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Martins Lima P, Ferreira L, Dias AL, Rodrigues D, Abelha F, Mourão J. Postoperative Acute Kidney Injury After Intraoperative Hypotension in Major Risk Procedures. Cureus 2024; 16:e64579. [PMID: 39144846 PMCID: PMC11323959 DOI: 10.7759/cureus.64579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2024] [Indexed: 08/16/2024] Open
Abstract
Background Reportedly prevalent, intraoperative hypotension (IOH) is linked to kidney injury and increased risk of mortality. In this study, we aimed to assess IOH incidence in high-risk non-cardiac surgery and its correlation with postoperative acute kidney injury (PO-AKI) and 30-day postoperative mortality. Methodology This retrospective cohort study included adult inpatients who underwent elective, non-cardiac, high-risk European Society of Anaesthesiology/European Society of Cardiology surgery from October to November of 2020, 2021, and 2022, excluding cardiac, intracranial, or emergency surgery. IOH was primarily defined by the 2022 Anesthesia Quality Institute. PO-AKI was defined as an increase in serum creatinine ≥0.3 mg/dL within 48 hours, the need for dialysis in dialysis-naïve patients, or the documentation of AKI in clinical records. For univariate analysis, the Mann-Whitney U test and chi-square or Fisher's exact tests were performed, as appropriate. Logistic regression was used to test risk factors for IOH in univariate analysis (p < 0.1). The significance level considered in multivariate analysis was 5%. Results Of the 197 patients included, 111 (56.3%) experienced IOH. After adjustment, surgical time >120 minutes remained associated with higher odds of IOH (odds ratio (OR) = 9.62, 95% confidence interval (CI) = 2.49-37.13), as well as combined general + locoregional (vs. general OR = 3.41, 95 CI% = 1.38-8.43, p = 0.008; vs. locoregional OR = 6.37, 95% CI = 1.48-27.47). No association was found between IOH and 30-day postoperative mortality (p = 0.565) or PO-AKI (p = 0.09). The incidence of PO-AKI was 14.9% (27 patients), being significantly associated with higher 30-day postoperative mortality (p = 0.018). Conclusions Our study highlights the high prevalence of IOH in high-risk non-cardiac surgical procedures. Its impact on PO-AKI and 30-day postoperative mortality appears less pronounced compared to the significant implications of PO-AKI, emphasizing the need for PO-AKI screening and renal protection strategies.
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Affiliation(s)
| | - Luana Ferreira
- Department of Anesthesiology, Unidade Local de Saúde São João, Porto, PRT
| | - Ana Lídia Dias
- Center for Research in Health Technologies and Health Systems (CINTESIS), Faculty of Medicine of Porto, Porto, PRT
- Department of Anesthesiology, Unidade Local de Saúde São João, Porto, PRT
| | - Diana Rodrigues
- Department of Anesthesiology, Unidade Local de Saúde São João, Porto, PRT
| | - Fernando Abelha
- Department of Anesthesiology, Unidade Local de Saúde São João, Porto, PRT
| | - Joana Mourão
- Physiology and Surgery, Faculdade de Medicina da Universidade do Porto, Porto, PRT
- Department of Anesthesiology, Unidade Local de Saúde São João, Porto, PRT
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Stannard B, Epstein RH, Gabel E, Nadkarni GN, Ouyang Y, Lin HM, Salari V, Hofer IS. Postoperative Acute Kidney Injury is Associated with Persistent Renal Dysfunction: A Multicenter Propensity Matched Cohort Study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.06.24308455. [PMID: 38883714 PMCID: PMC11178012 DOI: 10.1101/2024.06.06.24308455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Background The risk of developing a persistent reduction in renal function after postoperative acute kidney injury (pAKI) is not well-established. Objective Perform a multi-center retrospective propensity matched study evaluating whether patients that develop pAKI have a greater decline in long-term renal function than patients that did not develop postoperative AKI. Design Multi-center retrospective propensity matched study. Setting Anesthesia data warehouses at three tertiary care hospitals were queried. Patients Adult patients undergoing surgery with available preoperative and postoperative creatinine results and without baseline hemodialysis requirements. Measurements The primary outcome was a decline in follow-up glomerular filtration rate (GFR) of 40% relative to baseline, based on follow-up outpatient visits from 0-36 months after hospital discharge. A propensity score matched sample was used in Kaplan-Meier analysis and in a piecewise Cox model to compare time to first 40% decline in GFR for patients with and without pAKI. Results A total of 95,208 patients were included. The rate of pAKI ranged from 9.9% to 13.7%. In the piecewise Cox model, pAKI significantly increased the hazard of a 40% decline in GFR. The common effect hazard ratio was 13.35 (95% CI: 10.79 to 16.51, p<0.001) for 0-6 months, 7.07 (5.52 to 9.05, p<0.001) for 6-12 months, 6.02 (4.69 to 7.74, p<0.001) for 12-24 months, and 4.32 (2.65 to 7.05, p<0.001) for 24-36 months. Limitations Retrospective; Patients undergoing ambulatory surgery without postoperative lab tests drawn before discharge were not captured; certain variables like postoperative urine output were not reliably available. Conclusion Postoperative AKI significantly increases the risk of a 40% decline in GFR up to 36 months after the index surgery across three institutions.
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Bar S, Moussa MD, Descamps R, El Amine Y, Bouhemad B, Fischer MO, Lorne E, Dupont H, Diouf M, Guinot PG. Determinants of postoperative complications in high-risk noncardiac surgery patients optimized with hemodynamic treatment strategies: A post-hoc analysis of a randomized multicenter clinical trial. J Clin Anesth 2024; 93:111325. [PMID: 37992534 DOI: 10.1016/j.jclinane.2023.111325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 10/23/2023] [Accepted: 11/13/2023] [Indexed: 11/24/2023]
Abstract
STUDY OBJECTIVE This post-hoc analysis of a randomized controlled trial was undertaken to establish the determinants of postoperative complications and acute kidney injury in high-risk noncardiac surgery patients supported with hemodynamic treatment strategies. DESIGN We conducted a post-hoc analysis of patients enrolled in the OPtimization Hemodynamic Individualized by the respiratory QUotiEnt (OPHIQUE) trial. SETTING Operating rooms in four university medical centers and one non-university hospital from December 26, 2018, to September 9, 2021. PATIENTS We enrolled 350 patients with a high risk of postoperative complications undergoing high-risk noncardiac surgery lasting 2 h or longer under general anesthesia. INTERVENTIONS All patients were treated according to hemodynamic treatment strategies which included cardiac output optimization by titration of fluid challenge and targeted systolic blood pressure to remain within ±10% of the reference value. MEASUREMENTS We assessed the association between pre-operative and intra-operative exposure of interest with a composite primary outcome of major complications or death within seven days following surgery using a multivariable logistic regression model. We also assessed the association between these exposures of interest and acute kidney injury. MAIN RESULTS The data of 341 patients were analyzed. In multivariate analysis, the factors independently associated with the primary outcome were age (OR = 1.04 (1.01-1.06), P = 0.002), preoperative hemoglobin concentration (OR = 0.85 (0.75-0.96), P = 0.012), non-vascular surgery (OR = 0.30 (0.17-0.53), P < 0.0001), and intraoperative surgical complications (OR = 2.08 (1.02-4.24), P = 0.046). The factors independently associated with postoperative acute kidney injury were age (OR = 1.04 (1.01-1.08), P = 0.008), preoperative creatinine concentration (OR = 1.01 (1.00-1.01), P = 0.049), non-vascular surgery (OR = 0.36 (0.20-0.66), P = 0.001), and intraoperative surgical complications (OR = 3.36 (1.50-7.55), P = 0.031). CONCLUSIONS Surgical complications, a lower preoperative hemoglobin concentration, age, and vascular surgery were associated with postoperative complications in a high-risk noncardiac surgery population supported with hemodynamic treatment strategies.
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Affiliation(s)
- Stéphane Bar
- Department of Anesthesiology and Critical Care Medicine, Amiens University Medical Centre, Amiens, France; SSPC UPJV 7518 (Simplifications des Soins Patients Chirurgicaux Complexes - Simplification of Care of Complex Surgical Patients) Clinical Research Unit, Jules Verne University of Picardie, Amiens, France.
| | - Mouhamed Djahoum Moussa
- Department of Anesthesiology and Critical Care Medicine, Lille University Medical Centre, Lille, France
| | - Richard Descamps
- Department of Anesthesiology and Critical Care Medicine, Caen University Medical Center, Caen, France
| | - Younes El Amine
- Department of Anesthesiology and Critical Care Medicine, Valenciennes Medical Center, Valenciennes, France
| | - Belaid Bouhemad
- Department of Anesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, Dijon, France
| | | | - Emmanuel Lorne
- Department of Anesthesia and Critical Care Medicine, Millénaire Clinic, Montpellier, France
| | - Hervé Dupont
- Department of Anesthesiology and Critical Care Medicine, Amiens University Medical Centre, Amiens, France; SSPC UPJV 7518 (Simplifications des Soins Patients Chirurgicaux Complexes - Simplification of Care of Complex Surgical Patients) Clinical Research Unit, Jules Verne University of Picardie, Amiens, France
| | - Momar Diouf
- Biostatistical Unit, Direction de la Recherche Clinique, University Hospital of Amiens Picardy, Amiens, France
| | - Pierre Grégoire Guinot
- Department of Anesthesiology and Critical Care Medicine, Dijon University Medical Centre, Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, Dijon, France
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Ribeiro HS, Duarte MP, Burdmann EA, Ferreira AP, Inda-Filho AJ. Serum bicarbonate levels and kidney outcomes in critically ill patients: a prospective cohort study. Int Urol Nephrol 2024:10.1007/s11255-024-04029-1. [PMID: 38557818 DOI: 10.1007/s11255-024-04029-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/11/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The interplay between serum bicarbonate levels and kidney outcomes is not fully understood. We conducted a prospective cohort study in three intensive care units (ICUs) to evaluate the association of serum bicarbonate levels with acute kidney injury (AKI) and kidney function recovery in critically ill patients. METHODS A prospective cohort study in three intensive care units (ICUs) was performed. The serum bicarbonate level in the first 24 h after ICU admission was categorized as low (< 22 mEq/L), normal (22-26 mEq/L), or high (> 26 mEq/L). Serum creatinine (SCr) levels according to the KDIGO AKI guideline were used for defining AKI within the first 7 days of ICU stay. At ICU admission, SCr ≥ 1.1 for women and ≥ 1.3 mg/dL for men were indicative of impaired kidney function. Mortality outcome was tracked up to 28 days, and kidney function recovery was assessed at hospital discharge. RESULTS A total of 2732 patients (66 ± 19 years and 55% men) were analyzed, with 32% having impaired kidney function at ICU admission. Overall, 26% of patients had low bicarbonate levels, while 32% had high bicarbonate levels. Notably, patients with preserved kidney function showed a lower prevalence of low bicarbonate levels compared to those with impaired kidney function (20% vs. 39%, p < 0.001), while higher rates were observed for high bicarbonate (35% vs. 24%, p < 0.001). Compared with patients with normal serum bicarbonate levels, those with low bicarbonate were 81% more likely to develop AKI (OR = 1.81; 95% CI 1.10-2.99), whereas those with high bicarbonate were 44% less likely (OR = 0.56; 95% CI 0.32-0.98) in the adjusted model for confounders. Neither those with high nor low serum bicarbonate levels were associated with an increased risk of mortality (HR = 1.03; 95% CI 0.68-1.56 and 0.99; 95% CI 0.68-1.42, respectively). In subgroup analysis, regardless of the kidney function at ICU admission, serum bicarbonate levels were not associated with the development of AKI and all-cause mortality. Regarding kidney function recovery, higher non-recovery rates were found for those with low bicarbonate. CONCLUSION In critically ill ICU patients, low bicarbonate levels were associated with the more likely development of AKI and subsequent non-recovery of kidney function, while high bicarbonate levels showed no such association. Therefore, low bicarbonate levels may be considered a risk factor for adverse kidney outcomes in critically ill patients.
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Affiliation(s)
- Heitor S Ribeiro
- Faculty of Health Sciences, University of Brasília, Brasília, Brazil
- Interdisciplinary Research Department, University Center ICESP, Brasília, Brazil
- Faculdade de Medicina, Hospital das Clínicas HCFMUSP, Universidade de Sao Paulo, LIM 12, Sao Paulo, Brazil
| | - Marvery P Duarte
- Faculty of Health Sciences, University of Brasília, Brasília, Brazil
| | - Emmanuel A Burdmann
- Faculdade de Medicina, Hospital das Clínicas HCFMUSP, Universidade de Sao Paulo, LIM 12, Sao Paulo, Brazil
| | - Aparecido P Ferreira
- Interdisciplinary Research Department, University Center ICESP, Brasília, Brazil
- Post-Graduation Program, Santa Úrsula University, Rio de Janeiro, Brazil
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Karbasi A, Abbasi A, Mohagheghi A, Poorolajal J, Emami F, Moradkhani S, Khodadadi I, Gholyaf M, Tavilani H. The Effects of Coenzyme Q10 on Contrast-Induced Acute Kidney Injury in Type 2 Diabetes: A Randomized Clinical Trial. Chonnam Med J 2024; 60:59-68. [PMID: 38304125 PMCID: PMC10828077 DOI: 10.4068/cmj.2024.60.1.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 02/03/2024] Open
Abstract
Contrast-induced acute kidney injury (CI-AKI) is a frequent challenge following the injection of contrast media and its subsequent oxidative stress. The aim of the present study was to evaluate the preventive effects of coenzyme Q10 (Q10), as a mitochondrial-targeted antioxidant in CI-AKI in diabetic patients, who account for a large proportion of angiographic cases. A total of 118 diabetic patients were randomly assigned to receive 120 mg of oral coenzyme Q10 (Q10 group) or placebo (Placebo group) for four days, starting 24 hours before contrast media injection. Blood urea nitrogen (BUN), serum and urinary creatinine, estimated glomerular filtration rate (eGFR), urinary malondialdehyde (UMDA), urinary total antioxidant capacity (UTAC), and urinary mitochondrial to nuclearDNA ratios (mtDNA/nDNA ratio) were evaluated before and after the treatment period. Urine sediments were also evaluated to report the urine microscopy score (UMS).The levels of BUN, serum and urine creatinine, and UMS were similar in the Q10 and placebo groups. EGFR was lower in the Q10 group before the treatment (p=0.013) but not after. The urinary mtDNA/nDNA ratio was 3.05±1.68 and 3.69±2.58 in placebo and Q10 groups, but UTAC was found to be lower in Q10 both before (p=0.006) and after the treatment (p<0.001). The incidence of CI-AKI was 14.40% and the mtDNA/nNDA ratio was similar between CI-AKI and non-CI-AKI patients. In conclusion, Q10 treatment shows no favorable effect on prevention of CI-AKI or a urinary mtDNA/nDNA ratio among diabetic patients.
