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Yang X, Zhu L, Pan H, Yang Y. Cardiopulmonary bypass associated acute kidney injury: better understanding and better prevention. Ren Fail 2024; 46:2331062. [PMID: 38515271 PMCID: PMC10962309 DOI: 10.1080/0886022x.2024.2331062] [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: 10/17/2023] [Accepted: 03/11/2024] [Indexed: 03/23/2024] Open
Abstract
Cardiopulmonary bypass (CPB) is a common technique in cardiac surgery but is associated with acute kidney injury (AKI), which carries considerable morbidity and mortality. In this review, we explore the range and definition of CPB-associated AKI and discuss the possible impact of different disease recognition methods on research outcomes. Furthermore, we introduce the specialized equipment and procedural intricacies associated with CPB surgeries. Based on recent research, we discuss the potential pathogenesis of AKI that may result from CPB, including compromised perfusion and oxygenation, inflammatory activation, oxidative stress, coagulopathy, hemolysis, and endothelial damage. Finally, we explore current interventions aimed at preventing and attenuating renal impairment related to CPB, and presenting these measures from three perspectives: (1) avoiding CPB to eliminate the fundamental impact on renal function; (2) optimizing CPB by adjusting equipment parameters, optimizing surgical procedures, or using improved materials to mitigate kidney damage; (3) employing pharmacological or interventional measures targeting pathogenic factors.
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Affiliation(s)
- Xutao Yang
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - Li Zhu
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
- The Jinhua Affiliated Hospital of Zhejiang University School of Medicine, Yiwu, China
| | - Hong Pan
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - Yi Yang
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
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2
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Scurt FG, Bose K, Mertens PR, Chatzikyrkou C, Herzog C. Cardiac Surgery-Associated Acute Kidney Injury. KIDNEY360 2024; 5:909-926. [PMID: 38689404 PMCID: PMC11219121 DOI: 10.34067/kid.0000000000000466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 04/26/2024] [Indexed: 05/02/2024]
Abstract
AKI is a common and serious complication of cardiac surgery that has a significant impact on patient morbidity and mortality. The Kidney Disease Improving Global Outcomes definition of AKI is widely used to classify and identify AKI associated with cardiac surgery (cardiac surgery-associated AKI [CSA-AKI]) on the basis of changes in serum creatinine and/or urine output. There are various preoperative, intraoperative, and postoperative risk factors for the development of CSA-AKI which should be recognized and addressed as early as possible to expedite its diagnosis, reduce its occurrence, and prevent or ameliorate its devastating complications. Crucial issues are the inaccuracy of serum creatinine as a surrogate parameter of kidney function in the perioperative setting of cardiothoracic surgery and the necessity to discover more representative markers of the pathophysiology of AKI. However, except for the tissue inhibitor of metalloproteinase-2 and insulin-like growth factor binding protein 7 ratio, other diagnostic biomarkers with an acceptable sensitivity and specificity are still lacking. This article provides a comprehensive review of various aspects of CSA-AKI, including pathogenesis, risk factors, diagnosis, biomarkers, classification, prevention, and treatment management.
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Affiliation(s)
- Florian G. Scurt
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Katrin Bose
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany
| | - Peter R. Mertens
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Christos Chatzikyrkou
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Carolin Herzog
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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3
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Habas E, Al Adab A, Arryes M, Alfitori G, Farfar K, Habas AM, Akbar RA, Rayani A, Habas E, Elzouki A. Anemia and Hypoxia Impact on Chronic Kidney Disease Onset and Progression: Review and Updates. Cureus 2023; 15:e46737. [PMID: 38022248 PMCID: PMC10631488 DOI: 10.7759/cureus.46737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Chronic kidney disease (CKD) is caused by hypoxia in the renal tissue, leading to inflammation and increased migration of pathogenic cells. Studies showed that leukocytes directly sense hypoxia and respond by initiating gene transcription, encoding the 2-integrin adhesion molecules. Moreover, other mechanisms participate in hypoxia, including anemia. CKD-associated anemia is common, which induces and worsens hypoxia, contributing to CKD progression. Anemia correction can slow CKD progression, but it should be cautiously approached. In this comprehensive review, the underlying pathophysiology mechanisms and the impact of renal tissue hypoxia and anemia in CKD onset and progression will be reviewed and discussed in detail. Searching for the latest updates in PubMed Central, Medline, PubMed database, Google Scholar, and Google search engines were conducted for original studies, including cross-sectional studies, cohort studies, clinical trials, and review articles using different keywords, phrases, and texts such as "CKD progression, anemia in CKD, CKD, anemia effect on CKD progression, anemia effect on CKD progression, and hypoxia and CKD progression". Kidney tissue hypoxia and anemia have an impact on CKD onset and progression. Hypoxia causes nephron cell death, enhancing fibrosis by increasing interstitium protein deposition, inflammatory cell activation, and apoptosis. Severe anemia correction improves life quality and may delay CKD progression. Detection and avoidance of the risk factors of hypoxia prevent recurrent acute kidney injury (AKI) and reduce the CKD rate. A better understanding of kidney hypoxia would prevent AKI and CKD and lead to new therapeutic strategies.
