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Wang C, Gao Y, Tian Y, Wang Y, Zhao W, Sessler DI, Jia Y, Ji B, Diao X, Xu X, Wang J, Li J, Wang S, Liu J. Prediction of acute kidney injury after cardiac surgery from preoperative N-terminal pro-B-type natriuretic peptide. Br J Anaesth 2021; 127:862-870. [PMID: 34561052 DOI: 10.1016/j.bja.2021.08.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/28/2021] [Accepted: 08/19/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is common after cardiac surgery and is difficult to predict. N-terminal pro-B-type natriuretic peptide (NT-proBNP) is highly predictive for perioperative cardiovascular complications and may also predict renal injury. We therefore tested the hypothesis that preoperative NT-proBNP concentration is associated with renal injury after major cardiac surgery. METHODS We included 35 337 patients who had cardiac surgery and measurements of preoperative NT-proBNP and postoperative creatinine. The primary outcome was Kidney Disease: Improving Global Outcomes Stages 1-3 AKI. We also separately considered severe AKI, including Stage 2, Stage 3, and new-onset dialysis. RESULTS Postoperative AKI occurred in 11 999 (34.0%) patients. Stage 2 AKI occurred in 1200 (3.4%) patients, Stage 3 AKI in 474 (1.3%) patients, and new-onset dialysis was required in 241 (0.7%) patients. The NT-proBNP concentrations (considered continuously or in quartiles) were significantly correlated with any-stage AKI and severe AKI (all adjusted P<0.01). Including NT-proBNP significantly improved AKI prediction (net reclassification improvement: 0.24 [0.22-0.27]; P<0.001) beyond basic models derived from other baseline factors in the overall population. Reclassification was especially improved for higher grades of renal injury: 0.30 (0.25-0.36) for Stage 2, 0.46 (0.37-0.55) for Stage 3, and 0.47 (0.35-0.60) for dialysis. CONCLUSIONS Increased preoperative NT-proBNP concentrations were associated with postoperative AKI in patients having cardiac surgery. Including NT-proBNP substantially improves AKI predictions based on other preoperative factors.
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Affiliation(s)
- Chunrong Wang
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuchen Gao
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Tian
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuefu Wang
- Department of Anaesthesiology and Surgical Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.
| | - Wei Zhao
- Information Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Daniel I Sessler
- Department of Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Yuan Jia
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bingyang Ji
- Cardiopulmonary Bypass, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaolin Diao
- Information Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinyi Xu
- Information Centre, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianhui Wang
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Li
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sudena Wang
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jia Liu
- Department of Anaesthesiology, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Jiang H, Holm J, Friberg Ö, Vanky F, Vidlund M, Tajik B, Yang Y, Svedjeholm R. Utility of NT-proBNP as an objective marker of postoperative heart failure after coronary artery bypass surgery: a prospective observational study. Perioper Med (Lond) 2021; 10:21. [PMID: 34253255 PMCID: PMC8275184 DOI: 10.1186/s13741-021-00194-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 05/04/2021] [Indexed: 12/28/2022] Open
Abstract
Background Postoperative heart failure (PHF) is the main cause for mortality after cardiac surgery but unbiased evaluation of PHF is difficult. We investigated the utility of postoperative NT-proBNP as an objective marker of PHF after coronary artery bypass surgery (CABG). Methods Prospective study on 382 patients undergoing isolated CABG for acute coronary syndrome. NT-proBNP was measured preoperatively, the first (POD1) and third postoperative morning (POD3). A blinded Endpoints Committee used prespecified criteria for PHF. Use of circulatory support was scrutinized. Results After adjusting for confounders PHF was associated with 1.46 times higher NT-proBNP on POD1 (p = 0.002), 1.54 times higher on POD3 (p < 0.0001). In severe PHF, NT-proBNP was 2.18 times higher on POD1 (p = 0.001) and 1.81 times higher on POD3 (p = 0.019). Postoperative change of NT-proBNP was independently associated with PHF (OR 5.12, 95% CI 1.86–14.10, p = 0.002). The use of inotropes and ICU resources increased with incremental quartiles of postoperative NT-proBNP. Conclusions Postoperative NT-proBNP can serve as an objective marker of the severity of postoperative myocardial dysfunction. Due to overlap in individuals, NT-proBNP is useful mainly for comparisons at cohort level. As such, it provides a tool for study purposes when an unbiased assessment of prevention or treatment of PHF is desirable. Trial registration ClinicalTrials.gov Identifier: NCT00489827https://clinicaltrials.gov/ct2/show/NCT00489827?term=glutamics&draw=2&rank=1. Supplementary Information The online version contains supplementary material available at 10.1186/s13741-021-00194-4.
