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Kamalabadi M, Ghoorchian A, Derakhshandeh K, Gholyaf M, Ravan M. Design and Fabrication of a Gas Sensor Based on a Polypyrrole/Silver Nanoparticle Film for the Detection of Ammonia in Exhaled Breath of COVID-19 Patients Suffering from Acute Kidney Injury. Anal Chem 2022; 94:16290-16298. [DOI: 10.1021/acs.analchem.2c02760] [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)
- Mahdie Kamalabadi
- Department of Pharmaceutics, School of Pharmacy, Hamadan University of Medical Sciences, Hamadan 6517838736, Iran
- Medicinal Plants and Natural Products Research Center, Hamadan University of Medical Sciences, Hamadan 6517838736, Iran
| | - Arash Ghoorchian
- Department of Pharmaceutics, School of Pharmacy, Hamadan University of Medical Sciences, Hamadan 6517838736, Iran
- Medicinal Plants and Natural Products Research Center, Hamadan University of Medical Sciences, Hamadan 6517838736, Iran
| | - Katayoun Derakhshandeh
- Department of Pharmaceutics, School of Pharmacy, Hamadan University of Medical Sciences, Hamadan 6517838736, Iran
- Medicinal Plants and Natural Products Research Center, Hamadan University of Medical Sciences, Hamadan 6517838736, Iran
| | - Mahmoud Gholyaf
- Urology & Nephrology Research Center, Hamadan University of Medical Sciences, Hamadan 6517838736, Iran
| | - Maryam Ravan
- Department of Pharmaceutics, School of Pharmacy, Hamadan University of Medical Sciences, Hamadan 6517838736, Iran
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2
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Kararmaz A, Arslantas MK, Aksu U, Ulugol H, Cinel I, Toraman F. Evaluation of acute kidney injury with oxidative stress biomarkers and Renal Resistive Index after cardiac surgery. Acta Chir Belg 2021; 121:189-197. [PMID: 31823690 DOI: 10.1080/00015458.2019.1702371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND We investigated whether cardiopulmonary bypass (CPB) related oxidative stress mediated glycocalyx degradation can cause an increase in renal resistive index (RRI) or postoperative AKI. Additionally, to evaluate whether RRI and early postoperative serum cystatin C levels could improve the prediction sensitivity of acute kidney injury (AKI). METHODS Forty-two patients undergoing cardiac surgery were included in this prospective observational study. RRI was measured pre-operatively and in the cardiac intensive care unit. Blood samples were collected for analyzing of cellular injury biomarkers at preoperative and postoperative second hours. We determined areas under the receiver operating characteristic curve (AUC) and odds ratios for postoperative biomarkers and RRI to predict AKI. RESULTS While postoperative cystatin C level (AUC: 0.902, 95% CI = 0.79-1.00, p < .001) and RRI (AUC: 0.748, 95% CI = 0.56-0.93, p = .023) have diagnostic and predictive value in the prediction of AKI, we could not identify any relation between products of oxidative stress and the glycocalyx degradation and AKI. CONCLUSION These data suggest that CPB leads to structural and oxidative changes at the protein level and the integrity of glycocalyx is disturbing, but these changes are not specific to kidney injury. Our data suggest that serum cystatin C level and RRI could be used as an early biomarker for postoperative AKI after cardiac surgery.
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Affiliation(s)
- Alper Kararmaz
- Department of Anesthesiology and Reanimation, School of Medicine, Marmara University, Istanbul, Turkey
| | - Mustafa Kemal Arslantas
- Department of Anesthesiology and Reanimation, School of Medicine, Marmara University, Istanbul, Turkey
| | - Ugur Aksu
- Department of Biology, Faculty of Science, Istanbul University, Istanbul, Turkey
| | - Halim Ulugol
- Department of Anesthesiology and Reanimation, School of Medicine, Acibadem University, Istanbul, Turkey
| | - Ismail Cinel
- Department of Anesthesiology and Reanimation, School of Medicine, Marmara University, Istanbul, Turkey
| | - Fevzi Toraman
- Department of Anesthesiology and Reanimation, School of Medicine, Acibadem University, Istanbul, Turkey
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Fernandes M, Majoni M, Garg AX, Dubois L. Systematic Review and Meta-Analysis of Preventative Strategies for Acute Kidney Injury in Patients Undergoing Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2021; 74:419-430. [PMID: 33548402 DOI: 10.1016/j.avsg.2020.12.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/09/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
BACKGOUND To assess the effect of various preventative interventions for reducing the incidence of postoperative acute kidney injury (AKI) in patients undergoing elective abdominal aortic aneurysm (AAA) repair. METHODS We included randomized controlled trials of 10 patients or more which tested a preventative intervention versus standard therapy or placebo in patients undergoing elective AAA repair using the open or endovascular approach. Studies including mixed patient populations such as those with aortic occlusive disease, thoracoabdominal aneurysms or ruptured aneurysms were ineligible for review. We searched Medline (1966-2019), EMBASE (1947-2019), CINAHL (1961-2019), Web of Science (1945-2019), Scopus (1966-2019), and The Cochrane Library (1996-2019) for trials available as published manuscripts in English. Study quality was assessed using the Cochrane Collaboration risk of bias tool. Where possible we pooled the results of similar interventions using random effects meta-analysis. RESULTS We included 17 trials involving 1443 participants. Most trials were small, single-center studies, with varying definitions of AKI and a high or moderate risk of bias. The preventative strategies with possible protective effects were mannitol, a composite of antioxidant supplements, an open extraperitoneal approach, and human atrial natriuretic peptide (hANP). Curcumin, methylprednisolone, carbon dioxide contrast medium, hemodynamic monitoring and N-acetylcysteine were found to be ineffective. Six trials with a total of 355 participants reported on remote ischemic preconditioning (RIPC) and our meta-analysis showed no statistically significant difference between RIPC and standard treatment (OR 1.20, 95% CI 0.37, 3.89); although the results should be interpreted with caution due to considerable statistical heterogeneity (I2 = 70%). None of the interventions studied significantly reduced receipt of renal replacement therapy (RRT). CONCLUSIONS Interventions that have shown some potential to reduce AKI after AAA repair include mannitol, a composite of antioxidant supplements, an open extraperitoneal approach and hANP. These conclusions are limited by the small size, high risk of bias and inconsistency of the included trials. Large, high quality, multi-center randomized trials will help determine which interventions are effective in reducing the incidence of postoperative AKI among patients undergoing elective AAA repair.
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Affiliation(s)
- Michaela Fernandes
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Melissa Majoni
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Amit X Garg
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada; Institute for Clinical Evaluative Sciences, London, Ontario, Canada
| | - Luc Dubois
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Institute for Clinical Evaluative Sciences, London, Ontario, Canada; Division of Vascular Surgery, London Health Sciences Centre, London, Ontario, Canada.
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4
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Ishigami J, Kim Y, Sang Y, Menez SP, Grams ME, Skali H, Shah AM, Hoogeveen RC, Selvin E, Solomon SD, Ballantyne CM, Coresh J, Matsushita K. High-Sensitivity Cardiac Troponin, Natriuretic Peptide, and Long-Term Risk of Acute Kidney Injury: The Atherosclerosis Risk in Communities (ARIC) Study. Clin Chem 2021; 67:298-307. [PMID: 33418586 PMCID: PMC7793230 DOI: 10.1093/clinchem/hvaa288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 10/28/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND Cardiac markers such as high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-B natriuretic peptide (NTproBNP) are predictors of developing acute kidney injury (AKI) during hospitalization for surgery or revascularization. However, their associations with the long-term risk of AKI in the general population are uncharacterized. METHODS We conducted a prospective cohort study in 10 669 participants of the Atherosclerosis Risk in Communities Study (visit 4, 1996-1998, mean age, 63 years, 56% female, 22% black race) to examine the association of plasma concentrations of hs-cTnT and NTproBNP with the incident hospitalization with AKI. We used multivariable Cox regression analysis to estimate hazard ratios (HRs). RESULTS During follow-up, 1907 participants had an incident hospitalization with AKI. Participants with higher concentrations of hs-cTnT had a higher risk of hospitalization with AKI in a graded fashion (adjusted HR, 1.88 [95%CI , 1.59-2.21] for ≥14 ng/L, 1.36 [1.18-1.57] for 9-13 ng/L, and 1.16 [1.03-1.30] for 5-8 ng/L compared to <5 ng/L). The graded association was also observed for NTproBNP (HR, 2.27 [1.93-2.68] for ≥272.7 pg/mL, 1.67 [1.45-1.93] for 142.4-272.6 pg/mL, and 1.31 [1.17-1.47] for 64.0-142.3 pg/mL compared to <64.0 pg/mL). The addition of hs-cTnT and NTproBNP to a model with established predictors significantly improved 10-year risk prediction for hospitalization with AKI (Δc-statistic, 0.015 [95%CI, 0.006-0.024]). CONCLUSIONS In middle-aged to older black and white adults in the community, higher concentrations of hs-cTnT and NTproBNP were robustly associated with an increased risk of hospitalization with AKI. These results suggest the usefulness of hs-cTnT and NT-proBNP to identify people at risk of AKI in the general population.
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Affiliation(s)
- Junichi Ishigami
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Yuhree Kim
- Department of Population Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Steven P Menez
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Hicham Skali
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Amil M Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Ron C Hoogeveen
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Zilberman-Itskovich S, Abu-Hamad R, Stark M, Efrati S. Effect of anti-C5 antibody on recuperation from ischemia/reperfusion-induced acute kidney injury. Ren Fail 2020; 41:967-975. [PMID: 31662004 PMCID: PMC6830203 DOI: 10.1080/0886022x.2019.1677248] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Aim: The complement system is activated in acute kidney injury (AKI). Anti-C5 antibody targets the common terminal portion of the complement cascade that generate the terminal complex C5b-9 and has a renal-protective effect in paroxysmal nocturnal hemoglobinuria. However, the anti-C5 antibody’s role in ischemia/reperfusion (I/R)-induced AKI has not been fully investigated. We therefore evaluated its effect on the pathophysiological cascade of I/R-induced AKI. Methods: Sprague–Dawley rats underwent unilateral right kidney nephrectomies with simultaneous clamping of the contralateral hilum for 60 min (ischemia), followed by reperfusion. In addition to a placebo, two treatment groups received either high or low doses of anti-C5 monoclonal antibody. After 48 h, the rats were euthanized, blood was drawn to evaluate systemic inflammation and to estimate glomerular filtration rate (GFR). The remaining kidney was removed for pathological evaluation and intra-renal complement activation. Results: I/R induced significant intra-renal complement activation and systemic inflammation compared with unilateral nephrectomy group. The anti-C5 antibody ameliorated the intra-renal complement activation (intra-renal C3 and C6), reduced systemic inflammation (C-reactive protein, and systemic C3), decreased intra-renal acute tubular necrosis damage and improved GFR (seen by the sensitive marker, serum cystatin C; 1.63 mg/L (I/R + placebo), 1.36 mg/L (I/R + low dose) and 1.21 mg/L (I/R + high dose), p = .08 and .03 compared with I/R + placebo). Conclusion: In I/R-induced AKI, the monoclonal anti-C5 complement factor ameliorates intra renal complement activation, decreases local and systemic inflammation and may improve GFR.
