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Smith A, Turoczi Z, Al-Subaie N, Zilahi G. Postoperative Hypotension After Cardiac Surgery Is Associated With Acute Kidney Injury. J Cardiothorac Vasc Anesth 2024; 38:1683-1688. [PMID: 38879370 DOI: 10.1053/j.jvca.2024.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/30/2024] [Accepted: 04/17/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVES To describe the incidence of postoperative hypotension in patients undergoing cardiac surgery during the first 12 hours in the intensive care unit (ICU) and any relationship between hypotension and the development of acute kidney injury (AKI). DESIGN This was a retrospective, observational cohort study. SETTING The study took place in a single-center tertiary teaching hospital in London, UK. PARTICIPANTS Adult patients (n = 100) who underwent elective cardiac surgery requiring intraoperative cardiopulmonary bypass between May and November 2021 were enrolled. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A hypotensive event was defined as mean arterial pressure <65 mmHg lasting at least 1 minute. Invasive blood pressure data was analyzed for the first 12 hours after surgery, and any association between postoperative hypotension and AKI was assessed. A total of 91% of patients experienced hypotension in the first 12 hours postprocedure. On average, patients experienced 9 hypotensive events, with events lasting an average of 5 minutes. A total of 16 patients (16%) developed at least stage 1 AKI. The average duration of hypotension was significantly higher in the AKI group (4.6 min [IQR 3.3, 8.0] v 8.1 min [IQR 5.2, 14.2], p = 0.029). Those suffering AKI had longer ICU and hospital stays. CONCLUSIONS This study demonstrated that hypotension in the first 12 hours following cardiac surgery is common and prolonged hypotensive events are associated with developing AKI. This emphasizes the importance of treating hypotension aggressively and highlights a target for further research and intervention.
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Affiliation(s)
- Alexander Smith
- Cardiothoracic Intensive Care Unit, St George's University Hospital NHS Foundation Trust, London, United Kingdom.
| | - Zsolt Turoczi
- Cardiothoracic Intensive Care Unit, St George's University Hospital NHS Foundation Trust, London, United Kingdom
| | - Nawaf Al-Subaie
- Cardiothoracic Intensive Care Unit, St George's University Hospital NHS Foundation Trust, London, United Kingdom
| | - Gabor Zilahi
- Cardiothoracic Intensive Care Unit, St George's University Hospital NHS Foundation Trust, London, United Kingdom
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Bouisset B, Pozzi M, Ruste M, Varin T, Vola M, Rodriguez T, Jolivet ML, Chiari P, Fellahi JL, Jacquet-Lagreze M. Cardiopulmonary Bypass Blood Flow Rates and Major Adverse Kidney Events in Cardiac Surgery: A Propensity Score-adjusted Before-After Study. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00454-3. [PMID: 39095213 DOI: 10.1053/j.jvca.2024.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/06/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVES Cardiac surgery associated-acute kidney injury is a common and serious postoperative complication of cardiac surgery, which is associated with increased postoperative morbidity and mortality. This study aimed to explore the association between cardiopulmonary bypass (CPB) blood flow rate (BFR), and major adverse kidney events (MAKEs) at day 30. DESIGN Retrospective single-center before-after observational study. Patients were divided in 2 groups according to CPB flow rates: a first group with an institutional protocol targeting a CPB-BFR of >2.2 L/min/m² (low CPB-BFR group), and a second group with a modified institutional protocol targeting a CPB-BFR of >2.4 L/min/m² (high CPB-BFR group). The primary outcome was MAKE at 30 days, defined as the composite of death, renal replacement therapy or persistent renal dysfunction. SETTING The data were collected from clinical routines in university hospital. PARTICIPANTS Adult patients who underwent elective and urgent cardiac surgery without severe chronic renal failure, for whom CPB duration was ≥90 minutes. INTERVENTIONS We included 533 patients (low CPB-BFR group, n = 270; high CPB-BFR group, n = 263). MEASUREMENTS AND MAIN RESULTS A significant decrease in MAKE at 30 days was observed in the high CPB-BFR group (3% v 8%; odds ratio [OR], 0.779; 95% confidence interval [CI], 0.661-0.919; p < 0.001) mainly mediated by a lower 30-day mortality in the high CPB-BFR group (1% v 5%; OR, 0.697; 95% CI, 0.595-0.817; p = 0.001), as was renal replacement therapy (1% v 4%; OR, 0.739; 95% CI, 0.604-0.904; p = 0.016). CONCLUSIONS In patients undergoing cardiac surgery, increased CPB-BFR was associated with a decrease in MAKE at 30 days including mortality and renal replacement therapy.
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Affiliation(s)
- Benoit Bouisset
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France.
| | - Matteo Pozzi
- Service de Chirurgie Cardiovasculaire de l'Adulte, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France; Laboratoire RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon Cedex, France
| | - Martin Ruste
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France; Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon Cedex, France; Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Bron Cedex, France
| | - Thomas Varin
- Service de Chirurgie Cardiovasculaire de l'Adulte, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France
| | - Marco Vola
- Service de Chirurgie Cardiovasculaire de l'Adulte, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France; Laboratoire RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, Lyon Cedex, France
| | - Thomas Rodriguez
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France
| | - Maxime Le Jolivet
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France
| | - Pascal Chiari
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France; Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Bron Cedex, France
| | - Jean-Luc Fellahi
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France; Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon Cedex, France; Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Bron Cedex, France
| | - Matthias Jacquet-Lagreze
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron Cedex, France; Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon Cedex, France; Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Bron Cedex, France
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3
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Zhu MZ, Marasco SF, Evans RG, Kaye DM, McGiffin DC. Acute Kidney Injury after Heart Transplantation: Risk Stratification is Good; Risk Modification is Better-But can we do it? Transplant Direct 2024; 10:e1635. [PMID: 38769977 PMCID: PMC11104722 DOI: 10.1097/txd.0000000000001635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 05/22/2024] Open
Affiliation(s)
- Michael Z.L. Zhu
- Department of Cardiothoracic Surgery and Transplantation, The Alfred Hospital, Melbourne, VIC, Australia
- Department of Surgery, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, VIC, Australia
| | - Silvana F. Marasco
- Department of Cardiothoracic Surgery and Transplantation, The Alfred Hospital, Melbourne, VIC, Australia
- Department of Surgery, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Roger G. Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, VIC, Australia
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - David M. Kaye
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - David C. McGiffin
- Department of Cardiothoracic Surgery and Transplantation, The Alfred Hospital, Melbourne, VIC, Australia
- Department of Surgery, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Brisbane, QLD, Australia
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4
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O'Hanlon CJ, Sumpter A, Anderson BJ, Hannam JA. Time-Varying Clearance in Milrinone Pharmacokinetics from Premature Neonates to Adolescents. Clin Pharmacokinet 2024; 63:695-706. [PMID: 38613610 PMCID: PMC11106138 DOI: 10.1007/s40262-024-01372-5] [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] [Accepted: 03/19/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND AND OBJECTIVES Milrinone is an inotrope and vasodilator used for prophylaxis or treatment of low cardiac output syndrome after weaning from cardiopulmonary bypass (CPB). It is renally eliminated and has an acceptable therapeutic range of 100-300 μg/L, but weight-based dosing alone is associated with poor target attainment. We aimed to develop a population pharmacokinetic model for milrinone from premature neonates to adolescents, and to evaluate how age, renal function and recovery from CPB may impact dose selection. METHODS Fifty paediatric patients (aged 4 days to 16 years) were studied after undergoing cardiac surgery supported by CPB. Data from 29 premature neonates (23-28 weeks' postmenstrual age) treated for prophylaxis of low systemic blood flow were available for a pooled pharmacokinetic analysis. Population parameters were estimated using non-linear mixed effects modelling (NONMEM 7.5.1). RESULTS There were 369 milrinone measurements available for analysis. A one-compartment model with zero-order input and first-order elimination was used to describe milrinone disposition. Population parameters were clearance 17.8 L/70 kg [95% CI 15.8-19.9] and volume 20.4 L/h/70 kg [95% CI 17.8-22.1]. Covariates included size, postmenstrual age and renal function for clearance, and size and postnatal age for volume. Milrinone clearance is reduced by 39.5% [95% CI 24.0-53.7] immediately after bypass, and recovers to baseline clearance with a half-time of 12.0 h [95% CI 9.7-15.2]. Milrinone volume was 2.07 [95% CI 1.87-2.27] times greater at birth than the population standard and decreased over the first days of life with a half-time of 0.977 days [95% CI 0.833-1.12]. CONCLUSION Milrinone is predominately renally eliminated and so renal function is an important covariate describing variability in clearance. Increasing clearance over time likely reflects increasing cardiac output and renal perfusion due to milrinone and return to baseline following CPB.
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Affiliation(s)
- Conor J O'Hanlon
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Anita Sumpter
- Department of Anaesthesia, Auckland Hospital, Auckland, New Zealand
| | - Brian J Anderson
- Department of Anaesthesia, Auckland Hospital, Auckland, New Zealand
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Jacqueline A Hannam
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand.
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Evans RG, Cochrane AD, Hood SG, Marino B, Iguchi N, Bellomo R, McCall PR, Okazaki N, Jufar AH, Miles LF, Furukawa T, Ow CPC, Raman J, May CN, Lankadeva YR. Differential responses of cerebral and renal oxygenation to altered perfusion conditions during experimental cardiopulmonary bypass in sheep. Clin Exp Pharmacol Physiol 2024; 51:e13852. [PMID: 38452756 DOI: 10.1111/1440-1681.13852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 01/23/2024] [Accepted: 02/13/2024] [Indexed: 03/09/2024]
Abstract
We tested whether the brain and kidney respond differently to cardiopulmonary bypass (CPB) and to changes in perfusion conditions during CPB. Therefore, in ovine CPB, we assessed regional cerebral oxygen saturation (rSO2 ) by near-infrared spectroscopy and renal cortical and medullary tissue oxygen tension (PO2 ), and, in some protocols, brain tissue PO2 , by phosphorescence lifetime oximetry. During CPB, rSO2 correlated with mixed venous SO2 (r = 0.78) and brain tissue PO2 (r = 0.49) when arterial PO2 was varied. During the first 30 min of CPB, brain tissue PO2 , rSO2 and renal cortical tissue PO2 did not fall, but renal medullary tissue PO2 did. Nevertheless, compared with stable anaesthesia, during stable CPB, rSO2 (66.8 decreasing to 61.3%) and both renal cortical (90.8 decreasing to 43.5 mm Hg) and medullary (44.3 decreasing to 19.2 mm Hg) tissue PO2 were lower. Both rSO2 and renal PO2 increased when pump flow was increased from 60 to 100 mL kg-1 min-1 at a target arterial pressure of 70 mm Hg. They also both increased when pump flow and arterial pressure were increased simultaneously. Neither was significantly altered by partially pulsatile flow. The vasopressor, metaraminol, dose-dependently decreased rSO2 , but increased renal cortical and medullary PO2 . Increasing blood haemoglobin concentration increased rSO2 , but not renal PO2 . We conclude that both the brain and kidney are susceptible to hypoxia during CPB, which can be alleviated by increasing pump flow, even without increasing arterial pressure. However, increasing blood haemoglobin concentration increases brain, but not kidney oxygenation, whereas vasopressor support with metaraminol increases kidney, but not brain oxygenation.
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Affiliation(s)
- Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
- 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
| | - Sally G Hood
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Bruno Marino
- Cellsaving and Perfusion Resources, Melbourne, Victoria, Australia
| | - Naoya Iguchi
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Rinaldo Bellomo
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
| | - Peter R McCall
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Nobuki Okazaki
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Department of Anesthesiology and Resuscitology, Okayama University, Okayama, Japan
| | - Alemayehu H Jufar
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Lachlan F Miles
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Taku Furukawa
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Connie P C Ow
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Jaishankar Raman
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Clive N May
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
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Francica A, Mazzeo G, Galeone A, Linardi D, San Biagio L, Luciani GB, Onorati F. Mean Arterial Pressure (MAP) Trial: study protocol for a multicentre, randomized, controlled trial to compare three different strategies of mean arterial pressure management during cardiopulmonary bypass. Trials 2024; 25:191. [PMID: 38491507 PMCID: PMC10941373 DOI: 10.1186/s13063-024-07992-3] [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: 03/03/2023] [Accepted: 02/16/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND One of the main goals of cardiopulmonary bypass (CPB) is targeting an adequate mean arterial pressure (MAP) during heart surgery, in order to maintain appropriate perfusion pressures in all end-organs. As inheritance of early studies, a value of 50-60 mmHg has been historically accepted as the "gold standard" MAP. However, in the last decades, the CPB management has remarkably changed, thanks to the evolution of technology and the availability of new biomaterials. Therefore, as highlighted by the latest European Guidelines, the current management of CPB can no longer refer to those pioneering studies. To date, only few single-centre studies have compared different strategies of MAP management during CPB, but with contradictory findings and without achieving a real consensus. Therefore, what should be the ideal strategy of MAP management during CPB is still on debate. This trial is the first multicentre, randomized, controlled study which compares three different strategies of MAP management during the CPB. METHODS We described herein the methodology of a multicentre, randomized, controlled trial comparing three different approaches to MAP management during CPB in patients undergoing elective cardiac surgery: the historically accepted "standard MAP" (50-60 mmHg), the "high MAP" (70-80 mmHg) and the "patient-tailored MAP" (comparable to the patient's preoperative MAP). It is the aim of the study to find the most suitable management in order to obtain the most adequate perfusion of end-organs during cardiac surgery. For this purpose, the primary endpoint will be the peak of serum lactate (Lmax) released during CPB, as index of tissue hypoxia. The secondary outcomes will include all the intraoperative parameters of tissue oxygenation and major postoperative complications related to organ malperfusion. DISCUSSION This trial will assess the best strategy to target the MAP during CPB, thus further improving the outcomes of cardiac surgery. TRIAL REGISTRATION NCT05740397 (retrospectively registered; 22/02/2023).