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Affiliation(s)
| | - Aisha Al Adab
- Internal Medicine, Hamad General Hospital, Doha, QAT
| | - Mehdi Arryes
- Internal Medicine, Hamad General Hospital, Doha, QAT
| | | | | | - Ala M Habas
- Internal Medicine, Tripoli University, Tripoli, LBY
| | - Raza A Akbar
- Internal Medicine, Hamad General Hospital, Doha, QAT
| | - Amnna Rayani
- Hemat-oncology Department, Pediatric Tripoli Hospital, Tripoli University, Tripoli, LBY
| | - Eshrak Habas
- Internal Medicine, Tripoli University, Tripoli, LBY
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Layton AT. "Hi, how can i help you?": embracing artificial intelligence in kidney research. Am J Physiol Renal Physiol 2023; 325:F395-F406. [PMID: 37589052 DOI: 10.1152/ajprenal.00177.2023] [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: 06/21/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/18/2023] Open
Abstract
In recent years, biology and precision medicine have benefited from major advancements in generating large-scale molecular and biomedical datasets and in analyzing those data using advanced machine learning algorithms. Machine learning applications in kidney physiology and pathophysiology include segmenting kidney structures from imaging data and predicting conditions like acute kidney injury or chronic kidney disease using electronic health records. Despite the potential of machine learning to revolutionize nephrology by providing innovative diagnostic and therapeutic tools, its adoption in kidney research has been slower than in other organ systems. Several factors contribute to this underutilization. The complexity of the kidney as an organ, with intricate physiology and specialized cell populations, makes it challenging to extrapolate bulk omics data to specific processes. In addition, kidney diseases often present with overlapping manifestations and morphological changes, making diagnosis and treatment complex. Moreover, kidney diseases receive less funding compared with other pathologies, leading to lower awareness and limited public-private partnerships. To promote the use of machine learning in kidney research, this review provides an introduction to machine learning and reviews its notable applications in renal research, such as morphological analysis, omics data examination, and disease diagnosis and prognosis. Challenges and limitations associated with data-driven predictive techniques are also discussed. The goal of this review is to raise awareness and encourage the kidney research community to embrace machine learning as a powerful tool that can drive advancements in understanding kidney diseases and improving patient care.
