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Yang X, Zhu L, Pan H, Yang Y. Cardiopulmonary bypass associated acute kidney injury: better understanding and better prevention. Ren Fail 2024; 46:2331062. [PMID: 38515271 PMCID: PMC10962309 DOI: 10.1080/0886022x.2024.2331062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/11/2024] [Indexed: 03/23/2024] Open
Abstract
Cardiopulmonary bypass (CPB) is a common technique in cardiac surgery but is associated with acute kidney injury (AKI), which carries considerable morbidity and mortality. In this review, we explore the range and definition of CPB-associated AKI and discuss the possible impact of different disease recognition methods on research outcomes. Furthermore, we introduce the specialized equipment and procedural intricacies associated with CPB surgeries. Based on recent research, we discuss the potential pathogenesis of AKI that may result from CPB, including compromised perfusion and oxygenation, inflammatory activation, oxidative stress, coagulopathy, hemolysis, and endothelial damage. Finally, we explore current interventions aimed at preventing and attenuating renal impairment related to CPB, and presenting these measures from three perspectives: (1) avoiding CPB to eliminate the fundamental impact on renal function; (2) optimizing CPB by adjusting equipment parameters, optimizing surgical procedures, or using improved materials to mitigate kidney damage; (3) employing pharmacological or interventional measures targeting pathogenic factors.
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Affiliation(s)
- Xutao Yang
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - Li Zhu
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
- The Jinhua Affiliated Hospital of Zhejiang University School of Medicine, Yiwu, China
| | - Hong Pan
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - Yi Yang
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
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2
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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; 56:2983-2989. [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] [MESH Headings] [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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Hisham M, Ghalib HH, Kakar V, Kumar GP, Bader F, Atallah B. Anticoagulation practices and complications associated with Impella® support at an advanced cardiac center in the Middle East gulf region. J Thromb Thrombolysis 2023:10.1007/s11239-023-02807-9. [PMID: 37097552 DOI: 10.1007/s11239-023-02807-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2023] [Indexed: 04/26/2023]
Abstract
Anticoagulation during Impella® support is a challenge due to its complications and inconsistent practice across the globe. This observational, retrospective chart review included all patients with Impella® support at our advanced cardiac center at a quaternary care hospital in the Middle East gulf region. The study was conducted over six years (2016-2022), a time period during which manufacturer recommendations for purge solution, anticoagulation protocols as well as Impella® place in therapy and utilization were all evolving. We aimed to evaluate the efficacy of different anticoagulation practices and association with complications and outcomes. Forty-one patients underwent Impella® during the study period, including 25 patients with support for more than 12 h, and are the focus of our analysis. Cardiogenic shock (n = 25, 60.9%) was the primary indication for Impella®, followed by facilitating high-risk PCI (n = 15, 36.7%) and left ventricular afterload reduction in patients undergoing veno-arterial extracorporeal membrane oxygenation (n = 1, 2.4%). Our overall Impella® usage evolved over the years from a primary use to facilitate a high-risk PCI to the recent more common use of LV unloading in cardiogenic shock. No patients experienced device malfunction and the incidence of other complications including ischemic stroke and bleeding were comparable to those reported in the literature (12.2% and 24% respectively). The 30-day all-cause mortality of 41 patients was 53.6%. In line with the evolving recommendations and evidence, we observed an underutilization of non-heparin-based purge solutions and inconsistent management of anticoagulation in the setting of both Impella® and VA ECMO which necessitates more education and protocols.
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Affiliation(s)
- Mohamed Hisham
- Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Al Maryah Island, PO Box 112412, Abu Dhabi, UAE
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Hussam H Ghalib
- Cleveland Clinic Abu Dhabi, Heart and Vascular Institute, Al Maryah Island, PO Box 112412, Abu Dhabi, UAE
| | - Vivek Kakar
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, PO Box 112412, Abu Dhabi, UAE
| | - G Praveen Kumar
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, PO Box 112412, Abu Dhabi, UAE
| | - Feras Bader
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
- Cleveland Clinic Abu Dhabi, Heart and Vascular Institute, Al Maryah Island, PO Box 112412, Abu Dhabi, UAE
| | - Bassam Atallah
- Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, Al Maryah Island, PO Box 112412, Abu Dhabi, UAE.
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.
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4
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Jing H, Liao M, Tang S, Lin S, Ye L, Zhong J, Wang H, Zhou J. Predicting the risk of acute kidney injury after cardiopulmonary bypass: development and assessment of a new predictive nomogram. BMC Anesthesiol 2022; 22:379. [PMID: 36476178 PMCID: PMC9727998 DOI: 10.1186/s12871-022-01925-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common and severe complication of cardiac surgery with cardiopulmonary bypass (CPB). This study aimed to establish a model to predict the probability of postoperative AKI in patients undergoing cardiac surgery with CPB. METHODS We conducted a retrospective, multicenter study to analyze 1082 patients undergoing cardiac surgery under CPB. The least absolute shrinkage and selection operator regression model was used to optimize feature selection for the AKI model. Multivariable logistic regression analysis was applied to build a prediction model incorporating the feature selected in the previously mentioned model. Finally, we used multiple methods to evaluate the accuracy and clinical applicability of the model. RESULTS Age, gender, hypertension, CPB duration, intraoperative 5% bicarbonate solution and red blood cell transfusion, urine volume were identified as important factors. Then, these risk factors were created into nomogram to predict the incidence of AKI after cardiac surgery under CPB. CONCLUSION We developed a nomogram to predict the incidence of AKI after cardiac surgery. This model can be used as a reference tool for evaluating early medical intervention to prevent postoperative AKI.
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Affiliation(s)
- Huan Jing
- grid.413107.0The Third Affiliated Hospital of Southern Medical University, 183 Zhongshan Avenue West, Tianhe District, Guangdong Province Guangzhou City, China
| | - Meijuan Liao
- grid.452881.20000 0004 0604 5998The First People’s Hospital of Foshan, 81 Lingnan Avenue, Chancheng District, Guangdong Province Foshan City, China
| | - Simin Tang
- grid.413107.0The Third Affiliated Hospital of Southern Medical University, 183 Zhongshan Avenue West, Tianhe District, Guangdong Province Guangzhou City, China
| | - Sen Lin
- grid.452881.20000 0004 0604 5998The First People’s Hospital of Foshan, 81 Lingnan Avenue, Chancheng District, Guangdong Province Foshan City, China
| | - Li Ye
- grid.452881.20000 0004 0604 5998The First People’s Hospital of Foshan, 81 Lingnan Avenue, Chancheng District, Guangdong Province Foshan City, China
| | - Jiying Zhong
- grid.452881.20000 0004 0604 5998The First People’s Hospital of Foshan, 81 Lingnan Avenue, Chancheng District, Guangdong Province Foshan City, China
| | - Hanbin Wang
- grid.452881.20000 0004 0604 5998The First People’s Hospital of Foshan, 81 Lingnan Avenue, Chancheng District, Guangdong Province Foshan City, China
| | - Jun Zhou
- grid.413107.0The Third Affiliated Hospital of Southern Medical University, 183 Zhongshan Avenue West, Tianhe District, Guangdong Province Guangzhou City, China
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Chen JJ, Lee TH, Kuo G, Huang YT, Chen PR, Chen SW, Yang HY, Hsu HH, Hsiao CC, Yang CH, Lee CC, Chen YC, Chang CH. Strategies for post-cardiac surgery acute kidney injury prevention: A network meta-analysis of randomized controlled trials. Front Cardiovasc Med 2022; 9:960581. [PMID: 36247436 PMCID: PMC9555275 DOI: 10.3389/fcvm.2022.960581] [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: 06/03/2022] [Accepted: 09/12/2022] [Indexed: 12/05/2022] Open
Abstract
Objects Cardiac surgery is associated with acute kidney injury (AKI). However, the effects of various pharmacological and non-pharmacological strategies for AKI prevention have not been thoroughly investigated, and their effectiveness in preventing AKI-related adverse outcomes has not been systematically evaluated. Methods Studies from PubMed, Embase, and Medline and registered trials from published through December 2021 that evaluated strategies for preventing post-cardiac surgery AKI were identified. The effectiveness of these strategies was assessed through a network meta-analysis (NMA). The secondary outcomes were prevention of dialysis-requiring AKI, mortality, intensive care unit (ICU) length of stay (LOS), and hospital LOS. The interventions were ranked using the P-score method. Confidence in the results of the NMA was assessed using the Confidence in NMA (CINeMA) framework. Results A total of 161 trials (involving 46,619 participants) and 53 strategies were identified. Eight pharmacological strategies {natriuretic peptides [odds ratio (OR): 0.30, 95% confidence interval (CI): 0.19-0.47], nitroprusside [OR: 0.29, 95% CI: 0.12-0.68], fenoldopam [OR: 0.36, 95% CI: 0.17-0.76], tolvaptan [OR: 0.35, 95% CI: 0.14-0.90], N-acetyl cysteine with carvedilol [OR: 0.37, 95% CI: 0.16-0.85], dexmedetomidine [OR: 0.49, 95% CI: 0.32-0.76;], levosimendan [OR: 0.56, 95% CI: 0.37-0.84], and erythropoietin [OR: 0.62, 95% CI: 0.41-0.94]} and one non-pharmacological intervention (remote ischemic preconditioning, OR: 0.76, 95% CI: 0.63-0.92) were associated with a lower incidence of post-cardiac surgery AKI with moderate to low confidence. Among these nine strategies, five (fenoldopam, erythropoietin, natriuretic peptides, levosimendan, and remote ischemic preconditioning) were associated with a shorter ICU LOS, and two (natriuretic peptides [OR: 0.30, 95% CI: 0.15-0.60] and levosimendan [OR: 0.68, 95% CI: 0.49-0.95]) were associated with a lower incidence of dialysis-requiring AKI. Natriuretic peptides were also associated with a lower risk of mortality (OR: 0.50, 95% CI: 0.29-0.86). The results of a sensitivity analysis support the robustness and effectiveness of natriuretic peptides and dexmedetomidine. Conclusion Nine potentially effective strategies were identified. Natriuretic peptide therapy was the most effective pharmacological strategy, and remote ischemic preconditioning was the only effective non-pharmacological strategy. Preventive strategies might also help prevent AKI-related adverse outcomes. Additional studies are required to explore the optimal dosages and protocols for potentially effective AKI prevention strategies.
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Affiliation(s)
- Jia-Jin Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | | | - George Kuo
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yen-Ta Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Rung Chen
- Department of Anesthesiology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shao-Wei Chen
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Huang-Yu Yang
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hsiang-Hao Hsu
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ching-Chung Hsiao
- Department of Nephrology, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Chia-Hung Yang
- Department of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Cheng-Chia Lee
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yung-Chang Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
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Preservation of Renal Function. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00017-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Elitok S, Kuppe H, Devarajan P, Bellomo R, Isermann B, Westphal S, Kube J, Albert C, Ernst M, Kropf S, Haase-Fielitz A, Haase M. Urinary Neutrophil Gelatinase-Associated Lipocalin/Hepcidin-25 Ratio for Early Identification of Patients at Risk for Renal Replacement Therapy After Cardiac Surgery: A Substudy of the BICARBONATE Trial. Anesth Analg 2021; 133:1510-1519. [PMID: 34543256 DOI: 10.1213/ane.0000000000005741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Acute kidney injury requiring renal replacement therapy (AKI-RRT) is strongly associated with mortality after cardiac surgery; however, options for early identification of patients at high risk for AKI-RRT are extremely limited. Early after cardiac surgery, the predictive ability for AKI-RRT even of one of the most extensively evaluated novel urinary biomarkers, neutrophil gelatinase-associated lipocalin (NGAL), appears to be only moderate. We aimed to determine whether the NGAL/hepcidin-25 ratio (urinary concentrations of NGAL divided by that of hepcidin-25) early after surgery may compare favorably to NGAL for identification of high-risk patients after cardiac surgery. METHODS This is a prospective substudy of the BICARBONATE trial, a multicenter parallel-randomized controlled trial comparing perioperative bicarbonate infusion for AKI prevention to usual patient care. At a tertiary referral center, 198 patients at increased kidney risk undergoing cardiac surgery with cardiopulmonary bypass were included into the present study. The primary outcome measure was defined as AKI-RRT. Secondary outcomes were in-hospital mortality and long-term mortality. We compared area under the curve of the receiver operating characteristic (AUC-ROC) of urinary NGAL with that of the urinary NGAL/hepcidin-25 ratio within 60 minutes after end of surgery. We compared adjusted AUC and performed cross-validated reclassification statistics of the (logarithmic) urinary NGAL/hepcidin-25 ratio adjusted to Cleveland risk score/EuroScore, cross-clamp time, age, volume of packed red blood cells, and (logarithmic) urinary NGAL concentration. The association of the NGAL/hepcidin-25 ratio with long-term patient survival was assessed using Cox proportional hazard regression analysis adjusting for EuroScore, aortic cross-clamp time, packed red blood cells and urinary NGAL. RESULTS Patients with AKI-RRT (n = 13) had 13.7-times higher NGAL and 3.3-times lower hepcidin-25 concentrations resulting in 46.9-times higher NGAL/hepcidin-25 ratio early after surgery compared to patients without AKI-RRT. The NGAL/hepcidin-25 ratio had higher AUC-ROC compared with NGAL for risk of AKI-RRT and in-hospital mortality (unadjusted AUC-ROC difference 0.087, 95% confidence interval [CI], 0.036-0.138, P < .001; 0.082, 95% CI, 0.018-0.146, P = .012). For AKI-RRT, the NGAL/hepcidin-25 ratio increased adjusted category-free net reclassification improvement (cfNRI; 0.952, 95% CI, 0.437-1.468; P < .001) and integrated discrimination improvement (IDI; 0.040, 95% CI, 0.008-0.073; P = .016) but not AUC difference. For in-hospital mortality, the ratio improved AUC of the reference model (AUC difference 0.056, 95% CI, 0.003-0.108; P = .037) and cfNRI but not IDI. The urinary NGAL/hepcidin-25 ratio remained significantly associated with long-term mortality after adjusting for the model covariates. CONCLUSIONS The urinary NGAL/hepcidin-25 ratio appears to early identify high-risk patients and outperform NGAL after cardiac surgery. Confirmation of our findings in other cardiac surgery centers is now needed.