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Affiliation(s)
- Alessandra Francica
- Division of Cardiac Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy.
| | - Gina Mazzeo
- Division of Cardiac Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy
| | - Antonella Galeone
- Division of Cardiac Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy
| | - Daniele Linardi
- Division of Cardiac Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy
| | - Livio San Biagio
- Division of Cardiac Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy
| | - Giovanni Battista Luciani
- Division of Cardiac Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy
| | - Francesco Onorati
- Division of Cardiac Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Piazzale Stefani 1, 37126, Verona, Italy
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7
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Rasmussen SB, Jeppesen KK, Kjaergaard J, Hassager C, Schmidt H, Mølstrøm S, Beske RP, Grand J, Ravn HB, Winther-Jensen M, Meyer MAS, Møller JE. Blood Pressure and Oxygen Targets on Kidney Injury After Cardiac Arrest. Circulation 2023; 148:1860-1869. [PMID: 37791480 DOI: 10.1161/circulationaha.123.066012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 09/06/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) represents a common and serious complication to out-of-hospital cardiac arrest. The importance of post-resuscitation care targets for blood pressure and oxygenation for the development of AKI is unknown. METHODS This is a substudy of a randomized 2-by-2 factorial trial, in which 789 comatose adult patients who had out-of-hospital cardiac arrest with presumed cardiac cause and sustained return of spontaneous circulation were randomly assigned to a target mean arterial blood pressure of either 63 or 77 mm Hg. Patients were simultaneously randomly assigned to either a restrictive oxygen target of a partial pressure of arterial oxygen (Pao2) of 9 to 10 kPa or a liberal oxygenation target of a Pao2 of 13 to 14 kPa. The primary outcome for this study was AKI according to KDIGO (Kidney Disease: Improving Global Outcomes) classification in patients surviving at least 48 hours (N=759). Adjusted logistic regression was performed for patients allocated to high blood pressure and liberal oxygen target as reference. RESULTS The main population characteristics at admission were: age, 64 (54-73) years; 80% male; 90% shockable rhythm; and time to return of spontaneous circulation, 18 (12-26) minutes. Patients allocated to a low blood pressure and liberal oxygen target had an increased risk of developing AKI compared with patients with high blood pressure and liberal oxygen target (84/193 [44%] versus 56/187 [30%]; adjusted odds ratio, 1.87 [95% CI, 1.21-2.89]). Multinomial logistic regression revealed that the increased risk of AKI was only related to mild-stage AKI (KDIGO stage 1). There was no difference in risk of AKI in the other groups. Plasma creatinine remained high during hospitalization in the low blood pressure and liberal oxygen target group but did not differ between groups at 6- and 12-month follow-up. CONCLUSIONS In comatose patients who had been resuscitated after out-of-hospital cardiac arrest, patients allocated to a combination of a low mean arterial blood pressure and a liberal oxygen target had a significantly increased risk of mild-stage AKI. No difference was found in terms of more severe AKI stages or other kidney-related adverse outcomes, and creatinine had normalized at 1 year after discharge. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03141099.
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Affiliation(s)
- Sebastian Buhl Rasmussen
- Department of Anesthesiology and Intensive Care (S.B.R., H.S., S.M., H.B.R., M.A.S.M.), Odense University Hospital, Denmark
| | | | - Jesper Kjaergaard
- Department of Cardiology, the Heart Center, Copenhagen University Hospital Rigshospitalet, Denmark (J.K., C.H., R.P.B., J.G., M.W.-J., J.E.M.)
- Department of Clinical Medicine, University of Copenhagen, Denmark (J.K., C.H.)
| | - Christian Hassager
- Department of Cardiology, the Heart Center, Copenhagen University Hospital Rigshospitalet, Denmark (J.K., C.H., R.P.B., J.G., M.W.-J., J.E.M.)
- Department of Clinical Medicine, University of Copenhagen, Denmark (J.K., C.H.)
| | - Henrik Schmidt
- Department of Anesthesiology and Intensive Care (S.B.R., H.S., S.M., H.B.R., M.A.S.M.), Odense University Hospital, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense (H.S., H.B.R., J.E.M.)
| | - Simon Mølstrøm
- Department of Anesthesiology and Intensive Care (S.B.R., H.S., S.M., H.B.R., M.A.S.M.), Odense University Hospital, Denmark
| | - Rasmus Paulin Beske
- Department of Cardiology, the Heart Center, Copenhagen University Hospital Rigshospitalet, Denmark (J.K., C.H., R.P.B., J.G., M.W.-J., J.E.M.)
| | - Johannes Grand
- Department of Cardiology, the Heart Center, Copenhagen University Hospital Rigshospitalet, Denmark (J.K., C.H., R.P.B., J.G., M.W.-J., J.E.M.)
| | - Hanne Berg Ravn
- Department of Anesthesiology and Intensive Care (S.B.R., H.S., S.M., H.B.R., M.A.S.M.), Odense University Hospital, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense (H.S., H.B.R., J.E.M.)
| | - Matilde Winther-Jensen
- Department of Cardiology, the Heart Center, Copenhagen University Hospital Rigshospitalet, Denmark (J.K., C.H., R.P.B., J.G., M.W.-J., J.E.M.)
| | - Martin Abild Stengaard Meyer
- Department of Anesthesiology and Intensive Care (S.B.R., H.S., S.M., H.B.R., M.A.S.M.), Odense University Hospital, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology (K.K.J., J.E.M.), Odense University Hospital, Denmark
- Department of Cardiology, the Heart Center, Copenhagen University Hospital Rigshospitalet, Denmark (J.K., C.H., R.P.B., J.G., M.W.-J., J.E.M.)
- Department of Clinical Research, University of Southern Denmark, Odense (H.S., H.B.R., J.E.M.)
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8
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Noe KM, Don A, Cochrane AD, Zhu MZL, Ngo JP, Smith JA, Thrift AG, Vogiatjis J, Martin A, Bellomo R, McMillan J, Evans RG. Intraoperative hemodynamics and risk of cardiac surgery-associated acute kidney injury: An observation study and a feasibility clinical trial. Clin Exp Pharmacol Physiol 2023; 50:878-892. [PMID: 37549882 PMCID: PMC10947000 DOI: 10.1111/1440-1681.13812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 06/21/2023] [Accepted: 07/18/2023] [Indexed: 08/09/2023]
Abstract
Targeting greater pump flow and mean arterial pressure (MAP) during cardiopulmonary bypass (CPB) could potentially alleviate renal hypoxia and reduce the risk of postoperative acute kidney injury (AKI). Therefore, in an observational study of 93 patients undergoing on-pump cardiac surgery, we tested whether intraoperative hemodynamic management differed between patients who did and did not develop AKI. Then, in 20 patients, we assessed the feasibility of a larger-scale trial in which patients would be randomized to greater than normal target pump flow and MAP, or usual care, during CPB. In the observational cohort, MAP during hypothermic CPB averaged 68.8 ± 8.0 mmHg (mean ± SD) in the 36 patients who developed AKI and 68.9 ± 6.3 mmHg in the 57 patients who did not (p = 0.98). Pump flow averaged 2.4 ± 0.2 L/min/m2 in both groups. In the feasibility clinical trial, compared with usual care, those randomized to increased target pump flow and MAP had greater mean pump flow (2.70 ± 0.23 vs. 2.42 ± 0.09 L/min/m2 during the period before rewarming) and systemic oxygen delivery (363 ± 60 vs. 281 ± 45 mL/min/m2 ). Target MAP ≥80 mmHg was achieved in 66.6% of patients in the intervention group but in only 27.3% of patients in the usual care group. Nevertheless, MAP during CPB did not differ significantly between the two groups. We conclude that little insight was gained from our observational study regarding the impact of variations in pump flow and MAP on the risk of AKI. However, a clinical trial to assess the effects of greater target pump flow and MAP on the risk of AKI appears feasible.
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Affiliation(s)
- Khin M Noe
- Cardiovascular Disease Program, Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Andrea Don
- Cardiovascular Disease Program, Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
| | - Andrew D Cochrane
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
- Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Michael Z L Zhu
- Cardiovascular Disease Program, Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
- Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Jennifer P Ngo
- Cardiovascular Disease Program, Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
- Department of Cardiac Physiology, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Julian A Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
- Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Amanda G Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Johnny Vogiatjis
- Cardiovascular Disease Program, Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
| | - Andrew Martin
- Cardiovascular Disease Program, Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
- Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - James McMillan
- Perfusion Services Pty Ltd, Melbourne, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Department of Physiology, Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
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9
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Rasmussen SB, Boyko Y, Ranucci M, de Somer F, Ravn HB. Cardiac surgery-Associated acute kidney injury - A narrative review. Perfusion 2023:2676591231211503. [PMID: 37905794 DOI: 10.1177/02676591231211503] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Cardiac Surgery-Associated Acute Kidney Injury (CSA-AKI) is a serious complication seen in approximately 20-30% of cardiac surgery patients. The underlying pathophysiology is complex, often involving both patient- and procedure related risk factors. In contrast to AKI occurring after other types of major surgery, the use of cardiopulmonary bypass comprises both additional advantages and challenges, including non-pulsatile flow, targeted blood flow and pressure as well as the ability to manipulate central venous pressure (congestion). With an increasing focus on the impact of CSA-AKI on both short and long-term mortality, early identification and management of high-risk patients for CSA-AKI has evolved. The present narrative review gives an up-to-date summary on definition, diagnosis, underlying pathophysiology, monitoring and implications of CSA-AKI, including potential preventive interventions. The review will provide the reader with an in-depth understanding of how to identify, support and provide a more personalized and tailored perioperative management to avoid development of CSA-AKI.
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Affiliation(s)
- Sebastian Buhl Rasmussen
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Yuliya Boyko
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesiology and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | | | - Hanne Berg Ravn
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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10
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Dang PT, Lopez BE, Togashi K. A Decrease in Effective Renal Perfusion Pressure Is Associated With Increased Acute Kidney Injury in Patients Undergoing Cardiac Surgery. Cureus 2023; 15:e45036. [PMID: 37829983 PMCID: PMC10566397 DOI: 10.7759/cureus.45036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 10/14/2023] Open
Abstract
PURPOSE This study aimed to evaluate the relationship between intra-abdominal pressure (IAP), renal perfusion indices, and postoperative acute kidney injury (AKI) in cardiac patients. METHODS In a prospective cohort study conducted at a single academic institution, we collected data from adult patients undergoing open-heart operations with cardiopulmonary bypass (CPB) at our institution from February 2022 to April 2022 using the Accuryn SmartFoley system® (Potrero Medical, Hayward, CA). Patients on mechanical support devices, pregnant patients, and patients on hemodialysis were excluded. Demographics, hemodynamics, and mean airway pressure (mAir) were measured at the beginning of the cardiac operations and during the first four hours of ICU. Renal perfusion indices were then calculated (mean perfusion pressure (MPP) = mean arterial pressure (MAP) - central venous pressure (CVP); abdominal perfusion pressure (APP) = MAP - IAP; and effective renal perfusion pressure (eRPP) = MAP - (CVP + mAir + IAP)). Length of stay (LOS) was measured from the day of surgery to ICU discharge (ICU LOS) and hospital discharge (hospital LOS). RESULTS During the first four hours of ICU stay, the non-AKI group had lower IAP and higher renal perfusion indices (MPP, APP, and eRPP). Logistic regression showed high perfusion pressures correlated with lower postoperative AKI (all OR <1, p<0.05). The postoperative AKI group also had significantly longer ICU LOS (7.33 vs. 4.57 days) and hospital LOS (17.0 vs. 10.2 days). CONCLUSION Renal perfusion indices are a promising tool to predict postoperative AKI in cardiac surgery patients.
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Affiliation(s)
- Phat T Dang
- Anesthesiology and Perioperative Medicine, University of California Irvine Health, Orange, USA
| | - Balbino E Lopez
- Anesthesiology, University of California Irvine Health, Orange, USA
| | - Kei Togashi
- Anesthesiology and Critical Care, University of California Irvine Health, Orange, USA
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11
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Nam K, Nam JS, Kim HB, Chung J, Hwang IE, Ju JW, Bae J, Lee S, Cho YJ, Shim JK, Kwak YL, Chin JH, Choi IC, Lee EH, Jeon Y. Effects of intraoperative inspired oxygen fraction (FiO 2 0.3 vs 0.8) on patients undergoing off-pump coronary artery bypass grafting: the CARROT multicenter, cluster-randomized trial. Crit Care 2023; 27:286. [PMID: 37443130 PMCID: PMC10339585 DOI: 10.1186/s13054-023-04558-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND To maintain adequate oxygenation is of utmost importance in intraoperative care. However, clinical evidence supporting specific oxygen levels in distinct surgical settings is lacking. This study aimed to compare the effects of 30% and 80% oxygen in off-pump coronary artery bypass grafting (OPCAB). METHODS This multicenter trial was conducted in three tertiary hospitals from August 2019 to August 2021. Patients undergoing OPCAB were cluster-randomized to receive either 30% or 80% oxygen intraoperatively, based on the month when the surgery was performed. The primary endpoint was the length of hospital stay. Intraoperative hemodynamic data were also compared. RESULTS A total of 414 patients were cluster-randomized. Length of hospital stay was not different in the 30% oxygen group compared to the 80% oxygen group (median, 7.0 days vs 7.0 days; the sub-distribution hazard ratio, 0.98; 95% confidence interval [CI] 0.83-1.16; P = 0.808). The incidence of postoperative acute kidney injury was significantly higher in the 30% oxygen group than in the 80% oxygen group (30.7% vs 19.4%; odds ratio, 1.94; 95% CI 1.18-3.17; P = 0.036). Intraoperative time-weighted average mixed venous oxygen saturation was significantly higher in the 80% oxygen group (74% vs 64%; P < 0.001). The 80% oxygen group also had a significantly greater intraoperative time-weighted average cerebral regional oxygen saturation than the 30% oxygen group (56% vs 52%; P = 0.002). CONCLUSIONS In patients undergoing OPCAB, intraoperative administration of 80% oxygen did not decrease the length of hospital stay, compared to 30% oxygen, but may reduce postoperative acute kidney injury. Moreover, compared to 30% oxygen, intraoperative use of 80% oxygen improved oxygen delivery in patients undergoing OPCAB. Trial registration ClinicalTrials.gov (NCT03945565; April 8, 2019).