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Affiliation(s)
- Shani Zilberman-Itskovich
- Nephrology Division, Assaf-Harofeh Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ramzia Abu-Hamad
- Nephrology Division, Assaf-Harofeh Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Moshe Stark
- Nephrology Division, Assaf-Harofeh Medical Center, Zerifin, Israel
| | - Shai Efrati
- Nephrology Division, Assaf-Harofeh Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Sagatov IY, Medeubekov US. Dynamics of urine neutrophil gelatinase-associated lipocalin in cardiac surgery patients in the near term after surgery. Chirurgia (Bucur) 2019. [DOI: 10.23736/s0394-9508.18.04797-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Yuan SM. Acute kidney injury after pediatric cardiac surgery. Pediatr Neonatol 2019; 60:3-11. [PMID: 29891225 DOI: 10.1016/j.pedneo.2018.03.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 09/11/2017] [Accepted: 03/27/2018] [Indexed: 01/11/2023] Open
Abstract
Acute kidney injury (AKI) is a common complication of pediatric cardiac surgery and is associated with increased morbidity and mortality. Literature of AKI after pediatric cardiac surgery is comprehensively reviewed in terms of incidence, risk factors, biomarkers, treatment and prognosis. The novel RIFLE (pediatric RIFLE for pediatrics), Acute Kidney Injury Network (AKIN) and Kidney Disease Improving Global Outcomes (KDIGO) criteria have brought about unified diagnostic standards and comparable results for AKI after cardiac surgery. Numerous risk factors, either renal or extrarenal, can be responsible for the development of AKI after cardiac surgery, with low cardiac output syndrome being the most pronounced predictor. Early fluid overload is also crucial for the occurrence of AKI and prognosis in pediatric patients. Three sensitive biomarkers, neutrophil gelatinase-associated lipocalin, cystatin C (CysC) and liver fatty acid-binding protein, are regarded as the earliest (increase at 2-4 h), and another two, kidney injury molecule-1 and interleukin-18 represent the intermediate respondents (increase at 6-12 h after surgery). To ameliorate the cardiopulmonary bypass techniques, improve renal perfusion and eradicate the causative risk factors are imperative for the prevention of AKI in pediatric patients. The early and intermediate biomarkers are helpful for an early judgment of occurrence of postoperative AKI. Improved survival has been achieved by prevention, renal support and modifications of hemofiltration techniques. Further development is anticipated in small children.
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Affiliation(s)
- Shi-Min Yuan
- Department of Cardiothoracic Surgery, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, 389 Longdejing Street, Chengxiang District, Putian 351100, Fujian Province, People's Republic of China.
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Krawczeski CD. Cardiopulmonary Bypass and AKI: AKI Is Bad, So Let's Get Beyond the Diagnosis. Front Pediatr 2019; 7:492. [PMID: 31850289 PMCID: PMC6887652 DOI: 10.3389/fped.2019.00492] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/12/2019] [Indexed: 01/11/2023] Open
Abstract
It is now well-established that AKI is a serious and common complication following cardiopulmonary bypass (CPB) in both children and adults, adverse outcomes may occur in the short term as well as long term, with higher incidence of chronic kidney disease, increased healthcare utilization and higher frequency of cardiovascular events in patients who develop post-CPB AKI. Despite the advances in our understanding of the pathogenesis of the disease and the improvement in diagnostic tools, our therapeutic options have remained suboptimal. There are multiple challenges in designing a clinical therapeutic AKI trial, including a multi-factorial etiology, difficulties with accurate diagnosis of AKI, achievement of adequate study power, and determination of appropriate outcomes. We are often left with "supportive" care. Studies have shown some benefit to AKI bundles, but adherence to bundle guidelines may be suboptimal. Current best practices should include maintenance of adequate renal perfusion pressure and avoidance of fluid overload, with consideration of early renal replacement therapy. Finally, multi-center trials of AKI therapies are crucial to finding treatment for this devastating complication of CPB.
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Affiliation(s)
- Catherine D Krawczeski
- Pediatric Cardiology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, United States
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9
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Grundmann F, Müller RU, Reppenhorst A, Hülswitt L, Späth MR, Kubacki T, Scherner M, Faust M, Becker I, Wahlers T, Schermer B, Benzing T, Burst V. Preoperative Short-Term Calorie Restriction for Prevention of Acute Kidney Injury After Cardiac Surgery: A Randomized, Controlled, Open-Label, Pilot Trial. J Am Heart Assoc 2018. [PMID: 29535139 PMCID: PMC5907569 DOI: 10.1161/jaha.117.008181] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Acute kidney injury is a frequent complication after cardiac surgery and is associated with adverse outcomes. Although short-term calorie restriction (CR) has proven protective in rodent models of acute kidney injury, similar effects have not yet been demonstrated in humans. METHODS AND RESULTS CR_KCH (Effect of a Preoperative Calorie Restriction on Renal Function After Cardiac Surgery) is a randomized controlled trial in patients scheduled for cardiac surgery. Patients were randomly assigned to receive either a formula diet containing 60% of the daily energy requirement (CR group) or ad libitum food (control group) for 7 days before surgery. In total, 82 patients were enrolled between April 16, 2012, and February 5, 2015. There was no between-group difference in the primary end point of median serum creatinine increment after 24 hours (control group: 0.0 mg/dL [-0.1 - (+0.2) mg/dL]; CR group: 0.0 mg/dL [-0.2 - (+0.2) mg/dL]; P=0.39). CR prevented a rise in median creatinine at 48 hours (control group: +0.1 mg/dL [0.0 - 0.3 mg/dL]; CR group: -0.1 mg/dL [-0.2 - (+0.1) mg/dL]; P=0.03), with most pronounced effects observed in male patients and patients with a body mass index >25. This benefit persisted until discharge: Median creatinine decreased by 0.1 mg/dL (-0.2 - 0.0 mg/dL) in the CR group, whereas it increased by 0.1 mg/dL (0.0 - 0.3 mg/dL; P=0.0006) in the control group. Incidence of acute kidney injury was reduced by 5.8% (41.7% in the CR group compared with 47.5% in the control group). Safety-related events did not differ between groups. CONCLUSIONS Despite disappointing results with respect to creatinine rise within the first 24 hours, the benefits observed at later time points and the subgroup analyses suggest the protective potential of short-term CR in patients at risk for acute kidney injury, warranting further investigation. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01534364.
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Affiliation(s)
- Franziska Grundmann
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Germany
| | - Roman-Ulrich Müller
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Germany
| | - Annika Reppenhorst
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Germany
| | - Lennart Hülswitt
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Germany
| | - Martin R Späth
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Germany
| | - Torsten Kubacki
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Germany
| | | | - Michael Faust
- Center for Endocrinology, Diabetes and Preventive Medicine, University of Cologne, Germany
| | - Ingrid Becker
- Institute of Medical Statistics and Computational Biology, University of Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University of Cologne, Germany
| | - Bernhard Schermer
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Germany
| | - Thomas Benzing
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Germany
| | - Volker Burst
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Germany
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Zhang Y, Jiang L, Wang B, Xi X. Epidemiological characteristics of and risk factors for patients with postoperative acute kidney injury: a multicenter prospective study in 30 Chinese intensive care units. Int Urol Nephrol 2018; 50:1319-1328. [PMID: 29480442 DOI: 10.1007/s11255-018-1828-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 02/17/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Although there were studies to investigate the risk factors for acute kidney injury (AKI) after surgery, most of them focused on one specific type of surgeries. The risk factors for postoperative AKI in patients undergoing all surgeries in intensive care units (ICU) have not been reported. METHODS Data from 1731 patients undergoing surgery in 30 ICUs of 28 tertiary hospitals in Beijing from March to August 2012 were prospectively collected. AKI was defined and staged by the KDIGO criteria. Multivariate logistic regression analysis was performed to assess independent risk factors for postoperative AKI. RESULTS Postoperative AKI occurred in 44.8% of patients (stage 1 54.8%; stage 2 21.9%, stage 3 23.3%). Cardiovascular surgery was identified as an independent factor for postoperative AKI as well as emergency surgery [odds ratio (OR) 1.403], nephrotoxic drugs (OR 1.303), APACHE II score (OR 1.055), SOFA score (OR 1.115), duration for positive fluid balance (OR 1.165), use of diuretics (OR 2.293), sepsis (OR 1.501), and CKD (OR 4.517). AKI stage 3 versus stages 1-2 was associated with higher mortality in ICU, hospital, and 28-day follow-up after cardiovascular, abdominal, limb, and chest surgeries, while this was not observed after neurosurgery or other surgeries. CONCLUSION Risk factors for AKI in ICU patients after different types of surgery were identified. This might be the first step to reduce the high incidence of AKI after surgery. The presence of AKI in ICU patients was associated with higher mortality after most types of surgery, but not after neurosurgery. TRIAL REGISTRATION ChiCTR-ONC-11001875.
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Affiliation(s)
- Yu Zhang
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, Beijing, 100038, China
- Department of Intensive Care Units, Tangshan People's Hospital, Tangshan, 063000, China
| | - Li Jiang
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, Beijing, 100038, China
| | - Baomin Wang
- Department of Intensive Care Units, Tangshan People's Hospital, Tangshan, 063000, China
| | - Xiuming Xi
- Department of Critical Care Medicine, Fu Xing Hospital, Capital Medical University, Beijing, 100038, China.