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Affiliation(s)
- Anita T Layton
- Department of Applied Mathematics, University of Waterloo, Waterloo, Ontario, Canada
- Department of Biology, University of Waterloo, Waterloo, Ontario, Canada
- Cheriton School of Computer Science, University of Waterloo, Waterloo, Ontario, Canada
- School of Pharmacology, University of Waterloo, Waterloo, Ontario, Canada
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5
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Lofgren LR, Hoareau GL, Kuck K, Silverton NA. Noninvasive and Invasive Renal Hypoxia Monitoring in a Porcine Model of Hemorrhagic Shock. J Vis Exp 2022:10.3791/64461. [PMID: 36373937 PMCID: PMC10044407 DOI: 10.3791/64461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Up to 50% of patients with trauma develop acute kidney injury (AKI), in part due to poor renal perfusion after severe blood loss. AKI is currently diagnosed based on a change in serum creatinine concentration from baseline or prolonged periods of decreased urine output. Unfortunately, baseline serum creatinine concentration data is unavailable in most patients with trauma, and current estimation methods are inaccurate. In addition, serum creatinine concentration may not change until 24-48 h after the injury. Lastly, oliguria must persist for a minimum of 6 h to diagnose AKI, making it impractical for early diagnosis. AKI diagnostic approaches available today are not useful for predicting risk during the resuscitation of patients with trauma. Studies suggest that urinary partial pressure of oxygen (PuO2) may be useful for assessing renal hypoxia. A monitor that connects the urinary catheter and the urine collection bag was developed to measure PuO2 noninvasively. The device incorporates an optical oxygen sensor that estimates PuO2 based on luminescence quenching principles. In addition, the device measures urinary flow and temperature, the latter to adjust for confounding effects of temperature changes. Urinary flow is measured to compensate for the effects of oxygen ingress during periods of low urine flow. This article describes a porcine model of hemorrhagic shock to study the relationship between noninvasive PuO2, renal hypoxia, and AKI development. A key element of the model is the ultrasound-guided surgical placement in the renal medulla of an oxygen probe, which is based on an unsheathed optical microfiber. PuO2 will also be measured in the bladder and compared to the kidney and noninvasive PuO2 measurements. This model can be used to test PuO2 as an early marker of AKI and assess PuO2 as a resuscitative endpoint after hemorrhage that is indicative of end-organ rather than systemic oxygenation.
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Affiliation(s)
- Lars R Lofgren
- Department of Biomedical Engineering, University of Utah;
| | - Guillaume L Hoareau
- Department of Emergency Medicine, University of Utah; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah
| | - Kai Kuck
- Department of Biomedical Engineering, University of Utah; Department of Anesthesiology, University of Utah
| | - Natalie A Silverton
- Department of Anesthesiology, University of Utah; Geriatric Research, Education, and Clinical Centre, VAMC
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6
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Petrosyan Y, Mesana TG, Sun LY. Prediction of acute kidney injury risk after cardiac surgery: using a hybrid machine learning algorithm. BMC Med Inform Decis Mak 2022; 22:137. [PMID: 35585624 PMCID: PMC9118758 DOI: 10.1186/s12911-022-01859-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 04/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background Acute kidney injury (AKI) is a serious complication after cardiac surgery. We derived and internally validated a Machine Learning preoperative model to predict cardiac surgery-associated AKI of any severity and compared its performance with parametric statistical models. Methods We conducted a retrospective study of adult patients who underwent major cardiac surgery requiring cardiopulmonary bypass between November 1st, 2009 and March 31st, 2015. AKI was defined according to the KDIGO criteria as stage 1 or greater, within 7 days of surgery. We randomly split the cohort into derivation and validation datasets. We developed three AKI risk models: (1) a hybrid machine learning (ML) algorithm, using Random Forests for variable selection, followed by high performance logistic regression; (2) a traditional logistic regression model and (3) an enhanced logistic regression model with 500 bootstraps, with backward variable selection. For each model, we assigned risk scores to each of the retained covariate and assessed model discrimination (C statistic) and calibration (Hosmer–Lemeshow goodness-of-fit test) in the validation datasets. Results Of 6522 included patients, 1760 (27.0%) developed AKI. The best performance was achieved by the hybrid ML algorithm to predict AKI of any severity. The ML and enhanced statistical models remained robust after internal validation (C statistic = 0.75; Hosmer–Lemeshow p = 0.804, and AUC = 0.74, Hosmer–Lemeshow p = 0.347, respectively). Conclusions We demonstrated that a hybrid ML model provides higher accuracy without sacrificing parsimony, computational efficiency, or interpretability, when compared with parametric statistical models. This score-based model can easily be used at the bedside to identify high-risk patients who may benefit from intensive perioperative monitoring and personalized management strategies. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-022-01859-w.
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Affiliation(s)
- Yelena Petrosyan
- Cardiocore Big Data Research Unit, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Thierry G Mesana
- Cardiocore Big Data Research Unit, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Louise Y Sun
- Cardiocore Big Data Research Unit, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada. .,Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada. .,School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Cres, Ottawa, ON, K1G 5Z3, Canada.