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Affiliation(s)
- Karam Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jae-Sik Nam
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hye-Bin Kim
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jaeyeon Chung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Medical Service Corps of the First Logistics Support Command, Wonju, Gangwon State, Republic of Korea
| | - In Eob Hwang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jae-Woo Ju
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jinyoung Bae
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Ajou University Medical Center, Ajou University School of Medicine, Suwon, Gyeonggi Province, Republic of Korea
| | - Seohee Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Lan Kwak
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji-Hyun Chin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - In-Cheol Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Eun-Ho Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
- Hana Anesthesia Clinic, Seoul, Republic of Korea.
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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12
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Yu Y, Wu H, Liu C, Zhang C, Song Y, Ma Y, Li H, Lou J, Liu Y, Cao J, Zhang H, Xu Z, Evans RG, Duan C, Mi W. Intraoperative renal desaturation and postoperative acute kidney injury in older patients undergoing liver resection: A prospective cohort study. J Clin Anesth 2023; 87:111084. [PMID: 36905791 DOI: 10.1016/j.jclinane.2023.111084] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 02/15/2023] [Accepted: 02/18/2023] [Indexed: 03/13/2023]
Abstract
STUDY OBJECTIVE To determine the association between intraoperative renal tissue desaturation as measured using near-infrared spectroscopy and increased likelihood of developing postoperative acute kidney injury (AKI) in older patients undergoing hepatectomy. DESIGN A multicenter prospective cohort study. SETTING The study was conducted at two tertiary hospitals in China from September 2020 to October 2021. PATIENTS 157 older patients (≥ 60 years) undergoing open hepatectomy surgery. INTERVENTIONS AND MEASUREMENTS Renal tissue oxygen saturation was continuously monitored during operation using near-infrared spectroscopy. The exposure of interest was intraoperative renal desaturation, defined as at least 20% relative decline in renal tissue oxygen saturation from baseline. The primary outcome was postoperative AKI, defined using the Kidney Disease: Improving Global Outcomes criteria according to the serum creatinine criteria. MAIN RESULTS Renal desaturation occurred in 70 of 157 patients. Postoperative AKI was observed in 23% (16/70) and 8% (7/87) of patients with versus without renal desaturation. Patients with renal desaturation were at higher risk of AKI than patients without renal desaturation (adjusted odds ratio 3.41, 95% confidence interval: 1.12-10.36, p = 0.031). Predictive performance was 65.2% sensitivity and 33.6% specificity for hypotension alone, 69.6% sensitivity and 59.7% specificity for renal desaturation alone, and 95.7% sensitivity and 26.9% specificity for combined use of hypotension and renal desaturation. CONCLUSIONS Intraoperative renal desaturation occurred in >40% in our sample of older patients undergoing liver resection and was associated with increased risk of AKI. Intraoperative near-infrared spectroscopy monitoring enhances the detection of AKI.
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Affiliation(s)
- Yao Yu
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Haotian Wu
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Chang Liu
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Changsheng Zhang
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yuxiang Song
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yulong Ma
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Hao Li
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jingsheng Lou
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yanhong Liu
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jiangbei Cao
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Huan Zhang
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Zhipeng Xu
- Department of Anesthesiology, the Affiliated Hospital of Medical School, Ningbo University, Ningbo, China
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia; Florey Institute of Neurosciences and Mental Health, University of Melbourne, Melbourne, Australia
| | - Chongyang Duan
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China.
| | - Weidong Mi
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China.
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13
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Vogiatjis J, Noe KM, Don A, Cochrane AD, Zhu MZL, Smith JA, Ngo JP, Martin A, Thrift AG, Bellomo R, Evans RG. Association Between Changes in Norepinephrine Infusion Rate and Urinary Oxygen Tension After Cardiac Surgery. J Cardiothorac Vasc Anesth 2023; 37:237-245. [PMID: 36435720 DOI: 10.1053/j.jvca.2022.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/04/2022] [Accepted: 11/06/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To determine if the administration of norepinephrine to patients recovering from on-pump cardiac surgery is associated with changes in urinary oxygen tension (PO2), an indirect index of renal medullary oxygenation. DESIGN Single center, prospective observational study. SETTING Surgical intensive care unit (ICU). PARTICIPANTS A nonconsecutive sample of 93 patients recovering from on-pump cardiac surgery. MEASUREMENTS AND MAIN RESULTS In the ICU, norepinephrine was the most commonly used vasopressor agent (90% of patients, 84/93), with fewer patients receiving epinephrine (48%, 45/93) or vasopressin (4%, 4/93). During the 30-to-60-minute period after increasing the infused dose of norepinephrine (n = 89 instances), urinary PO2 decreased by (least squares mean ± SEM) 1.8 ± 0.5 mmHg from its baseline level of 25.1 ± 1.1 mmHg. Conversely, during the 30-to-60-minute period after the dose of norepinephrine was decreased (n = 134 instances), urinary PO2 increased by 2.6 ± 0.5 mmHg from its baseline level of 22.7 ± 1.2 mmHg. No significant change in urinary PO2 was detected when the dose of epinephrine was decreased (n = 21). There were insufficient observations to assess the effects of increasing the dose of epinephrine (n = 11) or of changing the dose of vasopressin (n <4). CONCLUSIONS In patients recovering from on-pump cardiac surgery, changes in norepinephrine dose are associated with reciprocal changes in urinary PO2, potentially reflecting an effect of norepinephrine on renal medullary oxygenation.
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Affiliation(s)
- Johnny Vogiatjis
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - Khin M Noe
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia; Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Andrea Don
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - Andrew D Cochrane
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Cardiothoracic Surgery, Monash Health, Melbourne, Australia
| | - Michael Z L Zhu
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia; Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Cardiothoracic Surgery, Monash Health, Melbourne, Australia
| | - Julian A Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Cardiothoracic Surgery, Monash Health, Melbourne, Australia
| | - Jennifer P Ngo
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia; Department of Cardiac Physiology, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Andrew Martin
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia; Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Cardiothoracic Surgery, Monash Health, Melbourne, Australia
| | - Amanda G Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia; Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.
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14
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Gao P, Jin Y, Zhang P, Wang W, Hu J, Liu J. Nadir oxygen delivery is associated with postoperative acute kidney injury in low-weight infants undergoing cardiopulmonary bypass. Front Cardiovasc Med 2022; 9:1020846. [PMID: 36588567 PMCID: PMC9800598 DOI: 10.3389/fcvm.2022.1020846] [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] [Received: 08/16/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022] Open
Abstract
Background Acute kidney injury (AKI) is common after cardiac surgery with cardiopulmonary bypass (CPB) and is associated with increased mortality and morbidity. Nadir indexed oxygen delivery (DO2i) lower than the critical threshold during CPB is a risk factor for postoperative AKI. The critical DO2i for preventing AKI in children has not been well studied. The study aimed to explore the association between nadir DO2i and postoperative AKI in infant cardiac surgery with CPB. Methods From August 2021 to July 2022, 413 low-weight infants (≤10 kg) undergoing cardiac surgery with CPB were consecutively enrolled in this prospective observational study. Nadir DO2i was calculated during the hypothermia and rewarming phases of CPB, respectively. The association between nadir DO2i and postoperative AKI was investigated in mild hypothermia (32-34°C) and moderate hypothermia (26-32°C). Results A total of 142 (38.3%) patients developed postoperative AKI. In patients undergoing mild hypothermia during CPB, nadir DO2i in hypothermia and rewarming phases was independently associated with postoperative AKI. The cutoff values of nadir DO2i during hypothermia and rewarming phases were 258 mL/min/m2 and 281 mL/min/m2, respectively. There was no significant association between nadir DO2i and postoperative AKI in patients undergoing moderate hypothermia during CPB. Conclusion In low-weight infants undergoing mild hypothermia during CPB, the critical DO2i for preventing AKI was 258 mL/min/m2 in the hypothermia phase and 281 mL/min/m2 for rewarming. Moreover, an individualized critical DO2i threshold should be advocated during CPB.
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15
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Jing H, Liao M, Tang S, Lin S, Ye L, Zhong J, Wang H, Zhou J. Predicting the risk of acute kidney injury after cardiopulmonary bypass: development and assessment of a new predictive nomogram. BMC Anesthesiol 2022; 22:379. [PMID: 36476178 PMCID: PMC9727998 DOI: 10.1186/s12871-022-01925-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common and severe complication of cardiac surgery with cardiopulmonary bypass (CPB). This study aimed to establish a model to predict the probability of postoperative AKI in patients undergoing cardiac surgery with CPB. METHODS We conducted a retrospective, multicenter study to analyze 1082 patients undergoing cardiac surgery under CPB. The least absolute shrinkage and selection operator regression model was used to optimize feature selection for the AKI model. Multivariable logistic regression analysis was applied to build a prediction model incorporating the feature selected in the previously mentioned model. Finally, we used multiple methods to evaluate the accuracy and clinical applicability of the model. RESULTS Age, gender, hypertension, CPB duration, intraoperative 5% bicarbonate solution and red blood cell transfusion, urine volume were identified as important factors. Then, these risk factors were created into nomogram to predict the incidence of AKI after cardiac surgery under CPB. CONCLUSION We developed a nomogram to predict the incidence of AKI after cardiac surgery. This model can be used as a reference tool for evaluating early medical intervention to prevent postoperative AKI.
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Affiliation(s)
- Huan Jing
- grid.413107.0The Third Affiliated Hospital of Southern Medical University, 183 Zhongshan Avenue West, Tianhe District, Guangdong Province Guangzhou City, China
| | - Meijuan Liao
- grid.452881.20000 0004 0604 5998The First People’s Hospital of Foshan, 81 Lingnan Avenue, Chancheng District, Guangdong Province Foshan City, China
| | - Simin Tang
- grid.413107.0The Third Affiliated Hospital of Southern Medical University, 183 Zhongshan Avenue West, Tianhe District, Guangdong Province Guangzhou City, China
| | - Sen Lin
- grid.452881.20000 0004 0604 5998The First People’s Hospital of Foshan, 81 Lingnan Avenue, Chancheng District, Guangdong Province Foshan City, China
| | - Li Ye
- grid.452881.20000 0004 0604 5998The First People’s Hospital of Foshan, 81 Lingnan Avenue, Chancheng District, Guangdong Province Foshan City, China
| | - Jiying Zhong
- grid.452881.20000 0004 0604 5998The First People’s Hospital of Foshan, 81 Lingnan Avenue, Chancheng District, Guangdong Province Foshan City, China
| | - Hanbin Wang
- grid.452881.20000 0004 0604 5998The First People’s Hospital of Foshan, 81 Lingnan Avenue, Chancheng District, Guangdong Province Foshan City, China
| | - Jun Zhou
- grid.413107.0The Third Affiliated Hospital of Southern Medical University, 183 Zhongshan Avenue West, Tianhe District, Guangdong Province Guangzhou City, China
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16
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Vasavada A, Llerena-Velastegui J, Guevara-Espinoza S. Intraoperative renal hypoxia and risk of cardiac surgery-associated acute kidney injury. J Card Surg 2022; 37:5683. [PMID: 36153655 DOI: 10.1111/jocs.16975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 01/06/2023]
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17
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Ju JW, Yoo SJ, Park D, Bae J, Lee S, Nam K, Cho YJ, Lee HC, Jeon Y. Association between intraoperative plantar regional oxygen saturation and acute kidney injury after cardiac surgery. J Clin Monit Comput 2022; 37:525-540. [PMID: 36319881 DOI: 10.1007/s10877-022-00917-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 09/09/2022] [Indexed: 11/05/2022]
Abstract
Acute kidney injury (AKI) is one of the most common complications after cardiac surgery, associated with increased mortality and morbidity. Near-infrared spectroscopy (NIRS) continuously measures regional oxygen saturation(rSO2) in real-time. This exploratory retrospective study aimed to investigate the association between intraoperative plantar rSO2 and postoperative AKI in cardiac surgery patients. Between August 2019 and March 2021, 394 patients were included. Plantar and cerebral rSO2 were monitored using NIRS intraoperatively. The primary outcome was AKI within 7 postoperative days. The nonlinear association between plantar rSO2, cerebral rSO2, and mean arterial blood pressure (MBP) and AKI was assessed, and plantar rSO2<45% was related to an increased risk of AKI. Multivariable logistic regression analyses revealed that longer duration and higher area under the curve below plantar rSO2<45% and MBP<65 mmHg were more likely to be associated with increased odds of AKI. In additional multivariable regression analyses, association between plantar rSO2<45% and AKI was still maintained after adjusting the duration or AUC of MBP<65 mmHg as a covariate. Cerebral rSO2 levels were not associated with AKI. Independent of MAP, intraoperative plantar rSO2 was associated with AKI after cardiac surgery. However, intraoperative cerebral rSO2 was not associated with AKI. Intraoperative plantar rSO2 monitoring may be helpful in preventing AKI.