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11
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Perico N, Casiraghi F, Remuzzi G. Mesenchymal Stromal Cells for AKI after Cardiac Surgery. J Am Soc Nephrol 2017; 29:7-9. [PMID: 29229766 DOI: 10.1681/asn.2017111207] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Norberto Perico
- IRCCS, Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy;
| | | | - Giuseppe Remuzzi
- IRCCS, Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy.,Unit of Nephrology and Dialysis, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy; and.,Department of Biomedical and Clinical Sciences "L. Sacco," University of Milan, Milan, Italy
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12
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Afonso N, Checchia PA. Avoiding kidney injury in the surgical patient: Further defining the role of age. J Thorac Cardiovasc Surg 2017; 155:266-267. [PMID: 28987738 DOI: 10.1016/j.jtcvs.2017.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 09/08/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Natasha Afonso
- Section of Critical Care Medicine, Texas Children's Hospital, Houston, Tex
| | - Paul A Checchia
- Section of Critical Care Medicine, Texas Children's Hospital, Houston, Tex.
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Incidence, risk factors, and outcomes of acute kidney injury in adults undergoing surgery for congenital heart disease. Cardiol Young 2017; 27:1068-1075. [PMID: 27869053 DOI: 10.1017/s1047951116002067] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Acute kidney injury after cardiac surgery is a frequent and serious complication among children with congenital heart disease (CHD) and adults with acquired heart disease; however, the significance of kidney injury in adults after congenital heart surgery is unknown. The primary objective of this study was to determine the incidence of acute kidney injury after surgery for adult CHD. Secondary objectives included determination of risk factors and associations with clinical outcomes. METHODS This single-centre, retrospective cohort study was performed in a quaternary cardiovascular ICU in a paediatric hospital including all consecutive patients ⩾18 years between 2010 and 2013. RESULTS Data from 118 patients with a median age of 29 years undergoing cardiac surgery were analysed. Using Kidney Disease: Improving Global Outcome creatinine criteria, 36% of patients developed kidney injury, with 5% being moderate to severe (stage 2/3). Among higher-complexity surgeries, incidence was 59%. Age ⩾35 years, preoperative left ventricular dysfunction, preoperative arrhythmia, longer bypass time, higher Risk Adjustment for Congenital Heart Surgery-1 category, and perioperative vancomycin use were significant risk factors for kidney injury development. In multivariable analysis, age ⩾35 years and vancomycin use were significant predictors. Those with kidney injury were more likely to have prolonged duration of mechanical ventilation and cardiovascular ICU stay in the univariable regression analysis. CONCLUSIONS We demonstrated that acute kidney injury is a frequent complication in adults after surgery for CHD and is associated with poor outcomes. Risk factors for development were identified but largely not modifiable. Further investigation within this cohort is necessary to better understand the problem of kidney injury.
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14
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Yang X, Chen C, Teng S, Fu X, Zha Y, Liu H, Wang L, Tian J, Zhang X, Liu Y, Nie J, Hou FF. Urinary Matrix Metalloproteinase-7 Predicts Severe AKI and Poor Outcomes after Cardiac Surgery. J Am Soc Nephrol 2017; 28:3373-3382. [PMID: 28698269 DOI: 10.1681/asn.2017020142] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 05/27/2017] [Indexed: 01/25/2023] Open
Abstract
Urinary matrix metalloproteinase-7 (uMMP-7) levels consistently reflect the activity of intrarenal Wnt/β-catenin, which is activated in AKI models. To test the hypothesis that uMMP-7 is a predictor for severe AKI in patients after cardiac surgery, we performed a prospective, multicenter, two-stage cohort study in 721 patients undergoing cardiac surgery. In stage 1, we enrolled 323 children from three academic medical centers. In stage 2, we enrolled 398 adults at six centers. We analyzed levels of uMMP-7 and other injury biomarkers during the perioperative period. Severe AKI was defined as Kidney Disease Improving Global Outcomes stage 2 or 3. uMMP-7 level peaked within 6 hours after surgery in patients who subsequently developed severe AKI. After multivariate adjustment, the highest quintile of postoperative uMMP-7 level, compared with the lowest quintile, associated with 17-fold (in adults) and 36-fold (in children) higher odds of severe AKI. Elevated uMMP-7 level associated with increased risk of composite events (severe AKI, acute dialysis, and in-hospital death) and longer stay in the intensive care unit and hospital. For predicting severe AKI, uMMP-7 had an area under the receiver operating characteristic curve of 0.81 (in children) and 0.76 (in adults), outperforming urinary IL-18, angiotensinogen, neutrophil gelatinase-associated lipocalin, albumin-to-creatinine ratio, and tissue inhibitor of metalloproteinase-2·IGF-binding protein-7 and the clinical model. uMMP-7 significantly improved risk reclassification over the clinical model alone, as measured by net reclassification improvement and integrated discrimination improvement. In conclusion, uMMP-7 is a promising predictor for severe AKI and poor in-hospital outcomes in patients after cardiac surgery.
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Affiliation(s)
- Xiaobing Yang
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangzhou, China
| | - Chunbo Chen
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangzhou, China
| | - Siyuan Teng
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangzhou, China
| | - Xiaorui Fu
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangzhou, China
| | - Yan Zha
- Department of Nephrology, Guizhou Provincial People's Hospital, Guiyang Medical University, Guiyang, China
| | - Huafeng Liu
- Division of Nephrology, Institute of Nephrology, Guangdong Medical College, Zhanjiang, China; and
| | - Li Wang
- Division of Nephrology, Sichuan Provincial People's Hospital, Chengdu, China
| | - Jianwei Tian
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangzhou, China
| | - Xiangyan Zhang
- Department of Nephrology, Guizhou Provincial People's Hospital, Guiyang Medical University, Guiyang, China
| | - Youhua Liu
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangzhou, China
| | - Jing Nie
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangzhou, China
| | - Fan Fan Hou
- Division of Nephrology, Nanfang Hospital, Southern Medical University, National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangzhou, China;
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Flechet M, Güiza F, Schetz M, Wouters P, Vanhorebeek I, Derese I, Gunst J, Spriet I, Casaer M, Van den Berghe G, Meyfroidt G. AKIpredictor, an online prognostic calculator for acute kidney injury in adult critically ill patients: development, validation and comparison to serum neutrophil gelatinase-associated lipocalin. Intensive Care Med 2017; 43:764-773. [PMID: 28130688 DOI: 10.1007/s00134-017-4678-3] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 01/03/2017] [Indexed: 01/20/2023]
Abstract
PURPOSE Early diagnosis of acute kidney injury (AKI) remains a major challenge. We developed and validated AKI prediction models in adult ICU patients and made these models available via an online prognostic calculator. We compared predictive performance against serum neutrophil gelatinase-associated lipocalin (NGAL) levels at ICU admission. METHODS Analysis of the large multicenter EPaNIC database. Model development (n = 2123) and validation (n = 2367) were based on clinical information available (1) before and (2) upon ICU admission, (3) after 1 day in ICU and (4) including additional monitoring data from the first 24 h. The primary outcome was a comparison of the predictive performance between models and NGAL for the development of any AKI (AKI-123) and AKI stages 2 or 3 (AKI-23) during the first week of ICU stay. RESULTS Validation cohort prevalence was 29% for AKI-123 and 15% for AKI-23. The AKI-123 model before ICU admission included age, baseline serum creatinine, diabetes and type of admission (medical/surgical, emergency/planned) and had an AUC of 0.75 (95% CI 0.75-0.75). The AKI-23 model additionally included height and weight (AUC 0.77 (95% CI 0.77-0.77)). Performance consistently improved with progressive data availability to AUCs of 0.82 (95% CI 0.82-0.82) for AKI-123 and 0.84 (95% CI 0.83-0.84) for AKI-23 after 24 h. NGAL was less discriminant with AUCs of 0.74 (95% CI 0.74-0.74) for AKI-123 and 0.79 (95% CI 0.79-0.79) for AKI-23. CONCLUSIONS AKI can be predicted early with models that only use routinely collected clinical information and outperform NGAL measured at ICU admission. The AKI-123 models are available at http://akipredictor.com/ . Trial registration Clinical Trials.gov NCT00512122.
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Affiliation(s)
- Marine Flechet
- Clinical Division and Laboratory of Intensive Care Medicine, Academic Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Herestraat 49, B-3000, Leuven, Belgium
| | - Fabian Güiza
- Clinical Division and Laboratory of Intensive Care Medicine, Academic Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - Miet Schetz
- Clinical Division and Laboratory of Intensive Care Medicine, Academic Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Herestraat 49, B-3000, Leuven, Belgium
| | - Pieter Wouters
- Clinical Division and Laboratory of Intensive Care Medicine, Academic Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Herestraat 49, B-3000, Leuven, Belgium
| | - Ilse Vanhorebeek
- Clinical Division and Laboratory of Intensive Care Medicine, Academic Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Herestraat 49, B-3000, Leuven, Belgium
| | - Inge Derese
- Clinical Division and Laboratory of Intensive Care Medicine, Academic Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Herestraat 49, B-3000, Leuven, Belgium
| | - Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Academic Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Herestraat 49, B-3000, Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Department, Department of Pharmaceutical and Pharmacological Sciences, University Hospitals Leuven and Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium
| | - Michaël Casaer
- Clinical Division and Laboratory of Intensive Care Medicine, Academic Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Herestraat 49, B-3000, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Academic Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Herestraat 49, B-3000, Leuven, Belgium
| | - Geert Meyfroidt
- Clinical Division and Laboratory of Intensive Care Medicine, Academic Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Herestraat 49, B-3000, Leuven, Belgium
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16
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Mei M, Zhao HW, Pan QG, Pu YM, Tang MZ, Shen BB. Efficacy of N-Acetylcysteine in Preventing Acute Kidney Injury After Cardiac Surgery: A Meta-Analysis Study. J INVEST SURG 2017; 31:14-23. [PMID: 28060555 DOI: 10.1080/08941939.2016.1269853] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE To evaluate whether perioperative N-acetylcysteine (NAC) administration reduces the risk of cardiac surgery associated acute kidney injury (CSA-AKI). MATERIALS AND METHODS A systematic literature review (Medline, PubMed, Cochrane, Biomedical central, Google Scholar) identified 10 studies (1391 patients; 695 NAC and 696 placebo) that compared the efficacy and adverse effects of perioperative NAC administration for CSA-AKI prevention in adults undergoing elective cardiac surgery. Meta-analysis was performed using Comprehensive Meta-Analysis statistical software. RESULTS Patients in the NAC-treated and placebo groups had similar rate of CSA-AKI occurrence, change in creatinine levels, as well as the in-hospital mortality rate (RR = 0.841, 95% CI = 0.691 to 1.023, p = 0.083; pooled difference in means = -0.328, 95% CI = -0.712 to 0.056, p = 0.094; RR = 0.741, 95% CI = 0.388 to 1.418, p = 0.366, respectively). CONCLUSIONS Our study does not support perioperative NAC administration as a mean to reduce the risk of CSA-AKI.
