HD, Kaplan-Meier survival analysis and Cox proportional hazards regression assay were conducted to analyze the association between HD and postoperative long-term survival.

RESULTS

Among 634 patients who eventually enrolled in this study, 401 (63.2%) experienced postoperative HD with a 30-Day mortality of 15.5%. Preoperative plasma fibrinogen level (PFL) [odds ratio (OR): 0.581, 95% confidence interval (CI): 0.362-0.933, P = 0.025], serum creatinine (sCr) on admission (OR: 1.050, 95% CI 1.022-1.079, P < 0.001), cardiopulmonary bypass (CPB) time (OR: 1.017, 95% CI 1.010-1.033, P = 0.039), and postoperative mechanical ventilation (MV) duration (OR: 1.019, 95% CI 1.003-1.035, P = 0.020) were identified as independent risk factors for developing postoperative HD by multivariate analyses. In addition, the Kaplan-Meier analysis indicated that the long-term survival rate was significantly different between patients with or without postoperative HD. However, the hazard ratios of long-term survival for these two groups were not significantly different.

CONCLUSIONS

HD was a common complication after ADIAD surgery and associated with an increasing 30-Day mortality rate. Decreased PFL, elevated sCr, prolonged CPB duration, and longer postoperative MV time were independent risk factors for postoperative HD.

Risk factors and long-term outcomes of acute kidney injury complication after type A acute aortic dissection surgery in young patients

OBJECTIVE

To identify risk factors and long-term outcomes of acute kidney injury (AKI) in young patients who underwent type A acute aortic dissection (TA-AAD) emergency surgeries.

METHODS

This retrospective study enrolled 121 consecutive patients less than 40 years old who received TA-AAD emergency surgeries between January 2014 to December 2018 in Nanjing Drum Tower hospital. The diagnosis of AKI was made based on the KDIGO criteria. Multivariable regression analysis was performed to identify risk factors for postoperative AKI. Kaplan-Meier curves were generated to compare long-term outcomes between patients with and without AKI complication after TA-AAD surgeries.

RESULTS

Among all enrolled patients, AKI occurred in 51 patients (42.1%) and renal replacement therapy (RRT) was required in 15 patients (12.4%). The development of postoperative AKI was associated with increased 30-day mortality (P = 0.041), longer ICU stay time (P < 0.001) and hospital stay time (P = 0.006). Multivariable analysis indicated that elevated preoperative serum cystatin C (sCyC) (OR = 6.506, 95% CI: 1.852-22.855, P = 0.003) was the only independent risk factor for developing AKI. The areas under the receiver-operating characteristic curve (AUC) of preoperative sCyC was 0.800 (95% CI: 0.719, 0.882). Preoperative sCyC had a sensitivity of 64.7% and a specificity of 83.8% in diagnosing postoperative AKI with a cut-off value of 0.895 mg/L. In addition, our data suggested there was no difference discovered regarding long-term cumulative survival rate between patients with and without AKI during a median 29 months follow-up period.

CONCLUSIONS

Postoperative AKI after TA-AAD surgeries was relatively common in young patients and associated with increased short-term mortality. Elevated preoperative sCyC was identified as an independent risk factor for AKI with potential diagnostic merit.