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18
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Ahmed A, Chaudhry M, Irshad A. Intraoperative renal hypoxia and risk of cardiac surgery-associated acute kidney injury. J Card Surg 2022; 37:4014. [PMID: 36047389 DOI: 10.1111/jocs.16893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 08/16/2022] [Indexed: 11/28/2022]
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Inoue T, Kohira S, Ebine T, Shikata F, Fujii K, Miyaji K. Monitoring of intraoperative femoral oxygenation predicts acute kidney injury after pediatric cardiac surgery. Int J Artif Organs 2022; 45:981-987. [PMID: 36032034 DOI: 10.1177/03913988221119527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cardiopulmonary bypass-associated acute kidney injury (CPB-AKI) is a pediatric cardiac surgery postoperative complication that is associated with a longer duration of mechanical ventilation and length of hospital stay. Identifying an early predictor of CPB-AKI is critical. Near infrared spectroscopy (NIRS), which can provide real-time monitoring of regional tissue oxygen saturation (rSO2) during CPB, may predict CPB-AKI in an early phase of surgical treatment. This study analyzed clinical data from 87 children who underwent an elective surgical repair of ventricular septal defect (VSD) from January 2013 to March 2019. NIRS sensors were placed on the patients' forehead, abdomen, and thighs. The pediatric modified risk, injury, failure, loss, and end-stage (p-RIFLE) score was determined for each patient postoperatively. The incidence of AKI based on the p-RIFLE classification was 11.5% at the end of surgery, 23.0% at 24 h after surgery, and 5.7% at 48 h after surgery. The AKI incidence rate was highest at 24 h after surgery. Multiple regression analysis revealed that femoral oxygenation (rSO2) during CPB, CPB time, oxygen delivery index (DO2i), and lactate at the end of CPB were independent risk factors for AKI. Receiver-operating characteristic curve analysis indicated that femoral oxygenation of 74% or less predicted AKI development within 24 h after surgery. In conclusion, rSO2 measured at the thigh during CPB is highly predictive of CPB-AKI.
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Affiliation(s)
- Takamichi Inoue
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Satoshi Kohira
- Department of Medical Engineering, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan
| | - Tomoyo Ebine
- Department of Medical Engineering, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan
| | - Fumiaki Shikata
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Kiyotaka Fujii
- Department of Medical Engineering, Kitasato University School of Allied Health Sciences, Sagamihara, Kanagawa, Japan
| | - Kagami Miyaji
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
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20
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Pal N, Abrams BA, Kertai M. Cardiothoracic Anesthesiology: Novel Milestone and Renewed Opportunities. Semin Cardiothorac Vasc Anesth 2022; 26:169-172. [DOI: 10.1177/10892532221121115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Nirvik Pal
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Benjamin A. Abrams
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Miklos Kertai
- Department of Anesthesiology, Vanderbilt University, Nashville, TN, USA
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21
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Jufar AH, May CN, Evans RG, Cochrane AD, Marino B, Hood SG, McCall PR, Bellomo R, Lankadeva YR. Influence of moderate-hypothermia on renal and cerebral haemodynamics and oxygenation during experimental cardiopulmonary bypass in sheep. Acta Physiol (Oxf) 2022; 236:e13860. [PMID: 35862484 DOI: 10.1111/apha.13860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 07/11/2022] [Accepted: 07/18/2022] [Indexed: 11/01/2022]
Abstract
AIM Cardiac surgery requiring cardiopulmonary bypass (CPB) can result in renal and cerebral injury. Intra-operative tissue hypoxia could contribute to such organ injury. Hypothermia, however, may alleviate organ hypoxia. Therefore, we tested whether moderate-hypothermia (30o C) improves cerebral and renal tissue perfusion and oxygenation during ovine CPB. METHODS Ten sheep were studied while conscious, under stable anaesthesia and during 3 hours of CPB. In a randomised within-animal cross-over design, 5 sheep commenced CPB at a target body temperature of 30 o C (moderate-hypothermia). After 90 minutes, body temperature was increased to 36 o C (standard-procedure). The remaining 5 sheep were randomised to the opposite order of target body temperature. RESULTS Compared with the standard-procedure, moderately-hypothermic CPB reduced renal oxygen delivery (-34.8 ± 19.6%, P = 0.003) and renal oxygen consumption (-42.7 ± 35.2%, P = 0.04). Nevertheless, moderately-hypothermic CPB did not significantly alter either renal cortical or medullary tissue PO2 . Moderately-hypothermic CPB also did not significantly alter cerebral perfusion, cerebral tissue PO2 , or cerebral oxygen saturation compared with the standard-procedure. Compared with anaesthetised state, standard-procedure reduced renal medullary PO2 (-21.0 ± 13.8 mmHg, P = 0.014) and cerebral oxygen saturation (65.0 ± 7.0 to 55.4 ± 9.6%, P = 0.022) but did not significantly alter either renal cortical or cerebral PO2 . CONCLUSION Ovine experimental CPB leads to renal medullary tissue hypoxia. Moderately-hypothermic CPB did not improve cerebral or renal tissue oxygenation. In the kidney, this is probably because renal tissue oxygen consumption is matched by reduced renal oxygen delivery.
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Affiliation(s)
- Alemayehu H Jufar
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
| | - Roger G Evans
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, 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
| | - Peter R McCall
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Rinaldo Bellomo
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Melbourne Medical School, University of Melbourne, Victoria, Australia
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22
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The lower threshold of hypothermic oxygen delivery to prevent neonatal acute kidney injury. Pediatr Res 2022; 91:1741-1747. [PMID: 34274961 DOI: 10.1038/s41390-021-01654-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/24/2021] [Accepted: 06/30/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Oxygen delivery during cardiopulmonary bypass (CPB) is closely related to postoperative acute kidney injury (AKI). The value of critical indexed oxygen delivery (DO2i) is a key indicator to reflect oxygen supply in cardiovascular surgery. However, the target DO2i value for neonates undergoing hypothermic CPB remains unclear. METHODS One hundred and twenty-six consecutive newborns (≤28 days) undergoing arterial switch operations were retrospectively divided into two groups according to AKI occurrence. Baseline characteristics, intraoperative variables, and clinical outcomes were collected. Multivariate logistic regression analysis and receiver-operating characteristic curve were performed to investigate the association between DO2i and AKI. RESULTS Neonates in the no-AKI group (n = 67) had significantly higher nadir bypass flow and DO2i during the hypothermic phase compared with the AKI group (n = 59). AKI group had remarkably higher incidences of hepatic dysfunction and peritoneal dialysis requirement compared with newborns without AKI. Mixed venous oxygen saturation (SvO2) was comparable between the two groups. Base excess (BE)(P = 0.011) value during the hypothermic phase of the AKI group was higher than the no-AKI group. Multivariate analysis showed that hypothermic DO2i was negatively associated with AKI. The cut-off value of hypothermic DO2i was 269 mL min-1 m-2. CONCLUSIONS The importance of hypothermic DO2i should be highlighted, even when SvO2 was satisfactory. A lower threshold of DO2i > 269 mL min-1 m-2 may help protect neonates from the risk of postoperative AKI. IMPACT The key message of our article is that the lower threshold of DO2i > 269 mL min-1 m-2 may help protect neonates from the risk of AKI after on-pump hypothermic cardiovascular surgery. The critical DO2i value for neonates undergoing hypothermic CPB remains unclear, and our study may add new evidence for this matter based on the 6-year experience of our center. In this study, the lowest critical value of DO2i in neonatal hypothermic CPB is determined for the first time, which provides a reference for intra-CPB management strategy to improve the postoperative outcomes of newborns.
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23
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Carrasco-Serrano E, Jorge-Monjas P, Muñoz-Moreno MF, Gómez-Sánchez E, Priede-Vimbela JM, Bardají-Carrillo M, Cubero-Gallego H, Tamayo E, Ortega-Loubon C. Impact of Oxygen Delivery on the Development of Acute Kidney Injury in Patients Undergoing Valve Heart Surgery. J Clin Med 2022; 11:jcm11113046. [PMID: 35683434 PMCID: PMC9180985 DOI: 10.3390/jcm11113046] [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: 04/11/2022] [Revised: 05/02/2022] [Accepted: 05/23/2022] [Indexed: 02/06/2023] Open
Abstract
One of the strongest risk factors for death in individuals undergoing cardiac surgery is Cardiac Surgery Associated-Acute Kidney Injury (CSA-AKI). Although the minimum kidney oxygen delivery index (DO2i) during cardiopulmonary bypass (CPB) has been reported, the optimal threshold value has not yet been established. A prospective study was conducted from June 2012 to January 2016 to asses how DO2i influences the pathogenesis of CSA-AKI, as well as its most favorable cut-off value. DO2 levels were recorded at the beginning, middle, and end of the CPB. The association between DO2i and CSA-AKI was investigated using multivariable logistic regression analysis. The optimal cut-off of DO2i as a predictor of CSA-AKI was determined using Classification and Regression Tree (CART) analysis. A total of 782 consecutive patients were enrolled. Of these, 231 (29.5%) patients developed AKI. Optimal DO2i thresholds of 303 mL/min/m2 during the CPB and 295 mL/min/m2 at the end of the intervention were identified, which increased the odds of CSA-AKI almost two-fold (Odds Ratio (OR), 1.90; 95% CI, 1.12–3.24) during the surgery and maintained that risk (OR 1.94; 95% CI, 1.15–3.29) until the end. Low DO2i during cardiopulmonary bypass is a risk factor for CSA-AKI that cannot be ruled out. Continuous renal oxygen supply monitoring for adult patients could be a promising method for predicting AKI during CPB.
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Affiliation(s)
- Elena Carrasco-Serrano
- BioCritic, Group for Biomedical Research in Critical Care Medicine, 47003 Valladolid, Spain; (E.C.-S.); (P.J.-M.); (J.M.P.-V.); (M.B.-C.); (E.T.); (C.O.-L.)
- Anesthesiology and Critical Care, Clinical University Hospital of Valladolid, 47003 Valladolid, Spain
| | - Pablo Jorge-Monjas
- BioCritic, Group for Biomedical Research in Critical Care Medicine, 47003 Valladolid, Spain; (E.C.-S.); (P.J.-M.); (J.M.P.-V.); (M.B.-C.); (E.T.); (C.O.-L.)
- Anesthesiology and Critical Care, Clinical University Hospital of Valladolid, 47003 Valladolid, Spain
- Department of Surgery, University of Valladolid, 47003 Valladolid, Spain
| | - María Fé Muñoz-Moreno
- Unit of Research, Clinical University Hospital of Valladolid, 47003 Valladolid, Spain;
| | - Esther Gómez-Sánchez
- BioCritic, Group for Biomedical Research in Critical Care Medicine, 47003 Valladolid, Spain; (E.C.-S.); (P.J.-M.); (J.M.P.-V.); (M.B.-C.); (E.T.); (C.O.-L.)
- Anesthesiology and Critical Care, Clinical University Hospital of Valladolid, 47003 Valladolid, Spain
- Department of Surgery, University of Valladolid, 47003 Valladolid, Spain
- Correspondence:
| | - Juan Manuel Priede-Vimbela
- BioCritic, Group for Biomedical Research in Critical Care Medicine, 47003 Valladolid, Spain; (E.C.-S.); (P.J.-M.); (J.M.P.-V.); (M.B.-C.); (E.T.); (C.O.-L.)
- Anesthesiology and Critical Care, Clinical University Hospital of Valladolid, 47003 Valladolid, Spain
| | - Miguel Bardají-Carrillo
- BioCritic, Group for Biomedical Research in Critical Care Medicine, 47003 Valladolid, Spain; (E.C.-S.); (P.J.-M.); (J.M.P.-V.); (M.B.-C.); (E.T.); (C.O.-L.)
- Anesthesiology and Critical Care, Clinical University Hospital of Valladolid, 47003 Valladolid, Spain
| | - Héctor Cubero-Gallego
- Interventional Cardiology Unit, Cardiology Department, Hospital del Mar, 08003 Barcelona, Spain;
| | - Eduardo Tamayo
- BioCritic, Group for Biomedical Research in Critical Care Medicine, 47003 Valladolid, Spain; (E.C.-S.); (P.J.-M.); (J.M.P.-V.); (M.B.-C.); (E.T.); (C.O.-L.)
- Anesthesiology and Critical Care, Clinical University Hospital of Valladolid, 47003 Valladolid, Spain
- Department of Surgery, University of Valladolid, 47003 Valladolid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Christian Ortega-Loubon
- BioCritic, Group for Biomedical Research in Critical Care Medicine, 47003 Valladolid, Spain; (E.C.-S.); (P.J.-M.); (J.M.P.-V.); (M.B.-C.); (E.T.); (C.O.-L.)
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24
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Lankadeva YR, May CN, Bellomo R, Evans RG. Role of perioperative hypotension in postoperative acute kidney injury: a narrative review. Br J Anaesth 2022; 128:931-948. [DOI: 10.1016/j.bja.2022.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/17/2022] [Accepted: 03/01/2022] [Indexed: 12/20/2022] Open
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25
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Jufar AH, Lankadeva YR, May CN, Cochrane AD, Marino B, Bellomo R, Evans RG. Renal and Cerebral Hypoxia and Inflammation During Cardiopulmonary Bypass. Compr Physiol 2021; 12:2799-2834. [PMID: 34964119 DOI: 10.1002/cphy.c210019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cardiac surgery-associated acute kidney injury and brain injury remain common despite ongoing efforts to improve both the equipment and procedures deployed during cardiopulmonary bypass (CPB). The pathophysiology of injury of the kidney and brain during CPB is not completely understood. Nevertheless, renal (particularly in the medulla) and cerebral hypoxia and inflammation likely play critical roles. Multiple practical factors, including depth and mode of anesthesia, hemodilution, pump flow, and arterial pressure can influence oxygenation of the brain and kidney during CPB. Critically, these factors may have differential effects on these two vital organs. Systemic inflammatory pathways are activated during CPB through activation of the complement system, coagulation pathways, leukocytes, and the release of inflammatory cytokines. Local inflammation in the brain and kidney may be aggravated by ischemia (and thus hypoxia) and reperfusion (and thus oxidative stress) and activation of resident and infiltrating inflammatory cells. Various strategies, including manipulating perfusion conditions and administration of pharmacotherapies, could potentially be deployed to avoid or attenuate hypoxia and inflammation during CPB. Regarding manipulating perfusion conditions, based on experimental and clinical data, increasing standard pump flow and arterial pressure during CPB appears to offer the best hope to avoid hypoxia and injury, at least in the kidney. Pharmacological approaches, including use of anti-inflammatory agents such as dexmedetomidine and erythropoietin, have shown promise in preclinical models but have not been adequately tested in human trials. However, evidence for beneficial effects of corticosteroids on renal and neurological outcomes is lacking. © 2021 American Physiological Society. Compr Physiol 11:1-36, 2021.