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Affiliation(s)
- Ashkan Karbasi
- Department of Clinical Biochemistry, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Ali Abbasi
- Department of Cardiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbas Mohagheghi
- Department of Cardiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Jalal Poorolajal
- Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Farzad Emami
- Department of Cardiology, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Shirin Moradkhani
- Department of Pharmacognosy, School of Pharmacy, Medicinal Plants and Natural Products, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Iraj Khodadadi
- Department of Clinical Biochemistry, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Mahmoud Gholyaf
- Department of Internal Medicine, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Heidar Tavilani
- Department of Clinical Biochemistry, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
- Infectious disease Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
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Thorsdottir H, Long TE, Palsson R, Sigurdsson MI. The epidemiology and outcomes of acute kidney injury following orthopaedic procedures: A retrospective cohort study. Acta Anaesthesiol Scand 2024; 68:26-34. [PMID: 37726880 DOI: 10.1111/aas.14332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a serious complication following major surgery. This study examined the incidence and risk factors of AKI following orthopaedic surgeries in an Icelandic cohort, as well as the association between AKI and patient- and surgery-related factors. METHODS This retrospective cohort study comprised all patients 18 years and older who underwent orthopaedic surgeries at Landspitali - The National University Hospital in the years 2006-2018 with available serum creatinine (SCr) measurements adjacent to the surgery to stage AKI. AKI was defined according to SCr portion of the KDIGO criteria. Logistic regression was used to identify patient- and surgical factors related to progression of AKI and Poisson-regression was used to explore changes in incidence. RESULTS A total of 222 cases of AKI following 3208 surgeries (6.9%) were identified in the study period with a rise in the incidence by about 17% per year. Higher age (odds ratio (OR), 1.02, 95% confidence interval (CI), 1.01-1.04 per year) and underlying reduction in kidney function (OR 1.93 (1.30-2.81), 3.24 (2.08-4.96) and 4.08 (2.35-6.96) for estimated glomerular filtration rate (eGFR) of 30-59, 15-29 and <15 mL/min/1.73 m2 compared with eGFR >60 mL/min/1.73 m2 ) were associated with higher risk of AKI, but female sex was associated with decreased odds (OR = 0.73; 95% CI, 0.54-0.98). After correcting for age, sex, preoperative kidney function, emergency surgery and underlying comorbidities and frailty, there was an increased risk of long-term mortality in patients with AKI (HR 1.41, 95% CI 1.08-1.85), and patients who developed AKI also had accelerated progression of chronic kidney disease compared with patients who did not develop AKI. CONCLUSIONS The incidence of AKI following orthopaedic surgeries is increasing and is associated with adverse outcomes. It is important that elderly individuals and patients who have reduced kidney function receive adequate monitoring and surveillance in the perioperative period.
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Affiliation(s)
| | - Thorir E Long
- Division of Nephrology, Skane University Hospital, Lund, Sweden
| | - Runolfur Palsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Division of Nephrology, Internal Medicine and Emergency Services, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Martin I Sigurdsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Division of Anesthesia and Intensive Care Medicine, Perioperative Services, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
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Xing J, Loh SKN. Perioperative acute kidney injury: Current knowledge and the role of anaesthesiologists. PROCEEDINGS OF SINGAPORE HEALTHCARE 2023. [DOI: 10.1177/20101058231163406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
Background Among the different types of perioperative organ injury, acute kidney injury (AKI) occurs frequently and is consistently associated with increased rates of mortality and mortality. Despite development of many clinical trials to assess perioperative interventions, reliable means to prevent or reverse AKI are still lacking. Objectives This narrative review discusses recent literature on modifiable risk factors, current approaches to prevention and potential directions for future research. Methods A Pubmed search with the relevant keywords was done for articles published in the last 10 years. Results New insights into preoperative identification and optimisation, intraoperative strategies, including the choice of anaesthetic, haemodynamic and fluid management, have been made, with the aim of preventing perioperative AKI. Conclusion A patient-centric multidisciplinary approach is essential to protect kidney function of patients going for surgery. Much can be done by anaesthesiologists perioperatively, to reduce the risk of development of AKI, especially in susceptible patients. There is a need for further multicentred trials to enhance the currently generic perioperative recommendations.
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Affiliation(s)
- Jieyin Xing
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Samuel Kent Neng Loh
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
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Wolf U, Ghadir H, Drewas L, Neef R. Underdiagnosed CKD in Geriatric Trauma Patients and Potent Prevention of Renal Impairment from Polypharmacy Risks through Individual Pharmacotherapy Management (IPM-III). J Clin Med 2023; 12:4545. [PMID: 37445580 DOI: 10.3390/jcm12134545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
The aging global patient population with multimorbidity and concomitant polypharmacy is at increased risk for acute and chronic kidney disease, particularly with severe additional disease states or invasive surgical procedures. Because from the expertise of more than 58,600 self-reviewed medications, adverse drug reactions, drug interactions, inadequate dosing, and contraindications all proved to cause or exacerbate the worsening of renal function, we analyzed the association of an electronic patient record- and Summaries of Product Characteristics (SmPCs)-based comprehensive individual pharmacotherapy management (IPM) in the setting of 14 daily interdisciplinary patient visits with the outcome: further renal impairment with reduction of eGFR ≥ 20 mL/min (redGFR) in hospitalized trauma patients ≥ 70 years of age. The retrospective clinical study of 404 trauma patients comparing the historical control group (CG) before IPM with the IPM intervention group (IG) revealed a group-match in terms of potential confounders such as age, sex, BMI, arterial hypertension, diabetes mellitus, and injury patterns. Preexisting chronic kidney disease (CKD) > stage 2 diagnosed as eGFR < 60 mL/min/1.73 m2 on hospital admission was 42% in the CG versus 50% in the IG, although in each group only less than 50% of this was coded as an ICD diagnosis in the patients' discharge letters (19% in CG and 21% in IG). IPM revealed an absolute risk reduction in redGFR of 5.5% (11 of 199 CG patients) to 0% in the IPM visit IG, a relative risk reduction of 100%, NNT 18, indicating high efficacy of IPM and benefit in improving outcomes. There even remained an additive superimposed significant association that included patients in the IPM group before/beyond the 14 daily IPM interventions, with a relative redGFR risk reduction of 0.55 (55%) to 2.5% (5 of 204 patients), OR 0.48 [95% CI 0.438-0.538] (p < 0.001). Bacteriuria, loop diuretics, allopurinol, eGFR ≥ 60 mL/min/1.73 m2, eGFR < 60 mL/min/1.73 m2, and CKD 3b were significantly associated with redGFR; of the latter, 10.5% developed redGFR. Further multivariable regression analysis adjusting for these and established risk factors revealed an additive, superimposed IPM effect on redGFR with an OR 0.238 [95% CI 0.06-0.91], relative risk reduction of 76.2%, regression coefficient -1.437 including patients not yet visited in the IPM period. As consequences of the IPM procedure, the IG differed from the CG by a significant reduction of NSAIDs (p < 0.001), HCT (p = 0.028) and Würzburger pain drip (p < 0.001), and significantly increased prescription rate of antibiotics (p = 0.004). In conclusion, (1) more than 50% of CKD in geriatric patients was not pre-recognized and underdiagnosed, and (2) the electronic patient records-based IPM interdisciplinary networking strategy was associated with effective prevention of further periinterventional renal impairment and requires obligatory implementation in all elderly patients to urgently improve patient and drug safety.
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Affiliation(s)
- Ursula Wolf
- Pharmacotherapy Management, University Hospital Halle (Saale), Martin Luther University Halle-Wittenberg, 06120 Halle (Saale), Germany
| | - Hassan Ghadir
- Medical Clinic II, University Hospital Schleswig-Holstein, Lübeck Campus, 23562 Lübeck, Germany
| | - Luise Drewas
- Internal Medicine Clinic II, Martha-Maria Hospital Halle-Dölau, 06120 Halle (Saale), Germany
| | - Rüdiger Neef
- Department of Orthopedics, Trauma and Reconstructive Surgery, Division of Geriatric Traumatology, University Hospital Halle (Saale), Martin Luther University Halle-Wittenberg, 06120 Halle (Saale), Germany
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Wu J, Li J, Chen H, Shang X, Yu R. Optimization of central venous pressure during the perioperative period is associated with improved prognosis of high-risk operation patients. JOURNAL OF INTENSIVE MEDICINE 2023; 3:165-170. [PMID: 37188112 PMCID: PMC10175704 DOI: 10.1016/j.jointm.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/18/2022] [Accepted: 06/24/2022] [Indexed: 05/17/2023]
Abstract
Background While central venous pressure (CVP) measurement is used to guide fluid management for high-risk surgical patients during the perioperative period, its relationship to patient prognosis is unknown. Methods This single-center, retrospective observational study enrolled patients undergoing high-risk surgery from February 1, 2014 to November 31, 2020, who were admitted to the surgical intensive care unit (ICU) directly after surgery. Patients were divided into the following three groups according to the first CVP measurement (CVP1) after admission to the ICU: low, CVP1 <8 mmHg; moderate, 8 mmHg≤ CVP1 ≤ 12 mmHg; and high, CVP1 >12 mmHg. Perioperative fluid balance, 28-day mortality, length of stay in the ICU, and hospitalization and surgical complications were compared across groups. Results Of the 775 high-risk surgical patients enrolled in the study, 228 were included in the analysis. Median (interquartile range) positive fluid balance during surgery was lowest in the low CVP1 group and highest in the high CVP1 group (low CVP1: 770 [410, 1205] mL; moderate CVP1: 1070 [685, 1500] mL; high CVP1: 1570 [1008, 2000] mL; all P <0.001). The volume of positive fluid balance during the perioperative period was correlated with CVP1 (r=0.336, P <0.001). The partial arterial pressure of oxygen(PaO2)/fraction of inspired oxygen(FiO2) ratio was significantly lower in the high CVP1 group than in the low and moderate CVP1 groups (low CVP1: 400.0 [299.5, 443.3] mmHg; moderate CVP1: 362.5 [330.0, 434.9] mmHg; high CVP1: 335.3 [254.0, 363.5] mmHg; all P <0.001). The incidence of postoperative acute kidney injury (AKI) was lowest in the moderate CVP1 group (low CVP1: 9.2%; moderate CVP1: 2.7%; high CVP1: 16.0%; P=0.007). The proportion of patients receiving renal replacement therapy was highest in the high CVP1 group (low CVP1: 1.5%; moderate CVP1: 0.9%; high CVP1: 10.0%; P=0.014). Logistic regression analysis showed that intraoperative hypotension and CVP1 >12 mmHg were risk factors for AKI within 72 h after surgery (adjusted odds ratio[aOR]=3.875, 95% confidence interval[CI]: 1.378-10.900, P=0.010 and aOR=1.147, 95%CI: 1.006-1.309, P=0.041). Conclusions CVP that is either too high or too low increases the incidence of postoperative AKI. Sequential fluid therapy based on CVP after patients are transferred to the ICU post-surgery does not reduce the risk of organ dysfunction caused by an excessive amount of intraoperative fluid. However, CVP can be used as a safety limit indicator for perioperative fluid management in high-risk surgical patients.
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Affiliation(s)
| | | | | | - Xiuling Shang
- Corresponding authors: Xiuling Shang and Rongguo Yu.
| | - Rongguo Yu
- Corresponding authors: Xiuling Shang and Rongguo Yu.
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Hofer IS, Lee A, Grogan T, Lucero J, Cannesson M. Laboratory Result Reference Ranges Stratified for Patient-Reported Sex and Ethnicity Are More Closely Associated With Postoperative Outcomes Than Currently Used Reference Ranges: A Retrospective Data Analysis. Anesth Analg 2023; 136:111-122. [PMID: 36534718 DOI: 10.1213/ane.0000000000006229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND A single laboratory range for all individuals may fail to take into account underlying physiologic differences based on sex and genetic factors. We hypothesized that laboratory distributions differ based on self-reported sex and ethnicity and that ranges stratified by these factors better correlate with postoperative mortality and acute kidney injury (AKI). METHODS Results from metabolic panels, complete blood counts, and coagulation panels for patients in outpatient encounters were identified from our electronic health record. Patients were grouped based on self-reported sex (2 groups) and ethnicity (6 groups). Stratified ranges were set to be the 2.5th/97.5th percentile for each sex/ethnic group. For patients undergoing procedures, each patient/laboratory result was classified as normal/abnormal using the stratified and nonstratified (traditional) ranges; overlap in the definitions was assessed between the 2 classifications by looking for the percentage of agreement in result classifications of normal/abnormal using the 2 methods. To assess which definitions of normal are most associated with adverse postoperative outcomes, the odds ratio (OR) for each outcome/laboratory result pair was assessed, and the frequency that the confidence intervals of ORs for the stratified versus nonstratified range did not overlap was examined. RESULTS Among the 300 unique combinations (race × sex × laboratory type), median proportion overlap (meaning patient was either "normal" or "abnormal" for both methodologies) was 0.86 [q1, 0.80; q3, 0.89]. All laboratory results except 6 overlapped at least 80% of the time. The frequency of overlap did not differ among the racial/ethnic groups. In cases where the ORs were different, the stratified range was better associated with both AKI and mortality (P < .001). There was no trend of bias toward any specific sex/ethnic group. CONCLUSIONS Baseline "normal" laboratory values differ across sex and ethnic groups, and ranges stratified by these groups are better associated with postoperative AKI and mortality as compared to the standard reference ranges.