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7
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Mediators of Regional Kidney Perfusion during Surgical Pneumo-Peritoneum Creation and the Risk of Acute Kidney Injury—A Review of Basic Physiology. J Clin Med 2022; 11:jcm11102728. [PMID: 35628855 PMCID: PMC9142947 DOI: 10.3390/jcm11102728] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/05/2022] [Accepted: 05/05/2022] [Indexed: 02/04/2023] Open
Abstract
Acute kidney injury (AKI), especially if recurring, represents a risk factor for future chronic kidney disease. In intensive care units, increased intra-abdominal pressure is well-recognized as a significant contributor to AKI. However, the importance of transiently increased intra-abdominal pressures procedures is less commonly appreciated during laparoscopic surgery, the use of which has rapidly increased over the last few decades. Unlike the well-known autoregulation of the renal cortical circulation, medulla perfusion is modulated via partially independent regulatory mechanisms and strongly impacted by changes in venous and lymphatic pressures. In our review paper, we will provide a comprehensive overview of this evolving topic, covering a broad range from basic pathophysiology up to and including current clinical relevance and examples. Key regulators of oxidative stress such as ischemia-reperfusion injury, the activation of inflammatory response and humoral changes interacting with procedural pneumo-peritoneum formation and AKI risk will be recounted. Moreover, we present an in-depth review of the interaction of pneumo-peritoneum formation with general anesthetic agents and animal models of congestive heart failure. A better understanding of the relationship between pneumo-peritoneum formation and renal perfusion will support basic and clinical research, leading to improved clinical care and collaboration among specialists.
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8
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Xie B, Fu L, Wu Y, Xie X, Zhang W, Hou J, Liu D, Li R, Zhang L, Zhou C, Huang J, Liang X, Wu M, Ye Z. Risk factors of renal replacement therapy after heart transplantation: a retrospective single-center study. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:257. [PMID: 35402585 PMCID: PMC8987878 DOI: 10.21037/atm-22-541] [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: 01/07/2022] [Accepted: 03/04/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) and renal replacement therapy (RRT) are common after heart transplantation (HT). The need for RRT has been reported to be one of the most important predictors of a poor prognosis after HT. Therefore, it is important to early identify risk factors of RRT after HT. However, in the heart transplantation setting, the risk factors are less well studied, and some of the conclusions are controversial. This study aimed to identify the clinical predictors of RRT after HT. METHODS This single-center, retrospective study from January 2010 to June 2021 analyzed risk factors (pre-, intra-, and postoperative characteristics) of 163 patients who underwent HT. The endpoint of the study was RRT within 7 days of HT. Risk factors were analyzed by multivariable logistic regression models. RESULTS Fifty-five (33.74%) recipients required RRT within 7 days of HT. Factors independently associated with RRT after HT were as follows: a baseline estimated glomerular filtration rate (eGFR) <60 mL/min per 1.73 m2 [odds ratio (OR) =3.123; 95% confidence interval (CI): 1.183-8.244; P=0.022], a dose of intraoperative methylprednisolone >10 mg/kg (OR =3.197; 95% CI: 1.290-7.923; P=0.012), the use of mechanical circulatory support (MCS) during surgery (OR =4.903; 95% CI: 1.628-14.766; P=0.005), a cardiopulmonary bypass (CPB) time ≥5 hours (OR =3.929; 95% CI: 1.222-12.634; P=0.022), and postoperative serum total bilirubin (TBIL) ≥60 umol/L (OR =5.105; 95% CI: 1.868-13.952; P=0.001). Protective factors were higher postoperative serum albumin (OR =0.907; 95% CI: 0.837-0.983; P=0.017) and higher postoperative left ventricular ejection fraction (LVEF) (OR =0.908; 95% CI: 0.838-0.985; P=0.020). CONCLUSIONS A low preoperative eGFR, a high intraoperative dose of methylprednisolone, a long CPB time, the use of mechanical circulatory support, and a high postoperative TBIL were risk factors for RRT after HT. While a high postoperative serum albumin level and a high left ventricular ejection fraction were protective factors. Understanding these risk factors may help us identify high-risk patients and intervene early.
