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Mishra S, Shelke V, Dagar N, Lech M, Gaikwad AB. Immunosuppressants against acute kidney injury: what to prefer or to avoid? Immunopharmacol Immunotoxicol 2024; 46:341-354. [PMID: 38477877 DOI: 10.1080/08923973.2024.2330641] [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: 08/14/2023] [Accepted: 03/09/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Acute kidney injury (AKI) is a critical global health issue associated with high mortality rates, particularly in patients undergoing renal transplants and major surgeries. These individuals often receive immunosuppressants to dampen immune responses, but the impact of these drugs on AKI remains unclear. OBJECTIVE This review aims to provide a detailed understanding of the effects of different classes of immunosuppressants against AKI, elucidating their role in either exacerbating or mitigating the occurrence or progression of AKI. METHODS Several preclinical and clinical reports were analyzed to evaluate the impact of various immunosuppressants on AKI. Relevant preclinical and clinical studies were reviewed through different databases such as Scopus, PubMed, Google Scholar, and ScienceDirect, and official websites like https://clinicaltrials.gov to understand the mechanisms underlying the effects of immunosuppressants on kidney function. RESULTS AND DISCUSSION Specific immunosuppressants have been linked to the progression of AKI, while others demonstrate renoprotective effects. However, there is no consensus on the preferred or avoided immunosuppressants for AKI patients. This review outlines the classes of immunosuppressants commonly used and their impact on AKI, providing guidance for physicians in selecting appropriate drugs to prevent or ameliorate AKI. CONCLUSION Understanding the effects of immunosuppressants on AKI is crucial for optimizing patient care. This review highlights the need for further research to determine the most suitable immunosuppressants for AKI patients, considering both their efficacy and potential side effects.
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Affiliation(s)
- Swati Mishra
- Department of Pharmacy, Birla Institute of Technology and Science Pilani, Pilani Campus, Rajasthan, India
| | - Vishwadeep Shelke
- Department of Pharmacy, Birla Institute of Technology and Science Pilani, Pilani Campus, Rajasthan, India
| | - Neha Dagar
- Department of Pharmacy, Birla Institute of Technology and Science Pilani, Pilani Campus, Rajasthan, India
| | - Maciej Lech
- Division of Nephrology, Department of Medicine IV, LMU University Hospital, Ludwig Maximilians University Munich, Munich, Germany
| | - Anil Bhanudas Gaikwad
- Department of Pharmacy, Birla Institute of Technology and Science Pilani, Pilani Campus, Rajasthan, India
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Abbasciano RG, Olivieri GM, Chubsey R, Gatta F, Tyson N, Easwarakumar K, Fudulu DP, Marsico R, Kofler M, Elshafie G, Lai F, Loubani M, Kendall S, Zakkar M, Murphy GJ. Prophylactic corticosteroids for cardiopulmonary bypass in adult cardiac surgery. Cochrane Database Syst Rev 2024; 3:CD005566. [PMID: 38506343 PMCID: PMC10952358 DOI: 10.1002/14651858.cd005566.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND Cardiac surgery triggers a strong inflammatory reaction, which carries significant clinical consequences. Corticosteroids have been suggested as a potential perioperative strategy to reduce inflammation and help prevent postoperative complications. However, the safety and effectiveness of perioperative corticosteroid use in adult cardiac surgery is uncertain. This is an update of the 2011 review with 18 studies added. OBJECTIVES Primary objective: to estimate the effects of prophylactic corticosteroid use in adults undergoing cardiac surgery with cardiopulmonary bypass on the: - co-primary endpoints of mortality, myocardial complications, and pulmonary complications; and - secondary outcomes including atrial fibrillation, infection, organ injury, known complications of steroid therapy, prolonged mechanical ventilation, prolonged postoperative stay, and cost-effectiveness. SECONDARY OBJECTIVE to explore the role of characteristics of the study cohort and specific features of the intervention in determining the treatment effects via a series of prespecified subgroup analyses. SEARCH