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Affiliation(s)
- Saban Elitok
- From the Department of Nephrology and Endocrinology, Ernst von Bergmann Hospital Potsdam, Potsdam, Germany
| | - Hermann Kuppe
- Institute of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine, German Heart Center Berlin & Charité-University Medicine Berlin, Berlin, Germany
| | - Prasad Devarajan
- Department of Nephrology and Hypertension, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia.,Department of Integrated Critical Care, Center for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Berend Isermann
- Department of Laboratory Medicine, Institute of Laboratory Medicine, Clinical Chemistry, and Molecular Diagnostic, Leipzig University Hospital, Leipzig, Germany
| | - Sabine Westphal
- Department of Laboratory Medicine, Institute of Laboratory Medicine, Tertiary Hospital Dessau, Dessau-Roßlau, Germany
| | - Johanna Kube
- Department of Anesthesiology and Intensive Care, Helios Klinikum Leisnig, Leisnig, Germany
| | - Christian Albert
- Diaverum Renal Care Center, Potsdam, Germany.,Medical Faculty, University Clinic for Cardiology and Angiology
| | - Martin Ernst
- From the Department of Nephrology and Endocrinology, Ernst von Bergmann Hospital Potsdam, Potsdam, Germany.,Medical Faculty
| | - Siegfried Kropf
- Medical Faculty, Institute for Biometrics and Medical Informatics, Otto von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Anja Haase-Fielitz
- Brandenburg Medical School Theodor Fontane, Neuruppin, Germany.,Faculty of Health Sciences Brandenburg, Potsdam, Germany.,Institute of Integrated Health Care Systems Research & Social Medicine, Otto von-Guericke-University Magdeburg, Magdeburg, Germany.,Department of Cardiology, Brandenburg Heart Center, Immanuel Hospital, Bernau, Germany
| | - Michael Haase
- Department of Anesthesiology and Intensive Care, Helios Klinikum Leisnig, Leisnig, Germany.,Medical Faculty
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Elitok S, Isermann B, Westphal S, Devarajan P, Albert C, Kuppe H, Ernst M, Bellomo R, Haase M, Haase-Fielitz A. Urinary biomarkers to predict severe fluid overload after cardiac surgery: a pilot study. Biomark Med 2021; 15:1451-1464. [PMID: 34672680 DOI: 10.2217/bmm-2021-0283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Aim: To assess the predictive ability of urinary and plasma biomarkers and clinical routine parameters for subsequent severe fluid overload. Patients & methods: In a pilot study, we studied 100 adult patients after cardiac surgery. On intensive care unit admission, we measured biomarkers in urine (midkine, IL-6, neutrophil gelatinase-associated lipocalin [NGAL], hepcidin-25) and plasma (creatinine, urea, B-type natriuretic peptide, lactate, C-reactive protein, leukocytes, IL-6, NGAL, hepcidin-25) to predict postoperative severe fluid overload. Results: Urinary midkine, IL-6, NGAL and hepcidin-25 (all AUCs ≥0.79) predicted postoperative severe fluid overload (n = 5 patients). Urinary NGAL/hepcidin-25 ratio (AUC 0.867) predicted postoperative severe fluid overload after adjustment to EuroScore and need for norepinephrine on surgery day (odds ratio: 2.4). Conclusion: Urinary biomarkers on intensive care unit admission might be helpful to predict subsequent severe fluid overload after cardiac surgery.
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Affiliation(s)
- Saban Elitok
- Department of Nephrology & Endocrinology, Ernst von Bergmann Hospital Potsdam, Charlottenstr. 72, Potsdam, 14467, Germany
| | - Berend Isermann
- Institute of Laboratory Medicine, Leipzig University Hospital, Paul-List-Str. 13/15, Leipzig, 04103, Germany
| | - Sabine Westphal
- Institute of Laboratory Medicine, Tertiary Hospital Dessau, Auenweg 38, Dessau-Roßlau, 06847, Germany
| | - Prasad Devarajan
- Department of Nephrology & Hypertension, Cincinnati Children's Hospital, 3333 Burnet Ave, Cincinnati, OH 45229, USA
| | - Christian Albert
- Diaverum Renal Care Center, Am Neuen Garten 11, 14469 Potsdam, Germany & Diaverum AB, Hyllie Boulevard 35, Malmö, 21532, Sweden.,Medical Faculty, University Clinic for Cardiology & Angiology, Otto von-Guericke-University Magdeburg, Leipziger Str. 44, Magdeburg, 39120, Germany
| | - Hermann Kuppe
- Institute of Anesthesiology, German Heart Center, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Martin Ernst
- Department of Nephrology & Endocrinology, Ernst von Bergmann Hospital Potsdam, Charlottenstr. 72, Potsdam, 14467, Germany.,Medical Faculty, Otto von-Guericke-University Magdeburg, Leipziger Str. 44, Magdeburg, 39120, Germany
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, 145 Studley Rd, Heidelberg VIC 3084, Melbourne, Australia.,Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Australia
| | - Michael Haase
- Diaverum Renal Care Center, Am Neuen Garten 11, 14469 Potsdam, Germany & Diaverum AB, Hyllie Boulevard 35, Malmö, 21532, Sweden.,Medical Faculty, Otto von-Guericke-University Magdeburg, Leipziger Str. 44, Magdeburg, 39120, Germany
| | - Anja Haase-Fielitz
- Department of Cardiology, Brandenburg Heart Center, Immanuel Hospital, Ladeburger Str. 17, Bernau, 16321, Germany.,Brandenburg Medical School Theodor Fontane, Fehrbelliner Str. 38, Neuruppin, 16816, Germany.,Faculty of Health Sciences Brandenburg, University of Potsdam, Potsdam, Germany.,Institute of Social Medicine & Health Care Systems Research, Otto von-Guericke-University Magdeburg, Leipziger Str. 44, Magdeburg, 39120, Germany
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9
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Albert C, Haase M, Albert A, Ernst M, Kropf S, Bellomo R, Westphal S, Braun-Dullaeus RC, Haase-Fielitz A, Elitok S. Predictive Value of Plasma NGAL:Hepcidin-25 for Major Adverse Kidney Events After Cardiac Surgery with Cardiopulmonary Bypass: A Pilot Study. Ann Lab Med 2021; 41:357-365. [PMID: 33536353 PMCID: PMC7884201 DOI: 10.3343/alm.2021.41.4.357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/14/2020] [Accepted: 01/13/2021] [Indexed: 12/23/2022] Open
Abstract
Background Neutrophil gelatinase-associated lipocalin (NGAL) and hepcidin-25 are involved in catalytic iron-related kidney injury after cardiac surgery with cardiopulmonary bypass. We explored the predictive value of plasma NGAL, plasma hepcidin-25, and the plasma NGAL:hepcidin-25 ratio for major adverse kidney events (MAKE) after cardiac surgery. Methods We compared the predictive value of plasma NGAL, hepcidin-25, and plasma NGAL:hepcidin-25 with that of serum creatinine (Cr) and urinary output and protein for primary-endpoint MAKE (acute kidney injury [AKI] stages 2 and 3, persistent AKI >48 hours, acute dialysis, and in-hospital mortality) and secondary-endpoint AKI in 100 cardiac surgery patients at intensive care unit (ICU) admission. We performed ROC curve, logistic regression, and reclassification analyses. Results At ICU admission, plasma NGAL, plasma NGAL:hepcidin-25, plasma interleukin-6, and Cr predicted MAKE (area under the ROC curve [AUC]: 0.77, 0.79, 0.74, and 0.74, respectively) and AKI (0.73, 0.89, 0.70, and 0.69). For AKI prediction, plasma NGAL:hepcidin-25 had a higher discriminatory power than Cr (AUC difference 0.26 [95% CI 0.00-0.53]). Urinary output and protein, plasma lactate, C-reactive protein, creatine kinase myocardial band, and brain natriuretic peptide did not predict MAKE or AKI (AUC <0.70). Only plasma NGAL:hepcidin-25 correctly reclassified patients according to their MAKE and AKI status (category-free net reclassification improvement: 0.82 [95% CI 0.12-1.52], 1.03 [0.29-1.77]). After adjustment to the Cleveland risk score, plasma NGAL:hepcidin-25 ≥0.9 independently predicted MAKE (adjusted odds ratio 16.34 [95% CI 1.77-150.49], P=0.014). Conclusions Plasma NGAL:hepcidin-25 is a promising marker for predicting postoperative MAKE.
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Affiliation(s)
- Christian Albert
- Medical Faculty, University Clinic for Cardiology and Angiology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany.,Diaverum Renal Services, MVZ Potsdam, Potsdam, Germany
| | - Michael Haase
- Diaverum Renal Services, MVZ Potsdam, Potsdam, Germany.,Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Annemarie Albert
- Diaverum Renal Services, MVZ Potsdam, Potsdam, Germany.,Department of Nephrology and Endocrinology, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Martin Ernst
- Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg, Germany.,Department of Nephrology and Endocrinology, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Siegfried Kropf
- Institute for Biometrics and Medical Informatics, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Rinaldo Bellomo
- Department of Intensive Care, The Austin Hospital, Melbourne, Australia.,Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Australia
| | - Sabine Westphal
- Institute of Laboratory Medicine, Hospital Dessau, Dessau, Germany
| | - Rüdiger C Braun-Dullaeus
- Medical Faculty, University Clinic for Cardiology and Angiology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Anja Haase-Fielitz
- Department of Cardiology, Immanuel Diakonie Bernau, Heart Center Brandenburg, Brandenburg Medical School Theodor Fontane, MHB, Germany.,Institute of Social Medicine and Health Systems Research, Otto-von-Guericke University Magdeburg, Magdeburg, Germany.,Faculty of Health Sciences Brandenburg, Potsdam, Germany
| | - Saban Elitok
- Department of Nephrology and Endocrinology, Klinikum Ernst von Bergmann, Potsdam, Germany
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10
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Elitok S, Devarajan P, Bellomo R, Isermann B, Haase M, Haase-Fielitz A. NGAL/hepcidin-25 ratio and AKI subtypes in patients following cardiac surgery: a prospective observational study. J Nephrol 2021; 35:597-605. [PMID: 34028701 PMCID: PMC8926978 DOI: 10.1007/s40620-021-01063-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/09/2021] [Indexed: 11/25/2022]
Abstract
Background Acute kidney injury (AKI) subtypes combining kidney functional parameters and injury biomarkers may have prognostic value. We aimed to determine whether neutrophil gelatinase-associated lipocalin (NGAL)/hepcidin-25 ratio (urinary concentrations of NGAL divided by that of hepcidin-25) defined subtypes are of prognostic relevance in cardiac surgery patients. Methods We studied 198 higher-risk cardiac surgery patients. We allocated patients to four groups: Kidney Disease Improving Global Outcomes (KDIGO)-AKI-negative and NGAL/hepcidin-25 ratio-negative (no AKI), KDIGO AKI-negative and NGAL/hepcidin-25 ratio-positive (subclinical AKI), KDIGO AKI-positive and NGAL/hepcidin-25 ratio-negative (clinical AKI), KDIGO AKI-positive and NGAL/hepcidin-25 ratio-positive (combined AKI). Outcomes included in-hospital mortality (primary) and long-term mortality (secondary). Results We identified 127 (61.6%) patients with no AKI, 13 (6.6%) with subclinical, 40 (20.2%) with clinical and 18 (9.1%) with combined AKI. Subclinical AKI patients had a 23-fold greater in-hospital mortality than no AKI patients. For combined AKI vs. no AKI or clinical AKI, findings were stronger (odds ratios (ORs): 126 and 39, respectively). After adjusting for EuroScore, volume of intraoperative packed red blood cells, and aortic cross-clamp time, subclinical and combined AKI remained associated with greater in-hospital mortality than no AKI and clinical AKI (adjusted ORs: 28.118, 95% CI 1.465–539.703; 3.737, 95% CI 1.746–7.998). Cox proportional hazard models found a significant association of biomarker-informed AKI subtypes with long-term survival compared with no AKI (adjusted ORs: pooled subclinical and clinical AKI: 1.885, 95% CI 1.003–3.542; combined AKI: 1.792, 95% CI 1.367–2.350). Conclusions In the presence or absence of KDIGO clinical criteria for AKI, the urinary NGAL/hepcidin-25-ratio appears to detect prognostically relevant AKI subtypes. Trial registration number NCT00672334, clinicaltrials.gov, date of registration: 6th May 2008, https://clinicaltrials.gov/ct2/show/NCT00672334. Graphic abstract ![]()
Definition of AKI subtypes: subclinical AKI (KDIGO negative AND Ratio-positive), clinical AKI (KDIGO positive AND Ratio-negative) and combined AKI (KDIGO positive AND Ratio-positive) with urinary NGAL/hepcidin-25 ratio-positive cut-off at 85% specificity for in-hospital death. AKI, acute kidney injury. AUC, area under the curve. NGAL, neutrophil gelatinase-associated lipocalin. KDIGO, Kidney Disease Improving Global Outcomes Initiative AKI definition. Supplementary Information The online version contains supplementary material available at 10.1007/s40620-021-01063-5.
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Affiliation(s)
- Saban Elitok
- Department of Nephrology and Endocrinology, Ernst Von Bergmann Hospital Potsdam, 14467, Potsdam, Germany
| | - Prasad Devarajan
- Department of Nephrology and Hypertension, Cincinnati Children's Hospital, Cincinnati, OH, 45229, USA
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Parkville, Melbourne, VIC, 3052, Australia.,Department of Intensive Care, Austin Health, Heidelberg, Melbourne, VIC, 3084, Australia.,Center for Integrated Critical Care, The University of Melbourne, Melbourne, Australia
| | - Berend Isermann
- Institute of Laboratory Medicine, Clinical Chemistry, and Molecular Diagnostic, Leipzig University Hospital, 04103, Leipzig, Germany
| | - Michael Haase
- Diaverum AB, Renal Care Center Potsdam, 21532, Malmö, Sweden. .,Medical Faculty, Otto Von-Guericke-University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany.
| | - Anja Haase-Fielitz
- Brandenburg Medical School Theodor Fontane, 16816, Neuruppin, Germany.,Faculty of Health Sciences Brandenburg, Potsdam, Germany.,Institute of Integrated Health Care Systems Research and Social Medicine, Otto Von-Guericke-University Magdeburg, 39120, Magdeburg, Germany.,Department of Cardiology, Brandenburg Heart Center, Immanuel Hospital, 16321, Bernau, Germany
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11
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Abstract
To characterize current evidence and current foci of perioperative clinical trials, we systematically reviewed Medline and identified perioperative trials involving 100 or more adult patients undergoing surgery and reporting renal end points that were published in high-impact journals since 2004. We categorized the 101 trials identified based on the nature of the intervention and summarized major trial findings from the five categories most applicable to perioperative management of patients. Trials that targeted ischemia suggested that increasing perioperative renal oxygen delivery with inotropes or blood transfusion does not reliably mitigate acute kidney injury (AKI), although goal-directed therapy with hemodynamic monitors appeared beneficial in some trials. Trials that have targeted inflammation or oxidative stress, including studies of nonsteroidal anti-inflammatory drugs, steroids, N-acetylcysteine, and sodium bicarbonate, have not shown renal benefits, and high-dose perioperative statin treatment increased AKI in some patient groups in two large trials. Balanced crystalloid intravenous fluids appear safer than saline, and crystalloids appear safer than colloids. Liberal compared with restrictive fluid administration reduced AKI in a recent large trial in open abdominal surgery. Remote ischemic preconditioning, although effective in several smaller trials, failed to reduce AKI in two larger trials. The translation of promising preclinical therapies to patients undergoing surgery remains poor, and most interventions that reduced perioperative AKI compared novel surgical management techniques or existing processes of care rather than novel pharmacologic interventions.
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Affiliation(s)
- David R McIlroy
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Marcos G Lopez
- Division of Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Frederic T Billings
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN; Division of Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
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12
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Coppola S, Caccioppola A, Froio S, Chiumello D. Sodium Bicarbonate in Different Critically Ill Conditions: From Physiology to Clinical Practice. Anesthesiology 2021; 134:774-783. [PMID: 33721887 DOI: 10.1097/aln.0000000000003733] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Intravenous sodium bicarbonate is commonly used in several critically ill conditions for the management of acute acidemia independently of the etiology, and for the prevention of acute kidney injury, although this is still controversial from a physiologic point of view.