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Affiliation(s)
- Mei Mei
- a Department of Kidney , Southwest Hospital, Third Military Medical University , Chongqing 400038 , P.R. China
| | - Hong-Wen Zhao
- a Department of Kidney , Southwest Hospital, Third Military Medical University , Chongqing 400038 , P.R. China
| | - Qian-Guang Pan
- a Department of Kidney , Southwest Hospital, Third Military Medical University , Chongqing 400038 , P.R. China
| | - You-Min Pu
- a Department of Kidney , Southwest Hospital, Third Military Medical University , Chongqing 400038 , P.R. China
| | - Mao-Zhi Tang
- a Department of Kidney , Southwest Hospital, Third Military Medical University , Chongqing 400038 , P.R. China
| | - Bing-Bing Shen
- a Department of Kidney , Southwest Hospital, Third Military Medical University , Chongqing 400038 , P.R. China
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Cardoso B, Laranjo S, Gomes I, Freitas I, Trigo C, Fragata I, Fragata J, Pinto FF. Acute kidney injury after pediatric cardiac surgery: Risk factors and outcomes. Proposal for a predictive model. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.repce.2016.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Cardoso B, Laranjo S, Gomes I, Freitas I, Trigo C, Fragata I, Fragata J, Pinto F. [Acute kidney injury after pediatric cardiac surgery: risk factors and outcomes. Proposal for a predictive model]. Rev Port Cardiol 2016; 35:99-104. [PMID: 26831910 DOI: 10.1016/j.repc.2015.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 06/24/2015] [Accepted: 06/25/2015] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES To characterize the epidemiology and risk factors for acute kidney injury (AKI) after pediatric cardiac surgery in our center, to determine its association with poor short-term outcomes, and to develop a logistic regression model that will predict the risk of AKI for the study population. METHODS This single-center, retrospective study included consecutive pediatric patients with congenital heart disease who underwent cardiac surgery between January 2010 and December 2012. Exclusion criteria were a history of renal disease, dialysis or renal transplantation. RESULTS Of the 325 patients included, median age three years (1 day-18 years), AKI occurred in 40 (12.3%) on the first postoperative day. Overall mortality was 13 (4%), nine of whom were in the AKI group. AKI was significantly associated with length of intensive care unit stay, length of mechanical ventilation and in-hospital death (p<0.01). Patients' age and postoperative serum creatinine, blood urea nitrogen and lactate levels were included in the logistic regression model as predictor variables. The model accurately predicted AKI in this population, with a maximum combined sensitivity of 82.1% and specificity of 75.4%. CONCLUSIONS AKI is common and is associated with poor short-term outcomes in this setting. Younger age and higher postoperative serum creatinine, blood urea nitrogen and lactate levels were powerful predictors of renal injury in this population. The proposed model could be a useful tool for risk stratification of these patients.
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Affiliation(s)
- Bárbara Cardoso
- Serviço de Cardiologia Pediátrica, Hospital Santa Marta - Centro Hospitalar de Lisboa Central, Lisboa, Portugal.
| | - Sérgio Laranjo
- Serviço de Cardiologia Pediátrica, Hospital Santa Marta - Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Inês Gomes
- Serviço de Cardiologia Pediátrica, Hospital Santa Marta - Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Isabel Freitas
- Serviço de Cardiologia Pediátrica, Hospital Santa Marta - Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Conceição Trigo
- Serviço de Cardiologia Pediátrica, Hospital Santa Marta - Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Isabel Fragata
- Serviço de Anestesiologia, Hospital de Santa Marta - Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - José Fragata
- Serviço de Cirurgia Cardiotorácica, Hospital de Santa Marta - Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Fátima Pinto
- Serviço de Cardiologia Pediátrica, Hospital Santa Marta - Centro Hospitalar de Lisboa Central, Lisboa, Portugal
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Abstract
PURPOSE OF REVIEW The indications for aspirin (ASA) for both primary and secondary prevention of thrombotic events continue to evolve. We review some of these indications and the recent literature regarding the perioperative administration of ASA. RECENT FINDINGS ASA for primary prevention of cardiac ischemia, stroke, cancer, and death remains controversial. When used for primary prevention, ASA may be safely discontinued perioperatively. Patients with coronary or carotid artery stents should continue to receive ASA perioperatively. For patients with ischemic heart disease currently receiving ASA for secondary prevention of cardiac ischemia and stroke undergoing general surgery, orthopedic surgery, ophthalmological surgery, cardiovascular surgery, major vascular surgery, or a urological procedure, continuation of ASA is probably well tolerated, but further study is required. There is no indication to initiate ASA perioperatively in patients with stable ischemic heart disease as the risks outweigh the benefits. Until further data become available, decisions regarding the perioperative continuation of ASA should be made on a case-by-case risk-benefit analysis. SUMMARY The continuation or discontinuation of ASA perioperatively remains a complicated issue. Further, well designed trials are needed for additional clarification.
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20
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Cheng H, Sun JZ, Ji FH, Liu H. Prevention and Treatment of Cardiac Surgery Associated Acute Kidney Injury. JOURNAL OF ANESTHESIA AND PERIOPERATIVE MEDICINE 2016; 3:42-51. [PMID: 31598583 PMCID: PMC6785192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
AIM OF REVIEW Acute kidney injury (AKI) after cardiac surgery is a relatively common postoperative complication and is independently related to increased mortality and morbidity. METHOD In this review, we will focus on risk factors of developing AKI, early detection by biomarkers and preventive strategies for AKI after adult cardiac surgery. RECENT FINDINGS Many perioperative factors affect renal function and acute AKI following cardiac surgery. Novel biomarkers of kidney injury such as neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18 (IL-18), cystatin C (CysC), have the potential to facilitate the early diagnosis of cardiac surgery associated AKI (CSA-AKI). Pharmacological interventions have been inconsistent to their efficacy, and to date, there is no compelling pharmacologic agent known to reduce the risk of AKI or treat established AKI. SUMMARY Preventive strategies of AKI focus on optimal perioperative management.
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Affiliation(s)
- Hao Cheng
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China,Department of Anesthesiology and Pain Medicine, University of California Davis Health System, Sacramento, USA
| | - Jian-Zhong Sun
- Department of Anesthesiology, Thomas Jefferson University and Hospitals, Philadelphia, USA
| | - Fu-Hai Ji
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California Davis Health System, Sacramento, USA
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21
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Kararmaz A, Kemal Arslantas M, Cinel I. Renal Resistive Index Measurement by Transesophageal Echocardiography: Comparison With Translumbar Ultrasonography and Relation to Acute Kidney Injury. J Cardiothorac Vasc Anesth 2015; 29:875-80. [DOI: 10.1053/j.jvca.2014.11.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Indexed: 12/29/2022]
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22
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Wong B, St Onge J, Korkola S, Prasad B. Validating a scoring tool to predict acute kidney injury (AKI) following cardiac surgery. Can J Kidney Health Dis 2015; 2:3. [PMID: 25780626 PMCID: PMC4349478 DOI: 10.1186/s40697-015-0037-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 01/20/2015] [Indexed: 12/31/2022] Open
Abstract
Background Acute kidney injury (AKI) after cardiac surgery is associated with an increased risk of mortality. Preoperative risk scores can identify patients at risk for AKI and facilitate preventive strategies. Currently, validated risk scores are used to predict AKI requiring dialysis (AKI-D); less is known about whether these tools predict less severe forms of AKI. Objective To evaluate the Cleveland Clinic scoring tool in predicting both AKI-D and less severe stages of AKI in patients after cardiac surgery in a Canadian tertiary care center. Design Retrospective case–control study. Setting Regina Qu’Appelle Health Region (RQHR) from 2007 to 2011. Patients Patients who underwent cardiac surgery and developed postoperative kidney injury (n = 2316). Measurements Data on risk factors for AKI and outcomes of cardiac surgery were collected from a retrospective chart review. Methods The primary outcome was AKI, defined as Stage 1 (increase in serum creatinine 1.5-1.9 X baseline within 5 days), Stage 2 (increase 2.0-2.9 X baseline), or Stage 3 (increase 3.0 X baseline or more OR initiation of dialysis during hospital stay). We assessed the performance of a modified version of the Cleveland Clinic tool using receiver operating curve analyses. Results The incidence of AKI was 6.1% (Stage 1), 2.6% (Stage 2), and 5.8% (Stage 3). The area under the curve (AUC) for the Cleveland score was 0.61 (95% CI: 0.56 to 0.65; p < 0.001) for Stage 1, 0.61 (95% CI: 0.54 to 0.68; p < 0.01) for Stage 2, and 0.78 (95% CI: 0.74 to 0.82; p < 0.001) for Stage 3. Greater level of risk on the Cleveland tool was associated with a higher risk of Stage 3 AKI. Limitations Lack of prospective validation. Conclusions The modified Cleveland Clinic tool was valid in identifying patients with severe stages of AKI but did not have strong discrimination for early AKI stages. Electronic supplementary material The online version of this article (doi:10.1186/s40697-015-0037-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Brian Wong
- College of Medicine - Regina Campus, University of Saskatchewan, Regina General Hospital, 1440-14th Avenue, Regina, SK S4P0W5 Canada
| | - Jennifer St Onge
- Research and Performance Support, Regina Qu'Appelle Health Region, Regina, SK, 2180 - 23rd Avenue, Regina, SK S4S 0A5 Canada
| | - Stephen Korkola
- Department of Surgery, Regina Qu'Appelle Health Region, Regina, SK, Regina General Hospital, 1440-14th Avenue, Regina, SK S4P0W5 Canada
| | - Bhanu Prasad
- Section of Nephrology, Department of Medicine, Regina Qu'Appelle Health Region, Regina, SK, Regina General Hospital, 1440-14th Avenue, 3401-B Pasqua Street, Regina, SK S4P0W5 Canada
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Fluid management in the cardiothoracic intensive care unit: diuresis--diuretics and hemofiltration. Curr Opin Anaesthesiol 2014; 27:133-9. [PMID: 24514030 DOI: 10.1097/aco.0000000000000055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW The present review discusses the current concepts of fluid management in cardiothoracic surgery, and its clinical implications with special reference to organ-related complications and their prevention. RECENT FINDINGS Current strategies in fluid management for cardiothoracic patients, various fluid formulation, and the preventive strategies for minimizing fluid-related complications are described, with particular reference to new discoveries and controversies that have arisen from recent literature. SUMMARY The optimal fluid management in cardiothoracic patients has not been settled. Results of recent clinical published trials highlight the need for minimizing fluid administration and attempting to use diuretics to achieve a negative fluid, although hypovolemia and hypoperfusion should be carefully considered. An individualized optimization of fluid status, using goal-directed therapy, has emerged as a possible preferable approach. The old debate between crystalloid and colloid solutions has been partially solved, as some colloids have demonstrated deleterious effect on renal function and coagulation system. Various preventive strategies have also emerged for minimizing fluid-related complications.