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Affiliation(s)
- Ira S Hofer
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California.,Department of Anesthesiology Pain and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Andrew Lee
- Department of Anesthesiology Pain and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Tristan Grogan
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Jennifer Lucero
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Maxime Cannesson
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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11
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Ojo B, Campbell CH. Perioperative acute kidney injury: impact and recent update. Curr Opin Anaesthesiol 2022; 35:215-223. [PMID: 35102042 DOI: 10.1097/aco.0000000000001104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) is common in hospitalized patients and is a major risk factor for increased length of stay, morbidity, and mortality in postoperative patients. There are multiple barriers to reducing perioperative AKI - the etiology is multi-factorial and the diagnosis is fraught with issues. We review the recent literature on perioperative AKI and some considerations for anesthesiologists that examine the far-reaching effects of AKI on multiple organ systems. RECENT FINDINGS This review will discuss recent literature that addresses the epidemiology, use of novel biomarkers in risk stratification, and therapeutic modalities for AKI in burn, pediatrics, sepsis, trauma, cardiac, and liver disease, contrast-induced AKI, as well as the evidence assessing goal-directed fluid therapy. SUMMARY Recent studies address the use of risk stratification models and biomarkers, more sensitive than creatinine, in the preoperative identification of patients at risk for AKI. Although exciting, these scores and models need validation. There is a need for research assessing whether early AKI detection improves outcomes. Enhanced recovery after surgery utilizing goal-directed fluid therapy has not been shown to make an appreciable difference in the incidence of AKI. Reducing perioperative AKI requires a multi-pronged and possibly disease-specific approach.
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Affiliation(s)
- Bukola Ojo
- Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA
| | - Cedric H Campbell
- Department of Anesthesiology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
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12
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Buhre W, de Korte-de Boer D, de Abreu MG, Scheeren T, Gruenewald M, Hoeft A, Spahn DR, Zarbock A, Daamen S, Westphal M, Brauer U, Dehnhardt T, Schmier S, Baron JF, De Hert S, Gavranović Ž, Cholley B, Vymazal T, Szczeklik W, Bornemann-Cimenti H, Soro Domingo MB, Grintescu I, Jankovic R, Belda J. Prospective, randomized, controlled, double-blind, multi-center, multinational study on the safety and efficacy of 6% Hydroxyethyl starch (HES) sOlution versus an Electrolyte solutioN In patients undergoing eleCtive abdominal Surgery: study protocol for the PHOENICS study. Trials 2022; 23:168. [PMID: 35193648 PMCID: PMC8862305 DOI: 10.1186/s13063-022-06058-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/27/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Hydroxyethyl starch (HES) solutions are used for volume therapy to treat hypovolemia due to acute blood loss and to maintain hemodynamic stability. This study was requested by the European Medicines Agency (EMA) to provide more evidence on the long-term safety and efficacy of HES solutions in the perioperative setting. METHODS PHOENICS is a randomized, controlled, double-blind, multi-center, multinational phase IV (IIIb) study with two parallel groups to investigate non-inferiority regarding the safety of a 6% HES 130 solution (Volulyte 6%, Fresenius Kabi, Germany) compared with a crystalloid solution (Ionolyte, Fresenius Kabi, Germany) for infusion in patients with acute blood loss during elective abdominal surgery. A total of 2280 eligible patients (male and female patients willing to participate, with expected blood loss ≥ 500 ml, aged > 40 and ≤ 85 years, and ASA Physical status II-III) are randomly assigned to receive either HES or crystalloid solution for the treatment of hypovolemia due to surgery-induced acute blood loss in hospitals in up to 11 European countries. The dosing of investigational products (IP) is individualized to patients' volume needs and guided by a volume algorithm. Patients are treated with IP for maximally 24 h or until the maximum daily dose of 30 ml/kg body weight is reached. The primary endpoint is the treatment group mean difference in the change from the pre-operative baseline value in cystatin-C-based estimated glomerular filtration rate (eGFR), to the eGFR value calculated from the highest cystatin-C level measured during post-operative days 1-3. Further safety and efficacy parameters include, e.g., combined mortality/major post-operative complications until day 90, renal function, coagulation, inflammation, hemodynamic variables, hospital length of stay, major post-operative complications, and 28-day, 90-day, and 1-year mortality. DISCUSSION The study will provide important information on the long-term safety and efficacy of HES 130/0.4 when administered according to the approved European product information. The results will be relevant for volume therapy of surgical patients. TRIAL REGISTRATION EudraCT 2016-002162-30 . ClinicalTrials.gov NCT03278548.
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Affiliation(s)
- Wolfgang Buhre
- Division of Acute and Critical Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands.
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - Dianne de Korte-de Boer
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Thomas Scheeren
- Department of Anesthesiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Matthias Gruenewald
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Andreas Hoeft
- Department of Anesthesiology and Operative Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital of Zürich, Zürich, Switzerland
- Anesthesiology, Intensive Care Medicine and OR Facilities, University and University Hospital of Zürich, Zürich, Switzerland
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Sylvia Daamen
- European Society of Anaesthesiology and Intensive Care, Brussels, Belgium
| | | | - Ute Brauer
- Department of Medical Scientific Affairs, Hospital Care Division, B. Braun Melsungen AG, Melsungen, Germany
| | - Tamara Dehnhardt
- Department of Medical Scientific Affairs, Hospital Care Division, B. Braun Melsungen AG, Melsungen, Germany
| | - Sonja Schmier
- Department of Medical Scientific Affairs, Hospital Care Division, B. Braun Melsungen AG, Melsungen, Germany
| | | | - Stefan De Hert
- Department of Anesthesioloy and Perioperative Medicine, Gent University Hospital - Gent University, Ghent, Belgium
| | - Željka Gavranović
- Department of Anesthesiology and Intensive Care, University Hospital Center Sestre Milosrdnice, Zagreb, Croatia
| | - Bernard Cholley
- Service d'Anesthésie-Réanimation, Hôpital Européen Georges Pompidou, Paris, France
| | - Tomas Vymazal
- Department of Anesthesiology and Intensive Medicine, University Hospital Motol, Prague, Czech Republic
| | - Wojciech Szczeklik
- Department of Anaesthesiology and Intensive Therapy, 5th Military Clinical Hosptial, Krakow, Poland
| | - Helmar Bornemann-Cimenti
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Marina Blanca Soro Domingo
- Department of Surgery, Clinic University Hospital, Valencia, Spain
- Department of Anesthesia, Reanimation and Pain Therapy, Clinic University Hospital, Valencia, Spain
| | - Ioana Grintescu
- Clinic of Anaesthesia and Intensive Care Medicine, Clinical Emergency Hospital of Bucharest, Bucharest, Romania
- Department of Anaesthesia and Intensive Care Medicine, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, Bucharest, Romania
| | - Radmilo Jankovic
- Clinic for Anesthesiology and Intensive Therapy, University Clinical Center Nis, School of Medicine, University of Nis, Nis, Serbia
| | - Javier Belda
- Department of Surgery, Clinic University Hospital, Valencia, Spain
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13
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Saikali M, Tanios A, Saab A. Evaluation of a Broad-Spectrum Partially Automated Adverse Event Surveillance System: A Potential Tool for Patient Safety Improvement in Hospitals With Limited Resources. J Patient Saf 2021; 17:e653-e664. [PMID: 29166298 DOI: 10.1097/pts.0000000000000442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the sensitivity and resource efficiency of a partially automated adverse event (AE) surveillance system for routine patient safety efforts in hospitals with limited resources. METHODS Twenty-eight automated triggers from the hospital information system's clinical and administrative databases identified cases that were then filtered by exclusion criteria per trigger and then reviewed by an interdisciplinary team. The system, developed and implemented using in-house resources, was applied for 45 days of surveillance, for all hospital inpatient admissions (N = 1107). Each trigger was evaluated for its positive predictive value (PPV). Furthermore, the sensitivity of the surveillance system (overall and by AE category) was estimated relative to incidence ranges in the literature. RESULTS The surveillance system identified a total of 123 AEs among 283 reviewed medical records, yielding an overall PPV of 52%. The tool showed variable levels of sensitivity across and within AE categories when compared with the literature, with a relatively low overall sensitivity estimated between 21% and 44%. Adverse events were detected in 23 of the 36 AE categories defined by an established harm classification system. Furthermore, none of the detected AEs were voluntarily reported. CONCLUSIONS The surveillance system showed variable sensitivity levels across a broad range of AE categories with an acceptable PPV, overcoming certain limitations associated with other harm detection methods. The number of cases captured was substantial, and none had been previously detected or voluntarily reported. For hospitals with limited resources, this methodology provides valuable safety information from which interventions for quality improvement can be formulated.
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Affiliation(s)
| | - Alain Tanios
- Emergency Department, Lebanese Hospital Geitaoui-University Medical Center, Beirut, Lebanon
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14
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Davis J, Raisis AL, Sharp CR, Cianciolo RE, Wallis SC, Ho KM. Improved Cardiovascular Tolerance to Hemorrhage after Oral Resveratrol Pretreatment in Dogs. Vet Sci 2021; 8:vetsci8070129. [PMID: 34357921 PMCID: PMC8310360 DOI: 10.3390/vetsci8070129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/06/2021] [Accepted: 07/10/2021] [Indexed: 11/21/2022] Open
Abstract
Resveratrol has been shown to preserve organ function and improve survival in hemorrhagic shock rat models. This study investigated whether seven days of oral resveratrol could improve hemodynamic response to hemorrhage and confer benefits on risk of acute kidney injury (AKI) without inducing coagulopathy in a canine model. Twelve greyhound dogs were randomly allocated to receive oral resveratrol (1000 mg/day) or placebo for seven days prior to inducing hemorrhage until a targeted mean blood pressure of ≤40 mmHg was achieved. AKI biomarkers and coagulation parameters were measured before, immediately following, and two hours after hemorrhage. Dogs were euthanized, and renal tissues were examined at the end of the experiment. All investigators were blinded to the treatment allocation. A linear mixed model was used to assess effect of resveratrol on AKI biomarkers and coagulation parameters while adjusting for volume of blood loss. A significant larger volume of blood loss was required to achieve the hypotension target in the resveratrol group compared to placebo group (median 64 vs. 55 mL/kg respectively, p = 0.041). Although histological evidence of AKI was evident in all dogs, the renal tubular injury scores were not significantly different between the two groups, neither were the AKI biomarkers. Baseline (pre-hemorrhage) maximum clot firmness on the Rotational Thromboelastometry (ROTEM®) was stronger in the resveratrol group than the placebo group (median 54 vs. 43 mm respectively, p = 0.009). In summary, seven days of oral resveratrol did not appear to induce increased bleeding risk and could improve greyhound dogs’ blood pressure tolerance to severe hemorrhage. Renal protective effect of resveratrol was, however, not observed.
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Affiliation(s)
- Jennifer Davis
- School of Veterinary Science, Murdoch University, Murdoch, WA 6150, Australia; (A.L.R.); (C.R.S.); (K.M.H.)
- Correspondence:
| | - Anthea L. Raisis
- School of Veterinary Science, Murdoch University, Murdoch, WA 6150, Australia; (A.L.R.); (C.R.S.); (K.M.H.)
| | - Claire R. Sharp
- School of Veterinary Science, Murdoch University, Murdoch, WA 6150, Australia; (A.L.R.); (C.R.S.); (K.M.H.)
- Centre for Terrestrial Ecosystem Science and Sustainability, Harry Butler Institute, Murdoch University, Murdoch, WA 6150, Australia
| | - Rachel E. Cianciolo
- Department of Veterinary Biosciences, The Ohio State University, Columbus, OH 43210, USA;
| | - Steven C. Wallis
- University of Queensland Centre for Clinical Research, Brisbane, QLD 4029, Australia;
| | - Kwok M. Ho
- School of Veterinary Science, Murdoch University, Murdoch, WA 6150, Australia; (A.L.R.); (C.R.S.); (K.M.H.)
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, WA 6000, Australia
- Medical School, University of Western Australia, Perth, WA 6009, Australia
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15
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Villa G, De Rosa S, Scirè Calabrisotto C, Nerini A, Saitta T, Degl'Innocenti D, Paparella L, Bocciero V, Allinovi M, De Gaudio AR, Ostermann M, Romagnoli S. Perioperative use of serum creatinine and postoperative acute kidney injury: a single-centre, observational retrospective study to explore physicians' perception and practice. Perioper Med (Lond) 2021; 10:13. [PMID: 34030728 PMCID: PMC8145835 DOI: 10.1186/s13741-021-00184-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 03/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postoperative acute kidney injury (PO-AKI) is a leading cause of short- and long-term morbidity and mortality, as well as progression to chronic kidney disease (CKD). The aim of this study was to explore the physicians' attitude toward the use of perioperative serum creatinine (sCr) for the identification of patients at risk for PO-AKI and long-term CKD. We also evaluated the incidence and risk factors associated with PO-AKI and renal function deterioration in patients undergoing major surgery for malignant disease. METHODS Adult oncological patients who underwent major abdominal surgery from November 2016 to February 2017 were considered for this single-centre, observational retrospective study. Routinely available sCr values were used to define AKI in the first three postoperative days. Long-term kidney dysfunction (LT-KDys) was defined as a reduction in the estimated glomerular filtration rate by more than 10 ml/min/m2 at 12 months postoperatively. A questionnaire was administered to 125 physicians caring for the enrolled patients to collect information on local attitudes regarding the use of sCr perioperatively and its relationship with PO-AKI. RESULTS A total of 423 patients were observed. sCr was not available in 59 patients (13.9%); the remaining 364 (86.1%) had at least one sCr value measured to allow for detection of postoperative kidney impairment. Among these, PO-AKI was diagnosed in 8.2% of cases. Of the 334 patients who had a sCr result available at 12-month follow-up, 56 (16.8%) developed LT-KDys. Data on long-term kidney function were not available for 21% of patients. Interestingly, 33 of 423 patients (7.8%) did not have a sCr result available in the immediate postoperative period or long term. All the physicians who participated in the survey (83 out of 125) recognised that postoperative assessment of sCr is required after major oncological abdominal surgery, particularly in those patients at high risk for PO-AKI and LT-KDys. CONCLUSION PO-AKI after major surgery for malignant disease is common, but clinical practice of measuring sCr is variable. As a result, the exact incidence of PO-AKI and long-term renal prognosis are unclear, including in high-risk patients. TRIAL REGISTRATION ClinicalTrials.gov , NCT04341974 .