METHODS We used standard, extensive Cochrane search methods to identify randomised studies assessing the effect of corticosteroids in adult cardiac surgery. The latest searches were performed on 14 October 2022. SELECTION CRITERIA We included randomised controlled trials in adults (over 18 years, either with a diagnosis of coronary artery disease or cardiac valve disease, or who were candidates for cardiac surgery with the use of cardiopulmonary bypass), comparing corticosteroids with no treatments. There were no restrictions with respect to length of the follow-up period. All selected studies qualified for pooling of results for one or more endpoints. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were all-cause mortality, and cardiac and pulmonary complications. Secondary outcomes were infectious complications, gastrointestinal bleeding, occurrence of new post-surgery atrial fibrillation, re-thoracotomy for bleeding, neurological complications, renal failure, inotropic support, postoperative bleeding, mechanical ventilation time, length of stays in the intensive care unit (ICU) and hospital, patient quality of life, and cost-effectiveness. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS This updated review includes 72 randomised trials with 17,282 participants (all 72 trials with 16,962 participants were included in data synthesis). Four trials (6%) were considered at low risk of bias in all the domains. The median age of participants included in the studies was 62.9 years. Study populations consisted mainly (89%) of low-risk, first-time coronary artery bypass grafting (CABG) or valve surgery. The use of perioperative corticosteroids may result in little to no difference in all-cause mortality (risk with corticosteroids: 25 to 36 per 1000 versus 33 per 1000 with placebo or no treatment; risk ratio (RR) 0.90, 95% confidence interval (CI) 0.75 to 1.07; 25 studies, 14,940 participants; low-certainty evidence). Corticosteroids may increase the risk of myocardial complications (68 to 86 per 1000) compared with placebo or no treatment (66 per 1000; RR 1.16, 95% CI 1.04 to 1.31; 25 studies, 14,766 participants; low-certainty evidence), and may reduce the risk of pulmonary complications (risk with corticosteroids: 61 to 77 per 1000 versus 78 per 1000 with placebo/no treatment; RR 0.88, 0.78 to 0.99; 18 studies, 13,549 participants; low-certainty evidence). Analyses of secondary endpoints showed that corticosteroids may reduce the incidence of infectious complications (risk with corticosteroids: 94 to 113 per 1000 versus 123 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.76 to 0.92; 28 studies, 14,771 participants; low-certainty evidence). Corticosteroids may result in little to no difference in incidence of gastrointestinal bleeding (risk with corticosteroids: 9 to 17 per 1000 versus 10 per 1000 with placebo/no treatment; RR 1.21, 95% CI 0.87 to 1.67; 6 studies, 12,533 participants; low-certainty evidence) and renal failure (risk with corticosteroids: 23 to 35 per 1000 versus 34 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.69 to 1.02; 13 studies, 12,799; low-certainty evidence). Corticosteroids may reduce the length of hospital stay, but the evidence is very uncertain (-0.5 days, 0.97 to 0.04 fewer days of length of hospital stay compared with placebo/no treatment; 25 studies, 1841 participants; very low-certainty evidence). The results from the two largest trials included in the review possibly skew the overall findings from the meta-analysis. AUTHORS' CONCLUSIONS A systematic review of trials evaluating the organ protective effects of corticosteroids in cardiac surgery demonstrated little or no treatment effect on mortality, gastrointestinal bleeding, and renal failure. There were opposing treatment effects on cardiac and pulmonary complications, with evidence that corticosteroids may increase cardiac complications but reduce pulmonary complications; however, the level of certainty for these estimates was low. There were minor benefits from corticosteroid therapy for infectious complications, but the evidence on hospital length of stay was very uncertain. The inconsistent treatment effects across different outcomes and the limited data on high-risk groups reduced the applicability of the findings. Further research should explore the role of these drugs in specific, vulnerable cohorts.