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Affiliation(s)
- Alemayehu H Jufar
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,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.,Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of 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
| | - Rinaldo Bellomo
- Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia.,Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
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26
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Noe KM, Ngo JP, Martin A, Zhu MZL, Cochrane AD, Smith JA, Thrift AG, Singh H, Evans RG. Intra-operative and early post-operative prediction of cardiac surgery-associated acute kidney injury: Urinary oxygen tension compared with plasma and urinary biomarkers. Clin Exp Pharmacol Physiol 2021; 49:228-241. [PMID: 34674291 DOI: 10.1111/1440-1681.13603] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/11/2021] [Accepted: 10/19/2021] [Indexed: 12/29/2022]
Abstract
Acute kidney injury (AKI) is a common and serious post-operative complication of cardiac surgery. The value of a predictive biomarker is determined not only by its predictive efficacy, but also by how early this prediction can be made. For a biomarker of cardiac surgery-associated AKI, this is ideally during the intra-operative period. Therefore, in 82 adult patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB), we prospectively compared the predictive efficacy of various blood and urinary biomarkers with that of continuous measurement of urinary oxygen tension (UPO2 ) at pre-determined intra- and post-operative time-points. None of the blood or urine biomarkers we studied showed predictive efficacy for post-operative AKI when measured intra-operatively. When treated as a binary variable (≤ or > median for the whole cohort), the earliest excess risk of AKI was predicted by an increase in urinary neutrophil gelatinase-associated lipocalin (NGAL) at 3 h after entry into the intensive care unit (odds ratio [95% confidence limits], 2.86 [1.14-7.21], p = 0.03). Corresponding time-points were 6 h for serum creatinine (3.59 [1.40-9.20], p = 0.008), and 24 h for plasma NGAL (4.54 [1.73-11.90], p = 0.002) and serum cystatin C (6.38 [2.35-17.27], p = 0.001). In contrast, indices of intra-operative urinary hypoxia predicted AKI after weaning from CPB, and in the case of a fall in UPO2 to ≤10 mmHg, during the rewarming phase of CPB (3.00 [1.19-7.56], p = 0.02). We conclude that continuous measurement of UPO2 predicts AKI earlier than plasma or urinary NGAL, serum cystatin C, or early post-operative changes in serum creatinine.
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Affiliation(s)
- Khin M Noe
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Jennifer P Ngo
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Department of Cardiac Physiology, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Andrew Martin
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Michael Z L Zhu
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Andrew D Cochrane
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Julian A Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Amanda G Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Harshil Singh
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
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27
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Lee CJ, Gardiner BS, Evans RG, Smith DW. Predicting oxygen tension along the ureter. Am J Physiol Renal Physiol 2021; 321:F527-F547. [PMID: 34459223 DOI: 10.1152/ajprenal.00122.2021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Continuous measurement of bladder urine oxygen tension (Po2) is a method to potentially detect renal medullary hypoxia in patients at risk of acute kidney injury (AKI). To assess its practicality, we developed a computational model of the peristaltic movement of a urine bolus along the ureter and the oxygen exchange between the bolus and ureter wall. This model quantifies the changes in urine Po2 as urine transits from the renal pelvis to the bladder. The model parameters were calibrated using experimental data in rabbits, such that most of the model predictions are within ±1 SE of the reported mean in the experiment, with the average percent difference being 7.0%. Based on parametric experiments performed using a model scaled to the geometric dimensions of a human ureter, we found that bladder urine Po2 is strongly dependent on the bolus volume (i.e., bolus volume-to-surface area ratio), especially at a volume less than its physiological (baseline) volume (<0.2 mL). For the model assumptions, changes in peristaltic frequency resulted in a minimal change in bladder urine Po2 (<1 mmHg). The model also predicted that there exists a family of linear relationships between the bladder-urine Po2 and pelvic urine Po2 for different input conditions. We conclude that it may technically be possible to predict renal medullary Po2 based on the measurement of bladder urine Po2, provided that there are accurate real-time measurements of model input parameters.NEW & NOTEWORTHY Measurement of bladder urine oxygen tension has been proposed as a new method to potentially detect the risk of acute kidney injury in patients. A computational model of oxygen exchange between urine bolus and ureteral tissue shows that it may be technically possible to determine the risk of acute kidney injury based on the measurement of bladder urine oxygen tension, provided that the measurement data are properly interpreted via a computational model.
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Affiliation(s)
- Chang-Joon Lee
- College of Science, Health, Engineering and Education, Murdoch University, Perth, Western Australia, Australia.,Faculty of Engineering and Mathematical Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Bruce S Gardiner
- College of Science, Health, Engineering and Education, Murdoch University, Perth, Western Australia, Australia.,Faculty of Engineering and Mathematical Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
| | - David W Smith
- Faculty of Engineering and Mathematical Sciences, The University of Western Australia, Perth, Western Australia, Australia
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28
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Smoor RM, van Dongen EPA, Verwijmeren L, Schreurs IAAM, Vernooij LM, van Klei WA, Noordzij PG. Critical oxygen delivery threshold during cardiopulmonary bypass in older cardiac surgery patients with increased frailty risk. Eur J Cardiothorac Surg 2021; 61:685-692. [PMID: 34448850 DOI: 10.1093/ejcts/ezab396] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/02/2021] [Accepted: 07/08/2021] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Older patients have a higher cardiac surgery-associated acute kidney injury (CSA-AKI) related mortality. Low oxygen delivery (DO2) during cardiopulmonary bypass (CPB) is a risk factor for CSA-AKI, but critical DO2 thresholds for older patients are unknown. This study investigated critical DO2 thresholds for CSA-AKI in patients ≥70 years undergoing on-pump cardiac surgery. METHODS Patients were enrolled from July 2015 until August 2017. CPB data from 432 patients were collected, and DO2 values were calculated per minute. The primary outcome was CSA-AKI. The association between DO2 and CSA-AKI was analysed with multivariable regression analysis. Multiple DO2 thresholds were analysed. The association between CSA-AKI and the area below the DO2 thresholds (DO2 deficit) was evaluated, as was the association between frailty and CSA-AKI. RESULTS CSA-AKI occurred in 63 (14.6%) patients. Mean and nadir (lowest) DO2 values were lower in patients with CSA-AKI (283 vs 312 ml/min/m2; P-value <0.001 and 238 vs 270 ml/min/m2; P-value <0.001, respectively). The adjusted relative risk for CSA-AKI was 1.006 [99% confidence interval (CI) 1.001-1.012] per ml/min/m2 nadir DO2 decrease. The critical DO2 threshold was 270 ml/min/m2 [adjusted relative risk 2.06 (99% CI 1.33-2.80)]. The DO2 deficit below 270 ml/min/m2 was associated with CSA-AKI [adjusted relative risk 2.84 (99% CI 1.87-3.81)]. No association between frailty and CSA-AKI was found (P = 0.82). CONCLUSIONS Low DO2 increased the risk for CSA-AKI in older patients who had cardiac surgery. A critical DO2 threshold of 270 ml/min/m2 was applicable for frail and non-frail patients. The efficacy of a DO2 >270 ml/min/m2 to reduce CSA-AKI in older patients needs further evaluation.
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Affiliation(s)
- Rosa M Smoor
- Department of Anaesthesiology, Intensive Care, and Pain Medicine, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Eric P A van Dongen
- Department of Anaesthesiology, Intensive Care, and Pain Medicine, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Lisa Verwijmeren
- Department of Anaesthesiology, Intensive Care, and Pain Medicine, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Inge A A M Schreurs
- Department of Extra-Corporeal Circulation, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Lisette M Vernooij
- Department of Anaesthesiology, Intensive Care, and Pain Medicine, St. Antonius Hospital, Nieuwegein, Netherlands.,Department of Anaesthesiology, Intensive Care, and Pain Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
| | - Wilton A van Klei
- Department of Anaesthesiology, Intensive Care, and Pain Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
| | - Peter G Noordzij
- Department of Anaesthesiology, Intensive Care, and Pain Medicine, St. Antonius Hospital, Nieuwegein, Netherlands
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Ow CPC, Trask-Marino A, Betrie AH, Evans RG, May CN, Lankadeva YR. Targeting Oxidative Stress in Septic Acute Kidney Injury: From Theory to Practice. J Clin Med 2021; 10:jcm10173798. [PMID: 34501245 PMCID: PMC8432047 DOI: 10.3390/jcm10173798] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/17/2021] [Accepted: 08/23/2021] [Indexed: 12/17/2022] Open
Abstract
Sepsis is the leading cause of acute kidney injury (AKI) and leads to increased morbidity and mortality in intensive care units. Current treatments for septic AKI are largely supportive and are not targeted towards its pathophysiology. Sepsis is commonly characterized by systemic inflammation and increased production of reactive oxygen species (ROS), particularly superoxide. Concomitantly released nitric oxide (NO) then reacts with superoxide, leading to the formation of reactive nitrogen species (RNS), predominantly peroxynitrite. Sepsis-induced ROS and RNS can reduce the bioavailability of NO, mediating renal microcirculatory abnormalities, localized tissue hypoxia and mitochondrial dysfunction, thereby initiating a propagating cycle of cellular injury culminating in AKI. In this review, we discuss the various sources of ROS during sepsis and their pathophysiological interactions with the immune system, microcirculation and mitochondria that can lead to the development of AKI. We also discuss the therapeutic utility of N-acetylcysteine and potential reasons for its efficacy in animal models of sepsis, and its inefficacy in ameliorating oxidative stress-induced organ dysfunction in human sepsis. Finally, we review the pre-clinical studies examining the antioxidant and pleiotropic actions of vitamin C that may be of benefit for mitigating septic AKI, including future implications for clinical sepsis.
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Affiliation(s)
- Connie P. C. Ow
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, VIC 3052, Australia; (C.P.C.O.); (A.T.-M.); (A.H.B.); (R.G.E.); (C.N.M.)
- Department of Cardiac Physiology, National Cerebral and Cardiovascular Center Research Institute, Osaka 564-8565, Japan
| | - Anton Trask-Marino
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, VIC 3052, Australia; (C.P.C.O.); (A.T.-M.); (A.H.B.); (R.G.E.); (C.N.M.)
| | - Ashenafi H. Betrie
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, VIC 3052, Australia; (C.P.C.O.); (A.T.-M.); (A.H.B.); (R.G.E.); (C.N.M.)
- Melbourne Dementia Research Centre, Florey Institute of Neuroscience and Mental Health, Melbourne, VIC 3052, Australia
| | - Roger G. Evans
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, VIC 3052, Australia; (C.P.C.O.); (A.T.-M.); (A.H.B.); (R.G.E.); (C.N.M.)
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, VIC 3800, Australia
| | - Clive N. May
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, VIC 3052, Australia; (C.P.C.O.); (A.T.-M.); (A.H.B.); (R.G.E.); (C.N.M.)
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC 3052, Australia
| | - Yugeesh R. Lankadeva
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, VIC 3052, Australia; (C.P.C.O.); (A.T.-M.); (A.H.B.); (R.G.E.); (C.N.M.)
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC 3052, Australia
- Correspondence: ; Tel.: +61-3-8344-0417; Fax: +61-3-9035-3107
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Ngo JP, Noe KM, Zhu MZL, Martin A, Ollason M, Cochrane AD, Smith JA, Thrift AG, Evans RG. Intraoperative renal hypoxia and risk of cardiac surgery-associated acute kidney injury. J Card Surg 2021; 36:3577-3585. [PMID: 34327740 DOI: 10.1111/jocs.15859] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/13/2021] [Accepted: 07/16/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is common after cardiac surgery requiring cardiopulmonary bypass. Renal hypoxia may precede clinically detectable AKI. We compared the efficacy of two indices of renal hypoxia, (i) intraoperative urinary oxygen tension (UPO2 ) and (ii) the change in plasma erythropoietin (pEPO) during surgery, in predicting AKI. We also investigated whether the performance of these prognostic markers varies with preoperative patient characteristics. METHODS In 82 patients undergoing on-pump cardiac surgery, blood samples were taken upon induction of anesthesia and upon entry into the intensive care unit. UPO2 was continuously measured throughout surgery. RESULTS Thirty-two (39%) patients developed postoperative AKI. pEPO increased during surgery, but this increase did not predict AKI, regardless of risk of postoperative mortality assessed by EuroSCORE-II. For patients categorized at higher risk by EuroSCORE-II >1.98 (median score for the cohort), UPO2 ≤10 mmHg at any time during surgery predicted a 4.04-fold excess risk of AKI (p = .04). However, UPO2 did not significantly predict AKI in lower-risk patients. UPO2 significantly predicted AKI in patients who were older, had previous myocardial infarction, diabetes, lower preoperative serum creatinine, or shorter bypass times. pEPO and UPO2 were only weakly correlated. CONCLUSIONS Intraoperative change in pEPO does not predict AKI. However, UPO2 shows promise, particularly in patients with higher risk of operative mortality. The disparity between these two markers of renal hypoxia may indicate that UPO2 reflects medullary oxygenation whereas pEPO reflects cortical oxygenation.