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Affiliation(s)
- Gianluca Villa
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy. .,Department of Anaesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
| | - Silvia De Rosa
- Department of Anaesthesia and Intensive Care, San Bortolo Hospital, Vicenza, Italy
| | - Caterina Scirè Calabrisotto
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
| | - Alessandro Nerini
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
| | - Thomas Saitta
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
| | - Dario Degl'Innocenti
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
| | - Laura Paparella
- Department of Anaesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Vittorio Bocciero
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy
| | - Marco Allinovi
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Angelo R De Gaudio
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy.,Department of Anaesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Marlies Ostermann
- Department of Nephrology and Critical Care, Guy's and St Thomas' Hospital, King's College London, London, UK
| | - Stefano Romagnoli
- Department of Health Sciences, Section of Anaesthesiology, Intensive Care and Pain Medicine, University of Florence, Viale Pieraccini 6, 50139, Florence, Italy.,Department of Anaesthesia and Intensive Care, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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16
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Inácio R, Gameiro J, Amaro S, Duarte M. Intraoperative oliguria does not predict postoperative acute kidney injury in major abdominal surgery: a cohort analysis. J Bras Nefrol 2021; 43:9-19. [PMID: 32779689 PMCID: PMC8061965 DOI: 10.1590/2175-8239-jbn-2019-0244] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 06/05/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication in patients undergoing major abdominal surgery and is associated with considerable morbidity and mortality. Several studies investigating the association between intraoperative urine output and postoperative AKI have shown conflicting results. Here, we investigated the association of intraoperative oliguria with postoperative AKI in a cohort of patients submitted to elective major abdominal surgery. METHODS This was a single-center retrospective analysis of adult patients who underwent elective major abdominal surgery from January 2016 to December 2018. AKI was defined according to the serum creatinine criteria of the KDIGO classification. Intraoperative oliguria was defined as urine output of less than 0.5 mL/kg/h. Risk factors were evaluated using multivariate logistic regression analysis. RESULTS A total of 165 patients were analyzed. In the first 48 h after surgery the incidence of AKI was 19.4%. Postoperative AKI was associated with hospital mortality (p=0.011). Twenty percent of patients developed intraoperative oliguria. There was no association between preexisting comorbidities and development of intraoperative oliguria. There was no correlation between the type of anesthesia used and occurrence of intraoperative oliguria, but longer anesthesia time was associated with intraoperative oliguria (p=0.007). Higher baseline SCr (p=0.001), need of vasoactive drugs (p=0.007), and NSAIDs use (p=0.022) were associated with development of intraoperative oliguria. Intraoperative oliguria was not associated with development of postoperative AKI (p=0.772), prolonged hospital stays (p=0.176) or in-hospital mortality (p=0.820). CONCLUSION In this cohort of patients we demonstrated that intraoperative oliguria does not predict postoperative AKI in major abdominal surgery.
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Affiliation(s)
- Rita Inácio
- Hospital Prof. Doutor Fernando da Fonseca, Divisão de Anestesiologia, Lisboa, Portugal
| | - Joana Gameiro
- Centro Hospitalar Lisboa Norte, Departmento de Medicina, Divisão de Nefrologia e Transpalntação Renal, Lisboa, Portugal
| | - Solange Amaro
- Hospital Prof. Doutor Fernando da Fonseca, Divisão de Anestesiologia, Lisboa, Portugal
| | - Mafalda Duarte
- Hospital Prof. Doutor Fernando da Fonseca, Lisboa, Portugal
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Hepatocyte Growth Factor Mimetic ANG-3777 for Cardiac Surgery-Associated Acute Kidney Injury. Kidney Int Rep 2020; 5:2325-2332. [PMID: 33305126 PMCID: PMC7710816 DOI: 10.1016/j.ekir.2020.09.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/02/2020] [Accepted: 09/08/2020] [Indexed: 12/28/2022] Open
Abstract
Introduction Nearly one-third of patients undergoing cardiac surgery involving cardiopulmonary bypass (CPB) experience cardiac surgery–associated (CSA) acute kidney injury (AKI); 5% require renal replacement therapy. ANG-3777 is a hepatocyte growth factor mimetic. In vitro, ANG-3777 reduces apoptosis and increases cell proliferation, migration, morphogenesis, and angiogenesis in injured kidneys. In animal models, ANG-3777 mitigates the effects of renal damage secondary to ischemia reperfusion injury and nephrotoxic chemicals. Phase 2 data in AKI of renal transplantation have shown improved renal function and comparable safety relative to placebo. The Guard Against Renal Damage (GUARD) study is a phase 2 proof of concept trial of ANG-3777 in CSA-AKI. Methods GUARD is a 240-patient, multicenter, double-blind, randomized placebo-controlled trial to assess the efficacy and safety of ANG-3777 in patients at elevated pre-surgery risk for AKI undergoing coronary artery bypass graft (CABG) or heart valve repair/replacement requiring CPB. Subjects are randomized 1:1 to receive ANG-3777 (2 mg/kg) or placebo. Study drug is dosed via 4 daily intravenous 30-minute infusions. The first dose is administered less than 4 hours after completing CPB, second at 24 ± 2 hours post-CPB, with two subsequent doses at 24 ± 2 hours after the previous dose. Results The primary efficacy endpoint is percent change from baseline serum creatinine to mean area under the curve from days 2 through 6. Secondary endpoints include change in estimated glomerular filtration rate from baseline to day 30, the proportion of patients diagnosed with AKI by stage through day 5, and the length of CSA-AKI hospitalization. Safety will include adverse events and laboratory measures. Conclusion This phase 2 study of ANG-3777 provides data to develop a phase 3 registrational study in this medically complex condition.
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Kang JS, Kyoung Ho M, Yung Hun Y, Jun Sung P, Sang Hyun K, Yoon Sang J. Reply to the Letter to the Editor. J Orthop Surg (Hong Kong) 2020; 28:2309499020917475. [PMID: 32314643 DOI: 10.1177/2309499020917475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Joon Soon Kang
- Department of Orthopedic Surgery, Inha University Hospital, Incheon, Republic of Korea
| | - Moon Kyoung Ho
- Department of Orthopedic Surgery, Inha University Hospital, Incheon, Republic of Korea
| | - Youn Yung Hun
- Department of Orthopedic Surgery, Inha University Hospital, Incheon, Republic of Korea
| | - Park Jun Sung
- Department of Orthopedic Surgery, Inha University Hospital, Incheon, Republic of Korea
| | - Ko Sang Hyun
- Department of Orthopedic Surgery, Inha University Hospital, Incheon, Republic of Korea
| | - Jeon Yoon Sang
- Department of Orthopedic Surgery, Inha University Hospital, Incheon, Republic of Korea
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Abstract
Postoperative acute kidney injury (AKI) is a common complication of surgery that is associated with significant adverse outcomes, including increased morbidity and mortality. The perioperative burden of AKI risk factors is complex and potentially large, including high-risk nephrotoxic medications, hypotension, hypovolemia, radiologic contrast, anemia, and surgery-specific factors. Understanding the pathogenesis, risk factors, and potential cumulative impact of perioperative nephrotoxic exposures is particularly important in the prevention and reduction of perioperative AKI. This review outlines the possible strategies to reduce perioperative nephrotoxicity and the development of postoperative AKI.
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Affiliation(s)
- Heather Walker
- Division of Population Health and Genomics, University of Dundee, Dundee, United Kingdom; Renal Unit, Ninewells Hospital, Dundee, United Kingdom
| | - Samira Bell
- Division of Population Health and Genomics, University of Dundee, Dundee, United Kingdom; Renal Unit, Ninewells Hospital, Dundee, United Kingdom.
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20
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Gumbert SD, Kork F, Jackson ML, Vanga N, Ghebremichael SJ, Wang CY, Eltzschig HK. Perioperative Acute Kidney Injury. Anesthesiology 2020; 132:180-204. [PMID: 31687986 PMCID: PMC10924686 DOI: 10.1097/aln.0000000000002968] [Citation(s) in RCA: 149] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Perioperative organ injury is among the leading causes of morbidity and mortality of surgical patients. Among different types of perioperative organ injury, acute kidney injury occurs particularly frequently and has an exceptionally detrimental effect on surgical outcomes. Currently, acute kidney injury is most commonly diagnosed by assessing increases in serum creatinine concentration or decreased urine output. Recently, novel biomarkers have become a focus of translational research for improving timely detection and prognosis for acute kidney injury. However, specificity and timing of biomarker release continue to present challenges to their integration into existing diagnostic regimens. Despite many clinical trials using various pharmacologic or nonpharmacologic interventions, reliable means to prevent or reverse acute kidney injury are still lacking. Nevertheless, several recent randomized multicenter trials provide new insights into renal replacement strategies, composition of intravenous fluid replacement, goal-directed fluid therapy, or remote ischemic preconditioning in their impact on perioperative acute kidney injury. This review provides an update on the latest progress toward the understanding of disease mechanism, diagnosis, and managing perioperative acute kidney injury, as well as highlights areas of ongoing research efforts for preventing and treating acute kidney injury in surgical patients.
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Affiliation(s)
- Sam D. Gumbert
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Felix Kork
- Department of Anaesthesiology, Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Maisie L. Jackson
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Naveen Vanga
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Semhar J. Ghebremichael
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Christy Y. Wang
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Holger K. Eltzschig
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX 77030
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King CR, Abraham J, Kannampallil TG, Fritz BA, Ben Abdallah A, Chen Y, Henrichs B, Politi M, Torres BA, Mickle A, Budelier TP, McKinnon S, Gregory S, Kheterpal S, Wildes T, Avidan MS. Protocol for the Effectiveness of an Anesthesiology Control Tower System in Improving Perioperative Quality Metrics and Clinical Outcomes: the TECTONICS randomized, pragmatic trial. F1000Res 2019; 8:2032. [PMID: 32201572 PMCID: PMC7076336 DOI: 10.12688/f1000research.21016.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2019] [Indexed: 01/25/2023] Open
Abstract
Introduction: Perioperative morbidity is a public health priority, and surgical volume is increasing rapidly. With advances in technology, there is an opportunity to research the utility of a telemedicine-based control center for anesthesia clinicians that assess risk, diagnoses negative patient trajectories, and implements evidence-based practices. Objectives: The primary objective of this trial is to determine whether an anesthesiology control tower (ACT) prevents clinically relevant adverse postoperative outcomes including 30-day mortality, delirium, respiratory failure, and acute kidney injury. Secondary objectives are to determine whether the ACT improves perioperative quality of care metrics including management of temperature, mean arterial pressure, mean airway pressure with mechanical ventilation, blood glucose, anesthetic concentration, antibiotic redosing, and efficient fresh gas flow. Methods and analysis: We are conducting a single center, randomized, controlled, phase 3 pragmatic clinical trial. A total of 58 operating rooms are randomized daily to receive support from the ACT or not. All adults (eighteen years and older) undergoing surgical procedures in these operating rooms are included and followed until 30 days after their surgery. Clinicians in operating rooms randomized to ACT support receive decision support from clinicians in the ACT. In operating rooms randomized to no intervention, the current standard of anesthesia care is delivered. The intention-to-treat principle will be followed for all analyses. Differences between groups will be presented with 99% confidence intervals; p-values <0.005 will be reported as providing compelling evidence, and p-values between 0.05 and 0.005 will be reported as providing suggestive evidence. Registration: TECTONICS is registered on ClinicalTrials.gov, NCT03923699; registered on 23 April 2019.
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Affiliation(s)
- Christopher R. King
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Joanna Abraham
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
- Institute for Informatics, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Thomas G. Kannampallil
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
- Institute for Informatics, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Bradley A. Fritz
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Yixin Chen
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Bernadette Henrichs
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Mary Politi
- Department of Surgery, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Brian A. Torres
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Angela Mickle
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Thaddeus P. Budelier
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Sherry McKinnon
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Stephen Gregory
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Troy Wildes
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
| | - TECTONICS Research Group
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, 63110, USA
- Institute for Informatics, Washington University in St Louis, St Louis, MO, 63110, USA
- Department of Computer Science and Engineering, Washington University in St Louis, St Louis, MO, 63110, USA
- Department of Surgery, Washington University in St Louis, St Louis, MO, 63110, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, 48109, USA
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22
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Zealley I, Wang H, Donnan PT, Bell S. Exposure to contrast media in the perioperative period confers no additional risk of acute kidney injury in surgical patients. Nephrol Dial Transplant 2019; 33:1751-1756. [PMID: 29237046 DOI: 10.1093/ndt/gfx325] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 10/09/2017] [Indexed: 11/14/2022] Open
Abstract
Background Iodinated contrast media (CM) used in angiography and computed tomography (CT) scans is an important cause of acute kidney injury (AKI) in hospitalized patients undergoing surgery. Contrast-induced nephropathy leads to AKI soon after CM administration. The aim of the study was to determine whether the timing of contrast media exposure related to diagnostic imaging during the immediate perioperative period influences the risk of post-operative AKI. Methods All patients aged 18 years or above who underwent diagnostic imaging within 7 days of non-cardiac surgery between 1 January 2003 and 31 December 2013 in the Tayside region of Scotland, UK were included in the analysis. The primary outcome of AKI was defined using the Kidney Disease: Improving Global Outcomes creatinine-based criteria. Multiple logistic regressions were performed to identify predictors for AKI. Results Of 9300 patients, 6224 were exposed to CM in the immediate perioperative period and 3076 were not. Post-operative AKI occurred in 678 (10.9%) of the 6224 patients who were exposed to CM. On multiple logistic regression, independent predictors of post-operative AKI were increasing age, male gender, lower baseline renal function and treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Timing of CM exposure did not affect risk of developing AKI, odds ratio 0.972 (95% confidence interval 0.935-1.010), P = 0.146. Conclusions For patients who have either just had or are soon to undergo general surgical procedures there appears to be no need to limit CT scan quality by avoiding the administration of CM. These patients may benefit from the increased diagnostic utility of contrast-enhanced CT scans without increasing their risk of perioperative AKI.