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13
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Afzal G, Ansari Aval Z, Beheshti Monfared M, Khesali H, Ziaie S, Barati S, Dastan F. Evaluating the Effect of Acetazolamide on the Prevention of Post-operative Acute Kidney Injury after Coronary Artery Bypass Grafting Surgery: A Randomized, Open-labeled Clinical Trial. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH : IJPR 2021; 20:71-79. [PMID: 35194429 PMCID: PMC8842620 DOI: 10.22037/ijpr.2021.115334.15323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Acute kidney injury (AKI) is a common complication after coronary artery bypass grafting (CABG) surgery and can be linked to the increased morbidity and mortality. Therefore, in the present study, the effect of preoperative administration of acetazolamide was evaluated to investigate whether it could prevent occurrence of post-operative AKI after CABG surgery. In this randomized controlled clinical trial, 130 patients who were candidates to undergo elective CABG surgery from January 21, 2020 to February 8, 2021 were randomly allocated to intervention group (receiving 500 mg of acetazolamide orally 2 h preoperatively) and control group. The patients were evaluated for AKI based on the kidney disease- improving global outcomes (KDIGO) criteria based on their serum creatinine (SCr) level and urine output until 7 days postoperatively. There was no significant difference in baseline demographics between the two groups. The total incidence of AKI was measured as 43%. Analysis of post-operative AKI incidence showed no statistically significant difference between the two groups (P = 0.860). Mean post-operative SCr level on day 1 was significantly higher in the acetazolamide group (P = 0.036). A significant difference was found in length of hospitalization stay between the groups, which was higher in the control group (P = 0.006). Our results did not demonstrate a significant protective effect of acetazolamide on incidence of post-operative AKI in the patients undergone elective on-pump CABG surgery.
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Affiliation(s)
- Golnaz Afzal
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Zahra Ansari Aval
- Clinical Research and Development Center at Shahid Modarress Hospital, Department of Cardiac Surgery, Shahid Beheshti of Medical Sciences, Tehran, Iran.
| | - Mahmoud Beheshti Monfared
- Department of Cardiovascular Surgery, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Hamed Khesali
- Department of Cardiovascular Surgery, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Shadi Ziaie
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran. ,Department of Nephrology and Kidney Transplantation, Shahid Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Saghar Barati
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Farzaneh Dastan
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran. ,Chronic Respiratory Diseases Research center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Corresponding author: E-mail:
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14
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Molinari L, Sakhuja A, Kellum JA. Perioperative Renoprotection: General Mechanisms and Treatment Approaches. Anesth Analg 2020; 131:1679-1692. [PMID: 33186157 DOI: 10.1213/ane.0000000000005107] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In the perioperative setting, acute kidney injury (AKI) is a frequent complication, and AKI itself is associated with adverse outcomes such as higher risk of chronic kidney disease and mortality. Various risk factors are associated with perioperative AKI, and identifying them is crucial to early interventions addressing modifiable risk and increasing monitoring for nonmodifiable risk. Different mechanisms are involved in the development of postoperative AKI, frequently picturing a multifactorial etiology. For these reasons, no single renoprotective strategy will be effective for all surgical patients, and efforts have been attempted to prevent kidney injury in different ways. Some renoprotective strategies and treatments have proven to be useful, some are no longer recommended because they are ineffective or even harmful, and some strategies are still under investigation to identify the best timing, setting, and patients for whom they could be beneficial. With this review, we aim to provide an overview of recent findings from studies examining epidemiology, risk factors, and mechanisms of perioperative AKI, as well as different renoprotective strategies and treatments presented in the literature.
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Affiliation(s)
- Luca Molinari
- From the Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Dipartimento di Medicina Traslazionale, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - Ankit Sakhuja
- From the Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - John A Kellum
- From the Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania
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15
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Albert C, Zapf A, Haase M, Röver C, Pickering JW, Albert A, Bellomo R, Breidthardt T, Camou F, Chen Z, Chocron S, Cruz D, de Geus HRH, Devarajan P, Di Somma S, Doi K, Endre ZH, Garcia-Alvarez M, Hjortrup PB, Hur M, Karaolanis G, Kavalci C, Kim H, Lentini P, Liebetrau C, Lipcsey M, Mårtensson J, Müller C, Nanas S, Nickolas TL, Pipili C, Ronco C, Rosa-Diez GJ, Ralib A, Soto K, Braun-Dullaeus RC, Heinz J, Haase-Fielitz A. Neutrophil Gelatinase-Associated Lipocalin Measured on Clinical Laboratory Platforms for the Prediction of Acute Kidney Injury and the Associated Need for Dialysis Therapy: A Systematic Review and Meta-analysis. Am J Kidney Dis 2020; 76:826-841.e1. [PMID: 32679151 PMCID: PMC8283708 DOI: 10.1053/j.ajkd.2020.05.015] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 05/24/2020] [Indexed: 01/02/2023]
Abstract
RATIONALE & OBJECTIVE The usefulness of measures of neutrophil gelatinase-associated lipocalin (NGAL) in urine or plasma obtained on clinical laboratory platforms for predicting acute kidney injury (AKI) and AKI requiring dialysis (AKI-D) has not been fully evaluated. We sought to quantitatively summarize published data to evaluate the value of urinary and plasma NGAL for kidney risk prediction. STUDY DESIGN Literature-based meta-analysis and individual-study-data meta-analysis of diagnostic studies following PRISMA-IPD guidelines. SETTING & STUDY POPULATIONS Studies of adults investigating AKI, severe AKI, and AKI-D in the setting of cardiac surgery, intensive care, or emergency department care using either urinary or plasma NGAL measured on clinical laboratory platforms. SELECTION CRITERIA FOR STUDIES PubMed, Web of Science, Cochrane Library, Scopus, and congress abstracts ever published through February 2020 reporting diagnostic test studies of NGAL measured on clinical laboratory platforms to predict AKI. DATA EXTRACTION Individual-study-data meta-analysis was accomplished by giving authors data specifications tailored to their studies and requesting standardized patient-level data analysis. ANALYTICAL APPROACH Individual-study-data meta-analysis used a bivariate time-to-event model for interval-censored data from which discriminative ability (AUC) was characterized. NGAL cutoff concentrations at 95% sensitivity, 95% specificity, and optimal sensitivity and specificity were also estimated. Models incorporated as confounders the clinical setting and use versus nonuse of urine output as a criterion for AKI. A literature-based meta-analysis was also performed for all published studies including those for which the authors were unable to provide individual-study data analyses. RESULTS We included 52 observational studies involving 13,040 patients. We analyzed 30 data sets for the individual-study-data meta-analysis. For AKI, severe AKI, and AKI-D, numbers of events were 837, 304, and 103 for analyses of urinary NGAL, respectively; these values were 705, 271, and 178 for analyses of plasma NGAL. Discriminative performance was similar in both meta-analyses. Individual-study-data meta-analysis AUCs for urinary NGAL were 0.75 (95% CI, 0.73-0.76) and 0.80 (95% CI, 0.79-0.81) for severe AKI and AKI-D, respectively; for plasma NGAL, the corresponding AUCs were 0.80 (95% CI, 0.79-0.81) and 0.86 (95% CI, 0.84-0.86). Cutoff concentrations at 95% specificity for urinary NGAL were>580ng/mL with 27% sensitivity for severe AKI and>589ng/mL with 24% sensitivity for AKI-D. Corresponding cutoffs for plasma NGAL were>364ng/mL with 44% sensitivity and>546ng/mL with 26% sensitivity, respectively. LIMITATIONS Practice variability in initiation of dialysis. Imperfect harmonization of data across studies. CONCLUSIONS Urinary and plasma NGAL concentrations may identify patients at high risk for AKI in clinical research and practice. The cutoff concentrations reported in this study require prospective evaluation.
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Affiliation(s)
- Christian Albert
- University Clinic for Cardiology and Angiology, Medical Faculty, Otto-von-Guericke University, Magdeburg, Germany; Diaverum Renal Services Germany, Potsdam, Germany.
| | - Antonia Zapf
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg-Eppendorf, Germany
| | - Michael Haase
- Faculty of Medicine, Otto-von-Guericke University, Magdeburg, Germany; Diaverum Renal Services Germany, Potsdam, Germany
| | - Christian Röver
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - John W Pickering
- Department of Medicine, University of Otago Christchurch; Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Annemarie Albert
- Diaverum Renal Services Germany, Potsdam, Germany; Department for Nephrology and Endocrinology, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Rinaldo Bellomo
- Department of Intensive Care, The Austin Hospital, Melbourne, Australia; Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Australia
| | - Tobias Breidthardt
- Department of Internal Medicine, University Hospital Basel, Basel, Switzerland; Department of Nephrology, University Hospital Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Fabrice Camou
- Service de réanimation médicale, hôpital Saint-André, CHU de Bordeaux, France
| | - Zhongquing Chen
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangdong, China
| | - Sidney Chocron
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Dinna Cruz
- Division of Nephrology-Hypertension, University of California, San Diego, CA
| | - Hilde R H de Geus
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, OH
| | - Salvatore Di Somma
- Emergency Medicine, Department of Medical-Surgery Sciences and Translational Medicine, Sapienza' University of Rome S. Andrea Hospital, Rome, Italy
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo, Japan
| | - Zoltan H Endre
- Department of Nephrology, Prince of Wales Hospital and Clinical School, University of New South Wales, Sydney, Australia
| | | | - Peter B Hjortrup
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mina Hur
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Georgios Karaolanis
- Vascular Unit, First Department of Surgery, "Laiko" General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Cemil Kavalci
- Emergency Department, Baskent University Faculty of Medicine, Ankara, Turkey
| | - Hanah Kim
- Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Paolo Lentini
- Department of Nephrology and Dialysis, San Bassiano Hospital, Bassano del Grappa, Italy
| | | | - Miklós Lipcsey
- CIRRUS, Hedenstierna laboratory, Anaesthesiology and Intensive care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Johan Mårtensson
- Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Christian Müller
- Department of Internal Medicine, University Hospital Basel, Basel, Switzerland; Department of Nephrology, University Hospital Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Serafim Nanas
- First Critical Care Department, 'Evangelismos' General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Thomas L Nickolas
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Chrysoula Pipili
- First Critical Care Department, 'Evangelismos' General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Claudio Ronco
- Department of Nephrology, Dialysis & Transplantation, University of Padova, Vicenza, Italy; International Renal Research Institute, San Bortolo Hospital, Vicenza, Italy
| | - Guillermo J Rosa-Diez
- Department of Nephrology, Dialysis and Transplantation, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Azrina Ralib
- Department of Anaesthesiology and Intensive Care, International Islamic University Malaysia, Pahang, Malaysia
| | - Karina Soto
- Department of Nephrology, Hospital Fernando Fonseca, Lisbon, Portugal; CEAUL, Centro de Estatística e Aplicações da Universidade de Lisboa, Lisbon, Portugal
| | - Rüdiger C Braun-Dullaeus
- University Clinic for Cardiology and Angiology, Medical Faculty, Otto-von-Guericke University, Magdeburg, Germany
| | - Judith Heinz
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Anja Haase-Fielitz
- Department of Cardiology, Immanuel Diakonie Bernau, Heart Center Brandenburg, Brandenburg Medical School Theodor Fontane, Faculty of Health Sciences, University of Potsdam, Potsdam, Germany
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16
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Weiss R, Meersch M, Pavenstädt HJ, Zarbock A. Acute Kidney Injury: A Frequently Underestimated Problem in Perioperative Medicine. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:833-842. [PMID: 31888797 DOI: 10.3238/arztebl.2019.0833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 03/20/2019] [Accepted: 10/10/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Surgical patients are getting older with increasing comorbidity. Acute kidney injury (AKI) is a commonly underesti- mated perioperative complication. 2-18% of hospitalized patients and 22-57% of patients in the intensive care unit develop AKI. Even though it has a major impact on patients' outcomes, it goes unrecognized in 57-75.6% of cases. METHODS This review is based on pertinent papers retrieved by a selective search in PubMed and the Cochrane Library employ- ing the searching terms "acute kidney injury," "biomarker," "perioperative," "renal function," and "KDIGO." RESULTS The pathophysiology of AKI is complex. Conventional biomarkers are either not specific enough (urine output) or not sensitive enough (serum creatinine) for timely diagnosis. In view of the pathophysiology of the condition and the limited treat- ment options for it, the early detection of subclinical AKI (kidney damage without functional impairment) would seem to be a reasonable first step toward the prevention of worsening or permanent renal injury. New biomarkers of damage enable the early initiation of nephroprotective interventions. According to the "Kidney Disease: Improving Global Outcomes" (KDIGO) statement, a multimodal treatment approach is needed, including, among other things, optimization of hemodynamics and the discontinu- ation of nephrotoxic drugs. CONCLUSION It is essential to identify patients at risk and sensitize the treating personnel to the implementation of the guidelines. The incorporation of new biomarkers into routine clinical practice is also reasonable and necessary. Future clinical trials must show in what form these biomarkers should be used (singly or collectively).
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Affiliation(s)
- Raphael Weiss
- Department of Anesthesiology, Intensive Care, and Pain Medicine, University Hospital Münster; Department of Internal Medicine D, General Internal Medicine, Renal and Hypertensive Dieases, and Rheumatology, University Hospital Münster
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17
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Haines RW, Kirwan CJ, Prowle JR. Managing Chloride and Bicarbonate in the Prevention and Treatment of Acute Kidney Injury. Semin Nephrol 2020; 39:473-483. [PMID: 31514911 DOI: 10.1016/j.semnephrol.2019.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Intravenous crystalloid therapy is one of the most ubiquitous aspects of hospital and critical care medicine. In recent years, there has been increasing focus on the electrolyte composition, and particularly chloride content, of crystalloid solutions. This has led to increasing clinical adoption of balanced solutions, containing substrates for bicarbonate generation and consequently a lower chloride content, in place of 0.9% saline. In this article we review the physiochemical rationale for avoidance of 0.9% saline and the effects of hyperchloremic acidosis on renal physiology. Finally, we review the current evidence and rationale for use of balanced solutions greater than 0.9% saline in acutely ill patients in a variety of clinical settings, as well as considering the role for sodium bicarbonate in preventing or correcting metabolic acidosis. In conclusion, there is a strong physiological rationale for avoidance of iatrogenic hyperchloremic acidosis from 0.9% saline administration in acutely unwell patients and an association with adverse renal outcomes in several studies. However, evidence from large definitive multicenter randomized trials is not yet available to establish the dose-relationship between 0.9% saline administration and potential harm and inform us if some 0.9% saline use is acceptable or if any exposure confers harm.
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Affiliation(s)
- Ryan W Haines
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Christopher J Kirwan
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - John R Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom; William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom.