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Affiliation(s)
| | | | - Rachel Chubsey
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Francesca Gatta
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Nathan Tyson
- Department of Cardiac Surgery, University Hospitals of Leicester, Leicester, UK
| | | | - Daniel P Fudulu
- Department of Cardiac Surgery, University Hospital Bristol NHS Trust, Bristol, UK
| | | | | | - Ghazi Elshafie
- Department of Cardiothoracic Surgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Florence Lai
- Leicester Clinical Trials Unit, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | | | - Mustafa Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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Ma K, Liu JF, Zheng ZR, Li HY, Hu B, Meng Y. The polarization of M2 macrophages can be adjusted to alleviate renal injury by methylprednisolone in sepsis-AKI. Arch Biochem Biophys 2023; 747:109738. [PMID: 37696383 DOI: 10.1016/j.abb.2023.109738] [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: 06/17/2023] [Revised: 08/21/2023] [Accepted: 09/03/2023] [Indexed: 09/13/2023]
Abstract
Acute kidney injury in sepsis patients has an extreme mortality rate in clinical. It obviously seems that immune cells, for example, macrophages are involved with this process. Macrophages, as highly important immune cells, play a significant role in the development of human kidney diseases. But the specific role of macrophages in this process is still unclear. Under different timeline points, we surprisingly found that macrophages had the most dynamic changes in acute kidney injury immune cells. Based on macrophages' functions, they are primarily classified into M1 macrophages (pro-inflammatory) and M2 macrophages (anti-inflammatory). The polarization of M2 macrophages is closely associated with the seriousness of sepsis-induced kidney injury, but how to modulate their polarization to alleviate sepsis-associated renal damage remains unknown. We discovered that the polarization of M2 macrophages after methylprednisolone injection can significantly alleviate acute kidney injury by reducing secreted cytokine. This study suggests that the proportion of macrophage subtypes can be regulated by methylprednisolone to alleviate acute kidney injury in sepsis to provide a new sight for a clinical to provide a promising strategy for renal injury caused.
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Affiliation(s)
- Ke Ma
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Guangzhou, 510000, China; Institute of Nephrology, Jinan University, Guangzhou, 510632, China
| | - Jin-Feng Liu
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Guangzhou, 510000, China; Institute of Nephrology, Jinan University, Guangzhou, 510632, China
| | - Zi-Run Zheng
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Guangzhou, 510000, China; Institute of Nephrology, Jinan University, Guangzhou, 510632, China
| | - Hong-Yue Li
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Guangzhou, 510000, China; Institute of Nephrology, Jinan University, Guangzhou, 510632, China
| | - Bo Hu
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Guangzhou, 510000, China; Department of Nephrology, The Fifth Affiliated Hospital of Jinan University, Heyuan, 570000, China; Institute of Nephrology, Jinan University, Guangzhou, 510632, China.
| | - Yu Meng
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Guangzhou, 510000, China; Department of Nephrology, The Fifth Affiliated Hospital of Jinan University, Heyuan, 570000, China; Institute of Nephrology, Jinan University, Guangzhou, 510632, 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] [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
- *Correspondence: Chih-Hsiang Chang,
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Narrative Review: Glucocorticoids in Alcoholic Hepatitis—Benefits, Side Effects, and Mechanisms. J Xenobiot 2022; 12:266-288. [PMID: 36278756 PMCID: PMC9589945 DOI: 10.3390/jox12040019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/03/2022] [Accepted: 09/05/2022] [Indexed: 11/17/2022] Open
Abstract
Alcoholic hepatitis is a major health and economic burden worldwide. Glucocorticoids (GCs) are the only first-line drugs recommended to treat severe alcoholic hepatitis (sAH), with limited short-term efficacy and significant side effects. In this review, I summarize the major benefits and side effects of GC therapy in sAH and the potential underlying mechanisms. The review of the literature and data mining clearly indicate that the hepatic signaling of glucocorticoid receptor (GR) is markedly impaired in sAH patients. The impaired GR signaling causes hepatic down-regulation of genes essential for gluconeogenesis, lipid catabolism, cytoprotection, and anti-inflammation in sAH patients. The efficacy of GCs in sAH may be compromised by GC resistance and/or GC’s extrahepatic side effects, particularly the side effects of intestinal epithelial GR on gut permeability and inflammation in AH. Prednisolone, a major GC used for sAH, activates both the GR and mineralocorticoid receptor (MR). When GC non-responsiveness occurs in sAH patients, the activation of MR by prednisolone might increase the risk of alcohol abuse, liver fibrosis, and acute kidney injury. To improve the GC therapy of sAH, the effort should be focused on developing the biomarker(s) for GC responsiveness, liver-targeting GR agonists, and strategies to overcome GC non-responsiveness and prevent alcohol relapse in sAH patients.