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Pan SY, Wu VC, Huang TM, Chou HC, Ko WJ, Wu KD, Lee CC. Effect of preoperative statin therapy on postoperative acute kidney injury in patients undergoing major surgery: systemic review and meta-analysis. Nephrology (Carlton) 2014; 19:750-63. [PMID: 25185964 DOI: 10.1111/nep.12334] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2014] [Indexed: 11/26/2022]
Abstract
We aimed to examine the association between preoperative use of statins and postoperative acute kidney injury (AKI) in patients undergoing major surgery by performing a systemic review and meta-analysis. MEDLINE and EMBASE, from inception to April 2013, and the reference lists of related articles were searched for relevant studies. Trials comparing preoperative statin therapy with no preoperative statin in patients undergoing major surgery were included. Outcome measures of interest were the risk of cumulative postoperative AKI and postoperative AKI requiring renal replacement therapy (RRT). Fixed or random effect meta-analysis was performed to derive summary effect estimates. In five randomized controlled trials (RCTs) and 19 observational studies, comprising a total of 989 173 patients undergoing major surgery, 112 840 patients (11.41%) received preoperative statin therapy. The specific type, dosage, and duration of statin therapy were not available in most studies. Preoperative statin therapy was associated with a significant risk reduction for cumulative postoperative AKI (weighted summary odds ratio (OR) 0.87, 95% CI 0.79 to 0.95). The effect of risk reduction was also significant when considering postoperative AKI requiring RRT (OR 0.80, 95% CI 0.72 to 0.90). When restricting the analysis to the five RCTs, preoperative statin therapy did not show significant protective effect on postoperative AKI (OR 0.49, 95% CI 0.22 to 1.09). In patients undergoing major surgery, preoperative statin therapy could associate with a reduced risk for postoperative AKI. However, considerable heterogeneity existed among included studies. Future randomized trials were warranted for this critical clinical question.
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Affiliation(s)
- Szu-Yu Pan
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Dou-Liou, Taiwan; Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Birnie K, Verheyden V, Pagano D, Bhabra M, Tilling K, Sterne JA, Murphy GJ. Predictive models for kidney disease: improving global outcomes (KDIGO) defined acute kidney injury in UK cardiac surgery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:606. [PMID: 25673427 PMCID: PMC4258283 DOI: 10.1186/s13054-014-0606-x] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 10/20/2014] [Indexed: 11/10/2022]
Abstract
Introduction Acute kidney injury (AKI) risk prediction scores are an objective and transparent means to enable cohort enrichment in clinical trials or to risk stratify patients preoperatively. Existing scores are limited in that they have been designed to predict only severe, or non-consensus AKI definitions and not less severe stages of AKI, which also have prognostic significance. The aim of this study was to develop and validate novel risk scores that could identify all patients at risk of AKI. Methods Prospective routinely collected clinical data (n = 30,854) were obtained from 3 UK cardiac surgical centres (Bristol, Birmingham and Wolverhampton). AKI was defined as per the Kidney Disease: Improving Global Outcomes (KDIGO) Guidelines. The model was developed using the Bristol and Birmingham datasets, and externally validated using the Wolverhampton data. Model discrimination was estimated using the area under the ROC curve (AUC). Model calibration was assessed using the Hosmer–Lemeshow test and calibration plots. Diagnostic utility was also compared to existing scores. Results The risk prediction score for any stage AKI (AUC = 0.74 (95% confidence intervals (CI) 0.72, 0.76)) demonstrated better discrimination compared to the Euroscore and the Cleveland Clinic Score, and equivalent discrimination to the Mehta and Ng scores. The any stage AKI score demonstrated better calibration than the four comparison scores. A stage 3 AKI risk prediction score also demonstrated good discrimination (AUC = 0.78 (95% CI 0.75, 0.80)) as did the four comparison risk scores, but stage 3 AKI scores were less well calibrated. Conclusions This is the first risk score that accurately identifies patients at risk of any stage AKI. This score will be useful in the perioperative management of high risk patients as well as in clinical trial design.
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Meersch M, Schmidt C, Van Aken H, Rossaint J, Görlich D, Stege D, Malec E, Januszewska K, Zarbock A. Validation of cell-cycle arrest biomarkers for acute kidney injury after pediatric cardiac surgery. PLoS One 2014; 9:e110865. [PMID: 25343505 PMCID: PMC4208780 DOI: 10.1371/journal.pone.0110865] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 09/25/2014] [Indexed: 12/22/2022] Open
Abstract
Background The lack of early biomarkers for acute kidney injury (AKI) seriously inhibits the initiation of preventive and therapeutic measures for this syndrome in a timely manner. We tested the hypothesis that insulin-like growth factor-binding protein 7 (IGFBP7) and tissue inhibitor of metalloproteinases-2 (TIMP-2), both inducers of G1 cell cycle arrest, function as early biomarkers for AKI after congenital heart surgery with cardiopulmonary bypass (CPB). Methods We prospectively studied 51 children undergoing cardiac surgery with CPB. Serial urine samples were analyzed for [TIMP-2]•[IGFBP7]. The primary outcome measure was AKI defined by the pRIFLE criteria within 72 hours after surgery. Results 12 children (24%) developed AKI within 1.67 (SE 0.3) days after surgery. Children who developed AKI after cardiac surgery had a significant higher urinary [TIMP-2]•[IGFBP7] as early as 4 h after the procedure, compared to children who did not develop AKI (mean of 1.93 ((ng/ml)2/1000) (SE 0.4) vs 0.47 ((ng/ml)2/1000) (SE 0.1), respectively; p<0.05). Urinary [TIMP-2]•[IGFBP7] 4 hours following surgery demonstrated an area under the receiver-operating characteristic curve of 0.85. Sensitivity was 0.83, and specificity was 0.77 for a cutoff value of 0.70 ((ng/ml)2/1000). Conclusions Urinary [TIMP-2]•[IGFBP7] represent sensitive, specific, and highly predictive early biomarkers for AKI after surgery for congenital heart disease. Trial Registration www.germanctr.de/, DRKS00005062
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Affiliation(s)
- Melanie Meersch
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany
| | - Christoph Schmidt
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany
| | - Hugo Van Aken
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany
| | - Jan Rossaint
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany
| | - Dennis Görlich
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Dirk Stege
- Department of Pediatric Cardiology, University of Münster, Münster, Germany
| | - Edward Malec
- Department of Pediatric Heart Surgery, University of Münster, Münster, Germany
| | | | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Münster, Münster, Germany
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Ozaydin M, Peker T, Akcay S, Uysal BA, Yucel H, Icli A, Erdogan D, Varol E, Dogan A, Okutan H. Addition of N-acetyl cysteine to carvedilol decreases the incidence of acute renal injury after cardiac surgery. Clin Cardiol 2014; 37:108-14. [PMID: 24672814 DOI: 10.1002/clc.22227] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Oxidative stress and inflammation during cardiac surgery may be associated with acute renal injury (ARI). N-acetyl cysteine (NAC) and carvedilol have antioxidant and anti-inflammatory properties. HYPOTHESIS A combination of carvedilol and NAC should decrease the incidence of ARI more than metoprolol or carvedilol. METHODS Patients undergoing cardiac surgery were randomized to metoprolol, carvedilol, or carvedilol plus NAC. End points were occurrence of ARI and change in preoperative to postoperative peak creatinine levels. RESULTS ARI incidence was lower in the carvedilol plus NAC group compared with the metoprolol (21.0% vs 42.1%; P = 0.002) or carvedilol (21.0% vs 38.6%; P = 0.006) groups, but was similar between the metoprolol and carvedilol groups (P = 0.62). Preoperative and postoperative day 1 creatinine levels were similar among the metoprolol (1.02 [0.9-1.2] and 1.2 [0.92-1.45]) the carvedilol (1.0 [0.88-1.08] and 1.2 [0.9-1.5]) and the carvedilol plus NAC groups (1.06 [0.9-1.18] and 1.1 [1.0-1.21] mg/dL; all P values >0.05). Postoperative day 3, day 5, and peak creatinine levels were lower in the carvedilol plus NAC group (1.11 [1.0-1.23], 1.14 [1.0-1.25] and 1.15 [1.0-1.25]) as compared with the metoprolol (1.4 [1.3-1.49], 1.3 [1.0-1.54] and 1.3 [1.0-1.54]) or carvedilol groups (1.2 [1.0-1.52], 1.25 [1.0-1.52] and 1.25 [1.0-1.55] mg/dL; all P values <0.05), but were similar between the metoprolol and carvedilol groups (all P values >0.05). CONCLUSIONS Combined carvedilol and NAC decreased ARI incidence as compared with carvedilol or metoprolol. No difference was detected between carvedilol and metoprolol.
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Paparella D, Guida P, Mazzei V, Carbone C, Speziale G, Fanelli V, Zaccaria S, Labriola C, Scrascia G. Hemoglobin and Renal Replacement Therapy after Cardiopulmonary Bypass surgery: A predictive score from the Cardiac Surgery Registry of Puglia. Int J Cardiol 2014; 176:866-73. [DOI: 10.1016/j.ijcard.2014.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 05/23/2014] [Accepted: 08/02/2014] [Indexed: 10/24/2022]
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Grams ME, Sang Y, Matsushita K. Does acute kidney injury cause longer-term kidney function decline? Am J Kidney Dis 2014; 65:12-4. [PMID: 25201022 DOI: 10.1053/j.ajkd.2014.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 08/11/2014] [Indexed: 11/11/2022]
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Long DM, Jenkins E, Griffith K. Perfusionist techniques of reducing acute kidney injury following cardiopulmonary bypass: an evidence-based review. Perfusion 2014; 30:25-32. [DOI: 10.1177/0267659114544395] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Cardiac surgery utilizing cardiopulmonary bypass has come a long way since its introduction nearly 60 years ago. In the early days, end-organ damage was linked to contact of the blood with the extracorporeal circuit. One potential cardiac surgery complication known to result in significant morbidity and mortality is acute kidney injury (AKI). Causes of AKI are multifaceted, but most of them are associated with techniques that perfusionists employ during extracorporeal circuit management. These can cause patients to either go on dialysis or renal replacement therapy. Patients with AKI have longer lengths of stay and consume significant resources beyond those with normal kidney function. Few current evidence-based markers determine if the kidneys are adequately protected during surgery. Most relevant literature does not address perfusion-specific techniques that reduce the incidence of AKI. This paper reviews the pathophysiology of the kidney and focuses on perfusion techniques that may reduce the incidence of AKI.