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18
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Albert C, Haase M, Albert A, Kropf S, Bellomo R, Westphal S, Westerman M, Braun-Dullaeus RC, Haase-Fielitz A. Urinary Biomarkers may Complement the Cleveland Score for Prediction of Adverse Kidney Events After Cardiac Surgery: A Pilot Study. Ann Lab Med 2020; 40:131-141. [PMID: 31650729 PMCID: PMC6822001 DOI: 10.3343/alm.2020.40.2.131] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 07/09/2019] [Accepted: 10/08/2019] [Indexed: 12/15/2022] Open
Abstract
Background The ability of urinary biomarkers to complement established clinical risk prediction models for postoperative adverse kidney events is unclear. We assessed the effect of urinary biomarkers linked to suspected pathogenesis of cardiac surgery-induced acute kidney injury (AKI) on the performance of the Cleveland Score, a risk assessment model for postoperative adverse kidney events. Methods This pilot study included 100 patients who underwent open-heart surgery. We determined improvements to the Cleveland Score when adding urinary biomarkers measured using clinical laboratory platforms (neutrophil gelatinase-associated lipocalin [NGAL], interleukin-6) and those in the preclinical stage (hepcidin-25, midkine, alpha-1 microglobulin), all sampled immediately post-surgery. The primary endpoint was major adverse kidney events (MAKE), and the secondary endpoint was AKI. We performed ROC curve analysis, assessed baseline model performance (odds ratios [OR], 95% CI), and carried out statistical reclassification analyses to assess model improvement. Results NGAL (OR [95% CI] per 20 concentration-units wherever applicable): (1.07 [1.01–1.14]), Interleukin-6 (1.51 [1.01–2.26]), midkine (1.01 [1.00–1.02]), 1-hepcidin-25 (1.08 [1.00–1.17]), and NGAL/hepcidin-ratio (2.91 [1.30–6.49]) were independent predictors of MAKE and AKI (1.38 [1.03–1.85], 1.08 [1.01–1.15], 1.01 [1.00–1.02], 1.09 [1.01–1.18], and 3.45 [1.54–7.72]). Category-free net reclassification improvement identified interleukin-6 as a model-improving biomarker for MAKE and NGAL for AKI. However, only NGAL/hepcidin-25 improved model performance for event- and event-free patients for MAKE and AKI. Conclusions NGAL and interleukin-6 measured immediately post cardiac surgery may complement the Cleveland Score. The combination of biomarkers with hepcidin-25 may further improve diagnostic discrimination.
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Affiliation(s)
- Christian Albert
- Faculty of Medicine, Otto-von-Guericke University Magdeburg, Magdeburg, Germany.,Diaverum Renal Services, MVZ Potsdam, Potsdam, Germany.
| | - Michael Haase
- Faculty of Medicine, Otto-von-Guericke University Magdeburg, Magdeburg, Germany.,Diaverum Renal Services, MVZ Potsdam, Potsdam, Germany
| | - Annemarie Albert
- Diaverum Renal Services, MVZ Potsdam, Potsdam, Germany.,Department of Nephrology and Endocrinology, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Siegfried Kropf
- Institute for Biometrics and Medical Informatics, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Rinaldo Bellomo
- School of Medicine, University of Melbourne, Melbourne, Australia
| | - Sabine Westphal
- Institute of Laboratory Medicine, Hospital Dessau, Dessau, Germany
| | | | - Rüdiger Christian Braun-Dullaeus
- Department of Internal Medicine, University Clinic for Cardiology and Angiology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Anja Haase-Fielitz
- Department of Cardiology, Immanuel Diakonie Bernau, Heart Center Brandenburg, Brandenburg Medical School Theodor Fontane (MHB), Germany.,Institute of Social Medicine and Health Economics, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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19
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Hoff U, Bubalo G, Fechner M, Blum M, Zhu Y, Pohlmann A, Hentschel J, Arakelyan K, Seeliger E, Flemming B, Gürgen D, Rothe M, Niendorf T, Manthati VL, Falck JR, Haase M, Schunck W, Dragun D. A synthetic epoxyeicosatrienoic acid analogue prevents the initiation of ischemic acute kidney injury. Acta Physiol (Oxf) 2019; 227:e13297. [PMID: 31077555 DOI: 10.1111/apha.13297] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 05/08/2019] [Accepted: 05/08/2019] [Indexed: 12/19/2022]
Abstract
AIM Imbalances in cytochrome P450 (CYP)-dependent eicosanoid formation may play a central role in ischemic acute kidney injury (AKI). We reported previously that inhibition of 20-hydroxyeicosatetraenoic acid (20-HETE) action ameliorated ischemia/reperfusion (I/R)-induced AKI in rats. Now we tested the hypothesis that enhancement of epoxyeicosatrienoic acid (EET) actions may counteract the detrimental effects of 20-HETE and prevent the initiation of AKI. METHODS Male Lewis rats underwent right nephrectomy and ischemia was induced by 45 min clamping of the left renal pedicle followed by up to 48 h of reperfusion. Circulating CYP-eicosanoid profiles were compared in patients who underwent cardiac surgery with (n = 21) and without (n = 38) developing postoperative AKI. RESULTS Ischemia induced an about eightfold increase of renal 20-HETE levels, whereas free EETs were not accumulated. To compensate for this imbalance, a synthetic 14,15-EET analogue was administered by intrarenal infusion before ischemia. The EET analogue improved renal reoxygenation as monitored by in vivo parametric MRI during the initial 2 h reperfusion phase. The EET analogue improved PI3K- as well as mTORC2-dependent rephosphorylation of Akt, induced inactivation of GSK-3β, reduced the development of tubular apoptosis and attenuated inflammatory cell infiltration. The EET analogue also significantly alleviated the I/R-induced drop in creatinine clearance. Patients developing postoperative AKI featured increased preoperative 20-HETE and 8,9-EET levels. CONCLUSIONS Pharmacological interventions targeting the CYP-eicosanoid pathway could offer promising new options for AKI prevention. Individual differences in CYP-eicosanoid formation may contribute to the risk of developing AKI in clinical settings.
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Affiliation(s)
- Uwe Hoff
- Nephrology and Intensive Care Medicine, Center for Cardiovascular Research Charité‐Universitätsmedizin Berlin Berlin Germany
| | - Gordana Bubalo
- Nephrology and Intensive Care Medicine, Center for Cardiovascular Research Charité‐Universitätsmedizin Berlin Berlin Germany
| | - Mandy Fechner
- Nephrology and Intensive Care Medicine, Center for Cardiovascular Research Charité‐Universitätsmedizin Berlin Berlin Germany
| | | | - Ye Zhu
- Nephrology and Intensive Care Medicine, Center for Cardiovascular Research Charité‐Universitätsmedizin Berlin Berlin Germany
- Department of Nephrology The Fifth Affiliated Hospital of Sun Yat‐sun University Zhuhai China
| | - Andreas Pohlmann
- Berlin Ultrahigh Field Facility (B.U.F.F.) Max Delbrueck Center for Molecular Medicine Berlin Germany
| | - Jan Hentschel
- Berlin Ultrahigh Field Facility (B.U.F.F.) Max Delbrueck Center for Molecular Medicine Berlin Germany
| | - Karen Arakelyan
- Berlin Ultrahigh Field Facility (B.U.F.F.) Max Delbrueck Center for Molecular Medicine Berlin Germany
- Center for Cardiovascular Research, Institute of Physiology Charité‐Universitätsmedizin Berlin Berlin Germany
| | - Erdmann Seeliger
- Center for Cardiovascular Research, Institute of Physiology Charité‐Universitätsmedizin Berlin Berlin Germany
| | - Bert Flemming
- Center for Cardiovascular Research, Institute of Physiology Charité‐Universitätsmedizin Berlin Berlin Germany
| | - Dennis Gürgen
- Nephrology and Intensive Care Medicine, Center for Cardiovascular Research Charité‐Universitätsmedizin Berlin Berlin Germany
| | | | - Thoralf Niendorf
- Max Delbrueck Center for Molecular Medicine Berlin Germany
- Berlin Ultrahigh Field Facility (B.U.F.F.) Max Delbrueck Center for Molecular Medicine Berlin Germany
| | | | - John R. Falck
- Biochemistry Department UT Southwestern Dallas Texas
| | - Michael Haase
- Medical Faculty Otto‐von‐Guericke University Magdeburg Germany
- Diaverum Deutschland Potsdam Germany
| | | | - Duska Dragun
- Nephrology and Intensive Care Medicine, Center for Cardiovascular Research Charité‐Universitätsmedizin Berlin Berlin Germany
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20
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Jacob KA, Leaf DE. Prevention of Cardiac Surgery-Associated Acute Kidney Injury: A Review of Current Strategies. Anesthesiol Clin 2019; 37:729-749. [PMID: 31677688 PMCID: PMC7644277 DOI: 10.1016/j.anclin.2019.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Acute kidney injury is a common and often severe postoperative complication after cardiac surgery, and is associated with poor short-term and long-term outcomes. Numerous randomized controlled trials have been conducted to investigate various strategies for prevention of cardiac surgery-associated acute kidney injury. Unfortunately, most trials that have been conducted to date have been negative. However, encouraging results have been demonstrated with preoperative administration of corticosteroids, leukocyte filtration, and administration of inhaled nitric oxide intraoperatively, and implementation of a Kidney Disease: Improving Global Outcomes bundle of care approach postoperatively. These findings require validation in large, multicenter trials.
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Affiliation(s)
- Kirolos A Jacob
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Mail Stop E03.511, PO Box 85500, Utrecht 3508 GA, the Netherlands.
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Medial Research Building Room MR416B, Boston, MA 02115, USA
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21
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Abstract
PURPOSE OF REVIEW The present article reviews the recent literature on the main aspects of perioperative acute kidney injury (AKI). RECENT FINDINGS AKI occurs in 1 in every 10 surgical patients, with cardiac, orthopedic, and major abdominal surgeries being the procedures associated with the highest risk. Overall, complex operations, bleeding, and hemodynamic instability are the most consistent procedure-related risk factors for AKI. AKI increases hospital stay, mortality, and chronic kidney disease, gradually with severity. Furthermore, delayed renal recovery negatively impacts on patients' outcomes. Cell cycle arrest biomarkers seem promising to identify high-risk patients who may benefit from the bundles recommended by the Kidney Disease: Improving Global Outcomes guidelines. Hemodynamic management using protocol-based administration of fluids and vasopressors helps reducing AKI. Recent studies have highlighted the benefit of personalizing the blood pressure target according to the patient's resting reference, and avoiding both hypovolemia and fluid overload. Preliminary research has reported encouraging renoprotective effects of angiotensin II and nitric oxide, which need to be confirmed. Moreover, urinary oxygenation monitoring appears feasible and a fair predictor of postoperative AKI. SUMMARY AKI remains a frequent and severe postoperative complication. A personalizedmulticomponent approach might help reducing the risk of AKI and improving patients' outcomes.
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22
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Impact of Early versus Late Initiation of Renal Replacement Therapy in Patients with Cardiac Surgery-Associated Acute Kidney Injury: Meta-Analysis with Trial Sequential Analysis of Randomized Controlled Trials. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6942829. [PMID: 30662912 PMCID: PMC6312615 DOI: 10.1155/2018/6942829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 11/09/2018] [Accepted: 11/15/2018] [Indexed: 12/29/2022]
Abstract
Background Previous studies have examined the effect of the initiation time of renal replacement therapy (RRT) in patients with cardiac surgery-associated acute kidney injury (CSA-AKI), but the findings remain controversial. The aim of this meta-analysis was to systematically and quantitatively compare the impact of early versus late initiation of RRT on the outcome of patients with CSA-AKI. Methods Four databases (PubMed, the Cochrane Library, ISI Web of Knowledge, and Embase) were systematically searched from inception to June 2018 for randomized clinical trials (RCTs). Two investigators independently performed the literature search, study selection, data extraction, and quality evaluation. Meta-analysis and trial sequential analysis (TSA) were used to examine the impact of RRT initiation time on all-cause mortality (primary outcome). The Grading of Recommendations Assessment Development and Evaluation (GRADE) was used to evaluate the level of evidence. Results We identified 4 RCTs with 355 patients that were eligible for inclusion. Pooled analyses indicated no difference in mortality for patients receiving early and late initiation of RRT (relative risk [RR] = 0.61, 95% confidence interval [CI] = 0.33 to 1.12). However, the results were not confirmed by TSA. Similarly, early RRT did not reduce the length of stay (LOS) in the intensive care unit (ICU) (mean difference [MD] = -1.04; 95% CI = -3.34 to 1.27) or the LOS in the hospital (MD = -1.57; 95% CI = -4.62 to 1.48). Analysis using GRADE indicated the certainty of the body of evidence was very low for a benefit from early initiation of RRT. Conclusion Early initiation of RRT had no beneficial impacts on outcomes in patients with CSA-AKI. Future larger and more adequately powered prospective RCTs are needed to verify the benefit of reduced mortality associated with early initiation of RRT. Trial Registration This trial is registered with PROSPERO registration number CRD42018084465, registered on 11 February 2018.
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23
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Albert C, Albert A, Bellomo R, Kropf S, Devarajan P, Westphal S, Baraki H, Kutschka I, Butter C, Haase M, Haase-Fielitz A. Urinary neutrophil gelatinase-associated lipocalin-guided risk assessment for major adverse kidney events after open-heart surgery. Biomark Med 2018; 12:975-985. [PMID: 30088425 DOI: 10.2217/bmm-2018-0071] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
AIM To assess weather doctors' clinical risk-assessment for major adverse kidney events (MAKE) and acute kidney injury (AKI) after open-heart surgery would improve when being informed about neutrophil gelatinase-associated lipocalin (NGAL) test result at ICU admission. PATIENTS & METHODS Clinical risk-assessment for MAKE and AKI were performed with and without providing NGAL test result and compared in an exploratory- and a validation-cohort using reclassification metrics, exemplary category-free net reclassification improvement (cfNRI). RESULTS Exploratory cohort: doctors' prediction of MAKE (cfNRI = 0.750 [0.130-1.370]; p = 0.018) and AKI (cfNRI = 0.565 [0.001-1.129]; p = 0.049) improved being provided with NGAL test information. This finding was confirmed in the validation-cohort (MAKE cfNRI = 0.930 [0.188-1.672]; p = 0.014) and the combined-cohort (MAKE: cfNRI = 0.847 [0.371-1.323], p < 0.001); AKI: cfNRI = 0.468 [0.099-0.836; p = 0.013]). Improvements mostly generated from correctly reclassifying patients who not developed events (p < 0.001). CONCLUSION Biomarker informed risk-assessment is superior in predicting MAKE and AKI after open-heart surgery.
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Affiliation(s)
- Christian Albert
- Medical Faculty, Otto-von-Guericke University, Magdeburg, ST, Germany.,Brandenburg Medical School (MHB), Brandenburg an der Havel, BB, Germany.,Diaverum Deutschland, Potsdam, BB, Germany
| | - Annemarie Albert
- Medical Faculty, Otto-von-Guericke University, Magdeburg, ST, Germany.,Brandenburg Medical School (MHB), Brandenburg an der Havel, BB, Germany.,Diaverum Deutschland, Potsdam, BB, Germany
| | - Rinaldo Bellomo
- School of Medicine, Intensive Care Unit, Austin Hospital, Heidelberg, VIC, 3084 Australia
| | - Siegfried Kropf
- Institute for Biometrics & Medical Informatics, Otto-von-Guericke University, Magdeburg, ST, Germany
| | - Prasad Devarajan
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital, Cincinnati, OH 45229, USA
| | - Sabine Westphal
- Institute of Laboratory Medicine, Hospital Dessau, Dessau, ST, Germany
| | - Hassina Baraki
- Department of Thoracic, Cardiac & Vascular Surgery, University of Göttingen, Göttingen, NI, Germany
| | - Ingo Kutschka
- Department of Thoracic, Cardiac & Vascular Surgery, University of Göttingen, Göttingen, NI, Germany
| | - Christian Butter
- Brandenburg Medical School (MHB), Brandenburg an der Havel, BB, Germany.,Department of Cardiology, Immanuel Diakonie Bernau, Heart Center Brandenburg, BB, Germany
| | - Michael Haase
- Medical Faculty, Otto-von-Guericke University, Magdeburg, ST, Germany.,Brandenburg Medical School (MHB), Brandenburg an der Havel, BB, Germany.,Diaverum Deutschland, Potsdam, BB, Germany
| | - Anja Haase-Fielitz
- Brandenburg Medical School (MHB), Brandenburg an der Havel, BB, Germany.,Department of Cardiology, Immanuel Diakonie Bernau, Heart Center Brandenburg, BB, Germany.,Institute of Social Medicine & Health Economics, Otto-von-Guericke University, Magdeburg, ST, Germany
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24
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Abstract
PURPOSE OF REVIEW To review epidemiology and pathophysiology of acute kidney injury (AKI) in trauma patients and propose strategies that aim at preventing AKI after trauma. RECENT FINDINGS AKI in trauma patients has been reported to be as frequent as 50% with an association to a prolonged length of stay and a raise in mortality. Among the specific risk factors encountered in trauma patients, hemorrhagic shock, rhabdomyolysis severity, age, and comorbidities are independently associated with AKI occurrence. Resuscitation with balanced solutes seems to have beneficial effects on renal outcome compared with NaCl 0.9%, particularly in the context of rhabdomyolysis. However, randomized clinical studies are needed to confirm this signal. Abdominal compartment syndrome (ACS) is rare but has to be diagnosed to initiate a dedicated therapy. SUMMARY The high incidence of AKI in trauma patients should lead to early identification of those at risk of AKI to establish a resuscitation strategy that aims at preventing AKI.