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Saeed H, Abdelrahim ME. A meta-analysis of pharmacological treatments for preventing acute renal injury after juvenile heart surgery. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Chen L, Xiang F, Hu Y. Corticosteroids in patients undergoing cardiac surgery: A meta-analysis of 12,559 patients. Perfusion 2022; 38:853-859. [PMID: 35657725 DOI: 10.1177/02676591221106324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Corticosteroids can attenuate the inflammatory response to cardiopulmonary bypass, but their benefits on clinical outcomes are unclear. We conducted a meta-analysis to evaluate whether corticosteroid therapy affects outcomes in patients undergoing cardiac surgery. METHODS We searched PubMed, Embase, EBSCO and Cochrane databases from 1 January 2010 to 14 March 2022 for randomized controlled trials (RCTs) that assessed corticosteroid versus non- corticosteroid therapy in patients undergoing cardiac surgery. The primary outcome was in-hospital mortality. Secondary outcomes were renal failure, infection, delirium, intensive care unit (ICU) and hospital stay. RESULTS Four RCTs including 12,559 patients (6265 randomized to corticosteroid therapy and 6294 to non-corticosteroid therapy) were included. One-hundred and 92 of 6265 patients (3.1%) randomized to the corticosteroid group versus 221 of 6294 patients (3.5%) randomized to the non-corticosteroid group experienced death during hospitalization. Compared the control group, corticosteroid therapy did not significantly reduce in-hospital mortality, with an RR of 0.87 (0.72-1.06), p = .16. There was no difference in the incidence of infection (RR 0.78 (0.56-1.10), p = .16), delirium during hospitalization (RR 1.01 (0.90-1.14), p = .85), or the length of hospital stay (MD -0.13 (-0.32 to 0.05), p = .17). However, corticosteroid therapy significantly reduced the risk of renal failure ( RR 0.82 (0.67-0.99), p = .04), and the length of ICU stay (MD -0.41 (-0.65 to -0.17), p < .01). CONCLUSIONS Corticosteroids did not significantly reduce the rates of in-hospital mortality, infection, or delirium, but reduce the incidence of renal failure and the length of ICU stay.
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Affiliation(s)
- Lei Chen
- Department of Pharmacy, 26452The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Feng Xiang
- Department of Pharmacy, 26452The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Yiyi Hu
- Department of Pharmacy, 26452The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
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CSA-AKI: Incidence, Epidemiology, Clinical Outcomes, and Economic Impact. J Clin Med 2021; 10:jcm10245746. [PMID: 34945041 PMCID: PMC8706363 DOI: 10.3390/jcm10245746] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/01/2021] [Accepted: 12/05/2021] [Indexed: 12/13/2022] Open
Abstract
Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common complication following cardiac surgery and reflects a complex biological combination of patient pathology, perioperative stress, and medical management. Current diagnostic criteria, though increasingly standardized, are predicated on loss of renal function (as measured by functional biomarkers of the kidney). The addition of new diagnostic injury biomarkers to clinical practice has shown promise in identifying patients at risk of renal injury earlier in their course. The accurate and timely identification of a high-risk population may allow for bundled interventions to prevent the development of CSA-AKI, but further validation of these interventions is necessary. Once the diagnosis of CSA-AKI is established, evidence-based treatment is limited to supportive care. The cost of CSA-AKI is difficult to accurately estimate, given the diverse ways in which it impacts patient outcomes, from ICU length of stay to post-hospital rehabilitation to progression to CKD and ESRD. However, with the global rise in cardiac surgery volume, these costs are large and growing.
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McIlroy DR, Roman B, Billings FT, Bollen BA, Fox A, Geube M, Liu H, Shore-Lesserson L, Zarbock A, Shaw AD. Potential Renoprotective Strategies in Adult Cardiac Surgery: A Survey of Society of Cardiovascular Anesthesiologists Members to Explore the Rationale and Beliefs Driving Current Clinical Decision-Making. J Cardiothorac Vasc Anesth 2021; 35:2043-2051. [PMID: 33674203 PMCID: PMC9933995 DOI: 10.1053/j.jvca.2021.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/29/2021] [Accepted: 02/01/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The authors sought to (1) characterize the rationale underpinning anesthesiologists' use of various perioperative strategies hypothesized to affect renal function in adult patients undergoing cardiac surgery, (2) characterize existing belief about the quality of evidence addressing the renal impact of these strategies, and (3) identify potentially renoprotective strategies for which anesthesiologists would most value a detailed, evidence-based review. DESIGN Survey of perioperative practice in adult patients undergoing cardiac surgery. SETTING Online survey. PARTICIPANTS Members of the Society of Cardiovascular Anesthesiologists (SCA). INTERVENTIONS None. MEASUREMENTS & MAIN RESULTS The survey was distributed to more than 2,000 SCA members and completed in whole or in part by 202 respondents. Selection of target intraoperative blood pressure (and relative hypotension avoidance) was the strategy most frequently reported to reflect belief about its potential renal effect (79%; 95% CI: 72-85). Most respondents believed the evidence supporting an effect on renal injury of intraoperative target blood pressure during cardiac surgery was of high or moderate quality. Other factors, including a specific nonrenal rationale, surgeon preference, department- or institution-level decisions, tradition, or habit, also frequently were reported to affect decision making across queried strategies. Potential renoprotective strategies most frequently requested for inclusion in a subsequent detailed, evidence-based review were intraoperative target blood pressure and choice of vasopressor agent to achieve target pressure. CONCLUSIONS A large number of perioperative strategies are believed to variably affect renal injury in adult patients undergoing cardiac surgery, with wide variation in perceived quality of evidence for a renal effect of these strategies.