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Affiliation(s)
- Ian Zealley
- Department of Radiology, Ninewells Hospital, Dundee, UK
| | - Huan Wang
- Population Health Sciences, University of Dundee, Dundee, UK
| | - Peter T Donnan
- Population Health Sciences, University of Dundee, Dundee, UK
| | - Samira Bell
- Population Health Sciences, University of Dundee, Dundee, UK.,Renal Unit, Ninewells Hospital, Dundee, UK
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Monteserín Matesanz C, de la Gala F, Rancan L, Piñeiro P, Simón C, Tejedor A, Vara E, Gonzalez-Cantero JL, Garutti I. [Predictive value of plasma cytokines for acute kidney injury following lung resection surgery: prospective observational study]. Rev Bras Anestesiol 2019; 69:242-252. [PMID: 31133282 DOI: 10.1016/j.bjan.2018.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 11/28/2018] [Accepted: 12/05/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Patients undergoing lung resection surgery are at risk of developing postoperative acute kidney injury. Determination of cytokine levels allows the detection of an early inflammatory response. We investigated any temporal relationship among perioperative inflammatory status and development of acute kidney injury after lung resection surgery. Furthermore, we evaluated the impact of acute kidney injury on outcome and analyzed the feasibility of cytokines to predict acute kidney injury. METHODS We prospectively analyzed 174 patients scheduled for elective lung resection surgery with intra-operative periods of one-lung ventilation. Fiberoptic broncho-alveolar lavage was performed in each lung before and after one-lung ventilation periods for cytokine analysis. As well, cytokine levels were measured from arterial blood samples at five time points. Acute kidney injury was diagnosed within 48h of surgery based estabilished criteria for its diagnosis. We analyzed the association between acute kidney injury and cardiopulmonary complications, length of intensive care unit and hospital stays, intensive care unit re-admission, and short-term and long-term mortality. RESULTS The incidence of acute kidney injury in our study was 6.9% (12/174). Acute kidney injury patients showed higher plasma cytokine levels after surgery, but differences in alveolar cytokines were not detected. Although no patient required renal replacement therapy, acute kidney injury patients had higher incidence of cardiopulmonary complications and increased overall mortality. Plasma interleukin-6 at 6h was the most predictive cytokine of acute kidney injury (cut-off point at 4.89pg.mL-1). CONCLUSIONS Increased postoperative plasma cytokine levels are associated with acute kidney injury after lung resection surgery in our study, which worsens the prognosis. Plasma interleukin-6 may be used as an early indicator for patients at risk of developing acute kidney injury after lung resection surgery.
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Affiliation(s)
| | - Francisco de la Gala
- Gregorio Marañón University General Hospital, Department of Anesthesiology, Madrid, Espanha
| | - Lisa Rancan
- Complutense University of Madrid, Medical Faculty, Department of Biochemistry and Molecular Biology III, Madrid, Espanha
| | - Patricia Piñeiro
- Gregorio Marañón University General Hospital, Department of Anesthesiology, Madrid, Espanha
| | - Carlos Simón
- Gregorio Marañón University General Hospital, Department of Thoracic Surgery, Madrid, Espanha
| | - Alberto Tejedor
- Gregorio Marañón University General Hospital, Department of Nephrology, Madrid, Espanha
| | - Elena Vara
- Complutense University of Madrid, Medical Faculty, Department of Biochemistry and Molecular Biology III, Madrid, Espanha
| | | | - Ignacio Garutti
- Gregorio Marañón University General Hospital, Department of Anesthesiology, Madrid, Espanha
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24
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Monteserín Matesanz C, de la Gala F, Rancan L, Piñeiro P, Simón C, Tejedor A, Vara E, Gonzalez-Cantero JL, Garutti I. Predictive value of plasma cytokines for acute kidney injury following lung resection surgery: prospective observational study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 31133282 PMCID: PMC9391883 DOI: 10.1016/j.bjane.2019.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background and objectives Patients undergoing lung resection surgery are at risk of developing postoperative acute kidney injury. Determination of cytokine levels allows the detection of an early inflammatory response. We investigated any temporal relationship among perioperative inflammatory status and development of acute kidney injury after lung resection surgery. Furthermore, we evaluated the impact of acute kidney injury on outcome and analyzed the feasibility of cytokines to predict acute kidney injury. Methods We prospectively analyzed 174 patients scheduled for elective lung resection surgery with intra-operative periods of one-lung ventilation periods. Fiberoptic broncho-alveolar lavage was performed in each lung before and after one-lung ventilation periods for cytokine analysis. As well, cytokine levels were measured from arterial blood samples at five time points. acute kidney injury was diagnosed within 48 h of surgery based on acute kidney injury criteria. We analyzed the association between acute kidney injury and cardiopulmonary complications, length of intensive care unit and hospital stays, intensive care unit re-admission, and short-term and long-term mortality. Results The incidence of acute kidney injury in our study was 6.9% (12/174). Acute kidney injury patients showed higher plasma cytokine levels after surgery but differences in alveolar cytokines were not detected. Although no patient required renal replacement therapy, acute kidney injury patients had higher incidence of cardiopulmonary complications and increased overall mortality. Plasma interleukin-6 at 6 h was the most predictive cytokine of acute kidney injury (cut-off point at 4.89 pg.mL−1). Conclusions Increased postoperative plasma cytokine levels are associated with acute kidney injury after lung resection surgery in our study, which worsens the prognosis. Plasma interleukin-6 may be used as an early indicator for patients at risk of developing acute kidney injury after lung resection surgery.
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Affiliation(s)
| | - Francisco de la Gala
- Gregorio Marañón University General Hospital, Department of Anesthesiology, Madrid, Espanha
| | - Lisa Rancan
- Complutense University of Madrid, Medical Faculty, Department of Biochemistry and Molecular Biology III, Madrid, Espanha
| | - Patricia Piñeiro
- Gregorio Marañón University General Hospital, Department of Anesthesiology, Madrid, Espanha
| | - Carlos Simón
- Gregorio Marañón University General Hospital, Department of Thoracic Surgery, Madrid, Espanha
| | - Alberto Tejedor
- Gregorio Marañón University General Hospital, Department of Nephrology, Madrid, Espanha
| | - Elena Vara
- Complutense University of Madrid, Medical Faculty, Department of Biochemistry and Molecular Biology III, Madrid, Espanha
| | | | - Ignacio Garutti
- Gregorio Marañón University General Hospital, Department of Anesthesiology, Madrid, Espanha
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25
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Saw KME, Ng RGR, Chan SP, Ang YH, Ti LK, Chew THS. Association of genetic polymorphisms with acute kidney injury after cardiac surgery in a Southeast Asian population. PLoS One 2019; 14:e0213997. [PMID: 30973904 PMCID: PMC6459593 DOI: 10.1371/journal.pone.0213997] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 03/05/2019] [Indexed: 12/25/2022] Open
Abstract
Introduction Genetic polymorphisms are important in explaining the wide interpatient variability that exists in the development of acute kidney injury (AKI) post cardiac surgery. We hypothesised that polymorphisms in 4 candidate genes, namely angiotensin-converting enzyme (ACE), apolipoprotein-E (ApoE), interleukin-6 (IL-6), and tumour necrosis factor-alpha (TNF-α) are associated with AKI. Methods 870 patients who underwent cardiac surgery in Singapore were analysed. All patients who fulfilled stage 1 KDIGO criteria and above were considered to have AKI. This was investigated against various demographic, clinical and genetic factors. Results Increased age, history of hypertension, anaemia and renal impairment remained important preoperative risk factors for AKI. Intraoperatively, longer cardiopulmonary bypass (CPB) time and the use of intra-aortic balloon pump (IABP) were shown to be associated with AKI. Among the genetic factors, ACE-D allele was associated with an increased risk of AKI while IL6-572C allele was associated with a decreased risk of AKI. Conclusion ACE-D allele was associated with the development of AKI similar to other studies. On the other hand, IL6-572C was shown to have a protective role against the development of AKI, contradictory to studies done in the Caucasian population. This contradictory effect of IL6-572C is a result of a complex interplay between the gene and population specific modulating factors. Our findings further underscored the necessity of taking into account population specific differences when developing prediction models for AKI.
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Affiliation(s)
- Kah Ming Eddy Saw
- Department of Anaesthesiology, Singapore General Hospital, Academia, Level 5, Singapore
| | - Rui Ge Roderica Ng
- Department of Anaesthesiology, Singapore General Hospital, Academia, Level 5, Singapore
| | - Siew Pang Chan
- Cardiovascular Research Institute, National University Health System, Singapore
- Department of Mathematics and Statistics, College of Science, Health and Engineering, La Trobe University, Melbourne, Victoria, Australia
| | - Yi Hui Ang
- Department of Anaesthesia, National University Health System, Singapore
| | - Lian Kah Ti
- Department of Anaesthesia, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- * E-mail:
| | - Tsong Huey Sophia Chew
- Department of Anaesthesiology, Singapore General Hospital, Academia, Level 5, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Duke-NUS Medical School, Singapore
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Trongtrakul K, Sawawiboon C, Wang AY, Chitsomkasem A, Limphunudom P, Kurathong S, Prommool S, Trakarnvanich T, Srisawat N. Acute kidney injury in critically ill surgical patients: Epidemiology, risk factors and outcomes. Nephrology (Carlton) 2019; 24:39-46. [PMID: 29124867 DOI: 10.1111/nep.13192] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2017] [Indexed: 12/27/2022]
Abstract
AIM Acute kidney injury (AKI) is one of the most serious complications seen in intensive care units (ICUs). However, its epidemiology, risk factors and clinical outcomes in surgical critically ill patients remains unclear. METHODS A prospective cohort study was conducted in surgical intensive care unit (ICU) of the university hospital in Bangkok, Thailand. AKI was diagnosed according to the KDIGO 2012 criteria. RESULTS A total of 189 of the 400 patients enrolled in our study developed AKI (47.3%). The severity was: stage 1 = 29.6% of all AKI (56 cases), stage 2 = 30.7% (58 cases), and stage 3 = 39.7% (75 cases). Risk factors of AKI development included a higher BMI, a greater APACHE-II score, septic shock, use of mechanical ventilation, acute medical complications during surgical admission, and pre-existing chronic kidney disease. After adjustment for covariates, only the most severe stage of AKI (stage 3) was associated with increasing 28-day ICU mortality compared with no AKI stage, HR = 7.75 (95% CI, 1.46-41.20, P = 0.02). CONCLUSION Acute kidney injury is common and is associated with an increase in mortality in surgical ICU patients. There should be more focus on patients with AKI risk factors to prevent this deleterious event.
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Affiliation(s)
- Konlawij Trongtrakul
- Critical Care Division, Department of Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Chaiwut Sawawiboon
- Critical Care Division, Department of Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Amanda Y Wang
- Renal and Metabolic Division, The George Institute for Global Health, Camperdown, New South Wales, Australia
| | - Anusang Chitsomkasem
- Critical Care Division, Department of Emergency Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Ploynapas Limphunudom
- Department of Anaesthesiology, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Sathit Kurathong
- Nephrology Division, Department of Internal Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Surazee Prommool
- Nephrology Division, Department of Internal Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Thananda Trakarnvanich
- Nephrology Division, Department of Internal Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Nattachai Srisawat
- Excellence Centre for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Thai Red Cross and Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Slagelse C, Gammelager H, Iversen LH, Sørensen HT, Christiansen CF. Acute kidney injury and 1-year mortality after colorectal cancer surgery: a population-based cohort study. BMJ Open 2019; 9:e024817. [PMID: 30872545 PMCID: PMC6429863 DOI: 10.1136/bmjopen-2018-024817] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Acute kidney injury (AKI) is a frequent postoperative complication, but the mortality impact within different postoperative time frames and severities of AKI are poorly understood. We examined the occurrence of postoperative AKI among colorectal cancer (CRC) surgery patients and the impact of AKI on mortality during 1 year after surgery. DESIGN Observational cohort study. We defined the exposure, AKI, as a 50% increase in plasma creatinine or initiation of renal replacement therapy within 7 days after surgery or an absolute increase in creatinine of 26 µmol/L within 48 hours. SETTING Population-based Danish medical databases. PARTICIPANTS A total of 6580 patients undergoing CRC surgery in Northern Denmark during 2005-2011 were included from the Danish Colorectal Cancer Group database. OUTCOMES MEASURE Occurrence of AKI and 8-30, 31-90 and 91-365 days mortality in patient with or without AKI. RESULTS AKI occurred in 1337 patients (20.3%) of the 6580 patients who underwent CRC surgery. Among patients with AKI, 8-30, 31-90 and 91-365 days mortality rates were 10.1% (95% CI 8.6% to 11.9%), 7.8% (95% CI 6.4% to 9.5%) and 12.0% (95% CI 10.3% to 14.2%), respectively. Compared with patients without AKI, AKI was associated with increased 8-30 days mortality (adjusted HR (aHR)=4.01,95% CI 3.11 to 5.17) and 31-90 days mortality (aHR 2.08,95% CI 1.60 to 2.69), while 91-365 days aHR was 1.12 (95% CI 0.89 to 1.41). We observed no major differences in stratified analyses. CONCLUSIONS AKI after surgery for CRC is a frequent postoperative complication associated with a substantially increased 90-day mortality. AKI should be considered a potential target for reducing 90-day mortality.
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Affiliation(s)
- Charlotte Slagelse
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Henrik Gammelager
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Intensive Care, Aarhus University Hospital, Aarhus N, Denmark
| | | | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
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McKinlay J, Tyson E, Forni LG. Renal complications of anaesthesia. Anaesthesia 2019; 73 Suppl 1:85-94. [PMID: 29313905 DOI: 10.1111/anae.14144] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2017] [Indexed: 12/15/2022]
Abstract
Peri-operative acute kidney injury is common, accounting for 30-40% of all in-hospital cases of acute kidney injury. It is associated with clinically significant morbidity and mortality even with what was hitherto regarded as relatively trivial increases in serum creatinine, and carries over a 12-fold relative risk of death following major abdominal surgery. Comorbid conditions such as diabetes, hypertension, liver disease and particularly pre-existing chronic kidney disease, as well as the type and urgency of surgery, are major risk factors for the development of postoperative acute kidney injury. As yet, there are no specific treatment options for the injured kidney, although there are several modifiable risk factors of which the anaesthetist should be aware. As well as the avoidance of potential nephrotoxins and appropriate volume balance, optimal anaesthetic management should aim to reduce the risk of postoperative renal complications. This may include careful ventilatory management and blood pressure control, as well as appropriate analgesic strategies. The choice of anaesthetic agent may also influence renal outcomes. Rather than concentrate on the classical management of acute kidney injury, this review focuses on the potential development of acute kidney injury peri-operatively, and the means by which this may be ameliorated.