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25
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Nadim MK, Forni LG, Bihorac A, Hobson C, Koyner JL, Shaw A, Arnaoutakis GJ, Ding X, Engelman DT, Gasparovic H, Gasparovic V, Herzog CA, Kashani K, Katz N, Liu KD, Mehta RL, Ostermann M, Pannu N, Pickkers P, Price S, Ricci Z, Rich JB, Sajja LR, Weaver FA, Zarbock A, Ronco C, Kellum JA. Cardiac and Vascular Surgery-Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group. J Am Heart Assoc 2018; 7:JAHA.118.008834. [PMID: 29858368 PMCID: PMC6015369 DOI: 10.1161/jaha.118.008834] [Citation(s) in RCA: 160] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Mitra K Nadim
- Division of Nephrology & Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Lui G Forni
- Department of Clinical & Experimental Medicine, University of Surrey, Guildford, United Kingdom.,Royal Surrey County Hospital NHS Foundation Trust, Guildford, United Kingdom
| | - Azra Bihorac
- Division of Nephrology, Hypertension & Renal Transplantation, Department of Medicine, University of Florida, Gainesville, FL
| | - Charles Hobson
- Division of Surgical Critical Care, Department of Surgery, Malcom Randall VA Medical Center, Gainesville, FL
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, IL
| | - Andrew Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - George J Arnaoutakis
- Division of Thoracic & Cardiovascular Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Xiaoqiang Ding
- Department of Nephrology, Shanghai Institute for Kidney Disease and Dialysis, Shanghai Medical Center for Kidney Disease, Zhongshan Hospital Fudan University, Shanghai, China
| | - Daniel T Engelman
- Division of Cardiac Surgery, Department of Surgery, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA
| | - Hrvoje Gasparovic
- Department of Cardiac Surgery, University Hospital Rebro, Zagreb, Croatia
| | | | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN
| | - Kianoush Kashani
- Division of Nephrology & Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Nevin Katz
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Kathleen D Liu
- Divisions of Nephrology and Critical Care, Departments of Medicine and Anesthesia, University of California, San Francisco, CA
| | - Ravindra L Mehta
- Department of Medicine, UCSD Medical Center, University of California, San Diego, CA
| | - Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Neesh Pannu
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Peter Pickkers
- Department Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Susanna Price
- Adult Intensive Care Unit, Imperial College, Royal Brompton Hospital, London, United Kingdom
| | - Zaccaria Ricci
- Department of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Roma, Italy
| | - Jeffrey B Rich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Lokeswara R Sajja
- Division of Cardiothoracic Surgery, STAR Hospitals, Hyderabad, India
| | - Fred A Weaver
- Division of Vascular Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital International Renal Research Institute of Vicenza, Italy
| | - John A Kellum
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, PA
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26
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Albert C, Albert A, Kube J, Bellomo R, Wettersten N, Kuppe H, Westphal S, Haase M, Haase-Fielitz A. Urinary biomarkers may provide prognostic information for subclinical acute kidney injury after cardiac surgery. J Thorac Cardiovasc Surg 2018; 155:2441-2452.e13. [DOI: 10.1016/j.jtcvs.2017.12.056] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 11/13/2017] [Accepted: 12/15/2017] [Indexed: 01/26/2023]
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27
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Fiorentino M, Castellano G, Kellum JA. Differences in acute kidney injury ascertainment for clinical and preclinical studies. Nephrol Dial Transplant 2018; 32:1789-1805. [PMID: 28371878 DOI: 10.1093/ndt/gfx002] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 01/03/2017] [Indexed: 12/25/2022] Open
Abstract
Background Acute kidney injury (AKI) is a common clinical condition directly associated with adverse outcomes. Several AKI biomarkers have been discovered, but their use in clinical and preclinical studies has not been well examined. This study aims to investigate the differences between clinical and preclinical studies on AKI biomarkers. Methods We performed a systematic review of clinical and preclinical interventional studies that considered AKI biomarkers in enrollment criteria and/or outcome assessment and described the main differences according to their setting, the inclusion of biomarkers in the definition of AKI and the use of biomarkers as primary or secondary end points. Results In the 151 included studies (76 clinical, 75 preclinical), clinical studies have prevalently focused on cardiac surgery (38.1%) and contrast-associated AKI (17.1%), while the majority of preclinical studies have focused on ether ischemia-reperfusion injury or drug-induced AKI (42.6% each). A total of 57.8% of clinical studies defined AKI using the standard criteria and only 19.7% of these studies used AKI biomarkers in the definition of renal injury. Conversely, the majority of preclinical studies defined AKI according to the increase in serum creatinine and blood urea nitrogen, and 32% included biomarkers in that definition. The percentage of both clinical and preclinical studies with biomarkers as a primary end point has not significantly increased in the last 10 years; however, preclinical studies are more likely to use AKI biomarkers as a primary end point compared with clinical studies [odds ratio 2.31 (95% confidence interval 1.17-4.59); P = 0.016]. Conclusion Differences between clinical and preclinical studies are evident and may affect the translation of preclinical findings in the clinical setting.
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Affiliation(s)
- Marco Fiorentino
- Department of Critical Care Medicine, Center for Critical Care Nephrology, CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, University of Pittsburgh School of Medicine, Pittsburgh, USA.,Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplantation Unit, University of Bari, Bari, Italy
| | - Giuseppe Castellano
- Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplantation Unit, University of Bari, Bari, Italy
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, University of Pittsburgh School of Medicine, Pittsburgh, USA
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28
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Joannidis M, Klein SJ, John S, Schmitz M, Czock D, Druml W, Jörres A, Kindgen-Milles D, Kielstein JT, Oppert M, Schwenger V, Willam C, Zarbock A. [Prevention of acute kidney injury in critically ill patients : Recommendations from the renal section of the DGIIN, ÖGIAIN and DIVI]. Med Klin Intensivmed Notfmed 2018; 113:358-369. [PMID: 29594317 DOI: 10.1007/s00063-018-0413-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 02/26/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) has both high mortality and morbidity. OBJECTIVES To prevent the occurrence of AKI, current recommendations from the renal section of the DGIIN (Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin), ÖGIAIN (Österreichischen Gesellschaft für Internistische und Allgemeine Intensivmedizin und Notfallmedizin) and DIVI (Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin) are stated. MATERIALS AND METHODS The recommendations stated in this paper are based on the current Kidney Disease Improving Global Outcomes (KDIGO) guidelines, the published statements of the "Working Group on Prevention, AKI section of the European Society of Intensive Care Medicine" and the expert knowledge and clinical experience of the authors. RESULTS Currently there are no approved clinically effective drugs for the prevention of AKI. Therefore the mainstay of prevention is the optimization of renal perfusion by improving the mean arterial pressure (>65 mm Hg, higher target may be considered in hypertensive patients). This can be done by vasopressors, preferably norepinephrine and achieving or maintaining euvolemia. Hyperhydration that can lead to AKI itself should be avoided. In patients with maintained diuresis this can be done by diuretics that are per se no preventive drug for AKI. Radiocontrast enhanced imaging should not be withheld from patients at risk for AKI; if indicated, however, the contrast media should be limited to the smallest possible volume.
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Affiliation(s)
- M Joannidis
- Gemeinsame Einrichtung Internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
| | - S J Klein
- Gemeinsame Einrichtung Internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - S John
- Abteilung Internistische Intensivmedizin, Medizinische Klinik 8, Paracelsus Medizinische Privatuniversität Nürnberg, Klinikum Nürnberg-Süd, Universität Erlangen-Nürnberg, Nürnberg, Deutschland
| | - M Schmitz
- Klinik für Nephrologie, Städtisches Klinikum Solingen, Solingen, Deutschland
| | - D Czock
- Medizinische Klinik, Abteilung Klinische Pharmakologie und Pharmakoepidemiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - W Druml
- Department für Innere Medizin III, Allgemeines Krankenhaus Wien, Wien, Österreich
| | - A Jörres
- Medizinische Klinik I für Nephrologie, Transplantationsmedizin und internistische Intensivmedizin, Klinikum der Universität Witten/Herdecke, Köln-Merheim, Deutschland
| | - D Kindgen-Milles
- Klinik für Anästhesiologie, Heinrich-Heine-Universität, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - J T Kielstein
- Medizinische Klinik V, Nephrologie
- Rheumatologie
- Blutreinigungsverfahren, Städtisches Klinikum Braunschweig, Braunschweig, Deutschland
| | - M Oppert
- Klinik für Notfall- und internistische Intensivmedizin, Klinikum Ernst von Bergmann, Potsdam, Deutschland
| | - V Schwenger
- Klinik für Nieren‑, Hochdruck- und Autoimmunerkrankungen, Klinikum Stuttgart, Stuttgart, Deutschland
| | - C Willam
- Nephrologie und Hypertensiologie, Medizinische Klinik 4, Erlangen, Deutschland
| | - A Zarbock
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
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Ekbal NJ, Hennis P, Dyson A, Mythen M, James MFM, Singer M. The anion study: effect of different crystalloid solutions on acid base balance, physiology, and survival in a rodent model of acute isovolaemic haemodilution. Br J Anaesth 2018; 120:1412-1419. [PMID: 29793606 PMCID: PMC6200115 DOI: 10.1016/j.bja.2018.01.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 01/05/2018] [Accepted: 01/31/2018] [Indexed: 01/16/2023] Open
Abstract
Background Commercially available crystalloid solutions used for volume replacement do not exactly match the balance of electrolytes found in plasma. Large volume administration may lead to electrolyte imbalance and potential harm. We hypothesised that haemodilution using solutions containing different anions would result in diverse biochemical effects, particularly on acid-base status, and different outcomes. Methods Anaesthetised, fluid-resuscitated, male Wistar rats underwent isovolaemic haemodilution by removal of 10% blood volume every 15 min, followed by replacement with one of three crystalloid solutions based on acetate, lactate, or chloride. Fluids were administered in a protocolised manner to achieve euvolaemia based on echocardiography-derived left ventrical volumetric measures. Removed blood was sampled for plasma ions, acid-base status, haemoglobin, and glucose. This cycle was repeated at 15-min intervals until death. The primary endpoint was change in plasma bicarbonate within each fluid group. Secondary endpoints included time to death and cardiac function. Results During haemodilution, chloride-treated rats showed significantly greater decreases in plasma bicarbonate and strong ion difference levels compared with acetate- and lactate-treated rats. Time to death, total volume of fluid administered: chloride group 56 (3) ml, lactate group 62 (3) ml, and acetate group 65 (3) ml; haemodynamic and tissue oxygenation changes were, however, similar between groups. Conclusions With progressive haemodilution, resuscitation with a chloride-based solution induced more acidosis compared with lactate- and acetate-based solutions, but outcomes were similar. No short-term impact was seen from hyperchloraemia in this model.
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Affiliation(s)
- N J Ekbal
- University College London, Bloomsbury Institute of Intensive Care Medicine, London, UK
| | - P Hennis
- UCL Centre for Anaesthesia, Critical Care and Pain Medicine, University College London, UK
| | - A Dyson
- University College London, Bloomsbury Institute of Intensive Care Medicine, London, UK
| | - M Mythen
- UCL Centre for Anaesthesia, Critical Care and Pain Medicine, University College London, UK
| | - M F M James
- University of Cape Town, Department of Anaesthesia, Cape Town, South Africa
| | - M Singer
- University College London, Bloomsbury Institute of Intensive Care Medicine, London, UK.
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Comparative Efficacy of Drugs for Preventing Acute Kidney Injury after Cardiac Surgery: A Network Meta-Analysis. Am J Cardiovasc Drugs 2018; 18:49-58. [PMID: 28819767 DOI: 10.1007/s40256-017-0245-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) occurs frequently after cardiac surgery and has been associated with increased hospital length of stay, mortality, and costs. OBJECTIVE We aimed to evaluate the efficacy of pharmacologic strategies for preventing AKI after cardiac surgery. METHODS We searched PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL) up to 6 May 2017 and the reference lists of relevant articles about trials. The outcome was the occurrence of AKI. This is the first network meta-analysis of the different prevention strategies using Bayesian methodology. RESULTS The study included 63 articles with 19,520 participants and evaluated the effect of ten pharmacologic strategies to prevent AKI in patients undergoing cardiac surgery. Compared with placebo, the odds ratio (OR) for the occurrence of AKI was 0.24 [95% confidence interval (CI) 0.16-0.34] with natriuretic peptide, 0.33 (95% CI 0.14-0.70) with fenoldopam, 0.54 (95% CI 0.31-0.84) with dexmedetomidine, 0.56 (95% CI 0.29-0.95) with low-dose erythropoietin, 0.63 (95% CI 0.43-0.88) with levosimendan, 0.76 (95% CI 0.52-1.10) with steroids, 0.83 (95% CI 0.48-1.40) with high-dose erythropoietin, 0.85 (95% CI 0.64-1.14) with N-acetylcysteine, 0.96 (95% CI 0.69-1.29) with sodium bicarbonate, and 1.05 (95% CI 0.70-1.41) with statins. The surface under the cumulative ranking curve probabilities indicated that natriuretic peptide was the best treatment therapy and that fenoldopam ranked second. CONCLUSIONS Natriuretic peptide is probably the preferred pharmacologic strategy to prevent AKI in adult patients undergoing cardiac surgery, especially in those at high risk of AKI.