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Affiliation(s)
- David R McIlroy
- Vanderbilt University Medical Center, Nashville, TN; Monash University, Commercial Road, Melbourne, Victoria, Australia.
| | - Bennett Roman
- Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA 70121
| | | | - Bruce A Bollen
- Missoula Anesthesiology and The International Heart Institute of Montana, 500 W Broadway St, Missoula, MT 59802
| | - Amanda Fox
- UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, Tx, 75390
| | - Mariya Geube
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44122
| | - Hong Liu
- University of California Davis Health, 4150 V Street, Sacramento, CA, 95817
| | - Linda Shore-Lesserson
- Zucker School of Medicine at Hofstra Northwell, 300 Community Drive, Manhasset, NY, 11030
| | | | - Andrew D Shaw
- University of Alberta, 8440-112 Street NW, Edmonton, AB, T6G 2G3, Canada
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Intraoperative cerebral oximetry in open heart surgeries reduced postoperative complications: A retrospective study. PLoS One 2021; 16:e0251157. [PMID: 34038405 PMCID: PMC8153416 DOI: 10.1371/journal.pone.0251157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 01/31/2021] [Indexed: 11/19/2022] Open
Abstract
Cardiothoracic surgeries are life-saving procedures but often it results in various complications. Intraoperative cerebral oximetry monitoring used to detect regional cerebral oxygen saturation (rScO2) is a non-invasive method that provides prognostic importance in cardiac surgery. The main aim of the present study was to evaluate the association of intraoperative cerebral oxygen monitoring during cardiac surgery on postoperative complications. This was a case-controlled retrospective study conducted on adult patients, who underwent open-heart surgery in National Heart Institute, Malaysia. The case group comprised patients on protocolized cerebral oximetry monitoring. They were treated using a standardized algorithm to maintain rScO2 not lower than 20% of baseline rScO2. The control group comprised patients with matched demographic background, preoperative risk factors, and type of surgical procedures. Propensity score stratification was utilized to contend with selection bias. Retrospective analysis was performed on 240 patients (case group) while comparing it to 407 patients (control group). The non-availability of cerebral oximetry monitoring during surgery was the prominent predictor for all outcome of complications; stroke (OR: 7.66), renal failure needing dialysis (OR: 5.12) and mortality (OR: 20.51). Postoperative complications revealed that there were significant differences for risk of mortality (p<0.001, OR = 20.51), renal failure that required dialysis (p<0.001, OR = 5.12) and stroke (p <0.05, OR = 7.66). Protocolized cerebral oximetry monitoring during cardiothoracic surgeries was found to be associated with lower incidence of stroke, renal failure requiring dialysis and mortality rate.