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Affiliation(s)
- J McKinlay
- Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group and Department of Intensive Care Medicine, University of Surrey, Surrey, UK
| | - E Tyson
- Department of Intensive Care Medicine, Royal Surrey County Hospital, University of Surrey, Surrey, UK
| | - L G Forni
- Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group and Department of Intensive Care Medicine, University of Surrey, Surrey, UK.,Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group and Department of Clinical and Experimental Medicine, Faculty of Health Care Sciences, University of Surrey, Surrey, UK
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30
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Gameiro J, Fonseca JA, Dias JM, Milho J, Rosa R, Jorge S, Lopes JA. Neutrophil, lymphocyte and platelet ratio as a predictor of postoperative acute kidney injury in major abdominal surgery. BMC Nephrol 2018; 19:320. [PMID: 30419844 PMCID: PMC6231266 DOI: 10.1186/s12882-018-1073-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 10/05/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Surgery is one of the leading causes of acute kidney injury (AKI) in hospitalized patients. Major abdominal surgery has the second higher incidences of AKI, after cardiac surgery. AKI results from a complex interaction between hemodynamic, toxic and inflammatory factors. The pathogenesis of AKI following major abdominal surgery is distinct from cardiac and vascular surgery. The neutrophil, lymphocytes and platelets (N/LP) ratio has been demonstrated as an inflammatory marker and an independent predictor for AKI and mortality after cardiovascular surgery. The aim of this study was to evaluate the prognostic ability of the post-operative N/LP ratio after major abdominal surgery. METHODS We cross-examined data of a retrospective analysis of 450 patients who underwent elective or urgent major nonvascular abdominal surgery at the Department of Surgery II of Centro Hospitalar Lisboa Norte from January 2010 to February 2011. N/LP ratio was determined using maximal neutrophil counts and minimal lymphocyte and platelet counts in the first 12 h after surgery. AKI was considered when developed within 48 h after surgery. RESULTS One-hundred and one patients (22.4%) developed AKI. Patients with higher N/LP ratio had an increased risk of developing postoperative AKI (6.36 ± 7.34 vs 4.33 ± 3.36, p < 0.001; unadjusted OR 1.1 (95% CI 1.04-1.16), p = 0.001; adjusted OR 1.05 (95% CI 1.00-1.10), p = 0.048). Twenty-nine patients died (6.44%). AKI was an independent predictor of mortality (20.8 vs 2.3%, p < 0.0001; unadjusted OR 11.2, 95% CI 4. 8-26.2, p < 0.0001; adjusted OR 3.56, 95% CI 1.0 2-12.43, p = 0.046). In a multivariate analysis higher N/LP ratio was not associated with increased in-hospital mortality. CONCLUSION Postoperative N/LP ratio was independently associated with AKI after major abdominal surgery, although there was no association with in-hospital mortality.
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Affiliation(s)
- Joana Gameiro
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal.
| | - José Agapito Fonseca
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
| | - Joana Monteiro Dias
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
| | - Joana Milho
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
| | - Rosário Rosa
- Department of Surgery, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
| | - Sofia Jorge
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
| | - José António Lopes
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
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Gameiro J, Fonseca JA, Neves M, Jorge S, Lopes JA. Acute kidney injury in major abdominal surgery: incidence, risk factors, pathogenesis and outcomes. Ann Intensive Care 2018; 8:22. [PMID: 29427134 PMCID: PMC5807256 DOI: 10.1186/s13613-018-0369-7] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 02/05/2018] [Indexed: 12/11/2022] Open
Abstract
Acute kidney injury (AKI) is a common complication in patients undergoing major abdominal surgery. Various recent studies using modern standardized classifications for AKI reported a variable incidence of AKI after major abdominal surgery ranging from 3 to 35%. Several patient-related, procedure-related factors and postoperative complications were identified as risk factors for AKI in this setting. AKI following major abdominal surgery has been shown to be associated with poor short- and long-term outcomes. Herein, we provide a contemporary and critical review of AKI after major abdominal surgery focusing on its incidence, risk factors, pathogeny and outcomes.
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Affiliation(s)
- Joana Gameiro
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal.
| | - José Agapito Fonseca
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
| | - Marta Neves
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
| | - Sofia Jorge
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
| | - José António Lopes
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035, Lisbon, Portugal
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Hamilton DA, Ernst CC, Kramer WG, Madden D, Lang E, Liao E, Lacouture PG, Ramaiya A, Carr DB. Pharmacokinetics of Diclofenac and Hydroxypropyl-β-Cyclodextrin (HPβCD) Following Administration of Injectable HPβCD-Diclofenac in Subjects With Mild to Moderate Renal Insufficiency or Mild Hepatic Impairment. Clin Pharmacol Drug Dev 2017; 7:110-122. [PMID: 29197175 PMCID: PMC5814843 DOI: 10.1002/cpdd.417] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 10/13/2017] [Indexed: 11/17/2022]
Abstract
Given their established analgesic properties, nonsteroidal anti‐inflammatory drugs (NSAIDs) represent an important postoperative pain management option. This study investigated: (1) the effects of mild or moderate renal insufficiency and mild hepatic impairment on the pharmacokinetics (PK) of diclofenac and hydroxypropyl‐β‐cyclodextrin (HPβCD) following administration of the injectable NSAID HPβCD‐diclofenac; and (2) the PK of HPβCD following administration of HPβCD‐diclofenac and intravenous itraconazole formulated with HPβCD in healthy adults. Diclofenac clearance (CL) and volume of distribution (Vz) tended to increase with decreasing renal function (moderate insufficiency versus mild insufficiency or healthy controls). Regression analysis demonstrated a significant relationship between Vz (but not CL or elimination half‐life, t½) and renal function. HPβCD CL was significantly decreased in subjects with renal insufficiency, with a corresponding increase in t½. There were no significant differences in diclofenac or HPβCD PK in subjects with mild hepatic impairment versus healthy subjects. Exposure to HPβCD in healthy subjects following HPβCD‐diclofenac administration was ∼12% of that with intravenous itraconazole, after adjusting for dosing schedule and predicted accumulation (<5% without adjustment). With respect to PK properties, these results suggest that HPβCD‐diclofenac might be administered to patients with mild or moderate renal insufficiency or mild hepatic impairment without dose adjustment (NCT00805090).
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Affiliation(s)
- Douglas A Hamilton
- Javelin Pharmaceuticals, Cambridge, MA, USA, (now Hospira, a Pfizer company, Lake Forest, IL, USA).,New Biology Ventures LLC, San Mateo, CA, USA
| | - Cynthia C Ernst
- Javelin Pharmaceuticals, Cambridge, MA, USA, (now Hospira, a Pfizer company, Lake Forest, IL, USA)
| | | | - Donna Madden
- Javelin Pharmaceuticals, Cambridge, MA, USA, (now Hospira, a Pfizer company, Lake Forest, IL, USA)
| | - Eric Lang
- Javelin Pharmaceuticals, Cambridge, MA, USA, (now Hospira, a Pfizer company, Lake Forest, IL, USA)
| | - Edward Liao
- Javelin Pharmaceuticals, Cambridge, MA, USA, (now Hospira, a Pfizer company, Lake Forest, IL, USA)
| | - Peter G Lacouture
- Magidom Discovery, LLC, St. Augustine, FL, USA.,Brown University School of Medicine, Providence, RI, USA
| | | | - Daniel B Carr
- Javelin Pharmaceuticals, Cambridge, MA, USA, (now Hospira, a Pfizer company, Lake Forest, IL, USA).,Department of Anesthesiology, Tufts Medical Center, Boston, MA, USA
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Rao SN, Shenoy M P, Gopalakrishnan M, Kiran B A. Applicability of the Cleveland clinic scoring system for the risk prediction of acute kidney injury after cardiac surgery in a South Asian cohort. Indian Heart J 2017; 70:533-537. [PMID: 30170649 PMCID: PMC6116709 DOI: 10.1016/j.ihj.2017.11.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/02/2017] [Accepted: 11/26/2017] [Indexed: 02/02/2023] Open
Abstract
Background Acute kidney injury (AKI) after cardiac surgery is a frequent post-operative complication associated with an increased risk of mortality, morbidity and hospital costs. Preoperative risk scores such as the Cleveland Clinic Scoring Tool (CCST) have been validated in Western population group to identify patients at higher risk of AKI and may facilitate preventive strategies. However, the scoring tool has not been validated systematically in a South Asian cohort. We aimed to evaluate the applicability of the CCST in prediction of AKI after open cardiac surgery in a South–Indian tertiary care center. Materials and methods A retrospective study of all patients who underwent elective open cardiac surgery over a 4 year period from Jan 2012 to Dec 2015 at a single centre were included and relevant details extracted from a comprehensive chart review. The primary outcome was AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Patients were risk stratified as per the CCST to assess for prediction of AKI into low risk (0–2), intermediate risk (3–5) and high risk (>6) groups. Results A total of 276 patients underwent open cardiac surgery with mean age of 51.5 ± 13.06 yrs. This included 177 (64.1%) males and 99 females (35.8%). Overall incidence of AKI was 6.88%. Mean age, gender, BMI, preoperative serum creatinine, diabetes mellitus, chronic obstructive pulmonary disease, cardiopulmonary bypass time was similar in patients who developed AKI vs those who did not have AKI postoperatively. The mean CCST scores were 1.6 in those without AKI, 1.5 in stage 1, 3.0 in stage 2 and 3.4 in stage 3 AKI. Higher risk scores predicted greater risk of AKI. A total of 106 patients (38.4%) were on ACE/ARB, 119 patients (43.1%) received beta-blockers, 110 (39.8%) received diuretics while 144(52.1%) had received preoperative statins. Comparison of drug use between the two groups revealed that preoperative use of ACEI/ARB was associated with highest risk of AKI (p = 0.006). Mortality rate was also high at 15.7% in those with AKI compared to 3.1% in non-AKI group (p = 0.04). Conclusion The modified CCST was valid in risk identification of patients with severe stage of AKI but did not have strong discrimination for early AKI stages. Preoperative statin use did not protect against AKI in our study, however preoperative ARB/ACEI use was significantly associated with occurrence of postoperative AKI.
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Affiliation(s)
- Shobhana Nayak Rao
- Deptartment of Nephrology, K.S.Hegde Medical Academy, Derlakatte, Mangalore, Karnataka, India.
| | - Pradeep Shenoy M
- Department of Cardiothoracic Surgery, K.S.Hegde Medical Academy, Derlakatte, Mangalore, Karnataka, India
| | - Mundayat Gopalakrishnan
- Department of Cardiothoracic Surgery, K.S.Hegde Medical Academy, Derlakatte, Mangalore, Karnataka, India
| | - Amith Kiran B
- Deptartment of Nephrology, K.S.Hegde Medical Academy, Derlakatte, Mangalore, Karnataka, India
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Gharaibeh KA, Hamadah AM, Sierra RJ, Leung N, Kremers WK, El-Zoghby ZM. The Rate of Acute Kidney Injury After Total Hip Arthroplasty Is Low but Increases Significantly in Patients with Specific Comorbidities. J Bone Joint Surg Am 2017; 99:1819-1826. [PMID: 29088036 DOI: 10.2106/jbjs.16.01027] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to investigate the rate and risk factors associated with the development of acute kidney injury after total hip arthroplasty, including the perioperative use of nonsteroidal anti-inflammatory drugs (NSAIDs). METHODS We retrospectively collected the demographic and comorbidity data of all patients who underwent total hip arthroplasty between 2004 and 2014 at our institution (n = 8,949). We conducted analyses of the entire cohort and a nested case-control subset. Subjects who developed acute kidney injury were matched by age, sex, and year of surgical procedure to subjects without acute kidney injury. Variables associated with acute kidney injury were determined using univariate and multivariate logistic regressions. RESULTS The mean patient age (and standard deviation) was 64.6 ± 13.8 years, 48.6% of patients were male, and 114 cases (1.1%) developed acute kidney injury, mostly stage 1 (79%). Variables associated with acute kidney injury included older age (odds ratio [OR], 1.4 per decade; p < 0.001), male sex (OR, 1.78; p = 0.005), chronic kidney disease (OR, 4.6; p < 0.001), heart failure (OR, 4.5; p < 0.001), diabetes (OR, 2.1; p < 0.001), and hypertension (OR, 2.1; p = 0.007). The results were consistent in the case-control analysis. NSAIDs were not associated with acute kidney injury (OR, 1.26; p = 0.36), but were avoided in subjects at risk, making any interpretation difficult because of confounding. A risk model for acute kidney injury after total hip arthroplasty was developed for clinical use and had good discrimination (area under the curve, 0.82; p < 0.001). CONCLUSIONS The rate of acute kidney injury after total hip arthroplasty is low, but increases significantly, from <1% to >20%, in those with several independent risk factors present preoperatively. Increasing awareness of these risk factors may help to decrease the risk of acute kidney injury after total hip arthroplasty. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kamel A Gharaibeh
- 1Division of Nephrology and Hypertension, Department of Internal Medicine (K.A.G., A.M.H., N.L., and Z.M.El-Z.), and Departments of Orthopedic Surgery (R.J.S.) and Biomedical Statistics and Informatics (W.K.K.), Mayo Clinic, Rochester, Minnesota
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Guerci P, Claudot JL, Novy E, Settembre N, Lalot JM, Losser MR. Immediate postoperative plasma neutrophil gelatinase-associated lipocalin to predict acute kidney injury after major open abdominal aortic surgery: A prospective observational study. Anaesth Crit Care Pain Med 2017; 37:327-334. [PMID: 29033359 DOI: 10.1016/j.accpm.2017.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 09/28/2017] [Accepted: 09/29/2017] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Plasma neutrophil gelatinase-associated lipocalin (pNGAL) has been used as a biomarker in acute kidney injury (AKI). AKI is a common postoperative complication of aortic surgery. We sought to evaluate the performance of the immediately postoperative pNGAL level in comparison with the serum creatinine (SCr) level in predicting AKI and the need for renal replacement therapy (RRT). PATIENTS AND METHODS Prospective non-interventional study in a university hospital. Fifty patients undergoing elective or emergent major intra-abdominal aortic surgery were included. Comparisons between groups of patients with or without postoperative AKI, according to KDIGO staging, were made. Performance of NGAL was determined by examining the area under receiver operating characteristic (AUROC) curve. RESULTS The incidence of AKI was 36%. At H+2, pNGAL values in AKI and non-AKI patients, respectively, were 221 [133-278] versus 50 [50-90] ng/mL (P<0.0001), and SCr values were 115 [96-178] versus 90 [72-99] μmol/L (P<0.0008). The AUROC of pNGAL for prediction of AKI was 0.90 (95% CI: 0.81-0.98) with an optimal cutoff of 112ng/mL, a sensitivity of 83%, specificity of 84%, and positive and negative predictive values of 75% and 90%, respectively. SCr produced an AUROC curve of 0.79 (0.65-0.92) at a cutoff of 110μmol/L. The diagnostic performance of pNGAL was significantly better than that of SCr (P=0.039). PNGAL at H+2 better predicted the RRT requirement [0.96 (0.90-1.0)] compared to SCr [0.86 (0.73-0.98)], but this difference was not statistically significant. CONCLUSIONS A 2-hour postoperative determination of pNGAL outperformed SCr level in predicting postoperative AKI after major aortic surgery.