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Affiliation(s)
- DM Long
- Perfusion Services, NorthShore University Health System, Evanston, IL, USA
| | - E Jenkins
- Cardiovascular Center-Perfusion Services, University of Michigan Hospitals, Ann Arbor, MI, USA
| | - K Griffith
- Cardiovascular Center-Perfusion Services, University of Michigan Hospitals, Ann Arbor, MI, USA
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Molnar AO, Parikh CR, Coca SG, Thiessen-Philbrook H, Koyner JL, Shlipak MG, Lee Myers M, Garg AX. Association between preoperative statin use and acute kidney injury biomarkers in cardiac surgical procedures. Ann Thorac Surg 2014; 97:2081-7. [PMID: 24725831 DOI: 10.1016/j.athoracsur.2014.02.033] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Revised: 12/19/2013] [Accepted: 02/04/2014] [Indexed: 01/23/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a serious complication of cardiac operations for which there remains no specific therapy. Animal data and several observational studies suggest that statins prevent AKI, but the results are not conclusive, and many studies are retrospective in nature. METHODS We conducted a multicenter prospective cohort study of 625 adult patients undergoing elective cardiac operations. All patients were taking statins and were grouped according to whether statins were continued or held in the 24 hours before operation. The primary outcome was AKI as defined by a doubling of serum creatinine or dialysis. The secondary outcome was the peak level of several kidney injury biomarkers. The results were adjusted for demographic and clinical factors. RESULTS Continuing (vs holding) a statin before operation was not associated with a lower risk of AKI, as defined by a doubling of serum creatinine or dialysis (adjusted relative risk [RR] 1.09; 95% confidence interval [CI] 0.44, 2.70). However, continuing a statin was associated with a lower risk of elevation of the following AKI biomarkers: urine interleukin-18, urine neutrophil gelatinase-associated lipocalin, urine kidney injury molecule-1, and plasma neutrophil gelatinase-associated lipocalin (adjusted RR 0.34; 95% CI 0.18, 0.62), (adjusted RR 0.41; 95% CI 0.22, 0.76), (adjusted RR 0.37; 95% CI 0.20, 0.76), (adjusted RR 0.62; 95% CI 0.39, 0.98), respectively. CONCLUSIONS Statins may prevent kidney injury after cardiac operations, as evidenced by lower levels of kidney injury biomarkers.
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Affiliation(s)
- Amber O Molnar
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Chirag R Parikh
- Section of Nephrology, Yale University School of Medicine, Veterans Affairs CT Healthcare System, and the Program of Applied Translational Research, New Haven, Connecticut; Department of Medicine, Veterans Affairs Medical Center, West Haven, Connecticut.
| | - Steven G Coca
- Section of Nephrology, Yale University School of Medicine, Veterans Affairs CT Healthcare System, and the Program of Applied Translational Research, New Haven, Connecticut
| | | | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Pritzker School of Medicine, Chicago, Illinois
| | - Michael G Shlipak
- Division of General Internal Medicine, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, California
| | - Mary Lee Myers
- Division of Cardiac Surgery, Western University, London, Ontario, Canada
| | - Amit X Garg
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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Garg AX, Vincent J, Cuerden M, Parikh C, Devereaux PJ, Teoh K, Yusuf S, Hildebrand A, Lamy A, Zuo Y, Sessler DI, Shah P, Abbasi SH, Quantz M, Yared JP, Noiseux N, Tagarakis G, Rochon A, Pogue J, Walsh M, Chan MTV, Lamontagne F, Salehiomran A, Whitlock R. Steroids In caRdiac Surgery (SIRS) trial: acute kidney injury substudy protocol of an international randomised controlled trial. BMJ Open 2014; 4:e004842. [PMID: 24598306 PMCID: PMC3948633 DOI: 10.1136/bmjopen-2014-004842] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Steroids In caRdiac Surgery trial (SIRS) is a large international randomised controlled trial of methylprednisolone or placebo in patients undergoing cardiac surgery with the use of a cardiopulmonary bypass pump. At the time of surgery, compared with placebo, methylprednisolone divided into two intravenous doses of 250 mg each may reduce the risk of postoperative acute kidney injury (AKI). METHODS AND ANALYSIS With respect to the study schedule, over 7000 substudy eligible patients from 81 centres in 18 countries were randomised in December 2013. The authors will use a logistic regression to estimate the adjusted OR of methylprednisolone versus placebo on the primary outcome of AKI in the 14 days following surgery (a postoperative increase in serum creatinine of ≥50%, or ≥26.5 μmol/L, from the preoperative value). The stage of AKI will also be considered, as will the outcome of AKI in those with and without preoperative chronic kidney disease. After receipt of grant funding, the authors began to record additional perioperative serum creatinine measurements in consecutive patients enrolled at substudy participating centres, and patients were invited to enroll in a 6-month serum creatinine collection. In these trial subpopulations, the authors will consider the outcome of AKI defined in alternate ways, and the outcome of a 6-month change in kidney function from the preoperative value. ETHICS AND DISSEMINATION The authors were competitively awarded a grant from the Canadian Institutes of Health Research for this SIRS AKI substudy. Ethics approval was obtained for additional serum creatinine recordings in consecutive patients enrolled at participating centres. The additional kidney data collection first began for patients enrolled after 1 March 2012. In patients who provided consent, the last 6-month kidney outcome data will be collected in 2014. The results will be reported no later than 2015. CLINICAL TRIAL REGISTRATION Number NCT00427388.
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Risk factors for endotracheal re-intubation following coronary artery bypass grafting. J Cardiothorac Surg 2013; 8:208. [PMID: 24209453 PMCID: PMC3842842 DOI: 10.1186/1749-8090-8-208] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 10/28/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Endotracheal re-intubation following coronary artery bypass grafting (CABG) is often associated with significant morbidity and mortality. However, few reports have focused on the independent risk factors for re-intubation following CABG. This study aimed to evaluate the independent risk factors for re-intubation following CABG. METHODS The pre-, intra-, and post-operative materials in patients who had selective and isolated CABG performed on them from January 2004 to July 2012 in our hospital were analyzed retrospectively. Unvariate analysis and logistic regression were used to analyze the risk factor of postoperative re-intubation following CABG. RESULTS Among the 1,244 patients investigated, 97 cases suffered from postoperative re-intubation, and the incidence rate of postoperative re-intubation was 7.8%. The in-hospital mortality in the re-intubation group was significantly higher than that in the non-re-intubation group (9.3% versus 1.4%, P = 0.004). Re-intubation also correlated with many negative outcomes such as pneumonia, tracheotomy, acute renal failure, infection of incision, prolonged mechanical ventilation time, prolonged intensive care unit (ICU) stay and prolonged hospital stay. The most commonly cause of re-intubation after CABG was hypoxemia due to cardiogenic and noncardiogenic disease, which accounted for 72.2%. The relative factors of postoperative re-intubation were tested through unvariate analysis and logistic regression, and the associated factors were obtained. The associated factors for re-intubation following CABG included preoperative chronic obstructive pulmonary disease (COPD) (OR = 2.134, 95% CI = 1.472-2.967), preoperative congestive heart failure (CHF) (OR = 2.325, 95% CI = 1.512-3.121), postoperative relative hypoxemia (OR = 2.743, 95% CI = 1.657-3.326), postoperative acute kidney injury (AKI) (OR = 2.976, 95% CI = 2.127-4.023), postoperative total mechanical ventilation time (OR = 1.976, 95% CI = 1.347-2.645). CONCLUSION Preoperative COPD, preoperative CHF, postoperative relative hypoxemia, postoperative AKI and postoperative total mechanical ventilation time were five independent risk factors for re-intubation following CABG.
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Ricci Z, Romagnoli S, Ronco C. Perioperative intravascular volume replacement and kidney insufficiency. Best Pract Res Clin Anaesthesiol 2013; 26:463-74. [PMID: 23351233 DOI: 10.1016/j.bpa.2012.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 11/06/2012] [Accepted: 11/07/2012] [Indexed: 01/05/2023]
Abstract
Perioperative acute kidney injury (AKI) occurrence is probably increased in recent years due to the increased level of complexity of surgical procedures and severity of illness of surgical patients. Perioperative AKI has a multifactorial aetiology (preoperative co-morbidities such as diabetes, heart failure and chronic kidney disease, emergent surgery, exposure to nephrotoxic drugs, haemodynamic instability, hypothermia, inflammatory response to surgery, hospital-acquired infections and abdominal compartment syndrome). However, fluid choice for perioperative volume replacement might have a major role in perioperative AKI, as administration of crystalloid solutions, colloids or haemoderivates has the potential for kidney injury. This review focusses on the issue of fluid replacement quality and quantity and their association with renal dysfunction.
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Affiliation(s)
- Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
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Tasanarong A, Duangchana S, Sumransurp S, Homvises B, Satdhabudha O. Prophylaxis with erythropoietin versus placebo reduces acute kidney injury and neutrophil gelatinase-associated lipocalin in patients undergoing cardiac surgery: a randomized, double-blind controlled trial. BMC Nephrol 2013; 14:136. [PMID: 23829828 PMCID: PMC3704968 DOI: 10.1186/1471-2369-14-136] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 05/09/2013] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common complication following coronary bypass graft (CABG) surgery. Multi-factorial causes of CSA-AKI involve oxidative stress and inflammation. Erythropoietin (EPO) has been shown from many studies to have a reno-protective effect. The present study was conducted to examine the role of EPO in preventing CSA-AKI. METHODS This prospective, randomized, double-blind, placebo-controlled trial was conducted in the Cardiovascular and Thoracic Unit. One hundred patients randomly received either 200 U/kg of rHuEPO (n = 50) or saline (n = 50) intravenously three days before operation, and rHuEPO 100 U/kg or saline at operation time. The serum creatinine (SCr), estimated glomerular filtration rate (eGFR) and urine neutrophil gelatinase-associated lipocaline (NGAL) were measured in order to evaluate renal injury following CABG. RESULTS The incidence of CSA-AKI was significantly lower in rHuEPO group (14%) when compared with the placebo group (38%; p < 0.01). The mean intensive care unit (ICU) and hospital stays of the rHuEPO group were significantly shorter than the placebo group (p < 0.01). Postoperative increases in SCr and decreases in eGFR were significantly lower in the rHuEPO group than the placebo group (p < 0.05). The mean urine NGAL in rHuEPO group was significantly lower than the placebo group at 3 hr, 6 hr, 12 hr and 18 hr after CABG (p < 0.05), respectively. CONCLUSIONS Prophylaxis administration with intravenous rHuEPO before cardiac surgery decreased the incidence of CSA-AKI and urine NGAL with reduced days in ICU and hospital in elective CABG patients. TRIAL REGISTRATION ClinicalTrials.gov: NCT01066351.