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McWilliam SJ, Wright RD, Welsh GI, Tuffin J, Budge KL, Swan L, Wilm T, Martinas IR, Littlewood J, Oni L. The complex interplay between kidney injury and inflammation. Clin Kidney J 2021; 14:780-788. [PMID: 33777361 PMCID: PMC7986351 DOI: 10.1093/ckj/sfaa164] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 06/10/2020] [Indexed: 12/11/2022] Open
Abstract
Acute kidney injury (AKI) has gained significant attention following patient safety alerts about the increased risk of harm to patients, including increased mortality and hospitalization. Common causes of AKI include hypovolaemia, nephrotoxic medications, ischaemia and acute glomerulonephritis, although in reality it may be undetermined or multifactorial. A period of inflammation either as a contributor to the kidney injury or resulting from the injury is almost universally seen. This article was compiled following a workshop exploring the interplay between injury and inflammation. AKI is characterized by some degree of renal cell death through either apoptosis or necrosis, together with a strong inflammatory response. Studies interrogating the resolution of renal inflammation identify a whole range of molecules that are upregulated and confirm that the kidneys are able to intrinsically regenerate after an episode of AKI, provided the threshold of damage is not too high. Kidneys are unable to generate new nephrons, and dysfunctional or repeated episodes will lead to further nephron loss that is ultimately associated with the development of renal fibrosis and chronic kidney disease (CKD). The AKI to CKD transition is a complex process mainly facilitated by maladaptive repair mechanisms. Early biomarkers mapping out this process would allow a personalized approach to identifying patients with AKI who are at high risk of developing fibrosis and subsequent CKD. This review article highlights this process and explains how laboratory models of renal inflammation and injury assist with understanding the underlying disease process and allow interrogation of medications aimed at targeting the mechanistic interplay.
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Affiliation(s)
- Stephen J McWilliam
- Department of Paediatric Pharmacology, Alder Hey Children’s Hospital, Liverpool, UK
- Department of Women and Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Rachael D Wright
- Department of Women and Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Gavin I Welsh
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jack Tuffin
- Bristol Renal, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kelly L Budge
- Department of Women and Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Laura Swan
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Thomas Wilm
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Ioana-Roxana Martinas
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - James Littlewood
- Department of Cellular and Molecular Physiology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Nephrology, Royal Liverpool University Hospital, Liverpool, UK
| | - Louise Oni
- Department of Women and Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Paediatric Nephrology, Alder Hey Children’s NHS Foundation Trust Hospital, Liverpool, UK
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12
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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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13
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Gutsche JT, Grant MC, Kiefer JJ, Ghadimi K, Lane-Fall MB, Mazzeffi MA. The Year in Cardiothoracic Critical Care: Selected Highlights from 2019. J Cardiothorac Vasc Anesth 2020; 36:45-57. [PMID: 33051148 DOI: 10.1053/j.jvca.2020.09.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 11/11/2022]
Abstract
In 2019, cardiothoracic and vascular critical care remained an important focus and subspecialty. This article continues the annual series to review relevant contributions in postoperative critical care that may affect the cardiac anesthesiologist. Herein, the pertinent literature published in 2019 is explored and organized by organ system.
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Affiliation(s)
- J T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - M C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J J Kiefer
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - K Ghadimi
- Department of Anesthesiology and Critical Care, Duke University, Durham, NC
| | - M B Lane-Fall
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - M A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
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14
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Venugopal H, Jacob KA, Dieleman JM, Leaf DE. Dexamethasone for Preventing Major Adverse Kidney Events following Cardiac Surgery: Post-Hoc Analysis to Identify Subgroups. KIDNEY360 2020; 1:530-533. [PMID: 35368593 DOI: 10.34067/kid.0000812019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Hema Venugopal
- Department of Cardiothoracic Surgery, University Medical Center, Utrecht, The Netherlands
| | - Kirolos A Jacob
- Department of Cardiothoracic Surgery, University Medical Center, Utrecht, The Netherlands
| | - Jan M Dieleman
- Department of Anaesthesia, Westmead Hospital, Sydney, New South Wales, Australia
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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15