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Affiliation(s)
- Huiqi Jiang
- Department of Cardiothoracic Surgery and Anesthesia, Faculty of Medicine and Health Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden.,Department of Cardiothoracic Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University of Medical Sciences, Guangzhou, Guangdong, China
| | - Jonas Holm
- Department of Cardiothoracic Surgery and Anesthesia, Faculty of Medicine and Health Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden
| | - Örjan Friberg
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Farkas Vanky
- Department of Cardiothoracic Surgery and Anesthesia, Faculty of Medicine and Health Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden
| | - Mårten Vidlund
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Bashir Tajik
- Department of Cardiothoracic Surgery and Anesthesia, Faculty of Medicine and Health Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden
| | - Yanqi Yang
- Department of Cardiothoracic Surgery and Anesthesia, Faculty of Medicine and Health Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden.,Department of Cardiothoracic Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University of Medical Sciences, Guangzhou, Guangdong, China
| | - Rolf Svedjeholm
- Department of Cardiothoracic Surgery and Anesthesia, Faculty of Medicine and Health Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden.
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Provenchère S, Guglielminotti J, Gouel-Chéron A, Bresson E, Desplanque L, Bouleti C, Iung B, Montravers P, Dehoux M, Longrois D. Postoperative Cardiac Troponin I Thresholds Associated With 1-Year Cardiac Mortality After Adult Cardiac Surgery: An Attempt to Link Risk Stratification With Management Stratification in an Observational Study. J Cardiothorac Vasc Anesth 2019; 33:3320-3330. [PMID: 31399305 DOI: 10.1053/j.jvca.2019.06.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 06/22/2019] [Accepted: 06/26/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Cardiac troponin (cTn) concentrations are measured routinely in some centers after cardiac surgery as part of risk stratification, but there are no data on how increased cTn concentrations could change patients' management. The aim of this study was to estimate relevant cTnI thresholds and identify potential interventions (additional monitoring/therapeutic interventions) that could be part of management changes of patients with cTnI greater than relevant thresholds. DESIGN Retrospective, single-center, observational study. SETTING Bichat-Claude Bernard Hospital, Paris, France, between January 1, 2009, and December 31, 2012. PARTICIPANTS Consecutive adult patients undergoing cardiac surgery. MEASUREMENTS AND MAIN RESULTS cTnI was measured on the 20th postoperative hour. Causes of death and possible interventions were determined by analysis of individual medical records. cTnI thresholds for 1-year cardiac mortality with a specificity >80% were calculated. For this study, 3,228 procedures were analyzed; 129 deaths occurred (4%), 83 of which (2.6%) were cardiac deaths. Threshold cTnI values were 4.2 µg/L for coronary artery bypass grafting (95% confidence interval [CI] 3.9-4.5) and 10.7 µg/L for non-coronary artery bypass grafting (95% CI 10.0-11.3). In multivariable analysis, the EuroSCORE II (odds ratio 1.1 [95% CI 1.06-1.13]; p < 0.001) and cTnI concentrations greater than the thresholds (odds ratio 5.62 [95% CI 3.37-9.37]; p < 0.001) were associated with significantly increased risk of death. The additive and absolute Net Reclassification Index were 0.288% and 14.1%, respectively, for a logistic model including cTnI and EuroSCORE II (area under the curve C-index 0.82 [95% CI 0.77-0.87]) compared with a model including only EuroSCORE II (area under the curve C-index 0.80 [95% CI 0.75-0.84]). Fifty-three of the 83 patients who experienced cardiac death (64%) had a cTnI concentration greater than the threshold, and an intervention was deemed possible in 47 of those 53 (89%) (mostly patients with mild postoperative cardiac dysfunction). For noncardiac deaths, 28% of patients had a cTnI concentration greater than the threshold and no interventions were deemed possible. CONCLUSIONS In an attempt to evolve from risk to management stratification, this study's results identified a subgroup of patients with mild cardiac dysfunction and a cTnI concentration greater than the threshold who could be the target for interventions in future validation studies concerning changes in patient management.