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Affiliation(s)
- Jennifer P Ngo
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia.,Department of Cardiac Physiology, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Khin M Noe
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Michael Z L Zhu
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia.,Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Australia
| | - Andrew Martin
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia.,Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Australia
| | - Meg Ollason
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia
| | - Andrew D Cochrane
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia.,Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Australia
| | - Julian A Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia.,Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Australia
| | - Amanda G Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
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Tholén M, Ricksten SE, Lannemyr L. Effects of levosimendan on renal blood flow and glomerular filtration in patients with acute kidney injury after cardiac surgery: a double blind, randomized placebo-controlled study. Crit Care 2021; 25:207. [PMID: 34118980 PMCID: PMC8199833 DOI: 10.1186/s13054-021-03628-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common and serious complication after cardiac surgery, and current strategies aimed at treating AKI have proven ineffective. Levosimendan, an inodilatating agent, has been shown to increase renal blood flow and glomerular filtration rate in uncomplicated postoperative patients and in patients with the cardiorenal syndrome. We hypothesized that levosimendan through its specific effects on renal vasculature, a preferential vasodilating effect on preglomerular resistance vessels, could improve renal function in AKI-patients with who did not have clinical indication for inotropic support. METHODS In this single-center, double-blind, randomized controlled study, adult patients with postoperative AKI within 2 days after cardiac surgery, who were hemodynamically stable with a central venous oxygen saturation (ScvO2) ≥ 60% without inotropic support were eligible for inclusion. After randomization, study drug infusions, levosimendan (n = 16) or placebo (n = 13) were given for 5 h. A bolus infusion of levosimendan (12 µg/kg), were given for 30 min followed by 0.1 µg/kg/min for 5 h. Renal blood flow and glomerular filtration rate were measured using infusion clearance of para-aminohippuric acid and a filtration marker, respectively. As a safety issue, norepinephrine was administered to maintain mean arterial pressure between 70-80 mmHg. Intra-group differences were tested by Mann-Whitney U-tests, and a linear mixed model was used to test time and group interaction. RESULTS Twenty-nine patients completed the study. At inclusion, the mean serum creatinine was higher in the patients randomized to levosimendan (148 ± 29 vs 127 ± 22 µmol/L, p = 0.030), and the estimated GFR was lower (46 ± 12 vs 57 ± 11 ml/min/1.73 m2, p = 0.025). Levosimendan induced a significantly (p = 0.011) more pronounced increase in renal blood flow (15%) compared placebo (3%) and a more pronounced decrease in renal vascular resistance (- 18% vs. - 4%, respectively, p = 0.043). There was a trend for a minor increase in glomerular filtration rate with levosimendan (4.5%, p = 0.079), which did differ significantly from the placebo group (p = 0.440). The mean norepinephrine dose was increased by 82% in the levosimedan group and decreased by 29% in the placebo group (p = 0.012). CONCLUSIONS In hemodynamically stable patients with AKI after cardiac surgery, levosimendan increases renal blood flow through renal vasodilatation. Trial registration NCT02531724, prospectly registered on 08/20/2015. https://clinicaltrials.gov/ct2/show/NCT02531724?cond=AKI&cntry=SE&age=1&draw=2&rank=1.
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Affiliation(s)
- Maria Tholén
- Department of Anesthesiology and Intensive Care Medicine At the Sahlgrenska Academy, University of Gothenburg and Section for Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Blå Stråket 7, 5th Floor, 413 45, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- Department of Anesthesiology and Intensive Care Medicine At the Sahlgrenska Academy, University of Gothenburg and Section for Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Blå Stråket 7, 5th Floor, 413 45, Gothenburg, Sweden
| | - Lukas Lannemyr
- Department of Anesthesiology and Intensive Care Medicine At the Sahlgrenska Academy, University of Gothenburg and Section for Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Blå Stråket 7, 5th Floor, 413 45, Gothenburg, Sweden.
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Affiliation(s)
- Falk Bach Lichtenberger
- Charité – Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinInstitute of Vegetative Physiology Berlin Germany
| | - Andreas Patzak
- Charité – Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinInstitute of Vegetative Physiology Berlin Germany
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Novak Z, Zaky A, Spangler EL, McFarland GE, Tolwani A, Beck AW. Incidence and predictors of early and delayed renal function decline after aortic aneurysm repair in the Vascular Quality Initiative database. J Vasc Surg 2021; 74:1537-1547. [PMID: 34019992 DOI: 10.1016/j.jvs.2021.04.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 04/16/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Postoperative acute kidney injury (AKI) may complicate both open and endovascular aortic aneurysm repair (EVAR) and is associated with substantial morbidity, mortality, and health care expense. We aim to evaluate the incidence of postoperative AKI and factors associated with its occurrence and the effects of postoperative AKI on long-term renal function and mortality after open and EVAR in the Society for Vascular Surgery Vascular Quality Initiative registry. METHODS Elective aneurysm cases were identified including thoracic endovascular aortic aneurysm repair (TEVAR) and complex endovascular aortic aneurysm repair (cEVAR), infrarenal endovascular repair (EVAR) and infrarenal open repair (OAR) from 2003 to 2019. The preoperative estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease formula and stratified based on chronic kidney disease (CKD) grades. Postoperative AKI was defined per the Vascular Quality Initiative definition as a creatinine increase of 0.5 mg/dL or if postoperative dialysis was required. Patients on preprocedural hemodialysis and those with previous renal transplant were excluded. Demographics and procedural factors were evaluated for predicting in-hospital postoperative AKI (all approaches) and at 9 to 21 months of long-term follow-up (EVAR only) using logistic regression modeling. RESULTS We identified a total of 2813 cEVAR, 2995 TEVAR, 39,945 EVAR, and 8143 OAR patients. Of those, postoperative AKI occurred in 377 cEVAR (13.5%), 199 TEVAR (6.7%), 1099 EVAR (2.8%), and 1249 OAR (15.5%). Risk factors for postoperative AKI across all groups were worse preoperative eGFR, total number of blood transfusions, perioperative anemia, reinterventions, and postoperative respiratory complications. Additional procedure-specific risk factors of postoperative AKI were preoperative hemoglobin of less than 10 and contrast volume of 125 to 150 mL, hypertension, a low ejection fraction, and a history of percutaneous revascularization for EVAR; for both EVAR/cEVAR, renal artery coverage was a risk factor, whereas for OAR, male sex, non-White race, hypertension, suprarenal aortic cross-clamp, and increased renal ischemic time were risk factors. Among 8133 EVAR patients with long-term follow-up, a decrease in kidney function occurred in 56.7% of patients with postoperative AKI vs 19.9% without postoperative AKI (P < .001). The following risk factors were associated with a decrease in renal function at long-term follow-up: postoperative AKI, a preoperative eGFR of less than 90, and hypertension. A preoperative hemoglobin of greater than 12 was protective. Postoperative AKI was associated with significantly lower survival compared with no postoperative AKI across all procedures (log rank <0.001). CONCLUSIONS Postoperative AKI occurs more often in patients with worse preoperative renal function, lower preoperative hemoglobin, and in open surgeries with inter-renal or suprarenal cross-clamping. Importantly, postoperative AKI is associated with increased mortality across all types of aortic repair. Given the long-term impact of postoperative AKI on outcomes for all aortic repairs and the limitations of current insensitive functional indices, there is a need to seek more sensitive indicators of decreases in early renal structural in this population.
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Affiliation(s)
- Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Ahmed Zaky
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Ala.
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Ashita Tolwani
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Ala
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
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Evans RG, Cochrane AD, Hood SG, Iguchi N, Marino B, Bellomo R, McCall PR, Okazaki N, Smith JA, Zhu MZ, Ngo JP, Noe KM, Martin A, Thrift AG, Lankadeva YR, May CN. Dynamic responses of renal oxygenation at the onset of cardiopulmonary bypass in sheep and man. Perfusion 2021; 37:624-632. [PMID: 33977810 DOI: 10.1177/02676591211013640] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The renal medulla is susceptible to hypoxia during cardiopulmonary bypass (CPB), which may contribute to the development of acute kidney injury. But the speed of onset of renal medullary hypoxia remains unknown. METHODS We continuously measured renal medullary oxygen tension (MPO2) in 24 sheep, and urinary PO2 (UPO2) as an index of MPO2 in 92 patients, before and after induction of CPB. RESULTS In laterally recumbent sheep with a right thoracotomy (n = 20), even before CPB commenced MPO2 fell from (mean ± SEM) 52 ± 4 to 41 ±5 mmHg simultaneously with reduced arterial pressure (from 108 ± 5 to 88 ± 5 mmHg). In dorsally recumbent sheep with a medial sternotomy (n = 4), MPO2 was even more severely reduced (to 12 ± 12 mmHg) before CPB. In laterally recumbent sheep in which a crystalloid prime was used (n = 7), after commencing CPB, MPO2 fell abruptly to 24 ±6 mmHg within 20-30 minutes. MPO2 during CPB was not improved by adding donor blood to the prime (n = 13). In patients undergoing cardiac surgery, UPO2 fell by 4 ± 1 mmHg and mean arterial pressure fell by 7 ± 1 mmHg during the 30 minutes before CPB. UPO2 then fell by a further 12 ± 2 mmHg during the first 30 minutes of CPB but remained relatively stable for the remaining 24 minutes of observation. CONCLUSIONS Renal medullary hypoxia is an early event during CPB. It starts to develop even before CPB, presumably due to a pressure-dependent decrease in renal blood flow. Medullary hypoxia during CPB appears to be promoted by hypotension and is not ameliorated by increasing blood hemoglobin concentration.
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Affiliation(s)
- Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, 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
| | - Sally G Hood
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Naoya Iguchi
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Bruno Marino
- Cellsaving and Perfusion Resources, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Peter R McCall
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Nobuki Okazaki
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Anesthesiology and Resuscitology, Okayama University, Okayama, Japan
| | - Julian A Smith
- Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Victoria, Australia
| | - Michael Zl Zhu
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Victoria, Australia
| | - Jennifer P Ngo
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Department of Cardiac Physiology, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Khin M Noe
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
| | - Andrew Martin
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Victoria, Australia
| | - Amanda G Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
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Abstract
Histone deacetylases (HDACs) are part of the epigenetic machinery that regulates transcriptional processes. The current paradigm is that HDACs silence gene expression via regulation of histone protein lysine deacetylation, or by forming corepressor complexes with transcription factors. However, HDACs are more than just nuclear proteins, and they can interact and deacetylate a growing number of nonhistone proteins to regulate cellular function. Cancer-field studies have shown that deranged HDAC activity results in uncontrolled proliferation, inflammation, and fibrosis; all pathologies that also may occur in kidney disease. Over the past decade, studies have emerged suggesting that HDAC inhibitors may prevent and potentially treat various models of acute kidney injury. This review focuses on the physiology of kidney HDACs and highlights the recent advances using HDAC inhibitors to potentially treat kidney disease patients.
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Affiliation(s)
- Kelly A Hyndman
- Cardio-Renal Physiology and Medicine, Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL.
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Lankadeva YR, Evans RG, Cochrane AD, Marino B, Hood SG, McCall PR, Iguchi N, Bellomo R, May CN. Reversal of renal tissue hypoxia during experimental cardiopulmonary bypass in sheep by increased pump flow and arterial pressure. Acta Physiol (Oxf) 2021; 231:e13596. [PMID: 34347356 DOI: 10.1111/apha.13596] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/17/2020] [Accepted: 12/04/2020] [Indexed: 12/15/2022]
Abstract
AIM Renal tissue hypoxia during cardiopulmonary bypass could contribute to the pathophysiology of acute kidney injury. We tested whether renal tissue hypoxia can be alleviated during cardiopulmonary bypass by the combined increase in target pump flow and mean arterial pressure. METHODS Cardiopulmonary bypass was established in eight instrumented sheep under isoflurane anaesthesia, at a target continuous pump flow of 80 mL·kg-1 min-1 and mean arterial pressure of 65 mmHg. We then tested the effects of simultaneously increasing target pump flow to 104 mL·kg-1 min-1 and mean arterial pressure to 80 mmHg with metaraminol (total dose 0.25-3.75 mg). We also tested the effects of transitioning from continuous flow to partially pulsatile flow (pulse pressure ~15 mmHg). RESULTS Compared with conscious sheep, at the lower target pump flow and mean arterial pressure, cardiopulmonary bypass was accompanied by reduced renal blood flow (6.8 ± 1.2 to 1.95 ± 0.76 mL·min-1 kg-1) and renal oxygen delivery (0.91 ± 0.18 to 0.24 ± 0.11 mL·O2 min-1 kg-1). There were profound reductions in cortical oxygen tension (PO2) (33 ± 13 to 6 ± 6 mmHg) and medullary PO2 (31 ± 12 to 8 ± 8 mmHg). Increasing target pump flow and mean arterial pressure increased renal blood flow (to 2.6 ± 1.0 mL·min-1 kg-1) and renal oxygen delivery (to 0.32 ± 0.13 mL·O2 min-1kg-1) and returned cortical PO2 to 58 ± 60 mmHg and medullary PO2 to 28 ± 16 mmHg; levels similar to those of conscious sheep. Partially pulsatile pump flow had no significant effects on renal perfusion or oxygenation. CONCLUSIONS Renal hypoxia during experimental CPB can be corrected by increasing target pump flow and mean arterial pressure within a clinically feasible range.