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Dou F, Ding Y, Wang C, Duan J, Wang W, Xu H, Zhao X, Wang J, Wen A. Chrysophanol ameliorates renal interstitial fibrosis by inhibiting the TGF-β/Smad signaling pathway. Biochem Pharmacol 2020; 180:114079. [PMID: 32511988 DOI: 10.1016/j.bcp.2020.114079] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/01/2020] [Accepted: 06/03/2020] [Indexed: 02/06/2023]
Abstract
Renal interstitial fibrosis (RIF) is a major pathological feature of chronic kidney disease at middle and end stages. Chrysophanol (CP), 1,8-dihydroxy-3-methyl-9,10-anthraquinone, is an anthraquinone isolated from Rheum palmatum L. with a variety of pharmacological activities including the suppression of RIF. However, the effect of CP on renal fibrosis and its potential mechanism have not been elucidated. We conducted a comprehensive study by determining the expression levels of fibrotic markers and proteins including TGF-β1, α-SMA, and Smad3 related to transforming growth factor-beta/Smad (TGF-β/Smad) pathway in unilateral ureteral obstruction (UUO) mice and TGF-β1-stimulated HK-2 cells with the treatment of CP using western blotting and RT-qPCR analyses. Using small interfering RNA and co-immunoprecipitation, we evaluated the influences of CP on the interactions between Smad3 and Smad7 proteins and also on TGF-β RI and TGF-βR II. We found that CP administration significantly ameliorated UUO-induced kidney damage by reversing abnormal serum and urine biochemical parameters and decreasing the production of fibrotic markers including collagen I, collagen III, fibronectin, and α-SMA. Our results showed that TGF-β1 and phospho-Smad3 (p-Smad3) expression was significantly down-regulated and Smad7 expression was up-regulated by CP in UUO mice compared to the model group; however, the expression of Smad2, Smad4, and TGF-β receptors was not affected. Furthermore, CP modulated these fibrotic markers as well as p-Smad3 and Smad7 in TGF-β1-induced HK-2 cells. The inhibitory effect of CP was markedly reduced in TGF-β1-treated HK-2 cells transfected with Smad3 siRNA. Additionally, co-immunoprecipitation analysis indicated that CP blocked the interaction between Smad3 and TGF-β receptor I to suppress p-Smad3 expression. These findings demonstrated that CP alleviated RIF by inhibiting Smad3 phosphorylation, which provides a molecular basis for a new drug candidate for the treatment of RIF.
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Affiliation(s)
- Fang Dou
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, No. 127, West Changle Road, Xi'an, Shaanxi 710032, China.
| | - Yi Ding
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, No. 127, West Changle Road, Xi'an, Shaanxi 710032, China
| | - Cheng Wang
- School of Pharmacy, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Jialin Duan
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, No. 127, West Changle Road, Xi'an, Shaanxi 710032, China
| | - Wenjun Wang
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, No. 127, West Changle Road, Xi'an, Shaanxi 710032, China
| | - Hang Xu
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, No. 127, West Changle Road, Xi'an, Shaanxi 710032, China
| | - Xian Zhao
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, No. 127, West Changle Road, Xi'an, Shaanxi 710032, China
| | - Jingwen Wang
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, No. 127, West Changle Road, Xi'an, Shaanxi 710032, China.
| | - Aidong Wen
- Department of Pharmacy, Xijing Hospital, Fourth Military Medical University, No. 127, West Changle Road, Xi'an, Shaanxi 710032, China.
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16
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Carlisle MA, Soranno DE, Basu RK, Gist KM. Acute Kidney Injury and Fluid Overload in Pediatric Cardiac Surgery. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2019; 5:326-342. [PMID: 33282633 PMCID: PMC7717109 DOI: 10.1007/s40746-019-00171-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Acute kidney injury (AKI) and fluid overload affect a large number of children undergoing cardiac surgery, and confers an increased risk for adverse complications and outcomes including death. Survivors of AKI suffer long-term sequelae. The purpose of this narrative review is to discuss the short and long-term impact of cardiac surgery associated AKI and fluid overload, currently available tools for diagnosis and risk stratification, existing management strategies, and future management considerations. RECENT FINDINGS Improved risk stratification, diagnostic prediction tools and clinically available early markers of tubular injury have the ability to improve AKI-associated outcomes. One of the major challenges in diagnosing AKI is the diagnostic imprecision in serum creatinine, which is impacted by a variety of factors unrelated to renal disease. In addition, many of the pharmacologic interventions for either AKI prevention or treatment have failed to show any benefit, while peritoneal dialysis catheters, either for passive drainage or prophylactic dialysis may be able to mitigate the detrimental effects of fluid overload. SUMMARY Until novel risk stratification and diagnostics tools are integrated into routine practice, supportive care will continue to be the mainstay of therapy for those affected by AKI and fluid overload after pediatric cardiac surgery. A viable series of preventative measures can be taken to mitigate the risk and severity of AKI and fluid overload following cardiac surgery, and improve care.