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Affiliation(s)
- Sophie Provenchère
- Département d'Anesthésie-Réanimation, APHP, Hôpital Bichat-Claude Bernard, Paris, France; Institut National de la Santé et de la Recherche Médicale, Centre d'Investigation Clinique 1425, APHP, Hôpital Bichat-Claude Bernard, Paris, France.
| | - Jean Guglielminotti
- Département d'Anesthésie-Réanimation, APHP, Hôpital Bichat-Claude Bernard, Paris, France; Institut National de la Santé et de la Recherche Médicale, UMR 1137, IAME, Paris, France; Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Aurélie Gouel-Chéron
- Département d'Anesthésie-Réanimation, APHP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Edouard Bresson
- Département d'Anesthésie-Réanimation, APHP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Laetitia Desplanque
- Département d'Anesthésie-Réanimation, APHP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Claire Bouleti
- Département de Cardiologie, DHU FIRE, APHP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Bernard Iung
- Département de Cardiologie, DHU FIRE, APHP, Hôpital Bichat-Claude Bernard, Paris, France; Université Paris 7-Diderot, Paris, France; Institut National de la Santé et de la Recherche Médicale 1148, Paris, France
| | - Philippe Montravers
- Département d'Anesthésie-Réanimation, APHP, Hôpital Bichat-Claude Bernard, Paris, France; Université Paris 7-Diderot, Paris, France
| | - Monique Dehoux
- Département de Biochimie Métabolique et Cellulaire, APHP, Hôpital Bichat-Claude Bernard, Paris, France; Institut National de la Santé et de la Recherche Médicale 1152, Paris, France
| | - Dan Longrois
- Département d'Anesthésie-Réanimation, APHP, Hôpital Bichat-Claude Bernard, Paris, France; Université Paris 7-Diderot, Paris, France; Institut National de la Santé et de la Recherche Médicale 1148, Paris, France
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Stawiarski K, Mookadam F, Ramakrishna H. The Increasing Perioperative Impact of Natriuretic Peptides on Cardiovascular Outcomes. J Cardiothorac Vasc Anesth 2018; 33:2065-2069. [PMID: 30269890 DOI: 10.1053/j.jvca.2018.08.200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Kristin Stawiarski
- Department of Internal Medicine, Yale New Haven Health System, Bridgeport, CT
| | - Farouk Mookadam
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Scottsdale, AZ.
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Krichevskiy LA, Kozlov IA. Natriuretic Peptides in Cardiac Anesthesia and Intensive Care. J Cardiothorac Vasc Anesth 2018; 33:1407-1419. [PMID: 30228053 DOI: 10.1053/j.jvca.2018.08.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Indexed: 01/16/2023]
Abstract
Natriuretic peptides, predominantly B-type, are widely used in cardiology as prognostic and diagnostic biomarkers or, much less often, as a substantive treatment tool. They are hormones that are produced mainly in the myocardium in response to overload and ischemia, and their level quite accurately reflects the degree of myocardial dysfunction. Although their use in cardiac anesthesia and intensive care setting seems to be very beneficial for assessing the risk of acute disturbance of myocardial function or its laboratory monitoring, the actual significance of natriuretic peptides in this area is not yet recognized. This is due to the lack of clear diagnostic and prognostic values for these biomarkers supported by high-quality researches. On the basis of the available data, main advantages, existing difficulties, and most effective ways of using natriuretic peptides for determining the risk of heart surgery and assessing the severity of sepsis, pneumonia, and other critical conditions have been discussed in this review. In addition, the expediency of using natriuretic peptides as target parameters for goal-oriented therapy and as a substantive tool for treatment is considered.
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Affiliation(s)
- Lev A Krichevskiy
- Department of Anesthesiology and Intensive Care, City Clinical Hospital n.a. S.S.Yudin, Department of Health of Moscow, Moscow, Russia.
| | - Igor A Kozlov
- Department of Anaesthesiology, Moscow Regional Research Clinical Institute n.a. M.F. Vladimirskiy, Moscow, Russia
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