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Affiliation(s)
- Yugeesh R. Lankadeva
- Pre‐Clinical Critical Care Unit Florey Institute of Neuroscience and Mental HealthUniversity of Melbourne Melbourne VIC Australia
| | - Roger G. Evans
- Cardiovascular Disease Program Biomedicine Discovery Institute and Department of Physiology Monash University Melbourne VIC Australia
| | - Andrew D. Cochrane
- Department of Cardiothoracic Surgery Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health) Monash University Melbourne VIC Australia
| | - Bruno Marino
- Cellsaving and Perfusion Resources Melbourne VIC Australia
| | - Sally G. Hood
- Pre‐Clinical Critical Care Unit Florey Institute of Neuroscience and Mental HealthUniversity of Melbourne Melbourne VIC Australia
| | - Peter R. McCall
- Department of Anaesthesia Austin Health Heidelberg VIC Australia
| | - Naoya Iguchi
- Pre‐Clinical Critical Care Unit Florey Institute of Neuroscience and Mental HealthUniversity of Melbourne Melbourne VIC Australia
| | - Rinaldo Bellomo
- Department of Intensive Care Austin Health Heidelberg VIC Australia
| | - Clive N. May
- Pre‐Clinical Critical Care Unit Florey Institute of Neuroscience and Mental HealthUniversity of Melbourne Melbourne VIC Australia
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Plummer MP, Lankadeva YR, Finnis ME, Harrois A, Harding C, Peiris RM, Okazaki N, May CN, Evans RG, Macisaac CM, Barge D, Bellomo R, Deane AM. Urinary and renal oxygenation during dexmedetomidine infusion in critically ill adults with mechanistic insights from an ovine model. J Crit Care 2021; 64:74-81. [PMID: 33794470 DOI: 10.1016/j.jcrc.2021.03.004] [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: 12/10/2020] [Revised: 03/10/2021] [Accepted: 03/12/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Examine effects of dexmedetomidine on bladder urinary oxygen tension (PuO2) in critically ill patients and delineate mechanisms in an ovine model. MATERIALS AND METHODS In 12 critically ill patients: oxygen-sensing probe inserted in the bladder catheter and dexmedetomidine infusion at a mean (SD) rate of 0.9 ± 0.3 μg/kg/h for 24-h. In 9 sheep: implantation of flow probes around the renal and pulmonary arteries, and oxygen-sensing probes in the renal cortex, renal medulla and bladder catheter; dexmedetomidine infusion at 0.5 μg/kg/h for 4-h and 1.0 μg/kg/h for 4-h then 16 h observation. RESULTS In patients, dexmedetomidine decreased bladder PuO2at 2 (-Δ11 (95% CI 7-16)mmHg), 8 (-Δ 7 (0.1-13)mmHg) and 24 h (-Δ 11 (0.4-21)mmHg). In sheep, dexmedetomidine at 1 μg/kg/h reduced renal medullary oxygenation (-Δ 19 (14-24)mmHg) and bladder PuO2 (-Δ 12 (7-17)mmHg). There was moderate correlation between renal medullary oxygenation and bladder PuO2; intraclass correlation co-efficient 0.59 (0.34-0.80). Reductions in renal medullary oxygenation were associated with reductions in blood pressure, cardiac output and renal blood flow (P < 0.01). CONCLUSIONS Dexmedetomidine decreases PuO2in critically ill patients and in sheep. In sheep this reflects a decrease in renal medullary oxygenation, associated with reductions in cardiac output, blood pressure and renal blood flow.
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Affiliation(s)
- Mark P Plummer
- Department of Intensive Care, Royal Melbourne Hospital, 300 Grattan Street Parkville, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia.
| | - Yugeesh R Lankadeva
- Department of Critical Care, University of Melbourne, Melbourne, Australia; Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, Australia.
| | - Mark E Finnis
- Department of Critical Care, University of Melbourne, Melbourne, Australia; Department of Intensive Care, Royal Adelaide Hospital, Adelaide, Australia.
| | - Anatole Harrois
- Department of Intensive Care, Royal Melbourne Hospital, 300 Grattan Street Parkville, Melbourne, Australia; Department of Anesthesia and Surgical Intensive Care, Paris-Saclay University, Bicêtre University Hospital, Le Kremlin Bicêtre, France
| | - Charlie Harding
- Department of Intensive Care, Royal Melbourne Hospital, 300 Grattan Street Parkville, Melbourne, Australia.
| | - Rachel M Peiris
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, Australia.
| | - Nobuki Okazaki
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
| | - Clive N May
- Department of Critical Care, University of Melbourne, Melbourne, Australia; Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, Australia.
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Australia.
| | - Christopher M Macisaac
- Department of Intensive Care, Royal Melbourne Hospital, 300 Grattan Street Parkville, Melbourne, Australia.
| | - Deborah Barge
- Department of Intensive Care, Royal Melbourne Hospital, 300 Grattan Street Parkville, Melbourne, Australia.
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, 300 Grattan Street Parkville, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia.
| | - Adam M Deane
- Department of Intensive Care, Royal Melbourne Hospital, 300 Grattan Street Parkville, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia.
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Lankadeva YR, May CN, Cochrane AD, Marino B, Hood SG, McCall PR, Okazaki N, Bellomo R, Evans RG. Influence of blood haemoglobin concentration on renal haemodynamics and oxygenation during experimental cardiopulmonary bypass in sheep. Acta Physiol (Oxf) 2021; 231:e13583. [PMID: 33222404 DOI: 10.1111/apha.13583] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/28/2020] [Accepted: 11/17/2020] [Indexed: 12/29/2022]
Abstract
AIM Blood transfusion may improve renal oxygenation during cardiopulmonary bypass (CPB). In an ovine model of experimental CPB, we tested whether increasing blood haemoglobin concentration [Hb] from ~7 g dL-1 to ~9 g dL-1 improves renal tissue oxygenation. METHODS Ten sheep were studied while conscious, under stable isoflurane anaesthesia, and during 3 hours of CPB. In a randomized cross-over design, 5 sheep commenced bypass at a high target [Hb], achieved by adding 600 mL donor blood to the priming solution. After 90 minutes of CPB, PlasmaLyte® was added to the blood reservoir to achieve low target [Hb]. For the other 5 sheep, no blood was added to the prime, but after 90 minutes of CPB, 800-900 mL of donor blood was given to achieve a high target [Hb]. RESULTS Overall, CPB was associated with marked reductions in renal oxygen delivery (-50 ± 12%, mean ± 95% confidence interval) and medullary tissue oxygen tension (PO2 , -54 ± 29%). Renal fractional oxygen extraction was 17 ± 10% less during CPB at high [Hb] than low [Hb] (P = .04). Nevertheless, no increase in tissue PO2 in either the renal medulla (0 ± 6 mmHg change, P > .99) or cortex (-19 ± 13 mmHg change, P = .08) was detected with high [Hb]. CONCLUSIONS In experimental CPB blood transfusion to increase Hb concentration from ~7 g dL-1 to ~9 g dL-1 did not improve renal cortical or medullary tissue PO2 even though it decreased whole kidney oxygen extraction.
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Affiliation(s)
- Yugeesh R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
- Centre for Integrated Critical Care, Department of Medicine and Radiology, The University of Melbourne, Melbourne, VIC, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
- Centre for Integrated Critical Care, Department of Medicine and Radiology, The University of Melbourne, Melbourne, VIC, Australia
| | - Andrew D Cochrane
- Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, VIC, Australia
| | - Bruno Marino
- Cellsaving and Perfusion Resources, Melbourne, VIC, Australia
| | - Sally G Hood
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Peter R McCall
- Department of Anaesthesia, Austin Health, Heidelberg, VIC, Australia
| | - Nobuki Okazaki
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
- Department of Anesthesiology and Resuscitology, Okayama University, Okayama, Japan
| | - Rinaldo Bellomo
- Centre for Integrated Critical Care, Department of Medicine and Radiology, The University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Health, Heidelberg, VIC, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, VIC, Australia
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Lankadeva YR, Shehabi Y, Deane AM, Plummer MP, Bellomo R, May CN. Emerging benefits and drawbacks of α 2 -adrenoceptor agonists in the management of sepsis and critical illness. Br J Pharmacol 2021; 178:1407-1425. [PMID: 33450087 DOI: 10.1111/bph.15363] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 12/21/2020] [Accepted: 12/29/2020] [Indexed: 12/29/2022] Open
Abstract
Agonists of α2 -adrenoceptors are increasingly being used for the provision of comfort, sedation and the management of delirium in critically ill patients, with and without sepsis. In this context, increased sympathetic and inflammatory activity are common pathophysiological features linked to multi-organ dysfunction, particularly in patients with sepsis or those undergoing cardiac surgery requiring cardiopulmonary bypass. Experimental and clinical studies support the notion that the α2 -adrenoceptor agonists, dexmedetomidine and clonidine, mitigate sympathetic and inflammatory overactivity in sepsis and cardiac surgery requiring cardiopulmonary bypass. These effects can protect vital organs, including the cardiovascular system, kidneys, heart and brain. We review the pharmacodynamic mechanisms by which α2 -adrenoceptor agonists might mitigate multi-organ dysfunction arising from pathophysiological conditions associated with excessive inflammatory and adrenergic stress in experimental studies. We also outline recent clinical trials that have examined the use of dexmedetomidine in critically ill patients with and without sepsis and in patients undergoing cardiac surgery.
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Affiliation(s)
- Yugeesh R Lankadeva
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Yahya Shehabi
- Department of Intensive Care Medicine, Monash Health, School of Clinical Sciences, Monash University, Melbourne, Prince of Wales Clinical School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Adam M Deane
- Centre for Integrated Critical Care, School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Intensive Care Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Mark P Plummer
- Centre for Integrated Critical Care, School of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Department of Intensive Care Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Centre for Integrated Critical Care, School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Clive N May
- Preclinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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Wittlinger T, Maus M, Kutschka I, Baraki H, Friedrich MG. Risk assessment of acute kidney injury following cardiopulmonary bypass. J Cardiothorac Surg 2021; 16:4. [PMID: 33407652 PMCID: PMC7789772 DOI: 10.1186/s13019-020-01382-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/08/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a frequent and serious complication of cardiac surgery, associated with a high incidence of morbidity and mortality. Although the RIFLE criteria serve as a prominent tool to identify patients at high risk of AKI, an optimized diagnosis model in clinical practice is desired. METHODS Based on the SOP-criteria, 365 patients (10%) developed AKI following surgery and were subjected to RRT. In contrast, the incidence of AKI, defined according to the RIFLE criteria, was only 7% (n = 251 patients). Prominent risk factors identified by SOP were patients' sex, valve and combined valve and bypass surgery, deep hypothermia, use of intra-aortic balloon pump (IABP) and previous coronary interventions. Ischemia, reperfusion, blood loss and surgery time also served as significant risk factors for patient evaluated by SOP. RESULTS Risk assessment by RIFLE differed in as much as most patients with normothermia and those receiving only cardiovascular bypass developed AKI. However, patients' sex and valve surgery did not serve as a risk factor. CONCLUSION Evaluation of patients by the RIFLE versus SOP criteria yielded different results with more AKI patients detected by SOP. Based on the present data, it is concluded that patients may not prone to AKI when surgery and ischemia time will be kept short, when blood loss is mitigated to a minimum and when surgery is performed under non-hypothermic conditions.
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Affiliation(s)
- Thomas Wittlinger
- Department of Cardiology, Asklepios Hospital Goslar, Köslinerstr 12, 38642, Goslar, Germany.
| | - Martin Maus
- Department Major Surgery, St. Elisabeth Hospital, Bonn, Germany
| | - Ingo Kutschka
- Department of Cardio-Thoracic and Vascular Surgery, University Hospital Göttingen, Göttingen, Germany
| | - Hassina Baraki
- Department of Cardio-Thoracic and Vascular Surgery, University Hospital Göttingen, Göttingen, Germany
| | - Martin G Friedrich
- Department of Cardio-Thoracic and Vascular Surgery, University Hospital Göttingen, Göttingen, Germany
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41
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Cantow K, Hummel L, Flemming B, Waiczies S, Niendorf T, Seeliger E. Imagine physiology without imaging. Acta Physiol (Oxf) 2020; 230:e13549. [PMID: 32852085 DOI: 10.1111/apha.13549] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Kathleen Cantow
- Institut für vegetative Physiologie Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Luis Hummel
- Institut für vegetative Physiologie Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Bert Flemming
- Institut für vegetative Physiologie Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
| | - Sonia Waiczies
- Berlin Ultrahigh Field Facility (B.U.F.F.) Max Delbrück Center for Molecular Medicine in the Helmholtz Association Berlin Germany
| | - Thoralf Niendorf
- Berlin Ultrahigh Field Facility (B.U.F.F.) Max Delbrück Center for Molecular Medicine in the Helmholtz Association Berlin Germany
| | - Erdmann Seeliger
- Institut für vegetative Physiologie Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt‐Universität zu Berlin, and Berlin Institute of Health Berlin Germany
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Jufar AH, Lankadeva YR, May CN, Cochrane AD, Bellomo R, Evans RG. Renal functional reserve: from physiological phenomenon to clinical biomarker and beyond. Am J Physiol Regul Integr Comp Physiol 2020; 319:R690-R702. [PMID: 33074016 DOI: 10.1152/ajpregu.00237.2020] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Glomerular filtration rate (GFR) is acutely increased following a high-protein meal or systemic infusion of amino acids. The mechanisms underlying this renal functional response remain to be fully elucidated. Nevertheless, they appear to culminate in preglomerular vasodilation. Inhibition of the tubuloglomerular feedback signal appears critical. However, nitric oxide, vasodilator prostaglandins, and glucagon also appear important. The increase in GFR during amino acid infusion reveals a "renal reserve," which can be utilized when the physiological demand for single nephron GFR increases. This has led to the concept that in subclinical renal disease, before basal GFR begins to reduce, renal functional reserve can be recruited in a manner that preserves renal function. The extension of this concept is that once a decline in basal GFR can be detected, renal disease is already well progressed. This concept likely applies both in the contexts of chronic kidney disease and acute kidney injury. Critically, its corollary is that deficits in renal functional reserve have the potential to provide early detection of renal dysfunction before basal GFR is reduced. There is growing evidence that the renal response to infusion of amino acids can be used to identify patients at risk of developing either chronic kidney disease or acute kidney injury and as a treatment target for acute kidney injury. However, large multicenter clinical trials are required to test these propositions. A renewed effort to understand the renal physiology underlying the response to amino acid infusion is also warranted.