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Affiliation(s)
- Michael A Carlisle
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora CO
| | - Danielle E. Soranno
- Department of Pediatrics, Division of Pediatric Nephrology, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora CO
| | - Rajit K Basu
- Department of Pediatrics, Division of Pediatric Critical Care, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta GA
| | - Katja M Gist
- Department of Pediatrics, Division of Pediatric Cardiology, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora CO
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17
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Borges FK, Devereaux PJ, Cuerden M, Bhandari M, Guerra-Farfán E, Patel A, Sigamani A, Umer M, Neary J, Tiboni M, Tandon V, Ramokgopa MT, Sancheti P, John B, Lawendy A, Balaguer-Castro M, Jenkinson R, Ślęczka P, Nabi Nur A, Wood GCA, Feibel R, McMahon JS, Sigamani A, Biccard BM, Landoni G, Szczeklik W, Wang CY, Tomas-Hernandez J, Abraham V, Vincent J, Harvey V, Pettit S, Sontrop J, Garg AX. Effects of accelerated versus standard care surgery on the risk of acute kidney injury in patients with a hip fracture: a substudy protocol of the hip fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) international randomised controlled trial. BMJ Open 2019; 9:e033150. [PMID: 31551393 PMCID: PMC6773307 DOI: 10.1136/bmjopen-2019-033150] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 08/28/2019] [Accepted: 08/29/2019] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Inflammation, dehydration, hypotension and bleeding may all contribute to the development of acute kidney injury (AKI). Accelerated surgery after a hip fracture can decrease the exposure time to such contributors and may reduce the risk of AKI. METHODS AND ANALYSIS Hip fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) is a multicentre, international, parallel-group randomised controlled trial (RCT). Patients who suffer a hip fracture are randomly allocated to either accelerated medical assessment and surgical repair with a goal of surgery within 6 hours of diagnosis or standard care where a repair typically occurs 24 to 48 hours after diagnosis. The primary outcome of this substudy is the development of AKI within 7 days of randomisation. We anticipate at least 1998 patients will participate in this substudy. ETHICS AND DISSEMINATION We obtained ethics approval for additional serum creatinine recordings in consecutive patients enrolled at 70 participating centres. All patients provide consent before randomisation. We anticipate reporting substudy results by 2021. TRIAL REGISTRATION NUMBER NCT02027896; Pre-results.
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Affiliation(s)
- Flavia K Borges
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Perioperative Medicine, Population Health Research Institute, Hamilton, Ontario, Canada
| | - P J Devereaux
- Department of Perioperative Medicine, Population Health Research Institute, Hamilton, Ontario, Canada
- Departments of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Meaghan Cuerden
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
| | - Mohit Bhandari
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Ernesto Guerra-Farfán
- Department of Orthopaedic Surgery and Traumatology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Ameen Patel
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Alben Sigamani
- Clinical Research, Narayana Hrudayalaya Limited, Bangalore, India
| | - Masood Umer
- Department of Orthopaedic Surgery, Aga Khan University, Karachi, Pakistan
| | - John Neary
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Maria Tiboni
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mmampapatla Thomas Ramokgopa
- Department of Orthopaedic Surgery, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
- Department of Orthopaedic Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Parag Sancheti
- Department of Orthopaedic Surgery, Sancheti Institute for Orthopaedics & Rehabilitation, Pune, India
| | - Bobby John
- Department of Orthopaedic Surgery, Christian Medical College and Hospital Ludhiana, Ludhiana, India
| | | | - Mariano Balaguer-Castro
- Department of Orthopaedic Surgery and Traumatology, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Richard Jenkinson
- Department of Surgery and Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Aamer Nabi Nur
- Department of Orthopaedic Surgery, Shifa International Hospital, Islamabad, Pakistan
| | - Gavin C A Wood
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
| | - Robert Feibel
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Alen Sigamani
- Department of Orthopaedic, Government TD Medical College, Allapuzha, India
| | - Bruce M Biccard
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Rondebosch, South Africa
| | - Giovanni Landoni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Anaesthesia and Intensive Care, Vita-Salute San Raffaele University, Milan, Italy
| | - Wojciech Szczeklik
- Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Chew Yin Wang
- Department of Anaesthesiology, University Malaya, Kuala Lumpur, Malaysia
| | - Jordi Tomas-Hernandez
- Department of Orthopaedic Surgery and Traumatology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Valsa Abraham
- Department of Orthopaedic Surgery, Christian Medical College and Hospital Ludhiana, Ludhiana, India
| | - Jessica Vincent
- Department of Perioperative Medicine, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Valerie Harvey
- Department of Perioperative Medicine, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Shirley Pettit
- Department of Perioperative Medicine, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jessica Sontrop
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Amit X Garg
- Departments of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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