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Preoperative hydration with 0.9% normal saline to prevent acute kidney injury after major elective open abdominal surgery: A randomised controlled trial. Eur J Anaesthesiol 2018; 33:436-43. [PMID: 26825017 DOI: 10.1097/eja.0000000000000421] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Postoperative acute kidney injury (AKI) is the second leading cause of hospital-acquired AKI. Although many preventive strategies have been tested, none of them has been totally effective. OBJECTIVE We investigated whether preoperative intravenous hydration with 0.9% normal saline could prevent postoperative AKI. DESIGN Randomised controlled trial. SETTING University Ramón y Cajal Hospital, Spain, from June 2006 to February 2011. PATIENTS Total 328 inpatients scheduled for major elective open abdominal surgery. INTERVENTION 0.9% normal saline at a dose of 1.5 ml kg h for 12 h before surgery. MAIN OUTCOME MEASURES The primary outcome was the overall postoperative AKI incidence during the first week after surgery defined by risk, injury, failure, loss, end-stage kidney disease (RIFLE) and AKI network (AKIN) creatinine criteria. Secondary endpoints were the need for ICU admission, renal replacement therapy during the study period and adverse events and hospital mortality during hospital admission. RESULTS There was no difference in the incidence of AKI between groups: 4.7% in the normal saline group versus 5.0% in the control group and 11.4% in the 0.9% normal saline group versus 7.9% in the control group as assessed by the RIFLE and AKIN creatinine criteria, respectively. Absolute risk reductions (95% confidence interval) were -0.3% (-5.3 to 4.7%) for RIFLE and 3.5% (-10.2 to 3.6%) for AKIN. ICU admission after surgery was required in 44.5% of all participants. Only 2 (0.7%) patients required renal replacement therapy during the first week after surgery. The analysis of adverse events did not show statistically significant differences between the groups except for pain. In our population, 8 (2.4%) patients died during their hospital admission. CONCLUSION Intravenous hydration with 0.9% normal saline before major open abdominal surgery was not effective in preventing postoperative AKI. No safety concerns were identified during the trial. TRIAL REGISTRATIONS Clinical trials.gov: NCT00953940 and EUDRA CT: 2005-004755-35.
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32
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Zhao BC, Shen P, Liu KX. Perioperative Statins Do Not Prevent Acute Kidney Injury After Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2017; 31:2086-2092. [DOI: 10.1053/j.jvca.2017.04.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Indexed: 11/11/2022]
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A Multicenter, Randomized, Controlled Phase IIb Trial of Avoidance of Hyperoxemia during Cardiopulmonary Bypass. Anesthesiology 2017; 125:465-73. [PMID: 27404222 DOI: 10.1097/aln.0000000000001226] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Cardiac surgery utilizing cardiopulmonary bypass (CPB) is one of the most common forms of major surgery. Cardiac surgery-associated multiorgan dysfunction (CSA-MOD) is well recognized and includes acute kidney injury (AKI), hepatic impairment, myocardial damage, and postoperative neurologic deficit. Pathophysiology of CSA-MOD involves numerous injurious pathways linked to the use of CPB including oxidative stress and formation of reactive iron species. During cardiac surgery with CPB, arterial return blood is oxygenated to supranormal levels. This study aimed to determine whether the avoidance of arterial hyperoxemia decreased oxidative stress and reduced the severity of the multiorgan dysfunction in patients undergoing cardiac surgery utilizing CPB. METHODS The study was a multicenter, open-label, parallel-group, randomized controlled study of the avoidance of arterial hyperoxemia versus usual care in patients undergoing cardiac surgery involving CPB. Primary outcome was the incidence and severity of AKI. Secondary outcomes included serum biomarkers for CSA-MOD, duration of mechanical ventilation, and length of intensive care and hospital stay. RESULTS A total of 298 patients were randomized and analyzed at two hospitals in New Zealand and Australia. Mean PaO2 was significantly different between groups during CPB. There was no difference in the development of AKI (intervention arm 72.0% vs. usual care 66.2%; difference, -5.8% [95% CI, -16.1 to 4.7%]; P = 0.28), other markers of organ damage, or intensive care unit and hospital length of stay. CONCLUSIONS Avoiding modest hyperoxemia during CPB failed to demonstrate any difference in AKI, markers of organ damage, or length of stay.
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Joannidis M, Druml W, Forni LG, Groeneveld ABJ, Honore PM, Hoste E, Ostermann M, Oudemans-van Straaten HM, Schetz M. Prevention of acute kidney injury and protection of renal function in the intensive care unit: update 2017 : Expert opinion of the Working Group on Prevention, AKI section, European Society of Intensive Care Medicine. Intensive Care Med 2017; 43:730-749. [PMID: 28577069 PMCID: PMC5487598 DOI: 10.1007/s00134-017-4832-y] [Citation(s) in RCA: 193] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/02/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) in the intensive care unit is associated with significant mortality and morbidity. OBJECTIVES To determine and update previous recommendations for the prevention of AKI, specifically the role of fluids, diuretics, inotropes, vasopressors/vasodilators, hormonal and nutritional interventions, sedatives, statins, remote ischaemic preconditioning and care bundles. METHOD A systematic search of the literature was performed for studies published between 1966 and March 2017 using these potential protective strategies in adult patients at risk of AKI. The following clinical conditions were considered: major surgery, critical illness, sepsis, shock, exposure to potentially nephrotoxic drugs and radiocontrast. Clinical endpoints included incidence or grade of AKI, the need for renal replacement therapy and mortality. Studies were graded according to the international GRADE system. RESULTS We formulated 12 recommendations, 13 suggestions and seven best practice statements. The few strong recommendations with high-level evidence are mostly against the intervention in question (starches, low-dose dopamine, statins in cardiac surgery). Strong recommendations with lower-level evidence include controlled fluid resuscitation with crystalloids, avoiding fluid overload, titration of norepinephrine to a target MAP of 65-70 mmHg (unless chronic hypertension) and not using diuretics or levosimendan for kidney protection solely. CONCLUSION The results of recent randomised controlled trials have allowed the formulation of new recommendations and/or increase the strength of previous recommendations. On the other hand, in many domains the available evidence remains insufficient, resulting from the limited quality of the clinical trials and the poor reporting of kidney outcomes.
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Affiliation(s)
- M Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstasse 35, 6020, Innsbruck, Austria.
| | - W Druml
- Department of Internal Medicine III, University Hospital Vienna, Vienna, Austria
| | - L G Forni
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey and Surrey Perioperative Anaesthesia and Critical Care Collaborative Research Group (SPACeR), Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, GU2 7XX, United Kingdom
| | | | - P M Honore
- Department of Intensive Care, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - E Hoste
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium
| | - M Ostermann
- Department of Critical Care and Nephrology, Guy's and St Thomas' Hospital, London, United Kingdom
| | - H M Oudemans-van Straaten
- Department of Adult Intensive Care, VU University Medical Centre, De Boelelaan 1118, 1081 HZ, Amsterdam, The Netherlands
| | - M Schetz
- Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
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Hertzberg D, Rydén L, Pickering JW, Sartipy U, Holzmann MJ. Acute kidney injury-an overview of diagnostic methods and clinical management. Clin Kidney J 2017; 10:323-331. [PMID: 28616210 PMCID: PMC5466115 DOI: 10.1093/ckj/sfx003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 01/13/2017] [Indexed: 12/12/2022] Open
Abstract
Acute kidney injury (AKI) is a common condition in multiple clinical settings. Patients with AKI are at an increased risk of death, over both the short and long term, and of accelerated renal impairment. As the condition has become more recognized and definitions more unified, there has been a rapid increase in studies examining AKI across many different clinical settings. This review focuses on the classification, diagnostic methods and clinical management that are available, or promising, for patients with AKI. Furthermore, preventive measures with fluids, acetylcysteine, statins and remote ischemic preconditioning, as well as when dialysis should be initiated in AKI patients are discussed. The classification of AKI includes both changes in serum creatinine concentrations and urine output. Currently, no kidney injury biomarkers are included in the classification of AKI, but proposals have been made to include them as independent diagnostic markers. Treatment of AKI is aimed at addressing the underlying causes of AKI, and at limiting damage and preventing progression. The key principles are: to treat the underlying disease, to optimize fluid balance and optimize hemodynamics, to treat electrolyte disturbances, to discontinue or dose-adjust nephrotoxic drugs and to dose-adjust drugs with renal elimination.
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Affiliation(s)
- Daniel Hertzberg
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Linda Rydén
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Anesthesiology, Surgical Services and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - John W. Pickering
- Deparment of Medicine, University of Otago Christchurch and Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Ulrik Sartipy
- Section of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Martin J. Holzmann
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Emergency Medicine, Huddinge, Karolinska University Hospital, Stockholm, Sweden
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Abstract
Acute kidney injury (AKI) is a common condition with multiple etiologies and variable clinical findings and pathologic manifestations. AKI is associated with serious adverse clinical outcomes, including the development of de novo chronic kidney disease, accelerated progression of pre-existing chronic kidney disease, end-stage kidney disease, and increased mortality. Past research has advanced our understanding of the pathophysiology, epidemiology, and outcomes of AKI significantly, however, little progress has been made in the development of evidence-based interventions for its prevention and treatment. In this review, we discuss key considerations in the design of clinical trials in AKI and highlight significant methodologic limitations that precluded many past studies from determining the effectiveness of preventive and therapeutic strategies for this common and serious condition.
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Cho JS, Soh S, Shim JK, Kang S, Choi H, Kwak YL. Effect of perioperative sodium bicarbonate administration on renal function following cardiac surgery for infective endocarditis: a randomized, placebo-controlled trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:3. [PMID: 28057030 PMCID: PMC5217446 DOI: 10.1186/s13054-016-1591-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 12/12/2016] [Indexed: 12/18/2022]
Abstract
Background Patients with infective endocarditis (IE) have an elevated risk of renal dysfunction because of extensive systemic inflammation and use of nephrotoxic antibiotics. In this randomized, placebo-controlled trial, we investigated whether perioperative sodium bicarbonate administration could attenuate postoperative renal dysfunction in patients with IE undergoing cardiac surgery. Methods Seventy patients randomly received sodium chloride (n = 35) or sodium bicarbonate (n = 35). Sodium bicarbonate was administered as a 0.5 mmol/kg loading dose for 1 h commencing with anesthetic induction, followed by a 0.15 mmol/kg/h infusion for 23 h. The primary outcome was peak serum creatinine (SCr) level during the first 48 h postoperatively. The incidence of acute kidney injury, SCr level, estimated glomerular filtration rate, and major morbidity endpoints were assessed postoperatively. Results The peak SCr during the first 48 h postoperatively (bicarbonate vs. control: 1.01 (0.74, 1.37) mg/dl vs. 0.88 (0.76, 1.27) mg/dl, P = 0.474) and the incidence of acute kidney injury (bicarbonate vs. control: 29% vs. 23%, P = 0.584) were similar in both groups. The postoperative increase in SCr above baseline was greater in the bicarbonate group than in the control group on postoperative day 2 (0.21 (0.07, 0.33) mg/dl vs. 0.06 (0.00, 0.23) mg/dl, P = 0.028) and postoperative day 5 (0.23 (0.08, 0.36) mg/dl vs. 0.06 (0.00, 0.23) mg/dl, P = 0.017). Conclusions Perioperative sodium bicarbonate administration had no favorable impact on postoperative renal function and outcomes in patients with IE undergoing cardiac surgery. Instead, it was associated with possibly harmful renal effects, illustrated by a greater increase in SCr postoperatively, compared to control. Trial registration ClinicalTrials.gov, NCT01920126. Registered on 31 July 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1591-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jin Sun Cho
- Department of Anesthesiology and Pain Medicine, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Sarah Soh
- Department of Anesthesiology and Pain Medicine, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sanghwa Kang
- Department of Anesthesiology and Pain Medicine, National Health Insurance Corporation Ilsan Hospital, Gyeonggi-do, Republic of Korea
| | - Haegi Choi
- Department of Anesthesiology and Pain Medicine, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Young-Lan Kwak
- Department of Anesthesiology and Pain Medicine, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea. .,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Ichai C, Vinsonneau C, Souweine B, Armando F, Canet E, Clec’h C, Constantin JM, Darmon M, Duranteau J, Gaillot T, Garnier A, Jacob L, Joannes-Boyau O, Juillard L, Journois D, Lautrette A, Muller L, Legrand M, Lerolle N, Rimmelé T, Rondeau E, Tamion F, Walrave Y, Velly L. Acute kidney injury in the perioperative period and in intensive care units (excluding renal replacement therapies). Ann Intensive Care 2016; 6:48. [PMID: 27230984 PMCID: PMC4882312 DOI: 10.1186/s13613-016-0145-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 04/19/2016] [Indexed: 12/17/2022] Open
Abstract
Acute kidney injury (AKI) is a syndrome that has progressed a great deal over the last 20 years. The decrease in urine output and the increase in classical renal biomarkers, such as blood urea nitrogen and serum creatinine, have largely been used as surrogate markers for decreased glomerular filtration rate (GFR), which defines AKI. However, using such markers of GFR as criteria for diagnosing AKI has several limits including the difficult diagnosis of non-organic AKI, also called "functional renal insufficiency" or "pre-renal insufficiency". This situation is characterized by an oliguria and an increase in creatininemia as a consequence of a reduction in renal blood flow related to systemic haemodynamic abnormalities. In this situation, "renal insufficiency" seems rather inappropriate as kidney function is not impaired. On the contrary, the kidney delivers an appropriate response aiming to recover optimal systemic physiological haemodynamic conditions. Considering the kidney as insufficient is erroneous because this suggests that it does not work correctly, whereas the opposite is occurring, because the kidney is healthy even in a threatening situation. With current definitions of AKI, normalization of volaemia is needed before defining AKI in order to avoid this pitfall.