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Khawaja MZ, Thomas M, Joshi A, Asrress KN, Wilson K, Bolter K, Young CP, Hancock J, Bapat V, Redwood S. The effects of VARC-defined acute kidney injury after transcatheter aortic valve implantation (TAVI) using the Edwards bioprosthesis. EUROINTERVENTION 2013; 8:563-70. [PMID: 22995082 DOI: 10.4244/eijv8i5a87] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this study was to identify the incidence and risk factors for acute kidney injury (AKI) after TAVI, a potentially serious complication of transcatheter aortic valve implantation (TAVI) that has been redefined by the Valve Academic Research Consortium (VARC). METHODS AND RESULTS We performed a retrospective analysis of 248 patients undergoing TAVI. AKI was defined as a VARC-modified Risk, Injury, Failure, Loss, and End-stage (RIFLE) kidney disease score ≥ 2. Eighty-nine patients suffered AKI (35.9%) and demonstrated increased mortality at 30 days (13.5% vs. 3.8%) and one year (31.5% vs. 15.0%) (p<0.001). Multivariate regression analysis identified diabetes mellitus (p<0.001), peripheral vascular disease (p=0.007), chronic kidney disease stage (p=0.010) as independently associated risk factors for AKI. CONCLUSIONS More than one third of patients sustain AKI after TAVI using the Edwards bioprosthesis, as defined by the VARC-modified RIFLE score. AKI increased the mortality at both 30 days and at one year. A history of diabetes mellitus, peripheral vascular disease and higher chronic kidney disease stage had the strongest independent associations with post-TAVI AKI.
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Affiliation(s)
- Muhammed Zeeshan Khawaja
- King's College London, BHF Centre of Research Excellence, Cardiovascular Division, The Rayne Institute, London, United Kingdom.
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Koyner JL, Parikh CR. Clinical utility of biomarkers of AKI in cardiac surgery and critical illness. Clin J Am Soc Nephrol 2013; 8:1034-42. [PMID: 23471130 DOI: 10.2215/cjn.05150512] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AKI is a common and serious complication that is associated with several adverse outcomes in hospitalized patients. The past several years have seen a large number of multicenter investigations of biomarkers of AKI in the setting of cardiac surgery and critical illness. This review summarizes these biomarker results to identify applications for clinical use. The Translational Research Investigating Biomarker Endpoints in AKI (TRIBE-AKI) study showed that blood and urine biomarkers measured preoperatively, immediately postoperatively, and at the time of the clinical increase in serum creatinine in the setting of cardiac surgery all had the ability to improve patient risk stratification for a variety of important clinical end points. Analyses of biomarkers concentrations from the Acute Respiratory Distress Syndrome Network, EARLY ARF, and other studies of critically ill subjects have similarly shown that biomarkers measured early in the clinical course can forecast the development of AKI and need for renal replacement therapy as well as inpatient mortality. Although biomarkers have informed the diagnosis, prognosis, and treatment of AKI and are inching closer to clinical application, large multicenter interventional clinical trials to prevent AKI using biomarkers should continue to be an active area of clinical investigation.
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Affiliation(s)
- Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
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Alsabbagh MM, Asmar A, Ejaz NI, Aiyer RK, Kambhampati G, Ejaz AA. Update on clinical trials for the prevention of acute kidney injury in patients undergoing cardiac surgery. Am J Surg 2013; 206:86-95. [PMID: 23411349 DOI: 10.1016/j.amjsurg.2012.08.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Revised: 07/05/2012] [Accepted: 08/28/2012] [Indexed: 01/11/2023]
Abstract
BACKGROUND Effective therapeutic agents for the prevention and treatment of acute kidney injury (AKI) after cardiac surgery remain elusive despite the tremendous advances in surgical techniques, technology, and understanding of disease processes. Recent developments and their effect on the incidence of AKI after cardiac surgery are discussed. DATA SOURCES Published clinical trials in PubMed, strength of evidence assessed by the guidelines of the American Family Physicians. CONCLUSIONS The definition of AKI has changed, and the focus of interventions has shifted from treatment to prevention to recovery from AKI. Antioxidants and biological agents have been added to classic armaments of hydration and diuretics in addition to tighter metabolic control to prevent AKI. Although the treatment options remain unsatisfactory, a lot of progress nevertheless continues to be made in the prevention and treatment of AKI.
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Affiliation(s)
- Mourad M Alsabbagh
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, P.O. Box 100224, Gainesville, FL 32610-0224, USA
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Kohl BA, Hammond MS, Ochroch EA. Implementation of an intraoperative glycemic control protocol for cardiac surgery in a high-acuity academic medical center: an observational study. J Clin Anesth 2013; 25:121-8. [PMID: 23333786 DOI: 10.1016/j.jclinane.2012.06.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 06/22/2012] [Accepted: 06/25/2012] [Indexed: 01/01/2023]
Abstract
STUDY OBJECTIVE To examine the effect on morbidity and mortality of an established intraoperative insulin protocol in cardiac surgical patients. DESIGN Retrospective observational study. SETTING Single-center, 782 bed, metropolitan academic hospital. PATIENTS 1,616 adult patients undergoing cardiac surgical procedures with cardiopulmonary bypass (CPB). INTERVENTIONS An intraoperative, intravenous (IV) insulin protocol designed to maintain blood glucose values less than 150 mg/dL was implemented. MEASUREMENTS Blood glucose was evaluated on entry to the operating room, every 30 minutes during CPB, and at least once after discontinuation of CPB. Blood glucose values were followed postoperatively, as dictated by institutional policy. MAIN RESULTS Intraoperative predictors of 30-day mortality using multivariate logistic regression included hyperglycemia on initiation of CPB (OR 1.0, P = 0.05). The strongest predictor of 30-day mortality was the development of postoperative renal failure requiring hemodialysis (OR 3.26, P = 0.001). CONCLUSIONS Implementation of an intraoperative IV insulin protocol, while associated with improved glycemic control, was not associated with improved outcomes. While improved glycemic control on initiating CPB was associated with decreased 30-day mortality, the effect was small. Implementation of our insulin protocol was highly associated with decreased renal failure postoperatively. Further prospective studies are warranted to better establish causality.
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Affiliation(s)
- Benjamin A Kohl
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
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de Seigneux S, Ponte B, Weiss L, Pugin J, Romand JA, Martin PY, Saudan P. Epoetin administrated after cardiac surgery: effects on renal function and inflammation in a randomized controlled study. BMC Nephrol 2012; 13:132. [PMID: 23033926 PMCID: PMC3506492 DOI: 10.1186/1471-2369-13-132] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 09/17/2012] [Indexed: 12/31/2022] Open
Abstract
Background Experimentally, erythropoietin (EPO) has nephroprotective as well as immunomodulatory properties when administered after ischemic renal injury. We tested the hypothesis that different doses of recombinant human EPO administered to patients after cardiac surgery would minimize kidney lesions and the systemic inflammatory response, thereby decreasing acute kidney injury (AKI) incidence. Methods In this double-blinded randomized control study, 80 patients admitted to the ICU post-cardiac surgery were randomized by computer to receive intravenously isotonic saline (n = 40) versus α-Epoetin (n = 40): either 40000 IU (n = 20) or 20000 IU (n = 20). The study lasted one year. The primary outcome was the change in urinary NGAL concentration from baseline and 48 h after EPO injection. Creatinine, cystatine C and urinary NGAL levels were measured on the day of randomization and 2–4 days after EPO injection. To assess acute inflammatory response, serum cytokines (IL6 and IL8) were measured at randomization and four days after r-HuEPO injection. Patients and care-takers were blinded for the assignment. Results No patient was excluded after randomization. Patient groups did not differ in terms of age, gender, comorbidities and renal function at randomization. The rate of AKI assessed by AKIN criteria was 22.5% in our population. EPO treatment did not significantly modify the difference in uNGAl between 48 hours and randomization compared to placebo [2.5 ng/ml (−17.3; 22.5) vs 0.7 ng/ml (−31.77; 25.15), p = 0.77] and the incidence of AKI was similar. Inflammatory cytokines levels were not influenced by EPO treatment. Mortality and hospital stays were similar between the groups and no adverse event was recorded. Conclusion In this randomized-controlled trial, α-Epoetin administrated after cardiac surgery, although safe, demonstrated neither nephroprotective nor anti-inflammatory properties. Trial registration number NCT00676234
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Affiliation(s)
- Sophie de Seigneux
- Service of Nephrology, Department of Medical Specialties, Geneva University Hospitals, Rue Gabrielle-Perret Gentil 4, 1211, Geneva, Switzerland
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Molnar AO, Parikh CR, Sint K, Coca SG, Koyner J, Patel UD, Butrymowicz I, Shlipak M, Garg AX. Association of postoperative proteinuria with AKI after cardiac surgery among patients at high risk. Clin J Am Soc Nephrol 2012; 7:1749-60. [PMID: 22977220 DOI: 10.2215/cjn.13421211] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND OBJECTIVES Preoperative proteinuria is associated with a higher incidence of postoperative AKI. Whether the same is true for postoperative proteinuria is uncertain. This study tested the hypothesis that increased proteinuria after cardiac surgery is associated with an increased risk for AKI. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This prospective cohort study included 1198 adults undergoing cardiac surgery at six hospitals between July 2007 and December 2009. Albuminuria, urine albumin-to-creatinine ratio (ACR), and dipstick proteinuria were measured 0-6 hours after surgery. The primary outcome was AKI, defined as a doubling in serum creatinine or receipt of acute dialysis during the hospital stay. Analyses were adjusted for patient characteristics, including preoperative albuminuria. RESULTS Compared with the lowest quintile, the highest quintile of albuminuria and highest grouping of dipstick proteinuria were associated with greatest risk for AKI (adjusted relative risks [RRs], 2.97 [95% confidence interval (CI), 1.20-6.91] and 2.46 [95% CI, 1.16-4.97], respectively). Higher ACR was not associated with AKI risk (highest quintile RR, 1.66 [95% CI, 0.68-3.90]). Of the three proteinuria measures, early postoperative albuminuria improved the prediction of AKI to the greatest degree (clinical model area under the curve, 0.75; 0.81 with albuminuria). Similar improvements with albuminuria were seen for net reclassification index (0.55; P<0.001) and integrated discrimination index (0.036; P<0.001). CONCLUSIONS Higher levels of proteinuria after cardiac surgery identify patients at increased risk for AKI during their hospital stay.