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Affiliation(s)
- Bingying Xie
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
| | - Lei Fu
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- School of Medicine, South China University of Technology, Guangzhou, China
| | - Yijin Wu
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xinfu Xie
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Wenhao Zhang
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
| | - Jihua Hou
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Dinglin Liu
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- School of Medicine, South China University of Technology, Guangzhou, China
| | - Ruizhao Li
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Li Zhang
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Chengbin Zhou
- Heart Transplantation and VAD Division, Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jinsong Huang
- Heart Transplantation and VAD Division, Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xinling Liang
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- School of Medicine, South China University of Technology, Guangzhou, China
| | - Min Wu
- Heart Transplantation and VAD Division, Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhiming Ye
- Department of Nephrology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
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McNair ED, Bezaire J, Moser M, Mondal P, Conacher J, Franczak A, Sawicki G, Reid D, Khani-Hanjani A. The Association of Matrix Metalloproteinases With Acute Kidney Injury Following CPB-Supported Cardiac Surgery. Can J Kidney Health Dis 2021; 8:20543581211019640. [PMID: 34350005 PMCID: PMC8287351 DOI: 10.1177/20543581211019640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 04/19/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Cardiac surgery-associated acute kidney injury (AKI) is an adverse outcome that increases morbidity and mortality in patients undergoing cardiac surgical procedures. To date, the use of serum creatinine levels as an early indicator of AKI has limitations because of its slow rise and poor predictive accuracy for renal injury. This delay in diagnosis may lead to prolonged initiation in treatment and increased risk for adverse outcomes. OBJECTIVE This pilot study explores serum and urine matrix metalloproteinases (MMPs)-2 and MMP-9 and their association, and potentially earlier detection of AKI in patients following cardiopulmonary bypass (CPB)-supported cardiac surgery. We hypothesize that increased activity of serum and urine levels MMP-2 and/ or MMP-9 are associated with AKI. Furthermore, MMP-2 and/ or MMP-9 may provide earlier identification of AKI as compared with serum levels of creatinine. METHODS During the study period, there were 150 CPB-supported surgeries, 21 of which developed AKI according to the Kidney Disease Improving Global Outcomes criteria. We then selected a sample of 21 matched cases from those patients who went through the surgery without developing AKI. Primary outcomes were the measurement via gel zymography of the serum and urine activity of MMP-2 and MMP-9 drawn at the following intervals: pre-CPB; 10-minute post-CPB; and 4-hour post-CPB time points. Secondary variables were the measurement of serum creatinine, intensive care unit (ICU) fluid balance, and length of ICU stay. RESULTS At the 10-minute and 4-hour post-CPB time points, the serum MMP-2 activity of AKI patients were significantly higher as compared with non-AKI patients (P < .001 and P = .004), respectively. Similarly, at the 10-minute and 4-hour post-CPB time points, the serum MMP-9 activity of AKI patients was significantly higher as compared with non-AKI patients (P = .001 and P = .014), respectively. The activity of urine MMP-2 and MMP-9 of AKI patients was significantly higher as compared with non-AKI patients at all 3 time points (P = .004, P < .001, P < .001), respectively. CONCLUSION Although the pilot study may have limitations, it has demonstrated that the serum and urine levels of activity of MMP-2 and MMP-9 are associated with the clinical endpoint of AKI and appear to have earlier rising levels as compared with those of serum creatinine. Furthermore, in depth, exploration is underway with a larger sample size to attempt validation of the analytical performance and reproducibility of the assay for MMP-2 and MMP-9 to aid in earlier diagnosis of AKI following CPB-supported cardiac surgery.