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Affiliation(s)
- Carole Ichai
- />Service de Réanimation Polyvalente, IRCAN (Inserm U1081, CNRS UMR7284 et CHU de Nice, Hôpital Pasteur 2, 30 Voie Romaine, CHU de Nice, 06000 Nice, France
| | | | - Bertrand Souweine
- />Service de Réanimation Polyvalente, CHU de Nice, 30 Voie Romaine, 06000 Nice, France
| | - Fabien Armando
- />Service de Réanimation médicale, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Emmanuel Canet
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
| | - Christophe Clec’h
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital d’Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France
| | - Jean-Michel Constantin
- />Département de Médecine périopératoire, Hôpital Estaing, CHU de Clermont-Ferrand, 1 place Louis Aubrac, 63000 Clermont-Ferrand, France
| | - Michaël Darmon
- />Service de réanimation, hôpital de la Charité, CHU de Saint-Etienne, 44 rue Pointe Cadet, 42100 Saint-Etienne, France
| | - Jacques Duranteau
- />Département d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Kremlin-Bicêtre, 78, rue de la division du général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Théophille Gaillot
- />Service de Pédiatrie, hôpital Sud, CHU de Rennes, 16 Bd Bulgarie, 35203 Rennes, France
| | - Arnaud Garnier
- />Service de Pédiatrie, Néphrologie, hôpital des Enfants, CHU de Toulouse, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex, France
| | - Laurent Jacob
- />Service d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Saint-Louis, 1, Avenue Claude-Vellefaux, 75010 Paris, France
| | - Olivier Joannes-Boyau
- />Service d’Anesthésie Réanimation II, Hôpital du Haut-Lévêque, CHU de Bordeaux, 33600 Pessac, France
| | - Laurent Juillard
- />Service de néphrologie-dialyse, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
| | - Didier Journois
- />Service de réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Européen Georges Pompidou, 20, rue Leblanc, 75908 Paris, France
| | - Alexandre Lautrette
- />Service de réanimation, hôpital Gabriel Montpied, CHU de Clermont-Ferrand, 58 rue Montalemberg, 63003 Clermont-Ferrand, France
| | - Laurent Muller
- />Service de réanimation, hôpital Carémeau, CHU de Nîmes, 4 rue du Professeur Robert-Debré, 30029 Nîmes, France
| | - Matthieu Legrand
- />Service d’anesthésie-réanimation, hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1, Avenue Claude-Vellefaux, 75010 Paris, France
| | - Nicolas Lerolle
- />Service de réanimation, centre hospitalier universitaire, CHU d’Angers, 4 rue Larrey, 49100 Angers, France
| | - Thomas Rimmelé
- />Service d’anesthésie réanimation, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
| | - Eric Rondeau
- />Service de néphrologie, hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France
| | - Fabienne Tamion
- />Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
| | - Yannick Walrave
- />Service de Réanimation Polyvalente, CHU de Nice, 30 Voie Romaine, 06000 Nice, France
| | - Lionel Velly
- />Service d’anesthésie-réanimation, hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, 13385 Marseille Cedex 5, France
| | - Société française d’anesthésie et de réanimation (Sfar)
- />Service de Réanimation Polyvalente, IRCAN (Inserm U1081, CNRS UMR7284 et CHU de Nice, Hôpital Pasteur 2, 30 Voie Romaine, CHU de Nice, 06000 Nice, France
- />Service de Réanimation, Hôpital Marc Jacquet, 77000 Melun, France
- />Service de Réanimation Polyvalente, CHU de Nice, 30 Voie Romaine, 06000 Nice, France
- />Service de Réanimation médicale, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital d’Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France
- />Département de Médecine périopératoire, Hôpital Estaing, CHU de Clermont-Ferrand, 1 place Louis Aubrac, 63000 Clermont-Ferrand, France
- />Service de réanimation, hôpital de la Charité, CHU de Saint-Etienne, 44 rue Pointe Cadet, 42100 Saint-Etienne, France
- />Département d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Kremlin-Bicêtre, 78, rue de la division du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- />Service de Pédiatrie, hôpital Sud, CHU de Rennes, 16 Bd Bulgarie, 35203 Rennes, France
- />Service de Pédiatrie, Néphrologie, hôpital des Enfants, CHU de Toulouse, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex, France
- />Service d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Saint-Louis, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service d’Anesthésie Réanimation II, Hôpital du Haut-Lévêque, CHU de Bordeaux, 33600 Pessac, France
- />Service de néphrologie-dialyse, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Européen Georges Pompidou, 20, rue Leblanc, 75908 Paris, France
- />Service de réanimation, hôpital Gabriel Montpied, CHU de Clermont-Ferrand, 58 rue Montalemberg, 63003 Clermont-Ferrand, France
- />Service de réanimation, hôpital Carémeau, CHU de Nîmes, 4 rue du Professeur Robert-Debré, 30029 Nîmes, France
- />Service d’anesthésie-réanimation, hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service de réanimation, centre hospitalier universitaire, CHU d’Angers, 4 rue Larrey, 49100 Angers, France
- />Service d’anesthésie réanimation, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de néphrologie, hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France
- />Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
- />Service d’anesthésie-réanimation, hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, 13385 Marseille Cedex 5, France
| | - Société de réanimation de langue française (SRLF)
- />Service de Réanimation Polyvalente, IRCAN (Inserm U1081, CNRS UMR7284 et CHU de Nice, Hôpital Pasteur 2, 30 Voie Romaine, CHU de Nice, 06000 Nice, France
- />Service de Réanimation, Hôpital Marc Jacquet, 77000 Melun, France
- />Service de Réanimation Polyvalente, CHU de Nice, 30 Voie Romaine, 06000 Nice, France
- />Service de Réanimation médicale, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital d’Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France
- />Département de Médecine périopératoire, Hôpital Estaing, CHU de Clermont-Ferrand, 1 place Louis Aubrac, 63000 Clermont-Ferrand, France
- />Service de réanimation, hôpital de la Charité, CHU de Saint-Etienne, 44 rue Pointe Cadet, 42100 Saint-Etienne, France
- />Département d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Kremlin-Bicêtre, 78, rue de la division du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- />Service de Pédiatrie, hôpital Sud, CHU de Rennes, 16 Bd Bulgarie, 35203 Rennes, France
- />Service de Pédiatrie, Néphrologie, hôpital des Enfants, CHU de Toulouse, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex, France
- />Service d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Saint-Louis, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service d’Anesthésie Réanimation II, Hôpital du Haut-Lévêque, CHU de Bordeaux, 33600 Pessac, France
- />Service de néphrologie-dialyse, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Européen Georges Pompidou, 20, rue Leblanc, 75908 Paris, France
- />Service de réanimation, hôpital Gabriel Montpied, CHU de Clermont-Ferrand, 58 rue Montalemberg, 63003 Clermont-Ferrand, France
- />Service de réanimation, hôpital Carémeau, CHU de Nîmes, 4 rue du Professeur Robert-Debré, 30029 Nîmes, France
- />Service d’anesthésie-réanimation, hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service de réanimation, centre hospitalier universitaire, CHU d’Angers, 4 rue Larrey, 49100 Angers, France
- />Service d’anesthésie réanimation, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de néphrologie, hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France
- />Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
- />Service d’anesthésie-réanimation, hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, 13385 Marseille Cedex 5, France
| | - Groupe francophone de réanimation et urgences pédiatriques (GFRUP)
- />Service de Réanimation Polyvalente, IRCAN (Inserm U1081, CNRS UMR7284 et CHU de Nice, Hôpital Pasteur 2, 30 Voie Romaine, CHU de Nice, 06000 Nice, France
- />Service de Réanimation, Hôpital Marc Jacquet, 77000 Melun, France
- />Service de Réanimation Polyvalente, CHU de Nice, 30 Voie Romaine, 06000 Nice, France
- />Service de Réanimation médicale, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital d’Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France
- />Département de Médecine périopératoire, Hôpital Estaing, CHU de Clermont-Ferrand, 1 place Louis Aubrac, 63000 Clermont-Ferrand, France
- />Service de réanimation, hôpital de la Charité, CHU de Saint-Etienne, 44 rue Pointe Cadet, 42100 Saint-Etienne, France
- />Département d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Kremlin-Bicêtre, 78, rue de la division du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- />Service de Pédiatrie, hôpital Sud, CHU de Rennes, 16 Bd Bulgarie, 35203 Rennes, France
- />Service de Pédiatrie, Néphrologie, hôpital des Enfants, CHU de Toulouse, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex, France
- />Service d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Saint-Louis, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service d’Anesthésie Réanimation II, Hôpital du Haut-Lévêque, CHU de Bordeaux, 33600 Pessac, France
- />Service de néphrologie-dialyse, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Européen Georges Pompidou, 20, rue Leblanc, 75908 Paris, France
- />Service de réanimation, hôpital Gabriel Montpied, CHU de Clermont-Ferrand, 58 rue Montalemberg, 63003 Clermont-Ferrand, France
- />Service de réanimation, hôpital Carémeau, CHU de Nîmes, 4 rue du Professeur Robert-Debré, 30029 Nîmes, France
- />Service d’anesthésie-réanimation, hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service de réanimation, centre hospitalier universitaire, CHU d’Angers, 4 rue Larrey, 49100 Angers, France
- />Service d’anesthésie réanimation, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de néphrologie, hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France
- />Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
- />Service d’anesthésie-réanimation, hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, 13385 Marseille Cedex 5, France
| | - Société française de néphrologie (SFN)
- />Service de Réanimation Polyvalente, IRCAN (Inserm U1081, CNRS UMR7284 et CHU de Nice, Hôpital Pasteur 2, 30 Voie Romaine, CHU de Nice, 06000 Nice, France
- />Service de Réanimation, Hôpital Marc Jacquet, 77000 Melun, France
- />Service de Réanimation Polyvalente, CHU de Nice, 30 Voie Romaine, 06000 Nice, France
- />Service de Réanimation médicale, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Louis, 1 Avenue Claude Vellefaux, 75010 Paris, France
- />Service de Réanimation, Assistance Publique-Hôpitaux de Paris, Hôpital d’Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France
- />Département de Médecine périopératoire, Hôpital Estaing, CHU de Clermont-Ferrand, 1 place Louis Aubrac, 63000 Clermont-Ferrand, France
- />Service de réanimation, hôpital de la Charité, CHU de Saint-Etienne, 44 rue Pointe Cadet, 42100 Saint-Etienne, France
- />Département d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Kremlin-Bicêtre, 78, rue de la division du général Leclerc, 94270 Le Kremlin-Bicêtre, France
- />Service de Pédiatrie, hôpital Sud, CHU de Rennes, 16 Bd Bulgarie, 35203 Rennes, France
- />Service de Pédiatrie, Néphrologie, hôpital des Enfants, CHU de Toulouse, 330 avenue de Grande-Bretagne, 31059 Toulouse Cedex, France
- />Service d’anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Saint-Louis, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service d’Anesthésie Réanimation II, Hôpital du Haut-Lévêque, CHU de Bordeaux, 33600 Pessac, France
- />Service de néphrologie-dialyse, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de réanimation, Assistance Publique-Hôpitaux de Paris, hôpital Européen Georges Pompidou, 20, rue Leblanc, 75908 Paris, France
- />Service de réanimation, hôpital Gabriel Montpied, CHU de Clermont-Ferrand, 58 rue Montalemberg, 63003 Clermont-Ferrand, France
- />Service de réanimation, hôpital Carémeau, CHU de Nîmes, 4 rue du Professeur Robert-Debré, 30029 Nîmes, France
- />Service d’anesthésie-réanimation, hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, 1, Avenue Claude-Vellefaux, 75010 Paris, France
- />Service de réanimation, centre hospitalier universitaire, CHU d’Angers, 4 rue Larrey, 49100 Angers, France
- />Service d’anesthésie réanimation, hôpital Édouard-Herriot, Hospices Civils de Lyon, 5, Place d’Arsonval, 69003 Lyon, France
- />Service de néphrologie, hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France
- />Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1 rue de Germont, 76031 Rouen, France
- />Service d’anesthésie-réanimation, hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, 13385 Marseille Cedex 5, France
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Park SK, Hur M, Kim E, Kim WH, Park JB, Kim Y, Yang JH, Jun TG, Kim CS. Risk Factors for Acute Kidney Injury after Congenital Cardiac Surgery in Infants and Children: A Retrospective Observational Study. PLoS One 2016; 11:e0166328. [PMID: 27832187 PMCID: PMC5104485 DOI: 10.1371/journal.pone.0166328] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 10/26/2016] [Indexed: 12/21/2022] Open
Abstract
Acute kidney injury (AKI) after pediatric cardiac surgery is associated with high morbidity and mortality. Modifiable risk factors for postoperative AKI including perioperative anesthesia-related parameters were assessed. The authors conducted a single-center, retrospective cohort study of 220 patients (aged 10 days to 19 years) who underwent congenital cardiac surgery between January and December 2012. The incidence of AKI within 7 days postoperatively was determined using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Ninety-two patients (41.8%) developed AKI and 18 (8.2%) required renal replacement therapy within the first postoperative week. Among patients who developed AKI, 57 patients (25.9%) were KDIGO stage 1, 27 patients (12.3%) were KDIGO stage 2, and eight patients (3.6%) were KDIGO stage 3. RACHS-1 (Risk-Adjusted classification for Congenital Heart Surgery) category, perioperative transfusion and fluid administration as well as fluid overload were compared between patients with and without AKI. Multivariable logistic regression analyses determined the risk factors for AKI. AKI was associated with longer hospital stay or ICU stay, and frequent sternal wound infections. Younger age (<12 months) [odds ratio (OR), 4.01; 95% confidence interval (CI), 1.77–9.06], longer cardiopulmonary bypass (CPB) time (OR, 2.45; 95% CI, 1.24–4.84), and low preoperative hemoglobin (OR, 2.40; 95% CI, 1.07–5.40) were independent risk factors for AKI. Fluid overload was not a significant predictor for AKI. When a variable of hemoglobin concentration increase (>3 g/dl) from preoperative level on POD1 was entered into the multivariable analysis, it was independently associated with postoperative AKI (OR, 6.51; 95% CI, 2.23–19.03 compared with no increase). This association was significant after adjustment with patient demographics, medication history and RACHS-1 category (hemoglobin increase >3g/dl vs. no increase: adjusted OR, 6.94; 95% CI, 2.33–20.69), regardless of different age groups and cyanotic or non-cyanotic heart disease. Prospective trials are required to evaluate whether correction of preoperative anemia and prevention of hemoconcentration may ameliorate postoperative AKI in patients who underwent congenital cardiac surgery.
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Affiliation(s)
- Sun-Kyung Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Min Hur
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eunhee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- * E-mail:
| | - Jung Bo Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Youngwon Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ji-Hyuk Yang
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tae-Gook Jun
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chung Su Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Soh S, Song JW, Shim JK, Kim JH, Kwak YL. Sodium bicarbonate does not prevent postoperative acute kidney injury after off-pump coronary revascularization: a double-blinded randomized controlled trial. Br J Anaesth 2016; 117:450-457. [PMID: 28077531 DOI: 10.1093/bja/aew256] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common morbidity after off-pump coronary revascularization. We investigated whether perioperative administration of sodium bicarbonate, which might reduce renal injury by alleviating oxidative stress in renal tubules, prevents postoperative AKI in off-pump coronary revascularization patients having renal risk factors. METHODS Patients (n=162) having at least one of the following AKI risk factors were enrolled: (i) age >70 yr; (ii) diabetes mellitus; (iii) chronic renal disease; (iv) congestive heart failure or left ventricular ejection fraction <35%; and (v) reoperation or emergency. Patients were evenly randomized to receive either sodium bicarbonate (0.5 mmol kg-1 for 1 h upon induction of anaesthesia followed by 0.15 mmol kg-1 h-1 for 23 h) or 0.9% saline. Acute kidney injury within 48 h after surgery was assessed using the Acute Kidney Injury Network criteria. RESULTS The incidences of AKI were 21 and 26% in the bicarbonate and control groups, respectively (P=0.458). Serially measured serum creatinine concentrations and perioperative fluid balance were also comparable between the groups. The length of postoperative hospitalization and incidence of morbidity end points were similar between the groups, whereas significantly more patients in the bicarbonate group required prolonged mechanical ventilation (>24 h) relative to the control group (20 vs 6, P=0.003). CONCLUSIONS Perioperative sodium bicarbonate administration did not decrease the incidence of AKI after off-pump coronary revascularization in high-risk patients and might even be associated with a need for prolonged ventilatory care. CLINICAL TRIAL REGISTRATION NCT01840241.