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Affiliation(s)
- Amber O Molnar
- Division of Nephrology, Department of Medicine, University of Western Ontario, London, Ontario, Canada
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Lésions d’ischémie-reperfusion rénale. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-012-0475-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Siddiqui NF, Coca SG, Devereaux PJ, Jain AK, Li L, Luo J, Parikh CR, Paterson M, Philbrook HT, Wald R, Walsh M, Whitlock R, Garg AX. Secular trends in acute dialysis after elective major surgery--1995 to 2009. CMAJ 2012; 184:1237-45. [PMID: 22733671 DOI: 10.1503/cmaj.110895] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Acute kidney injury is a serious complication of elective major surgery. Acute dialysis is used to support life in the most severe cases. We examined whether rates and outcomes of acute dialysis after elective major surgery have changed over time. METHODS We used data from Ontario's universal health care databases to study all consecutive patients who had elective major surgery at 118 hospitals between 1995 and 2009. Our primary outcomes were acute dialysis within 14 days of surgery, death within 90 days of surgery and chronic dialysis for patients who did not recover kidney function. RESULTS A total of 552,672 patients underwent elective major surgery during the study period, 2231 of whom received acute dialysis. The incidence of acute dialysis increased steadily from 0.2% in 1995 (95% confidence interval [CI] 0.15-0.2) to 0.6% in 2009 (95% CI 0.6-0.7). This increase was primarily in cardiac and vascular surgeries. Among patients who received acute dialysis, 937 died within 90 days of surgery (42.0%, 95% CI 40.0-44.1), with no change in 90-day survival over time. Among the 1294 patients who received acute dialysis and survived beyond 90 days, 352 required chronic dialysis (27.2%, 95% CI 24.8-29.7), with no change over time. INTERPRETATION The use of acute dialysis after cardiac and vascular surgery has increased substantially since 1995. Studies focusing on interventions to better prevent and treat perioperative acute kidney injury are needed.
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Garg AX, Devereaux PJ, Yusuf S, Cuerden MS, Parikh CR, Coca SG, Walsh M, Cook RJ, Whitlock RP, Noiseux N, Novick RJ, Ou Y, Lamy A. Coronary Artery Bypass Grafting Surgery Off- or On-pump Revascularisation Study (CORONARY): kidney substudy analytic protocol of an international randomised controlled trial. BMJ Open 2012; 2:e001080. [PMID: 22514244 PMCID: PMC3332245 DOI: 10.1136/bmjopen-2012-001080] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION CORONARY is a large international randomised controlled trial comparing coronary artery bypass graft (CABG) surgery done with and without a bypass pump. Compared with on-pump, off-pump surgery may prevent acute kidney injury (AKI) in the short term and may better preserve kidney function 1 year following surgery. Secondary analyses may also clarify whether effects are similar in patients with and without pre-operative chronic kidney disease and whether AKI avoidance mediates preserved 1-year kidney function. METHODS AND ANALYSIS With respect to the study schedule, the last of 4752 patients from 79 sites in 19 countries were randomised in November 2011 to cardiac surgery performed with an on-pump or off-pump procedure. The authors will use regression models to compare the groups in the outcome of peri-operative AKI (per cent change in serum creatinine, ≥50% increase in serum creatinine) and 1-year kidney function (per cent change in estimated glomerular filtration rate (eGFR), ≥20% eGFR loss 1 year after surgery). The authors will use interaction terms in regression models to determine if there is a differential impact of the intervention in those with and without pre-existing chronic kidney disease. The authors will use regression-based tests to determine the proportion of the total effect of surgery type (off-pump vs on-pump CABG) on 1-year eGFR that is mediated by peri-operative AKI. ETHICS AND DISSEMINATION In the year 2009, the authors were competitively awarded a grant from the Canadian Institutes of Health Research to answer these kidney questions in CORONARY. Ethics approval was obtained for additional renal data collection in centres that agreed to study participation (>90% of participating centres). This collection began for patients enrolled after 1 January 2010. Remaining 1-year renal outcome data will be collected throughout 2012. Results will be reported in 2013. CLINICAL TRIAL REGISTRATION NUMBER NCT 00463294.
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Affiliation(s)
- Amit X Garg
- Division of Nephrology, Department of Medicine, Western University, London, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - P J Devereaux
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
- Population Health Research Institute, Hamilton, Canada
| | - Salim Yusuf
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
- Population Health Research Institute, Hamilton, Canada
| | - Meaghan S Cuerden
- Division of Nephrology, Department of Medicine, Western University, London, Canada
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, Ontario, Canada
| | - Chirag R Parikh
- Section of Nephrology, Yale University School of Medicine, New Haven, USA
| | - Steven G Coca
- Section of Nephrology, Yale University School of Medicine, New Haven, USA
| | - Michael Walsh
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
- Population Health Research Institute, Hamilton, Canada
| | - Richard J Cook
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, Ontario, Canada
| | - Richard P Whitlock
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
- Population Health Research Institute, Hamilton, Canada
- Division of Cardiac Surgery, McMaster University, Hamilton, Canada
| | - Nicolas Noiseux
- Department of Cardiac Surgery, Université de Montreal, Montreal, Canada
| | | | - Yongning Ou
- Population Health Research Institute, Hamilton, Canada
| | - Andre Lamy
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
- Population Health Research Institute, Hamilton, Canada
- Division of Cardiac Surgery, McMaster University, Hamilton, Canada
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Mariscalco G, Lorusso R, Dominici C, Renzulli A, Sala A. Acute Kidney Injury: A Relevant Complication After Cardiac Surgery. Ann Thorac Surg 2011; 92:1539-47. [DOI: 10.1016/j.athoracsur.2011.04.123] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Revised: 04/27/2011] [Accepted: 04/29/2011] [Indexed: 11/25/2022]
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Parikh CR, Devarajan P, Zappitelli M, Sint K, Thiessen-Philbrook H, Li S, Kim RW, Koyner JL, Coca SG, Edelstein CL, Shlipak MG, Garg AX, Krawczeski CD. Postoperative biomarkers predict acute kidney injury and poor outcomes after pediatric cardiac surgery. J Am Soc Nephrol 2011; 22:1737-47. [PMID: 21836147 DOI: 10.1681/asn.2010111163] [Citation(s) in RCA: 260] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Acute kidney injury (AKI) occurs commonly after pediatric cardiac surgery and associates with poor outcomes. Biomarkers may help the prediction or early identification of AKI, potentially increasing opportunities for therapeutic interventions. Here, we conducted a prospective, multicenter cohort study involving 311 children undergoing surgery for congenital cardiac lesions to evaluate whether early postoperative measures of urine IL-18, urine neutrophil gelatinase-associated lipocalin (NGAL), or plasma NGAL could identify which patients would develop AKI and other adverse outcomes. Urine IL-18 and urine and plasma NGAL levels peaked within 6 hours after surgery. Severe AKI, defined by dialysis or doubling in serum creatinine during hospital stay, occurred in 53 participants at a median of 2 days after surgery. The first postoperative urine IL-18 and urine NGAL levels strongly associated with severe AKI. After multivariable adjustment, the highest quintiles of urine IL-18 and urine NGAL associated with 6.9- and 4.1-fold higher odds of AKI, respectively, compared with the lowest quintiles. Elevated urine IL-18 and urine NGAL levels associated with longer hospital stay, longer intensive care unit stay, and duration of mechanical ventilation. The accuracy of urine IL-18 and urine NGAL for diagnosis of severe AKI was moderate, with areas under the curve of 0.72 and 0.71, respectively. The addition of these urine biomarkers improved risk prediction over clinical models alone as measured by net reclassification improvement and integrated discrimination improvement. In conclusion, urine IL-18 and urine NGAL, but not plasma NGAL, associate with subsequent AKI and poor outcomes among children undergoing cardiac surgery.
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Affiliation(s)
- Chirag R Parikh
- Section of Nephrology, Yale University and VAMC, 950 Campbell Avenue, Mail Code 151B, West Haven, CT 06516, USA.
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Parikh CR, Coca SG, Thiessen-Philbrook H, Shlipak MG, Koyner JL, Wang Z, Edelstein CL, Devarajan P, Patel UD, Zappitelli M, Krawczeski CD, Passik CS, Swaminathan M, Garg AX. Postoperative biomarkers predict acute kidney injury and poor outcomes after adult cardiac surgery. J Am Soc Nephrol 2011; 22:1748-57. [PMID: 21836143 DOI: 10.1681/asn.2010121302] [Citation(s) in RCA: 403] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Acute kidney injury (AKI) is a frequent complication of cardiac surgery and increases morbidity and mortality. The identification of reliable biomarkers that allow earlier diagnosis of AKI in the postoperative period may increase the success of therapeutic interventions. Here, we conducted a prospective, multicenter cohort study involving 1219 adults undergoing cardiac surgery to evaluate whether early postoperative measures of urine IL-18, urine neutrophil gelatinase-associated lipocalin (NGAL), or plasma NGAL could identify which patients would develop AKI and other adverse patient outcomes. Urine IL-18 and urine and plasma NGAL levels peaked within 6 hours after surgery. After multivariable adjustment, the highest quintiles of urine IL-18 and plasma NGAL associated with 6.8-fold and 5-fold higher odds of AKI, respectively, compared with the lowest quintiles. Elevated urine IL-18 and urine and plasma NGAL levels associated with longer length of hospital stay, longer intensive care unit stay, and higher risk for dialysis or death. The clinical prediction model for AKI had an area under the receiver-operating characteristic curve (AUC) of 0.69. Urine IL-18 and plasma NGAL significantly improved the AUC to 0.76 and 0.75, respectively. Urine IL-18 and plasma NGAL significantly improved risk prediction over the clinical models alone as measured by net reclassification improvement (NRI) and integrated discrimination improvement (IDI). In conclusion, urine IL-18, urine NGAL, and plasma NGAL associate with subsequent AKI and poor outcomes among adults undergoing cardiac surgery.
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Affiliation(s)
- Chirag R Parikh
- Section of Nephrology, Yale University and Veterans Administration Medical Center, 950 Campbell Avenue, Mail Code 151B, West Haven, CT 06516, USA.
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