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Affiliation(s)
- Philippe Guerci
- Department of Anaesthesiology and Critical Care Medicine, Intensive Care Unit J.M.-Picard, University Hospital of Nancy - Brabois, Institut Lorrain du Cœur et des Vaisseaux Louis-Mathieu, 5, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France.
| | - Jean-Louis Claudot
- Department of Anaesthesiology and Critical Care Medicine, Intensive Care Unit J.M.-Picard, University Hospital of Nancy - Brabois, Institut Lorrain du Cœur et des Vaisseaux Louis-Mathieu, 5, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France.
| | - Emmanuel Novy
- Department of Anaesthesiology and Critical Care Medicine, Intensive Care Unit J.M.-Picard, University Hospital of Nancy - Brabois, Institut Lorrain du Cœur et des Vaisseaux Louis-Mathieu, 5, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France.
| | - Nicla Settembre
- Department of Vascular Surgery, University Hospital of Nancy - Brabois, 5, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France.
| | - Jean-Marc Lalot
- Department of Anaesthesiology and Critical Care Medicine, Intensive Care Unit J.M.-Picard, University Hospital of Nancy - Brabois, Institut Lorrain du Cœur et des Vaisseaux Louis-Mathieu, 5, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France.
| | - Marie-Reine Losser
- Department of Anaesthesiology and Critical Care Medicine, Intensive Care Unit J.M.-Picard, University Hospital of Nancy - Brabois, Institut Lorrain du Cœur et des Vaisseaux Louis-Mathieu, 5, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France.
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Abstract
Acute kidney injury (AKI) is a common complication in surgical patients and is associated with increases in mortality, an increased risk for chronic kidney disease and hemodialysis after discharge, and increased cost. Better understanding of the risk factors that contribute to perioperative AKI has led to improved AKI prediction and will eventually lead to improved prevention of AKI, mitigation of injury when AKI occurs, and enhanced recovery in patients who sustain AKI. The development of advanced clinical prediction scores for AKI, new imaging techniques, and novel biomarkers for early detection of AKI provides new tools toward these ends.
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Hunsicker O, Feldheiser A, Weimann A, Liehre D, Sehouli J, Wernecke KD, Spies C. Diagnostic value of plasma NGAL and intraoperative diuresis for AKI after major gynecological surgery in patients treated within an intraoperative goal-directed hemodynamic algorithm: A substudy of a randomized controlled trial. Medicine (Baltimore) 2017; 96:e7357. [PMID: 28700473 PMCID: PMC5515745 DOI: 10.1097/md.0000000000007357] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
UNLABELLED Data on early markers for acute kidney injury (AKI) after noncardiovascular surgery are still limited. This study aimed to determine the diagnostic value of plasma neutrophil-gelatinase-associated lipocalin (pNGAL) and intraoperative diuresis for AKI in patients undergoing major abdominal surgery treated within a goal-directed hemodynamic algorithm.This study is a post-hoc analysis of a randomized controlled pilot trial comparing intravenous solutions within a hemodynamic goal-directed algorithm based on the esophageal Doppler in patients undergoing epithelial ovarian cancer surgery. The diagnostic value of plasma NGAL obtained at ICU admission and intraoperative diuresis was determined with respect to patients already meeting AKI criteria 6 hours after surgery (AKI6h) and to all patients meeting AKI criteria at least once during the postoperative course (AKItotal). AKI was diagnosed by the definition of the Kidney Disease Improving Global Outcome (KDIGO) group creatinine criteria and was screened up to postoperative day 3. Receiver operating characteristic curves including a gray zone approach were performed.A total of 48 patients were analyzed. None of the patients had increased creatinine levels before surgery and 14 patients (29.2%) developed AKI after surgery. Plasma NGAL was predictive for AKI6h (AUCAKI6h 0.832 (95% confidence interval [CI], 0.629-0.976), P = .001) and AKItotal (AUCAKItotal 0.710 (CI 0.511-0.878), P = .023). The gray zones of pNGAL calculated for AKI6h and AKItotal were 210 to 245 and 207 to 274 ng mL, respectively. The lower cutoffs of the gray zone at 207 and 210 ng mL had a negative predictive value (NPV) (i.e., no AKI during the postoperative course) of 96.8% (CI 90-100) and 87.1% (CI 78-97), respectively. Intraoperative diuresis was also predictive for AKI6h (AUCAKI6h 0.742 (CI 0.581-0.871), P = .019) with a gray zone of 0.5 to 2.0 mL kg h. At the lower cutoff of the gray zone at 0.5 mL kg h, corresponding to the oliguric threshold, the NPV was 84.2% (78-92).This study indicates that pNGAL can be used as an early marker to rule out AKI occurring within 3 days after major abdominal surgery. Intraoperative diuresis can be used to rule out AKI occurring up to 6 hours after surgery. TRIAL REGISTRATION ISRCTN 53154834.
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Affiliation(s)
- Oliver Hunsicker
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin
| | - Aarne Feldheiser
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin
| | | | - David Liehre
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin
| | - Jalid Sehouli
- Department of Gynaecology, European Competence Center for Ovarian Cancer, Charité— University Medicine Berlin
| | | | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin
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Junot S, Keroak S, Del Castillo JRE, Ayoub JY, Paquet C, Bonnet-Garin JM, Troncy E. Inhaled nitric oxide prevents NSAID-induced renal impairment in pseudo-normovolaemic piglets. PLoS One 2017; 12:e0179475. [PMID: 28658254 PMCID: PMC5489163 DOI: 10.1371/journal.pone.0179475] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 05/31/2017] [Indexed: 01/17/2023] Open
Abstract
Objective Inhaled nitric oxide (iNO) is commonly used as a treatment of pulmonary hypertension. Its action is purported to be specific to the lung, but extrapulmonary effects have been reported. The objective of this study was to evaluate if iNO could compensate the renal impairment induced by ketoprofen, a conventional non-steroidal anti-inflammatory drug (NSAID), during general anaesthesia. Methods Under pseudo-normovolaemic condition, thirty piglets were randomly assigned into 5 equal groups and equipped for renal and systemic parameters measurements. A first experiment was carried out to validate methods and reproduce the renal effects of iNO (40 ppm) in comparison with a placebo (100% oxygen). In a second experiment, iNO was inhaled for 120 minutes right after NSAID treatment (ketoprofen 2 mg×kg-1 IV, and 40 ppm iNO; group KiNO) and its effects were compared to ketoprofen alone (2 mg×kg-1 IV; group K) and placebo (saline; group C). Results In this model, iNO increased significantly renal blood flow measured by ultrasonic (RBFUL: +53.2±17.2%; p = 0.008) and by PAH clearance (RBFPAH:+78.6±37.6%; p = 0.004) methods, glomerular filtration rate (GFR: +72.6±32.5%; p = 0.006) and urinary output (UO: +47.4±24.2%; p = 0.01). In the second experiment, no significant temporal variation was noted for renal parameters in groups KiNO and C, whereas a significant and constant decrease was observed in the group K for RBFUL (max -19.0±7.1%), GFR (max -26.6±10.4%) and UO (max -30.3±10.5%). Clinical significance Our experiments show that iNO, released from its transport forms after its inhalation, can improve renal safety of NSAIDs. This result is promising regarding the use of NSAIDs in critical conditions, but needs to receive clinical confirmation.
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Affiliation(s)
- Stephane Junot
- VetAgro Sup - Veterinary Campus of Lyon - University of Lyon, APCSE unit, Marcy l’Etoile, France
- * E-mail:
| | - Stephanie Keroak
- Faculty of Veterinary Medicine - University of Montreal, GREPAQ (Research group in animal pharmacology of Quebec) - Department of Veterinary Biomedicine, Saint-Hyacinthe, Québec, Canada
| | - Jerome R. E. Del Castillo
- Faculty of Veterinary Medicine - University of Montreal, GREPAQ (Research group in animal pharmacology of Quebec) - Department of Veterinary Biomedicine, Saint-Hyacinthe, Québec, Canada
| | - Jean-Yves Ayoub
- VetAgro Sup - Veterinary Campus of Lyon - University of Lyon, APCSE unit, Marcy l’Etoile, France
| | - Christian Paquet
- VetAgro Sup - Veterinary Campus of Lyon - University of Lyon, APCSE unit, Marcy l’Etoile, France
| | | | - Eric Troncy
- Faculty of Veterinary Medicine - University of Montreal, GREPAQ (Research group in animal pharmacology of Quebec) - Department of Veterinary Biomedicine, Saint-Hyacinthe, Québec, Canada
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Flores E, Lewinger JP, Rowe VL, Woo K, Weaver FA, Shavelle D, Clavijo L, Garg PK. Increased risk of mortality after lower extremity bypass in individuals with acute kidney injury in the Vascular Quality Initiative. J Vasc Surg 2017; 65:1055-1061. [DOI: 10.1016/j.jvs.2016.09.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 09/08/2016] [Indexed: 01/22/2023]
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Smith DK, Smith LE, Billings FT, Blume JD. A general approach to risk modeling using partial surrogate markers with application to perioperative acute kidney injury. Diagn Progn Res 2017; 1:21. [PMID: 31093550 PMCID: PMC6460789 DOI: 10.1186/s41512-017-0022-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 12/05/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Surrogate outcomes are often utilized when disease outcomes are difficult to directly measure. When a biological threshold effect exists, surrogate outcomes may only represent disease in specific subpopulations. We refer to these outcomes as "partial surrogate outcomes." We hypothesized that risk models of partial surrogate outcomes would perform poorly if they fail to account for this population heterogeneity. We developed criteria for predictive model development using partial surrogate outcomes and demonstrate their importance in model selection and evaluation within the clinical example of serum creatinine, a partial surrogate outcome for acute kidney injury. METHODS Data from 4737 patients who underwent cardiac surgery at a major academic center were obtained. Linear and mixture models were fit on maximum 2-day serum creatinine change as a surrogate for estimated glomerular filtration rate at 90 days after surgery (eGFR90), adjusted for known AKI risk factors. The AUC for eGFR90 decline and Spearman's rho were calculated to compare model discrimination between the linear model and a single component of the mixture model deemed to represent the informative subpopulation. Simulation studies based on the clinical data were conducted to further demonstrate the consistency and limitations of the procedure. RESULTS The mixture model was highly favored over the linear model with BICs of 2131.3 and 5034.3, respectively. When model discrimination was evaluated with respect to the partial surrogate, the linear model displays superior performance (p < 0.001); however, when it was evaluated with respect to the target outcome, the mixture model approach displays superior performance (AUC difference p = 0.002; Spearman's difference p = 0.020). Simulation studies demonstrate that the nature of the heterogeneity determines the magnitude of any advantage the mixture model. CONCLUSIONS Partial surrogate outcomes add complexity and limitations to risk score modeling, including the potential for the usual metrics of discrimination to be misleading. Partial surrogacy can be potentially uncovered and appropriately accounted for using a mixture model approach. Serum creatinine behaved as a partial surrogate outcome consistent with two patient subpopulations, one representing patients whose injury did not exceed their renal functional reserve and a second population representing patients whose injury did exceed renal functional reserve.
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Affiliation(s)
- Derek K. Smith
- 0000 0004 1936 9916grid.412807.8Department of Biostatistics, Vanderbilt University Medical Center, 2525 West End Ave, Suite 11000, Nashville, TN 37212 USA
| | - Loren E. Smith
- 0000 0004 1936 9916grid.412807.8Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Frederic T. Billings
- 0000 0004 1936 9916grid.412807.8Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Jeffrey D. Blume
- 0000 0004 1936 9916grid.412807.8Department of Biostatistics, Vanderbilt University Medical Center, 2525 West End Ave, Suite 11000, Nashville, TN 37212 USA
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Vijay A, Grover A, Coulson TG, Myles PS. Perioperative Management of Patients Treated with Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers: A Quality Improvement Audit. Anaesth Intensive Care 2016; 44:346-52. [DOI: 10.1177/0310057x1604400305] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Previous studies have shown that patients continuing angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers on the day of surgery are more likely to have significant intraoperative hypotension, higher rates of postoperative acute kidney injury and lower incidences of postoperative atrial fibrillation. However, many of these studies were prone to bias and confounding, and questions remain over the validity of these outcomes. This observational, before-and-after quality mprovement audit aimed to assess the effect of withholding these medications on the morning of surgery. We recruited 323 participants, with 83 (26%) having their preoperative angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB) withheld on the day of surgery. There were only very small Spearman rank-order correlations between time since last dose of these medications (rho −0.12, P=0.057) and intraoperative and recovery room intravenous fluid administration (rho −0.11, P=0.042). There was no statistically significant difference between the continued or withheld groups in vasopressor (metaraminol use 3.5 [1.5–8.3] mg versus 3.5 [1.5–8.5] mg, P=0.67) or intravenous fluid administration (1000 ml [800–1500] ml versus 1000 [800–1500] ml, P=0.096), nor rates of postoperative acute kidney injury (13% vs 18%, P=0.25) or atrial fibrillation (15% versus 18%, P=0.71). This audit found no significant differences in measured outcomes between the continued or withheld ACEi/ARB groups. This finding should be interpreted with caution due to the possibility of confounding and an insufficient sample size. However, as the finding is in contrast to many previous studies, future prospective randomised clinical trials are required to answer this important question.