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Affiliation(s)
- S Soh
- Department of Anaesthesiology and Pain Medicine and
| | - J W Song
- Department of Anaesthesiology and Pain Medicine and
- Anaesthesia and Pain Research Institute, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea
| | - J K Shim
- Department of Anaesthesiology and Pain Medicine and
- Anaesthesia and Pain Research Institute, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea
| | - J H Kim
- Department of Anaesthesiology and Pain Medicine, National Health Insurance Service Ilsan Hospital, Goyang City, Gyeonggi-do 410-719, Republic of Korea
| | - Y L Kwak
- Department of Anaesthesiology and Pain Medicine and
- Anaesthesia and Pain Research Institute, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea
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Renoprotection by remote ischemic conditioning during elective coronary revascularization: A systematic review and meta-analysis of randomized controlled trials. Int J Cardiol 2016; 222:295-302. [PMID: 27498373 DOI: 10.1016/j.ijcard.2016.07.176] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 07/27/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Remote ischemic conditioning (RIC) has been recognized an emerging non-invasive approach for preventing acute kidney injury (AKI) in patients undergoing either elective coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI). On the other hand, accumulating evidence has indicated the involving role of pre-CABG contrast usage for coronary angiography in post-surgery AKI risk. Along with the shortening time delay of CABG after coronary angiography, and the prevalent hybrid coronary revascularization (HCR), the AKI prevention by RIC has faced challenges following coronary revascuralization. METHODS Randomized controlled trials (RCTs) were searched from Pubmed, EMBase, and Cochrane library (until May 2016). The primary outcome was postoperative AKI. The second outcomes were included the requirement for renal replacement therapy (RRT), and in-hospital or 30-day mortality. RESULTS Twenty eligible RCTs (CABG, 3357 patients; PCI, 1501 patients) were selected. RIC significantly halved the incidence of AKI following PCI when compared with controls [n=1501; odds ratio (OR)=0.51; 95% CI, 0.32 to 0.82; P=0.006; I(2)=29.6%]. However, RIC did not affect the incidence of AKI following CABG (n=1850; OR=0.94; 95% CI, 0.73 to 1.19; P=0.586; I(2)=12.4%). The requirement for RRT and in-hospital mortality was not affected by RIC in CABG (n=2049, OR=1.04, P=0.87; n=1920, OR=0.89, P=0.7; respectively). CONCLUSIONS Our meta-analysis suggests that RIC for preventing AKI following CABG has faced with challenges in terms of AKI, the requirement for RRT, and mortality. However, RIC shows a renoprotective benefit for PCI. Hence, our findings may infer the preserved renal effects of RIC in CABG with preconditioning before the coronary angiography, or in HCR.
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43
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Prediction and Prevention of Acute Kidney Injury after Cardiac Surgery. BIOMED RESEARCH INTERNATIONAL 2016; 2016:2985148. [PMID: 27419130 PMCID: PMC4935903 DOI: 10.1155/2016/2985148] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 05/25/2016] [Accepted: 05/29/2016] [Indexed: 12/17/2022]
Abstract
The incidence of acute kidney injury after cardiac surgery (CS-AKI) ranges from 33% to 94% and is associated with a high incidence of morbidity and mortality. The etiology is suggested to be multifactorial and related to almost all aspects of perioperative management. Numerous studies have reported the risk factors and risk scores and novel biomarkers of AKI have been investigated to facilitate the subclinical diagnosis of AKI. Based on the known independent risk factors, many preventive interventions to reduce the risk of CS-AKI have been tested. However, any single preventive intervention did not show a definite and persistent benefit to reduce the incidence of CS-AKI. Goal-directed therapy has been considered to be a preventive strategy with a substantial level of efficacy. Many pharmacologic agents were tested for any benefit to treat or prevent CS-AKI but the results were conflicting and evidences are still lacking. The present review will summarize the current updated evidences about the risk factors and preventive strategies for CS-AKI.
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44
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Effect of atorvastatin on the incidence of acute kidney injury following valvular heart surgery: a randomized, placebo-controlled trial. Intensive Care Med 2016; 42:1398-407. [DOI: 10.1007/s00134-016-4358-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 04/15/2016] [Indexed: 10/21/2022]
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45
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Li B, Lang X, Cao L, Wang Y, Lu Y, Feng S, Yang Y, Chen J, Jiang H. Effect of remote ischemic preconditioning on postoperative acute kidney injury among patients undergoing cardiac and vascular interventions: a meta-analysis. J Nephrol 2016; 30:19-33. [PMID: 27091767 PMCID: PMC5316401 DOI: 10.1007/s40620-016-0301-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 03/25/2016] [Indexed: 12/17/2022]
Abstract
It is currently controversial whether remote ischemic preconditioning (RIPC) reduces the incidence of acute kidney injury (AKI) in patients undergoing cardiovascular interventions. The main objective of this meta-analysis was to investigate whether RIPC provides renal protection for patients undergoing cardiac or vascular surgery. We searched the PubMed database (1966-Oct 2015), Embase database (1966-Oct 2015), Google Scholar, Cochrane Library, ClinicalTrials Database and Open Grey. Then we conducted a meta-analysis of the randomized controlled trials that met the inclusion criteria of our study. The interventions included use of an inflatable tourniquet around the limbs or cross-clamping of the iliac arteries before surgery (RIPC groups) and general cardiovascular intervention (control groups). The main outcomes examined included the incidence of AKI; changes in acute kidney injury biomarkers; and use of renal replacement therapy. Other outcomes examined included in-hospital mortality and the lengths of hospital stay and intensive care unit (ICU) stay. Finally, we screened 26 eligible studies containing 6699 patients who underwent cardiac or vascular interventions with RIPC (n = 3343) or without RIPC (n = 3356). The AKI incidence was decreased in the RIPC group as was the length of ICU stay. There were no differences in the changes in AKI biomarkers, use of renal replacement therapy or in-hospital mortality between the two groups. Remote ischemic preconditioning may decrease the occurrence of AKI in cardiovascular surgery patients. Since studies included have a significant heterogeneity, meta-analyses using a stricter inclusion criteria are needed to clarify the renoprotection effect of RIPC.
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Affiliation(s)
- Bingjue Li
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Xiabing Lang
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Luxi Cao
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Yuchen Wang
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Yingying Lu
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Shi Feng
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Yi Yang
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Jianghua Chen
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China.,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China.,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China
| | - Hong Jiang
- Kidney Disease Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qinchun Road 79#, Hangzhou, 310003, People's Republic of China. .,Kidney Disease Immunology Laboratory, The Third Grade Laboratory, State Administration of Traditional Chinese Medicine of P.R. China, Hangzhou, People's Republic of China. .,Key Laboratory of Multiple Organ Transplantation, Ministry of Health, Hangzhou, People's Republic of China. .,Key Laboratory of Nephropathy, Zhejiang Province, Hangzhou, Zhejiang, People's Republic of China.
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Weinberg L, Broad J, Pillai P, Chen G, Nguyen M, Eastwood GM, Scurrah N, Nikfarjam M, Story D, McNicol L, Bellomo R. Sodium bicarbonate infusion in patients undergoing orthotopic liver transplantation: a single center randomized controlled pilot trial. Clin Transplant 2016; 30:556-65. [DOI: 10.1111/ctr.12721] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Laurence Weinberg
- Department of Anesthesia; The University of Melbourne; Melbourne Vic. Australia
- Department of Surgery and Centre for Anesthesia, Perioperative and Pain Medicine; The University of Melbourne; Melbourne Vic. Australia
| | - Jeremy Broad
- Department of Anesthesia; Austin Hospital; Heidelberg Vic. Australia
| | - Param Pillai
- Department of Anesthesia; Austin Hospital; Heidelberg Vic. Australia
| | - Guangjun Chen
- Department of Anesthesia; Austin Hospital; Heidelberg Vic. Australia
| | - Micheline Nguyen
- Department of Anesthesia; Austin Hospital; Heidelberg Vic. Australia
- Department of Anesthesiology; CHUM St-Luc Hospital; Montreal QC Canada
| | - Glenn M. Eastwood
- Faculty of Health; School of Nursing & Midwifery; Deakin University; Heidelberg Vic. Australia
- Faculty of MN&HS; Monash University; Heidelberg Vic. Australia
- Austin Hospital; Heidelberg Vic. Australia
| | - Nick Scurrah
- Department of Anesthesia; Austin Hospital; University of Melbourne; Heidelberg Vic. Australia
- Department of Surgery; Austin Hospital; University of Melbourne; Heidelberg Vic. Australia
| | | | - David Story
- Centre for Anesthesia, Perioperative and Pain Medicine; The University of Melbourne; Melbourne Vic. Australia
| | | | - Rinaldo Bellomo
- Department of Intensive Care; Austin Hospital; Heidelberg Vic. Australia
- The University of Melbourne; Melbourne Vic. Australia
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Remote ischemic conditioning for kidney protection: A meta-analysis. J Crit Care 2016; 33:224-32. [PMID: 26936039 DOI: 10.1016/j.jcrc.2016.01.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 12/30/2015] [Accepted: 01/31/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Results from randomized controlled trials (RCTs) concerning kidney effect of remote ischemic conditioning (RIC) are inconsistent. METHODS We searched for relevant studies in Medline, Embase, the Cochrane Library, Google Scholar and Chinese database (SinoMed), as well as relevant references from their inception to November 2015. We performed a systematic review and meta-analysis of all eligible RCTs of RIC with kidney events. RESULTS We included 37 RCTs from 2007 to 2015 involving 8168 patients. Pooled analyses of all RCTs showed RIC significantly reduced the incidence of investigator-defined acute kidney injury (AKI) compared with control groups (RR 0.84, 95% CI 0.73-0.96, P = .009) (I(2) = 25%). However, the difference was not significant when only RIFLE (Risk, Injury, Failure, Loss, End Stage), AKIN (Acute Kidney Injury Network), or KDIGO (Kidney Disease Improving Global Outcomes) criteria were applied to the definition of AKI (RR 0.87, 95% CI 0.74-1.02, P = .08) (I(2) = 22%). In subgroup analysis, RIC showed a significant benefit on reducing investigator-defined AKI in patients following percutaneous coronary intervention (RR 0.64, 95% CI 0.46-0.87), but not after cardiac surgery (RR 0.93, 95% CI 0.82-1.06). There was no difference for changes in the incidence of renal replacement therapy, estimated glomerular filtration rate or serum creatinine. CONCLUSIONS RIC might be beneficial for the prevention of investigator-defined AKI; however, the effect is likely small. Moreover, due to lack of an effect on use of renal replacement therapy, estimated glomerular filtration rate, RIFLE, AKIN, or KDIGO-defined AKI, and serum creatinine, the evidence for RIC is not robust. Finally, recent large-scale RCTs of RIC focusing on patient-centered outcomes do not support the wider application of RIC.
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Efficacy and safety of perioperative sodium bicarbonate therapy for cardiac surgery-associated acute kidney injury: a meta-analysis. J Cardiovasc Pharmacol 2016; 65:130-6. [PMID: 25264756 DOI: 10.1097/fjc.0000000000000169] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Urinary alkalinization with sodium bicarbonate infusion can theoretically protect against the mechanisms of acute kidney injury (AKI). Controversy exists regarding whether sodium bicarbonate infusion can reduce the incidence of AKI from cardiac surgery. A meta-analysis was conducted to show the efficacy and safety of perioperative sodium bicarbonate use for preventing AKI in patients undergoing cardiac surgery. DATA SOURCES PubMed, CBM, EMBASE, CENTRAL, and Cochrane renal group specialized register were searched for pertinent studies. STUDY SELECTION Randomized controlled trails and prospective observational cohort studies that compared sodium bicarbonate with sodium chloride or blank control in cardiac surgery with cardiopulmonary bypass were included. Exclusion criteria were duplicate publications, nonadult studies, oral administration of sodium bicarbonate, retrospective analyses, and studies with small sample size (n < 50) or with no data on AKI. DATA EXTRACTION Study end points, study design, population, operation information, and sodium bicarbonate doses were extracted. DATA SYNTHESIS Data from 1673 patients in 5 randomized trials and 1 prospective observational cohort study were analyzed. The analysis showed that sodium bicarbonate did not reduce the incidence of postoperative AKI and the need for renal replacement therapy. Postoperative ventilation time, hospital length of stay, hospital death, and mortality within 90 days had no statistical difference between 2 groups. Time in intensive care unit was even slightly longer in the experimental group. CONCLUSIONS Urinary alkalinization using sodium bicarbonate infusion failed to reduce the incidence rate of AKI or other outcomes in patients undergoing cardiac surgery. This intervention might even prolong intensive care unit stay.
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Cheng H, Sun JZ, Ji FH, Liu H. Prevention and Treatment of Cardiac Surgery Associated Acute Kidney Injury. JOURNAL OF ANESTHESIA AND PERIOPERATIVE MEDICINE 2016; 3:42-51. [PMID: 31598583 PMCID: PMC6785192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
AIM OF REVIEW Acute kidney injury (AKI) after cardiac surgery is a relatively common postoperative complication and is independently related to increased mortality and morbidity. METHOD In this review, we will focus on risk factors of developing AKI, early detection by biomarkers and preventive strategies for AKI after adult cardiac surgery. RECENT FINDINGS Many perioperative factors affect renal function and acute AKI following cardiac surgery. Novel biomarkers of kidney injury such as neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18 (IL-18), cystatin C (CysC), have the potential to facilitate the early diagnosis of cardiac surgery associated AKI (CSA-AKI). Pharmacological interventions have been inconsistent to their efficacy, and to date, there is no compelling pharmacologic agent known to reduce the risk of AKI or treat established AKI. SUMMARY Preventive strategies of AKI focus on optimal perioperative management.
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Affiliation(s)
- Hao Cheng
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China,Department of Anesthesiology and Pain Medicine, University of California Davis Health System, Sacramento, USA
| | - Jian-Zhong Sun
- Department of Anesthesiology, Thomas Jefferson University and Hospitals, Philadelphia, USA
| | - Fu-Hai Ji
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California Davis Health System, Sacramento, USA
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Zhou C, Gong J, Chen D, Wang W, Liu M, Liu B. Levosimendan for Prevention of Acute Kidney Injury After Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials. Am J Kidney Dis 2015; 67:408-16. [PMID: 26518388 DOI: 10.1053/j.ajkd.2015.09.015] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 09/03/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND Levosimendan has been shown to confer direct renoprotection in renal endotoxemic and ischemia-reperfusion injury and could increase renal blood flow in patients with low-cardiac-output heart failure. Results from clinical trials of levosimendan on acute kidney injury (AKI) following cardiac surgery are controversial. STUDY DESIGN A random-effect meta-analysis was conducted based on evidence from PubMed, EMBASE, and Cochrane Library. SETTINGS & POPULATION Adult patients undergoing cardiac surgery. SELECTION CRITERIA FOR STUDIES Randomized controlled trials comparing the renal effect of levosimendan versus placebo or other inotropic drugs during cardiac surgery. INTERVENTION Perioperative levosimendan continuous infusion at a rate of 0.1 to 0.2μg/kg/min following a loading dose (6-24μg/kg) for 24 hours or only 1 loading dose (24μg/kg) within 1 hour. OUTCOMES AKI, need for renal replacement therapy, mechanical ventilation duration, intensive care unit stay during hospitalization, and postoperative mortality (in-hospital or within 30 days). RESULTS 13 trials with a total of 1,345 study patients were selected. Compared with controls, levosimendan reduced the incidence of postoperative AKI (40/460 vs 78/499; OR, 0.51; 95% CI, 0.34-0.76; P=0.001; I(2)=0.0%), renal replacement therapy (22/492 vs 49/491; OR, 0.43; 95% CI, 0.25-0.76; P=0.002; I(2)=0.0%), postoperative mortality (35/658 vs 94/657; OR, 0.41; 95% CI, 0.27-0.62; P<0.001; I(2)=0.0%), mechanical ventilation duration (in days; n=235; weighted mean difference, -0.34; 95% CI, -0.58 to -0.09; P=0.007], and intensive care unit stay (in days; n=500; weighted mean difference, -2.2; 95% CI, -4.21 to -0.13; P=0.04). LIMITATIONS Different definitions for AKI among studies. Small sample size for some trials. CONCLUSIONS Perioperative administration of levosimendan in patients undergoing cardiac surgery may reduce complications. Future trials are needed to determine the dose effect of levosimendan in improving outcomes, especially in patients with decreased baseline kidney function.
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Affiliation(s)
- Chenghui Zhou
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Junsong Gong
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dong Chen
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weipeng Wang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mingzheng Liu
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Liu
- Department of Anesthesiology, Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, China.
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