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Affiliation(s)
- Alemayehu H Jufar
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,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
| | - Clive N May
- 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
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
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Persson PB. Bibliometrics for 2019: For the third year in row, the impact factor is between five and six. Acta Physiol (Oxf) 2020; 230:e13534. [PMID: 32627313 DOI: 10.1111/apha.13534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 01/13/2023]
Affiliation(s)
- Pontus B Persson
- Charité-Universitaetsmedizin Berlin, Institute of Vegetative Physiology, Berlin, Germany
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44
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Iguchi N, Kosaka J, Iguchi Y, Evans RG, Bellomo R, May CN, Lankadeva YR. Systemic haemodynamic, renal perfusion and renal oxygenation responses to changes in inspired oxygen fraction during total intravenous or volatile anaesthesia. Br J Anaesth 2020; 125:192-200. [DOI: 10.1016/j.bja.2020.03.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/13/2020] [Accepted: 03/18/2020] [Indexed: 02/03/2023] Open
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Tholén M, Ricksten SE, Lannemyr L. Renal Near-Infrared Spectroscopy for Assessment of Renal Oxygenation in Adults Undergoing Cardiac Surgery: A Method Validation Study. J Cardiothorac Vasc Anesth 2020; 34:3300-3305. [PMID: 32532694 DOI: 10.1053/j.jvca.2020.04.044] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/20/2020] [Accepted: 04/27/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the correlation between invasively measured renal venous oxygen saturation (SrvO2) and tissue oxygenation (rSO2) measured with near-infrared spectroscopy (NIRS) in adult patients undergoing cardiac surgery. DESIGN Prospective observational study. SETTING Single cardiac surgery center at a university hospital. PARTICIPANTS Thirteen adult patients with skin- to- kidney distance ≤4 cm undergoing open cardiac surgery with cardiopulmonary bypass (CPB). INTERVENTIONS All patients received renal vein catheters for invasive measurement of SrvO2, and NIRS electrodes for assessment of renal rSO2 were placed over the kidney using ultrasound guidance. Measurements were made before CPB, during CPB at 3 different flow rates (2.4, 2.7, and 3.0 L/min/m2), and after CPB. MEASUREMENTS AND MAIN RESULTS Repeated- measures correlation analyses and Bland-Altman plots were used to study the correlation and agreement between rSO2 and SrvO2. For all measurement points, renal rSO2 correlated with SrvO2 (rrm = 0.61, p < 0.001), and the mean difference (bias) between rSO2 and SrvO2 was -2.71 ± 7.22 (p = 0.002), with an error of 17.6%. When measurements during CPB and before and after CPB were studied separately, rSO2 and SrvO2 were correlated (rrm = 0.51, p < 0.007 and rrm = 0.73, p < 0.001, respectively). During CPB, renal rSO2 predicted SrvO2 with a bias of -3.41 ± 7.76 (p = 0.009) and an error of 18.8%. Before and after CPB, the mean difference was -1.93 ± 6.60 (p = 0.092), with an error of 16.2%. CONCLUSIONS Renal rSO2 is correlated to and predicts SrvO2 with a small bias and acceptable agreement. Further studies are needed before renal NIRS can be used as a surrogate marker of renal oxygenation in clinical practice.
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Affiliation(s)
- Maria Tholén
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lukas Lannemyr
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Lee CJ, Gardiner BS, Smith DW. A cardiovascular model for renal perfusion during cardiopulmonary bypass surgery. Comput Biol Med 2020; 119:103676. [PMID: 32339121 DOI: 10.1016/j.compbiomed.2020.103676] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/24/2020] [Accepted: 02/24/2020] [Indexed: 01/05/2023]
Abstract
Acute kidney injury (AKI) is a major complication following cardiac surgery requiring cardiopulmonary bypass (CPB). It is likely that poor renal perfusion contributes to the occurrence of AKI, via renal hypoxia, so it is imperative to maintain optimal renal perfusion during CPB. We have developed a straightforward cardiovascular perfusion model with parameter values calibrated against experimental and/or clinical data from several independent studies of CPB in humans and animals. Following model development and calibration, we performed a one-at-a-time parametric study to investigate the response of renal perfusion to several variables during CPB, namely pump flow (denoted CO for 'cardiac output'), renal vascular resistance, and non-renal vascular resistance. From the parametric study, we have found that all three parameters had a similarly strong influence on renal perfusion. We simulated three potential strategies for maintaining optimum renal perfusion during CPB and tested their effectiveness. The strategies were: (1) increasing the pump flow; (2) administrating noradrenaline (vasopressor); and (3) administrating fenoldopam (renal vasodilator). Simulations have revealed that administration of fenoldopam is likely to be the most effective of the three strategies. Other findings from our simulations are that increasing pump flow is less effective when central venous pressure is elevated. Further, renal autoregulation is likely inoperative during CPB, as evidenced by an unchanging renal vascular resistance with increasing CO and blood pressure. The cardiac-renal perfusion model developed in this study can be linked with other kidney models to simulate the changes in renal oxygenation during CPB.
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Affiliation(s)
- Chang-Joon Lee
- College of Science, Health, Engineering and Education Murdoch University, 90 South St, Murdoch, WA, 6150, Australia.
| | - Bruce S Gardiner
- College of Science, Health, Engineering and Education Murdoch University, 90 South St, Murdoch, WA, 6150, Australia
| | - David W Smith
- Faculty of Engineering and Mathematical Sciences, The University of Western Australia, Perth, Australia
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Niendorf T, Seeliger E, Cantow K, Flemming B, Waiczies S, Pohlmann A. Probing renal blood volume with magnetic resonance imaging. Acta Physiol (Oxf) 2020; 228:e13435. [PMID: 31876349 DOI: 10.1111/apha.13435] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 12/18/2019] [Accepted: 12/19/2019] [Indexed: 02/06/2023]
Abstract
Damage to the kidney substantially reduces life expectancy. Renal tissue hypoperfusion and hypoxia are key elements in the pathophysiology of acute kidney injury and its progression to chronic kidney disease. In vivo assessment of renal haemodynamics and tissue oxygenation remains a challenge. Blood oxygenation level-dependent (BOLD) magnetic resonance imaging (MRI) is sensitive to changes in the effective transversal relaxation time (T2 *) in vivo, and is non-invasive and indicative of renal tissue oxygenation. However, the renal T2 * to tissue pO2 relationship is not governed exclusively by renal blood oxygenation, but is affected by physiological confounders with alterations in renal blood volume fraction (BVf) being of particular relevance. To decipher this interference probing renal BVf is essential for the pursuit of renal MR oximetry. Superparamagnetic iron oxide nanoparticle (USPIO) preparations can be used as MRI visible blood pool markers for detailing alterations in BVf. This review promotes the opportunities of MRI-based assessment of renal BVf. Following an outline on the specifics of renal oxygenation and perfusion, changes in renal BVf upon interventions and their potential impact on renal T2 * are discussed. We also describe the basic principles of renal BVf assessment using ferumoxytol-enhanced MRI in the equilibrium concentration regimen. We demonstrate that ferumoxytol does not alter control of renal haemodynamics and oxygenation. Preclinical applications of ferumoxytol enhanced renal MRI as well as considerations for its clinical implementation for examining renal BVf changes are provided alongside practical considerations. Finally, we explore the future directions of MRI-based assessment of renal BVf.
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Affiliation(s)
- Thoralf Niendorf
- Berlin Ultrahigh Field Facility (B.U.F.F.) Max Delbrück Center for Molecular Medicine in the Helmholtz Association Berlin Germany
| | - Erdmann Seeliger
- Institute of Physiology Charité – Universitätsmedizin Berlin Campus Mitte, and Center for Cardiovascular Research (CCR) Berlin Germany
| | - Kathleen Cantow
- Institute of Physiology Charité – Universitätsmedizin Berlin Campus Mitte, and Center for Cardiovascular Research (CCR) Berlin Germany
| | - Bert Flemming
- Institute of Physiology Charité – Universitätsmedizin Berlin Campus Mitte, and Center for Cardiovascular Research (CCR) Berlin Germany
| | - Sonia Waiczies
- Berlin Ultrahigh Field Facility (B.U.F.F.) Max Delbrück Center for Molecular Medicine in the Helmholtz Association Berlin Germany
| | - Andreas Pohlmann
- Berlin Ultrahigh Field Facility (B.U.F.F.) Max Delbrück Center for Molecular Medicine in the Helmholtz Association Berlin Germany
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48
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Gardiner BS, Smith DW, Lee C, Ngo JP, Evans RG. Renal oxygenation: From data to insight. Acta Physiol (Oxf) 2020; 228:e13450. [PMID: 32012449 DOI: 10.1111/apha.13450] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 01/14/2020] [Accepted: 01/30/2020] [Indexed: 12/14/2022]
Abstract
Computational models have made a major contribution to the field of physiology. As the complexity of our understanding of biological systems expands, the need for computational methods only increases. But collaboration between experimental physiologists and computational modellers (ie theoretical physiologists) is not easy. One of the major challenges is to break down the barriers created by differences in vocabulary and approach between the two disciplines. In this review, we have two major aims. Firstly, we wish to contribute to the effort to break down these barriers and so encourage more interdisciplinary collaboration. So, we begin with a "primer" on the ways in which computational models can help us understand physiology and pathophysiology. Second, we aim to provide an update of recent efforts in one specific area of physiology, renal oxygenation. This work is shedding new light on the causes and consequences of renal hypoxia. But as importantly, computational modelling is providing direction for experimental physiologists working in the field of renal oxygenation by: (a) generating new hypotheses that can be tested in experimental studies, (b) allowing experiments that are technically unfeasible to be simulated in silico, or variables that cannot be measured experimentally to be estimated, and (c) providing a means by which the quality of experimental data can be assessed. Critically, based on our experience, we strongly believe that experimental and theoretical physiology should not be seen as separate exercises. Rather, they should be integrated to permit an iterative process between modelling and experimentation.
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Affiliation(s)
- Bruce S. Gardiner
- College of Science Health, Engineering and Education Murdoch University Perth Australia
- Faculty of Engineering and Mathematical Sciences The University of Western Australia Perth Australia
| | - David W. Smith
- Faculty of Engineering and Mathematical Sciences The University of Western Australia Perth Australia
| | - Chang‐Joon Lee
- College of Science Health, Engineering and Education Murdoch University Perth Australia
- Faculty of Engineering and Mathematical Sciences The University of Western Australia Perth Australia
| | - Jennifer P. Ngo
- Cardiovascular Disease Program Biomedicine Discovery Institute and Department of Physiology Monash University Melbourne Australia
- Department of Cardiac Physiology National Cerebral and Cardiovascular Research Center Osaka Japan
| | - Roger G. Evans
- Cardiovascular Disease Program Biomedicine Discovery Institute and Department of Physiology Monash University Melbourne Australia
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49
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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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50
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Lee CJ, Gardiner BS, Evans RG, Smith DW. Analysis of the critical determinants of renal medullary oxygenation. Am J Physiol Renal Physiol 2019; 317:F1483-F1502. [DOI: 10.1152/ajprenal.00315.2019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
We have previously developed a three-dimensional computational model of oxygen transport in the renal medulla. In the present study, we used this model to quantify the sensitivity of renal medullary oxygenation to four of its major known determinants: medullary blood flow (MBF), medullary oxygen consumption rate (V̇o2,M), hemoglobin (Hb) concentration in the blood, and renal perfusion pressure. We also examined medullary oxygenation under special conditions of hydropenia, extracellular fluid volume expansion by infusion of isotonic saline, and hemodilution during cardiopulmonary bypass. Under baseline (normal) conditions, the average medullary tissue Po2 predicted for the whole renal medulla was ~30 mmHg. The periphery of the interbundle region in the outer medulla was identified as the most hypoxic region in the renal medulla, which demonstrates that the model prediction is qualitatively accurate. Medullary oxygenation was most sensitive to changes in renal perfusion pressure followed by Hb, MBF, and V̇o2,M, in that order. The medullary oxygenation also became sensitized by prohypoxic changes in other parameters, leading to a greater fall in medullary tissue Po2 when multiple parameters changed simultaneously. Hydropenia did not induce a significant change in medullary oxygenation compared with the baseline state, while volume expansion resulted in a large increase in inner medulla tissue Po2 (by ~15 mmHg). Under conditions of cardiopulmonary bypass, the renal medulla became severely hypoxic, due to hemodilution, with one-third of the outer stripe of outer medulla tissue having a Po2 of <5 mmHg.
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Affiliation(s)
- Chang-Joon Lee
- College of Science, Health, Engineering and Education, Murdoch University, Perth, Western Australia, Australia
- Faculty of Engineering and Mathematical Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Bruce S. Gardiner
- College of Science, Health, Engineering and Education, Murdoch University, Perth, Western Australia, Australia
- Faculty of Engineering and Mathematical Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Roger G. Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
| | - David W. Smith
- Faculty of Engineering and Mathematical Sciences, The University of Western Australia, Perth, Western Australia, Australia
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