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Affiliation(s)
- Erick D. McNair
- Department of Pathology and Laboratory
Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Canada
- Department of Surgery/Division of
Cardiac Surgery, College of Medicine, University of Saskatchewan, Saskatoon,
Canada
| | - Jennifer Bezaire
- Department of Pathology and Laboratory
Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Michael Moser
- Department of Medicine, College of
Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Prosanta Mondal
- Department of Community Health and
Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon,
Canada
| | - Josie Conacher
- Department of Pathology and Laboratory
Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Aleksandra Franczak
- Department of Medicine, College of
Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Greg Sawicki
- Department of Pharmacology, College of
Medicine, University of Saskatchewan, Saskatoon, Canada
| | - David Reid
- Department of Medicine, College of
Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Abass Khani-Hanjani
- Department of Surgery/Division of
Cardiac Surgery, College of Medicine, University of Saskatchewan, Saskatoon,
Canada
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10
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Kato T, Kawasaki Y, Koyama K. Intermittent Urine Oxygen Tension Monitoring for Predicting Acute Kidney Injury After Cardiovascular Surgery: A Preliminary Prospective Observational Study. Cureus 2021; 13:e16135. [PMID: 34262826 PMCID: PMC8260214 DOI: 10.7759/cureus.16135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Novel biomarkers of acute kidney injury (AKI) are being developed and commercialized. However, none are universally available. The aim of this preliminary prospective observational study was to explore the effectiveness of intermittent urine oxygen tension (PuO2) monitoring without special equipment (using a blood gas analyzer) for predicting AKI after elective cardiovascular surgery requiring cardiopulmonary bypass (CPB). Methods Fifty patients who underwent elective cardiovascular surgery requiring CPB were enrolled in the study with written informed consent. Urine samples were intermittently collected from a urethral catheter at four points: T1, immediately after induction of general anesthesia in the operating room; T2, immediately after intensive care unit (ICU) admission; T3, six hours after ICU admission; and T4, 12 hours after ICU admission. PuO2 was measured with a blood gas analyzer. The Kidney Disease Improving Global Outcomes classification was used for the diagnosis of AKI, then patients were followed up until postoperative day 7. By generating the receiver operating characteristic curves, the cut-off value of PuO2 and area under the curve (AUC) for predicting the onset of AKI was calculated. The odds ratio (OR) and 95% confidence interval (CI) of each time point were calculated using logistic regression analysis or exact logistic regression method. P < 0.05 was considered significant. Results Twelve patients were diagnosed with AKI (24% morbidity). The cut-off values of PuO2 for predicting onset of AKI at the four time points were T1, PuO2 ≥ 132.4 mmHg (OR 3.1, 95% CI 0.78-12.0, p = 0.11, AUC 0.57); T2, PuO2 ≥ 153.3 mmHg (OR 5.8, 95% CI 1.08-31.4, p = 0.04, AUC 0.51); T3, PuO2 ≥ 130.1 mmHg (OR 0.19, 95% CI 0.05-0.75, p = 0.018, AUC 0.68); T4, PuO2 ≥ 88.6 mmHg (OR 0.07, 95% CI 0-0.486, p = 0.011, AUC 0.64). Conclusion Intermittent PuO2 values at six and 12 hours after ICU admission may be predictors of AKI, although the AUCs to predict AKI were low (0.68 and 0.64). AKI prediction by PuO2 was not possible immediately after induction of general anesthesia (not statistically significant) and immediately after ICU admission (AUC was very low). Further studies are required to confirm the validity of intermittent PuO2 monitoring.
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Affiliation(s)
- Takao Kato
- Department of Anesthesiology, Saitama Medical Center, Saitama Medical University, Kawagoe, JPN
| | - Yohei Kawasaki
- Department of Anesthesiology, Saitama Medical Center, Saitama Medical University, Kawagoe, JPN
| | - Kaoru Koyama
- Department of Anesthesiology, Saitama Medical Center, Saitama Medical University, Kawagoe, JPN
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Abstract
Acute kidney injury (AKI) occurs frequently after cardiac surgery and is associated with high morbidity and mortality. Although the number of cardiac surgical procedures is constantly growing worldwide, incidence of cardiac surgery-associated AKI is still around 40% and has a significant impact on global health care costs. Numerous trials attempted to identify strategies to prevent AKI and attenuate its detrimental consequences. Effective options remained elusive. Current evidence supports a multimodal risk-stratification approach with biomarker-guided management of high-risk patients, perioperative administration of dexmedetomidine, and implementation of a care bundle as recommended by the Kidney Disease: Improving Global Outcomes group.