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Affiliation(s)
- A. Vijay
- Alfred Hospital, Melbourne, Victoria
| | - A. Grover
- Department of Anaesthesia and Perioperative Medicine, The Alfred Hospital and Monash University, Melbourne, Victoria
| | - T. G. Coulson
- Department of Anaesthesia and Perioperative Medicine, The Alfred Hospital, Melbourne, Victoria
| | - P. S. Myles
- Department of Anaesthesia and Perioperative Medicine, The Alfred Hospital and Monash University, Melbourne, Victoria
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Golden D, Corbett J, Forni LG. Peri-operative renal dysfunction: prevention and management. Anaesthesia 2016; 71 Suppl 1:51-7. [PMID: 26620147 DOI: 10.1111/anae.13313] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2015] [Indexed: 01/05/2023]
Abstract
Postoperative increases in serum creatinine concentration, by amounts historically viewed as trivial, are associated with increased morbidity and mortality. Acute kidney injury is common, affecting one in five patients admitted with acute medical disease and up to four in five patients admitted to intensive care, of whom one in two have had operations. This review is focused principally on the identification of patients at risk of acute kidney injury and the prevention of injury. In the main, there are no interventions that directly treat the damaged kidney. The management of acute kidney injury is based on correction of dehydration, hypotension, and urinary tract obstruction, stopping nephrotoxic drugs, giving antibiotics for bacterial infection, and commencing renal replacement therapy if necessary.
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Affiliation(s)
- D Golden
- Department of Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - J Corbett
- Department of Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - L G Forni
- Department of Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey, UK.,Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group and Faculty of Health Care Sciences, University of Surrey, Guildford, Surrey, UK
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44
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Perioperative dexmedetomidine reduces the incidence and severity of acute kidney injury following valvular heart surgery. Kidney Int 2016; 89:693-700. [DOI: 10.1038/ki.2015.306] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 06/25/2015] [Accepted: 07/02/2015] [Indexed: 11/08/2022]
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Bell S, Dekker FW, Vadiveloo T, Marwick C, Deshmukh H, Donnan PT, Van Diepen M. Risk of postoperative acute kidney injury in patients undergoing orthopaedic surgery--development and validation of a risk score and effect of acute kidney injury on survival: observational cohort study. BMJ 2015; 351:h5639. [PMID: 26561522 PMCID: PMC4641433 DOI: 10.1136/bmj.h5639] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
STUDY QUESTION What is the predicted risk of acute kidney injury after orthopaedic surgery and does it affect short term and long term survival? METHODS The cohort comprised adults resident in the National Health Service Tayside region of Scotland who underwent orthopaedic surgery from 1 January 2005 to 31 December 2011. The model was developed in 6220 patients (two hospitals) and externally validated in 4395 patients from a third hospital. Several preoperative variables were selected for candidate predictors, based on literature, clinical expertise, and availability in the orthopaedic surgery setting. The main outcomes were the development of any severity of acute kidney injury (stages 1-3) within the first postoperative week, and 90 day, one year, and longer term survival. STUDY ANSWER AND LIMITATIONS Using logistic regression analysis, independent predictors of acute kidney injury were older age, male sex, diabetes, number of prescribed drugs, lower estimated glomerular filtration rate, use of angiotensin converting enzyme inhibitors or angiotensin receptor blockers, and American Society of Anesthesiologists grade. The model's predictive performance for discrimination was good (C statistic 0.74 in development cohort, 0.70 in validation cohort). Calibration was good in the development cohort and after recalibration in the validation cohort. Only the highest risks were over-predicted. Survival was worse in patients with acute kidney injury compared with those without (adjusted hazard ratio 1.53, 95% confidence interval 1.38 to 1.70). This was most noticeable in the short term (adjusted hazard ratio: 90 day 2.36, 1.94 to 2.87) and diminished over time (90 day-one year 1.40, 1.10 to 1.79; >1 year 1.28, 1.10 to 1.48). The model used routinely collected data in the orthopaedic surgery setting therefore some variables that could potentially improve predictive performance were not available. However, the readily available predictors make the model easily applicable. WHAT THIS STUDY ADDS A preoperative risk prediction model consisting of seven predictors for acute kidney injury was developed, with good predictive performance in patients undergoing orthopaedic surgery. Survival was significantly poorer in patients even with mild (stage 1) postoperative acute kidney injury. FUNDING, COMPETING INTERESTS, DATA SHARING SB received grants from Tenovus Tayside, Chief Scientist Office, and the Royal College of Physicians and Surgeons of Glasgow; PT receives grants from Novo Nordisk, GlaxoSmithKline, and the New Drugs Committee of the Scottish Medicines Consortium. No additional data are available.
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Affiliation(s)
- Samira Bell
- Renal Unit, Ninewells Hospital, NHS Tayside, Dundee DD1 9SY, UK
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, Netherlands
| | - Thenmalar Vadiveloo
- Division of Population Health Sciences , School of Medicine, University of Dundee, Dundee, UK
| | - Charis Marwick
- Division of Population Health Sciences , School of Medicine, University of Dundee, Dundee, UK
| | - Harshal Deshmukh
- Division of Population Health Sciences , School of Medicine, University of Dundee, Dundee, UK
| | - Peter T Donnan
- Division of Population Health Sciences , School of Medicine, University of Dundee, Dundee, UK
| | - Merel Van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, Netherlands
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Abstract
Perioperative acute kidney injury (AKI) is a common, morbid, and costly surgical complication. Current efforts to understand and manage AKI in surgical patients focus on prevention, mitigation of further injury when AKI has occurred, treatment of associated conditions, and facilitation of renal recovery. Lesser severity AKI is now understood to be much more common, and more morbid, than was previously thought. The ability to detect AKI within hours of onset would be helpful in protecting the kidney and in preserving renal function, and several imaging and biomarker modalities are currently being evaluated.
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Affiliation(s)
- Charles Hobson
- Department of Surgery, Malcom Randall VA Medical Center, NF/SG VAMC, Gainesville, FL 32608, USA; Department of Health Services Research, Management, and Policy, University of Florida, Gainesville, FL, USA
| | - Girish Singhania
- Department of Medicine, University of Florida, PO Box 100254, Gainesville, FL 32610-0254, USA
| | - Azra Bihorac
- Department of Medicine, University of Florida, PO Box 100254, Gainesville, FL 32610-0254, USA; Department of Anesthesiology, University of Florida, PO Box 100254, Gainesville, FL 32610-0254, USA.
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47
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Whitaker RM, Stallons LJ, Kneff JE, Alge JL, Harmon JL, Rahn JJ, Arthur JM, Beeson CC, Chan SL, Schnellmann RG. Urinary mitochondrial DNA is a biomarker of mitochondrial disruption and renal dysfunction in acute kidney injury. Kidney Int 2015; 88:1336-1344. [PMID: 26287315 PMCID: PMC4675682 DOI: 10.1038/ki.2015.240] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 05/20/2015] [Accepted: 06/04/2015] [Indexed: 12/13/2022]
Abstract
Recent studies show the importance of mitochondrial dysfunction in the initiation and progression of acute kidney injury (AKI). However, no biomarkers exist linking renal injury to mitochondrial function and integrity. To this end, we evaluated urinary mitochondrial DNA (UmtDNA) as a biomarker of renal injury and function in humans with AKI following cardiac surgery. mtDNA was isolated from the urine of patients following cardiac surgery and quantified by quantitative PCR. Patients were stratified into no AKI, stable AKI, and progressive AKI groups based on Acute Kidney Injury Network (AKIN) staging. UmtDNA was elevated in progressive AKI patients and was associated with progression of patients with AKI at collection to higher AKIN stages. To evaluate the relationship of UmtDNA to measures of renal mitochondrial integrity in AKI, mice were subjected to sham surgery or varying degrees of ischemia followed by 24 h of reperfusion. UmtDNA increased in mice after 10-15 min of ischemia and positively correlated with ischemia time. Furthermore, UmtDNA was predictive of AKI in the mouse model. Finally, UmtDNA levels were negatively correlated with renal cortical mtDNA and mitochondrial gene expression. These translational studies demonstrate that UmtDNA is associated with recovery from AKI following cardiac surgery by serving as an indicator of mitochondrial integrity. Thus UmtDNA may serve as valuable biomarker for the development of mitochondrial-targeted therapies in AKI.
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Affiliation(s)
- Ryan M Whitaker
- Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - L Jay Stallons
- Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Joshua E Kneff
- Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Joseph L Alge
- Division of Nephrology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jennifer L Harmon
- Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jennifer J Rahn
- Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - John M Arthur
- Division of Nephrology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA.,Ralph H. Johnson Veterans Administration Medical Center, Charleston, South Carolina, USA
| | - Craig C Beeson
- Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sherine L Chan
- Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Rick G Schnellmann
- Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, Charleston, South Carolina, USA.,Ralph H. Johnson Veterans Administration Medical Center, Charleston, South Carolina, USA
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Delfino Duarte PA, Fumagalli AC, Wandeur V, Becker D. Urinary neutrophil gelatinase-associated lipocalin in critically ill surgical cancer patients. Indian J Crit Care Med 2015; 19:251-6. [PMID: 25983430 PMCID: PMC4430742 DOI: 10.4103/0972-5229.156459] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND AND AIMS Neutrophil gelatinase-associated lipocalin (N-GAL) is an early biomarker of acute kidney injury (AKI) due to various etiologies. On the other hand, N-GAL is also elevated in patients with acute inflammatory conditions and in several solid neoplasms. The goal of this study was to assess the efficacy of N-GAL as a predictor of AKI and mortality in oncological surgical patients postoperatively in the intensive care unit (ICU). METHODS This was a prospective cohort observation study on adult cancer patients submitted to elective or emergency surgeries and admitted in the ICU. Urinary N-GAL was measured at the first 2 h after admission. AKI incidence and other complications were assessed, including hospital mortality. RESULTS A total of 22 patients were assessed (77% male, age 52.8 years, Acute Physiology and Chronic Health Evaluation II [APACHE II] 17.3) in whom the most frequent site of cancer was the gastrointestinal tract. AKI incidence was 13.6%. Urinary N-GAL was a predictor of AKI (22.0 ng/ml in patients without AKI vs. 239.1 ng/ml in patients with AKI, P < 0.001). Multivariate analysis showed that the main predictors of AKI were age, APACHE II, and N-GAL. N-GAL was also higher, although not statistically significant in patients who died in the hospital. CONCLUSIONS In oncological postoperative patients admitted to the ICU, urinary N-GAL was an independent predictor of AKI; moreover, its level was higher in the deceased patients.
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Affiliation(s)
- Pericles Almeida Delfino Duarte
- From: General Intensive Care Unit, Cancer Hospital/Western Paraná State League for Cancer Treatment and Research (UOPECCAN), Cascavel, PR, Brazil
| | - Andreia Cristina Fumagalli
- From: General Intensive Care Unit, Cancer Hospital/Western Paraná State League for Cancer Treatment and Research (UOPECCAN), Cascavel, PR, Brazil
| | | | - Delmiro Becker
- From: General Intensive Care Unit, Cancer Hospital/Western Paraná State League for Cancer Treatment and Research (UOPECCAN), Cascavel, PR, Brazil
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Gujadhur A, Tiruvoipati R, Cole E, Malouf S, Ansari ES, Wong K. Serum bicarbonate may independently predict acute kidney injury in critically ill patients: An observational study. World J Crit Care Med 2015; 4:71-76. [PMID: 25685725 PMCID: PMC4326766 DOI: 10.5492/wjccm.v4.i1.71] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Revised: 12/04/2014] [Accepted: 01/12/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To explore whether serum bicarbonate at admission to intensive care unit (ICU) predicted development of acute kidney injury (AKI).
METHODS: We studied all patients admitted to our ICU over a 2 year period (February 2010 to 2012). The ICU has a case mix of medical and surgical patients excluding cardiac surgical, trauma and neurosurgical patients. We analysed 2035 consecutive patients admitted to ICU during the study period. Data were collected by two investigators independently and in duplicate using a standardised spread sheet to ensure accuracy. Ambiguous data were checked for accuracy where indicated. AKI was defined using the Kidney Disease Improving Global Outcomes criteria. Patients were divided into two groups; patients who developed AKI or those who did not, in order to compare the baseline characteristics, and laboratory and physiologic data of the two cohorts. Regression analysis was used to identify if serum bicarbonate on admission predicted the development of AKI.
RESULTS: Of 2036 patients 152 (7.5%) were excluded due to missing data. AKI developed in 43.1% of the patients. The AKI group, compared to the non-AKI group, was sicker based on their lower systolic, diastolic and mean arterial pressures and a higher acute physiology and chronic health evaluation (APACHE) III and SAPS II scores. Moreover, patients who developed AKI had more co-morbidities and a higher proportion of patients who developed AKI required mechanical ventilation. The multi-regression analysis of independent variables showed that serum bicarbonate on admission (OR = 0.821; 95%CI: 0.796-0.846; P < 0.0001), APACHE III (OR = 1.011; 95%CI: 1.007-1.015; P < 0.0001), age (OR = 1.016; 95%CI: 1.008-1.024; P < 0.0001) and presence of sepsis at ICU admission (OR = 2.819; 95%CI: 2.122-23.744; P = 0.004) were each significant independent predictors of AKI. The area under the ROC curve was 0.8 (95%CI: 0.78-0.83), thereby demonstrating that the predictive model has relatively good discriminating power for predicting AKI.
CONCLUSION: Serum bicarbonate on admission may independently be used to make a diagnosis of AKI.
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