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Ristovic V, de Roock S, Mesana TG, van Diepen S, Sun LY. The Impact of Preoperative Risk on the Association between Hypotension and Mortality after Cardiac Surgery: An Observational Study. J Clin Med 2020; 9:jcm9072057. [PMID: 32629948 PMCID: PMC7408639 DOI: 10.3390/jcm9072057] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 06/25/2020] [Accepted: 06/28/2020] [Indexed: 12/28/2022] Open
Abstract
Background: Despite steady improvements in cardiac surgery-related outcomes, our understanding of the physiologic mechanisms leading to perioperative mortality remains incomplete. Intraoperative hypotension is an important risk factor for mortality after noncardiac surgery but remains relatively unexplored in the context of cardiac surgery. We examined whether the association between intraoperative hypotension and in-hospital mortality varied by patient and procedure characteristics, as defined by the validated Cardiac Anesthesia Risk Evaluation (CARE) mortality risk score. Methods: We conducted a retrospective cohort study of consecutive adult patients who underwent cardiac surgery requiring cardiopulmonary bypass (CPB) from November 2009–March 2015. Those who underwent off-pump, thoracic aorta, transplant and ventricular assist device procedures were excluded. The primary outcome was in-hospital mortality. Hypotension was categorized by mean arterial pressure (MAP) of <55 and between 55–64 mmHg before, during and after CPB. The relationship between hypotension and death was modeled using multivariable logistic regression in the intermediate and high-risk groups. Results: Among 6627 included patients, 131 (2%) died in-hospital. In-hospital mortality in patients with CARE scores of 1, 2, 3, 4 and 5 was 0 (0%), 7 (0.3%), 35 (1.3%), 41 (4.6%) and 48 (13.6%), respectively. In the intermediate-risk group (CARE = 3–4), MAP < 65 mmHg post-CPB was associated with increased odds of death in a dose-dependent fashion (adjusted OR 1.30, 95% CI 1.13–1.49, per 10 min exposure to MAP < 55 mmHg, p = 0.002; adjusted OR 1.18 [1.07–1.30] per 10 min exposure to MAP 55–64 mmHg, p = 0.001). We did not observe an association between hypotension and mortality in the high-risk group (CARE = 5). Conclusions: Post-CPB hypotension is a potentially modifiable risk factor for mortality in intermediate-risk patients. Our findings provide impetus for clinical trials to determine if hemodynamic goal-directed therapies could improve survival in these patients.
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Affiliation(s)
- Vanja Ristovic
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada;
| | - Sophie de Roock
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada;
| | - Thierry G. Mesana
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada;
- Cardiocore Big Data Research Unit, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB T6G 2R7, Canada;
| | - Louise Y. Sun
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada;
- Cardiocore Big Data Research Unit, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON K1Y 4W7, Canada
- Correspondence: ; Tel.: +1-613-696-7381
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Regional thigh tissue oxygen saturation during cardiopulmonary bypass predicts acute kidney injury after cardiac surgery. J Artif Organs 2020; 23:315-320. [PMID: 32448955 DOI: 10.1007/s10047-020-01175-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 05/11/2020] [Indexed: 10/24/2022]
Abstract
Cardiopulmonary bypass-associated acute kidney injury may appear postoperatively, but predictive factors are unclear. We investigated the potential of regional tissue oxygen saturation as a predictor of cardiopulmonary bypass-associated acute kidney injury. We analyzed the clinical data of 150 adult patients not on dialysis who underwent elective cardiac surgical procedures during January 2015-March 2017. Near-infrared spectroscopy was used to measure regional oxygen saturation. Sensors were placed on the patients' forehead, abdomen, and thigh. The incidence of acute kidney injury was 2% at the end of surgery, 13% at 24 h, and 9% at 48 h, with the highest at 24 h after surgery. The multiple regression analysis revealed that the thigh regional oximetry during cardiopulmonary bypass, oxygen delivery index, and neutrophil count at the end of cardiopulmonary bypass and surgery were independent risk factors for acute kidney injury. The receiver-operating characteristic curve analysis suggested that a cutoff of regional oxygen saturation at the thigh of ≤ 67% was predictive of acute kidney injury within 24 h after surgery. In conclusion, the regional oxygen saturation at the thigh during cardiopulmonary bypass is a crucial marker to predict postoperative acute kidney injury in adults undergoing cardiac surgery.
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Evans RG, Iguchi N, Cochrane AD, Marino B, Hood SG, Bellomo R, McCall PR, May CN, Lankadeva YR. Renal hemodynamics and oxygenation during experimental cardiopulmonary bypass in sheep under total intravenous anesthesia. Am J Physiol Regul Integr Comp Physiol 2019; 318:R206-R213. [PMID: 31823674 DOI: 10.1152/ajpregu.00290.2019] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Renal medullary hypoxia may contribute to the pathophysiology of acute kidney injury, including that associated with cardiac surgery requiring cardiopulmonary bypass (CPB). When performed under volatile (isoflurane) anesthesia in sheep, CPB causes renal medullary hypoxia. There is evidence that total intravenous anesthesia (TIVA) may preserve renal perfusion and renal oxygen delivery better than volatile anesthesia. Therefore, we assessed the effects of CPB on renal perfusion and oxygenation in sheep under propofol/fentanyl-based TIVA. Sheep (n = 5) were chronically instrumented for measurement of whole renal blood flow and cortical and medullary perfusion and oxygenation. Five days later, these variables were monitored under TIVA using propofol and fentanyl and then on CPB at a pump flow of 80 mL·kg-1·min-1 and target mean arterial pressure of 70 mmHg. Under anesthesia, before CPB, renal blood flow was preserved under TIVA (mean difference ± SD from conscious state: -16 ± 14%). However, during CPB renal blood flow was reduced (-55 ± 13%) and renal medullary tissue became hypoxic (-20 ± 13 mmHg versus conscious sheep). We conclude that renal perfusion and medullary oxygenation are well preserved during TIVA before CPB. However, CPB under TIVA leads to renal medullary hypoxia, of a similar magnitude to that we observed previously under volatile (isoflurane) anesthesia. Thus use of propofol/fentanyl-based TIVA may not be a useful strategy to avoid renal medullary hypoxia during CPB.
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Affiliation(s)
- Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
| | - Naoya Iguchi
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew D Cochrane
- Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Victoria, Australia
| | - Bruno Marino
- Cellsaving and Perfusion Resources, Melbourne, Victoria, Australia
| | - Sally G Hood
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Peter R McCall
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
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Nadim MK, Forni LG, Bihorac A, Hobson C, Koyner JL, Shaw A, Arnaoutakis GJ, Ding X, Engelman DT, Gasparovic H, Gasparovic V, Herzog CA, Kashani K, Katz N, Liu KD, Mehta RL, Ostermann M, Pannu N, Pickkers P, Price S, Ricci Z, Rich JB, Sajja LR, Weaver FA, Zarbock A, Ronco C, Kellum JA. Cardiac and Vascular Surgery-Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group. J Am Heart Assoc 2018; 7:JAHA.118.008834. [PMID: 29858368 PMCID: PMC6015369 DOI: 10.1161/jaha.118.008834] [Citation(s) in RCA: 160] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Mitra K Nadim
- Division of Nephrology & Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Lui G Forni
- Department of Clinical & Experimental Medicine, University of Surrey, Guildford, United Kingdom.,Royal Surrey County Hospital NHS Foundation Trust, Guildford, United Kingdom
| | - Azra Bihorac
- Division of Nephrology, Hypertension & Renal Transplantation, Department of Medicine, University of Florida, Gainesville, FL
| | - Charles Hobson
- Division of Surgical Critical Care, Department of Surgery, Malcom Randall VA Medical Center, Gainesville, FL
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, IL
| | - Andrew Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - George J Arnaoutakis
- Division of Thoracic & Cardiovascular Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Xiaoqiang Ding
- Department of Nephrology, Shanghai Institute for Kidney Disease and Dialysis, Shanghai Medical Center for Kidney Disease, Zhongshan Hospital Fudan University, Shanghai, China
| | - Daniel T Engelman
- Division of Cardiac Surgery, Department of Surgery, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA
| | - Hrvoje Gasparovic
- Department of Cardiac Surgery, University Hospital Rebro, Zagreb, Croatia
| | | | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN
| | - Kianoush Kashani
- Division of Nephrology & Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Nevin Katz
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Kathleen D Liu
- Divisions of Nephrology and Critical Care, Departments of Medicine and Anesthesia, University of California, San Francisco, CA
| | - Ravindra L Mehta
- Department of Medicine, UCSD Medical Center, University of California, San Diego, CA
| | - Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Neesh Pannu
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Peter Pickkers
- Department Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Susanna Price
- Adult Intensive Care Unit, Imperial College, Royal Brompton Hospital, London, United Kingdom
| | - Zaccaria Ricci
- Department of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Roma, Italy
| | - Jeffrey B Rich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Lokeswara R Sajja
- Division of Cardiothoracic Surgery, STAR Hospitals, Hyderabad, India
| | - Fred A Weaver
- Division of Vascular Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital International Renal Research Institute of Vicenza, Italy
| | - John A Kellum
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, PA
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